2010 Medicare Part D Plan Formulary Information |
Community Care's Partnership Program Disab (H2034-002-0)
Benefit Details
|
The Community Care's Partnership Program Disab (H2034-002-0) Formulary Drugs Starting with the Letter P in Ozauk County, WI: CMS MA Region 14 which includes: WI
|
Drugs Starting with Letter P
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
PACERONE 200MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
PANRETIN 0.1% GEL 60GM TUBE |
2 |
Tier 2 |
N/A | N/A | None |
PANTOPRAZOLE SODIUM 40MG TABLET DELAYED RELEASE 90 CRC BOT |
1 |
Tier 1 |
N/A | N/A | S |
PAROXETINE 40MG TABLET (500 CT) |
1 |
Tier 1 |
N/A | N/A | None |
PAROXETINE FILM COATED 20MG TABLET (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
PAROXETINE HCL 10MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
PAROXETINE HCL 10MG/5ML SUSPENSION ORAL |
1 |
Tier 1 |
N/A | N/A | None |
PAROXETINE HCL TABLET 24 12.5MG |
1 |
Tier 1 |
N/A | N/A | S |
PAROXETINE HCL TABLET 24 25MG |
1 |
Tier 1 |
N/A | N/A | S |
PAROXETINE TABLETS 30MG 90 BOT |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PASER GRANULES 4GM PACKET |
2 |
Tier 2 |
N/A | N/A | None |
PAXIL CR 37.5MG TABLET |
2 |
Tier 2 |
N/A | N/A | S |
PEDIARIX SOLUTION INJECTION 25-25-10 10 X .5ML VIAL |
2 |
Tier 2 |
N/A | N/A | None |
PEDVAXHIB VACCINE VIAL |
2 |
Tier 2 |
N/A | N/A | None |
PEG 3350/ELECTROLYTE 240-22.72G SOLUTION RECONSTITUTED ORAL |
1 |
Tier 1 |
N/A | N/A | None |
PEG-INTRON 100MCG KIT |
2 |
Tier 2 |
N/A | N/A | P |
PEG-INTRON REDIPEN 120MCG |
2 |
Tier 2 |
N/A | N/A | P |
PEG-INTRON REDIPEN 80MCG |
2 |
Tier 2 |
N/A | N/A | P |
PEG-INTRON REDIPEN 80MCG 4PK |
2 |
Tier 2 |
N/A | N/A | P |
PEG-INTRON REDIPEN PAK 4 |
2 |
Tier 2 |
N/A | N/A | P |
PEGANONE 250MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PEGASYS 180MCG/0.5ML CONV.PK |
2 |
Tier 2 |
N/A | N/A | P |
PEGINTRON REDIPEN 150MCG 4PK |
2 |
Tier 2 |
N/A | N/A | P |
PENICILLIN V POTASSIUM 250MG TABLET (1000 CT) |
1 |
Tier 1 |
N/A | N/A | None |
PENICILLIN V POTASSIUM 500MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
PENTASA 250MG CAPSULE SA |
2 |
Tier 2 |
N/A | N/A | None |
PENTASA 500MG CAPSULE |
2 |
Tier 2 |
N/A | N/A | None |
PENTOXIFYLLINE 400MG TABLET SA |
1 |
Tier 1 |
N/A | N/A | None |
PERMETHRIN 5% CREAM |
1 |
Tier 1 |
N/A | N/A | None |
PERPHENAZINE TABLETS 16MG 100 BOT |
1 |
Tier 1 |
N/A | N/A | None |
PERPHENAZINE TABLETS 4MG 100 BOXUD |
1 |
Tier 1 |
N/A | N/A | None |
PERPHENAZINE TABLETS 8MG 100 BOT |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PERPHENAZINE TABLETS USP 2MG 100 BOT |
1 |
Tier 1 |
N/A | N/A | None |
PHENADOZ 25MG SUPPOSITORY |
1 |
Tier 1 |
N/A | N/A | None |
PHENYTEK 200MG CAPSULE |
2 |
Tier 2 |
N/A | N/A | None |
PHENYTEK 300MG CAPSULE |
2 |
Tier 2 |
N/A | N/A | None |
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT |
1 |
Tier 1 |
N/A | N/A | None |
PHENYTOIN SODIUM EXTENDED CAPSULES 100MG (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
PHENYTOIN SODIUM INJECTION 50MG 25 X 2ML AMP |
1 |
Tier 1 |
N/A | N/A | None |
PILOCARPINE HCL 5MG TABLET (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
PILOCARPINE HCL 7.5MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
PILOPINE HS 4% EYE GEL |
2 |
Tier 2 |
N/A | N/A | None |
PIPERACILLIN 3GM VIAL |
2 |
Tier 2 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PIROXICAM 10MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
PIROXICAM 20MG CAPSULE (500 CT) |
1 |
Tier 1 |
N/A | N/A | None |
PLAN B 0.75MG TABLET 2 BLPK |
2 |
Tier 2 |
N/A | N/A | None |
PLAVIX 75MG TABLET |
2 |
Tier 2 |
N/A | N/A | P |
PODOFILOX 0.5% TOPICAL TUBEX |
1 |
Tier 1 |
N/A | N/A | None |
POLY-PRED EYE DROPS |
2 |
Tier 2 |
N/A | N/A | None |
POLYGAM S/D 10GM VL W/DILUENT |
2 |
Tier 2 |
N/A | N/A | None |
POLYMYXIN B SUL-TRIMETHOPRIM 10K U-0.1% |
1 |
Tier 1 |
N/A | N/A | None |
POLYMYXIN B SULFATE VIAL |
1 |
Tier 1 |
N/A | N/A | None |
POTASSIUM CHLORIDE 0.075%/D5W/SODIUM CHLORIDE 0.2% |
1 |
Tier 1 |
N/A | N/A | None |
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.3% |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.45% |
1 |
Tier 1 |
N/A | N/A | None |
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.9% 1000ML |
1 |
Tier 1 |
N/A | N/A | None |
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.2% |
1 |
Tier 1 |
N/A | N/A | None |
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.45% 1000ML BAG |
1 |
Tier 1 |
N/A | N/A | None |
POTASSIUM CHLORIDE 10MEQ TABLET SA |
1 |
Tier 1 |
N/A | N/A | None |
POTASSIUM CHLORIDE 10MEQ/100ML SOL |
1 |
Tier 1 |
N/A | N/A | None |
POTASSIUM CHLORIDE 10MEQ/50ML SOL |
2 |
Tier 2 |
N/A | N/A | None |
POTASSIUM CHLORIDE 20MEQ TABLET SR PARTICLES/CRYSTALS |
1 |
Tier 1 |
N/A | N/A | None |
POTASSIUM CHLORIDE 20MEQ/50ML SOL |
1 |
Tier 1 |
N/A | N/A | None |
POTASSIUM CHLORIDE 30MEQ/100ML SOL |
1 |
Tier 1 |
N/A | N/A | None |
POTASSIUM CHLORIDE 40MEQ IN D5W LACT RNG |
2 |
Tier 2 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTASSIUM CHLORIDE ER CAPSULES 10MEQ |
1 |
Tier 1 |
N/A | N/A | None |
POTASSIUM CHLORIDE FOR INJECTION CONCENTRATE |
1 |
Tier 1 |
N/A | N/A | None |
POTASSIUM CHLORIDE IN 10% DEXTROSE AND NACL SOLUTION FOR INJECTION |
2 |
Tier 2 |
N/A | N/A | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND 0.2% NACL SOLUTION FOR INJECTION USP 0.15% 250ML X 24 CASE |
1 |
Tier 1 |
N/A | N/A | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND NACL SOLUTION FOR INJECTION 0.075% 1000ML PLASTIC BAGS X 12 CA |
1 |
Tier 1 |
N/A | N/A | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION |
1 |
Tier 1 |
N/A | N/A | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE INJECTION 40 12 X 1000ML CTR |
1 |
Tier 1 |
N/A | N/A | None |
POTASSIUM CHLORIDE IN DEXTROSE AND SODIUM CHLORIDE INJECTION 5-30-.225 12 X 1000ML CTR |
1 |
Tier 1 |
N/A | N/A | None |
POTASSIUM CHLORIDE IN DEXTROSE INJECTION 5GM/75MG |
2 |
Tier 2 |
N/A | N/A | None |
POTASSIUM CITRATE 10MEQ TABLET SA |
1 |
Tier 1 |
N/A | N/A | None |
POTASSIUM CITRATE 5MEQ TABLET SA |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRANDIN 0.5MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
PRANDIN 1MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
PRANDIN 2MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
PRAZOSIN 5MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
PRAZOSIN HCL 1MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
PRAZOSIN HCL 2MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
PRED MILD 0.12% EYE DROPS |
2 |
Tier 2 |
N/A | N/A | None |
PREDNISOLONE 5MG/5ML TUBEX |
1 |
Tier 1 |
N/A | N/A | None |
PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION 1.0% STERILE 10ML BOTDR |
1 |
Tier 1 |
N/A | N/A | None |
PREDNISOLONE SOD 1% EYE DROP |
2 |
Tier 2 |
N/A | N/A | None |
PREDNISONE 10MG TABLET (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREDNISONE 1MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
PREDNISONE 2.5MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
PREDNISONE 20MG TABLET (1000 CT) |
1 |
Tier 1 |
N/A | N/A | None |
PREDNISONE 50MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
PREDNISONE 5MG TABLET (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
PREDNISONE 5MG/5ML SOLUTION |
2 |
Tier 2 |
N/A | N/A | None |
PREMARIN 0.3MG (100 CT) |
2 |
Tier 2 |
N/A | N/A | None |
PREMARIN 0.45MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
PREMARIN 0.625MG (100 CT) |
2 |
Tier 2 |
N/A | N/A | None |
PREMARIN 0.9MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
PREMARIN 1.25MG (100 CT) |
2 |
Tier 2 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREMARIN 25MG VIAL |
2 |
Tier 2 |
N/A | N/A | None |
PREMARIN VAGINAL CREAM /APPL |
2 |
Tier 2 |
N/A | N/A | None |
PRENATABS OBN TABLETS 200;1;150;MG;MG;MCG; 90 BOT |
1 |
Tier 1 |
N/A | N/A | None |
PREVACID SOLUTAB EXTENDED RELEASE ORALLY DISINTEGRATING 30MG 100 BOXUD |
2 |
Tier 2 |
N/A | N/A | S |
PREVALITE POW 4GM PK |
1 |
Tier 1 |
N/A | N/A | None |
PREZISTA TABLET 600MG |
2 |
Tier 2 |
N/A | N/A | None |
PREZISTA TABLET 75MG |
2 |
Tier 2 |
N/A | N/A | None |
PREZISTA TABLETS 400MG 60 TABLETS BOT |
2 |
Tier 2 |
N/A | N/A | None |
PRIFTIN 150MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
PRIMIDONE 250MG TABLET (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
PRIMIDONE 50MG TABLET (500 CT) |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRISTIQ 100MG TABLET SR 24HR |
2 |
Tier 2 |
N/A | N/A | P |
PRISTIQ 50MG TABLET SR 24HR |
2 |
Tier 2 |
N/A | N/A | P |
PROBENECID 500MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
PROCHLORPERAZINE EDISYLATE INJECTION 10MG 10 X 2ML VIALS CRTN |
1 |
Tier 1 |
N/A | N/A | None |
PROCHLORPERAZINE MALEATE 10MG TABLET (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
PROCHLORPERAZINE MALEATE 5MG TABLET (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX |
1 |
Tier 1 |
N/A | N/A | None |
PROCRIT 10000U/ML VIAL |
2 |
Tier 2 |
N/A | N/A | P |
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL |
2 |
Tier 2 |
N/A | N/A | P |
PROCRIT 3000U/ML VIAL |
2 |
Tier 2 |
N/A | N/A | P |
PROCRIT 40000U/ML VIAL PR |
2 |
Tier 2 |
N/A | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROCRIT 4000U/ML VIAL 25 X 1ML VIAL |
2 |
Tier 2 |
N/A | N/A | P |
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY |
2 |
Tier 2 |
N/A | N/A | P |
PROCTO-PAK 1% CREAM |
1 |
Tier 1 |
N/A | N/A | None |
PROCTOSOL-HC 2.5% CREAM |
1 |
Tier 1 |
N/A | N/A | None |
PROGLYCEM 50MG/ML ORAL SUSP |
2 |
Tier 2 |
N/A | N/A | None |
PROGRAF 0.5MG CAPSULE |
2 |
Tier 2 |
N/A | N/A | P |
PROGRAF 1MG CAPSULE |
2 |
Tier 2 |
N/A | N/A | P |
PROGRAF 5MG CAPSULE |
2 |
Tier 2 |
N/A | N/A | P |
PROGRAF 5MG/ML AMPULE |
2 |
Tier 2 |
N/A | N/A | P |
PROLASTIN 500MG VIAL |
2 |
Tier 2 |
N/A | N/A | None |
PROLEUKIN 22 MILLION UNITS VL |
2 |
Tier 2 |
N/A | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROMETHAZINE 50MG/ML VIAL |
1 |
Tier 1 |
N/A | N/A | None |
PROMETHAZINE HCL 12.5MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
PROMETHAZINE HCL 25MG TABLET (1000 CT) |
1 |
Tier 1 |
N/A | N/A | None |
PROMETHAZINE HCL 50MG TABLET (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
PROMETHAZINE HCL 6.25MG/5ML SYRUP |
1 |
Tier 1 |
N/A | N/A | None |
PROMETHAZINE HCL INJECTION 25MG 10 X 1ML VIAL |
1 |
Tier 1 |
N/A | N/A | None |
PROMETRIUM 100MG CAPSULE |
2 |
Tier 2 |
N/A | N/A | None |
PROMETRIUM 200MG CAPSULE |
2 |
Tier 2 |
N/A | N/A | None |
PROPAFENONE HCL 150MG TABLET (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
PROPAFENONE HCL 225MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
PROPAFENONE HCL 300MG TABLET (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROPOXY-N/APAP 100-650 TABLET |
1 |
Tier 1 |
N/A | N/A | None |
PROPRANOLOL 60MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
PROPRANOLOL 80MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
PROPRANOLOL HCL 20MG TABLET (1000 CT) |
1 |
Tier 1 |
N/A | N/A | None |
PROPRANOLOL HCL CAPSULES ER 120MG (1000 CT) |
1 |
Tier 1 |
N/A | N/A | None |
PROPRANOLOL HCL CAPSULES ER 160MG (1000 CT) |
1 |
Tier 1 |
N/A | N/A | None |
PROPRANOLOL HCL CAPSULES ER 60MG (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
PROPRANOLOL HCL CAPSULES ER 80MG (1000 CT) |
1 |
Tier 1 |
N/A | N/A | None |
PROPRANOLOL HCL TABLET USP 10MG (1000 CT) |
1 |
Tier 1 |
N/A | N/A | None |
PROPRANOLOL HCL TABLET USP 40MG (1000 CT) |
1 |
Tier 1 |
N/A | N/A | None |
PROPYLTHIOURACIL 50MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROQUAD VIAL |
2 |
Tier 2 |
N/A | N/A | None |
PROTOPIC 0.03% OINTMENT 100GM TUBE |
2 |
Tier 2 |
N/A | N/A | None |
PROTOPIC 0.1% OINTMENT 60GM TUBE |
2 |
Tier 2 |
N/A | N/A | None |
PROTRIPTYLINE HYDROCHLORIDE TABLETS |
1 |
Tier 1 |
N/A | N/A | None |
PROTRIPTYLINE HYDROCHLORIDE TABLETS 5MG |
1 |
Tier 1 |
N/A | N/A | None |
PROVENTIL HFA INHALER 90MCG AE |
2 |
Tier 2 |
N/A | N/A | None |
PROVIGIL 100MG TABLET |
2 |
Tier 2 |
N/A | N/A | P Q:68 /34Days |
PROVIGIL 200MG TABLET |
2 |
Tier 2 |
N/A | N/A | P Q:68 /34Days |
PULMICORT .25MG/2ML RESPULE |
2 |
Tier 2 |
N/A | N/A | None |
PULMICORT 0.5MG/2ML RESPULE |
2 |
Tier 2 |
N/A | N/A | None |
PYRAZINAMIDE 500MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PYRIDOSTIGMINE BROMIDE 60MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |