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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 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
ABILIFY 10MG TABLET   3 Level 3: Covered Brand 50%50%S Q:30
/30Days
ABILIFY 15MG TABLET   3 Level 3: Covered Brand 50%50%S Q:30
/30Days
ABILIFY 1MG/ML SOLUTION   3 Level 3: Covered Brand 50%50%S Q:900
/30Days
ABILIFY 20MG TABLET   3 Level 3: Covered Brand 50%50%S Q:30
/30Days
ABILIFY 2MG TABLET   3 Level 3: Covered Brand 50%50%S Q:30
/30Days
ABILIFY 30MG TABLET   3 Level 3: Covered Brand 50%50%S Q:30
/30Days
ABILIFY 5MG TABLET (OTSUKA)   3 Level 3: Covered Brand 50%50%S Q:30
/30Days
ABILIFY DISCMELT 10MG TABLET   3 Level 3: Covered Brand 50%50%S Q:60
/30Days
ABILIFY DISCMELT 15MG TABLET   3 Level 3: Covered Brand 50%50%S Q:60
/30Days
ABRAXANE 100MG VIAL   4 Covered Specialty 25%25%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ACARBOSE 100MG TABLET S   1 Level 1: Covered Generic 10%10%None
ACARBOSE 25MG TABLET S   1 Level 1: Covered Generic 10%10%None
ACARBOSE 50MG TABLET S   1 Level 1: Covered Generic 10%10%None
ACCOLATE 10MG TABLET   2 Level 2: Covered Preferred Brand 22%22%None
ACCOLATE 20MG TABLET   2 Level 2: Covered Preferred Brand 22%22%S
ACEBUTOLOL 200MG CAPSULE   1 Level 1: Covered Generic 10%10%None
ACEBUTOLOL 400MG CAPSULE   1 Level 1: Covered Generic 10%10%None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-15MG (1000 CT)   1 Level 1: Covered Generic 10%10%None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT)   1 Level 1: Covered Generic 10%10%None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT)   1 Level 1: Covered Generic 10%10%None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 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
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT)   1 Level 1: Covered Generic 10%10%None
ACETAMINOPHEN/COD SOLUTION   1 Level 1: Covered Generic 10%10%None
ACETASOL HC SOLUTION 10ML 10 ML BOT   1 Level 1: Covered Generic 10%10%None
ACETAZOLAMIDE 125MG TABLET   1 Level 1: Covered Generic 10%10%None
ACETAZOLAMIDE 250MG TABLET (100 CT)   1 Level 1: Covered Generic 10%10%None
ACETIC ACID 2% SOLUTION NON-ORAL   1 Level 1: Covered Generic 10%10%None
ACETIC ACID-HYDROCORTISONE 2%-1% DROPS   1 Level 1: Covered Generic 10%10%None
ACTHIB VACCINE VIAL 10-24UNT/5ML   3 Level 3: Covered Brand 50%50%None
ACTICIN 5% CREAM   1 Level 1: Covered Generic 10%10%None
ACTIMMUNE SOLUTION FOR INJECTION 100MCG   4 Covered Specialty 25%25%None
ACTONEL 150MG TABLET   3 Level 3: Covered Brand 50%50%S Q:1
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ACTONEL 30MG TABLET   3 Level 3: Covered Brand 50%50%S Q:30
/30Days
ACTONEL 35MG TABLET   3 Level 3: Covered Brand 50%50%S Q:4
/30Days
ACTONEL 5MG TABLET   3 Level 3: Covered Brand 50%50%S Q:30
/30Days
ACTONEL 75MG TABLET   3 Level 3: Covered Brand 50%50%S Q:2
/30Days
ACTOPLUS MET 15MG/500MG TABLET   2 Level 2: Covered Preferred Brand 22%22%S
ACTOPLUS MET 15MG/850MG TABLET   2 Level 2: Covered Preferred Brand 22%22%S
ACTOS 15MG TABLET   2 Level 2: Covered Preferred Brand 22%22%S
ACTOS 30MG TABLET (500 CT)   2 Level 2: Covered Preferred Brand 22%22%S
ACTOS 45MG TABLET   2 Level 2: Covered Preferred Brand 22%22%S
ACULAR 0.5% EYE DROPS   2 Level 2: Covered Preferred Brand 22%22%None
ACULAR LS 0.4% OPHTH SOL   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
ACULAR PF 0.5% EYE DROPS   3 Level 3: Covered Brand 50%50%None
ACYCLOVIR 200MG CAPSULE (1000 CT)   1 Level 1: Covered Generic 10%10%None
ACYCLOVIR 200MG/5ML SUSP   1 Level 1: Covered Generic 10%10%None
ACYCLOVIR 400MG TABLET (100 CT)   1 Level 1: Covered Generic 10%10%None
ACYCLOVIR SOD 50MG/ML VIAL   3 Level 3: Covered Brand 50%50%P
ACYCLOVIR SODIUM 1GM VIAL   3 Level 3: Covered Brand 50%50%P
ACYCLOVIR SODIUM 500MG VIAL   1 Level 1: Covered Generic 10%10%P
ACYCLOVIR TABLET USP 800MG (100 CT)   1 Level 1: Covered Generic 10%10%None
ADACEL VIAL 2UNT/5UNT   3 Level 3: Covered Brand 50%50%None
ADAGEN 250U/ML VIAL   4 Covered Specialty 25%25%None
ADRIAMYCIN 10MG VIAL   1 Level 1: Covered Generic 10%10%P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ADRIAMYCIN 20MG VIAL   1 Level 1: Covered Generic 10%10%P
ADRIAMYCIN 50MG VIAL   1 Level 1: Covered Generic 10%10%P
ADVAIR DISKU MIS 100/50   2 Level 2: Covered Preferred Brand 22%22%Q:60
/30Days
ADVAIR DISKU MIS 250/50   2 Level 2: Covered Preferred Brand 22%22%Q:60
/30Days
ADVAIR DISKU MIS 500/50   2 Level 2: Covered Preferred Brand 22%22%Q:60
/30Days
ADVAIR HFA 115/21MCG INHALER   2 Level 2: Covered Preferred Brand 22%22%Q:12
/30Days
ADVAIR HFA 230/21MCG INHALER   2 Level 2: Covered Preferred Brand 22%22%Q:12
/30Days
ADVAIR HFA 45/21MCG INHALER   2 Level 2: Covered Preferred Brand 22%22%Q:12
/30Days
AFEDITAB CR 30MG TABLET SA   1 Level 1: Covered Generic 10%10%None
AFEDITAB CR 60MG TABLET SA   1 Level 1: Covered Generic 10%10%None
AGGRENOX 25-200MG CAPSULE   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
AK-CON 0.1% EYE DROPS   1 Level 1: Covered Generic 10%10%None
AK-POLY-BAC EYE OINTMENT 500UNT/1000UNT   1 Level 1: Covered Generic 10%10%None
AK-SPORE EYE OINTMENT 3.5 MG   1 Level 1: Covered Generic 10%10%None
AKTOB 0.3% EYE DROPS   1 Level 1: Covered Generic 10%10%None
ALA-CORT 1% CREAM   1 Level 1: Covered Generic 10%10%None
ALA-CORT 1% LOTION   1 Level 1: Covered Generic 10%10%None
ALBENZA 200MG TABLET   3 Level 3: Covered Brand 50%50%None
ALBUTEROL SULFATE 0.63MG/3ML VIAL NEBULIZER   1 Level 1: Covered Generic 10%10%P
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER   1 Level 1: Covered Generic 10%10%P
ALBUTEROL SULFATE 2.5MG/3ML VIAL NEBULIZER   1 Level 1: Covered Generic 10%10%P
ALBUTEROL SULFATE 4MG TABLET SR 12HR   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
ALBUTEROL SULFATE 8MG TABLET SR 12HR   1 Level 1: Covered Generic 10%10%None
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   1 Level 1: Covered Generic 10%10%P
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT   1 Level 1: Covered Generic 10%10%None
ALBUTEROL SULFATE TABLET 2MG (500 CT)   1 Level 1: Covered Generic 10%10%None
ALBUTEROL TABLET 4MG (500 CT)   1 Level 1: Covered Generic 10%10%None
ALCLOMETASONE DIPROPIONATE 0.05% CREAM   1 Level 1: Covered Generic 10%10%None
ALCLOMETASONE DIPROPIONATE 0.05% OINTMENT   1 Level 1: Covered Generic 10%10%None
ALCOHOL ANTISEPTIC PADS   2 Level 2: Covered Preferred Brand 22%22%None
ALDARA 5% CREAM   3 Level 3: Covered Brand 50%50%P Q:12
/30Days
ALDURAZYME 2.9MG/5ML VIAL   4 Covered Specialty 25%25%None
ALENDRONATE SODIUM 10MG TABLET   1 Level 1: Covered Generic 10%10%Q:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ALENDRONATE SODIUM 40MG TABLET   1 Level 1: Covered Generic 10%10%Q:30
/30Days
ALENDRONATE SODIUM 5MG TABLET   1 Level 1: Covered Generic 10%10%Q:30
/30Days
ALENDRONATE SODIUM 70MG TABLET 4 BLPK   1 Level 1: Covered Generic 10%10%Q:4
/30Days
ALENDRONATE SODIUM TABLET 35MG 20 CRTN   1 Level 1: Covered Generic 10%10%Q:4
/30Days
ALFERON N INJ 5MU/ML   4 Covered Specialty 25%25%None
ALIMTA 500MG VIAL   4 Covered Specialty 25%25%None
ALIMTA INJECTION   4 Covered Specialty 25%25%None
ALKERAN 50MG VIAL   4 Covered Specialty 25%25%None
ALLOPURINOL SODIUM 500MG VIAL   1 Level 1: Covered Generic 10%10%None
ALLOPURINOL TABLET 300MG (1000 CT)   1 Level 1: Covered Generic 10%10%None
ALLOPURINOL TABLET USP 100MG (1000 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
ALPHAGAN P 0.1% DROPS   3 Level 3: Covered Brand 50%50%None
ALPHAGAN P 0.15% EYE DROPS   3 Level 3: Covered Brand 50%50%None
ALREX 0.2% EYE DROPS   3 Level 3: Covered Brand 50%50%None
AMANTADINE 100MG CAPSULE   1 Level 1: Covered Generic 10%10%None
AMCINONIDE 0.1% CREAM   1 Level 1: Covered Generic 10%10%None
AMEVIVE ADMISTRATION PACK FOR INTRAMUSCULAR ADMINISTRATION KIT 15MG 1 X 4 PKGCOM   4 Covered Specialty 25%25%S
AMIKACIN 250MG/ML VIAL   1 Level 1: Covered Generic 10%10%None
AMIKACIN 50MG/ML VIAL   1 Level 1: Covered Generic 10%10%None
AMILORIDE HCL 5MG TABLET   1 Level 1: Covered Generic 10%10%None
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET   1 Level 1: Covered Generic 10%10%None
AMINOPHYLLINE 100MG TABLET (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
AMINOPHYLLINE 200MG TABLET (1000 CT)   1 Level 1: Covered Generic 10%10%None
AMINOSYN-HF 8% IV SOLUTION   1 Level 1: Covered Generic 10%10%P
AMIODARONE HCL 200MG TABLET (60 CT)   1 Level 1: Covered Generic 10%10%None
AMIODARONE HCL 400MG TABLET   1 Level 1: Covered Generic 10%10%None
AMITRIP/CDP 25-10 TABLET   1 Level 1: Covered Generic 10%10%None
AMITRIPTYLINE HCL 100MG TABLET   1 Level 1: Covered Generic 10%10%None
AMITRIPTYLINE HCL 10MG TABLET   1 Level 1: Covered Generic 10%10%None
AMITRIPTYLINE HCL 150MG TABLET (100 CT)   1 Level 1: Covered Generic 10%10%None
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)   1 Level 1: Covered Generic 10%10%None
AMITRIPTYLINE HCL 50MG TABLET   1 Level 1: Covered Generic 10%10%None
AMITRIPTYLINE HCL 75MG TABLET USP (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
AMLODIPINE BESYLATE 10MG TABLET (90 CT)   1 Level 1: Covered Generic 10%10%None
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)   1 Level 1: Covered Generic 10%10%None
AMLODIPINE BESYLATE 5MG TABLET (90 CT)   1 Level 1: Covered Generic 10%10%None
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE   1 Level 1: Covered Generic 10%10%None
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE   1 Level 1: Covered Generic 10%10%None
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE   1 Level 1: Covered Generic 10%10%None
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE   1 Level 1: Covered Generic 10%10%None
AMMONIUM LACTATE 12% CREAM   1 Level 1: Covered Generic 10%10%None
AMMONIUM LACTATE 12% LOTION   1 Level 1: Covered Generic 10%10%None
AMMONIUM LACTATE 12% LOTION   1 Level 1: Covered Generic 10%10%None
AMNESTEEM 10MG CAPSULE   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
AMNESTEEM 20MG CAPSULE   1 Level 1: Covered Generic 10%10%None
AMNESTEEM 40MG CAPSULE   1 Level 1: Covered Generic 10%10%None
AMOCLAN 200-28.5/5 SUSPENSION RECONSTITUTED ORAL   1 Level 1: Covered Generic 10%10%None
AMOCLAN 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   1 Level 1: Covered Generic 10%10%None
AMOX TR-K CLV 200-28.5 CHEW   1 Level 1: Covered Generic 10%10%None
AMOX TR-K CLV 200-28.5/5 SU   1 Level 1: Covered Generic 10%10%None
AMOX TR-K CLV 400-57 CHW TABLET   1 Level 1: Covered Generic 10%10%None
AMOX TR-K CLV 400-57/5 SUSP   1 Level 1: Covered Generic 10%10%None
AMOX TR-K CLV 500-125MG TABLET   1 Level 1: Covered Generic 10%10%None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL   1 Level 1: Covered Generic 10%10%None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE   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
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET   1 Level 1: Covered Generic 10%10%None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE   1 Level 1: Covered Generic 10%10%None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   1 Level 1: Covered Generic 10%10%None
AMOX TR-POTASSIUM CLAVULANATE 500-125MG TABLET   1 Level 1: Covered Generic 10%10%None
AMOXAPINE 100MG TABLET   3 Level 3: Covered Brand 50%50%None
AMOXAPINE 150MG TABLET   3 Level 3: Covered Brand 50%50%None
AMOXAPINE 25MG TABLET   3 Level 3: Covered Brand 50%50%None
AMOXAPINE 50MG TABLET   3 Level 3: Covered Brand 50%50%None
AMOXICIILIN CLAVULNATE POTASSIUM FOR ORAL SUSPENSION   1 Level 1: Covered Generic 10%10%None
AMOXICILLIN 125MG TABLET CHEW   1 Level 1: Covered Generic 10%10%None
AMOXICILLIN 200MG TABLET CHEW   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
AMOXICILLIN 250MG CAPSULE   1 Level 1: Covered Generic 10%10%None
AMOXICILLIN 400MG TABLET CHEW   1 Level 1: Covered Generic 10%10%None
AMOXICILLIN 500MG CAPSULE   1 Level 1: Covered Generic 10%10%None
AMOXICILLIN 500MG TABLET (100 CT)   1 Level 1: Covered Generic 10%10%None
AMOXICILLIN 875MG TABLET   1 Level 1: Covered Generic 10%10%None
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT   1 Level 1: Covered Generic 10%10%None
AMOXICILLIN CLAVULANATE POTASSIUM TABLET 875-125MG 1 BLPK   1 Level 1: Covered Generic 10%10%None
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT   1 Level 1: Covered Generic 10%10%None
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL   1 Level 1: Covered Generic 10%10%None
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   1 Level 1: Covered Generic 10%10%None
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL   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
AMOXICILLIN TABLET USP CHEWABLE 250MG (250 CT)   1 Level 1: Covered Generic 10%10%None
AMOXIL 250MG/5ML SUSPENSION   1 Level 1: Covered Generic 10%10%None
AMOXIL 500MG CAPSULE   1 Level 1: Covered Generic 10%10%None
AMOXIL 50MG/ML PED DROPS   1 Level 1: Covered Generic 10%10%None
AMPHET ASP/ AMPHET/ D-AMPHET 10MG TABLET   1 Level 1: Covered Generic 10%10%None
AMPHET ASP/ AMPHET/ D-AMPHET 5MG TABLET   1 Level 1: Covered Generic 10%10%None
AMPHETAMINE SALT COMBO 12.5MG TABLET   1 Level 1: Covered Generic 10%10%None
AMPHETAMINE SALT COMBO 15MG TABLET   1 Level 1: Covered Generic 10%10%None
AMPHETAMINE SALT COMBO 30MG TABLET   1 Level 1: Covered Generic 10%10%None
AMPHETAMINE SALT COMBO 7.5MG TABLET   1 Level 1: Covered Generic 10%10%None
AMPHETAMINE SALTS 20MG 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
AMPHETAMINE SALTS 30MG TABLET   1 Level 1: Covered Generic 10%10%None
AMPICILLIN FOR INJECTION   1 Level 1: Covered Generic 10%10%None
AMPICILLIN FOR INJECTION 1GM VIAL   1 Level 1: Covered Generic 10%10%None
AMPICILLIN FOR INJECTION 2GM/ML 10 VIAL   1 Level 1: Covered Generic 10%10%None
AMPICILLIN FOR INJECTION 500MG VIAL   1 Level 1: Covered Generic 10%10%None
AMPICILLIN FOR INJECTION POWDER   1 Level 1: Covered Generic 10%10%None
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT   1 Level 1: Covered Generic 10%10%None
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT   1 Level 1: Covered Generic 10%10%None
AMPICILLIN POWDER FOR INJECTION 1 GM/ML   1 Level 1: Covered Generic 10%10%None
AMPICILLIN SODIUM STERILE 2 GM/VIAL   1 Level 1: Covered Generic 10%10%None
AMPICILLIN TR 250MG CAPSULE   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
AMPICILLIN TR 500MG CAPSULE   1 Level 1: Covered Generic 10%10%None
ANADROL-50 50MG TABLET (100 CT)   3 Level 3: Covered Brand 50%50%None
ANAGRELIDE HCL 0.5MG CAPSULE   1 Level 1: Covered Generic 10%10%None
ANAGRELIDE HCL 1MG CAPSULE   1 Level 1: Covered Generic 10%10%None
ANCOBON 250MG CAPSULE   3 Level 3: Covered Brand 50%50%None
ANCOBON 500MG CAPSULE   3 Level 3: Covered Brand 50%50%None
ANDRODERM 2.5MG/24HR PATCH   2 Level 2: Covered Preferred Brand 22%22%None
ANDRODERM 5MG/24HR PATCH   2 Level 2: Covered Preferred Brand 22%22%None
ANDROGEL 1%(25MG) GEL PACKET   2 Level 2: Covered Preferred Brand 22%22%None
ANDROGEL 1.25G (1%) GEL IN METERED-DOSE PUMP   2 Level 2: Covered Preferred Brand 22%22%None
ANDROGEL 1%(50MG) GEL PACKET   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
ANTABUSE 250MG TABLET   1 Level 1: Covered Generic 10%10%None
ANTABUSE 500MG TABLET   1 Level 1: Covered Generic 10%10%None
ANTIZOL INJECTION 1GM 4 X 1.5ML VIAL CRTN   4 Covered Specialty 25%25%None
APOKYN FOR INJECTION 30MG 5 CTG   4 Covered Specialty 25%25%None
APRI 0.15-0.03 TABLET   1 Level 1: Covered Generic 10%10%None
APTIVUS 250MG CAPSULE   3 Level 3: Covered Brand 50%50%None
ARANELLE 7-9-5 TABLET   1 Level 1: Covered Generic 10%10%None
ARANESP 100MCG/ML VIAL   4 Covered Specialty 25%25%P
ARANESP 200MCG/0.4ML SYRINGE   4 Covered Specialty 25%25%P
ARANESP 200MCG/ML VIAL   4 Covered Specialty 25%25%P
ARANESP 25MCG/ML VIAL   2 Level 2: Covered Preferred Brand 22%22%P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ARANESP 300MCG/ML VIAL   4 Covered Specialty 25%25%P
ARANESP 500MCG/1ML SYRINGE   4 Covered Specialty 25%25%P
ARANESP 60MCG/ML VIAL   4 Covered Specialty 25%25%P
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR   4 Covered Specialty 25%25%P
ARANESP PREFILLED SYRINGE SINGLE USE 25MCG/0.42ML SYR   2 Level 2: Covered Preferred Brand 22%22%P
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR   4 Covered Specialty 25%25%P
ARANESP SINGLE USE PREFILLED AUTOINJECTOR SOLUTION 100MCG/.5ML   4 Covered Specialty 25%25%P
ARANESP SINGLE USE PREFILLED SURECLICK AUTOINJECTOR SOLUTION 500MCG/ML   4 Covered Specialty 25%25%P
ARANESP SINGLE USE PREFILLED SURECLIK AUTOINJECTOR 60MCG/.3ML   4 Covered Specialty 25%25%P
ARANESP SINGLE USE VIAL 150MCG 4 X 150MCG/ 0.75ML VIALSD   4 Covered Specialty 25%25%P
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD   4 Covered Specialty 25%25%P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ARICEPT 10MG TABLET   2 Level 2: Covered Preferred Brand 22%22%None
ARICEPT 5MG TABLET   2 Level 2: Covered Preferred Brand 22%22%None
ARICEPT ODT 10MG TABLET   2 Level 2: Covered Preferred Brand 22%22%None
ARICEPT ODT 5MG TABLET   2 Level 2: Covered Preferred Brand 22%22%None
ARIMIDEX 1MG TABLET   2 Level 2: Covered Preferred Brand 22%22%None
ARIXTRA 10MG SYRINGE   4 Covered Specialty 25%25%Q:24
/90Days
ARIXTRA 2.5MG SYRINGE   4 Covered Specialty 25%25%Q:15
/90Days
ARIXTRA 5MG SYRINGE   4 Covered Specialty 25%25%Q:12
/90Days
ARIXTRA 7.5MG SYRINGE   4 Covered Specialty 25%25%Q:18
/90Days
AROMASIN 25MG TABLET   2 Level 2: Covered Preferred Brand 22%22%None
ARRANON 250MG VIAL   4 Covered Specialty 25%25%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ASACOL 400MG TABLET EC   2 Level 2: Covered Preferred Brand 22%22%None
ASCOMP W/CODEINE 30-50-325 CAPSULE   1 Level 1: Covered Generic 10%10%None
ASMANEX 220MCG(14) AEROSOL POWDER BREATH ACTIVATED   2 Level 2: Covered Preferred Brand 22%22%None
ASMANEX TWISTHALER 220MCG #120   2 Level 2: Covered Preferred Brand 22%22%None
ASMANEX TWISTHALER 220MCG #30   2 Level 2: Covered Preferred Brand 22%22%None
ASMANEX TWISTHALER 220MCG #60   2 Level 2: Covered Preferred Brand 22%22%None
ASTELIN 137MCG AEROSOL SPRAY W/PUMP   3 Level 3: Covered Brand 50%50%Q:60
/30Days
ASTRAMORPH-PF 0.5MG/ML VIAL   1 Level 1: Covered Generic 10%10%P
ASTRAMORPH-PF 1MG/ML VIAL   1 Level 1: Covered Generic 10%10%P
ATAMET   1 Level 1: Covered Generic 10%10%None
ATENOLOL 25MG TABLET (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
ATENOLOL TABLET 100MG (100 CT)   1 Level 1: Covered Generic 10%10%None
ATENOLOL TABLET USP 50MG (100 CT)   1 Level 1: Covered Generic 10%10%None
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT)   1 Level 1: Covered Generic 10%10%None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   1 Level 1: Covered Generic 10%10%None
ATGAM 50MG/ML AMPUL   4 Covered Specialty 25%25%P
ATRIPLA TABLET 600MG/200MG   3 Level 3: Covered Brand 50%50%None
ATROVENT HFA AER 17MCG   3 Level 3: Covered Brand 50%50%Q:25
/30Days
ATTENUVAX VACCINE W/DILUENT 1 DOSE/0.5ML   3 Level 3: Covered Brand 50%50%None
AVANDAMET 2MG/1000MG TABLET   2 Level 2: Covered Preferred Brand 22%22%S
AVANDAMET 2MG/500MG TABLET   2 Level 2: Covered Preferred Brand 22%22%S
AVANDAMET 4MG/500MG TABLET   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
AVANDAMET TABLET 4-1000MG   2 Level 2: Covered Preferred Brand 22%22%S
AVANDARYL 4MG/1MG TABLET   2 Level 2: Covered Preferred Brand 22%22%S
AVANDARYL 4MG/2MG TABLET   2 Level 2: Covered Preferred Brand 22%22%S
AVANDARYL 4MG/4MG TABLET   2 Level 2: Covered Preferred Brand 22%22%S
AVANDARYL 8MG-2MG TABLET   2 Level 2: Covered Preferred Brand 22%22%S
AVANDARYL 8MG-4MG TABLET   2 Level 2: Covered Preferred Brand 22%22%S
AVANDIA 2MG TABLET   2 Level 2: Covered Preferred Brand 22%22%S
AVANDIA 4MG TABLET (90 CT)   2 Level 2: Covered Preferred Brand 22%22%S
AVANDIA 8MG TABLET (90 CT)   2 Level 2: Covered Preferred Brand 22%22%S
AVASTIN 100MG/4ML VIAL   4 Covered Specialty 25%25%None
AVASTIN 400MG/16ML VIAL   4 Covered Specialty 25%25%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
AVELOX IV 400MG/250ML   3 Level 3: Covered Brand 50%50%None
AVIANE 0.1-0.02 TABLET   1 Level 1: Covered Generic 10%10%None
AVINZA 120MG CAPSULE MULTIPHASIC RELEASE 24 HR   2 Level 2: Covered Preferred Brand 22%22%None
AVINZA 30MG CAPSULE MULTIPHASIC RELEASE 24 HR   2 Level 2: Covered Preferred Brand 22%22%None
AVINZA 60MG CAPSULE MULTIPHASIC RELEASE 24 HR   2 Level 2: Covered Preferred Brand 22%22%None
AVINZA 90MG CAPSULE MULTIPHASIC RELEASE 24 HR   2 Level 2: Covered Preferred Brand 22%22%None
AVINZA CAPSULES EXTENDED RELEASE 45MG 100 BOTPL   2 Level 2: Covered Preferred Brand 22%22%None
AVINZA CAPSULES EXTENDED RELEASE 75MG 100 BOTPL   2 Level 2: Covered Preferred Brand 22%22%None
AVITA 0.025% CREAM   1 Level 1: Covered Generic 10%10%None
AVODART 0.5MG SOFTGEL   2 Level 2: Covered Preferred Brand 22%22%None
AVONEX ADMIN PACK 30MCG SYR   4 Covered Specialty 25%25%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
AVONEX ADMIN PACK 30MCG VL   4 Covered Specialty 25%25%None
AZACTAM 1GM VIAL   2 Level 2: Covered Preferred Brand 22%22%None
AZACTAM 2GM VIAL   2 Level 2: Covered Preferred Brand 22%22%None
AZACTAM INJECTION 1GM 50ML BAG   2 Level 2: Covered Preferred Brand 22%22%None
AZACTAM/ISO-OSMOT 2GM/50ML   2 Level 2: Covered Preferred Brand 22%22%None
AZASAN 100MG TABLET   1 Level 1: Covered Generic 10%10%P
AZASAN 75MG TABLET   1 Level 1: Covered Generic 10%10%P
AZATHIOPRINE 50MG TABLET   1 Level 1: Covered Generic 10%10%P
AZATHIOPRINE SOD 100MG VIAL   1 Level 1: Covered Generic 10%10%P
AZELEX 20% CREAM 30GM TUBE   3 Level 3: Covered Brand 50%50%None
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL   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
AZITHROMYCIN 1G PACKET   2 Level 2: Covered Preferred Brand 22%22%None
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Level 1: Covered Generic 10%10%None
AZITHROMYCIN 250MG TABLET (30 CT)   1 Level 1: Covered Generic 10%10%None
AZITHROMYCIN 500MG TABLET (30 CT)   1 Level 1: Covered Generic 10%10%None
AZITHROMYCIN FOR INJECTION 500MG 10 VIALSD   1 Level 1: Covered Generic 10%10%None
AZITHROMYCIN TABLET 600MG (30 CT)   1 Level 1: Covered Generic 10%10%None
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT   3 Level 3: Covered Brand 50%50%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.