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2010 Medicare Part D Plan (PDP Only) Formulary Browser

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BravoRx (PDP) (S5998-021-0)
Tier 1 (1764)
Tier 2 (980)
Tier 3 (168)


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Uses Step Therapy:
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2010 Medicare Part D Plan Formulary Information
BravoRx (PDP) (S5998-021-0)
Benefit Details  
The BravoRx (PDP) (S5998-021-0)
Formulary Drugs Starting with the Letter A

in CMS PDP Region 15 which includes: IN KY
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 Tier 1 25%25%None
A-HYDROCORT 100MG VIAL   1 Tier 1 25%25%None
A-METHAPRED 40MG UNIVIAL   1 Tier 1 25%25%None
ABILIFY 10MG TABLET   2 Tier 2 25%25%P Q:270
/90Days
ABILIFY 15MG TABLET   2 Tier 2 25%25%P Q:180
/90Days
ABILIFY 1MG/ML SOLUTION   2 Tier 2 25%25%P
ABILIFY 20MG TABLET   2 Tier 2 25%25%P Q:90
/90Days
ABILIFY 2MG TABLET   2 Tier 2 25%25%P Q:90
/90Days
ABILIFY 30MG TABLET   2 Tier 2 25%25%P Q:90
/90Days
ABILIFY 5MG TABLET (OTSUKA)   2 Tier 2 25%25%P Q:90
/90Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ABILIFY DISCMELT 10MG TABLET   2 Tier 2 25%25%P Q:270
/90Days
ABILIFY DISCMELT 15MG TABLET   2 Tier 2 25%25%P Q:180
/90Days
ABILIFY INJ 9.75MG   2 Tier 2 25%25%P
ABRAXANE 100MG VIAL   2 Tier 2 25%25%P
ACARBOSE 100MG TABLET S   1 Tier 1 25%25%Q:270
/90Days
ACARBOSE 25MG TABLET S   1 Tier 1 25%25%Q:270
/90Days
ACARBOSE 50MG TABLET S   1 Tier 1 25%25%Q:270
/90Days
ACCOLATE 10MG TABLET   2 Tier 2 25%25%Q:180
/90Days
ACCOLATE 20MG TABLET   2 Tier 2 25%25%Q:180
/90Days
ACEBUTOLOL 200MG CAPSULE   1 Tier 1 25%25%None
ACEBUTOLOL 400MG CAPSULE   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD   1 Tier 1 25%25%None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT)   1 Tier 1 25%25%None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT)   1 Tier 1 25%25%None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT)   1 Tier 1 25%25%None
ACETASOL HC OTIC SOLUTION   1 Tier 1 25%25%None
ACETASOL HC SOLUTION 10ML 10 ML BOT   1 Tier 1 25%25%None
ACETAZOLAMIDE 125MG TABLET   1 Tier 1 25%25%None
ACETAZOLAMIDE 250MG TABLET (100 CT)   1 Tier 1 25%25%None
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT   1 Tier 1 25%25%None
ACETAZOLAMIDE SOD 500MG VL   1 Tier 1 25%25%None
ACETIC ACID 2% SOLUTION NON-ORAL   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETYLCYSTEINE 10% VIAL   1 Tier 1 25%25%P
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN   1 Tier 1 25%25%P
ACTHIB VACCINE VIAL 10-24UNT/5ML   2 Tier 2 25%25%None
ACTICIN 5% CREAM   1 Tier 1 25%25%None
ACTIMMUNE SOLUTION FOR INJECTION 100MCG   3 Tier 3 25%25%P
ACTIVELLA 0.5-0.1MG TABLET 28 DLPK   2 Tier 2 25%25%None
ACTONEL 30MG TABLET   2 Tier 2 25%25%P Q:90
/90Days
ACTOPLUS MET 15MG/500MG TABLET   2 Tier 2 25%25%S Q:270
/90Days
ACTOPLUS MET 15MG/850MG TABLET   2 Tier 2 25%25%S Q:270
/90Days
ACTOS 15MG TABLET   2 Tier 2 25%25%S Q:90
/90Days
ACTOS 30MG TABLET (500 CT)   2 Tier 2 25%25%S Q:90
/90Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACTOS 45MG TABLET   2 Tier 2 25%25%S Q:90
/90Days
ACULAR 0.5% EYE DROPS   2 Tier 2 25%25%None
ACULAR LS 0.4% OPHTH SOL   2 Tier 2 25%25%None
ACYCLOVIR 200MG CAPSULE (1000 CT)   1 Tier 1 25%25%None
ACYCLOVIR 200MG/5ML SUSP   1 Tier 1 25%25%None
ACYCLOVIR 400MG TABLET (100 CT)   1 Tier 1 25%25%None
ACYCLOVIR SODIUM 500MG VIAL   1 Tier 1 25%25%None
ACYCLOVIR TABLET USP 800MG (100 CT)   1 Tier 1 25%25%None
ADACEL VIAL 2UNT/5UNT   2 Tier 2 25%25%None
ADAGEN 250U/ML VIAL   3 Tier 3 25%25%None
AFEDITAB CR 30MG TABLET SA   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AFEDITAB CR 60MG TABLET SA   1 Tier 1 25%25%None
AGGRENOX 25-200MG CAPSULE   2 Tier 2 25%25%Q:180
/90Days
AK-CON 0.1% EYE DROPS   1 Tier 1 25%25%None
AK-POLY-BAC EYE OINTMENT 500UNT/1000UNT   1 Tier 1 25%25%None
AKTOB 0.3% EYE DROPS   1 Tier 1 25%25%None
ALA-CORT 1% CREAM   1 Tier 1 25%25%None
ALA-CORT 1% LOTION   1 Tier 1 25%25%None
ALAMAST 0.1% DROPS   2 Tier 2 25%25%None
ALBENZA 200MG TABLET   2 Tier 2 25%25%None
ALBUTEROL SULFATE 0.63MG/3ML VIAL NEBULIZER   1 Tier 1 25%25%P
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER   1 Tier 1 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALBUTEROL SULFATE 2.5MG/3ML VIAL NEBULIZER   1 Tier 1 25%25%P
ALBUTEROL SULFATE 4MG TABLET SR 12HR   1 Tier 1 25%25%None
ALBUTEROL SULFATE 8MG TABLET SR 12HR   1 Tier 1 25%25%None
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   1 Tier 1 25%25%P
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT   1 Tier 1 25%25%None
ALBUTEROL SULFATE TABLET 2MG (500 CT)   1 Tier 1 25%25%None
ALBUTEROL TABLET 4MG (500 CT)   1 Tier 1 25%25%None
ALCLOMETASONE DIPROPIONATE 0.05% CREAM   1 Tier 1 25%25%None
ALCLOMETASONE DIPROPIONATE 0.05% OINTMENT   1 Tier 1 25%25%None
ALCOHOL 5%/DEXTROSE 5%   1 Tier 1 25%25%None
ALDARA IMIQUIMOD CREAM 5% 24 PKT X 250 MG CRTN   2 Tier 2 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALDURAZYME 2.9MG/5ML VIAL   3 Tier 3 25%25%P
ALENDRONATE SODIUM 10MG TABLET   1 Tier 1 25%25%Q:30
/30Days
ALENDRONATE SODIUM 40MG TABLET   1 Tier 1 25%25%P Q:30
/30Days
ALENDRONATE SODIUM 5MG TABLET   1 Tier 1 25%25%Q:30
/30Days
ALENDRONATE SODIUM 70MG TABLET 4 BLPK   1 Tier 1 25%25%None
ALENDRONATE SODIUM TABLET 35MG 20 CRTN   1 Tier 1 25%25%None
ALIMTA 500MG VIAL   2 Tier 2 25%25%P
ALINIA 100MG/5ML SUSPENSION   2 Tier 2 25%25%None
ALINIA 500MG TABLET   2 Tier 2 25%25%None
ALKERAN FOR INJECTION 50MG/VIAL 1 VIALSU   2 Tier 2 25%25%P
ALLOPURINOL TABLET 300MG (1000 CT)   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALLOPURINOL TABLET USP 100MG (1000 CT)   1 Tier 1 25%25%None
ALOCRIL 2% EYE DROPS   2 Tier 2 25%25%None
ALORA 0.025MG PATCH   2 Tier 2 25%25%Q:24
/90Days
ALORA 0.05MG PATCH   2 Tier 2 25%25%Q:24
/90Days
ALORA 0.075MG PATCH   2 Tier 2 25%25%Q:24
/90Days
ALORA 0.1MG PATCH   2 Tier 2 25%25%Q:24
/90Days
ALPHAGAN P 0.1% DROPS   2 Tier 2 25%25%None
ALPHAGAN P 0.15% EYE DROPS   2 Tier 2 25%25%None
AMANTADINE 100MG CAPSULE   1 Tier 1 25%25%None
AMANTADINE 100MG TABLET   1 Tier 1 25%25%None
AMBIEN CR 12.5MG TABLET   2 Tier 2 25%25%S Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMBIEN CR 6.25MG TABLET   2 Tier 2 25%25%S Q:30
/30Days
AMCINONIDE 0.1% CREAM   1 Tier 1 25%25%None
AMCINONIDE 0.1% LOTION   1 Tier 1 25%25%None
AMCINONIDE 0.1% OINTMENT 60GM TUBE   1 Tier 1 25%25%None
AMIKACIN 250MG/ML VIAL   1 Tier 1 25%25%None
AMIKACIN 50MG/ML VIAL   1 Tier 1 25%25%None
AMIKIN 250MG/ML VIAL   1 Tier 1 25%25%None
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET   1 Tier 1 25%25%None
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT   1 Tier 1 25%25%None
AMINOPHYLLINE 100MG TABLET   1 Tier 1 25%25%None
AMINOPHYLLINE 200MG TABLET (1000 CT)   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOPHYLLINE INJECTION 250MG 10ML X 25 VIALSD   1 Tier 1 25%25%None
AMINOSYN 10% IV SOLUTION   2 Tier 2 25%25%None
AMINOSYN 3.5% IV SOLUTION   2 Tier 2 25%25%None
AMINOSYN 5% IV SOLUTION   2 Tier 2 25%25%None
AMINOSYN 7% IV SOLUTION   2 Tier 2 25%25%None
AMINOSYN 8.5% IV SOLUTION   2 Tier 2 25%25%None
AMINOSYN II 10% IV SOLUTION   2 Tier 2 25%25%None
AMINOSYN II 15% IV SOLUTION   1 Tier 1 25%25%None
AMINOSYN II 3.5% IN D25W IV   2 Tier 2 25%25%None
AMINOSYN II 3.5% M/D5W IV   2 Tier 2 25%25%None
AMINOSYN II 4.25% IN D10W   2 Tier 2 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN II 4.25% IN D20W   2 Tier 2 25%25%None
AMINOSYN II 4.25%-D25W IV   1 Tier 1 25%25%None
AMINOSYN II 7% IV SOLUTION   2 Tier 2 25%25%None
AMINOSYN II 8.5% IV SOLUTION   2 Tier 2 25%25%None
AMINOSYN PF INJECTION   2 Tier 2 25%25%None
AMINOSYN-HBC 7% IV SOLUTION   2 Tier 2 25%25%None
AMINOSYN-HF 8% IV SOLUTION   2 Tier 2 25%25%None
AMINOSYN-PF 7% IV SOLUTION   2 Tier 2 25%25%None
AMIODARONE HCL 200MG TABLET (60 CT)   1 Tier 1 25%25%None
AMIODARONE HCL 400MG TABLET   1 Tier 1 25%25%None
AMIODARONE HCL INJECTION   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITIZA 8MCG CAPSULE   2 Tier 2 25%25%P Q:60
/30Days
AMITIZA CAPSULES 24MCG 60 CAP BOT   2 Tier 2 25%25%P Q:60
/30Days
AMITRIP/CDP 25-10 TABLET   1 Tier 1 25%25%None
AMITRIP/PERPHEN 10-2 TABLET   1 Tier 1 25%25%None
AMITRIP/PERPHEN 10-4 TABLET   1 Tier 1 25%25%None
AMITRIP/PERPHEN 25-2 TABLET   1 Tier 1 25%25%None
AMITRIP/PERPHEN 25-4 TABLET   1 Tier 1 25%25%None
AMITRIP/PERPHEN 50-4 TABLET   1 Tier 1 25%25%None
AMITRIPTYLINE HCL 100MG TABLET   1 Tier 1 25%25%None
AMITRIPTYLINE HCL 10MG TABLET   1 Tier 1 25%25%None
AMITRIPTYLINE HCL 150MG TABLET (100 CT)   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)   1 Tier 1 25%25%None
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)   1 Tier 1 25%25%None
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT   1 Tier 1 25%25%None
AMLODIPINE BESYLATE 10MG TABLET (90 CT)   1 Tier 1 25%25%None
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)   1 Tier 1 25%25%None
AMLODIPINE BESYLATE 5MG TABLET (90 CT)   1 Tier 1 25%25%None
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE   1 Tier 1 25%25%None
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE   1 Tier 1 25%25%None
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE   1 Tier 1 25%25%None
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE   1 Tier 1 25%25%None
AMMONIUM LACTATE 12% CREAM   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMMONIUM LACTATE 12% LOTION   1 Tier 1 25%25%None
AMNESTEEM 10MG CAPSULE   1 Tier 1 25%25%None
AMNESTEEM 20MG CAPSULE   1 Tier 1 25%25%None
AMNESTEEM 40MG CAPSULE   1 Tier 1 25%25%None
AMOCLAN 200-28.5/5 SUSPENSION RECONSTITUTED ORAL   1 Tier 1 25%25%None
AMOCLAN 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   1 Tier 1 25%25%None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL   1 Tier 1 25%25%None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE   1 Tier 1 25%25%None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET   1 Tier 1 25%25%None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE   1 Tier 1 25%25%None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOX TR-POTASSIUM CLAVULANATE 500-125MG TABLET   1 Tier 1 25%25%None
AMOXAPINE 100MG TABLET   1 Tier 1 25%25%None
AMOXAPINE 150MG TABLET   1 Tier 1 25%25%None
AMOXAPINE 25MG TABLET   1 Tier 1 25%25%None
AMOXAPINE 50MG TABLET   1 Tier 1 25%25%None
AMOXICILLIN 125MG TABLET CHEW   1 Tier 1 25%25%None
AMOXICILLIN 200MG TABLET CHEW   1 Tier 1 25%25%None
AMOXICILLIN 250MG CAPSULE   1 Tier 1 25%25%None
AMOXICILLIN 400MG TABLET CHEW   1 Tier 1 25%25%None
AMOXICILLIN 500MG CAPSULE   1 Tier 1 25%25%None
AMOXICILLIN 500MG TABLET (100 CT)   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN 875MG TABLET   1 Tier 1 25%25%None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT   1 Tier 1 25%25%None
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT   1 Tier 1 25%25%None
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT   1 Tier 1 25%25%None
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL   1 Tier 1 25%25%None
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   1 Tier 1 25%25%None
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL   1 Tier 1 25%25%None
AMOXICILLIN TABLET USP CHEWABLE 250MG (250 CT)   1 Tier 1 25%25%None
AMOXIL 250MG/5ML SUSPENSION   1 Tier 1 25%25%None
AMOXIL CAPSULES 500MG   1 Tier 1 25%25%None
AMPHET ASP/ AMPHET/ D-AMPHET 5MG TABLET   1 Tier 1 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPHETAMINE SALT COMBO 12.5MG TABLET   1 Tier 1 25%25%P
AMPHETAMINE SALT COMBO 15MG TABLET   1 Tier 1 25%25%P
AMPHETAMINE SALT COMBO 30MG TABLET   1 Tier 1 25%25%P
AMPHETAMINE SALT COMBO 7.5MG TABLET   1 Tier 1 25%25%P
AMPHETAMINE SALTS 20MG TABLET   1 Tier 1 25%25%P
AMPHOTERICIN B FOR INJECTION 50 MG   1 Tier 1 25%25%P
AMPICILLIN AND SULBACTAM FOR INJECTION 10-5 1 VIAL   1 Tier 1 25%25%None
AMPICILLIN AND SULBACTAM FOR INJECTION 2-1 10 VIAL   1 Tier 1 25%25%None
AMPICILLIN CAPSULES 250MG 100 BOT   1 Tier 1 25%25%None
AMPICILLIN CAPSULES 500MG 100 BOT   1 Tier 1 25%25%None
AMPICILLIN FOR INJECTION POWDER   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPICILLIN FOR INJECTION USP 125MG/ML 1 VIAL   2 Tier 2 25%25%None
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT   1 Tier 1 25%25%None
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT   1 Tier 1 25%25%None
AMPICILLIN POWDER FOR INJECTION 1 GM/ML   1 Tier 1 25%25%None
ANADROL-50 50MG TABLET (100 CT)   2 Tier 2 25%25%P
ANAGRELIDE HCL 0.5MG CAPSULE   1 Tier 1 25%25%None
ANAGRELIDE HCL 1MG CAPSULE   1 Tier 1 25%25%None
ANCOBON 250MG CAPSULE   2 Tier 2 25%25%None
ANCOBON 500MG CAPSULE   2 Tier 2 25%25%None
ANDRODERM 2.5MG/24HR PATCH   2 Tier 2 25%25%P Q:60
/30Days
ANDRODERM 5MG/24HR PATCH   2 Tier 2 25%25%P Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANDROGEL 1%(50MG) GEL PACKET   2 Tier 2 25%25%P
ANTABUSE 250MG TABLET   2 Tier 2 25%25%None
ANTABUSE 500MG TABLET   2 Tier 2 25%25%None
ANTARA 130MG CAPSULE   2 Tier 2 25%25%None
ANTARA 43MG CAPSULE   2 Tier 2 25%25%None
APOKYN FOR INJECTION 30MG 5 CTG   2 Tier 2 25%25%P
APRI 0.15-0.03 TABLET   1 Tier 1 25%25%None
APTIVUS 250MG CAPSULE   3 Tier 3 25%25%None
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT   3 Tier 3 25%25%Q:900
/90Days
ARANELLE 7-9-5 TABLET   1 Tier 1 25%25%None
ARANESP 100MCG/ML VIAL   3 Tier 3 25%25%P Q:4
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP 200MCG/0.4ML SYRINGE   3 Tier 3 25%25%P Q:2
/30Days
ARANESP 200MCG/ML VIAL   3 Tier 3 25%25%P Q:4
/30Days
ARANESP 25MCG/ML VIAL   2 Tier 2 25%25%P Q:8
/30Days
ARANESP 300MCG/ML VIAL   3 Tier 3 25%25%P Q:4
/30Days
ARANESP 500MCG/1ML SYRINGE   3 Tier 3 25%25%P Q:1
/30Days
ARANESP 60MCG/ML VIAL   3 Tier 3 25%25%P Q:8
/30Days
ARANESP PREFILLED SYRINGE SINGLE USE 100MCG/0.5ML 1 SYR   3 Tier 3 25%25%P Q:2
/30Days
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR   3 Tier 3 25%25%P Q:1
/30Days
ARANESP PREFILLED SYRINGE SINGLE USE 25MCG/0.42ML SYR   2 Tier 2 25%25%P Q:3
/30Days
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR   3 Tier 3 25%25%P Q:2
/30Days
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR   2 Tier 2 25%25%P Q:3
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP PREFILLED SYRINGE SINGLE USE 60MCG/0.3ML 60MCG/ 0.3ML SYR   3 Tier 3 25%25%P Q:2
/30Days
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD   2 Tier 2 25%25%P Q:8
/30Days
ARICEPT 10MG TABLET   2 Tier 2 25%25%Q:90
/90Days
ARICEPT 5MG TABLET   2 Tier 2 25%25%Q:90
/90Days
ARICEPT ODT 10MG TABLET   2 Tier 2 25%25%Q:90
/90Days
ARICEPT ODT 5MG TABLET   2 Tier 2 25%25%Q:90
/90Days
ARIMIDEX 1MG TABLET   2 Tier 2 25%25%None
ARIXTRA 10MG SYRINGE   3 Tier 3 25%25%None
ARIXTRA 2.5MG SYRINGE   2 Tier 2 25%25%None
ARIXTRA 5MG SYRINGE   3 Tier 3 25%25%None
ARIXTRA 7.5MG SYRINGE   3 Tier 3 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AROMASIN 25MG TABLET   2 Tier 2 25%25%None
ARRANON 250MG VIAL   2 Tier 2 25%25%P
ARTHROTEC 50 50MG TABLET -200MCG (60 CT)   2 Tier 2 25%25%None
ARTHROTEC 75 TABLET EC   2 Tier 2 25%25%None
ASACOL 400MG TABLET EC   2 Tier 2 25%25%None
ASMANEX TWISTHALER 220MCG #120   2 Tier 2 25%25%Q:3
/90Days
ASMANEX TWISTHALER 220MCG #30   2 Tier 2 25%25%Q:3
/90Days
ASMANEX TWISTHALER 220MCG #60   2 Tier 2 25%25%Q:3
/90Days
ASTELIN 137MCG AEROSOL SPRAY W/PUMP   2 Tier 2 25%25%None
ATENOLOL 25MG TABLET (100 CT)   1 Tier 1 25%25%None
ATENOLOL TABLET USP 50MG (100 CT)   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATENOLOL TABLETS USP 100MG 1 BLPK   1 Tier 1 25%25%None
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT)   1 Tier 1 25%25%None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   1 Tier 1 25%25%None
ATRIPLA TABLET 600MG/200MG   3 Tier 3 25%25%None
ATROPINE 0.05MG/ML SYRINGE   2 Tier 2 25%25%None
ATROPINE 0.1MG/ML SYRINGE   1 Tier 1 25%25%None
ATROVENT HFA AER 17MCG   2 Tier 2 25%25%Q:77
/90Days
ATTENUVAX VACCINE W/DILUENT 1 DOSE/0.5ML   2 Tier 2 25%25%None
AUGMENTIN XR 1000-62.5 TABLET   2 Tier 2 25%25%None
AVASTIN 100MG/4ML VIAL   2 Tier 2 25%25%P
AVELOX IV 400MG/250ML   2 Tier 2 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVIANE 0.1-0.02 TABLET   1 Tier 1 25%25%None
AVITA 0.025% CREAM   1 Tier 1 25%25%None
AVONEX ADMIN PACK 30MCG SYR   3 Tier 3 25%25%P Q:12
/90Days
AVONEX ADMIN PACK 30MCG VL   3 Tier 3 25%25%P Q:12
/90Days
AZACTAM 2GM VIAL   2 Tier 2 25%25%None
AZACTAM INJECTION 1GM 50ML BAG   2 Tier 2 25%25%None
AZACTAM/ISO-OSMOT 2GM/50ML   2 Tier 2 25%25%None
AZATHIOPRINE 50MG TABLET   1 Tier 1 25%25%P
AZATHIOPRINE SOD 100MG VIAL   1 Tier 1 25%25%P
AZELEX 20% CREAM 30GM TUBE   2 Tier 2 25%25%None
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Tier 1 25%25%None
AZITHROMYCIN 250MG TABLET (30 CT)   1 Tier 1 25%25%None
AZITHROMYCIN 500MG TABLET (30 CT)   1 Tier 1 25%25%None
AZITHROMYCIN FOR INJECTION 500MG 10 VIALSD   1 Tier 1 25%25%None
AZITHROMYCIN TABLET 600MG (30 CT)   1 Tier 1 25%25%None
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT   2 Tier 2 25%25%None

Chart Legend:

Below are a few notes to help you understand the above 2010 Medicare Part D BravoRx (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 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 wit 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 which tier the drug is in. 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.







Tips & Disclaimers
  • 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 PDP-Compare.com and MA-Compare.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.
  • 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.