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2010 Medicare Part D Plan (PDP Only) Formulary Browser
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.
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MedicareBlue Rx Standard (PDP) (S5743-001-0)
Tier 1 (1626)
Tier 2 (339)
Tier 3 (499)
Tier 4 (212)

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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 
2010 Medicare Part D Plan Formulary Information
MedicareBlue Rx Standard (PDP) (S5743-001-0)
Benefit Details  
The MedicareBlue Rx Standard (PDP) (S5743-001-0)
Formulary Drugs Starting with the Letter C
in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY
Drugs Starting with Letter C

Drug Name		 Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order
CABERGOLINE 0.5MG TABLET   1 Level 1: Covered Generics 10%10%None
CALCIPOTRIENE TOPICAL SOLUTION   1 Level 1: Covered Generics 10%10%None
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY   1 Level 1: Covered Generics 10%10%None
CALCITRIOL 0.25MCG CAPSULE   1 Level 1: Covered Generics 10%10%None
CALCITRIOL 0.5MCG CAPSULE   1 Level 1: Covered Generics 10%10%None
CALCITRIOL 1MCG/ML SOLUTION ORAL   1 Level 1: Covered Generics 10%10%None
CALCITRIOL INJECTION SOLUTION 1MCG 50 X 01ML AMP   1 Level 1: Covered Generics 10%10%None
CALCIUM ACETATE CAPSULE 667 MG   1 Level 1: Covered Generics 10%10%None
CAMILA 0.35MG TABLET   1 Level 1: Covered Generics 10%10%None
CAMPATH 30MG/ML VIAL   4 Covered Specialty 25%25%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CANASA RECTAL SUPPOSITORIES 1000MG 30 BOX   2 Level 2: Covered Preferred Brand 22%22%None
CANCIDAS IV 50MG VIAL   4 Covered Specialty 25%25%None
CANCIDAS IV 70MG VIAL   4 Covered Specialty 25%25%None
CAPASTAT SULFATE 1GM VIAL   3 Level 3: Covered Brand 50%50%None
CAPTOPRIL 100MG TABLET   1 Level 1: Covered Generics 10%10%None
CAPTOPRIL 12.5MG TABLET   1 Level 1: Covered Generics 10%10%None
CAPTOPRIL 25MG TABLET   1 Level 1: Covered Generics 10%10%None
CAPTOPRIL 50MG TABLET   1 Level 1: Covered Generics 10%10%None
CAPTOPRIL/HCTZ 25/15 TABLET   1 Level 1: Covered Generics 10%10%None
CAPTOPRIL/HCTZ 25/25 TABLET   1 Level 1: Covered Generics 10%10%None
CAPTOPRIL/HCTZ 50/15 TABLET   1 Level 1: Covered Generics 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CAPTOPRIL/HCTZ 50/25 TABLET   1 Level 1: Covered Generics 10%10%None
CARAC CRE 0.5%   3 Level 3: Covered Brand 50%50%None
CARBAMAZEPINE 100MG/5ML SUSPENSION ORAL   1 Level 1: Covered Generics 10%10%None
CARBAMAZEPINE EXTENDED RELEASE TABLETS 200MG   1 Level 1: Covered Generics 10%10%None
CARBAMAZEPINE EXTENDED RELEASE TABLETS 400MG   1 Level 1: Covered Generics 10%10%None
CARBAMAZEPINE TABLET CHEWABLE 100MG (100 CT)   1 Level 1: Covered Generics 10%10%None
CARBAMAZEPINE TABLET USP 200MG (1000 CT)   1 Level 1: Covered Generics 10%10%None
CARBATROL 100MG CAPSULE SA   3 Level 3: Covered Brand 50%50%None
CARBATROL 200MG CAPSULE SA   3 Level 3: Covered Brand 50%50%None
CARBATROL 300MG CAPSULE SA   3 Level 3: Covered Brand 50%50%None
CARBIDOPA-LEVODOPA 25MG-100MG TABLET SA   1 Level 1: Covered Generics 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CARBIDOPA-LEVODOPA 50MG-200MG TABLET SA   1 Level 1: Covered Generics 10%10%None
CARBIDOPA/LEVO 10/100 TABLET   1 Level 1: Covered Generics 10%10%None
CARBIDOPA/LEVO 25/100 TABLET   1 Level 1: Covered Generics 10%10%None
CARBIDOPA/LEVO 25/250 TABLET   1 Level 1: Covered Generics 10%10%None
CARBINOXAMINE MALEATE SOLUTION 4MG/5ML 16 OZ BOT   1 Level 1: Covered Generics 10%10%None
CARBINOXAMINE MALEATE TABLETS 4MG 100 BOT   1 Level 1: Covered Generics 10%10%None
CARBOPLATIN AQUEOUS SOLUTION INJECTION 150MG 15ML VIAL   1 Level 1: Covered Generics 10%10%None
CARTEOLOL HCL OPHTHALMIC SOLUTION USP 1% 15ML BOT   1 Level 1: Covered Generics 10%10%None
CARTIA XT 120MG CAPSULE SA   1 Level 1: Covered Generics 10%10%None
CARTIA XT 180MG CAPSULE SA   1 Level 1: Covered Generics 10%10%None
CARTIA XT 240MG CAPSULE SA   1 Level 1: Covered Generics 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CARTIA XT 300MG CAPSULE SR 24 HR   1 Level 1: Covered Generics 10%10%None
CARVEDILOL 12.5MG TABLET (100 CT)   1 Level 1: Covered Generics 10%10%None
CARVEDILOL 25MG TABLET (500 CT)   1 Level 1: Covered Generics 10%10%None
CARVEDILOL 3.125MG TABLET (100 CT)   1 Level 1: Covered Generics 10%10%None
CARVEDILOL 6.25MG TABLET (500 CT)   1 Level 1: Covered Generics 10%10%None
CEENU 100MG CAPSULE   3 Level 3: Covered Brand 50%50%None
CEENU 10MG CAPSULE   3 Level 3: Covered Brand 50%50%None
CEENU 40MG CAPSULE   3 Level 3: Covered Brand 50%50%None
CEFACLOR CAPSULES USP 250MG (100 CT)   1 Level 1: Covered Generics 10%10%None
CEFACLOR CAPSULES USP 500MG (100 CT)   1 Level 1: Covered Generics 10%10%None
CEFADROXIL 1G TABLET   1 Level 1: Covered Generics 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CEFADROXIL 500MG CAPSULE   1 Level 1: Covered Generics 10%10%None
CEFADROXIL 500MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Level 1: Covered Generics 10%10%None
CEFADROXIL FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   1 Level 1: Covered Generics 10%10%None
CEFAZOLIN 1GM/D5W BAG   3 Level 3: Covered Brand 50%50%None
CEFAZOLIN 20GM BULK VIAL   1 Level 1: Covered Generics 10%10%None
CEFAZOLIN 500MG/D5W BAG   3 Level 3: Covered Brand 50%50%None
CEFAZOLIN FOR INJECTION   1 Level 1: Covered Generics 10%10%None
CEFAZOLIN FOR INJECTION 1MG 25 VIALGL   1 Level 1: Covered Generics 10%10%None
CEFDINIR 250MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Level 1: Covered Generics 10%10%None
CEFDINIR CAPSULES 300MG (60 CT)   1 Level 1: Covered Generics 10%10%None
CEFDINIR FOR ORAL SUSPENSION 125MG/5ML (100 CT)   1 Level 1: Covered Generics 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CEFEPIME HCL 2 GRAM VIAL   1 Level 1: Covered Generics 10%10%None
CEFEPIME INJ 1GM 20ML APX 10x1G VIAL   1 Level 1: Covered Generics 10%10%None
CEFIZOX 1GM IN D5W 50ML   3 Level 3: Covered Brand 50%50%None
CEFIZOX 2GM IN D5W 50ML   3 Level 3: Covered Brand 50%50%None
CEFOTAXIME FOR INJECTION   1 Level 1: Covered Generics 10%10%None
CEFOTAXIME FOR INJECTION 1GM 50 BOX VIALGL   1 Level 1: Covered Generics 10%10%None
CEFOTAXIME FOR INJECTION 2GM 25 VIAL   1 Level 1: Covered Generics 10%10%None
CEFOTAXIME FOR INJECTION 500MG 10 VIAL   1 Level 1: Covered Generics 10%10%None
CEFOXITIN FOR INJECTION 10GM 10 X 100ML VIAL   1 Level 1: Covered Generics 10%10%None
CEFOXITIN FOR INJECTION 1GM 25 X 20ML VIAL   1 Level 1: Covered Generics 10%10%None
CEFOXITIN FOR INJECTION 2GM 20ML VIAL   1 Level 1: Covered Generics 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CEFPODOXIME PROXETIL 200MG TABLET   1 Level 1: Covered Generics 10%10%None
CEFPODOXIME PROXETIL FILM COATED TABLET 100MG (20 CT)   1 Level 1: Covered Generics 10%10%None
CEFPODOXIME PROXETIL FOR ORAL SUSPENSION 100MG 50ML BOT   1 Level 1: Covered Generics 10%10%None
CEFPODOXIME PROXETIL FOR ORAL SUSPENSION 50MG 50ML BOT   1 Level 1: Covered Generics 10%10%None
CEFPROZIL 250MG TABLET (100 CT)   1 Level 1: Covered Generics 10%10%None
CEFPROZIL 250MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Level 1: Covered Generics 10%10%None
CEFPROZIL FOR ORAL SUSPENSION 125MG/5ML 75ML BOT   1 Level 1: Covered Generics 10%10%None
CEFPROZIL TABLETS 500MG 100 BOT   1 Level 1: Covered Generics 10%10%None
CEFTAZIDIME FOR INJECTION 1GM/VIAL 1 SINGLE VIAL VIAL   1 Level 1: Covered Generics 10%10%None
CEFTAZIDIME FOR INJECTION 2GM/VIAL 10 X 2 CRTN   1 Level 1: Covered Generics 10%10%None
CEFTAZIDIME FOR INJECTION 6GM/VIAL 6 X 6 CRTN   1 Level 1: Covered Generics 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CEFTRIAXONE 10GM VIAL   1 Level 1: Covered Generics 10%10%None
CEFTRIAXONE FOR INJECTION 250MG BOX OF 10 VIALGL   1 Level 1: Covered Generics 10%10%None
CEFTRIAXONE FOR INJECTION 500MG BOX OF 10 VIALGL   1 Level 1: Covered Generics 10%10%None
CEFTRIAXONE FOR INJECTION AND DEXTROSE INJECTION 1 GM/50ML   3 Level 3: Covered Brand 50%50%None
CEFTRIAXONE FOR INJECTION AND DEXTROSE INJECTION 2 GM/50ML   3 Level 3: Covered Brand 50%50%None
CEFUROXIME 250MG TABLET   1 Level 1: Covered Generics 10%10%None
CEFUROXIME AXETIL 125MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Level 1: Covered Generics 10%10%None
CEFUROXIME AXETIL 250MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Level 1: Covered Generics 10%10%None
CEFUROXIME AXETIL 500MG TABLET (20 CT)   1 Level 1: Covered Generics 10%10%None
CEFUROXIME FOR INJECTION   1 Level 1: Covered Generics 10%10%None
CEFUROXIME FOR INJECTION   1 Level 1: Covered Generics 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CEFUROXIME FOR INJECTION 7.5GM 10 X 7.5 VIALPHR   1 Level 1: Covered Generics 10%10%None
CEFUROXIME FOR INJECTION AND DEXTROSE INJECTION   3 Level 3: Covered Brand 50%50%None
CEFUROXIME FOR INJECTION AND DEXTROSE INJECTION   3 Level 3: Covered Brand 50%50%None
CELEBREX 100MG CAPSULE   2 Level 2: Covered Preferred Brand 22%22%Q:60
/30Days
CELEBREX 200MG CAPSULE   2 Level 2: Covered Preferred Brand 22%22%Q:60
/30Days
CELEBREX 400MG CAPSULE   2 Level 2: Covered Preferred Brand 22%22%Q:60
/30Days
CELEBREX 50MG CAPSULE   2 Level 2: Covered Preferred Brand 22%22%Q:60
/30Days
CELLCEPT 200MG/ML ORAL SUSP   4 Covered Specialty 25%25%P
CELLCEPT IV INJ 500MG   3 Level 3: Covered Brand 50%50%P
CELONTIN 300MG KAPSEAL   3 Level 3: Covered Brand 50%50%None
CEPHALEXIN 250MG CAPSULE   1 Level 1: Covered Generics 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CEPHALEXIN 250MG/5ML ORAL SUSP   1 Level 1: Covered Generics 10%10%None
CEPHALEXIN CAPSULES 500MG (500 CT)   1 Level 1: Covered Generics 10%10%None
CEPHALEXIN POWDER FOR SUSPENSION ORAL USP 125MG 200ML BOT   1 Level 1: Covered Generics 10%10%None
CEREZYME INJ 200UNIT   4 Covered Specialty 25%25%None
CESIA 7 DAYS X 3 TABLET   1 Level 1: Covered Generics 10%10%None
CHANTIX 0.5MG TABLET   3 Level 3: Covered Brand 50%50%Q:336
/365Days
CHANTIX 1MG TABLET   3 Level 3: Covered Brand 50%50%Q:336
/365Days
CHANTIX STARTING MONTH PAK   3 Level 3: Covered Brand 50%50%Q:336
/365Days
CHEMET 100MG CAPSULE   3 Level 3: Covered Brand 50%50%None
CHLORAMPHEN NA SUCC 1GM VL   3 Level 3: Covered Brand 50%50%None
CHLORHEXIDINE GLUCONATE 0.12% MOUTHWASH   1 Level 1: Covered Generics 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CHLOROQUINE PH 500MG TABLET   1 Level 1: Covered Generics 10%10%None
CHLOROQUINE PHOSPHATE 250MG TABLET (50 CT)   1 Level 1: Covered Generics 10%10%None
CHLOROTHIAZIDE 250MG TABLET   1 Level 1: Covered Generics 10%10%None
CHLOROTHIAZIDE 500MG TABLET   1 Level 1: Covered Generics 10%10%None
CHLORPROMAZINE 100MG TABLET   1 Level 1: Covered Generics 10%10%None
CHLORPROMAZINE 10MG TABLET   1 Level 1: Covered Generics 10%10%None
CHLORPROMAZINE 25MG TABLET   1 Level 1: Covered Generics 10%10%None
CHLORPROMAZINE 25MG/ML AMP   3 Level 3: Covered Brand 50%50%None
CHLORPROMAZINE 50MG TABLET   1 Level 1: Covered Generics 10%10%None
CHLORPROMAZINE HCL 200MG TABLET   1 Level 1: Covered Generics 10%10%None
CHLORTHALIDONE 25MG TABLET (100 CT)   1 Level 1: Covered Generics 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CHLORTHALIDONE 50MG TABLET (1000 CT)   1 Level 1: Covered Generics 10%10%None
CHOLESTYRAMINE LIGHT ORAL SUSP USP POWDER 4GM 210GM CAN   1 Level 1: Covered Generics 10%10%None
CHOLESTYRAMINE LIGHT ORAL SUSP USP POWDER 4GM 60 X 5 SINGLE DOSE CRTN   1 Level 1: Covered Generics 10%10%None
CHOLESTYRAMINE POWDER FOR ORAL SUSPENSION USP 4GM 60 X 9GM SINGLE DOSE CRTN   1 Level 1: Covered Generics 10%10%None
CHOLESTYRAMINE POWDER FOR ORAL SUSPENSION USP 4GM 378GM CAN   1 Level 1: Covered Generics 10%10%None
CHORIONIC GONAD 10000U VIAL   1 Level 1: Covered Generics 10%10%None
CICLOPIROX 0.77% CREAM   1 Level 1: Covered Generics 10%10%None
CICLOPIROX 0.77% GEL   1 Level 1: Covered Generics 10%10%None
CICLOPIROX 0.77% TOPICAL SUSPENSION   1 Level 1: Covered Generics 10%10%None
CICLOPIROX 8% TOPICAL SOLUTION NAIL LACQUER 6.6ML BOT   1 Level 1: Covered Generics 10%10%None
CILOSTAZOL 50MG TABLET (60 CT)   1 Level 1: Covered Generics 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CILOSTAZOL TABLET 100MG (60 CT)   1 Level 1: Covered Generics 10%10%None
CIMETIDINE 150MG/ML VIAL   1 Level 1: Covered Generics 10%10%None
CIMETIDINE 200MG TABLET   1 Level 1: Covered Generics 10%10%None
CIMETIDINE HCL 300MG/5ML SOL   1 Level 1: Covered Generics 10%10%None
CIMETIDINE TABLET USP 300MG (1000 CT)   1 Level 1: Covered Generics 10%10%None
CIMETIDINE TABLET USP 400MG (1000 CT)   1 Level 1: Covered Generics 10%10%None
CIMETIDINE TABLET USP 800MG (30 CT)   1 Level 1: Covered Generics 10%10%None
CIPRO (10%) SUS 500MG/5   3 Level 3: Covered Brand 50%50%None
CIPRO (5%) SUS 250MG/5   3 Level 3: Covered Brand 50%50%None
CIPRODEX OTIC SUSPENSION   3 Level 3: Covered Brand 50%50%None
CIPROFLOXACIN 10MG/ML VIAL   1 Level 1: Covered Generics 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CIPROFLOXACIN 250MG TABLET (100 CT)   1 Level 1: Covered Generics 10%10%None
CIPROFLOXACIN 500MG TABLET   1 Level 1: Covered Generics 10%10%None
CIPROFLOXACIN ER 1000MG TABLET (30 CT)   1 Level 1: Covered Generics 10%10%None
CIPROFLOXACIN ER 500MG TABLET (30 CT)   1 Level 1: Covered Generics 10%10%None
CIPROFLOXACIN HCL 0.3% DROPS   1 Level 1: Covered Generics 10%10%None
CIPROFLOXACIN TABLETS 750MG 100 BOT   1 Level 1: Covered Generics 10%10%None
CISPLATIN INJECTION 1MG   1 Level 1: Covered Generics 10%10%None
CITALOPRAM HBR 20MG TABLET (100 CT)   1 Level 1: Covered Generics 10%10%None
CITALOPRAM HBR ORAL SOLUTION 10MG 240ML BOTPL   1 Level 1: Covered Generics 10%10%None
CITALOPRAM HYDROBROMIDE TABLETS 40MG 30 BOT   1 Level 1: Covered Generics 10%10%None
CITOLOPRAM HBR 10MG TABLET (100 CT)   1 Level 1: Covered Generics 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CLADRIBINE 1MG/ML VIAL   4 Covered Specialty 25%25%P
CLAFORAN 1GM/50ML GALAXY   3 Level 3: Covered Brand 50%50%None
CLAFORAN 2GM/50ML GALAXY   3 Level 3: Covered Brand 50%50%None
CLARAVIS 10MG CAPSULE   1 Level 1: Covered Generics 10%10%None
CLARAVIS 20MG CAPSULE   1 Level 1: Covered Generics 10%10%None
CLARAVIS 30MG CAPSULE   1 Level 1: Covered Generics 10%10%None
CLARAVIS 40MG CAPSULE   1 Level 1: Covered Generics 10%10%None
CLARITHROMYCIN 250MG TABLET   1 Level 1: Covered Generics 10%10%None
CLARITHROMYCIN 250MG/5ML. SUS. 100ML   1 Level 1: Covered Generics 10%10%None
CLARITHROMYCIN 500MG TABLET   1 Level 1: Covered Generics 10%10%None
CLARITHROMYCIN ER 500MG TABLET (60 CT)   1 Level 1: Covered Generics 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CLARITHROMYCIN FOR ORAL SUSPENSION 125/5ML 125MG BOT   1 Level 1: Covered Generics 10%10%None
CLEMASTINE FUM 2.68MG TABLET   1 Level 1: Covered Generics 10%10%None
CLEMASTINE FUMARATE 0.67MG/5ML SYRUP   1 Level 1: Covered Generics 10%10%None
CLEOCIN 300MG/D5W/GALAXY   3 Level 3: Covered Brand 50%50%None
CLEOCIN 600MG/D5W/GALAXY   3 Level 3: Covered Brand 50%50%None
CLEOCIN 900MG/D5W/GALAXY   3 Level 3: Covered Brand 50%50%None
CLEOCIN HCL 75MG CAPSULE   3 Level 3: Covered Brand 50%50%None
CLINDAMYCIN 150MG/ML ADDVAN   1 Level 1: Covered Generics 10%10%None
CLINDAMYCIN HCL 150MG CAPSULE   1 Level 1: Covered Generics 10%10%None
CLINDAMYCIN HCL 300MG CAPS   1 Level 1: Covered Generics 10%10%None
CLINDAMYCIN PHOSP 1% LOTION   1 Level 1: Covered Generics 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CLINDAMYCIN PHOSPHATE 1% SOLUTION NON-ORAL   1 Level 1: Covered Generics 10%10%None
CLINDAMYCIN PHOSPHATE 2% CREAM WITH APPLICATOR   1 Level 1: Covered Generics 10%10%None
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE   1 Level 1: Covered Generics 10%10%None
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX   1 Level 1: Covered Generics 10%10%None
CLINISOL 15% SOLUTION   1 Level 1: Covered Generics 10%10%P
CLOBETASOL 0.05% OINTMENT   1 Level 1: Covered Generics 10%10%None
CLOBETASOL 0.05% SOLUTION   1 Level 1: Covered Generics 10%10%None
CLOBETASOL E 0.05% CREAM   1 Level 1: Covered Generics 10%10%None
CLOBETASOL PROPIONATE CRM 0.05% 15GM   1 Level 1: Covered Generics 10%10%None
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE   1 Level 1: Covered Generics 10%10%None
CLOLAR 1MG/ML VIAL   4 Covered Specialty 25%25%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CLOMIPRAMINE HCL 25MG CAPSULE   1 Level 1: Covered Generics 10%10%None
CLOMIPRAMINE HCL 50MG CAPSULE   1 Level 1: Covered Generics 10%10%None
CLOMIPRAMINE HCL 75MG CAPSULE   1 Level 1: Covered Generics 10%10%None
CLONIDINE HCL 0.2MG TABLET (500 CT)   1 Level 1: Covered Generics 10%10%None
CLONIDINE HCL TABLET 0.1MG (500 CT)   1 Level 1: Covered Generics 10%10%None
CLONIDINE HCL TABLET 0.3MG (100 CT)   1 Level 1: Covered Generics 10%10%None
CLOTRIMAZOLE 1% CREAM   1 Level 1: Covered Generics 10%10%None
CLOTRIMAZOLE 10MG TROCHE   1 Level 1: Covered Generics 10%10%None
CLOTRIMAZOLE-BETAMETHASONE 1-0.05% LOTION   1 Level 1: Covered Generics 10%10%None
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE CREAM USP .5MG-10GM 45GM TUBE   1 Level 1: Covered Generics 10%10%None
CLOZAPINE 200MG TABLET (500 CT)   3 Level 3: Covered Brand 50%50%Q:120
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CLOZAPINE 25MG TABLET (100 CT)   1 Level 1: Covered Generics 10%10%Q:90
/30Days
CLOZAPINE 50MG TABLET (500 CT)   1 Level 1: Covered Generics 10%10%Q:90
/30Days
CLOZAPINE TABLETS 100MG 100 BOT   1 Level 1: Covered Generics 10%10%Q:270
/30Days
CO-GESIC 5/500 TABLET   1 Level 1: Covered Generics 10%10%None
COLESTIPOL HCL 1G TABLET   1 Level 1: Covered Generics 10%10%None
COLESTIPOL HCL 5G GRANULES   1 Level 1: Covered Generics 10%10%None
COLISTIMETHATE 150MG VIAL   4 Covered Specialty 25%25%None
COLLAGENASE SANTYL OINTMENT 250UNT 30GM TUBE   2 Level 2: Covered Preferred Brand 22%22%None
COLOCORT 100MG ENEMA   1 Level 1: Covered Generics 10%10%None
COMBIGAN 0.2%-0.5% DROPS   2 Level 2: Covered Preferred Brand 22%22%None
COMBIPATCH 0.05/0.14MG PTCH   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
COMBIPATCH 0.05/0.25MG PTCH   2 Level 2: Covered Preferred Brand 22%22%None
COMBIVIR TABLET   2 Level 2: Covered Preferred Brand 22%22%None
COMPRO 25MG SUPPOSITORY   1 Level 1: Covered Generics 10%10%None
COMTAN 200MG TABLET   3 Level 3: Covered Brand 50%50%None
COMVAX VACCINE VIAL   3 Level 3: Covered Brand 50%50%None
CONSTULOSE 10GM/15ML SYRUP   1 Level 1: Covered Generics 10%10%None
COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN   4 Covered Specialty 25%25%None
CORMAX 0.05% CREAM   1 Level 1: Covered Generics 10%10%None
CORTIFOAM 10% FOAM   3 Level 3: Covered Brand 50%50%None
CORTISONE ACETATE 25MG TABLET (100 CT)   1 Level 1: Covered Generics 10%10%None
CORTOMYCIN EAR SOLUTION   1 Level 1: Covered Generics 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CORTOMYCIN EAR SUSPENSION   1 Level 1: Covered Generics 10%10%None
COSMEGEN 0.5MG VIAL   4 Covered Specialty 25%25%None
COZAAR 100MG TABLET   3 Level 3: Covered Brand 50%50%S
COZAAR 25MG TABLET (1000 CT)   3 Level 3: Covered Brand 50%50%S
COZAAR 50MG TABLET 10000 BOT   3 Level 3: Covered Brand 50%50%S
CREON DELAYED RELEASE CAPSULES 12000MG 100 BOT   3 Level 3: Covered Brand 50%50%None
CREON DELAYED RELEASE CAPSULES 24000MG 100 BOT   3 Level 3: Covered Brand 50%50%None
CREON DELAYED RELEASE CAPSULES 6000MG 100 BOT   3 Level 3: Covered Brand 50%50%None
CRESTOR 10MG TABLET   2 Level 2: Covered Preferred Brand 22%22%Q:45
/30Days
CRESTOR 20MG TABLET   2 Level 2: Covered Preferred Brand 22%22%Q:45
/30Days
CRESTOR 40MG TABLET   2 Level 2: Covered Preferred Brand 22%22%Q:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CRESTOR 5MG TABLET   2 Level 2: Covered Preferred Brand 22%22%Q:45
/30Days
CRIXIVAN 100MG CAPSULE   3 Level 3: Covered Brand 50%50%None
CRIXIVAN 200MG CAPSULE   3 Level 3: Covered Brand 50%50%None
CRIXIVAN 333MG CAPSULE   3 Level 3: Covered Brand 50%50%None
CRIXIVAN 400MG CAPSULE (120 CT)   3 Level 3: Covered Brand 50%50%None
CROMOLYN SODIUM 4% 40MG 10ML BOT   1 Level 1: Covered Generics 10%10%None
CRYSELLE-28 TABLET 28 TABLET S   1 Level 1: Covered Generics 10%10%None
CUBICIN 500MG VIAL   4 Covered Specialty 25%25%None
CUPRIMINE 125MG CAPSULE   2 Level 2: Covered Preferred Brand 22%22%None
CUPRIMINE CAPSULES 250MG (100 CT)   2 Level 2: Covered Preferred Brand 22%22%None
CYCLOBENZAPRINE HCL 10MG TABLET (1000 CT)   1 Level 1: Covered Generics 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CYCLOBENZAPRINE HCL 5MG TABLET (500 CT)   1 Level 1: Covered Generics 10%10%None
CYCLOPHOSPHAMIDE 1GM VIAL   3 Level 3: Covered Brand 50%50%None
CYCLOPHOSPHAMIDE 25MG TABLET   3 Level 3: Covered Brand 50%50%P
CYCLOPHOSPHAMIDE 500MG VIAL   3 Level 3: Covered Brand 50%50%None
CYCLOPHOSPHAMIDE 50MG TABLET   3 Level 3: Covered Brand 50%50%P
CYCLOSPORINE 100MG CAPSULE   1 Level 1: Covered Generics 10%10%P
CYCLOSPORINE 100MG CAPSULE   1 Level 1: Covered Generics 10%10%P
CYCLOSPORINE 25MG CAPSULE   1 Level 1: Covered Generics 10%10%P
CYCLOSPORINE 50MG CAPSULE   3 Level 3: Covered Brand 50%50%P
CYCLOSPORINE 50MG/ML AMP   1 Level 1: Covered Generics 10%10%P
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT   1 Level 1: Covered Generics 10%10%P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CYKLOKAPRON 100MG/ML AMPUL   2 Level 2: Covered Preferred Brand 22%22%None
CYMBALTA 20MG CAPSULE   3 Level 3: Covered Brand 50%50%S
CYMBALTA 60MG CAPSULE   3 Level 3: Covered Brand 50%50%S
CYMBALTA CAPSULES DELAYED RELEASE 30MG (30 CT)   3 Level 3: Covered Brand 50%50%S
CYPROHEPTADINE 4MG TABLET   1 Level 1: Covered Generics 10%10%None
CYPROHEPTADINE HYDROCHLORIDE SOLUTION USP SYRUP 2MG 473 ML BOTGL   1 Level 1: Covered Generics 10%10%None
CYSTADANE POWDER FOR ORAL SOLUTION 180GM   3 Level 3: Covered Brand 50%50%None
CYSTAGON 150MG CAPSULE   3 Level 3: Covered Brand 50%50%None
CYSTAGON 50MG CAPSULE   3 Level 3: Covered Brand 50%50%None
CYTARABINE 20MG/ML VIAL   3 Level 3: Covered Brand 50%50%P
CYTARABINE 500MG VIAL   1 Level 1: Covered Generics 10%10%P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CYTOVENE 500MG VIAL   3 Level 3: Covered Brand 50%50%P
CYTOXAN 500MG VIAL   3 Level 3: Covered Brand 50%50%None

Chart Legend:

Below are a few notes to help you understand the above 2010 Medicare Part D MedicareBlue Rx Standard (PDP) 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 $310 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 $2830) 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 2010 )

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.





 
 


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Tips & Disclaimers
  • Q1Medicare®, Q1Rx®, and Q1Group® are registered Service Marks of Q1Group LLC and may not be used in any advertising, publicity, or for commercial purposes without the express authorization of Q1Group.
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDPCompare.com and MACompare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
    Statement required by Medicare:
    "We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options."
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.
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