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UA Medicare Part D Prescription Drug Cov (S5755-028-0)
Tier 1 (1971)
Tier 2 (1222)
Tier 3 (268)
Tier 4 (146)

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Has Quantity Limits:
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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
UA Medicare Part D Prescription Drug Cov (S5755-028-0)
Benefit Details  
The UA Medicare Part D Prescription Drug Cov (S5755-028-0)
Formulary Drugs Starting with the Letter A

in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY
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   1 Generic $5.00$13.00P
A-HYDROCORT 100MG VIAL   1 Generic $5.00$13.00None
A-METHAPRED 40MG UNIVIAL   1 Generic $5.00$13.00P
ABILIFY 10MG TABLET   3 Non-Preferred Brand $62.00$124.00Q:270
/90Days
ABILIFY 15MG TABLET   3 Non-Preferred Brand $62.00$124.00Q:180
/90Days
ABILIFY 1MG/ML SOLUTION   3 Non-Preferred Brand $62.00$124.00None
ABILIFY 20MG TABLET   3 Non-Preferred Brand $62.00$124.00Q:90
/90Days
ABILIFY 2MG TABLET   3 Non-Preferred Brand $62.00$124.00Q:90
/90Days
ABILIFY 30MG TABLET   3 Non-Preferred Brand $62.00$124.00Q:90
/90Days
ABILIFY 5MG TABLET (OTSUKA)   3 Non-Preferred Brand $62.00$124.00Q:90
/90Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ABILIFY DISCMELT 10MG TABLET   3 Non-Preferred Brand $62.00$124.00Q:270
/90Days
ABILIFY DISCMELT 15MG TABLET   3 Non-Preferred Brand $62.00$124.00Q:180
/90Days
ABILIFY INJ 9.75MG   3 Non-Preferred Brand $62.00$124.00None
ABRAXANE 100MG VIAL   3 Non-Preferred Brand $62.00$124.00None
ACARBOSE 100MG TABLET S   1 Generic $5.00$13.00Q:270
/90Days
ACARBOSE 25MG TABLET S   1 Generic $5.00$13.00Q:270
/90Days
ACARBOSE 50MG TABLET S   1 Generic $5.00$13.00Q:270
/90Days
ACCOLATE 10MG TABLET   3 Non-Preferred Brand $62.00$124.00Q:180
/90Days
ACCOLATE 20MG TABLET   3 Non-Preferred Brand $62.00$124.00Q:180
/90Days
ACEBUTOLOL 200MG CAPSULE   1 Generic $5.00$13.00None
ACEBUTOLOL 400MG CAPSULE   1 Generic $5.00$13.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACEON 2MG TABLET   2 Preferred Brand $31.00$62.00Q:180
/90Days
ACEON 4MG TABLET   2 Preferred Brand $31.00$62.00Q:180
/90Days
ACEON 8MG TABLET   2 Preferred Brand $31.00$62.00Q:180
/90Days
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-15MG (1000 CT)   1 Generic $5.00$13.00None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT)   1 Generic $5.00$13.00None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT)   1 Generic $5.00$13.00None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT)   1 Generic $5.00$13.00None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT)   1 Generic $5.00$13.00None
ACETAMINOPHEN/COD SOLUTION   1 Generic $5.00$13.00None
ACETASOL HC SOLUTION 10ML 10 ML BOT   1 Generic $5.00$13.00None
ACETAZOLAMIDE 125MG TABLET   1 Generic $5.00$13.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETAZOLAMIDE 250MG TABLET (100 CT)   1 Generic $5.00$13.00None
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT   1 Generic $5.00$13.00None
ACETAZOLAMIDE SOD 500MG VL   1 Generic $5.00$13.00None
ACETIC ACID 2% SOLUTION NON-ORAL   1 Generic $5.00$13.00None
ACETIC ACID-HYDROCORTISONE 2%-1% DROPS   1 Generic $5.00$13.00None
ACETYLCYSTEINE 10% VIAL   1 Generic $5.00$13.00P
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN   1 Generic $5.00$13.00P
ACTHIB VACCINE VIAL 10-24UNT/5ML   2 Preferred Brand $31.00$62.00None
ACTICIN 5% CREAM   1 Generic $5.00$13.00None
ACTIMMUNE SOLUTION FOR INJECTION 100MCG   4 Specialty 33%33%P
ACTIVELLA 0.5-0.1MG TABLET 28 DLPK   2 Preferred Brand $31.00$62.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACTIVELLA 1-0.5MG TABLET 28 DLPK   2 Preferred Brand $31.00$62.00None
ACTONEL 150MG TABLET   2 Preferred Brand $31.00$62.00None
ACTONEL 30MG TABLET   2 Preferred Brand $31.00$62.00P
ACTONEL 35MG TABLET   2 Preferred Brand $31.00$62.00None
ACTONEL 5MG TABLET   2 Preferred Brand $31.00$62.00None
ACTONEL 75MG TABLET   2 Preferred Brand $31.00$62.00None
ACTONEL WITH CALCIUM TABLET   2 Preferred Brand $31.00$62.00None
ACTOPLUS MET 15MG/500MG TABLET   2 Preferred Brand $31.00$62.00Q:270
/90Days
ACTOPLUS MET 15MG/850MG TABLET   2 Preferred Brand $31.00$62.00Q:270
/90Days
ACTOS 15MG TABLET   2 Preferred Brand $31.00$62.00Q:90
/90Days
ACTOS 30MG TABLET (500 CT)   2 Preferred Brand $31.00$62.00Q:90
/90Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACTOS 45MG TABLET   2 Preferred Brand $31.00$62.00Q:90
/90Days
ACULAR 0.5% EYE DROPS   2 Preferred Brand $31.00$62.00None
ACULAR LS 0.4% OPHTH SOL   2 Preferred Brand $31.00$62.00None
ACULAR PF 0.5% EYE DROPS   2 Preferred Brand $31.00$62.00None
ACYCLOVIR 200MG CAPSULE (1000 CT)   1 Generic $5.00$13.00Q:450
/90Days
ACYCLOVIR 200MG/5ML SUSP   1 Generic $5.00$13.00None
ACYCLOVIR 400MG TABLET (100 CT)   1 Generic $5.00$13.00Q:180
/90Days
ACYCLOVIR SOD 50MG/ML VIAL   1 Generic $5.00$13.00None
ACYCLOVIR SODIUM 1GM VIAL   1 Generic $5.00$13.00None
ACYCLOVIR SODIUM 500MG VIAL   1 Generic $5.00$13.00None
ACYCLOVIR TABLET USP 800MG (100 CT)   1 Generic $5.00$13.00Q:180
/90Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADACEL VIAL 2UNT/5UNT   2 Preferred Brand $31.00$62.00None
ADAGEN 250U/ML VIAL   4 Specialty 33%33%None
ADDERALL XR 10MG CAPSULE SA   2 Preferred Brand $31.00$62.00P
ADDERALL XR 15MG CAPSULE SA   2 Preferred Brand $31.00$62.00P
ADDERALL XR 20MG CAPSULE SA   2 Preferred Brand $31.00$62.00P
ADDERALL XR 25MG CAPSULE SA   2 Preferred Brand $31.00$62.00P
ADDERALL XR 30MG CAPSULE SA   2 Preferred Brand $31.00$62.00P
ADDERALL XR 5MG CAPSULE SA   2 Preferred Brand $31.00$62.00P
ADRIAMYCIN 10MG VIAL   1 Generic $5.00$13.00None
ADRIAMYCIN 20MG VIAL   3 Non-Preferred Brand $62.00$124.00None
ADRIAMYCIN 50MG VIAL   1 Generic $5.00$13.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADVAIR DISKU MIS 100/50   2 Preferred Brand $31.00$62.00Q:180
/90Days
ADVAIR DISKU MIS 250/50   2 Preferred Brand $31.00$62.00Q:180
/90Days
ADVAIR DISKU MIS 500/50   2 Preferred Brand $31.00$62.00Q:180
/90Days
ADVAIR HFA 115/21MCG INHALER   2 Preferred Brand $31.00$62.00Q:36
/90Days
ADVAIR HFA 230/21MCG INHALER   2 Preferred Brand $31.00$62.00Q:36
/90Days
ADVAIR HFA 45/21MCG INHALER   2 Preferred Brand $31.00$62.00Q:36
/90Days
ADVICOR 1000-20MG TABLET   3 Non-Preferred Brand $62.00$124.00None
ADVICOR 1000MG/40MG TABLET   3 Non-Preferred Brand $62.00$124.00None
ADVICOR 500-20MG TABLET   3 Non-Preferred Brand $62.00$124.00None
ADVICOR ER 20-750MG TABLET (90 CT)   3 Non-Preferred Brand $62.00$124.00None
AFEDITAB CR 30MG TABLET SA   1 Generic $5.00$13.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AFEDITAB CR 60MG TABLET SA   1 Generic $5.00$13.00None
AGGRENOX 25-200MG CAPSULE   2 Preferred Brand $31.00$62.00Q:180
/90Days
AK-CON 0.1% EYE DROPS   1 Generic $5.00$13.00None
AK-POLY-BAC EYE OINTMENT 500UNT/1000UNT   1 Generic $5.00$13.00None
AK-SPORE EYE OINTMENT 3.5 MG   1 Generic $5.00$13.00None
AKTOB 0.3% EYE DROPS   1 Generic $5.00$13.00None
ALA-CORT 1% CREAM   1 Generic $5.00$13.00None
ALA-CORT 1% LOTION   1 Generic $5.00$13.00None
ALAMAST 0.1% DROPS   2 Preferred Brand $31.00$62.00None
ALBENZA 200MG TABLET   2 Preferred Brand $31.00$62.00None
ALBUTEROL SULFATE 0.63MG/3ML VIAL NEBULIZER   1 Generic $5.00$13.00P
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 Generic $5.00$13.00P
ALBUTEROL SULFATE 2.5MG/3ML VIAL NEBULIZER   1 Generic $5.00$13.00P
ALBUTEROL SULFATE 4MG TABLET SR 12HR   1 Generic $5.00$13.00None
ALBUTEROL SULFATE 8MG TABLET SR 12HR   1 Generic $5.00$13.00None
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   1 Generic $5.00$13.00P
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT   1 Generic $5.00$13.00None
ALBUTEROL SULFATE TABLET 2MG (500 CT)   1 Generic $5.00$13.00None
ALBUTEROL TABLET 4MG (500 CT)   1 Generic $5.00$13.00None
ALCLOMETASONE DIPROPIONATE 0.05% CREAM   1 Generic $5.00$13.00None
ALCLOMETASONE DIPROPIONATE 0.05% OINTMENT   1 Generic $5.00$13.00None
ALCOHOL 5%/DEXTROSE 5%   1 Generic $5.00$13.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALCOHOL ANTISEPTIC PADS   2 Preferred Brand $31.00$62.00None
ALDARA 5% CREAM   3 Non-Preferred Brand $62.00$124.00None
ALDURAZYME 2.9MG/5ML VIAL   4 Specialty 33%33%P
ALENDRONATE SODIUM 10MG TABLET   1 Generic $5.00$13.00None
ALENDRONATE SODIUM 40MG TABLET   1 Generic $5.00$13.00P
ALENDRONATE SODIUM 5MG TABLET   1 Generic $5.00$13.00None
ALENDRONATE SODIUM 70MG TABLET 4 BLPK   1 Generic $5.00$13.00None
ALENDRONATE SODIUM TABLET 35MG 20 CRTN   1 Generic $5.00$13.00None
ALIMTA 500MG VIAL   3 Non-Preferred Brand $62.00$124.00None
ALIMTA INJECTION   3 Non-Preferred Brand $62.00$124.00None
ALINIA 100MG/5ML SUSPENSION   2 Preferred Brand $31.00$62.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALINIA 500MG TABLET   2 Preferred Brand $31.00$62.00None
ALKERAN 50MG VIAL   3 Non-Preferred Brand $62.00$124.00None
ALLEGRA-D 12 HOUR TABLET 60-120MG (500 CT)   3 Non-Preferred Brand $62.00$124.00Q:180
/90Days
ALLEGRA-D 24 HOUR TABLET   3 Non-Preferred Brand $62.00$124.00Q:90
/90Days
ALLOPURINOL TABLET 300MG (1000 CT)   1 Generic $5.00$13.00None
ALLOPURINOL TABLET USP 100MG (1000 CT)   1 Generic $5.00$13.00None
ALOCRIL 2% EYE DROPS   3 Non-Preferred Brand $62.00$124.00None
ALORA 0.025MG PATCH   2 Preferred Brand $31.00$62.00Q:24
/90Days
ALORA 0.05MG PATCH   2 Preferred Brand $31.00$62.00Q:24
/90Days
ALORA 0.075MG PATCH   2 Preferred Brand $31.00$62.00Q:24
/90Days
ALORA 0.1MG PATCH   2 Preferred Brand $31.00$62.00Q:24
/90Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALPHAGAN P 0.1% DROPS   2 Preferred Brand $31.00$62.00None
ALPHAGAN P 0.15% EYE DROPS   2 Preferred Brand $31.00$62.00None
ALREX 0.2% EYE DROPS   3 Non-Preferred Brand $62.00$124.00None
ALTABAX 1% OINTMENT   2 Preferred Brand $31.00$62.00None
AMANTADINE 100MG CAPSULE   1 Generic $5.00$13.00None
AMANTADINE 100MG TABLET   1 Generic $5.00$13.00None
AMBIEN CR 12.5MG TABLET   2 Preferred Brand $31.00$62.00None
AMBIEN CR 6.25MG TABLET   2 Preferred Brand $31.00$62.00None
AMCINONIDE 0.1% CREAM   1 Generic $5.00$13.00None
AMCINONIDE 0.1% LOTION   1 Generic $5.00$13.00None
AMCINONIDE 0.1% OINTMENT 60GM TUBE   1 Generic $5.00$13.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMERGE 1MG TABLET   2 Preferred Brand $31.00$62.00Q:36
/90Days
AMERGE 2.5MG TABLET   2 Preferred Brand $31.00$62.00Q:24
/90Days
AMIKACIN 250MG/ML VIAL   1 Generic $5.00$13.00None
AMIKACIN 50MG/ML VIAL   1 Generic $5.00$13.00None
AMIKIN 250MG/ML VIAL   1 Generic $5.00$13.00None
AMILORIDE HCL 5MG TABLET   1 Generic $5.00$13.00None
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET   1 Generic $5.00$13.00None
AMINOPHYLLINE 100MG TABLET (100 CT)   1 Generic $5.00$13.00None
AMINOPHYLLINE 200MG TABLET (1000 CT)   1 Generic $5.00$13.00None
AMINOPHYLLINE INJECTION 250MG 10ML X 25 VIALSD   1 Generic $5.00$13.00None
AMINOSYN 10% IV SOLUTION   2 Preferred Brand $31.00$62.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN 3.5% IV SOLUTION   2 Preferred Brand $31.00$62.00None
AMINOSYN 5% IV SOLUTION   2 Preferred Brand $31.00$62.00None
AMINOSYN 7% IV SOLUTION   2 Preferred Brand $31.00$62.00None
AMINOSYN 8.5% IV SOLUTION   2 Preferred Brand $31.00$62.00None
AMINOSYN II 10% IV SOLUTION   2 Preferred Brand $31.00$62.00None
AMINOSYN II 15% IV SOLUTION   1 Generic $5.00$13.00None
AMINOSYN II 3.5% IN D25W IV   2 Preferred Brand $31.00$62.00None
AMINOSYN II 3.5% IN D5W IV   2 Preferred Brand $31.00$62.00None
AMINOSYN II 4.25% IN D10W   2 Preferred Brand $31.00$62.00None
AMINOSYN II 4.25% IN D20W   2 Preferred Brand $31.00$62.00None
AMINOSYN II 4.25%-D25W IV   1 Generic $5.00$13.00None
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 $31.00$62.00None
AMINOSYN II 8.5% IV SOLUTION   2 Preferred Brand $31.00$62.00None
AMINOSYN PF INJECTION   2 Preferred Brand $31.00$62.00None
AMINOSYN-HBC 7% IV SOLUTION   2 Preferred Brand $31.00$62.00None
AMINOSYN-HF 8% IV SOLUTION   2 Preferred Brand $31.00$62.00None
AMINOSYN-PF 7% IV SOLUTION   2 Preferred Brand $31.00$62.00None
AMIODARONE HCL 200MG TABLET (60 CT)   1 Generic $5.00$13.00None
AMIODARONE HCL 400MG TABLET   1 Generic $5.00$13.00None
AMIODARONE HCL INJECTION   1 Generic $5.00$13.00None
AMITIZA 24 MCG CAPSULES   2 Preferred Brand $31.00$62.00None
AMITIZA 8MCG CAPSULE   2 Preferred Brand $31.00$62.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITRIP/CDP 25-10 TABLET   1 Generic $5.00$13.00None
AMITRIPTYLINE HCL 100MG TABLET   1 Generic $5.00$13.00None
AMITRIPTYLINE HCL 10MG TABLET   1 Generic $5.00$13.00None
AMITRIPTYLINE HCL 150MG TABLET (100 CT)   1 Generic $5.00$13.00None
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)   1 Generic $5.00$13.00None
AMITRIPTYLINE HCL 50MG TABLET   1 Generic $5.00$13.00None
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)   1 Generic $5.00$13.00None
AMLODIPINE BESYLATE 10MG TABLET (90 CT)   1 Generic $5.00$13.00None
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)   1 Generic $5.00$13.00None
AMLODIPINE BESYLATE 5MG TABLET (90 CT)   1 Generic $5.00$13.00None
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE   1 Generic $5.00$13.00Q:90
/90Days
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 $5.00$13.00Q:90
/90Days
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE   1 Generic $5.00$13.00Q:90
/90Days
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE   1 Generic $5.00$13.00Q:90
/90Days
AMMONIUM LACTATE 12% CREAM   1 Generic $5.00$13.00None
AMMONIUM LACTATE 12% LOTION   1 Generic $5.00$13.00None
AMMONIUM LACTATE 12% LOTION   1 Generic $5.00$13.00None
AMNESTEEM 10MG CAPSULE   1 Generic $5.00$13.00None
AMNESTEEM 20MG CAPSULE   1 Generic $5.00$13.00None
AMNESTEEM 40MG CAPSULE   1 Generic $5.00$13.00None
AMOCLAN 200-28.5/5 SUSPENSION RECONSTITUTED ORAL   1 Generic $5.00$13.00None
AMOCLAN 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   1 Generic $5.00$13.00None
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 Generic $5.00$13.00None
AMOX TR-K CLV 200-28.5/5 SU   1 Generic $5.00$13.00None
AMOX TR-K CLV 400-57 CHW TABLET   1 Generic $5.00$13.00None
AMOX TR-K CLV 400-57/5 SUSP   1 Generic $5.00$13.00None
AMOX TR-K CLV 500-125MG TABLET   1 Generic $5.00$13.00None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL   1 Generic $5.00$13.00None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE   1 Generic $5.00$13.00None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET   1 Generic $5.00$13.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE   1 Generic $5.00$13.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   1 Generic $5.00$13.00None
AMOX TR-POTASSIUM CLAVULANATE 500-125MG TABLET   1 Generic $5.00$13.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXAPINE 100MG TABLET   1 Generic $5.00$13.00None
AMOXAPINE 150MG TABLET   1 Generic $5.00$13.00None
AMOXAPINE 25MG TABLET   1 Generic $5.00$13.00None
AMOXAPINE 50MG TABLET   1 Generic $5.00$13.00None
AMOXICIILIN CLAVULNATE POTASSIUM FOR ORAL SUSPENSION   1 Generic $5.00$13.00None
AMOXICILLIN 125MG TABLET CHEW   1 Generic $5.00$13.00None
AMOXICILLIN 200MG TABLET CHEW   1 Generic $5.00$13.00None
AMOXICILLIN 250MG CAPSULE   1 Generic $5.00$13.00None
AMOXICILLIN 400MG TABLET CHEW   1 Generic $5.00$13.00None
AMOXICILLIN 500MG CAPSULE   1 Generic $5.00$13.00None
AMOXICILLIN 500MG TABLET (100 CT)   1 Generic $5.00$13.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN 875MG TABLET   1 Generic $5.00$13.00None
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT   1 Generic $5.00$13.00None
AMOXICILLIN CLAVULANATE POTASSIUM TABLET 875-125MG 1 BLPK   1 Generic $5.00$13.00None
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT   1 Generic $5.00$13.00None
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL   1 Generic $5.00$13.00None
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   1 Generic $5.00$13.00None
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL   1 Generic $5.00$13.00None
AMOXICILLIN TABLET USP CHEWABLE 250MG (250 CT)   1 Generic $5.00$13.00None
AMOXIL 250MG/5ML SUSPENSION   1 Generic $5.00$13.00None
AMOXIL 500MG CAPSULE   1 Generic $5.00$13.00None
AMOXIL 50MG/ML PED DROPS   1 Generic $5.00$13.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPHET ASP/ AMPHET/ D-AMPHET 10MG TABLET   1 Generic $5.00$13.00P
AMPHET ASP/ AMPHET/ D-AMPHET 5MG TABLET   1 Generic $5.00$13.00P
AMPHETAMINE SALT COMBO 12.5MG TABLET   1 Generic $5.00$13.00P
AMPHETAMINE SALT COMBO 15MG TABLET   1 Generic $5.00$13.00P
AMPHETAMINE SALT COMBO 30MG TABLET   1 Generic $5.00$13.00P
AMPHETAMINE SALT COMBO 7.5MG TABLET   1 Generic $5.00$13.00P
AMPHETAMINE SALTS 20MG TABLET   1 Generic $5.00$13.00P
AMPHETAMINE SALTS 30MG TABLET   1 Generic $5.00$13.00P
AMPHOTERICIN B FOR INJECTION 50 MG   1 Generic $5.00$13.00P
AMPICILLIN AND SULBACTAM FOR INJECTION 1-0.5 10 VIAL VIAL   1 Generic $5.00$13.00None
AMPICILLIN AND SULBACTAM FOR INJECTION 10-5 1 VIAL   1 Generic $5.00$13.00None
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   1 Generic $5.00$13.00None
AMPICILLIN FOR INJECTION   1 Generic $5.00$13.00None
AMPICILLIN FOR INJECTION 1GM VIAL   1 Generic $5.00$13.00None
AMPICILLIN FOR INJECTION 2GM/ML 10 VIAL   1 Generic $5.00$13.00None
AMPICILLIN FOR INJECTION 500MG VIAL   1 Generic $5.00$13.00None
AMPICILLIN FOR INJECTION POWDER   1 Generic $5.00$13.00None
AMPICILLIN FOR INJECTION USP 125MG/ML 1 VIAL   2 Preferred Brand $31.00$62.00None
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT   1 Generic $5.00$13.00None
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT   1 Generic $5.00$13.00None
AMPICILLIN POWDER FOR INJECTION 1 GM/ML   1 Generic $5.00$13.00None
AMPICILLIN SODIUM STERILE 2 GM/VIAL   1 Generic $5.00$13.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPICILLIN TR 250MG CAPSULE   1 Generic $5.00$13.00None
AMPICILLIN TR 500MG CAPSULE   1 Generic $5.00$13.00None
ANADROL-50 50MG TABLET (100 CT)   3 Non-Preferred Brand $62.00$124.00P
ANAGRELIDE HCL 0.5MG CAPSULE   1 Generic $5.00$13.00Q:1800
/90Days
ANAGRELIDE HCL 1MG CAPSULE   1 Generic $5.00$13.00Q:900
/90Days
ANCOBON 250MG CAPSULE   2 Preferred Brand $31.00$62.00None
ANCOBON 500MG CAPSULE   2 Preferred Brand $31.00$62.00None
ANDRODERM 2.5MG/24HR PATCH   2 Preferred Brand $31.00$62.00P Q:60
/30Days
ANDRODERM 5MG/24HR PATCH   2 Preferred Brand $31.00$62.00P Q:60
/30Days
ANDROGEL 1%(25MG) GEL PACKET   2 Preferred Brand $31.00$62.00P
ANDROGEL 1.25G (1%) GEL IN METERED-DOSE PUMP   2 Preferred Brand $31.00$62.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANDROGEL 1%(50MG) GEL PACKET   2 Preferred Brand $31.00$62.00P
ANTABUSE 250MG TABLET   2 Preferred Brand $31.00$62.00None
ANTARA 130MG CAPSULE   2 Preferred Brand $31.00$62.00None
ANTARA 43MG CAPSULE   2 Preferred Brand $31.00$62.00None
APIDRA 100UNITS/ML VIAL   2 Preferred Brand $31.00$62.00None
APOKYN FOR INJECTION 30MG 5 CTG   2 Preferred Brand $31.00$62.00P
APRI 0.15-0.03 TABLET   1 Generic $5.00$13.00None
APTIVUS 250MG CAPSULE   4 Specialty 33%33%None
ARANELLE 7-9-5 TABLET   1 Generic $5.00$13.00None
ARANESP 100MCG/ML VIAL   2 Preferred Brand $31.00$62.00P Q:4
/30Days
ARANESP 200MCG/0.4ML SYRINGE   2 Preferred Brand $31.00$62.00P Q:1
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP 200MCG/ML VIAL   2 Preferred Brand $31.00$62.00P Q:4
/30Days
ARANESP 25MCG/ML VIAL   2 Preferred Brand $31.00$62.00P Q:8
/30Days
ARANESP 300MCG/ML VIAL   2 Preferred Brand $31.00$62.00P Q:4
/30Days
ARANESP 500MCG/1ML SYRINGE   2 Preferred Brand $31.00$62.00P Q:1
/30Days
ARANESP 60MCG/ML VIAL   2 Preferred Brand $31.00$62.00P Q:8
/30Days
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR   2 Preferred Brand $31.00$62.00P Q:1
/30Days
ARANESP PREFILLED SYRINGE SINGLE USE 25MCG/0.42ML SYR   2 Preferred Brand $31.00$62.00P Q:3
/30Days
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR   2 Preferred Brand $31.00$62.00P Q:3
/30Days
ARANESP SINGLE USE PREFILLED AUTOINJECTOR SOLUTION 100MCG/.5ML   2 Preferred Brand $31.00$62.00P Q:2
/30Days
ARANESP SINGLE USE PREFILLED SURECLICK AUTOINJECTOR SOLUTION 500MCG/ML   2 Preferred Brand $31.00$62.00P Q:2
/30Days
ARANESP SINGLE USE PREFILLED SURECLIK AUTOINJECTOR 60MCG/.3ML   2 Preferred Brand $31.00$62.00P Q:2
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP SINGLE USE VIAL 150MCG 4 X 150MCG/ 0.75ML VIALSD   2 Preferred Brand $31.00$62.00P Q:3
/30Days
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD   2 Preferred Brand $31.00$62.00P Q:8
/30Days
ARCALYST INJECTION 220MG/VIAL   4 Specialty 33%33%None
ARICEPT 10MG TABLET   2 Preferred Brand $31.00$62.00Q:90
/90Days
ARICEPT 5MG TABLET   2 Preferred Brand $31.00$62.00Q:90
/90Days
ARICEPT ODT 10MG TABLET   2 Preferred Brand $31.00$62.00Q:90
/90Days
ARICEPT ODT 5MG TABLET   2 Preferred Brand $31.00$62.00Q:90
/90Days
ARIMIDEX 1MG TABLET   2 Preferred Brand $31.00$62.00None
ARIXTRA 10MG SYRINGE   2 Preferred Brand $31.00$62.00None
ARIXTRA 2.5MG SYRINGE   2 Preferred Brand $31.00$62.00None
ARIXTRA 5MG SYRINGE   2 Preferred Brand $31.00$62.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARIXTRA 7.5MG SYRINGE   2 Preferred Brand $31.00$62.00None
AROMASIN 25MG TABLET   2 Preferred Brand $31.00$62.00None
ARRANON 250MG VIAL   3 Non-Preferred Brand $62.00$124.00None
ARTHROTEC 50 50MG TABLET -200MCG (60 CT)   3 Non-Preferred Brand $62.00$124.00None
ARTHROTEC 75 TABLET EC   3 Non-Preferred Brand $62.00$124.00None
ASACOL 400MG TABLET EC   2 Preferred Brand $31.00$62.00None
ASMANEX TWISTHALER 220MCG #120   2 Preferred Brand $31.00$62.00Q:3
/90Days
ASMANEX TWISTHALER 220MCG #30   2 Preferred Brand $31.00$62.00Q:3
/90Days
ASMANEX TWISTHALER 220MCG #60   2 Preferred Brand $31.00$62.00Q:3
/90Days
ASTELIN 137MCG AEROSOL SPRAY W/PUMP   3 Non-Preferred Brand $62.00$124.00None
ASTEPRO NASAL SPRAY 137 MCG/SPRY   3 Non-Preferred Brand $62.00$124.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATACAND 16MG TABLET   2 Preferred Brand $31.00$62.00Q:180
/90Days
ATACAND 32MG TABLET   2 Preferred Brand $31.00$62.00Q:90
/90Days
ATACAND 4MG TABLET   2 Preferred Brand $31.00$62.00Q:90
/90Days
ATACAND 8MG TABLET   2 Preferred Brand $31.00$62.00Q:90
/90Days
ATACAND HCT 16/12.5MG TABLET   2 Preferred Brand $31.00$62.00Q:90
/90Days
ATACAND HCT 32/12.5MG TABLET   2 Preferred Brand $31.00$62.00Q:90
/90Days
ATACAND HCT TABLETS 32;25MG;MG 90 TABLETS BOT   2 Preferred Brand $31.00$62.00Q:90
/90Days
ATENOLOL 25MG TABLET (100 CT)   1 Generic $5.00$13.00None
ATENOLOL TABLET 100MG (100 CT)   1 Generic $5.00$13.00None
ATENOLOL TABLET USP 50MG (100 CT)   1 Generic $5.00$13.00None
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT)   1 Generic $5.00$13.00None
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 $5.00$13.00None
ATRIPLA TABLET 600MG/200MG   4 Specialty 33%33%None
ATROPINE 0.05MG/ML SYRINGE   2 Preferred Brand $31.00$62.00None
ATROPINE 0.1MG/ML SYRINGE   1 Generic $5.00$13.00None
ATROVENT HFA AER 17MCG   2 Preferred Brand $31.00$62.00Q:78
/90Days
ATTENUVAX VACCINE W/DILUENT 1 DOSE/0.5ML   2 Preferred Brand $31.00$62.00None
AUGMENTIN XR 1000-62.5 TABLET   2 Preferred Brand $31.00$62.00None
AVALIDE 150-12.5MG TABLET   2 Preferred Brand $31.00$62.00Q:90
/90Days
AVALIDE 300-12.5MG TABLET   2 Preferred Brand $31.00$62.00Q:90
/90Days
AVALIDE 300-25MG TABLET   2 Preferred Brand $31.00$62.00Q:90
/90Days
AVANDAMET 2MG/1000MG TABLET   2 Preferred Brand $31.00$62.00Q:180
/90Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVANDAMET 2MG/500MG TABLET   2 Preferred Brand $31.00$62.00Q:180
/90Days
AVANDAMET 4MG/500MG TABLET   2 Preferred Brand $31.00$62.00Q:180
/90Days
AVANDAMET TABLET 4-1000MG   2 Preferred Brand $31.00$62.00Q:180
/90Days
AVANDARYL 4MG/1MG TABLET   2 Preferred Brand $31.00$62.00Q:180
/90Days
AVANDARYL 4MG/2MG TABLET   2 Preferred Brand $31.00$62.00Q:180
/90Days
AVANDARYL 4MG/4MG TABLET   2 Preferred Brand $31.00$62.00Q:90
/90Days
AVANDARYL 8MG-2MG TABLET   2 Preferred Brand $31.00$62.00Q:90
/90Days
AVANDARYL 8MG-4MG TABLET   2 Preferred Brand $31.00$62.00Q:90
/90Days
AVANDIA 2MG TABLET   2 Preferred Brand $31.00$62.00Q:180
/90Days
AVANDIA 4MG TABLET (90 CT)   2 Preferred Brand $31.00$62.00Q:180
/90Days
AVANDIA 8MG TABLET (90 CT)   2 Preferred Brand $31.00$62.00Q:90
/90Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVAPRO 150MG TABLET   2 Preferred Brand $31.00$62.00Q:90
/90Days
AVAPRO 300MG TABLET   2 Preferred Brand $31.00$62.00Q:90
/90Days
AVAPRO 75MG TABLET (30 CT)   2 Preferred Brand $31.00$62.00Q:90
/90Days
AVASTIN 100MG/4ML VIAL   3 Non-Preferred Brand $62.00$124.00None
AVASTIN 400MG/16ML VIAL   3 Non-Preferred Brand $62.00$124.00None
AVELOX 400MG TABLET   2 Preferred Brand $31.00$62.00None
AVELOX ABC PACK 400MG TABLET   2 Preferred Brand $31.00$62.00None
AVELOX IV 400MG/250ML   2 Preferred Brand $31.00$62.00None
AVIANE 0.1-0.02 TABLET   1 Generic $5.00$13.00None
AVITA 0.025% CREAM   1 Generic $5.00$13.00None
AVODART 0.5MG SOFTGEL   2 Preferred Brand $31.00$62.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVONEX ADMIN PACK 30MCG SYR   4 Specialty 33%33%P Q:12
/90Days
AVONEX ADMIN PACK 30MCG VL   4 Specialty 33%33%P Q:12
/90Days
AZACTAM 1GM VIAL   2 Preferred Brand $31.00$62.00None
AZACTAM 2GM VIAL   2 Preferred Brand $31.00$62.00None
AZACTAM INJECTION 1GM 50ML BAG   2 Preferred Brand $31.00$62.00None
AZACTAM/ISO-OSMOT 2GM/50ML   2 Preferred Brand $31.00$62.00None
AZASITE 1% DROPS   2 Preferred Brand $31.00$62.00None
AZATHIOPRINE 50MG TABLET   1 Generic $5.00$13.00P
AZATHIOPRINE SOD 100MG VIAL   1 Generic $5.00$13.00P
AZELEX 20% CREAM 30GM TUBE   2 Preferred Brand $31.00$62.00None
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Generic $5.00$13.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZITHROMYCIN 1G PACKET   1 Generic $5.00$13.00None
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Generic $5.00$13.00None
AZITHROMYCIN 250MG TABLET (30 CT)   1 Generic $5.00$13.00None
AZITHROMYCIN 500MG TABLET (30 CT)   1 Generic $5.00$13.00None
AZITHROMYCIN FOR INJECTION 500MG 10 VIALSD   1 Generic $5.00$13.00None
AZITHROMYCIN TABLET 600MG (30 CT)   1 Generic $5.00$13.00None
AZMACORT AER 75MCG   3 Non-Preferred Brand $62.00$124.00Q:120
/90Days
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT   2 Preferred Brand $31.00$62.00None

Chart Legend:

Below are a few notes to help you understand the above 2009 Medicare Part D UA Medicare Part D Prescription Drug Cov 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.