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2009 Medicare Part D Plan (PDP Only) Formulary Browser

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Prescription Blue Option A (S5584-001-0)
Tier 1 (1647)
Tier 2 (607)
Tier 3 (1929)
Tier 4 (358)
Tier 5 (826)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
Yes No Show either
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2009 Medicare Part D Plan Formulary Information
Prescription Blue Option A (S5584-001-0)
Benefit Details  
The Prescription Blue Option A (S5584-001-0)
Formulary Drugs Starting with the Letter A

in CMS PDP Region 13 which includes: MI
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   5 Non Self Administered Injectable 25%N/ANone
A-HYDROCORT 100MG VIAL   5 Non Self Administered Injectable 25%N/ANone
A-METHAPRED 40MG UNIVIAL   5 Non Self Administered Injectable 25%N/ANone
ABELCENT INJECTION SUSPENSION 5MG/ML   5 Non Self Administered Injectable 25%N/AP
ABILIFY 10MG TABLET   2 Preferred Brand $30.00$75.00None
ABILIFY 15MG TABLET   2 Preferred Brand $30.00$75.00None
ABILIFY 1MG/ML SOLUTION   2 Preferred Brand $30.00$75.00None
ABILIFY 20MG TABLET   2 Preferred Brand $30.00$75.00None
ABILIFY 2MG TABLET   2 Preferred Brand $30.00$75.00None
ABILIFY 30MG TABLET   2 Preferred Brand $30.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ABILIFY 5MG TABLET (OTSUKA)   2 Preferred Brand $30.00$75.00None
ABILIFY DISCMELT 10MG TABLET   2 Preferred Brand $30.00$75.00None
ABILIFY DISCMELT 15MG TABLET   2 Preferred Brand $30.00$75.00None
ABILIFY INJ 9.75MG   5 Non Self Administered Injectable 25%N/ANone
ABRAXANE 100MG VIAL   5 Non Self Administered Injectable 25%N/ANone
ACANYA TOPICAL GEL   3 Non Preferred $55.00$137.50None
ACARBOSE 100MG TABLET S   1 Generic $7.00$17.50None
ACARBOSE 25MG TABLET S   1 Generic $7.00$17.50None
ACARBOSE 50MG TABLET S   1 Generic $7.00$17.50None
ACCOLATE 10MG TABLET   2 Preferred Brand $30.00$75.00None
ACCOLATE 20MG TABLET   2 Preferred Brand $30.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACCUNEB 0.63MG/3ML INH TUBEX   3 Non Preferred $55.00$137.50None
ACCUNEB 1.25MG/3ML INH TUBEX   3 Non Preferred $55.00$137.50None
ACCUPRIL 10MG TABLET   3 Non Preferred $55.00$137.50None
ACCUPRIL 20MG TABLET   3 Non Preferred $55.00$137.50None
ACCUPRIL 40MG TABLET   3 Non Preferred $55.00$137.50None
ACCUPRIL 5MG TABLET   3 Non Preferred $55.00$137.50None
ACCURETIC 10-12.5MG TABLET   3 Non Preferred $55.00$137.50None
ACCURETIC 20-12.5MG TABLET   3 Non Preferred $55.00$137.50None
ACCURETIC 20-25MG TABLET   3 Non Preferred $55.00$137.50None
ACCUTANE 10MG CAPSULE   3 Non Preferred $55.00$137.50None
ACCUTANE 20MG CAPSULE   3 Non Preferred $55.00$137.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACCUTANE 40MG CAPSULE   3 Non Preferred $55.00$137.50None
ACEBUTOLOL 200MG CAPSULE   1 Generic $7.00$17.50None
ACEBUTOLOL 400MG CAPSULE   1 Generic $7.00$17.50None
ACEON 2MG TABLET   3 Non Preferred $55.00$137.50None
ACEON 4MG TABLET   3 Non Preferred $55.00$137.50None
ACEON 8MG TABLET   3 Non Preferred $55.00$137.50None
ACETADOTE 200MG/ML VIAL   5 Non Self Administered Injectable 25%N/ANone
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-15MG (1000 CT)   1 Generic $7.00$17.50None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT)   1 Generic $7.00$17.50None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT)   1 Generic $7.00$17.50None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT)   1 Generic $7.00$17.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT)   1 Generic $7.00$17.50None
ACETAMINOPHEN/COD SOLUTION   1 Generic $7.00$17.50None
ACETASOL HC SOLUTION 10ML 10 ML BOT   1 Generic $7.00$17.50None
ACETAZOLAMIDE 125MG TABLET   1 Generic $7.00$17.50None
ACETAZOLAMIDE 250MG TABLET (100 CT)   1 Generic $7.00$17.50None
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT   1 Generic $7.00$17.50None
ACETAZOLAMIDE SOD 500MG VL   5 Non Self Administered Injectable 25%N/ANone
ACETIC ACID 2% SOLUTION NON-ORAL   1 Generic $7.00$17.50None
ACETIC ACID-HYDROCORTISONE 2%-1% DROPS   1 Generic $7.00$17.50None
ACETYLCYSTEINE 10% VIAL   1 Generic $7.00$17.50None
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN   1 Generic $7.00$17.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACIPHEX 20MG TABLET EC   3 Non Preferred $55.00$137.50S
ACLOVATE 0.05% CREAM   3 Non Preferred $55.00$137.50None
ACLOVATE ALCLOMETASONE DIPROPIONATE 0.05% OINTMENT(GM) TOPICAL   3 Non Preferred $55.00$137.50None
ACTHIB VACCINE VIAL 10-24UNT/5ML   5 Non Self Administered Injectable 25%N/ANone
ACTICIN 5% CREAM   1 Generic $7.00$17.50None
ACTIGALL 300MG CAPSULE   3 Non Preferred $55.00$137.50None
ACTIMMUNE SOLUTION FOR INJECTION 100MCG   4 Specialty 25%N/ANone
ACTIQ 1200MCG LOZENGE   3 Non Preferred $55.00$137.50Q:136
/34Days
ACTIQ 1600MCG LOZENGE   3 Non Preferred $55.00$137.50Q:136
/34Days
ACTIQ 200MCG LOZENGE   3 Non Preferred $55.00$137.50Q:136
/34Days
ACTIQ 400MCG LOZENGE   3 Non Preferred $55.00$137.50Q:136
/34Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACTIQ 600MCG LOZENGE   3 Non Preferred $55.00$137.50Q:136
/34Days
ACTIQ 800MCG LOZENGE   3 Non Preferred $55.00$137.50Q:136
/34Days
ACTIVELLA 0.5-0.1MG TABLET 28 DLPK   3 Non Preferred $55.00$137.50None
ACTIVELLA 1-0.5MG TABLET 28 DLPK   3 Non Preferred $55.00$137.50None
ACTONEL 150MG TABLET   2 Preferred Brand $30.00$75.00S Q:1
/28Days
ACTONEL 30MG TABLET   2 Preferred Brand $30.00$75.00S Q:34
/34Days
ACTONEL 35MG TABLET   2 Preferred Brand $30.00$75.00S Q:4
/28Days
ACTONEL 5MG TABLET   2 Preferred Brand $30.00$75.00S Q:34
/34Days
ACTONEL 75MG TABLET   2 Preferred Brand $30.00$75.00S Q:2
/28Days
ACTONEL WITH CALCIUM TABLET   2 Preferred Brand $30.00$75.00S Q:28
/28Days
ACTOPLUS MET 15MG/500MG TABLET   3 Non Preferred $55.00$137.50P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACTOPLUS MET 15MG/850MG TABLET   3 Non Preferred $55.00$137.50P
ACTOS 15MG TABLET   2 Preferred Brand $30.00$75.00None
ACTOS 30MG TABLET (500 CT)   2 Preferred Brand $30.00$75.00None
ACTOS 45MG TABLET   2 Preferred Brand $30.00$75.00None
ACULAR 0.5% EYE DROPS   3 Non Preferred $55.00$137.50None
ACULAR LS 0.4% OPHTH SOL   3 Non Preferred $55.00$137.50None
ACULAR PF 0.5% EYE DROPS   3 Non Preferred $55.00$137.50None
ACYCLOVIR 200MG CAPSULE (1000 CT)   1 Generic $7.00$17.50None
ACYCLOVIR 200MG/5ML SUSP   1 Generic $7.00$17.50None
ACYCLOVIR 400MG TABLET (100 CT)   1 Generic $7.00$17.50None
ACYCLOVIR SOD 50MG/ML VIAL   5 Non Self Administered Injectable 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACYCLOVIR SODIUM 1GM VIAL   5 Non Self Administered Injectable 25%N/AP
ACYCLOVIR SODIUM 500MG VIAL   5 Non Self Administered Injectable 25%N/AP
ACYCLOVIR TABLET USP 800MG (100 CT)   1 Generic $7.00$17.50None
ADACEL VIAL 2UNT/5UNT   5 Non Self Administered Injectable 25%N/ANone
ADAGEN 250U/ML VIAL   4 Specialty 25%N/ANone
ADALAT CC 30MG TABLET   3 Non Preferred $55.00$137.50None
ADALAT CC 60MG TABLET   3 Non Preferred $55.00$137.50None
ADALAT CC 90MG TABLET   3 Non Preferred $55.00$137.50None
ADDERALL 10MG TABLET   3 Non Preferred $55.00$137.50None
ADDERALL 12.5MG TABLET   1 Generic $7.00$17.50None
ADDERALL 15MG TABLET   3 Non Preferred $55.00$137.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADDERALL 20MG TABLET   3 Non Preferred $55.00$137.50None
ADDERALL 30MG TABLET   3 Non Preferred $55.00$137.50None
ADDERALL 5MG TABLET   3 Non Preferred $55.00$137.50None
ADDERALL 7.5MG TABLET   1 Generic $7.00$17.50None
ADDERALL XR 10MG CAPSULE SA   2 Preferred Brand $30.00$75.00Q:68
/34Days
ADDERALL XR 15MG CAPSULE SA   2 Preferred Brand $30.00$75.00Q:68
/34Days
ADDERALL XR 20MG CAPSULE SA   2 Preferred Brand $30.00$75.00Q:102
/34Days
ADDERALL XR 25MG CAPSULE SA   2 Preferred Brand $30.00$75.00Q:68
/34Days
ADDERALL XR 30MG CAPSULE SA   2 Preferred Brand $30.00$75.00Q:68
/34Days
ADDERALL XR 5MG CAPSULE SA   2 Preferred Brand $30.00$75.00Q:34
/34Days
ADOXA 100MG TABLET   3 Non Preferred $55.00$137.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADOXA 50MG TABLET   3 Non Preferred $55.00$137.50None
ADOXA 75MG TABLET   3 Non Preferred $55.00$137.50None
ADOXA PAK 100MG TABLET DSPK-31   3 Non Preferred $55.00$137.50None
ADOXA PAK 100MG TABLET DSPK-60   3 Non Preferred $55.00$137.50None
ADOXA PAK 150MG TABLET   3 Non Preferred $55.00$137.50None
ADOXA PAK 75MG TABLET   3 Non Preferred $55.00$137.50None
ADRIAMYCIN 10MG VIAL   5 Non Self Administered Injectable 25%N/AP
ADRIAMYCIN 20MG VIAL   5 Non Self Administered Injectable 25%N/AP
ADRIAMYCIN 50MG VIAL   5 Non Self Administered Injectable 25%N/AP
ADVAIR DISKU MIS 100/50   2 Preferred Brand $30.00$75.00None
ADVAIR DISKU MIS 250/50   2 Preferred Brand $30.00$75.00None
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 $30.00$75.00None
ADVAIR HFA 115/21MCG INHALER   2 Preferred Brand $30.00$75.00None
ADVAIR HFA 230/21MCG INHALER   2 Preferred Brand $30.00$75.00None
ADVAIR HFA 45/21MCG INHALER   2 Preferred Brand $30.00$75.00None
ADVICOR 1000-20MG TABLET   3 Non Preferred $55.00$137.50S Q:68
/34Days
ADVICOR 1000MG/40MG TABLET   3 Non Preferred $55.00$137.50S Q:68
/34Days
ADVICOR 500-20MG TABLET   3 Non Preferred $55.00$137.50S Q:68
/34Days
ADVICOR ER 20-750MG TABLET (90 CT)   3 Non Preferred $55.00$137.50S Q:68
/34Days
AEROBID AEROSOL W/ADAPTER   3 Non Preferred $55.00$137.50None
AEROBID-M AEROSOL W/ADAPTER   3 Non Preferred $55.00$137.50None
AFEDITAB CR 30MG TABLET SA   1 Generic $7.00$17.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AFEDITAB CR 60MG TABLET SA   1 Generic $7.00$17.50None
AGGRENOX 25-200MG CAPSULE   2 Preferred Brand $30.00$75.00None
AGRYLIN 0.5MG CAPSULE   4 Specialty 25%N/ANone
AK-CON 0.1% EYE DROPS   1 Generic $7.00$17.50None
AK-POLY-BAC EYE OINTMENT 500UNT/1000UNT   1 Generic $7.00$17.50None
AK-SPORE EYE OINTMENT 3.5 MG   1 Generic $7.00$17.50None
AKNE-MYCIN 2% OINTMENT   3 Non Preferred $55.00$137.50None
AKTOB 0.3% EYE DROPS   1 Generic $7.00$17.50None
ALA-CORT 1% CREAM   1 Generic $7.00$17.50None
ALA-CORT 1% LOTION   1 Generic $7.00$17.50None
ALA-SCALP HP 2% LOTION   1 Generic $7.00$17.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALAMAST 0.1% DROPS   3 Non Preferred $55.00$137.50None
ALBALON LIQUIFILM 0.1% DROP   3 Non Preferred $55.00$137.50None
ALBENZA 200MG TABLET   3 Non Preferred $55.00$137.50None
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER   1 Generic $7.00$17.50None
ALBUTEROL SULFATE 2.5MG/3ML VIAL NEBULIZER   1 Generic $7.00$17.50None
ALBUTEROL SULFATE 4MG TABLET SR 12HR   1 Generic $7.00$17.50None
ALBUTEROL SULFATE 8MG TABLET SR 12HR   1 Generic $7.00$17.50None
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   1 Generic $7.00$17.50None
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT   1 Generic $7.00$17.50None
ALBUTEROL SULFATE TABLET 2MG (500 CT)   1 Generic $7.00$17.50None
ALBUTEROL TABLET 4MG (500 CT)   1 Generic $7.00$17.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALCAINE 0.5% EYE DROPS   1 Generic $7.00$17.50None
ALCLOMETASONE DIPROPIONATE 0.05% CREAM   1 Generic $7.00$17.50None
ALCLOMETASONE DIPROPIONATE 0.05% OINTMENT   1 Generic $7.00$17.50None
ALCOHOL 5%/DEXTROSE 5%   5 Non Self Administered Injectable 25%N/ANone
ALCOHOL ANTISEPTIC PADS   1 Generic $7.00$17.50None
ALDACTAZIDE 25/25 TABLET   3 Non Preferred $55.00$137.50None
ALDACTAZIDE 50/50 TABLET   3 Non Preferred $55.00$137.50None
ALDACTONE 100MG TABLET   3 Non Preferred $55.00$137.50None
ALDACTONE 25MG TABLET   3 Non Preferred $55.00$137.50None
ALDACTONE 50MG TABLET   3 Non Preferred $55.00$137.50None
ALDARA 5% CREAM   3 Non Preferred $55.00$137.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALDURAZYME 2.9MG/5ML VIAL   4 Specialty 25%N/ANone
ALENDRONATE SODIUM 10MG TABLET   1 Generic $7.00$17.50None
ALENDRONATE SODIUM 40MG TABLET   1 Generic $7.00$17.50None
ALENDRONATE SODIUM 5MG TABLET   1 Generic $7.00$17.50None
ALENDRONATE SODIUM 70MG TABLET 4 BLPK   1 Generic $7.00$17.50Q:4
/23Days
ALENDRONATE SODIUM TABLET 35MG 20 CRTN   1 Generic $7.00$17.50Q:4
/23Days
ALFERON N INJ 5MU/ML   4 Specialty 25%N/ANone
ALIMTA 500MG VIAL   5 Non Self Administered Injectable 25%N/ANone
ALIMTA INJECTION   5 Non Self Administered Injectable 25%N/ANone
ALINIA 100MG/5ML SUSPENSION   2 Preferred Brand $30.00$75.00None
ALINIA 500MG TABLET   2 Preferred Brand $30.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALKERAN 50MG VIAL   5 Non Self Administered Injectable 25%N/ANone
ALLEGRA 180MG TABLET   3 Non Preferred $55.00$137.50S
ALLEGRA 30MG TABLET   3 Non Preferred $55.00$137.50S
ALLEGRA 30MG/5ML SUSPENSION ORAL   3 Non Preferred $55.00$137.50None
ALLEGRA 60MG TABLET   3 Non Preferred $55.00$137.50S
ALLEGRA-D 12 HOUR TABLET 60-120MG (500 CT)   2 Preferred Brand $30.00$75.00S
ALLEGRA-D 24 HOUR TABLET   2 Preferred Brand $30.00$75.00S Q:34
/34Days
ALLOPURINOL SODIUM 500MG VIAL   5 Non Self Administered Injectable 25%N/ANone
ALLOPURINOL TABLET 300MG (1000 CT)   1 Generic $7.00$17.50None
ALLOPURINOL TABLET USP 100MG (1000 CT)   1 Generic $7.00$17.50None
ALOCRIL 2% EYE DROPS   2 Preferred Brand $30.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALOMIDE 0.1% EYE DROPS   2 Preferred Brand $30.00$75.00None
ALOPRIM 500MG VIAL   5 Non Self Administered Injectable 25%N/ANone
ALORA 0.025MG PATCH   2 Preferred Brand $30.00$75.00Q:8
/28Days
ALORA 0.05MG PATCH   2 Preferred Brand $30.00$75.00Q:8
/28Days
ALORA 0.075MG PATCH   2 Preferred Brand $30.00$75.00Q:8
/28Days
ALORA 0.1MG PATCH   2 Preferred Brand $30.00$75.00Q:8
/28Days
ALOXI 0.25MG/5ML VIAL   4 Specialty 25%N/ANone
ALPHAGAN P 0.1% DROPS   2 Preferred Brand $30.00$75.00None
ALPHAGAN P 0.15% EYE DROPS   2 Preferred Brand $30.00$75.00None
ALREX 0.2% EYE DROPS   3 Non Preferred $55.00$137.50None
ALTABAX 1% OINTMENT   3 Non Preferred $55.00$137.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALTACE 1.25MG CAPSULE   3 Non Preferred $55.00$137.50None
ALTACE 10MG CAPSULE (100 CT)   3 Non Preferred $55.00$137.50None
ALTACE 2.5MG CAPSULE   3 Non Preferred $55.00$137.50None
ALTACE 5MG CAPSULE   3 Non Preferred $55.00$137.50None
ALTACE TABLETS 1.25MG 100 BOTPL   3 Non Preferred $55.00$137.50None
ALTACE TABLETS 10MG 100 BOTPL   3 Non Preferred $55.00$137.50None
ALTACE TABLETS 2.5MG 100 BOTPL   3 Non Preferred $55.00$137.50None
ALTACE TABLETS 5MG 100 BOTPL   3 Non Preferred $55.00$137.50None
ALTOPREV 20MG TABLET SR 24HR   3 Non Preferred $55.00$137.50S Q:34
/34Days
ALTOPREV 40MG TABLET SR 24HR   3 Non Preferred $55.00$137.50S Q:34
/34Days
ALTOPREV 60MG TABLET SR 24HR   3 Non Preferred $55.00$137.50S Q:34
/34Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALUPENT 650MCG INHALER COMP   2 Preferred Brand $30.00$75.00None
ALVESCO 160MCG/ACT AERS   3 Non Preferred $55.00$137.50None
ALVESCO 80MCG/ACT AERS   3 Non Preferred $55.00$137.50None
AMANTADINE 100MG CAPSULE   1 Generic $7.00$17.50None
AMANTADINE 100MG TABLET   1 Generic $7.00$17.50None
AMARYL 1MG TABLET   3 Non Preferred $55.00$137.50None
AMARYL 2MG TABLET   3 Non Preferred $55.00$137.50None
AMARYL 4MG TABLET   3 Non Preferred $55.00$137.50None
AMBIEN 10MG TABLET   3 Non Preferred $55.00$137.50Q:34
/34Days
AMBIEN 5MG TABLET   3 Non Preferred $55.00$137.50Q:34
/34Days
AMBIEN CR 12.5MG TABLET   3 Non Preferred $55.00$137.50S Q:34
/34Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMBIEN CR 6.25MG TABLET   3 Non Preferred $55.00$137.50S Q:34
/34Days
AMBISOME 50MG VIAL   5 Non Self Administered Injectable 25%N/AP
AMCINONIDE 0.1% CREAM   1 Generic $7.00$17.50None
AMCINONIDE 0.1% LOTION   1 Generic $7.00$17.50None
AMCINONIDE 0.1% OINTMENT 60GM TUBE   1 Generic $7.00$17.50None
AMERGE 1MG TABLET   3 Non Preferred $55.00$137.50Q:9
/1Days
AMERGE 2.5MG TABLET   3 Non Preferred $55.00$137.50Q:9
/1Days
AMEVIVE ADMISTRATION PACK FOR INTRAMUSCULAR ADMINISTRATION KIT 15MG 1 X 4 PKGCOM   4 Specialty 25%N/ANone
AMIFOSTINE FOR INJECTION 500MG/VIAL   4 Specialty 25%N/ANone
AMIKACIN 250MG/ML VIAL   5 Non Self Administered Injectable 25%N/ANone
AMIKACIN 50MG/ML VIAL   5 Non Self Administered 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   5 Non Self Administered Injectable 25%N/ANone
AMIKIN POWDER FOR INJECTION   5 Non Self Administered Injectable 25%N/ANone
AMILORIDE HCL 5MG TABLET   1 Generic $7.00$17.50None
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET   1 Generic $7.00$17.50None
AMINOPHYLLINE 100MG TABLET (100 CT)   1 Generic $7.00$17.50None
AMINOPHYLLINE 200MG TABLET (1000 CT)   1 Generic $7.00$17.50None
AMINOPHYLLINE INJECTION 250MG 10ML X 25 VIALSD   5 Non Self Administered Injectable 25%N/ANone
AMINOSYN 10% IV SOLUTION   5 Non Self Administered Injectable 25%N/AP
AMINOSYN 3.5% IV SOLUTION   5 Non Self Administered Injectable 25%N/AP
AMINOSYN 5% IV SOLUTION   5 Non Self Administered Injectable 25%N/AP
AMINOSYN 7% IV SOLUTION   5 Non Self Administered Injectable 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN 7%-ELECTROLYTE SOL   5 Non Self Administered Injectable 25%N/AP
AMINOSYN 8.5% IV SOLUTION   5 Non Self Administered Injectable 25%N/AP
AMINOSYN II 10% IV SOLUTION   5 Non Self Administered Injectable 25%N/AP
AMINOSYN II 15% IV SOLUTION   5 Non Self Administered Injectable 25%N/AP
AMINOSYN II 3.5% IN D25W IV   5 Non Self Administered Injectable 25%N/AP
AMINOSYN II 3.5% IN D5W IV   5 Non Self Administered Injectable 25%N/AP
AMINOSYN II 3.5% M/D5W IV   5 Non Self Administered Injectable 25%N/AP
AMINOSYN II 3.5% W/ELEC DEX   5 Non Self Administered Injectable 25%N/AP
AMINOSYN II 4.25% IN D10W   5 Non Self Administered Injectable 25%N/AP
AMINOSYN II 4.25% IN D20W   5 Non Self Administered Injectable 25%N/AP
AMINOSYN II 4.25% M/D10W IV   5 Non Self Administered 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% W/ELEC DW   5 Non Self Administered Injectable 25%N/AP
AMINOSYN II 4.25%-D25W IV   5 Non Self Administered Injectable 25%N/AP
AMINOSYN II 5% IN D25W IV   5 Non Self Administered Injectable 25%N/AP
AMINOSYN II 7% IV SOLUTION   5 Non Self Administered Injectable 25%N/AP
AMINOSYN II 8.5% ELECTROLYT   5 Non Self Administered Injectable 25%N/AP
AMINOSYN II 8.5% IV SOLUTION   5 Non Self Administered Injectable 25%N/AP
AMINOSYN M 3.5% IV SOLUTION   5 Non Self Administered Injectable 25%N/AP
AMINOSYN PF INJECTION   5 Non Self Administered Injectable 25%N/AP
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5%   5 Non Self Administered Injectable 25%N/AP
AMINOSYN-HBC 7% IV SOLUTION   5 Non Self Administered Injectable 25%N/AP
AMINOSYN-HF 8% IV SOLUTION   5 Non Self Administered Injectable 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN-PF 7% IV SOLUTION   5 Non Self Administered Injectable 25%N/AP
AMIODARONE HCL 200MG TABLET (60 CT)   1 Generic $7.00$17.50None
AMIODARONE HCL 400MG TABLET   1 Generic $7.00$17.50None
AMIODARONE HCL INJECTION   5 Non Self Administered Injectable 25%N/ANone
AMITIZA 24 MCG CAPSULES   3 Non Preferred $55.00$137.50P
AMITIZA 8MCG CAPSULE   3 Non Preferred $55.00$137.50P
AMITRIP/CDP 25-10 TABLET   3 Non Preferred $55.00$137.50None
AMITRIP/PERPHEN 10-2 TABLET   3 Non Preferred $55.00$137.50None
AMITRIP/PERPHEN 10-4 TABLET   3 Non Preferred $55.00$137.50None
AMITRIP/PERPHEN 25-2 TABLET   3 Non Preferred $55.00$137.50None
AMITRIP/PERPHEN 25-4 TABLET   3 Non Preferred $55.00$137.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITRIP/PERPHEN 50-4 TABLET   3 Non Preferred $55.00$137.50None
AMITRIPTYLINE HCL 100MG TABLET   3 Non Preferred $55.00$137.50None
AMITRIPTYLINE HCL 10MG TABLET   3 Non Preferred $55.00$137.50None
AMITRIPTYLINE HCL 150MG TABLET (100 CT)   3 Non Preferred $55.00$137.50None
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)   3 Non Preferred $55.00$137.50None
AMITRIPTYLINE HCL 50MG TABLET   3 Non Preferred $55.00$137.50None
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)   3 Non Preferred $55.00$137.50None
AMLODIPINE BESYLATE 10MG TABLET (90 CT)   1 Generic $7.00$17.50None
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)   1 Generic $7.00$17.50None
AMLODIPINE BESYLATE 5MG TABLET (90 CT)   1 Generic $7.00$17.50None
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE   1 Generic $7.00$17.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE   1 Generic $7.00$17.50None
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE   1 Generic $7.00$17.50None
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE   1 Generic $7.00$17.50None
AMMONIUM CHLORIDE 5 MEQ/ML   5 Non Self Administered Injectable 25%N/ANone
AMMONIUM LACTATE 12% LOTION   1 Generic $7.00$17.50None
AMMONIUM LACTATE 12% LOTION   1 Generic $7.00$17.50None
AMNESTEEM 10MG CAPSULE   1 Generic $7.00$17.50None
AMNESTEEM 20MG CAPSULE   1 Generic $7.00$17.50None
AMNESTEEM 40MG CAPSULE   1 Generic $7.00$17.50None
AMOCLAN 200-28.5/5 SUSPENSION RECONSTITUTED ORAL   1 Generic $7.00$17.50None
AMOCLAN 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   1 Generic $7.00$17.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOX TR-K CLV 200-28.5 CHEW   1 Generic $7.00$17.50None
AMOX TR-K CLV 200-28.5/5 SU   1 Generic $7.00$17.50None
AMOX TR-K CLV 400-57 CHW TABLET   1 Generic $7.00$17.50None
AMOX TR-K CLV 400-57/5 SUSP   1 Generic $7.00$17.50None
AMOX TR-K CLV 500-125MG TABLET   1 Generic $7.00$17.50None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL   1 Generic $7.00$17.50None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE   1 Generic $7.00$17.50None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET   1 Generic $7.00$17.50None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE   1 Generic $7.00$17.50None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   1 Generic $7.00$17.50None
AMOX TR-POTASSIUM CLAVULANATE 500-125MG TABLET   1 Generic $7.00$17.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXAPINE 100MG TABLET   1 Generic $7.00$17.50None
AMOXAPINE 150MG TABLET   1 Generic $7.00$17.50None
AMOXAPINE 25MG TABLET   1 Generic $7.00$17.50None
AMOXAPINE 50MG TABLET   1 Generic $7.00$17.50None
AMOXICIILIN CLAVULNATE POTASSIUM FOR ORAL SUSPENSION   1 Generic $7.00$17.50None
AMOXICILLIN 125MG TABLET CHEW   1 Generic $7.00$17.50None
AMOXICILLIN 200MG TABLET CHEW   1 Generic $7.00$17.50None
AMOXICILLIN 250MG CAPSULE   1 Generic $7.00$17.50None
AMOXICILLIN 400MG TABLET CHEW   1 Generic $7.00$17.50None
AMOXICILLIN 500MG CAPSULE   1 Generic $7.00$17.50None
AMOXICILLIN 500MG TABLET (100 CT)   1 Generic $7.00$17.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN 875MG TABLET   1 Generic $7.00$17.50None
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT   1 Generic $7.00$17.50None
AMOXICILLIN CLAVULANATE POTASSIUM TABLET 875-125MG 1 BLPK   1 Generic $7.00$17.50None
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT   1 Generic $7.00$17.50None
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL   1 Generic $7.00$17.50None
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   1 Generic $7.00$17.50None
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL   1 Generic $7.00$17.50None
AMOXICILLIN TABLET USP CHEWABLE 250MG (250 CT)   1 Generic $7.00$17.50None
AMOXIL 250MG/5ML SUSPENSION   3 Non Preferred $55.00$137.50None
AMOXIL 400MG/5ML SUSPENSION   3 Non Preferred $55.00$137.50None
AMOXIL 500MG CAPSULE   3 Non Preferred $55.00$137.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXIL 50MG/ML PED DROPS   2 Preferred Brand $30.00$75.00None
AMPHET ASP/ AMPHET/ D-AMPHET 5MG TABLET   1 Generic $7.00$17.50None
AMPHETAMINE SALT COMBO 12.5MG TABLET   1 Generic $7.00$17.50None
AMPHETAMINE SALT COMBO 15MG TABLET   1 Generic $7.00$17.50None
AMPHETAMINE SALT COMBO 7.5MG TABLET   1 Generic $7.00$17.50None
AMPHETAMINE SALTS 30MG TABLET   1 Generic $7.00$17.50None
AMPHOTEC 100MG VIAL   5 Non Self Administered Injectable 25%N/AP
AMPHOTEC INJ 50MG   5 Non Self Administered Injectable 25%N/AP
AMPHOTERICIN B FOR INJECTION 50 MG   5 Non Self Administered Injectable 25%N/AP
AMPICILLIN AND SULBACTAM FOR INJECTION 1-0.5 10 VIAL VIAL   5 Non Self Administered Injectable 25%N/ANone
AMPICILLIN AND SULBACTAM FOR INJECTION 10-5 1 VIAL   5 Non Self Administered 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 2-1 10 VIAL   5 Non Self Administered Injectable 25%N/ANone
AMPICILLIN FOR INJECTION   5 Non Self Administered Injectable 25%N/ANone
AMPICILLIN FOR INJECTION 1GM VIAL   5 Non Self Administered Injectable 25%N/ANone
AMPICILLIN FOR INJECTION 2GM/ML 10 VIAL   5 Non Self Administered Injectable 25%N/ANone
AMPICILLIN FOR INJECTION 500MG VIAL   5 Non Self Administered Injectable 25%N/ANone
AMPICILLIN FOR INJECTION POWDER   5 Non Self Administered Injectable 25%N/ANone
AMPICILLIN FOR INJECTION USP 125MG/ML 1 VIAL   5 Non Self Administered Injectable 25%N/ANone
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT   1 Generic $7.00$17.50None
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT   1 Generic $7.00$17.50None
AMPICILLIN POWDER FOR INJECTION 1 GM/ML   5 Non Self Administered Injectable 25%N/ANone
AMPICILLIN SODIUM STERILE 2 GM/VIAL   5 Non Self Administered Injectable 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPICILLIN TR 250MG CAPSULE   1 Generic $7.00$17.50None
AMPICILLIN TR 500MG CAPSULE   1 Generic $7.00$17.50None
AMRIX 15MG CAPSULE SR 24 HR   3 Non Preferred $55.00$137.50Q:34
/180Days
AMRIX 30MG CAPSULE SR 24 HR   3 Non Preferred $55.00$137.50Q:34
/180Days
ANADROL-50 50MG TABLET (100 CT)   3 Non Preferred $55.00$137.50None
ANAFRANIL 25MG CAPSULE   3 Non Preferred $55.00$137.50None
ANAFRANIL 50MG CAPSULE   3 Non Preferred $55.00$137.50None
ANAFRANIL 75MG CAPSULE   3 Non Preferred $55.00$137.50None
ANAGRELIDE HCL 0.5MG CAPSULE   4 Specialty 25%N/ANone
ANAGRELIDE HCL 1MG CAPSULE   4 Specialty 25%N/ANone
ANAPROX 275MG TABLET   3 Non Preferred $55.00$137.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANAPROX DS 550MG TABLET   3 Non Preferred $55.00$137.50None
ANCOBON 250MG CAPSULE   2 Preferred Brand $30.00$75.00None
ANCOBON 500MG CAPSULE   2 Preferred Brand $30.00$75.00None
ANDRODERM 2.5MG/24HR PATCH   2 Preferred Brand $30.00$75.00None
ANDRODERM 5MG/24HR PATCH   2 Preferred Brand $30.00$75.00None
ANDROGEL 1%(25MG) GEL PACKET   3 Non Preferred $55.00$137.50None
ANDROGEL 1.25G (1%) GEL IN METERED-DOSE PUMP   3 Non Preferred $55.00$137.50None
ANDROGEL 1%(50MG) GEL PACKET   3 Non Preferred $55.00$137.50None
ANDROID 10MG CAPSULE   3 Non Preferred $55.00$137.50None
ANGELIQ 1-0.5MG TABLET   3 Non Preferred $55.00$137.50None
ANTABUSE 250MG TABLET   2 Preferred Brand $30.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANTABUSE 500MG TABLET   2 Preferred Brand $30.00$75.00None
ANTARA 130MG CAPSULE   3 Non Preferred $55.00$137.50Q:34
/34Days
ANTARA 43MG CAPSULE   3 Non Preferred $55.00$137.50Q:34
/34Days
ANTIVERT 12.5MG TABLET   3 Non Preferred $55.00$137.50None
ANTIVERT 25MG TABLET   3 Non Preferred $55.00$137.50None
ANTIVERT 50MG TABLET   2 Preferred Brand $30.00$75.00None
ANTIZOL INJECTION 1GM 4 X 1.5ML VIAL CRTN   5 Non Self Administered Injectable 25%N/ANone
ANUSOL-HC 2.5% CREAM   1 Generic $7.00$17.50None
ANZEMET 100MG TABLET   3 Non Preferred $55.00$137.50P
ANZEMET 20MG/ML VIAL   5 Non Self Administered Injectable 25%N/ANone
ANZEMET 50MG TABLET   3 Non Preferred $55.00$137.50P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
APHTHASOL 5% PASTE   3 Non Preferred $55.00$137.50None
APIDRA 100UNITS/ML VIAL   2 Preferred Brand $30.00$75.00None
APLENZIN TABLETS EXTENDED RELEASE 348 MG   3 Non Preferred $55.00$137.50S
APLENZIN TABLETS EXTENDED RELEASE 522 MG   3 Non Preferred $55.00$137.50S
APOKYN FOR INJECTION 30MG 5 CTG   2 Preferred Brand $30.00$75.00None
APRI 0.15-0.03 TABLET   1 Generic $7.00$17.50None
APRISO CP24   3 Non Preferred $55.00$137.50None
APTIVUS 250MG CAPSULE   4 Specialty 25%N/ANone
ARALAST 1000MG VIAL   5 Non Self Administered Injectable 25%N/ANone
ARALAST 500MG VIAL   5 Non Self Administered Injectable 25%N/ANone
ARALEN PHOSPHATE 500MG TABLET   3 Non Preferred $55.00$137.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANELLE 7-9-5 TABLET   1 Generic $7.00$17.50None
ARANESP 100MCG/ML VIAL   4 Specialty 25%N/AP
ARANESP 200MCG/0.4ML SYRINGE   4 Specialty 25%N/AP
ARANESP 200MCG/ML VIAL   4 Specialty 25%N/AP
ARANESP 25MCG/ML VIAL   3 Non Preferred $55.00$137.50P Q:12
/28Days
ARANESP 300MCG/ML VIAL   4 Specialty 25%N/AP
ARANESP 500MCG/1ML SYRINGE   4 Specialty 25%N/AP
ARANESP 60MCG/ML VIAL   4 Specialty 25%N/AP
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR   4 Specialty 25%N/AP
ARANESP PREFILLED SYRINGE SINGLE USE 25MCG/0.42ML SYR   3 Non Preferred $55.00$137.50P Q:12
/28Days
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR   4 Specialty 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP SINGLE USE PREFILLED AUTOINJECTOR SOLUTION 100MCG/.5ML   4 Specialty 25%N/AP
ARANESP SINGLE USE PREFILLED SURECLICK AUTOINJECTOR SOLUTION 500MCG/ML   4 Specialty 25%N/AP
ARANESP SINGLE USE PREFILLED SURECLIK AUTOINJECTOR 60MCG/.3ML   4 Specialty 25%N/AP
ARANESP SINGLE USE VIAL 150MCG 4 X 150MCG/ 0.75ML VIALSD   4 Specialty 25%N/AP
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD   4 Specialty 25%N/AP
ARAVA 10MG TABLET   3 Non Preferred $55.00$137.50None
ARAVA 20MG TABLET   3 Non Preferred $55.00$137.50None
ARCALYST INJECTION 220MG/VIAL   4 Specialty 25%N/ANone
AREDIA 30MG VIAL   5 Non Self Administered Injectable 25%N/ANone
AREDIA 90MG VIAL   5 Non Self Administered Injectable 25%N/ANone
ARICEPT 10MG TABLET   2 Preferred Brand $30.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARICEPT 5MG TABLET   2 Preferred Brand $30.00$75.00None
ARICEPT ODT 10MG TABLET   2 Preferred Brand $30.00$75.00None
ARICEPT ODT 5MG TABLET   2 Preferred Brand $30.00$75.00None
ARIMIDEX 1MG TABLET   2 Preferred Brand $30.00$75.00None
ARIXTRA 10MG SYRINGE   4 Specialty 25%N/ANone
ARIXTRA 2.5MG SYRINGE   4 Specialty 25%N/ANone
ARIXTRA 5MG SYRINGE   4 Specialty 25%N/ANone
ARIXTRA 7.5MG SYRINGE   4 Specialty 25%N/ANone
AROMASIN 25MG TABLET   2 Preferred Brand $30.00$75.00None
ARRANON 250MG VIAL   5 Non Self Administered Injectable 25%N/ANone
ARTHROTEC 50 50MG TABLET -200MCG (60 CT)   3 Non Preferred $55.00$137.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARTHROTEC 75 TABLET EC   3 Non Preferred $55.00$137.50None
ASACOL 400MG TABLET EC   2 Preferred Brand $30.00$75.00None
ASCOMP W/CODEINE 30-50-325 CAPSULE   3 Non Preferred $55.00$137.50None
ASMANEX 220MCG(14) AEROSOL POWDER BREATH ACTIVATED   2 Preferred Brand $30.00$75.00None
ASMANEX TWISTHALER 220MCG #120   2 Preferred Brand $30.00$75.00None
ASMANEX TWISTHALER 220MCG #30   2 Preferred Brand $30.00$75.00None
ASMANEX TWISTHALER 220MCG #60   2 Preferred Brand $30.00$75.00None
ASTELIN 137MCG AEROSOL SPRAY W/PUMP   2 Preferred Brand $30.00$75.00None
ASTEPRO NASAL SPRAY 137 MCG/SPRY   3 Non Preferred $55.00$137.50None
ASTRAMORPH-PF 0.5MG/ML VIAL   5 Non Self Administered Injectable 25%N/ANone
ASTRAMORPH-PF 1MG/ML VIAL   5 Non Self Administered Injectable 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATACAND 16MG TABLET   3 Non Preferred $55.00$137.50S
ATACAND 32MG TABLET   3 Non Preferred $55.00$137.50S
ATACAND 4MG TABLET   3 Non Preferred $55.00$137.50S
ATACAND 8MG TABLET   3 Non Preferred $55.00$137.50S
ATACAND HCT 16/12.5MG TABLET   3 Non Preferred $55.00$137.50S
ATACAND HCT 32/12.5MG TABLET   3 Non Preferred $55.00$137.50S
ATACAND HCT TABLETS 32;25MG;MG 90 TABLETS BOT   3 Non Preferred $55.00$137.50S
ATENOLOL 25MG TABLET (100 CT)   1 Generic $7.00$17.50None
ATENOLOL TABLET 100MG (100 CT)   1 Generic $7.00$17.50None
ATENOLOL TABLET USP 50MG (100 CT)   1 Generic $7.00$17.50None
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT)   1 Generic $7.00$17.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   1 Generic $7.00$17.50None
ATGAM 50MG/ML AMPUL   4 Specialty 25%N/ANone
ATRALIN 0.05% GEL   2 Preferred Brand $30.00$75.00None
ATRIPLA TABLET 600MG/200MG   4 Specialty 25%N/ANone
ATROPINE 0.05MG/ML SYRINGE   5 Non Self Administered Injectable 25%N/ANone
ATROPINE 0.1MG/ML SYRINGE   5 Non Self Administered Injectable 25%N/ANone
ATROVENT HFA AER 17MCG   2 Preferred Brand $30.00$75.00None
ATROVENT NASAL SPRAY 0.03%   3 Non Preferred $55.00$137.50None
ATROVENT NASAL SPRAY 0.06%   3 Non Preferred $55.00$137.50None
ATTENUVAX VACCINE W/DILUENT 1 DOSE/0.5ML   5 Non Self Administered Injectable 25%N/AP
AUGMENTIN 125 SUSPENSION   2 Preferred Brand $30.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AUGMENTIN 200MG/5ML SUSP   3 Non Preferred $55.00$137.50None
AUGMENTIN 250 SUSPENSION   2 Preferred Brand $30.00$75.00None
AUGMENTIN 250 TABLET   3 Non Preferred $55.00$137.50None
AUGMENTIN 250 TABLET CHEW   2 Preferred Brand $30.00$75.00None
AUGMENTIN 400MG/5ML SUSP   3 Non Preferred $55.00$137.50None
AUGMENTIN 500MG TABLET   3 Non Preferred $55.00$137.50None
AUGMENTIN 875MG TABLET   3 Non Preferred $55.00$137.50None
AUGMENTIN ES-600 SUSPENSION   3 Non Preferred $55.00$137.50None
AUGMENTIN XR 1000-62.5 TABLET   3 Non Preferred $55.00$137.50None
AVALIDE 150-12.5MG TABLET   3 Non Preferred $55.00$137.50S
AVALIDE 300-12.5MG TABLET   3 Non Preferred $55.00$137.50S
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVALIDE 300-25MG TABLET   3 Non Preferred $55.00$137.50S
AVANDAMET 2MG/1000MG TABLET   3 Non Preferred $55.00$137.50P
AVANDAMET 2MG/500MG TABLET   3 Non Preferred $55.00$137.50P
AVANDAMET 4MG/500MG TABLET   3 Non Preferred $55.00$137.50P
AVANDAMET TABLET 4-1000MG   3 Non Preferred $55.00$137.50P
AVANDARYL 4MG/1MG TABLET   3 Non Preferred $55.00$137.50P
AVANDARYL 4MG/2MG TABLET   3 Non Preferred $55.00$137.50P
AVANDARYL 4MG/4MG TABLET   3 Non Preferred $55.00$137.50P
AVANDARYL 8MG-2MG TABLET   3 Non Preferred $55.00$137.50P
AVANDARYL 8MG-4MG TABLET   3 Non Preferred $55.00$137.50P
AVANDIA 2MG TABLET   2 Preferred Brand $30.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVANDIA 4MG TABLET (90 CT)   2 Preferred Brand $30.00$75.00None
AVANDIA 8MG TABLET (90 CT)   2 Preferred Brand $30.00$75.00None
AVAPRO 150MG TABLET   3 Non Preferred $55.00$137.50S
AVAPRO 300MG TABLET   3 Non Preferred $55.00$137.50S
AVAPRO 75MG TABLET (30 CT)   3 Non Preferred $55.00$137.50S
AVASTIN 100MG/4ML VIAL   4 Specialty 25%N/ANone
AVASTIN 400MG/16ML VIAL   4 Specialty 25%N/ANone
AVELOX 400MG TABLET   2 Preferred Brand $30.00$75.00None
AVELOX ABC PACK 400MG TABLET   2 Preferred Brand $30.00$75.00None
AVELOX IV 400MG/250ML   5 Non Self Administered Injectable 25%N/ANone
AVIANE 0.1-0.02 TABLET   1 Generic $7.00$17.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVINZA 120MG CAPSULE MULTIPHASIC RELEASE 24 HR   3 Non Preferred $55.00$137.50Q:34
/34Days
AVINZA 30MG CAPSULE MULTIPHASIC RELEASE 24 HR   3 Non Preferred $55.00$137.50Q:34
/34Days
AVINZA 60MG CAPSULE MULTIPHASIC RELEASE 24 HR   3 Non Preferred $55.00$137.50Q:34
/34Days
AVINZA 90MG CAPSULE MULTIPHASIC RELEASE 24 HR   3 Non Preferred $55.00$137.50Q:34
/34Days
AVINZA CAPSULES EXTENDED RELEASE 45MG 100 BOTPL   3 Non Preferred $55.00$137.50Q:34
/34Days
AVINZA CAPSULES EXTENDED RELEASE 75MG 100 BOTPL   3 Non Preferred $55.00$137.50Q:34
/34Days
AVITA 0.025% CREAM   1 Generic $7.00$17.50None
AVODART 0.5MG SOFTGEL   3 Non Preferred $55.00$137.50None
AVONEX ADMIN PACK 30MCG SYR   4 Specialty 25%N/ANone
AVONEX ADMIN PACK 30MCG VL   4 Specialty 25%N/ANone
AXERT 12.5MG TABLET   3 Non Preferred $55.00$137.50Q:6
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AXERT 6.25MG TABLET   3 Non Preferred $55.00$137.50Q:6
/1Days
AXID 150MG PULVULE   3 Non Preferred $55.00$137.50None
AXID 15MG/ML ORAL SOLUTION   2 Preferred Brand $30.00$75.00None
AXID NIZATIDINE CAPSULES 300MG (30 CT)   3 Non Preferred $55.00$137.50None
AYGESTIN 5MG TABLET   3 Non Preferred $55.00$137.50None
AZACTAM 1GM VIAL   5 Non Self Administered Injectable 25%N/ANone
AZACTAM 2GM VIAL   5 Non Self Administered Injectable 25%N/ANone
AZACTAM INJECTION 1GM 50ML BAG   5 Non Self Administered Injectable 25%N/ANone
AZACTAM/ISO-OSMOT 2GM/50ML   5 Non Self Administered Injectable 25%N/ANone
AZASAN 100MG TABLET   3 Non Preferred $55.00$137.50P
AZASAN 75MG TABLET   3 Non Preferred $55.00$137.50P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZASITE 1% DROPS   3 Non Preferred $55.00$137.50None
AZATHIOPRINE 50MG TABLET   1 Generic $7.00$17.50P
AZATHIOPRINE SOD 100MG VIAL   5 Non Self Administered Injectable 25%N/AP
AZELEX 20% CREAM 30GM TUBE   3 Non Preferred $55.00$137.50None
AZILECT 0.5MG TABLET   3 Non Preferred $55.00$137.50None
AZILECT 1MG TABLET   3 Non Preferred $55.00$137.50None
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Generic $7.00$17.50None
AZITHROMYCIN 1G PACKET   1 Generic $7.00$17.50None
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Generic $7.00$17.50None
AZITHROMYCIN 250MG TABLET (30 CT)   1 Generic $7.00$17.50None
AZITHROMYCIN 500MG TABLET (30 CT)   1 Generic $7.00$17.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZITHROMYCIN FOR INJECTION 500MG 10 VIALSD   5 Non Self Administered Injectable 25%N/ANone
AZITHROMYCIN TABLET 600MG (30 CT)   1 Generic $7.00$17.50None
AZMACORT AER 75MCG   2 Preferred Brand $30.00$75.00None
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT   2 Preferred Brand $30.00$75.00None
AZOR 10MG-20MG TABLET   3 Non Preferred $55.00$137.50Q:34
/34Days
AZOR 10MG-40MG TABLET (30 CT)   3 Non Preferred $55.00$137.50Q:34
/34Days
AZOR 5MG-20MG TABLET (30 CT)   3 Non Preferred $55.00$137.50Q:34
/34Days
AZOR 5MG-40MG TABLET   3 Non Preferred $55.00$137.50Q:34
/34Days
AZULFIDINE 500MG TABLET   3 Non Preferred $55.00$137.50None
AZULFIDINE EN TABLET S 500MG TABLET 6 X (300 CT)PL   3 Non Preferred $55.00$137.50None

Chart Legend:

Below are a few notes to help you understand the above 2009 Medicare Part D Prescription Blue Option A 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.