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2010 Medicare Part D Plan (PDP Only) Formulary Browser

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Community CCRx Choice (PDP) (S5803-169-0)
Tier 1 (1644)
Tier 2 (545)
Tier 3 (443)
Tier 4 (255)

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2010 Medicare Part D Plan Formulary Information
Community CCRx Choice (PDP) (S5803-169-0)
Benefit Details  
The Community CCRx Choice (PDP) (S5803-169-0)
Formulary Drugs Starting with the Letter A

in CMS PDP Region 32 which includes: CA
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 $5.00N/ANone
A-METHAPRED 40MG UNIVIAL   1 Generic $5.00N/ANone
ABELCENT INJECTION SUSPENSION 5MG/ML   4 Specialty 29%N/AP
ABILIFY 10MG TABLET   3 Non-Preferred Brand $65.00N/AS Q:30
/30Days
ABILIFY 15MG TABLET   3 Non-Preferred Brand $65.00N/AS Q:30
/30Days
ABILIFY 1MG/ML SOLUTION   3 Non-Preferred Brand $65.00N/AS Q:900
/30Days
ABILIFY 20MG TABLET   3 Non-Preferred Brand $65.00N/AS Q:30
/30Days
ABILIFY 2MG TABLET   3 Non-Preferred Brand $65.00N/AS Q:30
/30Days
ABILIFY 30MG TABLET   3 Non-Preferred Brand $65.00N/AS Q:30
/30Days
ABILIFY 5MG TABLET (OTSUKA)   3 Non-Preferred Brand $65.00N/AS Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ABILIFY DISCMELT 10MG TABLET   3 Non-Preferred Brand $65.00N/AS Q:30
/30Days
ABILIFY DISCMELT 15MG TABLET   3 Non-Preferred Brand $65.00N/AS Q:60
/30Days
ABILIFY INJ 9.75MG   3 Non-Preferred Brand $65.00N/AQ:4
/1Days
ACARBOSE 100MG TABLET S   1 Generic $5.00N/AQ:90
/30Days
ACARBOSE 25MG TABLET S   1 Generic $5.00N/AQ:90
/30Days
ACARBOSE 50MG TABLET S   1 Generic $5.00N/AQ:90
/30Days
ACCOLATE 10MG TABLET   2 Preferred Brand $35.00N/AS Q:60
/30Days
ACCOLATE 20MG TABLET   2 Preferred Brand $35.00N/AS Q:60
/30Days
ACEBUTOLOL 200MG CAPSULE   1 Generic $5.00N/ANone
ACEBUTOLOL 400MG CAPSULE   1 Generic $5.00N/ANone
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD   1 Generic $5.00N/AQ:5000
/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 $5.00N/AQ:400
/30Days
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT)   1 Generic $5.00N/AQ:400
/30Days
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT)   1 Generic $5.00N/AQ:400
/30Days
ACETASOL HC OTIC SOLUTION   1 Generic $5.00N/ANone
ACETASOL HC SOLUTION 10ML 10 ML BOT   1 Generic $5.00N/ANone
ACETAZOLAMIDE 125MG TABLET   1 Generic $5.00N/ANone
ACETAZOLAMIDE 250MG TABLET (100 CT)   1 Generic $5.00N/ANone
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT   1 Generic $5.00N/ANone
ACETIC ACID 2% SOLUTION NON-ORAL   1 Generic $5.00N/ANone
ACETIC ACID IN AQUEOUS ALUMINUM ACETATE OTIC SOLUTION 2% 60 ML BOT   1 Generic $5.00N/ANone
ACETYLCYSTEINE 10% VIAL   1 Generic $5.00N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN   1 Generic $5.00N/AP
ACTHIB VACCINE VIAL 10-24UNT/5ML   2 Preferred Brand $35.00N/ANone
ACTICIN 5% CREAM   1 Generic $5.00N/ANone
ACTIMMUNE SOLUTION FOR INJECTION 100MCG   4 Specialty 29%N/AP
ACTOPLUS MET 15MG/500MG TABLET   3 Non-Preferred Brand $65.00N/AS Q:90
/30Days
ACTOPLUS MET 15MG/850MG TABLET   3 Non-Preferred Brand $65.00N/AS Q:90
/30Days
ACTOS 15MG TABLET   3 Non-Preferred Brand $65.00N/AS Q:30
/30Days
ACTOS 30MG TABLET (500 CT)   3 Non-Preferred Brand $65.00N/AS Q:30
/30Days
ACTOS 45MG TABLET   3 Non-Preferred Brand $65.00N/AS Q:30
/30Days
ACULAR 0.5% EYE DROPS   3 Non-Preferred Brand $65.00N/AQ:10
/30Days
ACYCLOVIR 200MG CAPSULE (1000 CT)   1 Generic $5.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACYCLOVIR 200MG/5ML SUSP   1 Generic $5.00N/ANone
ACYCLOVIR 400MG TABLET (100 CT)   1 Generic $5.00N/ANone
ACYCLOVIR SODIUM 500MG VIAL   1 Generic $5.00N/AP
ACYCLOVIR TABLET USP 800MG (100 CT)   1 Generic $5.00N/ANone
ADACEL VIAL 2UNT/5UNT   2 Preferred Brand $35.00N/ANone
ADAGEN 250U/ML VIAL   4 Specialty 29%N/ANone
ADVAIR DISKU MIS 100/50   2 Preferred Brand $35.00N/AQ:60
/30Days
ADVAIR DISKU MIS 250/50   2 Preferred Brand $35.00N/AQ:60
/30Days
ADVAIR DISKU MIS 500/50   2 Preferred Brand $35.00N/AQ:60
/30Days
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL   2 Preferred Brand $35.00N/AQ:12
/30Days
ADVAIR HFA INHALER 230;21MCG;MCG   2 Preferred Brand $35.00N/AQ:12
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL   2 Preferred Brand $35.00N/AQ:12
/30Days
AFEDITAB CR 30MG TABLET SA   1 Generic $5.00N/AS Q:30
/30Days
AFEDITAB CR 60MG TABLET SA   1 Generic $5.00N/AS Q:30
/30Days
AGGRENOX 25-200MG CAPSULE   2 Preferred Brand $35.00N/AQ:60
/30Days
AK-CON 0.1% EYE DROPS   1 Generic $5.00N/ANone
AK-POLY-BAC EYE OINTMENT 500UNT/1000UNT   1 Generic $5.00N/ANone
AKNE-MYCIN 2% OINTMENT   3 Non-Preferred Brand $65.00N/ANone
AKTOB 0.3% EYE DROPS   1 Generic $5.00N/ANone
ALA-CORT 1% CREAM   1 Generic $5.00N/ANone
ALA-CORT 1% LOTION   1 Generic $5.00N/ANone
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER   1 Generic $5.00N/AP Q:450
/30Days
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 Generic $5.00N/AP Q:450
/30Days
ALBUTEROL SULFATE 4MG TABLET SR 12HR   1 Generic $5.00N/AQ:120
/30Days
ALBUTEROL SULFATE 8MG TABLET SR 12HR   1 Generic $5.00N/AQ:120
/30Days
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   1 Generic $5.00N/AP Q:100
/30Days
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT   1 Generic $5.00N/AQ:2400
/30Days
ALBUTEROL SULFATE TABLET 2MG (500 CT)   1 Generic $5.00N/AQ:240
/30Days
ALBUTEROL TABLET 4MG (500 CT)   1 Generic $5.00N/AQ:240
/30Days
ALCLOMETASONE DIPROPIONATE 0.05% CREAM   1 Generic $5.00N/ANone
ALCLOMETASONE DIPROPIONATE 0.05% OINTMENT   1 Generic $5.00N/ANone
ALDACTAZIDE 50/50 TABLET   2 Preferred Brand $35.00N/ANone
ALDARA IMIQUIMOD CREAM 5% 24 PKT X 250 MG CRTN   3 Non-Preferred Brand $65.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALDURAZYME 2.9MG/5ML VIAL   3 Non-Preferred Brand $65.00N/ANone
ALENDRONATE SODIUM 10MG TABLET   1 Generic $5.00N/AQ:30
/30Days
ALENDRONATE SODIUM 40MG TABLET   1 Generic $5.00N/AQ:30
/30Days
ALENDRONATE SODIUM 5MG TABLET   1 Generic $5.00N/AQ:30
/30Days
ALENDRONATE SODIUM 70MG TABLET 4 BLPK   1 Generic $5.00N/AQ:4
/28Days
ALENDRONATE SODIUM TABLET 35MG 20 CRTN   1 Generic $5.00N/AQ:4
/28Days
ALFERON N INJ 5MU/ML   4 Specialty 29%N/ANone
ALINIA 500MG TABLET   3 Non-Preferred Brand $65.00N/ANone
ALLOPURINOL TABLET 300MG (1000 CT)   1 Generic $5.00N/ANone
ALLOPURINOL TABLET USP 100MG (1000 CT)   1 Generic $5.00N/ANone
ALORA 0.025MG PATCH   3 Non-Preferred Brand $65.00N/AQ:8
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALORA 0.05MG PATCH   3 Non-Preferred Brand $65.00N/AQ:8
/28Days
ALORA 0.075MG PATCH   3 Non-Preferred Brand $65.00N/AQ:8
/28Days
ALORA 0.1MG PATCH   3 Non-Preferred Brand $65.00N/AQ:8
/28Days
ALPHAGAN P 0.1% DROPS   2 Preferred Brand $35.00N/AQ:10
/30Days
ALPHAGAN P 0.15% EYE DROPS   2 Preferred Brand $35.00N/AQ:10
/30Days
ALREX 0.2% EYE DROPS   2 Preferred Brand $35.00N/ANone
AMANTADINE 100MG CAPSULE   1 Generic $5.00N/ANone
AMCINONIDE 0.1% CREAM   1 Generic $5.00N/ANone
AMCINONIDE 0.1% LOTION   1 Generic $5.00N/ANone
AMCINONIDE 0.1% OINTMENT 60GM TUBE   1 Generic $5.00N/ANone
AMEVIVE ADMISTRATION PACK FOR INTRAMUSCULAR ADMINISTRATION KIT 15MG 1 X 4 PKGCOM   4 Specialty 29%N/AP Q:4
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMIKACIN 250MG/ML VIAL   1 Generic $5.00N/ANone
AMIKACIN 50MG/ML VIAL   1 Generic $5.00N/ANone
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET   1 Generic $5.00N/ANone
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT   1 Generic $5.00N/ANone
AMINESS 5.2% IV SOLUTION   3 Non-Preferred Brand $65.00N/AP
AMINOPHYLLINE 100MG TABLET   1 Generic $5.00N/ANone
AMINOPHYLLINE 200MG TABLET (1000 CT)   1 Generic $5.00N/ANone
AMINOSYN 10% IV SOLUTION   3 Non-Preferred Brand $65.00N/AP
AMINOSYN 3.5% IV SOLUTION   3 Non-Preferred Brand $65.00N/AP
AMINOSYN 5% IV SOLUTION   3 Non-Preferred Brand $65.00N/AP
AMINOSYN 7% IV SOLUTION   3 Non-Preferred Brand $65.00N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN 7%-ELECTROLYTE SOL   3 Non-Preferred Brand $65.00N/AP
AMINOSYN 8.5% IV SOLUTION   3 Non-Preferred Brand $65.00N/AP
AMINOSYN II 10% IV SOLUTION   3 Non-Preferred Brand $65.00N/AP
AMINOSYN II 3.5% IN D25W IV   3 Non-Preferred Brand $65.00N/AP
AMINOSYN II 3.5% M/D5W IV   3 Non-Preferred Brand $65.00N/AP
AMINOSYN II 3.5% W/ELEC DEX   3 Non-Preferred Brand $65.00N/AP
AMINOSYN II 4.25% IN D10W   3 Non-Preferred Brand $65.00N/AP
AMINOSYN II 4.25% IN D20W   3 Non-Preferred Brand $65.00N/AP
AMINOSYN II 4.25% W/ELEC DW   3 Non-Preferred Brand $65.00N/AP
AMINOSYN II 4.25%-D25W IV   3 Non-Preferred Brand $65.00N/AP
AMINOSYN II 5% IN D25W IV   3 Non-Preferred Brand $65.00N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN II 7% IV SOLUTION   3 Non-Preferred Brand $65.00N/AP
AMINOSYN II 8.5% ELECTROLYT   3 Non-Preferred Brand $65.00N/AP
AMINOSYN II 8.5% IV SOLUTION   3 Non-Preferred Brand $65.00N/AP
AMINOSYN M 3.5% IV SOLUTION   3 Non-Preferred Brand $65.00N/AP
AMINOSYN PF INJECTION   3 Non-Preferred Brand $65.00N/AP
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5%   3 Non-Preferred Brand $65.00N/AP
AMINOSYN-HBC 7% IV SOLUTION   3 Non-Preferred Brand $65.00N/AP
AMINOSYN-HF 8% IV SOLUTION   3 Non-Preferred Brand $65.00N/AP
AMINOSYN-PF 7% IV SOLUTION   3 Non-Preferred Brand $65.00N/AP
AMIODARONE HCL 200MG TABLET (60 CT)   1 Generic $5.00N/ANone
AMIODARONE HCL 400MG TABLET   1 Generic $5.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITRIP/PERPHEN 10-2 TABLET   1 Generic $5.00N/ANone
AMITRIP/PERPHEN 10-4 TABLET   1 Generic $5.00N/ANone
AMITRIP/PERPHEN 25-2 TABLET   1 Generic $5.00N/ANone
AMITRIP/PERPHEN 25-4 TABLET   1 Generic $5.00N/ANone
AMITRIP/PERPHEN 50-4 TABLET   1 Generic $5.00N/ANone
AMITRIPTYLINE HCL 100MG TABLET   1 Generic $5.00N/ANone
AMITRIPTYLINE HCL 10MG TABLET   1 Generic $5.00N/ANone
AMITRIPTYLINE HCL 150MG TABLET (100 CT)   1 Generic $5.00N/ANone
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)   1 Generic $5.00N/ANone
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)   1 Generic $5.00N/ANone
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT   1 Generic $5.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE BESYLATE 10MG TABLET (90 CT)   1 Generic $5.00N/AQ:30
/30Days
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)   1 Generic $5.00N/AQ:30
/30Days
AMLODIPINE BESYLATE 5MG TABLET (90 CT)   1 Generic $5.00N/AQ:45
/30Days
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE   1 Generic $5.00N/AQ:30
/30Days
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE   1 Generic $5.00N/AQ:30
/30Days
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE   1 Generic $5.00N/AQ:30
/30Days
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE   1 Generic $5.00N/AQ:30
/30Days
AMMONIUM LACTATE 12% CREAM   1 Generic $5.00N/ANone
AMMONIUM LACTATE 12% LOTION   1 Generic $5.00N/ANone
AMNESTEEM 10MG CAPSULE   1 Generic $5.00N/AP
AMNESTEEM 20MG CAPSULE   1 Generic $5.00N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMNESTEEM 40MG CAPSULE   1 Generic $5.00N/AP
AMOCLAN 200-28.5/5 SUSPENSION RECONSTITUTED ORAL   1 Generic $5.00N/ANone
AMOCLAN 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   1 Generic $5.00N/ANone
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL   1 Generic $5.00N/ANone
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE   1 Generic $5.00N/ANone
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET   1 Generic $5.00N/ANone
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE   1 Generic $5.00N/ANone
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   1 Generic $5.00N/ANone
AMOX TR-POTASSIUM CLAVULANATE 500-125MG TABLET   1 Generic $5.00N/ANone
AMOXAPINE 100MG TABLET   1 Generic $5.00N/ANone
AMOXAPINE 150MG TABLET   1 Generic $5.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXAPINE 25MG TABLET   1 Generic $5.00N/ANone
AMOXAPINE 50MG TABLET   1 Generic $5.00N/ANone
AMOXICILLIN 125MG TABLET CHEW   1 Generic $5.00N/ANone
AMOXICILLIN 200MG TABLET CHEW   1 Generic $5.00N/ANone
AMOXICILLIN 250MG CAPSULE   1 Generic $5.00N/ANone
AMOXICILLIN 400MG TABLET CHEW   1 Generic $5.00N/ANone
AMOXICILLIN 500MG CAPSULE   1 Generic $5.00N/ANone
AMOXICILLIN 500MG TABLET (100 CT)   1 Generic $5.00N/ANone
AMOXICILLIN 875MG TABLET   1 Generic $5.00N/ANone
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT   1 Generic $5.00N/ANone
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT   1 Generic $5.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT   1 Generic $5.00N/ANone
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL   1 Generic $5.00N/ANone
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   1 Generic $5.00N/ANone
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL   1 Generic $5.00N/ANone
AMOXICILLIN TABLET USP CHEWABLE 250MG (250 CT)   1 Generic $5.00N/ANone
AMOXIL 250MG/5ML SUSPENSION   1 Generic $5.00N/ANone
AMOXIL CAPSULES 500MG   1 Generic $5.00N/ANone
AMPHET ASP/ AMPHET/ D-AMPHET 5MG TABLET   1 Generic $5.00N/ANone
AMPHETAMINE SALT COMBO 12.5MG TABLET   1 Generic $5.00N/ANone
AMPHETAMINE SALT COMBO 15MG TABLET   1 Generic $5.00N/ANone
AMPHETAMINE SALT COMBO 30MG TABLET   1 Generic $5.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPHETAMINE SALT COMBO 7.5MG TABLET   1 Generic $5.00N/ANone
AMPHETAMINE SALTS 20MG TABLET   1 Generic $5.00N/ANone
AMPHOTERICIN B FOR INJECTION 50 MG   1 Generic $5.00N/AP
AMPICILLIN AND SULBACTAM FOR INJECTION 10-5 1 VIAL   1 Generic $5.00N/ANone
AMPICILLIN AND SULBACTAM FOR INJECTION 2-1 10 VIAL   1 Generic $5.00N/ANone
AMPICILLIN CAPSULES 250MG 100 BOT   1 Generic $5.00N/ANone
AMPICILLIN CAPSULES 500MG 100 BOT   1 Generic $5.00N/ANone
AMPICILLIN FOR INJECTION POWDER   1 Generic $5.00N/ANone
AMPICILLIN FOR INJECTION USP 125MG/ML 1 VIAL   2 Preferred Brand $35.00N/ANone
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT   1 Generic $5.00N/ANone
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT   1 Generic $5.00N/ANone
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 $5.00N/ANone
ANADROL-50 50MG TABLET (100 CT)   2 Preferred Brand $35.00N/AP
ANAGRELIDE HCL 0.5MG CAPSULE   1 Generic $5.00N/ANone
ANAGRELIDE HCL 1MG CAPSULE   1 Generic $5.00N/ANone
ANCOBON 250MG CAPSULE   3 Non-Preferred Brand $65.00N/ANone
ANCOBON 500MG CAPSULE   3 Non-Preferred Brand $65.00N/ANone
ANDRODERM 2.5MG/24HR PATCH   2 Preferred Brand $35.00N/AQ:30
/30Days
ANDRODERM 5MG/24HR PATCH   2 Preferred Brand $35.00N/AQ:30
/30Days
ANDROID 10MG CAPSULE   1 Generic $5.00N/ANone
ANESTACON 15ML   1 Generic $5.00N/ANone
ANTABUSE 250MG TABLET   2 Preferred Brand $35.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
APOKYN FOR INJECTION 30MG 5 CTG   4 Specialty 29%N/ANone
APRI 0.15-0.03 TABLET   1 Generic $5.00N/AQ:28
/28Days
APRISO CP24   2 Preferred Brand $35.00N/ANone
APTIVUS 250MG CAPSULE   4 Specialty 29%N/ANone
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT   4 Specialty 29%N/ANone
ARALAST 500MG VIAL   4 Specialty 29%N/AP
ARANELLE 7-9-5 TABLET   1 Generic $5.00N/AQ:28
/28Days
ARANESP 100MCG/ML VIAL   4 Specialty 29%N/AP Q:8
/28Days
ARANESP 200MCG/0.4ML SYRINGE   4 Specialty 29%N/AP Q:3
/28Days
ARANESP 200MCG/ML VIAL   4 Specialty 29%N/AP Q:8
/28Days
ARANESP 25MCG/ML VIAL   3 Non-Preferred Brand $65.00N/AP Q:8
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP 300MCG/ML VIAL   4 Specialty 29%N/AP Q:4
/28Days
ARANESP 500MCG/1ML SYRINGE   4 Specialty 29%N/AP Q:4
/28Days
ARANESP 60MCG/ML VIAL   4 Specialty 29%N/AP Q:8
/28Days
ARANESP PREFILLED SYRINGE SINGLE USE 100MCG/0.5ML 1 SYR   4 Specialty 29%N/AP Q:4
/28Days
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR   4 Specialty 29%N/AP Q:2
/28Days
ARANESP PREFILLED SYRINGE SINGLE USE 25MCG/0.42ML SYR   3 Non-Preferred Brand $65.00N/AP Q:3
/28Days
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR   4 Specialty 29%N/AP Q:2
/28Days
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR   3 Non-Preferred Brand $65.00N/AP Q:3
/28Days
ARANESP PREFILLED SYRINGE SINGLE USE 60MCG/0.3ML 60MCG/ 0.3ML SYR   4 Specialty 29%N/AP Q:2
/28Days
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD   3 Non-Preferred Brand $65.00N/AP Q:8
/28Days
ARICEPT 10MG TABLET   2 Preferred Brand $35.00N/AQ:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARICEPT 5MG TABLET   2 Preferred Brand $35.00N/AQ:30
/30Days
ARICEPT ODT 10MG TABLET   2 Preferred Brand $35.00N/AQ:30
/30Days
ARICEPT ODT 5MG TABLET   2 Preferred Brand $35.00N/AQ:30
/30Days
ARIMIDEX 1MG TABLET   2 Preferred Brand $35.00N/AQ:30
/30Days
ARIXTRA 10MG SYRINGE   4 Specialty 29%N/AQ:24
/30Days
ARIXTRA 2.5MG SYRINGE   2 Preferred Brand $35.00N/AQ:15
/30Days
ARIXTRA 5MG SYRINGE   4 Specialty 29%N/AQ:12
/30Days
ARIXTRA 7.5MG SYRINGE   4 Specialty 29%N/AQ:18
/30Days
AROMASIN 25MG TABLET   3 Non-Preferred Brand $65.00N/AS Q:60
/30Days
ASACOL 400MG TABLET EC   3 Non-Preferred Brand $65.00N/ANone
ASACOL HD DELAYED RELEASE TABLETS 800MG 180 BOT   3 Non-Preferred Brand $65.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ASTELIN 137MCG AEROSOL SPRAY W/PUMP   2 Preferred Brand $35.00N/AQ:30
/25Days
ATAMET   1 Generic $5.00N/ANone
ATENOLOL 25MG TABLET (100 CT)   1 Generic $5.00N/ANone
ATENOLOL TABLET USP 50MG (100 CT)   1 Generic $5.00N/ANone
ATENOLOL TABLETS USP 100MG 1 BLPK   1 Generic $5.00N/ANone
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT)   1 Generic $5.00N/ANone
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   1 Generic $5.00N/ANone
ATRIPLA TABLET 600MG/200MG   4 Specialty 29%N/AQ:30
/30Days
ATROVENT HFA AER 17MCG   2 Preferred Brand $35.00N/AQ:26
/30Days
ATTENUVAX VACCINE W/DILUENT 1 DOSE/0.5ML   3 Non-Preferred Brand $65.00N/ANone
AUGMENTIN 125 SUSPENSION   2 Preferred Brand $35.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AUGMENTIN 250 SUSPENSION   2 Preferred Brand $35.00N/ANone
AUGMENTIN TABLETS COMBO   2 Preferred Brand $35.00N/ANone
AUGMENTIN XR 1000-62.5 TABLET   2 Preferred Brand $35.00N/ANone
AVELOX 400MG TABLET   3 Non-Preferred Brand $65.00N/AQ:30
/30Days
AVELOX ABC PACK 400MG TABLET   3 Non-Preferred Brand $65.00N/AQ:30
/30Days
AVELOX IV 400MG/250ML   3 Non-Preferred Brand $65.00N/ANone
AVIANE 0.1-0.02 TABLET   1 Generic $5.00N/AQ:28
/28Days
AVINZA 120MG CAPSULE MULTIPHASIC RELEASE 24 HR   3 Non-Preferred Brand $65.00N/AS Q:300
/30Days
AVINZA 30MG CAPSULE MULTIPHASIC RELEASE 24 HR   3 Non-Preferred Brand $65.00N/AS Q:30
/30Days
AVINZA 60MG CAPSULE MULTIPHASIC RELEASE 24 HR   3 Non-Preferred Brand $65.00N/AS Q:30
/30Days
AVINZA 90MG CAPSULE MULTIPHASIC RELEASE 24 HR   3 Non-Preferred Brand $65.00N/AS Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVINZA CAPSULES EXTENDED RELEASE 45MG 100 BOTPL   3 Non-Preferred Brand $65.00N/AS Q:30
/30Days
AVINZA CAPSULES EXTENDED RELEASE 75MG 100 BOTPL   3 Non-Preferred Brand $65.00N/AS Q:30
/30Days
AVITA 0.025% CREAM   1 Generic $5.00N/ANone
AVODART 0.5MG SOFTGEL   2 Preferred Brand $35.00N/AQ:30
/30Days
AVONEX ADMIN PACK 30MCG SYR   4 Specialty 29%N/AP Q:4
/28Days
AVONEX ADMIN PACK 30MCG VL   4 Specialty 29%N/AP Q:4
/28Days
AZACTAM 2GM VIAL   4 Specialty 29%N/ANone
AZACTAM INJECTION 1GM 50ML BAG   2 Preferred Brand $35.00N/ANone
AZACTAM/ISO-OSMOT 2GM/50ML   4 Specialty 29%N/ANone
AZASITE 1% DROPS   2 Preferred Brand $35.00N/AQ:3
/30Days
AZATHIOPRINE 50MG TABLET   1 Generic $5.00N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZILECT 0.5MG TABLET   2 Preferred Brand $35.00N/AQ:30
/30Days
AZILECT 1MG TABLET   2 Preferred Brand $35.00N/AQ:30
/30Days
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Generic $5.00N/ANone
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Generic $5.00N/ANone
AZITHROMYCIN 250MG TABLET (30 CT)   1 Generic $5.00N/ANone
AZITHROMYCIN 500MG TABLET (30 CT)   1 Generic $5.00N/ANone
AZITHROMYCIN FOR INJECTION 500MG 10 VIALSD   1 Generic $5.00N/ANone
AZITHROMYCIN TABLET 600MG (30 CT)   1 Generic $5.00N/ANone
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT   2 Preferred Brand $35.00N/AQ:10
/30Days
AZOR 10MG-20MG TABLET   3 Non-Preferred Brand $65.00N/AS Q:30
/30Days
AZOR 10MG-40MG TABLET (30 CT)   3 Non-Preferred Brand $65.00N/AS Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZOR 5MG-20MG TABLET (30 CT)   3 Non-Preferred Brand $65.00N/AS Q:30
/30Days
AZOR 5MG-40MG TABLET   3 Non-Preferred Brand $65.00N/AS Q:30
/30Days

Chart Legend:

Below are a few notes to help you understand the above 2010 Medicare Part D Community CCRx Choice (PDP) Plan Formulary.
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  • 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.