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2009 Medicare Part D Plan (PDP Only) Formulary Browser

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First Health Part D-Premier (S5768-009-0)
Tier 1 (1612)
Tier 2 (502)
Tier 3 (994)
Tier 4 (285)

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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
First Health Part D-Premier (S5768-009-0)
Benefit Details  
The First Health Part D-Premier (S5768-009-0)
Formulary Drugs Starting with the Letter A

in CMS PDP Region 6 which includes: PA WV
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-HYDROCORT 100MG VIAL   1 Preferred Generic $7.00N/ANone
ABILIFY 10MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP Q:30
/30Days
ABILIFY 15MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP Q:30
/30Days
ABILIFY 1MG/ML SOLUTION   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP Q:900
/30Days
ABILIFY 20MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP Q:30
/30Days
ABILIFY 2MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP Q:30
/30Days
ABILIFY 30MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP Q:30
/30Days
ABILIFY 5MG TABLET (OTSUKA)   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP Q:30
/30Days
ABILIFY DISCMELT 10MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP Q:60
/30Days
ABILIFY DISCMELT 15MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ABILIFY INJ 9.75MG   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP
ACARBOSE 100MG TABLET S   1 Preferred Generic $7.00N/ANone
ACARBOSE 25MG TABLET S   1 Preferred Generic $7.00N/ANone
ACARBOSE 50MG TABLET S   1 Preferred Generic $7.00N/ANone
ACCOLATE 10MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:60
/30Days
ACCOLATE 20MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:60
/30Days
ACEBUTOLOL 200MG CAPSULE   1 Preferred Generic $7.00N/ANone
ACEBUTOLOL 400MG CAPSULE   1 Preferred Generic $7.00N/ANone
ACEON 2MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:30
/30Days
ACEON 4MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:30
/30Days
ACEON 8MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-15MG (1000 CT)   1 Preferred Generic $7.00N/ANone
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT)   1 Preferred Generic $7.00N/ANone
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT)   1 Preferred Generic $7.00N/ANone
ACETAMINOPHEN/COD SOLUTION   1 Preferred Generic $7.00N/ANone
ACETAZOLAMIDE 125MG TABLET   1 Preferred Generic $7.00N/ANone
ACETAZOLAMIDE 250MG TABLET (100 CT)   1 Preferred Generic $7.00N/ANone
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT   1 Preferred Generic $7.00N/ANone
ACETIC ACID 2% SOLUTION NON-ORAL   1 Preferred Generic $7.00N/ANone
ACETIC ACID-HYDROCORTISONE 2%-1% DROPS   1 Preferred Generic $7.00N/ANone
ACETYLCYSTEINE 10% VIAL   1 Preferred Generic $7.00N/ANone
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN   1 Preferred Generic $7.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACIPHEX 20MG TABLET EC   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AS Q:30
/30Days
ACTHIB VACCINE VIAL 10-24UNT/5ML   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/ANone
ACTICIN 5% CREAM   1 Preferred Generic $7.00N/ANone
ACTIMMUNE SOLUTION FOR INJECTION 100MCG   4 Specialty-Generic and Brand 33%N/ANone
ACTIVELLA 0.5-0.1MG TABLET 28 DLPK   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:28
/28Days
ACTONEL 150MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:1
/30Days
ACTONEL 30MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:30
/30Days
ACTONEL 35MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:5
/30Days
ACTONEL 5MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:30
/30Days
ACTONEL 75MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:2
/30Days
ACTONEL WITH CALCIUM TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:28
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACTOS 15MG TABLET   2 Preferred Brand $27.00N/AS Q:30
/30Days
ACTOS 30MG TABLET (500 CT)   2 Preferred Brand $27.00N/AS Q:30
/30Days
ACTOS 45MG TABLET   2 Preferred Brand $27.00N/AS Q:30
/30Days
ACULAR 0.5% EYE DROPS   2 Preferred Brand $27.00N/AQ:10
/30Days
ACULAR LS 0.4% OPHTH SOL   2 Preferred Brand $27.00N/AQ:10
/30Days
ACULAR PF 0.5% EYE DROPS   2 Preferred Brand $27.00N/AQ:24
/30Days
ACYCLOVIR 200MG CAPSULE (1000 CT)   1 Preferred Generic $7.00N/ANone
ACYCLOVIR 200MG/5ML SUSP   1 Preferred Generic $7.00N/ANone
ACYCLOVIR 400MG TABLET (100 CT)   1 Preferred Generic $7.00N/ANone
ACYCLOVIR TABLET USP 800MG (100 CT)   1 Preferred Generic $7.00N/ANone
ADACEL VIAL 2UNT/5UNT   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADAGEN 250U/ML VIAL   4 Specialty-Generic and Brand 33%N/AP
ADDERALL XR 10MG CAPSULE SA   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:30
/30Days
ADDERALL XR 15MG CAPSULE SA   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:30
/30Days
ADDERALL XR 20MG CAPSULE SA   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:30
/30Days
ADDERALL XR 25MG CAPSULE SA   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:30
/30Days
ADDERALL XR 30MG CAPSULE SA   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:60
/30Days
ADDERALL XR 5MG CAPSULE SA   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:30
/30Days
ADVAIR DISKU MIS 100/50   2 Preferred Brand $27.00N/AQ:60
/30Days
ADVAIR DISKU MIS 250/50   2 Preferred Brand $27.00N/AQ:60
/30Days
ADVAIR DISKU MIS 500/50   2 Preferred Brand $27.00N/AQ:60
/30Days
ADVAIR HFA 115/21MCG INHALER   2 Preferred Brand $27.00N/AQ:12
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADVAIR HFA 230/21MCG INHALER   2 Preferred Brand $27.00N/AQ:12
/30Days
ADVAIR HFA 45/21MCG INHALER   2 Preferred Brand $27.00N/AQ:12
/30Days
ADVICOR 1000-20MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:60
/30Days
ADVICOR 1000MG/40MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:30
/30Days
ADVICOR 500-20MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:30
/30Days
ADVICOR ER 20-750MG TABLET (90 CT)   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:60
/30Days
AEROBID AEROSOL W/ADAPTER   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:21
/30Days
AEROBID-M AEROSOL W/ADAPTER   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:21
/30Days
AFINITOR TABLETS   4 Specialty-Generic and Brand 33%N/AP Q:30
/30Days
AFINITOR TABLETS 5 MG   4 Specialty-Generic and Brand 33%N/AP Q:30
/30Days
AGGRENOX 25-200MG CAPSULE   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AK-CON 0.1% EYE DROPS   1 Preferred Generic $7.00N/ANone
AK-POLY-BAC EYE OINTMENT 500UNT/1000UNT   1 Preferred Generic $7.00N/ANone
AKNE-MYCIN 2% OINTMENT   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/ANone
ALAMAST 0.1% DROPS   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:20
/30Days
ALBENZA 200MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/ANone
ALBUTEROL SULFATE 0.63MG/3ML VIAL NEBULIZER   1 Preferred Generic $7.00N/AP
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER   1 Preferred Generic $7.00N/AP
ALBUTEROL SULFATE 2.5MG/3ML VIAL NEBULIZER   1 Preferred Generic $7.00N/AP
ALBUTEROL SULFATE 4MG TABLET SR 12HR   1 Preferred Generic $7.00N/ANone
ALBUTEROL SULFATE 8MG TABLET SR 12HR   1 Preferred Generic $7.00N/ANone
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   1 Preferred Generic $7.00N/AP
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 $7.00N/ANone
ALBUTEROL SULFATE TABLET 2MG (500 CT)   1 Preferred Generic $7.00N/ANone
ALBUTEROL TABLET 4MG (500 CT)   1 Preferred Generic $7.00N/ANone
ALCLOMETASONE DIPROPIONATE 0.05% CREAM   1 Preferred Generic $7.00N/ANone
ALCLOMETASONE DIPROPIONATE 0.05% OINTMENT   1 Preferred Generic $7.00N/ANone
ALCOHOL ANTISEPTIC PADS   1 Preferred Generic $7.00N/ANone
ALDARA 5% CREAM   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:12
/30Days
ALDURAZYME 2.9MG/5ML VIAL   4 Specialty-Generic and Brand 33%N/AP
ALENDRONATE SODIUM 10MG TABLET   1 Preferred Generic $7.00N/ANone
ALENDRONATE SODIUM 40MG TABLET   1 Preferred Generic $7.00N/ANone
ALENDRONATE SODIUM 5MG TABLET   1 Preferred Generic $7.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALENDRONATE SODIUM 70MG TABLET 4 BLPK   1 Preferred Generic $7.00N/ANone
ALENDRONATE SODIUM TABLET 35MG 20 CRTN   1 Preferred Generic $7.00N/ANone
ALIMTA 500MG VIAL   4 Specialty-Generic and Brand 33%N/AP
ALIMTA INJECTION   4 Specialty-Generic and Brand 33%N/AP
ALINIA 100MG/5ML SUSPENSION   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/ANone
ALINIA 500MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/ANone
ALKERAN 50MG VIAL   2 Preferred Brand $27.00N/AP
ALLEGRA-D 12 HOUR TABLET 60-120MG (500 CT)   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:60
/30Days
ALLOPURINOL TABLET 300MG (1000 CT)   1 Preferred Generic $7.00N/ANone
ALLOPURINOL TABLET USP 100MG (1000 CT)   1 Preferred Generic $7.00N/ANone
ALOCRIL 2% EYE DROPS   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:10
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALOMIDE 0.1% EYE DROPS   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:20
/30Days
ALORA 0.025MG PATCH   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:8
/28Days
ALORA 0.05MG PATCH   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:8
/28Days
ALORA 0.075MG PATCH   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:8
/28Days
ALORA 0.1MG PATCH   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:8
/28Days
ALPHAGAN P 0.1% DROPS   2 Preferred Brand $27.00N/AQ:10
/30Days
ALPHAGAN P 0.15% EYE DROPS   2 Preferred Brand $27.00N/AQ:10
/30Days
ALREX 0.2% EYE DROPS   2 Preferred Brand $27.00N/AQ:15
/30Days
ALTABAX 1% OINTMENT   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:15
/30Days
ALTOPREV 20MG TABLET SR 24HR   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:30
/30Days
ALTOPREV 40MG TABLET SR 24HR   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALTOPREV 60MG TABLET SR 24HR   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:30
/30Days
ALUPENT 650MCG INHALER COMP   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/ANone
ALVESCO 160MCG/ACT AERS   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:6
/30Days
ALVESCO 80MCG/ACT AERS   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:6
/30Days
AMANTADINE 100MG CAPSULE   1 Preferred Generic $7.00N/ANone
AMANTADINE 100MG TABLET   1 Preferred Generic $7.00N/ANone
AMCINONIDE 0.1% CREAM   1 Preferred Generic $7.00N/ANone
AMCINONIDE 0.1% LOTION   1 Preferred Generic $7.00N/ANone
AMCINONIDE 0.1% OINTMENT 60GM TUBE   1 Preferred Generic $7.00N/ANone
AMERGE 1MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:9
/30Days
AMERGE 2.5MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:9
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMEVIVE ADMISTRATION PACK FOR INTRAMUSCULAR ADMINISTRATION KIT 15MG 1 X 4 PKGCOM   4 Specialty-Generic and Brand 33%N/AP
AMIKACIN 250MG/ML VIAL   1 Preferred Generic $7.00N/ANone
AMIKACIN 50MG/ML VIAL   1 Preferred Generic $7.00N/ANone
AMILORIDE HCL 5MG TABLET   1 Preferred Generic $7.00N/ANone
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET   1 Preferred Generic $7.00N/ANone
AMINOPHYLLINE 100MG TABLET (100 CT)   1 Preferred Generic $7.00N/ANone
AMINOPHYLLINE 200MG TABLET (1000 CT)   1 Preferred Generic $7.00N/ANone
AMINOPHYLLINE INJECTION 250MG 10ML X 25 VIALSD   1 Preferred Generic $7.00N/ANone
AMINOSYN 10% IV SOLUTION   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP
AMINOSYN 3.5% IV SOLUTION   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP
AMINOSYN 5% IV SOLUTION   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN 7% IV SOLUTION   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP
AMINOSYN 7%-ELECTROLYTE SOL   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP
AMINOSYN 8.5% IV SOLUTION   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP
AMINOSYN II 10% IV SOLUTION   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP
AMINOSYN II 15% IV SOLUTION   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP
AMINOSYN II 3.5% IN D25W IV   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP
AMINOSYN II 3.5% IN D5W IV   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP
AMINOSYN II 3.5% M/D5W IV   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP
AMINOSYN II 3.5% W/ELEC DEX   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP
AMINOSYN II 4.25% IN D10W   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP
AMINOSYN II 4.25% IN D20W   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/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   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP
AMINOSYN II 4.25% W/ELEC DW   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP
AMINOSYN II 4.25%-D25W IV   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP
AMINOSYN II 5% IN D25W IV   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP
AMINOSYN II 7% IV SOLUTION   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP
AMINOSYN II 8.5% ELECTROLYT   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP
AMINOSYN II 8.5% IV SOLUTION   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP
AMINOSYN M 3.5% IV SOLUTION   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP
AMINOSYN PF INJECTION   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP
AMINOSYN-HBC 7% IV SOLUTION   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP
AMINOSYN-HF 8% IV SOLUTION   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN-PF 7% IV SOLUTION   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP
AMIODARONE HCL 200MG TABLET (60 CT)   1 Preferred Generic $7.00N/ANone
AMIODARONE HCL 400MG TABLET   1 Preferred Generic $7.00N/ANone
AMITIZA 24 MCG CAPSULES   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AS Q:60
/30Days
AMITIZA 8MCG CAPSULE   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AS Q:60
/30Days
AMITRIP/CDP 25-10 TABLET   1 Preferred Generic $7.00N/ANone
AMITRIP/PERPHEN 10-2 TABLET   1 Preferred Generic $7.00N/ANone
AMITRIP/PERPHEN 10-4 TABLET   1 Preferred Generic $7.00N/ANone
AMITRIP/PERPHEN 25-2 TABLET   1 Preferred Generic $7.00N/ANone
AMITRIP/PERPHEN 25-4 TABLET   1 Preferred Generic $7.00N/ANone
AMITRIP/PERPHEN 50-4 TABLET   1 Preferred Generic $7.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITRIPTYLINE HCL 100MG TABLET   1 Preferred Generic $7.00N/ANone
AMITRIPTYLINE HCL 10MG TABLET   1 Preferred Generic $7.00N/ANone
AMITRIPTYLINE HCL 150MG TABLET (100 CT)   1 Preferred Generic $7.00N/ANone
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)   1 Preferred Generic $7.00N/ANone
AMITRIPTYLINE HCL 50MG TABLET   1 Preferred Generic $7.00N/ANone
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)   1 Preferred Generic $7.00N/ANone
AMLODIPINE BESYLATE 10MG TABLET (90 CT)   1 Preferred Generic $7.00N/ANone
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)   1 Preferred Generic $7.00N/ANone
AMLODIPINE BESYLATE 5MG TABLET (90 CT)   1 Preferred Generic $7.00N/ANone
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:30
/30Days
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:30
/30Days
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:60
/30Days
AMMONIUM LACTATE 12% CREAM   1 Preferred Generic $7.00N/ANone
AMMONIUM LACTATE 12% LOTION   1 Preferred Generic $7.00N/AQ:400
/30Days
AMOX TR-K CLV 500-125MG TABLET   1 Preferred Generic $7.00N/ANone
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL   1 Preferred Generic $7.00N/ANone
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE   1 Preferred Generic $7.00N/ANone
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET   1 Preferred Generic $7.00N/ANone
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE   1 Preferred Generic $7.00N/ANone
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   1 Preferred Generic $7.00N/ANone
AMOXAPINE 100MG TABLET   2 Preferred Brand $27.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXAPINE 150MG TABLET   2 Preferred Brand $27.00N/ANone
AMOXAPINE 25MG TABLET   2 Preferred Brand $27.00N/ANone
AMOXAPINE 50MG TABLET   2 Preferred Brand $27.00N/ANone
AMOXICILLIN 125MG TABLET CHEW   1 Preferred Generic $7.00N/ANone
AMOXICILLIN 200MG TABLET CHEW   1 Preferred Generic $7.00N/ANone
AMOXICILLIN 250MG CAPSULE   1 Preferred Generic $7.00N/ANone
AMOXICILLIN 400MG TABLET CHEW   1 Preferred Generic $7.00N/ANone
AMOXICILLIN 500MG CAPSULE   1 Preferred Generic $7.00N/ANone
AMOXICILLIN 500MG TABLET (100 CT)   1 Preferred Generic $7.00N/ANone
AMOXICILLIN 875MG TABLET   1 Preferred Generic $7.00N/ANone
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT   1 Preferred Generic $7.00N/ANone
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 $7.00N/ANone
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT   1 Preferred Generic $7.00N/ANone
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL   1 Preferred Generic $7.00N/ANone
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   1 Preferred Generic $7.00N/ANone
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL   1 Preferred Generic $7.00N/ANone
AMOXICILLIN TABLET USP CHEWABLE 250MG (250 CT)   1 Preferred Generic $7.00N/ANone
AMOXIL 500MG CAPSULE   1 Preferred Generic $7.00N/ANone
AMPHET ASP/ AMPHET/ D-AMPHET 5MG TABLET   1 Preferred Generic $7.00N/ANone
AMPHETAMINE SALT COMBO 12.5MG TABLET   1 Preferred Generic $7.00N/ANone
AMPHETAMINE SALT COMBO 15MG TABLET   1 Preferred Generic $7.00N/ANone
AMPHETAMINE SALT COMBO 7.5MG TABLET   1 Preferred Generic $7.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPHETAMINE SALTS 30MG TABLET   1 Preferred Generic $7.00N/ANone
AMPICILLIN AND SULBACTAM FOR INJECTION 1-0.5 10 VIAL VIAL   1 Preferred Generic $7.00N/ANone
AMPICILLIN AND SULBACTAM FOR INJECTION 10-5 1 VIAL   1 Preferred Generic $7.00N/ANone
AMPICILLIN AND SULBACTAM FOR INJECTION 2-1 10 VIAL   1 Preferred Generic $7.00N/ANone
AMPICILLIN FOR INJECTION   1 Preferred Generic $7.00N/ANone
AMPICILLIN FOR INJECTION 1GM VIAL   1 Preferred Generic $7.00N/ANone
AMPICILLIN FOR INJECTION 2GM/ML 10 VIAL   1 Preferred Generic $7.00N/ANone
AMPICILLIN FOR INJECTION 500MG VIAL   1 Preferred Generic $7.00N/ANone
AMPICILLIN FOR INJECTION POWDER   1 Preferred Generic $7.00N/ANone
AMPICILLIN FOR INJECTION USP 125MG/ML 1 VIAL   1 Preferred Generic $7.00N/ANone
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT   1 Preferred Generic $7.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT   1 Preferred Generic $7.00N/ANone
AMPICILLIN POWDER FOR INJECTION 1 GM/ML   1 Preferred Generic $7.00N/ANone
AMPICILLIN SODIUM STERILE 2 GM/VIAL   1 Preferred Generic $7.00N/ANone
AMPICILLIN TR 250MG CAPSULE   1 Preferred Generic $7.00N/ANone
AMPICILLIN TR 500MG CAPSULE   1 Preferred Generic $7.00N/ANone
ANADROL-50 50MG TABLET (100 CT)   2 Preferred Brand $27.00N/AP
ANAGRELIDE HCL 0.5MG CAPSULE   1 Preferred Generic $7.00N/ANone
ANAGRELIDE HCL 1MG CAPSULE   1 Preferred Generic $7.00N/ANone
ANCOBON 250MG CAPSULE   4 Specialty-Generic and Brand 33%N/AP
ANCOBON 500MG CAPSULE   4 Specialty-Generic and Brand 33%N/AP
ANDRODERM 2.5MG/24HR PATCH   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANDRODERM 5MG/24HR PATCH   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP Q:30
/30Days
ANDROGEL 1%(25MG) GEL PACKET   2 Preferred Brand $27.00N/AP
ANDROGEL 1.25G (1%) GEL IN METERED-DOSE PUMP   2 Preferred Brand $27.00N/AP
ANDROGEL 1%(50MG) GEL PACKET   2 Preferred Brand $27.00N/AP
ANDROID 10MG CAPSULE   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP
ANGELIQ 1-0.5MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:30
/30Days
ANTABUSE 250MG TABLET   2 Preferred Brand $27.00N/ANone
ANTABUSE 500MG TABLET   2 Preferred Brand $27.00N/ANone
ANTARA 130MG CAPSULE   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:30
/30Days
ANTARA 43MG CAPSULE   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:30
/30Days
APHTHASOL 5% PASTE   2 Preferred Brand $27.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
APOKYN FOR INJECTION 30MG 5 CTG   4 Specialty-Generic and Brand 33%N/AP
APRI 0.15-0.03 TABLET   1 Preferred Generic $7.00N/ANone
APTIVUS 250MG CAPSULE   4 Specialty-Generic and Brand 33%N/AQ:120
/30Days
ARALAST 1000MG VIAL   2 Preferred Brand $27.00N/AP
ARALAST 500MG VIAL   2 Preferred Brand $27.00N/AP
ARANELLE 7-9-5 TABLET   1 Preferred Generic $7.00N/ANone
ARANESP 100MCG/ML VIAL   4 Specialty-Generic and Brand 33%N/AP S Q:4
/28Days
ARANESP 200MCG/0.4ML SYRINGE   4 Specialty-Generic and Brand 33%N/AP S Q:4
/28Days
ARANESP 200MCG/ML VIAL   4 Specialty-Generic and Brand 33%N/AP S Q:4
/28Days
ARANESP 25MCG/ML VIAL   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP S Q:4
/28Days
ARANESP 300MCG/ML VIAL   4 Specialty-Generic and Brand 33%N/AP S Q:4
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP 500MCG/1ML SYRINGE   4 Specialty-Generic and Brand 33%N/AP S Q:1
/21Days
ARANESP 60MCG/ML VIAL   4 Specialty-Generic and Brand 33%N/AP S Q:4
/28Days
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR   4 Specialty-Generic and Brand 33%N/AP S Q:4
/28Days
ARANESP PREFILLED SYRINGE SINGLE USE 25MCG/0.42ML SYR   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP S Q:4
/28Days
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR   4 Specialty-Generic and Brand 33%N/AP S Q:4
/28Days
ARANESP SINGLE USE PREFILLED AUTOINJECTOR SOLUTION 100MCG/.5ML   4 Specialty-Generic and Brand 33%N/AP S Q:4
/28Days
ARANESP SINGLE USE PREFILLED SURECLICK AUTOINJECTOR SOLUTION 500MCG/ML   4 Specialty-Generic and Brand 33%N/AP S Q:4
/28Days
ARANESP SINGLE USE PREFILLED SURECLIK AUTOINJECTOR 60MCG/.3ML   4 Specialty-Generic and Brand 33%N/AP S Q:4
/28Days
ARANESP SINGLE USE VIAL 150MCG 4 X 150MCG/ 0.75ML VIALSD   4 Specialty-Generic and Brand 33%N/AP S Q:4
/28Days
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD   4 Specialty-Generic and Brand 33%N/AP S Q:4
/28Days
ARCALYST INJECTION 220MG/VIAL   4 Specialty-Generic and Brand 33%N/AP Q:4
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARICEPT 10MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:30
/30Days
ARICEPT 5MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:30
/30Days
ARICEPT ODT 10MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:30
/30Days
ARICEPT ODT 5MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:30
/30Days
ARIMIDEX 1MG TABLET   2 Preferred Brand $27.00N/AQ:30
/30Days
ARIXTRA 10MG SYRINGE   4 Specialty-Generic and Brand 33%N/AP
ARIXTRA 2.5MG SYRINGE   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP
ARIXTRA 5MG SYRINGE   4 Specialty-Generic and Brand 33%N/AP
ARIXTRA 7.5MG SYRINGE   4 Specialty-Generic and Brand 33%N/AP
AROMASIN 25MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:60
/30Days
ARTHROTEC 50 50MG TABLET -200MCG (60 CT)   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARTHROTEC 75 TABLET EC   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/ANone
ASACOL 400MG TABLET EC   2 Preferred Brand $27.00N/ANone
ASCOMP W/CODEINE 30-50-325 CAPSULE   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/ANone
ASMANEX TWISTHALER 220MCG #120   2 Preferred Brand $27.00N/AQ:1
/30Days
ASMANEX TWISTHALER 220MCG #30   2 Preferred Brand $27.00N/AQ:1
/30Days
ASMANEX TWISTHALER 220MCG #60   2 Preferred Brand $27.00N/AQ:1
/30Days
ASTELIN 137MCG AEROSOL SPRAY W/PUMP   2 Preferred Brand $27.00N/ANone
ATACAND 16MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:30
/30Days
ATACAND 32MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:30
/30Days
ATACAND 4MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:30
/30Days
ATACAND 8MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATACAND HCT 16/12.5MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:30
/30Days
ATACAND HCT 32/12.5MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:30
/30Days
ATACAND HCT TABLETS 32;25MG;MG 90 TABLETS BOT   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:30
/30Days
ATENOLOL 25MG TABLET (100 CT)   1 Preferred Generic $7.00N/ANone
ATENOLOL TABLET 100MG (100 CT)   1 Preferred Generic $7.00N/ANone
ATENOLOL TABLET USP 50MG (100 CT)   1 Preferred Generic $7.00N/ANone
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT)   1 Preferred Generic $7.00N/ANone
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   1 Preferred Generic $7.00N/ANone
ATRIPLA TABLET 600MG/200MG   4 Specialty-Generic and Brand 33%N/AQ:30
/30Days
ATROVENT HFA AER 17MCG   2 Preferred Brand $27.00N/AQ:25
/30Days
ATTENUVAX VACCINE W/DILUENT 1 DOSE/0.5ML   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AUGMENTIN XR 1000-62.5 TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/ANone
AVALIDE 150-12.5MG TABLET   2 Preferred Brand $27.00N/AQ:30
/30Days
AVALIDE 300-12.5MG TABLET   2 Preferred Brand $27.00N/AQ:30
/30Days
AVALIDE 300-25MG TABLET   2 Preferred Brand $27.00N/AQ:30
/30Days
AVANDAMET 2MG/1000MG TABLET   2 Preferred Brand $27.00N/AS Q:60
/30Days
AVANDAMET 2MG/500MG TABLET   2 Preferred Brand $27.00N/AS Q:60
/30Days
AVANDAMET 4MG/500MG TABLET   2 Preferred Brand $27.00N/AS Q:60
/30Days
AVANDAMET TABLET 4-1000MG   2 Preferred Brand $27.00N/AS Q:60
/30Days
AVANDARYL 4MG/1MG TABLET   2 Preferred Brand $27.00N/AS Q:60
/30Days
AVANDARYL 4MG/2MG TABLET   2 Preferred Brand $27.00N/AS Q:60
/30Days
AVANDARYL 4MG/4MG TABLET   2 Preferred Brand $27.00N/AS Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVANDARYL 8MG-2MG TABLET   2 Preferred Brand $27.00N/AS Q:30
/30Days
AVANDARYL 8MG-4MG TABLET   2 Preferred Brand $27.00N/AS Q:30
/30Days
AVANDIA 2MG TABLET   2 Preferred Brand $27.00N/AS Q:60
/30Days
AVANDIA 4MG TABLET (90 CT)   2 Preferred Brand $27.00N/AS Q:60
/30Days
AVANDIA 8MG TABLET (90 CT)   2 Preferred Brand $27.00N/AS Q:30
/30Days
AVAPRO 150MG TABLET   2 Preferred Brand $27.00N/AQ:30
/30Days
AVAPRO 300MG TABLET   2 Preferred Brand $27.00N/AQ:30
/30Days
AVAPRO 75MG TABLET (30 CT)   2 Preferred Brand $27.00N/AQ:30
/30Days
AVASTIN 100MG/4ML VIAL   4 Specialty-Generic and Brand 33%N/AP
AVASTIN 400MG/16ML VIAL   4 Specialty-Generic and Brand 33%N/AP
AVELOX 400MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVELOX IV 400MG/250ML   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/ANone
AVIANE 0.1-0.02 TABLET   1 Preferred Generic $7.00N/ANone
AVODART 0.5MG SOFTGEL   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:30
/30Days
AVONEX ADMIN PACK 30MCG SYR   4 Specialty-Generic and Brand 33%N/AP Q:4
/30Days
AVONEX ADMIN PACK 30MCG VL   4 Specialty-Generic and Brand 33%N/AP Q:4
/30Days
AXERT 12.5MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP Q:8
/30Days
AXERT 6.25MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AP Q:8
/30Days
AXID 15MG/ML ORAL SOLUTION   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/ANone
AZACTAM 1GM VIAL   2 Preferred Brand $27.00N/AP
AZACTAM 2GM VIAL   2 Preferred Brand $27.00N/AP
AZACTAM INJECTION 1GM 50ML BAG   2 Preferred Brand $27.00N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZACTAM/ISO-OSMOT 2GM/50ML   2 Preferred Brand $27.00N/AP
AZASITE 1% DROPS   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AQ:2
/30Days
AZATHIOPRINE 50MG TABLET   1 Preferred Generic $7.00N/ANone
AZELEX 20% CREAM 30GM TUBE   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/ANone
AZILECT 0.5MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AS Q:30
/30Days
AZILECT 1MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $52.00N/AS Q:30
/30Days
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Preferred Generic $7.00N/ANone
AZITHROMYCIN 1G PACKET   1 Preferred Generic $7.00N/AQ:2
/30Days
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Preferred Generic $7.00N/ANone
AZITHROMYCIN 250MG TABLET (30 CT)   1 Preferred Generic $7.00N/ANone
AZITHROMYCIN 500MG TABLET (30 CT)   1 Preferred Generic $7.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZITHROMYCIN FOR INJECTION 500MG 10 VIALSD   1 Preferred Generic $7.00N/ANone
AZITHROMYCIN TABLET 600MG (30 CT)   1 Preferred Generic $7.00N/ANone
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT   2 Preferred Brand $27.00N/ANone

Chart Legend:

Below are a few notes to help you understand the above 2009 Medicare Part D First Health Part D-Premier 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.