2010 Medicare Part D Plan Formulary Information |
Gateway Health Plan Medicare Assured (HMO) (H5932-001-0)
Benefit Details
|
The Gateway Health Plan Medicare Assured (HMO) (H5932-001-0) Formulary Drugs Starting with the Letter P in Blair County, PA: CMS MA Region 6 which includes: PA
|
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 100MG TABLET |
2 |
Tier 2 |
$45.00 | N/A | None |
PACLITAXEL INJECTION SOLUTION 6MG 50ML VIALMD |
1* |
Tier 1 |
$0.00 | N/A | P |
PAMIDRONATE 60MG/10ML VIAL |
1* |
Tier 1 |
$0.00 | N/A | P |
PAMIDRONATE DISODIUM INJECTION 3MG 10ML VIALSD |
1* |
Tier 1 |
$0.00 | N/A | P |
PAMIDRONATE DISODIUM INJECTION 9MG 10ML VIALSD |
1* |
Tier 1 |
$0.00 | N/A | P |
PANCREASE MT 4 CAPSULE EC |
3 |
Tier 3 |
$94.75 | N/A | None |
PANCRELIPASE 16-48-48 CAPSULE |
1* |
Tier 1 |
$0.00 | N/A | None |
PANCRELIPASE TABLET 8000;30000 MG; |
1* |
Tier 1 |
$0.00 | N/A | None |
PANCRON 10 CAPSULE EC |
1* |
Tier 1 |
$0.00 | N/A | None |
PANCRON 20 CAPSULE SA |
1* |
Tier 1 |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PANRETIN 0.1% GEL 60GM TUBE |
4 |
Tier 4 |
25% | N/A | None |
PAROMOMYCIN 250MG CAPSULE |
1* |
Tier 1 |
$0.00 | N/A | None |
PAROXETINE 40MG TABLET (500 CT) |
1* |
Tier 1 |
$0.00 | N/A | None |
PAROXETINE FILM COATED 20MG TABLET (100 CT) |
1* |
Tier 1 |
$0.00 | N/A | Q:30 /30Days |
PAROXETINE HCL 10MG TABLET |
1* |
Tier 1 |
$0.00 | N/A | Q:30 /30Days |
PAROXETINE HCL 10MG/5ML SUSPENSION ORAL |
1* |
Tier 1 |
$0.00 | N/A | None |
PAROXETINE TABLETS 30MG 90 BOT |
1* |
Tier 1 |
$0.00 | N/A | None |
PASER GRANULES 4GM PACKET |
3 |
Tier 3 |
$94.75 | N/A | None |
PATADAY 0.2% DROPS |
2 |
Tier 2 |
$45.00 | N/A | None |
PATANOL 0.1% EYE DROPS |
2 |
Tier 2 |
$45.00 | N/A | None |
PEDIARIX SOLUTION INJECTION 25-25-10 10 X .5ML VIAL |
2 |
Tier 2 |
$45.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PEDVAXHIB VACCINE VIAL |
2 |
Tier 2 |
$45.00 | N/A | None |
PEG 3350/ELECTROLYTE 240-22.72G SOLUTION RECONSTITUTED ORAL |
1* |
Tier 1 |
$0.00 | N/A | None |
PEG-INTRON 100MCG KIT |
4 |
Tier 4 |
25% | N/A | P |
PEG-INTRON REDIPEN 150MCG |
4 |
Tier 4 |
25% | N/A | P |
PEG-INTRON REDIPEN 80MCG |
4 |
Tier 4 |
25% | N/A | P |
PEG-INTRON REDIPEN 80MCG 4PK |
4 |
Tier 4 |
25% | N/A | P |
PEG-INTRON REDIPEN PAK 4 |
4 |
Tier 4 |
25% | N/A | P |
PEGANONE 250MG TABLET |
2 |
Tier 2 |
$45.00 | N/A | None |
PEGASYS 180MCG/0.5ML CONV.PK |
4 |
Tier 4 |
25% | N/A | P |
PEGINTRON REDIPEN 150MCG 4PK |
4 |
Tier 4 |
25% | N/A | P |
PENICILLIN V POTASSIUM 250MG TABLET (1000 CT) |
1* |
Tier 1 |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PENICILLIN V POTASSIUM 250MG/5ML LIQUID |
1* |
Tier 1 |
$0.00 | N/A | None |
PENICILLIN V POTASSIUM 500MG TABLET |
1* |
Tier 1 |
$0.00 | N/A | None |
PENICILLIN V POTASSIUM FOR ORAL SOLUTION CONCENTRATE 125MG 200ML BOT |
1* |
Tier 1 |
$0.00 | N/A | None |
PENTASA 250MG CAPSULE SA |
2 |
Tier 2 |
$45.00 | N/A | None |
PENTASA 500MG CAPSULE |
2 |
Tier 2 |
$45.00 | N/A | None |
PENTAZOCINE/NALOXONE TABLET |
1* |
Tier 1 |
$0.00 | N/A | None |
PENTOXIFYLLINE 400MG TABLET SA |
1* |
Tier 1 |
$0.00 | N/A | None |
PERPHENAZINE TABLETS 16MG 100 BOT |
1* |
Tier 1 |
$0.00 | N/A | None |
PERPHENAZINE TABLETS 4MG 100 BOXUD |
1* |
Tier 1 |
$0.00 | N/A | None |
PERPHENAZINE TABLETS 8MG 100 BOT |
1* |
Tier 1 |
$0.00 | N/A | None |
PERPHENAZINE TABLETS USP 2MG 100 BOT |
1* |
Tier 1 |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PFIZERPEN 20MMU VIAL |
1* |
Tier 1 |
$0.00 | N/A | None |
PFIZERPEN 5MMU VIAL |
1* |
Tier 1 |
$0.00 | N/A | None |
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT |
1* |
Tier 1 |
$0.00 | N/A | None |
PHENYTOIN SODIUM EXTENDED CAPSULES 100MG (100 CT) |
1* |
Tier 1 |
$0.00 | N/A | None |
PHENYTOIN SODIUM INJECTION 50MG 25 X 2ML AMP |
1* |
Tier 1 |
$0.00 | N/A | None |
PHOSPHOLINE IODIDE 0.125% |
2 |
Tier 2 |
$45.00 | N/A | None |
PILOCARPINE HCL 5MG TABLET (100 CT) |
1* |
Tier 1 |
$0.00 | N/A | None |
PILOCARPINE HCL 7.5MG TABLET |
1* |
Tier 1 |
$0.00 | N/A | None |
PILOPINE HS 4% EYE GEL |
2 |
Tier 2 |
$45.00 | N/A | None |
PINDOLOL 10MG TABLET |
1* |
Tier 1 |
$0.00 | N/A | None |
PINDOLOL 5MG TABLET |
1* |
Tier 1 |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PIPERACILLIN 3GM VIAL |
1* |
Tier 1 |
$0.00 | N/A | None |
PIPERACILLIN 40GM BULK VIAL |
1* |
Tier 1 |
$0.00 | N/A | None |
PIROXICAM 10MG CAPSULE |
1* |
Tier 1 |
$0.00 | N/A | None |
PIROXICAM 20MG CAPSULE (500 CT) |
1* |
Tier 1 |
$0.00 | N/A | None |
PLAN B 0.75MG TABLET 2 BLPK |
2 |
Tier 2 |
$45.00 | N/A | None |
PLAVIX 75MG TABLET |
2 |
Tier 2 |
$45.00 | N/A | None |
PODOFILOX 0.5% TOPICAL TUBEX |
1* |
Tier 1 |
$0.00 | N/A | None |
POLY-DEX 0.1% SUSPENSION DROPS |
1* |
Tier 1 |
$0.00 | N/A | None |
POLY-PRED EYE DROPS |
2 |
Tier 2 |
$45.00 | N/A | None |
POLYCIN-B 500-10KU/G OINTMENT |
1* |
Tier 1 |
$0.00 | N/A | None |
POLYGAM S/D 10GM VL W/DILUENT |
4 |
Tier 4 |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POLYMYXIN B SUL-TRIMETHOPRIM 10K U-0.1% |
1* |
Tier 1 |
$0.00 | N/A | None |
POTASSIUM CHLORIDE 10MEQ/50ML SOL |
1* |
Tier 1 |
$0.00 | N/A | None |
POTASSIUM CHLORIDE 20MEQ TABLET SR PARTICLES/CRYSTALS |
1* |
Tier 1 |
$0.00 | N/A | None |
POTASSIUM CHLORIDE 40MEQ IN D5W LACT RNG |
1* |
Tier 1 |
$0.00 | N/A | None |
POTASSIUM CHLORIDE 8MEQ TABLET SA |
1* |
Tier 1 |
$0.00 | N/A | None |
POTASSIUM CHLORIDE ER CAPSULES 10MEQ |
1* |
Tier 1 |
$0.00 | N/A | None |
POTASSIUM CHLORIDE FOR INJECTION CONCENTRATE |
1* |
Tier 1 |
$0.00 | N/A | None |
POTASSIUM CITRATE 10MEQ TABLET SA |
1* |
Tier 1 |
$0.00 | N/A | None |
POTASSIUM CITRATE 5MEQ TABLET SA |
1* |
Tier 1 |
$0.00 | N/A | None |
PRANDIN 0.5MG TABLET |
2 |
Tier 2 |
$45.00 | N/A | None |
PRANDIN 1MG TABLET |
2 |
Tier 2 |
$45.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRANDIN 2MG TABLET |
2 |
Tier 2 |
$45.00 | N/A | None |
PRAVASTATIN SODIUM 20MG TABLET 500 BOT |
1* |
Tier 1 |
$0.00 | N/A | None |
PRAVASTATIN SODIUM 40MG TABLET (500 CT) |
1* |
Tier 1 |
$0.00 | N/A | None |
PRAVASTATIN SODIUM 80MG TABLET (90 CT) |
1* |
Tier 1 |
$0.00 | N/A | None |
PRAVASTATIN SODIUM TABLETS 10MG 90 BOT |
1* |
Tier 1 |
$0.00 | N/A | None |
PRAZOSIN 5MG CAPSULE |
1* |
Tier 1 |
$0.00 | N/A | None |
PRAZOSIN HCL 1MG CAPSULE |
1* |
Tier 1 |
$0.00 | N/A | None |
PRAZOSIN HCL 2MG CAPSULE |
1* |
Tier 1 |
$0.00 | N/A | None |
PRED MILD 0.12% EYE DROPS |
2 |
Tier 2 |
$45.00 | N/A | None |
PREDNISOLONE 5MG/5ML TUBEX |
1* |
Tier 1 |
$0.00 | N/A | None |
PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION 1.0% STERILE 10ML BOTDR |
1* |
Tier 1 |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREDNISOLONE SOD 1% EYE DROP |
1* |
Tier 1 |
$0.00 | N/A | None |
PREDNISOLONE SODIUM PHOSPHATE 15MG/5ML SOLUTION ORAL |
1* |
Tier 1 |
$0.00 | N/A | None |
PREDNISONE 10MG TABLET (100 CT) |
1* |
Tier 1 |
$0.00 | N/A | None |
PREDNISONE 1MG TABLET |
1* |
Tier 1 |
$0.00 | N/A | None |
PREDNISONE 2.5MG TABLET |
1* |
Tier 1 |
$0.00 | N/A | None |
PREDNISONE 20MG TABLET (1000 CT) |
1* |
Tier 1 |
$0.00 | N/A | None |
PREDNISONE 50MG TABLET |
1* |
Tier 1 |
$0.00 | N/A | None |
PREDNISONE 5MG TABLET (100 CT) |
1* |
Tier 1 |
$0.00 | N/A | None |
PREDNISONE 5MG/5ML SOLUTION |
1* |
Tier 1 |
$0.00 | N/A | None |
PREDNISONE 5MG/ML SOLUTION |
1* |
Tier 1 |
$0.00 | N/A | None |
PREMARIN 0.3MG (100 CT) |
2 |
Tier 2 |
$45.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREMARIN 0.45MG TABLET |
2 |
Tier 2 |
$45.00 | N/A | Q:30 /30Days |
PREMARIN 0.625MG (100 CT) |
2 |
Tier 2 |
$45.00 | N/A | Q:30 /30Days |
PREMARIN 0.9MG TABLET |
2 |
Tier 2 |
$45.00 | N/A | None |
PREMARIN 1.25MG (100 CT) |
2 |
Tier 2 |
$45.00 | N/A | None |
PREMARIN VAGINAL CREAM /APPL |
2 |
Tier 2 |
$45.00 | N/A | None |
PREMPHASE 0.625/5MG TABLET |
2 |
Tier 2 |
$45.00 | N/A | None |
PREMPRO 0.3MG/1.5MG TABLET |
2 |
Tier 2 |
$45.00 | N/A | None |
PREMPRO 0.45/1.5MG TABLET |
2 |
Tier 2 |
$45.00 | N/A | None |
PREMPRO 0.625/2.5MG TABLET DIALPK |
2 |
Tier 2 |
$45.00 | N/A | None |
PREMPRO 0.625/5MG TABLET |
2 |
Tier 2 |
$45.00 | N/A | None |
PRENATABS OBN TABLETS 200;1;150;MG;MG;MCG; 90 BOT |
1* |
Tier 1 |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREVACID CAPSULES EXTENDED RELEASE 15MG 100 BOXUD |
2 |
Tier 2 |
$45.00 | N/A | S Q:30 /30Days |
PREVACID CAPSULES EXTENDED RELEASE 30MG 100 BOXUD |
2 |
Tier 2 |
$45.00 | N/A | S Q:30 /30Days |
PREVACID SOLUTAB EXTENDED RELEASE ORALLY DISINTEGRATING 30MG 100 BOXUD |
2 |
Tier 2 |
$45.00 | N/A | S Q:30 /30Days |
PREVACID SOLUTAB TABLETS DELAYED RELEASE ORALLY DISINTEGRATING 15MG 100 BOXUD |
2 |
Tier 2 |
$45.00 | N/A | S Q:30 /30Days |
PREZISTA TABLET 600MG |
3 |
Tier 3 |
$94.75 | N/A | None |
PREZISTA TABLET 75MG |
3 |
Tier 3 |
$94.75 | N/A | None |
PREZISTA TABLETS 400MG 60 TABLETS BOT |
3 |
Tier 3 |
$94.75 | N/A | None |
PRIFTIN 150MG TABLET |
2 |
Tier 2 |
$45.00 | N/A | None |
PRIMAQUINE 26.3MG TABLET |
1* |
Tier 1 |
$0.00 | N/A | None |
PRIMAXIN I.M. 500MG VIAL |
2 |
Tier 2 |
$45.00 | N/A | None |
PRIMAXIN IV 250MG VIAL |
2 |
Tier 2 |
$45.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRIMAXIN IV INJ 500MG |
2 |
Tier 2 |
$45.00 | N/A | None |
PRIMIDONE 250MG TABLET (100 CT) |
1* |
Tier 1 |
$0.00 | N/A | None |
PRIMIDONE 50MG TABLET (500 CT) |
1* |
Tier 1 |
$0.00 | N/A | None |
PRISTIQ 100MG TABLET SR 24HR |
3 |
Tier 3 |
$94.75 | N/A | S Q:30 /30Days |
PRISTIQ 50MG TABLET SR 24HR |
3 |
Tier 3 |
$94.75 | N/A | S Q:30 /30Days |
PROBENECID 500MG TABLET |
1* |
Tier 1 |
$0.00 | N/A | None |
PROBENECID/COLCHICINE TABLET S |
1* |
Tier 1 |
$0.00 | N/A | None |
PROCHLORPERAZINE EDISYLATE INJECTION 10MG 10 X 2ML VIALS CRTN |
1* |
Tier 1 |
$0.00 | N/A | None |
PROCHLORPERAZINE MALEATE 10MG TABLET (100 CT) |
1* |
Tier 1 |
$0.00 | N/A | None |
PROCHLORPERAZINE MALEATE 5MG TABLET (100 CT) |
1* |
Tier 1 |
$0.00 | N/A | None |
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX |
1* |
Tier 1 |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROCRIT 10000U/ML VIAL |
4 |
Tier 4 |
25% | N/A | P |
PROCRIT 3000U/ML VIAL |
3 |
Tier 3 |
$94.75 | N/A | P |
PROCRIT 40000U/ML VIAL PR |
4 |
Tier 4 |
25% | N/A | P |
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY |
4 |
Tier 4 |
25% | N/A | P |
PROCTOZONE-HC 2.5% CREAM |
1* |
Tier 1 |
$0.00 | N/A | None |
PROGLYCEM 50MG/ML ORAL SUSP |
3 |
Tier 3 |
$94.75 | N/A | None |
PROGRAF 0.5MG CAPSULE |
2 |
Tier 2 |
$45.00 | N/A | None |
PROGRAF 1MG CAPSULE |
2 |
Tier 2 |
$45.00 | N/A | None |
PROGRAF 5MG CAPSULE |
2 |
Tier 2 |
$45.00 | N/A | None |
PROLASTIN 500MG VIAL |
4 |
Tier 4 |
25% | N/A | P |
PROLEUKIN 22 MILLION UNITS VL |
4 |
Tier 4 |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROPAFENONE HCL 150MG TABLET (100 CT) |
1* |
Tier 1 |
$0.00 | N/A | None |
PROPAFENONE HCL 225MG TABLET |
1* |
Tier 1 |
$0.00 | N/A | None |
PROPAFENONE HCL 300MG TABLET (100 CT) |
1* |
Tier 1 |
$0.00 | N/A | None |
PROPANTHELINE 15MG TABLET |
1* |
Tier 1 |
$0.00 | N/A | None |
PROPARACAINE 0.5% EYE DROPS |
1* |
Tier 1 |
$0.00 | N/A | None |
PROPRANOLOL 20MG/5ML TUBEX |
1* |
Tier 1 |
$0.00 | N/A | None |
PROPRANOLOL 40MG/5ML TUBEX |
1* |
Tier 1 |
$0.00 | N/A | None |
PROPRANOLOL 60MG TABLET |
1* |
Tier 1 |
$0.00 | N/A | None |
PROPRANOLOL 80MG TABLET |
1* |
Tier 1 |
$0.00 | N/A | None |
PROPRANOLOL HCL 20MG TABLET (1000 CT) |
1* |
Tier 1 |
$0.00 | N/A | None |
PROPRANOLOL HCL CAPSULES ER 120MG (1000 CT) |
1* |
Tier 1 |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROPRANOLOL HCL CAPSULES ER 160MG (1000 CT) |
1* |
Tier 1 |
$0.00 | N/A | None |
PROPRANOLOL HCL CAPSULES ER 60MG (100 CT) |
1* |
Tier 1 |
$0.00 | N/A | None |
PROPRANOLOL HCL CAPSULES ER 80MG (1000 CT) |
1* |
Tier 1 |
$0.00 | N/A | None |
PROPRANOLOL HCL TABLET USP 10MG (1000 CT) |
1* |
Tier 1 |
$0.00 | N/A | None |
PROPRANOLOL HCL TABLET USP 40MG (1000 CT) |
1* |
Tier 1 |
$0.00 | N/A | None |
PROPRANOLOL/HCTZ 40/25 TABLET |
1* |
Tier 1 |
$0.00 | N/A | None |
PROPRANOLOL/HCTZ 80/25 TABLET |
1* |
Tier 1 |
$0.00 | N/A | None |
PROPYLTHIOURACIL 50MG TABLET |
1* |
Tier 1 |
$0.00 | N/A | None |
PROQUAD VIAL |
2 |
Tier 2 |
$45.00 | N/A | None |
PROTONIX IV 40MG VIAL |
3 |
Tier 3 |
$94.75 | N/A | None |
PROVIGIL 100MG TABLET |
3 |
Tier 3 |
$94.75 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROVIGIL 200MG TABLET |
3 |
Tier 3 |
$94.75 | N/A | P |
PULMICORT .25MG/2ML RESPULE |
3 |
Tier 3 |
$94.75 | N/A | P Q:120 /30Days |
PULMICORT 0.5MG/2ML RESPULE |
3 |
Tier 3 |
$94.75 | N/A | P Q:120 /30Days |
PULMOZYME 1MG/ML AMPUL |
4 |
Tier 4 |
25% | N/A | P Q:150 /30Days |
PYRAZINAMIDE 500MG TABLET |
1* |
Tier 1 |
$0.00 | N/A | None |
PYRIDOSTIGMINE BROMIDE 60MG TABLET |
1* |
Tier 1 |
$0.00 | N/A | None |