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MedicareBlue Rx Option 1 (S5743-001-0)
Tier 1 (1877)
Tier 2 (398)
Tier 3 (462)
Tier 4 (324)

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2009 Medicare Part D Plan Formulary Information
MedicareBlue Rx Option 1 (S5743-001-0)
Benefit Details  
The MedicareBlue Rx Option 1 (S5743-001-0)
Formulary Drugs Starting with the Letter P
in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY
Drugs Starting with Letter P

Drug Name		 Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order
PACERONE 200MG TABLET   1 Level 1: Covered Generic 10%10%None
PACLITAXEL INJECTION 30MG/5ML 50ML VIALMD   1 Level 1: Covered Generic 10%10%None
PACLITAXEL INJECTION 30MG/5ML VILMD CRTN   1 Level 1: Covered Generic 10%10%None
PACLITAXEL INJECTION SOLUTION 6MG 50ML VIALMD   1 Level 1: Covered Generic 10%10%None
PACLITAXEL INJECTION USP 6MG/ML 300MG/50ML VIALMD   1 Level 1: Covered Generic 10%10%None
PALGIC 4MG TABLET   1 Level 1: Covered Generic 10%10%None
PAMIDRONATE 60MG/10ML VIAL   1 Level 1: Covered Generic 10%10%None
PAMIDRONATE DISODIUM FOR INJECTION   1 Level 1: Covered Generic 10%10%None
PAMIDRONATE DISODIUM FOR INJECTION   1 Level 1: Covered Generic 10%10%None
PAMIDRONATE DISODIUM INJECTION 3MG 10ML VIALSD   1 Level 1: Covered Generic 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
PAMIDRONATE DISODIUM INJECTION 9MG 10ML VIALSD   1 Level 1: Covered Generic 10%10%None
PANRETIN 0.1% GEL 60GM TUBE   2 Level 2: Covered Preferred Brand 22%22%None
PAROMOMYCIN 250MG CAPSULE   1 Level 1: Covered Generic 10%10%None
PAROXETINE 40MG TABLET (500 CT)   1 Level 1: Covered Generic 10%10%None
PAROXETINE FILM COATED 20MG TABLET (100 CT)   1 Level 1: Covered Generic 10%10%None
PAROXETINE HCL 10MG TABLET   1 Level 1: Covered Generic 10%10%None
PAROXETINE HCL 10MG/5ML SUSPENSION ORAL   1 Level 1: Covered Generic 10%10%None
PAROXETINE HCL 30MG TABLET (30 CT)   1 Level 1: Covered Generic 10%10%None
PAROXETINE HCL TABLET 24 12.5MG   1 Level 1: Covered Generic 10%10%None
PAROXETINE HCL TABLET 24 25MG   1 Level 1: Covered Generic 10%10%None
PATANOL 0.1% EYE DROPS   2 Level 2: Covered Preferred Brand 22%22%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
PEDI-DRI TOPICAL POWDER   1 Level 1: Covered Generic 10%10%None
PEDIARIX SOLUTION INJECTION 25-25-10 10 X .5ML VIAL   3 Level 3: Covered Brand 50%50%None
PEDVAXHIB VACCINE VIAL   3 Level 3: Covered Brand 50%50%None
PEG 3350/ELECTROLYTE 240-22.72G SOLUTION RECONSTITUTED ORAL   1 Level 1: Covered Generic 10%10%None
PEG-INTRON 100MCG KIT   4 Covered Specialty 25%25%P
PEG-INTRON 160MCG KIT   4 Covered Specialty 25%25%P
PEG-INTRON 240MCG KIT   4 Covered Specialty 25%25%P
PEG-INTRON 300MCG KIT   4 Covered Specialty 25%25%P
PEG-INTRON REDIPEN 120MCG   4 Covered Specialty 25%25%P
PEG-INTRON REDIPEN 150MCG   4 Covered Specialty 25%25%P
PEG-INTRON REDIPEN 50MCG   4 Covered Specialty 25%25%P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
PEG-INTRON REDIPEN 50MCG 4PK   4 Covered Specialty 25%25%P
PEG-INTRON REDIPEN 80MCG   4 Covered Specialty 25%25%P
PEG-INTRON REDIPEN 80MCG 4PK   4 Covered Specialty 25%25%P
PEG-INTRON REDIPEN PAK 4   4 Covered Specialty 25%25%P
PEGANONE 250MG TABLET   3 Level 3: Covered Brand 50%50%None
PEGASYS 180MCG/0.5ML CONV.PK   4 Covered Specialty 25%25%P
PEGINTRON REDIPEN 150MCG 4PK   4 Covered Specialty 25%25%P
PENICILLIN G POTASSIUM 1MMUNITS/50ML ISO-OSM   3 Level 3: Covered Brand 50%50%None
PENICILLIN G POTASSIUM 2MMUNITS/50ML ISO-OSM   3 Level 3: Covered Brand 50%50%None
PENICILLIN G POTASSIUM 3MMUNITS/50ML ISO-OSM   3 Level 3: Covered Brand 50%50%None
PENICILLIN G POTASSIUM FOR INJECTION   1 Level 1: Covered Generic 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
PENICILLIN G POTASSIUM FOR INJECTION   1 Level 1: Covered Generic 10%10%None
PENICILLIN G SODIUM FOR INJECTION 5000000UNT 1 VIAL   3 Level 3: Covered Brand 50%50%None
PENICILLIN V POTASSIUM 250MG TABLET (1000 CT)   1 Level 1: Covered Generic 10%10%None
PENICILLIN V POTASSIUM 250MG/5ML LIQUID   1 Level 1: Covered Generic 10%10%None
PENICILLIN V POTASSIUM 500MG TABLET   1 Level 1: Covered Generic 10%10%None
PENICILLIN V POTASSIUM FOR ORAL SOLUTION CONCENTRATE 125MG 200ML BOT   1 Level 1: Covered Generic 10%10%None
PENTAM 300 INJ 300MG   3 Level 3: Covered Brand 50%50%P
PENTASA 250MG CAPSULE SA   2 Level 2: Covered Preferred Brand 22%22%None
PENTASA 500MG CAPSULE   2 Level 2: Covered Preferred Brand 22%22%None
PENTOPAK 400MG TABLET SA   1 Level 1: Covered Generic 10%10%None
PENTOSTATIN FOR INJECTION 10MG/VIAL   4 Covered Specialty 25%25%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
PENTOXIFYLLINE 400MG TABLET SA   1 Level 1: Covered Generic 10%10%None
PENTOXIL 400MG TABLET SA   1 Level 1: Covered Generic 10%10%None
PERIOGARD 0.12% ORAL RINSE   1 Level 1: Covered Generic 10%10%None
PERMETHRIN 5% CREAM   1 Level 1: Covered Generic 10%10%None
PERPHENAZINE 16MG TABLET (100 CT)   1 Level 1: Covered Generic 10%10%None
PERPHENAZINE 2MG TABLET   1 Level 1: Covered Generic 10%10%None
PERPHENAZINE 4MG TABLET (500 CT)   1 Level 1: Covered Generic 10%10%None
PERPHENAZINE 8MG TABLET (500 CT)   1 Level 1: Covered Generic 10%10%None
PFIZERPEN 5MMU VIAL   1 Level 1: Covered Generic 10%10%None
PHENADOZ 12.5MG SUPPOSITORY   1 Level 1: Covered Generic 10%10%None
PHENADOZ 25MG SUPPOSITORY   1 Level 1: Covered Generic 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
PHENYTEK 200MG CAPSULE   3 Level 3: Covered Brand 50%50%None
PHENYTEK 300MG CAPSULE   3 Level 3: Covered Brand 50%50%None
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT   1 Level 1: Covered Generic 10%10%None
PHENYTOIN SODIUM EXTENDED CAPSULES 100MG (100 CT)   1 Level 1: Covered Generic 10%10%None
PHOSLO 667MG CAPSULE   3 Level 3: Covered Brand 50%50%None
PHOSPHOLINE IODIDE 0.125%   3 Level 3: Covered Brand 50%50%None
PHOTOFRIN 75MG VIAL   4 Covered Specialty 25%25%None
PHRENILIN W/CAFF/CODEINE CP   1 Level 1: Covered Generic 10%10%None
PILOCARPINE HCL 5MG TABLET (100 CT)   1 Level 1: Covered Generic 10%10%None
PILOCARPINE HCL 7.5MG TABLET   1 Level 1: Covered Generic 10%10%None
PIPERACILLIN 2GM VIAL   3 Level 3: Covered Brand 50%50%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
PIPERACILLIN 3GM VIAL   3 Level 3: Covered Brand 50%50%None
PIPERACILLIN 40GM BULK VIAL   3 Level 3: Covered Brand 50%50%None
PIPERACILLIN 4GM VIAL   3 Level 3: Covered Brand 50%50%None
PIROXICAM 10MG CAPSULE   1 Level 1: Covered Generic 10%10%None
PIROXICAM 20MG CAPSULE (500 CT)   1 Level 1: Covered Generic 10%10%None
PLAVIX 75MG TABLET   2 Level 2: Covered Preferred Brand 22%22%None
PODOFILOX 0.5% TOPICAL TUBEX   1 Level 1: Covered Generic 10%10%None
POLY-DEX 0.1% SUSPENSION DROPS   1 Level 1: Covered Generic 10%10%None
POLY-DEX 3.5-10K-.1 OINTMENT   1 Level 1: Covered Generic 10%10%None
POLYCIN-B 500-10KU/G OINTMENT   1 Level 1: Covered Generic 10%10%None
POLYETH GLYC NF POWDER FOR ORAL SOLUTION 17GM (527 CT)   1 Level 1: Covered Generic 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
POLYMYXIN B SUL-TRIMETHOPRIM 10K U-0.1%   1 Level 1: Covered Generic 10%10%None
POLYMYXIN B SUL-TRIMETHOPRIM 10K U-0.1%   1 Level 1: Covered Generic 10%10%None
PORTIA 0.15-0.03 TABLET   1 Level 1: Covered Generic 10%10%None
POTASSIUM CHLORIDE 0.075%/D5W/SODIUM CHLORIDE 0.2%   1 Level 1: Covered Generic 10%10%None
POTASSIUM CHLORIDE 0.075%/D5W/SODIUM CHLORIDE 0.2%   1 Level 1: Covered Generic 10%10%None
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.3%   1 Level 1: Covered Generic 10%10%None
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.3%   1 Level 1: Covered Generic 10%10%None
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.45%   1 Level 1: Covered Generic 10%10%None
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.45%   1 Level 1: Covered Generic 10%10%None
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.2%   1 Level 1: Covered Generic 10%10%None
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.45% 1000ML BAG   1 Level 1: Covered Generic 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
POTASSIUM CHLORIDE 10MEQ CAPSULE SA   1 Level 1: Covered Generic 10%10%None
POTASSIUM CHLORIDE 10MEQ TABLET SA   1 Level 1: Covered Generic 10%10%None
POTASSIUM CHLORIDE 20MEQ TABLET SR PARTICLES/CRYSTALS   1 Level 1: Covered Generic 10%10%None
POTASSIUM CHLORIDE 40MEQ/NS 1000ML IV SOLUTION   1 Level 1: Covered Generic 10%10%None
POTASSIUM CHLORIDE 8MEQ TABLET SA   1 Level 1: Covered Generic 10%10%None
POTASSIUM CHLORIDE 8MEQ TABLET SA   1 Level 1: Covered Generic 10%10%None
POTASSIUM CHLORIDE IN 5% DEXTROSE AND 0.2% NACL SOLUTION FOR INJECTION USP 0.15% 250ML X 24 CASE   1 Level 1: Covered Generic 10%10%None
POTASSIUM CHLORIDE IN 5% DEXTROSE AND NACL SOLUTION FOR INJECTION 0.075% 1000ML PLASTIC BAGS X 12 CA   1 Level 1: Covered Generic 10%10%None
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION   1 Level 1: Covered Generic 10%10%None
POTASSIUM CHLORIDE IN 5% DEXTROSE INJECTION 40 12 X 1000ML CTR   1 Level 1: Covered Generic 10%10%None
POTASSIUM CHLORIDE IN 5% DEXTROSE INJECTION USP 0.15% 1000ML PLASTIC BAGS X 12 CASE   1 Level 1: Covered Generic 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
POTASSIUM CHLORIDE IN DEXTROSE AND SODIUM CHLORIDE INJECTION 5-30-.225 12 X 1000ML CTR   1 Level 1: Covered Generic 10%10%None
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION 0.15%-0.9% 12 X 1000ML BAG   1 Level 1: Covered Generic 10%10%None
POTASSIUM CHLORIDE TABLET ER USP 750MG (1000 CT)   1 Level 1: Covered Generic 10%10%None
POTASSIUM CHLORIDE TABLET ERD 1500MG (500 CT)   1 Level 1: Covered Generic 10%10%None
POTASSIUM CITRATE 10MEQ TABLET SA   1 Level 1: Covered Generic 10%10%None
POTASSIUM CITRATE 5MEQ TABLET SA   1 Level 1: Covered Generic 10%10%None
PRANDIN 0.5MG TABLET   2 Level 2: Covered Preferred Brand 22%22%None
PRANDIN 1MG TABLET   2 Level 2: Covered Preferred Brand 22%22%None
PRANDIN 2MG TABLET   2 Level 2: Covered Preferred Brand 22%22%None
PRAVASTATIN SODIUM 10MG TABLET (1000 CT)   1 Level 1: Covered Generic 10%10%Q:45
/30Days
PRAVASTATIN SODIUM 20MG TABLET 500 BOT   1 Level 1: Covered Generic 10%10%Q:45
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
PRAVASTATIN SODIUM 40MG TABLET (500 CT)   1 Level 1: Covered Generic 10%10%Q:45
/30Days
PRAVASTATIN SODIUM 80MG TABLET (90 CT)   1 Level 1: Covered Generic 10%10%Q:30
/30Days
PRAZOSIN 5MG CAPSULE   1 Level 1: Covered Generic 10%10%None
PRAZOSIN HCL 1MG CAPSULE   1 Level 1: Covered Generic 10%10%None
PRAZOSIN HCL 2MG CAPSULE   1 Level 1: Covered Generic 10%10%None
PREDNICARBATE 0.1% CREAM   1 Level 1: Covered Generic 10%10%None
PREDNICARBATE 0.1% OINTMENT   1 Level 1: Covered Generic 10%10%None
PREDNISOLONE 15MG/5ML SOLUTION ORAL   1 Level 1: Covered Generic 10%10%P
PREDNISOLONE 5MG TABLET   1 Level 1: Covered Generic 10%10%P
PREDNISOLONE 5MG/5ML SYRUP   1 Level 1: Covered Generic 10%10%P
PREDNISOLONE 5MG/5ML TUBEX   1 Level 1: Covered Generic 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION 1.0% STERILE 10ML BOTDR   1 Level 1: Covered Generic 10%10%None
PREDNISOLONE SOD 1% EYE DROP   1 Level 1: Covered Generic 10%10%None
PREDNISOLONE SODIUM PHOSPHATE 15MG/5ML SOLUTION ORAL   1 Level 1: Covered Generic 10%10%None
PREDNISONE 10MG TABLET (100 CT)   1 Level 1: Covered Generic 10%10%P
PREDNISONE 1MG TABLET   1 Level 1: Covered Generic 10%10%P
PREDNISONE 2.5MG TABLET   1 Level 1: Covered Generic 10%10%P
PREDNISONE 20MG TABLET (1000 CT)   1 Level 1: Covered Generic 10%10%P
PREDNISONE 5MG TABLET (100 CT)   1 Level 1: Covered Generic 10%10%P
PREGNYL INJ 10000UNT   1 Level 1: Covered Generic 10%10%None
PREMARIN 0.3MG (100 CT)   2 Level 2: Covered Preferred Brand 22%22%None
PREMARIN 0.45MG TABLET   2 Level 2: Covered Preferred Brand 22%22%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
PREMARIN 0.625MG (100 CT)   2 Level 2: Covered Preferred Brand 22%22%None
PREMARIN 0.9MG TABLET   2 Level 2: Covered Preferred Brand 22%22%None
PREMARIN 1.25MG (100 CT)   2 Level 2: Covered Preferred Brand 22%22%None
PREMARIN VAGINAL CREAM /APPL   2 Level 2: Covered Preferred Brand 22%22%None
PREMASOL 6% IV SOLUTION   1 Level 1: Covered Generic 10%10%P
PREMPHASE 0.625/5MG TABLET   2 Level 2: Covered Preferred Brand 22%22%None
PREMPRO 0.3MG/1.5MG TABLET   2 Level 2: Covered Preferred Brand 22%22%None
PREMPRO 0.45/1.5MG TABLET   2 Level 2: Covered Preferred Brand 22%22%None
PREMPRO 0.625/2.5MG TABLET DIALPK   2 Level 2: Covered Preferred Brand 22%22%None
PREMPRO 0.625/5MG TABLET   2 Level 2: Covered Preferred Brand 22%22%None
PRENATAL RX 1 TABLET 4000UNT-400UNT (100 CT)   1 Level 1: Covered Generic 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
PREVALITE POW 4GM   1 Level 1: Covered Generic 10%10%None
PREVALITE POW 4GM PK   1 Level 1: Covered Generic 10%10%None
PREVIFEM 0.25-0.035 TABLET   1 Level 1: Covered Generic 10%10%None
PREVPAC PATIENT PACK   2 Level 2: Covered Preferred Brand 22%22%None
PREZISTA 300MG TABLET   3 Level 3: Covered Brand 50%50%None
PREZISTA TABLET   3 Level 3: Covered Brand 50%50%None
PREZISTA TABLET 75MG   3 Level 3: Covered Brand 50%50%None
PREZISTA TABLETS 400MG 60 TABLETS BOT   3 Level 3: Covered Brand 50%50%None
PRIMAQUINE 26.3MG TABLET   3 Level 3: Covered Brand 50%50%None
PRIMAXIN 250MG VIAL ADD-VANTAG   4 Covered Specialty 25%25%None
PRIMAXIN I.M. 500MG VIAL   4 Covered Specialty 25%25%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
PRIMAXIN IV 250MG VIAL   4 Covered Specialty 25%25%None
PRIMAXIN IV INJ 500MG   4 Covered Specialty 25%25%None
PRIMAXIN IV INJ 500MG   4 Covered Specialty 25%25%None
PRIMIDONE 250MG TABLET (100 CT)   1 Level 1: Covered Generic 10%10%None
PRIMIDONE 50MG TABLET (500 CT)   1 Level 1: Covered Generic 10%10%None
PRISTIQ 100MG TABLET SR 24HR   3 Level 3: Covered Brand 50%50%S
PRISTIQ 50MG TABLET SR 24HR   3 Level 3: Covered Brand 50%50%S
PROAIR HFA 90MCG HFA AEROSOL WITH ADAPTER   2 Level 2: Covered Preferred Brand 22%22%Q:36
/30Days
PROBENECID 500MG TABLET   1 Level 1: Covered Generic 10%10%None
PROBENECID/COLCHICINE TABLET S   1 Level 1: Covered Generic 10%10%None
PROCHLORPERAZINE EDISYLATE INJECTION 10MG 10 X 2ML VIALS CRTN   1 Level 1: Covered Generic 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
PROCHLORPERAZINE MALEATE 10MG TABLET (100 CT)   1 Level 1: Covered Generic 10%10%None
PROCHLORPERAZINE MALEATE 25MG SUPPOSITORY RECTAL   1 Level 1: Covered Generic 10%10%None
PROCHLORPERAZINE MALEATE 5MG TABLET (100 CT)   1 Level 1: Covered Generic 10%10%None
PROCRIT 10000U/ML VIAL   4 Covered Specialty 25%25%P
PROCRIT 20000U/ML VIAL MDV   4 Covered Specialty 25%25%P
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL   2 Level 2: Covered Preferred Brand 22%22%P
PROCRIT 3000U/ML VIAL   3 Level 3: Covered Brand 50%50%P
PROCRIT 40000U/ML VIAL PR   4 Covered Specialty 25%25%P
PROCRIT 4000U/ML VIAL 25 X 1ML VIAL   3 Level 3: Covered Brand 50%50%P
PROCTO-PAK 1% CREAM   1 Level 1: Covered Generic 10%10%None
PROCTOCREAM-HC 2.5% CREAM   1 Level 1: Covered Generic 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
PROCTOSOL-HC 2.5% CREAM   1 Level 1: Covered Generic 10%10%None
PROCTOZONE-HC 2.5% CREAM   1 Level 1: Covered Generic 10%10%None
PROGLYCEM 50MG/ML ORAL SUSP   3 Level 3: Covered Brand 50%50%None
PROGRAF 0.5MG CAPSULE   4 Covered Specialty 25%25%P
PROGRAF 1MG CAPSULE   4 Covered Specialty 25%25%P
PROGRAF 5MG CAPSULE   4 Covered Specialty 25%25%P
PROGRAF 5MG/ML AMPULE   3 Level 3: Covered Brand 50%50%P
PROLASTIN 1000MG VIAL   4 Covered Specialty 25%25%None
PROLASTIN 500MG VIAL   4 Covered Specialty 25%25%None
PROLEUKIN 22 MILLION UNITS VL   4 Covered Specialty 25%25%None
PROMETHAZINE HCL 12.5MG SUPPOSITORY RECTAL   1 Level 1: Covered Generic 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
PROMETHAZINE HCL 12.5MG TABLET   1 Level 1: Covered Generic 10%10%None
PROMETHAZINE HCL 25MG SUPPOSITORY RECTAL   1 Level 1: Covered Generic 10%10%None
PROMETHAZINE HCL 25MG TABLET (1000 CT)   1 Level 1: Covered Generic 10%10%None
PROMETHAZINE HCL 50MG SUPPOSITORY RECTAL   1 Level 1: Covered Generic 10%10%None
PROMETHAZINE HCL 50MG TABLET (100 CT)   1 Level 1: Covered Generic 10%10%None
PROMETHAZINE HCL 6.25MG/5ML SYRUP   1 Level 1: Covered Generic 10%10%None
PROMETHAZINE SYRUP PLAIN 6.25MG 16 FL OZ BOT   1 Level 1: Covered Generic 10%10%None
PROMETHAZINE VC PLAIN 6.25-5MG 16 FL OZ BOT   1 Level 1: Covered Generic 10%10%None
PROMETHEGAN 12.5MG SUPPOSITORY RECTAL   1 Level 1: Covered Generic 10%10%None
PROMETHEGAN 25MG SUPP   1 Level 1: Covered Generic 10%10%None
PROMETHEGAN 50MG SUPPOS   1 Level 1: Covered Generic 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
PRONESTYL-SR 500MG TABLET   3 Level 3: Covered Brand 50%50%None
PROPAFENONE HCL 150MG TABLET (100 CT)   1 Level 1: Covered Generic 10%10%None
PROPAFENONE HCL 225MG TABLET   1 Level 1: Covered Generic 10%10%None
PROPAFENONE HCL 300MG TABLET (100 CT)   1 Level 1: Covered Generic 10%10%None
PROPOXY-N/APAP 100-500MG TABLET   1 Level 1: Covered Generic 10%10%None
PROPOXY-N/APAP 100-650 TABLET   1 Level 1: Covered Generic 10%10%None
PROPOXY-N/APAP 50-325 TABLET   1 Level 1: Covered Generic 10%10%None
PROPOXYPHENE HCL AND ACETAMINOPHEN TABLET 650/65MG (500 CT)   1 Level 1: Covered Generic 10%10%None
PROPOXYPHENE HCL CAPSULES 65MG (100 CT)   1 Level 1: Covered Generic 10%10%None
PROPRANOLOL 60MG TABLET   1 Level 1: Covered Generic 10%10%None
PROPRANOLOL 80MG TABLET   1 Level 1: Covered Generic 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
PROPRANOLOL HCL 20MG TABLET (1000 CT)   1 Level 1: Covered Generic 10%10%None
PROPRANOLOL HCL CAPSULES ER 120MG (1000 CT)   1 Level 1: Covered Generic 10%10%None
PROPRANOLOL HCL CAPSULES ER 160MG (1000 CT)   1 Level 1: Covered Generic 10%10%None
PROPRANOLOL HCL CAPSULES ER 60MG (100 CT)   1 Level 1: Covered Generic 10%10%None
PROPRANOLOL HCL CAPSULES ER 80MG (1000 CT)   1 Level 1: Covered Generic 10%10%None
PROPRANOLOL HCL TABLET USP 10MG (1000 CT)   1 Level 1: Covered Generic 10%10%None
PROPRANOLOL HCL TABLET USP 40MG (1000 CT)   1 Level 1: Covered Generic 10%10%None
PROPYLTHIOURACIL 50MG TABLET   1 Level 1: Covered Generic 10%10%None
PROQUAD VIAL   3 Level 3: Covered Brand 50%50%None
PROTOPIC 0.03% OINTMENT 100GM TUBE   2 Level 2: Covered Preferred Brand 22%22%S
PROTOPIC 0.1% OINTMENT 60GM TUBE   2 Level 2: Covered Preferred Brand 22%22%S
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
PROTRIPTYLINE HYDROCHLORIDE TABLETS   1 Level 1: Covered Generic 10%10%None
PROTRIPTYLINE HYDROCHLORIDE TABLETS 5MG   1 Level 1: Covered Generic 10%10%None
PROVIGIL 100MG TABLET   3 Level 3: Covered Brand 50%50%P Q:30
/30Days
PROVIGIL 200MG TABLET   3 Level 3: Covered Brand 50%50%P Q:30
/30Days
PULMICORT FLEXHALER 180MCG AEROSOL POWDER BREATH ACTIVATED   3 Level 3: Covered Brand 50%50%Q:2
/30Days
PULMICORT FLEXHALER 90MCG AEROSOL POWDER BREATH ACTIVATED   3 Level 3: Covered Brand 50%50%Q:1
/30Days
PULMOZYME 1MG/ML AMPUL   4 Covered Specialty 25%25%P
PYLERA 125-125MG CAPSULE   2 Level 2: Covered Preferred Brand 22%22%None
PYRAZINAMIDE 500MG TABLET   1 Level 1: Covered Generic 10%10%None
PYRIDOSTIGMINE BROMIDE 60MG TABLET   1 Level 1: Covered Generic 10%10%None

Chart Legend:

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

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

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

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

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

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




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

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