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Advantage Star Plan by RxAmerica (S5644-073-0)
Tier 1 (1648)
Tier 2 (1055)
Tier 3 (144)
Tier 4 (75)

Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
Yes No Show either
Cick on the first letter of your drug name to browse the formulary:

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
Advantage Star Plan by RxAmerica (S5644-073-0)
Benefit Details  
The Advantage Star Plan by RxAmerica (S5644-073-0)
Formulary Drugs Starting with the Letter A

in CMS PDP Region 7 which includes: VA
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
ABILIFY 10MG TABLET   4 Non-Preferred 45%45%None
ABILIFY 15MG TABLET   4 Non-Preferred 45%45%None
ABILIFY 1MG/ML SOLUTION   4 Non-Preferred 45%45%None
ABILIFY 20MG TABLET   4 Non-Preferred 45%45%None
ABILIFY 2MG TABLET   4 Non-Preferred 45%45%None
ABILIFY 30MG TABLET   4 Non-Preferred 45%45%None
ABILIFY 5MG TABLET (OTSUKA)   4 Non-Preferred 45%45%None
ABILIFY DISCMELT 10MG TABLET   4 Non-Preferred 45%45%None
ABILIFY DISCMELT 15MG TABLET   4 Non-Preferred 45%45%None
ACARBOSE 100MG TABLET S   1 Preferred Generic $5.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACARBOSE 25MG TABLET S   1 Preferred Generic $5.00$0.00None
ACARBOSE 50MG TABLET S   1 Preferred Generic $5.00$0.00None
ACCOLATE 10MG TABLET   2 Preferred Brand 25%30%None
ACCOLATE 20MG TABLET   2 Preferred Brand 25%30%None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-15MG (1000 CT)   1 Preferred Generic $5.00$0.00None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT)   1 Preferred Generic $5.00$0.00None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT)   1 Preferred Generic $5.00$0.00None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT)   1 Preferred Generic $5.00$0.00None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT)   1 Preferred Generic $5.00$0.00None
ACETAMINOPHEN/COD SOLUTION   1 Preferred Generic $5.00$0.00None
ACETAZOLAMIDE 125MG TABLET   1 Preferred Generic $5.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETAZOLAMIDE 250MG TABLET (100 CT)   1 Preferred Generic $5.00$0.00None
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT   1 Preferred Generic $5.00$0.00None
ACETIC ACID 2% SOLUTION NON-ORAL   1 Preferred Generic $5.00$0.00None
ACETIC ACID-HYDROCORTISONE 2%-1% DROPS   1 Preferred Generic $5.00$0.00None
ACETYLCYSTEINE 10% VIAL   1 Preferred Generic $5.00$0.00P
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN   1 Preferred Generic $5.00$0.00P
ACTHIB VACCINE VIAL 10-24UNT/5ML   2 Preferred Brand 25%30%None
ACTICIN 5% CREAM   1 Preferred Generic $5.00$0.00None
ACTIMMUNE SOLUTION FOR INJECTION 100MCG   3 Specialty 25%N/AP
ACTONEL 150MG TABLET   2 Preferred Brand 25%30%P
ACTONEL 30MG TABLET   2 Preferred Brand 25%30%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACTONEL 35MG TABLET   2 Preferred Brand 25%30%P
ACTONEL 5MG TABLET   2 Preferred Brand 25%30%P
ACTONEL 75MG TABLET   2 Preferred Brand 25%30%P
ACTONEL WITH CALCIUM TABLET   2 Preferred Brand 25%30%P
ACTOPLUS MET 15MG/500MG TABLET   2 Preferred Brand 25%30%Q:90
/30Days
ACTOPLUS MET 15MG/850MG TABLET   2 Preferred Brand 25%30%Q:90
/30Days
ACTOS 15MG TABLET   2 Preferred Brand 25%30%None
ACTOS 30MG TABLET (500 CT)   2 Preferred Brand 25%30%None
ACTOS 45MG TABLET   2 Preferred Brand 25%30%None
ACULAR 0.5% EYE DROPS   2 Preferred Brand 25%30%None
ACULAR LS 0.4% OPHTH SOL   2 Preferred Brand 25%30%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACULAR PF 0.5% EYE DROPS   2 Preferred Brand 25%30%None
ACYCLOVIR 200MG CAPSULE (1000 CT)   1 Preferred Generic $5.00$0.00None
ACYCLOVIR 200MG/5ML SUSP   1 Preferred Generic $5.00$0.00None
ACYCLOVIR 400MG TABLET (100 CT)   1 Preferred Generic $5.00$0.00None
ACYCLOVIR TABLET USP 800MG (100 CT)   1 Preferred Generic $5.00$0.00None
ADAGEN 250U/ML VIAL   2 Preferred Brand 25%30%P
ADVAIR DISKU MIS 100/50   2 Preferred Brand 25%30%None
ADVAIR DISKU MIS 250/50   2 Preferred Brand 25%30%None
ADVAIR DISKU MIS 500/50   2 Preferred Brand 25%30%None
ADVAIR HFA 115/21MCG INHALER   2 Preferred Brand 25%30%None
ADVAIR HFA 230/21MCG INHALER   2 Preferred Brand 25%30%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADVAIR HFA 45/21MCG INHALER   2 Preferred Brand 25%30%None
AFEDITAB CR 30MG TABLET SA   1 Preferred Generic $5.00$0.00None
AFEDITAB CR 60MG TABLET SA   1 Preferred Generic $5.00$0.00None
AGGRENOX 25-200MG CAPSULE   2 Preferred Brand 25%30%None
AGRYLIN 0.5MG CAPSULE   2 Preferred Brand 25%30%P
AK-CON 0.1% EYE DROPS   1 Preferred Generic $5.00$0.00None
AKNE-MYCIN 2% OINTMENT   2 Preferred Brand 25%30%None
ALA-CORT 1% CREAM   1 Preferred Generic $5.00$0.00None
ALA-CORT 1% LOTION   1 Preferred Generic $5.00$0.00None
ALA-SCALP HP 2% LOTION   2 Preferred Brand 25%30%None
ALAMAST 0.1% DROPS   2 Preferred Brand 25%30%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER   1 Preferred Generic $5.00$0.00None
ALBUTEROL SULFATE 2.5MG/3ML VIAL NEBULIZER   1 Preferred Generic $5.00$0.00None
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   1 Preferred Generic $5.00$0.00None
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT   1 Preferred Generic $5.00$0.00None
ALBUTEROL SULFATE TABLET 2MG (500 CT)   1 Preferred Generic $5.00$0.00None
ALBUTEROL TABLET 4MG (500 CT)   1 Preferred Generic $5.00$0.00None
ALCOHOL ANTISEPTIC PADS   1 Preferred Generic $5.00$0.00Q:100
/30Days
ALDACTAZIDE 50/50 TABLET   2 Preferred Brand 25%30%None
ALDARA 5% CREAM   2 Preferred Brand 25%30%None
ALDURAZYME 2.9MG/5ML VIAL   2 Preferred Brand 25%30%P
ALENDRONATE SODIUM 10MG TABLET   1 Preferred Generic $5.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALENDRONATE SODIUM 40MG TABLET   1 Preferred Generic $5.00$0.00None
ALENDRONATE SODIUM 5MG TABLET   1 Preferred Generic $5.00$0.00None
ALENDRONATE SODIUM 70MG TABLET 4 BLPK   1 Preferred Generic $5.00$0.00None
ALENDRONATE SODIUM TABLET 35MG 20 CRTN   1 Preferred Generic $5.00$0.00None
ALFERON N INJ 5MU/ML   3 Specialty 25%N/AP
ALKERAN 50MG VIAL   2 Preferred Brand 25%30%None
ALLEGRA-D 12 HOUR TABLET 60-120MG (500 CT)   2 Preferred Brand 25%30%S
ALLEGRA-D 24 HOUR TABLET   2 Preferred Brand 25%30%S
ALLOPURINOL TABLET 300MG (1000 CT)   1 Preferred Generic $5.00$0.00None
ALLOPURINOL TABLET USP 100MG (1000 CT)   1 Preferred Generic $5.00$0.00None
ALORA 0.025MG PATCH   2 Preferred Brand 25%30%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALORA 0.05MG PATCH   2 Preferred Brand 25%30%None
ALORA 0.075MG PATCH   2 Preferred Brand 25%30%None
ALORA 0.1MG PATCH   2 Preferred Brand 25%30%None
ALPHAGAN P 0.15% EYE DROPS   2 Preferred Brand 25%30%None
ALREX 0.2% EYE DROPS   4 Non-Preferred 45%45%None
ALUPENT 650MCG INHALER COMP   2 Preferred Brand 25%30%None
AMANTADINE 100MG CAPSULE   1 Preferred Generic $5.00$0.00None
AMANTADINE 100MG TABLET   1 Preferred Generic $5.00$0.00None
AMIFOSTINE FOR INJECTION 500MG/VIAL   1 Preferred Generic $5.00$0.00P
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET   1 Preferred Generic $5.00$0.00None
AMINESS 5.2% IV SOLUTION   2 Preferred Brand 25%30%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOPHYLLINE 100MG TABLET (100 CT)   1 Preferred Generic $5.00$0.00None
AMINOPHYLLINE 200MG TABLET (1000 CT)   1 Preferred Generic $5.00$0.00None
AMINOPHYLLINE INJECTION 250MG 10ML X 25 VIALSD   1 Preferred Generic $5.00$0.00None
AMINOSYN 10% IV SOLUTION   2 Preferred Brand 25%30%P
AMINOSYN 3.5% IV SOLUTION   2 Preferred Brand 25%30%P
AMINOSYN 5% IV SOLUTION   2 Preferred Brand 25%30%P
AMINOSYN 7% IV SOLUTION   2 Preferred Brand 25%30%P
AMINOSYN 8.5% IV SOLUTION   2 Preferred Brand 25%30%P
AMINOSYN II 10% IV SOLUTION   2 Preferred Brand 25%30%P
AMINOSYN II 15% IV SOLUTION   2 Preferred Brand 25%30%P
AMINOSYN II 4.25% IN D10W   2 Preferred Brand 25%30%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN II 7% IV SOLUTION   2 Preferred Brand 25%30%P
AMINOSYN II 8.5% ELECTROLYT   2 Preferred Brand 25%30%P
AMINOSYN II 8.5% IV SOLUTION   2 Preferred Brand 25%30%P
AMINOSYN PF INJECTION   2 Preferred Brand 25%30%P
AMINOSYN-HBC 7% IV SOLUTION   2 Preferred Brand 25%30%P
AMINOSYN-HF 8% IV SOLUTION   1 Preferred Generic $5.00$0.00P
AMINOSYN-PF 7% IV SOLUTION   2 Preferred Brand 25%30%P
AMIODARONE HCL 200MG TABLET (60 CT)   1 Preferred Generic $5.00$0.00None
AMIODARONE HCL 400MG TABLET   1 Preferred Generic $5.00$0.00None
AMIODARONE HCL INJECTION   1 Preferred Generic $5.00$0.00None
AMITIZA 24 MCG CAPSULES   2 Preferred Brand 25%30%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITIZA 8MCG CAPSULE   2 Preferred Brand 25%30%P
AMITRIPTYLINE HCL 100MG TABLET   1 Preferred Generic $5.00$0.00None
AMITRIPTYLINE HCL 10MG TABLET   1 Preferred Generic $5.00$0.00None
AMITRIPTYLINE HCL 150MG TABLET (100 CT)   1 Preferred Generic $5.00$0.00None
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)   1 Preferred Generic $5.00$0.00None
AMITRIPTYLINE HCL 50MG TABLET   1 Preferred Generic $5.00$0.00None
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)   1 Preferred Generic $5.00$0.00None
AMLODIPINE BESYLATE 10MG TABLET (90 CT)   1 Preferred Generic $5.00$0.00None
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)   1 Preferred Generic $5.00$0.00None
AMLODIPINE BESYLATE 5MG TABLET (90 CT)   1 Preferred Generic $5.00$0.00None
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE   1 Preferred Generic $5.00$0.00None
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 Preferred Generic $5.00$0.00None
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE   1 Preferred Generic $5.00$0.00None
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE   1 Preferred Generic $5.00$0.00None
AMMONIUM LACTATE 12% CREAM   1 Preferred Generic $5.00$0.00None
AMMONIUM LACTATE 12% LOTION   1 Preferred Generic $5.00$0.00None
AMMONIUM LACTATE 12% LOTION   1 Preferred Generic $5.00$0.00None
AMNESTEEM 10MG CAPSULE   1 Preferred Generic $5.00$0.00P
AMNESTEEM 20MG CAPSULE   1 Preferred Generic $5.00$0.00P
AMNESTEEM 40MG CAPSULE   1 Preferred Generic $5.00$0.00P
AMOCLAN 200-28.5/5 SUSPENSION RECONSTITUTED ORAL   1 Preferred Generic $5.00$0.00None
AMOCLAN 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   1 Preferred Generic $5.00$0.00None
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 Preferred Generic $5.00$0.00None
AMOX TR-K CLV 200-28.5/5 SU   1 Preferred Generic $5.00$0.00None
AMOX TR-K CLV 400-57 CHW TABLET   1 Preferred Generic $5.00$0.00None
AMOX TR-K CLV 400-57/5 SUSP   1 Preferred Generic $5.00$0.00None
AMOX TR-K CLV 500-125MG TABLET   1 Preferred Generic $5.00$0.00None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL   1 Preferred Generic $5.00$0.00None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE   1 Preferred Generic $5.00$0.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE   1 Preferred Generic $5.00$0.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   1 Preferred Generic $5.00$0.00None
AMOX TR-POTASSIUM CLAVULANATE 500-125MG TABLET   1 Preferred Generic $5.00$0.00None
AMOXAPINE 100MG TABLET   1 Preferred Generic $5.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXAPINE 150MG TABLET   1 Preferred Generic $5.00$0.00None
AMOXAPINE 25MG TABLET   1 Preferred Generic $5.00$0.00None
AMOXAPINE 50MG TABLET   1 Preferred Generic $5.00$0.00None
AMOXICIILIN CLAVULNATE POTASSIUM FOR ORAL SUSPENSION   1 Preferred Generic $5.00$0.00None
AMOXICILLIN 125MG TABLET CHEW   1 Preferred Generic $5.00$0.00None
AMOXICILLIN 200MG TABLET CHEW   1 Preferred Generic $5.00$0.00None
AMOXICILLIN 250MG CAPSULE   1 Preferred Generic $5.00$0.00None
AMOXICILLIN 400MG TABLET CHEW   1 Preferred Generic $5.00$0.00None
AMOXICILLIN 500MG CAPSULE   1 Preferred Generic $5.00$0.00None
AMOXICILLIN 500MG TABLET (100 CT)   1 Preferred Generic $5.00$0.00None
AMOXICILLIN 875MG TABLET   1 Preferred Generic $5.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT   1 Preferred Generic $5.00$0.00None
AMOXICILLIN CLAVULANATE POTASSIUM TABLET 875-125MG 1 BLPK   1 Preferred Generic $5.00$0.00None
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT   1 Preferred Generic $5.00$0.00None
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL   1 Preferred Generic $5.00$0.00None
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   1 Preferred Generic $5.00$0.00None
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL   1 Preferred Generic $5.00$0.00None
AMOXICILLIN TABLET USP CHEWABLE 250MG (250 CT)   1 Preferred Generic $5.00$0.00None
AMOXIL 250MG/5ML SUSPENSION   1 Preferred Generic $5.00$0.00None
AMOXIL 500MG CAPSULE   1 Preferred Generic $5.00$0.00None
AMPHET ASP/ AMPHET/ D-AMPHET 10MG TABLET   1 Preferred Generic $5.00$0.00None
AMPHET ASP/ AMPHET/ D-AMPHET 5MG TABLET   1 Preferred Generic $5.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPHETAMINE SALT COMBO 12.5MG TABLET   1 Preferred Generic $5.00$0.00None
AMPHETAMINE SALT COMBO 15MG TABLET   1 Preferred Generic $5.00$0.00None
AMPHETAMINE SALT COMBO 30MG TABLET   1 Preferred Generic $5.00$0.00None
AMPHETAMINE SALT COMBO 7.5MG TABLET   1 Preferred Generic $5.00$0.00None
AMPHETAMINE SALTS 20MG TABLET   1 Preferred Generic $5.00$0.00None
AMPHETAMINE SALTS 30MG TABLET   1 Preferred Generic $5.00$0.00None
AMPHOTERICIN B FOR INJECTION 50 MG   1 Preferred Generic $5.00$0.00P
AMPICILLIN AND SULBACTAM FOR INJECTION 1-0.5 10 VIAL VIAL   1 Preferred Generic $5.00$0.00None
AMPICILLIN AND SULBACTAM FOR INJECTION 10-5 1 VIAL   1 Preferred Generic $5.00$0.00None
AMPICILLIN AND SULBACTAM FOR INJECTION 2-1 10 VIAL   1 Preferred Generic $5.00$0.00None
AMPICILLIN FOR INJECTION   1 Preferred Generic $5.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPICILLIN FOR INJECTION 1GM VIAL   1 Preferred Generic $5.00$0.00None
AMPICILLIN FOR INJECTION 2GM/ML 10 VIAL   1 Preferred Generic $5.00$0.00None
AMPICILLIN FOR INJECTION 500MG VIAL   1 Preferred Generic $5.00$0.00None
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT   1 Preferred Generic $5.00$0.00None
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT   1 Preferred Generic $5.00$0.00None
AMPICILLIN TR 250MG CAPSULE   1 Preferred Generic $5.00$0.00None
AMPICILLIN TR 500MG CAPSULE   1 Preferred Generic $5.00$0.00None
ANAGRELIDE HCL 0.5MG CAPSULE   1 Preferred Generic $5.00$0.00P
ANAGRELIDE HCL 1MG CAPSULE   1 Preferred Generic $5.00$0.00P
ANCOBON 250MG CAPSULE   2 Preferred Brand 25%30%None
ANCOBON 500MG CAPSULE   2 Preferred Brand 25%30%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANDRODERM 2.5MG/24HR PATCH   2 Preferred Brand 25%30%None
ANDRODERM 5MG/24HR PATCH   2 Preferred Brand 25%30%None
ANDROID 10MG CAPSULE   2 Preferred Brand 25%30%None
ANTABUSE 250MG TABLET   2 Preferred Brand 25%30%None
ANTABUSE 500MG TABLET   2 Preferred Brand 25%30%None
ANTIVERT 50MG TABLET   2 Preferred Brand 25%30%None
ANTIZOL INJECTION 1GM 4 X 1.5ML VIAL CRTN   2 Preferred Brand 25%30%P
ANZEMET 100MG TABLET   2 Preferred Brand 25%30%P
ANZEMET 20MG/ML VIAL   2 Preferred Brand 25%30%P
ANZEMET 50MG TABLET   2 Preferred Brand 25%30%P
APIDRA 100UNITS/ML VIAL   2 Preferred Brand 25%30%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
APRI 0.15-0.03 TABLET   1 Preferred Generic $5.00$0.00None
APTIVUS 250MG CAPSULE   2 Preferred Brand 25%30%None
ARALAST 1000MG VIAL   2 Preferred Brand 25%30%None
ARALAST 500MG VIAL   2 Preferred Brand 25%30%None
ARANELLE 7-9-5 TABLET   1 Preferred Generic $5.00$0.00None
ARANESP 100MCG/ML VIAL   3 Specialty 25%N/AP
ARANESP 200MCG/0.4ML SYRINGE   3 Specialty 25%N/AP
ARANESP 200MCG/ML VIAL   3 Specialty 25%N/AP
ARANESP 25MCG/ML VIAL   4 Non-Preferred 45%45%P
ARANESP 300MCG/ML VIAL   3 Specialty 25%N/AP
ARANESP 500MCG/1ML SYRINGE   3 Specialty 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP 60MCG/ML VIAL   3 Specialty 25%N/AP
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR   3 Specialty 25%N/AP
ARANESP PREFILLED SYRINGE SINGLE USE 25MCG/0.42ML SYR   4 Non-Preferred 45%45%P
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR   3 Specialty 25%N/AP
ARANESP SINGLE USE PREFILLED AUTOINJECTOR SOLUTION 100MCG/.5ML   3 Specialty 25%N/AP
ARANESP SINGLE USE PREFILLED SURECLICK AUTOINJECTOR SOLUTION 500MCG/ML   3 Specialty 25%N/AP
ARANESP SINGLE USE PREFILLED SURECLIK AUTOINJECTOR 60MCG/.3ML   3 Specialty 25%N/AP
ARANESP SINGLE USE VIAL 150MCG 4 X 150MCG/ 0.75ML VIALSD   3 Specialty 25%N/AP
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD   3 Specialty 25%N/AP
ARICEPT 10MG TABLET   2 Preferred Brand 25%30%None
ARICEPT 5MG TABLET   2 Preferred Brand 25%30%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARICEPT ODT 10MG TABLET   2 Preferred Brand 25%30%None
ARICEPT ODT 5MG TABLET   2 Preferred Brand 25%30%None
ARIMIDEX 1MG TABLET   2 Preferred Brand 25%30%None
ARIXTRA 10MG SYRINGE   3 Specialty 25%N/AQ:11
/7Days
ARIXTRA 2.5MG SYRINGE   3 Specialty 25%N/AQ:7
/7Days
ARIXTRA 5MG SYRINGE   3 Specialty 25%N/AQ:5
/7Days
ARIXTRA 7.5MG SYRINGE   3 Specialty 25%N/AQ:8
/7Days
AROMASIN 25MG TABLET   2 Preferred Brand 25%30%None
ARTHROTEC 50 50MG TABLET -200MCG (60 CT)   2 Preferred Brand 25%30%None
ARTHROTEC 75 TABLET EC   2 Preferred Brand 25%30%None
ASACOL 400MG TABLET EC   2 Preferred Brand 25%30%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ASCOMP W/CODEINE 30-50-325 CAPSULE   1 Preferred Generic $5.00$0.00None
ASMANEX 220MCG(14) AEROSOL POWDER BREATH ACTIVATED   2 Preferred Brand 25%30%None
ASMANEX TWISTHALER 220MCG #120   2 Preferred Brand 25%30%None
ASMANEX TWISTHALER 220MCG #30   2 Preferred Brand 25%30%None
ASMANEX TWISTHALER 220MCG #60   2 Preferred Brand 25%30%None
ASTELIN 137MCG AEROSOL SPRAY W/PUMP   2 Preferred Brand 25%30%None
ASTEPRO NASAL SPRAY 137 MCG/SPRY   2 Preferred Brand 25%30%None
ASTRAMORPH-PF 0.5MG/ML VIAL   1 Preferred Generic $5.00$0.00P
ASTRAMORPH-PF 1MG/ML VIAL   1 Preferred Generic $5.00$0.00P
ATAMET   1 Preferred Generic $5.00$0.00None
ATENOLOL 25MG TABLET (100 CT)   1 Preferred Generic $5.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATENOLOL TABLET 100MG (100 CT)   1 Preferred Generic $5.00$0.00None
ATENOLOL TABLET USP 50MG (100 CT)   1 Preferred Generic $5.00$0.00None
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT)   1 Preferred Generic $5.00$0.00None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   1 Preferred Generic $5.00$0.00None
ATGAM 50MG/ML AMPUL   2 Preferred Brand 25%30%P
ATRIPLA TABLET 600MG/200MG   2 Preferred Brand 25%30%None
ATROVENT HFA AER 17MCG   2 Preferred Brand 25%30%None
ATTENUVAX VACCINE W/DILUENT 1 DOSE/0.5ML   2 Preferred Brand 25%30%None
AUGMENTIN 125 SUSPENSION   2 Preferred Brand 25%30%None
AUGMENTIN 250 SUSPENSION   2 Preferred Brand 25%30%None
AUGMENTIN 250 TABLET CHEW   2 Preferred Brand 25%30%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AUGMENTIN XR 1000-62.5 TABLET   2 Preferred Brand 25%30%None
AVANDAMET 2MG/1000MG TABLET   2 Preferred Brand 25%30%None
AVANDAMET 2MG/500MG TABLET   2 Preferred Brand 25%30%None
AVANDAMET 4MG/500MG TABLET   2 Preferred Brand 25%30%None
AVANDAMET TABLET 4-1000MG   2 Preferred Brand 25%30%None
AVANDARYL 4MG/1MG TABLET   2 Preferred Brand 25%30%Q:60
/30Days
AVANDARYL 4MG/2MG TABLET   2 Preferred Brand 25%30%Q:60
/30Days
AVANDARYL 4MG/4MG TABLET   2 Preferred Brand 25%30%Q:30
/30Days
AVANDARYL 8MG-2MG TABLET   2 Preferred Brand 25%30%Q:30
/30Days
AVANDARYL 8MG-4MG TABLET   2 Preferred Brand 25%30%Q:30
/30Days
AVANDIA 2MG TABLET   2 Preferred Brand 25%30%None
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 25%30%None
AVANDIA 8MG TABLET (90 CT)   2 Preferred Brand 25%30%None
AVIANE 0.1-0.02 TABLET   1 Preferred Generic $5.00$0.00None
AVITA 0.025% CREAM   1 Preferred Generic $5.00$0.00P
AVODART 0.5MG SOFTGEL   2 Preferred Brand 25%30%None
AVONEX ADMIN PACK 30MCG SYR   3 Specialty 25%N/AP
AVONEX ADMIN PACK 30MCG VL   3 Specialty 25%N/AP
AZASAN 100MG TABLET   2 Preferred Brand 25%30%P
AZASAN 75MG TABLET   2 Preferred Brand 25%30%P
AZATHIOPRINE 50MG TABLET   1 Preferred Generic $5.00$0.00P
AZATHIOPRINE SOD 100MG VIAL   2 Preferred Brand 25%30%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Preferred Generic $5.00$0.00None
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Preferred Generic $5.00$0.00None
AZITHROMYCIN 250MG TABLET (30 CT)   1 Preferred Generic $5.00$0.00None
AZITHROMYCIN 500MG TABLET (30 CT)   1 Preferred Generic $5.00$0.00None
AZITHROMYCIN TABLET 600MG (30 CT)   1 Preferred Generic $5.00$0.00None
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT   2 Preferred Brand 25%30%None

Chart Legend:

Below are a few notes to help you understand the above 2009 Medicare Part D Advantage Star Plan by RxAmerica 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.