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Prescriba Rx Platinum (S5597-222-0)
Tier 1 (1759)
Tier 2 (1119)
Tier 3 (345)


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
Prescriba Rx Platinum (S5597-222-0)
Benefit Details  
The Prescriba Rx Platinum (S5597-222-0)
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 $6.00$12.00None
A-METHAPRED 40MG UNIVIAL   1 Generic $6.00$12.00None
ABELCENT INJECTION SUSPENSION 5MG/ML   3 Specialty 33%N/AP
ABILIFY 10MG TABLET   2 Brand $44.00$88.00Q:30
/30Days
ABILIFY 15MG TABLET   2 Brand $44.00$88.00Q:30
/30Days
ABILIFY 1MG/ML SOLUTION   2 Brand $44.00$88.00Q:900
/30Days
ABILIFY 20MG TABLET   2 Brand $44.00$88.00Q:30
/30Days
ABILIFY 2MG TABLET   2 Brand $44.00$88.00Q:30
/30Days
ABILIFY 30MG TABLET   2 Brand $44.00$88.00Q:30
/30Days
ABILIFY 5MG TABLET (OTSUKA)   2 Brand $44.00$88.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ABILIFY DISCMELT 10MG TABLET   2 Brand $44.00$88.00Q:30
/30Days
ABILIFY DISCMELT 15MG TABLET   2 Brand $44.00$88.00Q:60
/30Days
ABILIFY INJ 9.75MG   2 Brand $44.00$88.00Q:3
/1Days
ACARBOSE 100MG TABLET S   1 Generic $6.00$12.00Q:90
/30Days
ACARBOSE 25MG TABLET S   1 Generic $6.00$12.00Q:90
/30Days
ACARBOSE 50MG TABLET S   1 Generic $6.00$12.00Q:90
/30Days
ACCOLATE 10MG TABLET   2 Brand $44.00$88.00S Q:60
/30Days
ACCOLATE 20MG TABLET   2 Brand $44.00$88.00S Q:60
/30Days
ACEBUTOLOL 200MG CAPSULE   1 Generic $6.00$12.00None
ACEBUTOLOL 400MG CAPSULE   1 Generic $6.00$12.00None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-15MG (1000 CT)   1 Generic $6.00$12.00Q:400
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT)   1 Generic $6.00$12.00Q:400
/30Days
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT)   1 Generic $6.00$12.00Q:400
/30Days
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT)   1 Generic $6.00$12.00Q:400
/30Days
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT)   1 Generic $6.00$12.00Q:400
/30Days
ACETAMINOPHEN/COD SOLUTION   1 Generic $6.00$12.00Q:5000
/30Days
ACETASOL HC SOLUTION 10ML 10 ML BOT   1 Generic $6.00$12.00None
ACETAZOLAMIDE 125MG TABLET   1 Generic $6.00$12.00None
ACETAZOLAMIDE 250MG TABLET (100 CT)   1 Generic $6.00$12.00None
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT   1 Generic $6.00$12.00None
ACETIC ACID 2% SOLUTION NON-ORAL   1 Generic $6.00$12.00None
ACETIC ACID-HYDROCORTISONE 2%-1% DROPS   1 Generic $6.00$12.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETYLCYSTEINE 10% VIAL   1 Generic $6.00$12.00P
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN   1 Generic $6.00$12.00P
ACIPHEX 20MG TABLET EC   2 Brand $44.00$88.00Q:60
/30Days
ACTHIB VACCINE VIAL 10-24UNT/5ML   2 Brand $44.00$88.00None
ACTICIN 5% CREAM   1 Generic $6.00$12.00None
ACTIMMUNE SOLUTION FOR INJECTION 100MCG   3 Specialty 33%N/AP
ACTOPLUS MET 15MG/500MG TABLET   2 Brand $44.00$88.00Q:90
/30Days
ACTOPLUS MET 15MG/850MG TABLET   2 Brand $44.00$88.00Q:90
/30Days
ACTOS 15MG TABLET   2 Brand $44.00$88.00Q:30
/30Days
ACTOS 30MG TABLET (500 CT)   2 Brand $44.00$88.00Q:30
/30Days
ACTOS 45MG TABLET   2 Brand $44.00$88.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACYCLOVIR 200MG CAPSULE (1000 CT)   1 Generic $6.00$12.00None
ACYCLOVIR 200MG/5ML SUSP   1 Generic $6.00$12.00None
ACYCLOVIR 400MG TABLET (100 CT)   1 Generic $6.00$12.00None
ACYCLOVIR SOD 50MG/ML VIAL   1 Generic $6.00$12.00P
ACYCLOVIR SODIUM 1GM VIAL   1 Generic $6.00$12.00P
ACYCLOVIR SODIUM 500MG VIAL   1 Generic $6.00$12.00P
ACYCLOVIR TABLET USP 800MG (100 CT)   1 Generic $6.00$12.00None
ADACEL VIAL 2UNT/5UNT   2 Brand $44.00$88.00None
ADAGEN 250U/ML VIAL   3 Specialty 33%N/ANone
ADVAIR DISKU MIS 100/50   2 Brand $44.00$88.00Q:60
/30Days
ADVAIR DISKU MIS 250/50   2 Brand $44.00$88.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADVAIR DISKU MIS 500/50   2 Brand $44.00$88.00Q:60
/30Days
ADVAIR HFA 115/21MCG INHALER   2 Brand $44.00$88.00Q:12
/30Days
ADVAIR HFA 230/21MCG INHALER   2 Brand $44.00$88.00Q:12
/30Days
ADVAIR HFA 45/21MCG INHALER   2 Brand $44.00$88.00Q:12
/30Days
AFEDITAB CR 30MG TABLET SA   1 Generic $6.00$12.00S Q:30
/30Days
AFEDITAB CR 60MG TABLET SA   1 Generic $6.00$12.00S Q:30
/30Days
AGGRENOX 25-200MG CAPSULE   2 Brand $44.00$88.00Q:60
/30Days
AK-CON 0.1% EYE DROPS   1 Generic $6.00$12.00None
AK-POLY-BAC EYE OINTMENT 500UNT/1000UNT   1 Generic $6.00$12.00None
AK-SPORE EYE OINTMENT 3.5 MG   1 Generic $6.00$12.00None
AKTOB 0.3% EYE DROPS   1 Generic $6.00$12.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALA-CORT 1% CREAM   1 Generic $6.00$12.00None
ALA-CORT 1% LOTION   1 Generic $6.00$12.00None
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER   1 Generic $6.00$12.00P Q:450
/30Days
ALBUTEROL SULFATE 2.5MG/3ML VIAL NEBULIZER   1 Generic $6.00$12.00P Q:450
/30Days
ALBUTEROL SULFATE 4MG TABLET SR 12HR   2 Brand $44.00$88.00Q:120
/30Days
ALBUTEROL SULFATE 8MG TABLET SR 12HR   2 Brand $44.00$88.00Q:120
/30Days
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   1 Generic $6.00$12.00P Q:100
/30Days
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT   1 Generic $6.00$12.00Q:2400
/30Days
ALBUTEROL SULFATE TABLET 2MG (500 CT)   1 Generic $6.00$12.00Q:240
/30Days
ALBUTEROL TABLET 4MG (500 CT)   1 Generic $6.00$12.00Q:240
/30Days
ALCLOMETASONE DIPROPIONATE 0.05% CREAM   1 Generic $6.00$12.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALCLOMETASONE DIPROPIONATE 0.05% OINTMENT   1 Generic $6.00$12.00None
ALCOHOL ANTISEPTIC PADS   2 Brand $44.00$88.00Q:200
/30Days
ALDACTAZIDE 50/50 TABLET   2 Brand $44.00$88.00None
ALDARA 5% CREAM   2 Brand $44.00$88.00None
ALDURAZYME 2.9MG/5ML VIAL   2 Brand $44.00$88.00None
ALENDRONATE SODIUM 10MG TABLET   1 Generic $6.00$12.00Q:30
/30Days
ALENDRONATE SODIUM 40MG TABLET   2 Brand $44.00$88.00Q:30
/30Days
ALENDRONATE SODIUM 5MG TABLET   1 Generic $6.00$12.00Q:30
/30Days
ALENDRONATE SODIUM 70MG TABLET 4 BLPK   1 Generic $6.00$12.00Q:4
/28Days
ALENDRONATE SODIUM TABLET 35MG 20 CRTN   1 Generic $6.00$12.00Q:4
/28Days
ALFERON N INJ 5MU/ML   3 Specialty 33%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALINIA 500MG TABLET   2 Brand $44.00$88.00None
ALLOPURINOL TABLET 300MG (1000 CT)   1 Generic $6.00$12.00None
ALLOPURINOL TABLET USP 100MG (1000 CT)   1 Generic $6.00$12.00None
ALOCRIL 2% EYE DROPS   2 Brand $44.00$88.00Q:10
/25Days
ALORA 0.025MG PATCH   2 Brand $44.00$88.00Q:8
/28Days
ALORA 0.05MG PATCH   2 Brand $44.00$88.00Q:8
/28Days
ALORA 0.075MG PATCH   2 Brand $44.00$88.00Q:8
/28Days
ALORA 0.1MG PATCH   2 Brand $44.00$88.00Q:8
/28Days
ALPHAGAN P 0.1% DROPS   2 Brand $44.00$88.00Q:10
/30Days
ALPHAGAN P 0.15% EYE DROPS   2 Brand $44.00$88.00Q:10
/30Days
ALREX 0.2% EYE DROPS   2 Brand $44.00$88.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMANTADINE 100MG CAPSULE   1 Generic $6.00$12.00None
AMCINONIDE 0.1% CREAM   1 Generic $6.00$12.00None
AMCINONIDE 0.1% LOTION   2 Brand $44.00$88.00None
AMCINONIDE 0.1% OINTMENT 60GM TUBE   2 Brand $44.00$88.00None
AMEVIVE ADMISTRATION PACK FOR INTRAMUSCULAR ADMINISTRATION KIT 15MG 1 X 4 PKGCOM   3 Specialty 33%N/AP Q:4
/28Days
AMIKACIN 250MG/ML VIAL   1 Generic $6.00$12.00None
AMIKACIN 50MG/ML VIAL   1 Generic $6.00$12.00None
AMILORIDE HCL 5MG TABLET   1 Generic $6.00$12.00None
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET   1 Generic $6.00$12.00None
AMINESS 5.2% IV SOLUTION   2 Brand $44.00$88.00P
AMINOPHYLLINE 100MG TABLET (100 CT)   1 Generic $6.00$12.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOPHYLLINE 200MG TABLET (1000 CT)   1 Generic $6.00$12.00None
AMINOSYN 10% IV SOLUTION   2 Brand $44.00$88.00P
AMINOSYN 3.5% IV SOLUTION   2 Brand $44.00$88.00P
AMINOSYN 5% IV SOLUTION   2 Brand $44.00$88.00P
AMINOSYN 7% IV SOLUTION   2 Brand $44.00$88.00P
AMINOSYN 7%-ELECTROLYTE SOL   2 Brand $44.00$88.00P
AMINOSYN 8.5% IV SOLUTION   2 Brand $44.00$88.00P
AMINOSYN II 10% IV SOLUTION   2 Brand $44.00$88.00P
AMINOSYN II 3.5% IN D25W IV   2 Brand $44.00$88.00P
AMINOSYN II 3.5% IN D5W IV   2 Brand $44.00$88.00P
AMINOSYN II 3.5% M/D5W IV   2 Brand $44.00$88.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN II 3.5% W/ELEC DEX   2 Brand $44.00$88.00P
AMINOSYN II 4.25% IN D10W   2 Brand $44.00$88.00P
AMINOSYN II 4.25% IN D20W   2 Brand $44.00$88.00P
AMINOSYN II 4.25% M/D10W IV   2 Brand $44.00$88.00P
AMINOSYN II 4.25% W/ELEC DW   2 Brand $44.00$88.00P
AMINOSYN II 4.25%-D25W IV   2 Brand $44.00$88.00P
AMINOSYN II 5% IN D25W IV   2 Brand $44.00$88.00P
AMINOSYN II 7% IV SOLUTION   2 Brand $44.00$88.00P
AMINOSYN II 8.5% ELECTROLYT   1 Generic $6.00$12.00P
AMINOSYN II 8.5% IV SOLUTION   2 Brand $44.00$88.00P
AMINOSYN M 3.5% IV SOLUTION   2 Brand $44.00$88.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN PF INJECTION   2 Brand $44.00$88.00P
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5%   1 Generic $6.00$12.00P
AMINOSYN-HBC 7% IV SOLUTION   2 Brand $44.00$88.00P
AMINOSYN-HF 8% IV SOLUTION   1 Generic $6.00$12.00P
AMINOSYN-PF 7% IV SOLUTION   2 Brand $44.00$88.00P
AMIODARONE HCL 200MG TABLET (60 CT)   1 Generic $6.00$12.00None
AMIODARONE HCL 400MG TABLET   1 Generic $6.00$12.00None
AMITIZA 24 MCG CAPSULES   2 Brand $44.00$88.00S Q:60
/30Days
AMITIZA 8MCG CAPSULE   2 Brand $44.00$88.00S Q:60
/30Days
AMITRIP/PERPHEN 10-2 TABLET   1 Generic $6.00$12.00None
AMITRIP/PERPHEN 10-4 TABLET   1 Generic $6.00$12.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITRIP/PERPHEN 25-2 TABLET   1 Generic $6.00$12.00None
AMITRIP/PERPHEN 25-4 TABLET   1 Generic $6.00$12.00None
AMITRIP/PERPHEN 50-4 TABLET   1 Generic $6.00$12.00None
AMITRIPTYLINE HCL 100MG TABLET   1 Generic $6.00$12.00None
AMITRIPTYLINE HCL 10MG TABLET   1 Generic $6.00$12.00None
AMITRIPTYLINE HCL 150MG TABLET (100 CT)   1 Generic $6.00$12.00None
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)   1 Generic $6.00$12.00None
AMITRIPTYLINE HCL 50MG TABLET   1 Generic $6.00$12.00None
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)   1 Generic $6.00$12.00None
AMLODIPINE BESYLATE 10MG TABLET (90 CT)   1 Generic $6.00$12.00Q:30
/30Days
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)   1 Generic $6.00$12.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE BESYLATE 5MG TABLET (90 CT)   1 Generic $6.00$12.00Q:45
/30Days
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE   1 Generic $6.00$12.00Q:30
/30Days
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE   1 Generic $6.00$12.00Q:30
/30Days
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE   1 Generic $6.00$12.00Q:30
/30Days
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE   1 Generic $6.00$12.00Q:30
/30Days
AMMONIUM LACTATE 12% CREAM   1 Generic $6.00$12.00None
AMMONIUM LACTATE 12% LOTION   1 Generic $6.00$12.00None
AMMONIUM LACTATE 12% LOTION   1 Generic $6.00$12.00None
AMNESTEEM 10MG CAPSULE   1 Generic $6.00$12.00P
AMNESTEEM 20MG CAPSULE   1 Generic $6.00$12.00P
AMNESTEEM 40MG CAPSULE   1 Generic $6.00$12.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOCLAN 200-28.5/5 SUSPENSION RECONSTITUTED ORAL   1 Generic $6.00$12.00None
AMOCLAN 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   1 Generic $6.00$12.00None
AMOX TR-K CLV 200-28.5 CHEW   1 Generic $6.00$12.00None
AMOX TR-K CLV 200-28.5/5 SU   1 Generic $6.00$12.00None
AMOX TR-K CLV 400-57 CHW TABLET   1 Generic $6.00$12.00None
AMOX TR-K CLV 400-57/5 SUSP   1 Generic $6.00$12.00None
AMOX TR-K CLV 500-125MG TABLET   1 Generic $6.00$12.00None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL   1 Generic $6.00$12.00None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE   1 Generic $6.00$12.00None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET   1 Generic $6.00$12.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE   1 Generic $6.00$12.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   1 Generic $6.00$12.00None
AMOX TR-POTASSIUM CLAVULANATE 500-125MG TABLET   1 Generic $6.00$12.00None
AMOXAPINE 100MG TABLET   2 Brand $44.00$88.00None
AMOXAPINE 150MG TABLET   2 Brand $44.00$88.00None
AMOXAPINE 25MG TABLET   2 Brand $44.00$88.00None
AMOXAPINE 50MG TABLET   2 Brand $44.00$88.00None
AMOXICIILIN CLAVULNATE POTASSIUM FOR ORAL SUSPENSION   1 Generic $6.00$12.00None
AMOXICILLIN 125MG TABLET CHEW   1 Generic $6.00$12.00None
AMOXICILLIN 200MG TABLET CHEW   1 Generic $6.00$12.00None
AMOXICILLIN 250MG CAPSULE   1 Generic $6.00$12.00None
AMOXICILLIN 400MG TABLET CHEW   2 Brand $44.00$88.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN 500MG CAPSULE   1 Generic $6.00$12.00None
AMOXICILLIN 500MG TABLET (100 CT)   1 Generic $6.00$12.00None
AMOXICILLIN 875MG TABLET   1 Generic $6.00$12.00None
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT   1 Generic $6.00$12.00None
AMOXICILLIN CLAVULANATE POTASSIUM TABLET 875-125MG 1 BLPK   1 Generic $6.00$12.00None
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT   1 Generic $6.00$12.00None
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL   1 Generic $6.00$12.00None
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   1 Generic $6.00$12.00None
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL   1 Generic $6.00$12.00None
AMOXICILLIN TABLET USP CHEWABLE 250MG (250 CT)   1 Generic $6.00$12.00None
AMOXIL 250MG/5ML SUSPENSION   1 Generic $6.00$12.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXIL 500MG CAPSULE   1 Generic $6.00$12.00None
AMOXIL 50MG/ML PED DROPS   2 Brand $44.00$88.00None
AMPHET ASP/ AMPHET/ D-AMPHET 10MG TABLET   1 Generic $6.00$12.00None
AMPHET ASP/ AMPHET/ D-AMPHET 5MG TABLET   1 Generic $6.00$12.00None
AMPHETAMINE SALT COMBO 12.5MG TABLET   1 Generic $6.00$12.00None
AMPHETAMINE SALT COMBO 15MG TABLET   1 Generic $6.00$12.00None
AMPHETAMINE SALT COMBO 30MG TABLET   1 Generic $6.00$12.00None
AMPHETAMINE SALT COMBO 7.5MG TABLET   1 Generic $6.00$12.00None
AMPHETAMINE SALTS 20MG TABLET   1 Generic $6.00$12.00None
AMPHETAMINE SALTS 30MG TABLET   1 Generic $6.00$12.00None
AMPHOTERICIN B FOR INJECTION 50 MG   1 Generic $6.00$12.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPICILLIN AND SULBACTAM FOR INJECTION 1-0.5 10 VIAL VIAL   1 Generic $6.00$12.00None
AMPICILLIN AND SULBACTAM FOR INJECTION 10-5 1 VIAL   1 Generic $6.00$12.00None
AMPICILLIN AND SULBACTAM FOR INJECTION 2-1 10 VIAL   1 Generic $6.00$12.00None
AMPICILLIN FOR INJECTION   1 Generic $6.00$12.00None
AMPICILLIN FOR INJECTION 1GM VIAL   1 Generic $6.00$12.00None
AMPICILLIN FOR INJECTION 2GM/ML 10 VIAL   1 Generic $6.00$12.00None
AMPICILLIN FOR INJECTION 500MG VIAL   1 Generic $6.00$12.00None
AMPICILLIN FOR INJECTION POWDER   2 Brand $44.00$88.00None
AMPICILLIN FOR INJECTION USP 125MG/ML 1 VIAL   2 Brand $44.00$88.00None
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT   1 Generic $6.00$12.00None
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT   1 Generic $6.00$12.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPICILLIN POWDER FOR INJECTION 1 GM/ML   1 Generic $6.00$12.00None
AMPICILLIN SODIUM STERILE 2 GM/VIAL   1 Generic $6.00$12.00None
AMPICILLIN TR 250MG CAPSULE   1 Generic $6.00$12.00None
AMPICILLIN TR 500MG CAPSULE   1 Generic $6.00$12.00None
ANADROL-50 50MG TABLET (100 CT)   2 Brand $44.00$88.00P
ANAGRELIDE HCL 0.5MG CAPSULE   1 Generic $6.00$12.00None
ANAGRELIDE HCL 1MG CAPSULE   1 Generic $6.00$12.00None
ANCOBON 250MG CAPSULE   2 Brand $44.00$88.00None
ANCOBON 500MG CAPSULE   2 Brand $44.00$88.00None
ANDRODERM 2.5MG/24HR PATCH   2 Brand $44.00$88.00Q:30
/30Days
ANDRODERM 5MG/24HR PATCH   2 Brand $44.00$88.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANDROID 10MG CAPSULE   2 Brand $44.00$88.00None
ANTABUSE 250MG TABLET   2 Brand $44.00$88.00None
ANTARA 130MG CAPSULE   2 Brand $44.00$88.00Q:30
/30Days
ANTARA 43MG CAPSULE   2 Brand $44.00$88.00Q:60
/30Days
APOKYN FOR INJECTION 30MG 5 CTG   3 Specialty 33%N/ANone
APRI 0.15-0.03 TABLET   1 Generic $6.00$12.00Q:28
/28Days
APRISO CP24   2 Brand $44.00$88.00Q:120
/30Days
APTIVUS 250MG CAPSULE   3 Specialty 33%N/ANone
ARALAST 1000MG VIAL   3 Specialty 33%N/AP
ARALAST 500MG VIAL   3 Specialty 33%N/AP
ARANELLE 7-9-5 TABLET   1 Generic $6.00$12.00Q:28
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP 100MCG/ML VIAL   3 Specialty 33%N/AP Q:8
/28Days
ARANESP 200MCG/0.4ML SYRINGE   3 Specialty 33%N/AP Q:3
/28Days
ARANESP 200MCG/ML VIAL   3 Specialty 33%N/AP Q:8
/28Days
ARANESP 25MCG/ML VIAL   2 Brand $44.00$88.00P Q:8
/28Days
ARANESP 300MCG/ML VIAL   3 Specialty 33%N/AP Q:4
/28Days
ARANESP 500MCG/1ML SYRINGE   3 Specialty 33%N/AP Q:4
/28Days
ARANESP 60MCG/ML VIAL   3 Specialty 33%N/AP Q:8
/28Days
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR   3 Specialty 33%N/AP Q:2
/28Days
ARANESP PREFILLED SYRINGE SINGLE USE 25MCG/0.42ML SYR   2 Brand $44.00$88.00P Q:3
/28Days
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR   3 Specialty 33%N/AP Q:3
/28Days
ARANESP SINGLE USE PREFILLED AUTOINJECTOR SOLUTION 100MCG/.5ML   3 Specialty 33%N/AP Q:4
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP SINGLE USE PREFILLED SURECLICK AUTOINJECTOR SOLUTION 500MCG/ML   3 Specialty 33%N/AP Q:2
/28Days
ARANESP SINGLE USE PREFILLED SURECLIK AUTOINJECTOR 60MCG/.3ML   3 Specialty 33%N/AP Q:2
/28Days
ARANESP SINGLE USE VIAL 150MCG 4 X 150MCG/ 0.75ML VIALSD   3 Specialty 33%N/AP Q:8
/28Days
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD   3 Specialty 33%N/AP Q:8
/28Days
ARICEPT 10MG TABLET   2 Brand $44.00$88.00Q:30
/30Days
ARICEPT 5MG TABLET   2 Brand $44.00$88.00Q:30
/30Days
ARICEPT ODT 10MG TABLET   2 Brand $44.00$88.00Q:30
/30Days
ARICEPT ODT 5MG TABLET   2 Brand $44.00$88.00Q:30
/30Days
ARIMIDEX 1MG TABLET   2 Brand $44.00$88.00Q:30
/30Days
ARIXTRA 10MG SYRINGE   2 Brand $44.00$88.00Q:24
/30Days
ARIXTRA 2.5MG SYRINGE   2 Brand $44.00$88.00Q:15
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARIXTRA 5MG SYRINGE   2 Brand $44.00$88.00Q:12
/30Days
ARIXTRA 7.5MG SYRINGE   2 Brand $44.00$88.00Q:18
/30Days
AROMASIN 25MG TABLET   2 Brand $44.00$88.00Q:60
/30Days
ASACOL 400MG TABLET EC   2 Brand $44.00$88.00None
ASCOMP W/CODEINE 30-50-325 CAPSULE   1 Generic $6.00$12.00Q:180
/30Days
ASMANEX 220MCG(14) AEROSOL POWDER BREATH ACTIVATED   2 Brand $44.00$88.00Q:240
/14Days
ASMANEX TWISTHALER 220MCG #120   2 Brand $44.00$88.00Q:240
/30Days
ASMANEX TWISTHALER 220MCG #30   2 Brand $44.00$88.00Q:240
/30Days
ASMANEX TWISTHALER 220MCG #60   2 Brand $44.00$88.00Q:240
/30Days
ASTELIN 137MCG AEROSOL SPRAY W/PUMP   2 Brand $44.00$88.00Q:30
/25Days
ATAMET   1 Generic $6.00$12.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATENOLOL 25MG TABLET (100 CT)   1 Generic $6.00$12.00None
ATENOLOL TABLET 100MG (100 CT)   1 Generic $6.00$12.00None
ATENOLOL TABLET USP 50MG (100 CT)   1 Generic $6.00$12.00None
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT)   1 Generic $6.00$12.00None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   1 Generic $6.00$12.00None
ATRIPLA TABLET 600MG/200MG   3 Specialty 33%N/AQ:30
/30Days
ATROVENT HFA AER 17MCG   2 Brand $44.00$88.00Q:25
/30Days
ATTENUVAX VACCINE W/DILUENT 1 DOSE/0.5ML   2 Brand $44.00$88.00None
AUGMENTIN 125 SUSPENSION   2 Brand $44.00$88.00None
AUGMENTIN 250 SUSPENSION   2 Brand $44.00$88.00None
AUGMENTIN 250 TABLET CHEW   2 Brand $44.00$88.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AUGMENTIN XR 1000-62.5 TABLET   2 Brand $44.00$88.00None
AVIANE 0.1-0.02 TABLET   1 Generic $6.00$12.00Q:28
/28Days
AVINZA 120MG CAPSULE MULTIPHASIC RELEASE 24 HR   2 Brand $44.00$88.00S Q:300
/30Days
AVINZA 30MG CAPSULE MULTIPHASIC RELEASE 24 HR   2 Brand $44.00$88.00S Q:30
/30Days
AVINZA 60MG CAPSULE MULTIPHASIC RELEASE 24 HR   2 Brand $44.00$88.00S Q:30
/30Days
AVINZA 90MG CAPSULE MULTIPHASIC RELEASE 24 HR   2 Brand $44.00$88.00S Q:30
/30Days
AVINZA CAPSULES EXTENDED RELEASE 45MG 100 BOTPL   2 Brand $44.00$88.00S Q:30
/30Days
AVINZA CAPSULES EXTENDED RELEASE 75MG 100 BOTPL   2 Brand $44.00$88.00S Q:30
/30Days
AVITA 0.025% CREAM   1 Generic $6.00$12.00None
AVODART 0.5MG SOFTGEL   2 Brand $44.00$88.00Q:30
/30Days
AVONEX ADMIN PACK 30MCG SYR   3 Specialty 33%N/AP Q:4
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVONEX ADMIN PACK 30MCG VL   3 Specialty 33%N/AP Q:4
/28Days
AZACTAM 1GM VIAL   3 Specialty 33%N/ANone
AZACTAM 2GM VIAL   3 Specialty 33%N/ANone
AZACTAM INJECTION 1GM 50ML BAG   3 Specialty 33%N/ANone
AZACTAM/ISO-OSMOT 2GM/50ML   3 Specialty 33%N/ANone
AZASITE 1% DROPS   2 Brand $44.00$88.00Q:2
/30Days
AZATHIOPRINE 50MG TABLET   1 Generic $6.00$12.00P
AZILECT 0.5MG TABLET   2 Brand $44.00$88.00Q:30
/30Days
AZILECT 1MG TABLET   2 Brand $44.00$88.00Q:30
/30Days
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Generic $6.00$12.00None
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Generic $6.00$12.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZITHROMYCIN 250MG TABLET (30 CT)   1 Generic $6.00$12.00None
AZITHROMYCIN 500MG TABLET (30 CT)   1 Generic $6.00$12.00None
AZITHROMYCIN FOR INJECTION 500MG 10 VIALSD   1 Generic $6.00$12.00None
AZITHROMYCIN TABLET 600MG (30 CT)   1 Generic $6.00$12.00None
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT   2 Brand $44.00$88.00Q:10
/30Days

Chart Legend:

Below are a few notes to help you understand the above 2009 Medicare Part D Prescriba Rx Platinum 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.