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AARP MedicareRx Saver (PDP) (S5921-001-0)
Tier 1 (1691)
Tier 2 (777)
Tier 3 (807)
Tier 4 (339)

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2010 Medicare Part D Plan Formulary Information
AARP MedicareRx Saver (PDP) (S5921-001-0)
Benefit Details  
The AARP MedicareRx Saver (PDP) (S5921-001-0)
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 Tier 1 Preferred Generic Brand $6.00$4.00None
A-HYDROCORT 100MG VIAL   1 Tier 1 Preferred Generic Brand $6.00$4.00None
A-METHAPRED 40MG UNIVIAL   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ABELCENT INJECTION SUSPENSION 5MG/ML   4 Tier 4 Specialty 25%25%P
ABILIFY 10MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75S Q:31
/31Days
ABILIFY 15MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75S Q:31
/31Days
ABILIFY 1MG/ML SOLUTION   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75S Q:775
/31Days
ABILIFY 20MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75S Q:31
/31Days
ABILIFY 2MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75S Q:31
/31Days
ABILIFY 30MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75S Q:31
/31Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ABILIFY 5MG TABLET (OTSUKA)   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75S Q:31
/31Days
ABILIFY DISCMELT 10MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75S Q:62
/31Days
ABILIFY DISCMELT 15MG TABLET   4 Tier 4 Specialty 25%25%S Q:62
/31Days
ABILIFY INJ 9.75MG   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75None
ABRAXANE 100MG VIAL   4 Tier 4 Specialty 25%25%None
ACARBOSE 100MG TABLET S   1 Tier 1 Preferred Generic Brand $6.00$4.00S
ACARBOSE 25MG TABLET S   1 Tier 1 Preferred Generic Brand $6.00$4.00S
ACARBOSE 50MG TABLET S   1 Tier 1 Preferred Generic Brand $6.00$4.00S
ACCOLATE 10MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75S Q:62
/31Days
ACCOLATE 20MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75S Q:62
/31Days
ACEBUTOLOL 200MG CAPSULE   1 Tier 1 Preferred Generic Brand $6.00$4.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACEBUTOLOL 400MG CAPSULE   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ACETADOTE 200MG/ML VIAL   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75None
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT)   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT)   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT)   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ACETASOL HC OTIC SOLUTION   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ACETASOL HC SOLUTION 10ML 10 ML BOT   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ACETAZOLAMIDE 125MG TABLET   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ACETAZOLAMIDE 250MG TABLET (100 CT)   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT   2 Tier 2 Generic Preferred Brand $25.00$60.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETAZOLAMIDE SOD 500MG VL   2 Tier 2 Generic Preferred Brand $25.00$60.00None
ACETIC ACID 2% SOLUTION NON-ORAL   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ACETIC ACID IN AQUEOUS ALUMINUM ACETATE OTIC SOLUTION 2% 60 ML BOT   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ACETYLCYSTEINE 10% VIAL   1 Tier 1 Preferred Generic Brand $6.00$4.00P
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN   1 Tier 1 Preferred Generic Brand $6.00$4.00P
ACTHIB VACCINE VIAL 10-24UNT/5ML   2 Tier 2 Generic Preferred Brand $25.00$60.00None
ACTICIN 5% CREAM   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ACTIMMUNE SOLUTION FOR INJECTION 100MCG   4 Tier 4 Specialty 25%25%None
ACTIVELLA 0.5-0.1MG TABLET 28 DLPK   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75None
ACTIVELLA 1-0.5MG TABLET 28 DLPK   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75None
ACTONEL 150MG TABLET   2 Tier 2 Generic Preferred Brand $25.00$60.00Q:1
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACTONEL 30MG TABLET   2 Tier 2 Generic Preferred Brand $25.00$60.00Q:31
/31Days
ACTONEL 35MG TABLET   2 Tier 2 Generic Preferred Brand $25.00$60.00Q:4
/28Days
ACTONEL 5MG TABLET   2 Tier 2 Generic Preferred Brand $25.00$60.00Q:31
/31Days
ACTONEL 75MG TABLET   2 Tier 2 Generic Preferred Brand $25.00$60.00Q:2
/28Days
ACTONEL WITH CALCIUM TABLET   2 Tier 2 Generic Preferred Brand $25.00$60.00Q:31
/31Days
ACTOPLUS MET 15MG/500MG TABLET   2 Tier 2 Generic Preferred Brand $25.00$60.00S
ACTOPLUS MET 15MG/850MG TABLET   2 Tier 2 Generic Preferred Brand $25.00$60.00S
ACTOS 15MG TABLET   2 Tier 2 Generic Preferred Brand $25.00$60.00S
ACTOS 30MG TABLET (500 CT)   2 Tier 2 Generic Preferred Brand $25.00$60.00S
ACTOS 45MG TABLET   2 Tier 2 Generic Preferred Brand $25.00$60.00S
ACULAR 0.5% EYE DROPS   2 Tier 2 Generic Preferred Brand $25.00$60.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACULAR LS 0.4% OPHTH SOL   2 Tier 2 Generic Preferred Brand $25.00$60.00None
ACYCLOVIR 200MG CAPSULE (1000 CT)   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ACYCLOVIR 200MG/5ML SUSP   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ACYCLOVIR 400MG TABLET (100 CT)   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ACYCLOVIR SODIUM 500MG VIAL   2 Tier 2 Generic Preferred Brand $25.00$60.00P
ACYCLOVIR TABLET USP 800MG (100 CT)   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ADACEL VIAL 2UNT/5UNT   2 Tier 2 Generic Preferred Brand $25.00$60.00None
ADAGEN 250U/ML VIAL   4 Tier 4 Specialty 25%25%None
ADCIRCA TABLETS 20MG 60 BOT   4 Tier 4 Specialty 25%25%P Q:62
/31Days
ADDERALL XR 10MG CAPSULE SA   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75Q:62
/31Days
ADDERALL XR 15MG CAPSULE SA   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75Q:62
/31Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADDERALL XR 20MG CAPSULE SA   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75Q:31
/31Days
ADDERALL XR 25MG CAPSULE SA   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75Q:31
/31Days
ADDERALL XR 30MG CAPSULE SA   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75Q:31
/31Days
ADDERALL XR 5MG CAPSULE SA   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75Q:62
/31Days
ADVAIR DISKU MIS 100/50   2 Tier 2 Generic Preferred Brand $25.00$60.00Q:60
/30Days
ADVAIR DISKU MIS 250/50   2 Tier 2 Generic Preferred Brand $25.00$60.00Q:60
/30Days
ADVAIR DISKU MIS 500/50   2 Tier 2 Generic Preferred Brand $25.00$60.00Q:60
/30Days
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL   2 Tier 2 Generic Preferred Brand $25.00$60.00Q:12
/30Days
ADVAIR HFA INHALER 230;21MCG;MCG   2 Tier 2 Generic Preferred Brand $25.00$60.00Q:12
/30Days
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL   2 Tier 2 Generic Preferred Brand $25.00$60.00Q:12
/30Days
AEROBID-M AEROSOL W/ADAPTER   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75S Q:21
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AFEDITAB CR 30MG TABLET SA   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AFEDITAB CR 60MG TABLET SA   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AGGRENOX 25-200MG CAPSULE   2 Tier 2 Generic Preferred Brand $25.00$60.00Q:62
/31Days
AK-CON 0.1% EYE DROPS   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AK-POLY-BAC EYE OINTMENT 500UNT/1000UNT   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AKNE-MYCIN 2% OINTMENT   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75None
AKTOB 0.3% EYE DROPS   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ALA-CORT 1% CREAM   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ALA-CORT 1% LOTION   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ALA-SCALP HP 2% LOTION   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75None
ALAMAST 0.1% DROPS   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALBENZA 200MG TABLET   2 Tier 2 Generic Preferred Brand $25.00$60.00None
ALBUTEROL SULFATE 0.63MG/3ML VIAL NEBULIZER   1 Tier 1 Preferred Generic Brand $6.00$4.00P
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER   1 Tier 1 Preferred Generic Brand $6.00$4.00P
ALBUTEROL SULFATE 2.5MG/3ML VIAL NEBULIZER   1 Tier 1 Preferred Generic Brand $6.00$4.00P
ALBUTEROL SULFATE 4MG TABLET SR 12HR   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ALBUTEROL SULFATE 8MG TABLET SR 12HR   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   1 Tier 1 Preferred Generic Brand $6.00$4.00P
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ALBUTEROL SULFATE TABLET 2MG (500 CT)   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ALBUTEROL TABLET 4MG (500 CT)   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ALCAINE 0.5% EYE DROPS   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALCLOMETASONE DIPROPIONATE 0.05% CREAM   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ALCLOMETASONE DIPROPIONATE 0.05% OINTMENT   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ALCOHOL 5%/DEXTROSE 5%   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ALDARA IMIQUIMOD CREAM 5% 24 PKT X 250 MG CRTN   2 Tier 2 Generic Preferred Brand $25.00$60.00None
ALDURAZYME 2.9MG/5ML VIAL   4 Tier 4 Specialty 25%25%None
ALENDRONATE SODIUM 10MG TABLET   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ALENDRONATE SODIUM 40MG TABLET   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ALENDRONATE SODIUM 5MG TABLET   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ALENDRONATE SODIUM 70MG TABLET 4 BLPK   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ALENDRONATE SODIUM TABLET 35MG 20 CRTN   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ALFERON N INJ 5MU/ML   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALIMTA 500MG VIAL   4 Tier 4 Specialty 25%25%P
ALINIA 100MG/5ML SUSPENSION   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75None
ALINIA 500MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75None
ALKERAN FOR INJECTION 50MG/VIAL 1 VIALSU   4 Tier 4 Specialty 25%25%None
ALLOPURINOL SODIUM 500MG VIAL   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ALLOPURINOL TABLET 300MG (1000 CT)   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ALLOPURINOL TABLET USP 100MG (1000 CT)   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ALOCRIL 2% EYE DROPS   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75None
ALOMIDE 0.1% EYE DROPS   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75None
ALORA 0.025MG PATCH   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75None
ALORA 0.05MG PATCH   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALORA 0.075MG PATCH   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75None
ALORA 0.1MG PATCH   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75None
ALOXI 0.25MG/5ML   4 Tier 4 Specialty 25%25%None
ALPHAGAN P 0.1% DROPS   2 Tier 2 Generic Preferred Brand $25.00$60.00None
ALPHAGAN P 0.15% EYE DROPS   2 Tier 2 Generic Preferred Brand $25.00$60.00None
ALREX 0.2% EYE DROPS   2 Tier 2 Generic Preferred Brand $25.00$60.00None
ALTABAX 1% OINTMENT   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75None
ALVESCO 160MCG/ACT AERS   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75S Q:12
/30Days
ALVESCO 80MCG/ACT AERS   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75S Q:12
/30Days
AMANTADINE 100MG CAPSULE   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMANTADINE 100MG TABLET   1 Tier 1 Preferred Generic Brand $6.00$4.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMBISOME 50MG VIAL   4 Tier 4 Specialty 25%25%P
AMCINONIDE 0.1% CREAM   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMCINONIDE 0.1% LOTION   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMCINONIDE 0.1% OINTMENT 60GM TUBE   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMEVIVE ADMISTRATION PACK FOR INTRAMUSCULAR ADMINISTRATION KIT 15MG 1 X 4 PKGCOM   4 Tier 4 Specialty 25%25%P
AMIFOSTINE FOR INJECTION 500MG/VIAL   4 Tier 4 Specialty 25%25%None
AMIKACIN 250MG/ML VIAL   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMIKACIN 50MG/ML VIAL   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMINESS 5.2% IV SOLUTION   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOPHYLLINE 100MG TABLET   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMINOPHYLLINE 200MG TABLET (1000 CT)   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMINOPHYLLINE INJECTION 250MG 10ML X 25 VIALSD   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMINOSYN 10% IV SOLUTION   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75P
AMINOSYN 3.5% IV SOLUTION   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75P
AMINOSYN 5% IV SOLUTION   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75P
AMINOSYN 7% IV SOLUTION   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75P
AMINOSYN 7%-ELECTROLYTE SOL   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75P
AMINOSYN 8.5% IV SOLUTION   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75P
AMINOSYN II 10% IV SOLUTION   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75P
AMINOSYN II 3.5% IN D25W IV   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN II 3.5% M/D5W IV   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75P
AMINOSYN II 3.5% W/ELEC DEX   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75P
AMINOSYN II 4.25% IN D10W   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75P
AMINOSYN II 4.25% IN D20W   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75P
AMINOSYN II 4.25% W/ELEC DW   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75P
AMINOSYN II 4.25%-D25W IV   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75P
AMINOSYN II 5% IN D25W IV   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75P
AMINOSYN II 7% IV SOLUTION   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75P
AMINOSYN II 8.5% ELECTROLYT   1 Tier 1 Preferred Generic Brand $6.00$4.00P
AMINOSYN II 8.5% IV SOLUTION   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75P
AMINOSYN M 3.5% IV SOLUTION   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN PF INJECTION   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75P
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5%   1 Tier 1 Preferred Generic Brand $6.00$4.00P
AMINOSYN-HBC 7% IV SOLUTION   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75P
AMINOSYN-HF 8% IV SOLUTION   2 Tier 2 Generic Preferred Brand $25.00$60.00P
AMINOSYN-PF 7% IV SOLUTION   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75P
AMIODARONE HCL 200MG TABLET (60 CT)   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMIODARONE HCL 400MG TABLET   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMIODARONE HCL INJECTION   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMITIZA 8MCG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75P Q:62
/31Days
AMITIZA CAPSULES 24MCG 60 CAP BOT   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75P Q:62
/31Days
AMITRIP/CDP 25-10 TABLET   1 Tier 1 Preferred Generic Brand $6.00$4.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITRIP/PERPHEN 10-2 TABLET   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMITRIP/PERPHEN 10-4 TABLET   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMITRIP/PERPHEN 25-2 TABLET   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMITRIP/PERPHEN 25-4 TABLET   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMITRIP/PERPHEN 50-4 TABLET   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMITRIPTYLINE HCL 100MG TABLET   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMITRIPTYLINE HCL 10MG TABLET   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMITRIPTYLINE HCL 150MG TABLET (100 CT)   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT   1 Tier 1 Preferred Generic Brand $6.00$4.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE BESYLATE 10MG TABLET (90 CT)   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMLODIPINE BESYLATE 5MG TABLET (90 CT)   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE   1 Tier 1 Preferred Generic Brand $6.00$4.00Q:31
/31Days
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE   1 Tier 1 Preferred Generic Brand $6.00$4.00Q:31
/31Days
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE   1 Tier 1 Preferred Generic Brand $6.00$4.00Q:31
/31Days
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE   1 Tier 1 Preferred Generic Brand $6.00$4.00Q:31
/31Days
AMMONIUM CHLORIDE 5 MEQ/ML   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75None
AMMONIUM LACTATE 12% CREAM   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMMONIUM LACTATE 12% LOTION   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMNESTEEM 10MG CAPSULE   2 Tier 2 Generic Preferred Brand $25.00$60.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMNESTEEM 20MG CAPSULE   2 Tier 2 Generic Preferred Brand $25.00$60.00None
AMNESTEEM 40MG CAPSULE   2 Tier 2 Generic Preferred Brand $25.00$60.00None
AMOCLAN 200-28.5/5 SUSPENSION RECONSTITUTED ORAL   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMOCLAN 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMOX TR-POTASSIUM CLAVULANATE 500-125MG TABLET   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMOXAPINE 100MG TABLET   1 Tier 1 Preferred Generic Brand $6.00$4.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXAPINE 150MG TABLET   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMOXAPINE 25MG TABLET   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMOXAPINE 50MG TABLET   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMOXICILLIN 125MG TABLET CHEW   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMOXICILLIN 200MG TABLET CHEW   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMOXICILLIN 250MG CAPSULE   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMOXICILLIN 400MG TABLET CHEW   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMOXICILLIN 500MG CAPSULE   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMOXICILLIN 500MG TABLET (100 CT)   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMOXICILLIN 875MG TABLET   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT   1 Tier 1 Preferred Generic Brand $6.00$4.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMOXICILLIN TABLET USP CHEWABLE 250MG (250 CT)   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMOXIL 250MG/5ML SUSPENSION   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMOXIL 400MG/5ML SUSPENSION   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75None
AMOXIL CAPSULES 500MG   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMPHET ASP/ AMPHET/ D-AMPHET 5MG TABLET   1 Tier 1 Preferred Generic Brand $6.00$4.00Q:372
/31Days
AMPHETAMINE SALT COMBO 12.5MG TABLET   1 Tier 1 Preferred Generic Brand $6.00$4.00Q:155
/31Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPHETAMINE SALT COMBO 15MG TABLET   1 Tier 1 Preferred Generic Brand $6.00$4.00Q:124
/31Days
AMPHETAMINE SALT COMBO 30MG TABLET   1 Tier 1 Preferred Generic Brand $6.00$4.00Q:62
/31Days
AMPHETAMINE SALT COMBO 7.5MG TABLET   1 Tier 1 Preferred Generic Brand $6.00$4.00Q:248
/31Days
AMPHETAMINE SALTS 20MG TABLET   1 Tier 1 Preferred Generic Brand $6.00$4.00Q:93
/31Days
AMPHOTEC INJ 50MG   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75P
AMPHOTERICIN B FOR INJECTION 50 MG   2 Tier 2 Generic Preferred Brand $25.00$60.00P
AMPICILLIN AND SULBACTAM FOR INJECTION 10-5 1 VIAL   2 Tier 2 Generic Preferred Brand $25.00$60.00None
AMPICILLIN AND SULBACTAM FOR INJECTION 2-1 10 VIAL   2 Tier 2 Generic Preferred Brand $25.00$60.00None
AMPICILLIN CAPSULES 250MG 100 BOT   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMPICILLIN CAPSULES 500MG 100 BOT   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMPICILLIN FOR INJECTION POWDER   2 Tier 2 Generic Preferred Brand $25.00$60.00None
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 Generic Preferred Brand $25.00$60.00None
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AMPICILLIN POWDER FOR INJECTION 1 GM/ML   2 Tier 2 Generic Preferred Brand $25.00$60.00None
ANADROL-50 50MG TABLET (100 CT)   4 Tier 4 Specialty 25%25%P
ANAGRELIDE HCL 0.5MG CAPSULE   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ANAGRELIDE HCL 1MG CAPSULE   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ANCOBON 250MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75None
ANCOBON 500MG CAPSULE   4 Tier 4 Specialty 25%25%None
ANDRODERM 2.5MG/24HR PATCH   2 Tier 2 Generic Preferred Brand $25.00$60.00P
ANDRODERM 5MG/24HR PATCH   2 Tier 2 Generic Preferred Brand $25.00$60.00P
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 Generic Preferred Brand $25.00$60.00P
ANESTACON 15ML   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ANTABUSE 250MG TABLET   2 Tier 2 Generic Preferred Brand $25.00$60.00None
ANTABUSE 500MG TABLET   2 Tier 2 Generic Preferred Brand $25.00$60.00None
APAP-CAFFEINE-DIHYDROCODE TAB 30 EA   1 Tier 1 Preferred Generic Brand $6.00$4.00None
APOKYN FOR INJECTION 30MG 5 CTG   4 Tier 4 Specialty 25%25%P
APRI 0.15-0.03 TABLET   1 Tier 1 Preferred Generic Brand $6.00$4.00None
APTIVUS 250MG CAPSULE   4 Tier 4 Specialty 25%25%None
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT   4 Tier 4 Specialty 25%25%None
ARALAST 500MG VIAL   4 Tier 4 Specialty 25%25%None
ARANELLE 7-9-5 TABLET   1 Tier 1 Preferred Generic Brand $6.00$4.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP 100MCG/ML VIAL   4 Tier 4 Specialty 25%25%P
ARANESP 200MCG/0.4ML SYRINGE   4 Tier 4 Specialty 25%25%P
ARANESP 200MCG/ML VIAL   4 Tier 4 Specialty 25%25%P
ARANESP 25MCG/ML VIAL   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75P Q:5
/31Days
ARANESP 300MCG/ML VIAL   4 Tier 4 Specialty 25%25%P
ARANESP 500MCG/1ML SYRINGE   4 Tier 4 Specialty 25%25%P
ARANESP 60MCG/ML VIAL   4 Tier 4 Specialty 25%25%P
ARANESP PREFILLED SYRINGE SINGLE USE 100MCG/0.5ML 1 SYR   4 Tier 4 Specialty 25%25%P
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR   4 Tier 4 Specialty 25%25%P
ARANESP PREFILLED SYRINGE SINGLE USE 25MCG/0.42ML SYR   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75P Q:2
/31Days
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR   4 Tier 4 Specialty 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75P
ARANESP PREFILLED SYRINGE SINGLE USE 60MCG/0.3ML 60MCG/ 0.3ML SYR   4 Tier 4 Specialty 25%25%P
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75P
ARCALYST INJECTION 220MG/VIAL   4 Tier 4 Specialty 25%25%P
ARICEPT 10MG TABLET   2 Tier 2 Generic Preferred Brand $25.00$60.00Q:31
/31Days
ARICEPT 5MG TABLET   2 Tier 2 Generic Preferred Brand $25.00$60.00Q:31
/31Days
ARICEPT ODT 10MG TABLET   2 Tier 2 Generic Preferred Brand $25.00$60.00Q:31
/31Days
ARICEPT ODT 5MG TABLET   2 Tier 2 Generic Preferred Brand $25.00$60.00Q:31
/31Days
ARIMIDEX 1MG TABLET   2 Tier 2 Generic Preferred Brand $25.00$60.00None
ARIXTRA 10MG SYRINGE   4 Tier 4 Specialty 25%25%None
ARIXTRA 2.5MG SYRINGE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARIXTRA 5MG SYRINGE   4 Tier 4 Specialty 25%25%None
ARIXTRA 7.5MG SYRINGE   4 Tier 4 Specialty 25%25%None
AROMASIN 25MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75None
ARRANON 250MG VIAL   4 Tier 4 Specialty 25%25%None
ARTHROTEC 50 50MG TABLET -200MCG (60 CT)   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75None
ARTHROTEC 75 TABLET EC   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75None
ASACOL 400MG TABLET EC   2 Tier 2 Generic Preferred Brand $25.00$60.00None
ASCOMP W/CODEINE 30-50-325 CAPSULE   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ASMANEX 220MCG(14) AEROSOL POWDER BREATH ACTIVATED   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75S Q:240
/30Days
ASMANEX TWISTHALER 220MCG #120   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75S Q:240
/30Days
ASMANEX TWISTHALER 220MCG #30   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75S Q:240
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ASMANEX TWISTHALER 220MCG #60   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75S Q:240
/30Days
ASTELIN 137MCG AEROSOL SPRAY W/PUMP   2 Tier 2 Generic Preferred Brand $25.00$60.00Q:60
/31Days
ASTRAMORPH-PF 0.5MG/ML VIAL   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ASTRAMORPH-PF 1MG/ML VIAL   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ATAMET   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ATENOLOL 25MG TABLET (100 CT)   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ATENOLOL TABLET USP 50MG (100 CT)   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ATENOLOL TABLETS USP 100MG 1 BLPK   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT)   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ATGAM 50MG/ML AMPUL   4 Tier 4 Specialty 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATRIPLA TABLET 600MG/200MG   4 Tier 4 Specialty 25%25%None
ATROPINE 0.05MG/ML SYRINGE   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ATROPINE 0.1MG/ML SYRINGE   1 Tier 1 Preferred Generic Brand $6.00$4.00None
ATROVENT HFA AER 17MCG   2 Tier 2 Generic Preferred Brand $25.00$60.00None
ATTENUVAX VACCINE W/DILUENT 1 DOSE/0.5ML   2 Tier 2 Generic Preferred Brand $25.00$60.00None
AUGMENTIN 125 SUSPENSION   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75None
AUGMENTIN 250 SUSPENSION   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75None
AUGMENTIN TABLETS COMBO   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75None
AUGMENTIN XR 1000-62.5 TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75None
AVANDAMET 2MG/1000MG TABLET   2 Tier 2 Generic Preferred Brand $25.00$60.00S
AVANDAMET 2MG/500MG TABLET   2 Tier 2 Generic Preferred Brand $25.00$60.00S
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVANDAMET 4MG/500MG TABLET   2 Tier 2 Generic Preferred Brand $25.00$60.00S
AVANDAMET TABLET 4-1000MG   2 Tier 2 Generic Preferred Brand $25.00$60.00S
AVANDARYL 4MG/1MG TABLET   2 Tier 2 Generic Preferred Brand $25.00$60.00S
AVANDARYL 4MG/2MG TABLET   2 Tier 2 Generic Preferred Brand $25.00$60.00S
AVANDARYL 4MG/4MG TABLET   2 Tier 2 Generic Preferred Brand $25.00$60.00S
AVANDARYL 8MG-2MG TABLET   2 Tier 2 Generic Preferred Brand $25.00$60.00S
AVANDARYL 8MG-4MG TABLET   2 Tier 2 Generic Preferred Brand $25.00$60.00S
AVANDIA 2MG TABLET   2 Tier 2 Generic Preferred Brand $25.00$60.00S
AVANDIA 4MG TABLET (90 CT)   2 Tier 2 Generic Preferred Brand $25.00$60.00S
AVANDIA 8MG TABLET (90 CT)   2 Tier 2 Generic Preferred Brand $25.00$60.00S
AVASTIN 100MG/4ML VIAL   4 Tier 4 Specialty 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVELOX 400MG TABLET   2 Tier 2 Generic Preferred Brand $25.00$60.00None
AVELOX ABC PACK 400MG TABLET   2 Tier 2 Generic Preferred Brand $25.00$60.00None
AVELOX IV 400MG/250ML   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75None
AVIANE 0.1-0.02 TABLET   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AVITA 0.025% CREAM   1 Tier 1 Preferred Generic Brand $6.00$4.00P
AVODART 0.5MG SOFTGEL   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75Q:31
/31Days
AVONEX ADMIN PACK 30MCG SYR   4 Tier 4 Specialty 25%25%P
AVONEX ADMIN PACK 30MCG VL   4 Tier 4 Specialty 25%25%P
AZACTAM 2GM VIAL   2 Tier 2 Generic Preferred Brand $25.00$60.00None
AZACTAM INJECTION 1GM 50ML BAG   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75None
AZACTAM/ISO-OSMOT 2GM/50ML   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZASAN 100MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75None
AZASAN 75MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75None
AZATHIOPRINE 50MG TABLET   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AZATHIOPRINE SOD 100MG VIAL   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AZILECT 0.5MG TABLET   2 Tier 2 Generic Preferred Brand $25.00$60.00None
AZILECT 1MG TABLET   2 Tier 2 Generic Preferred Brand $25.00$60.00None
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AZITHROMYCIN 250MG TABLET (30 CT)   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AZITHROMYCIN 500MG TABLET (30 CT)   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AZITHROMYCIN FOR INJECTION 500MG 10 VIALSD   2 Tier 2 Generic Preferred Brand $25.00$60.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZITHROMYCIN TABLET 600MG (30 CT)   1 Tier 1 Preferred Generic Brand $6.00$4.00None
AZMACORT INHALATION AEROSOL .1MG/1IHL 20 GM CSTR   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $80.25$225.75S Q:40
/30Days
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT   2 Tier 2 Generic Preferred Brand $25.00$60.00None
AZOR 10MG-20MG TABLET   2 Tier 2 Generic Preferred Brand $25.00$60.00Q:31
/31Days
AZOR 10MG-40MG TABLET (30 CT)   2 Tier 2 Generic Preferred Brand $25.00$60.00Q:31
/31Days
AZOR 5MG-20MG TABLET (30 CT)   2 Tier 2 Generic Preferred Brand $25.00$60.00Q:31
/31Days
AZOR 5MG-40MG TABLET   2 Tier 2 Generic Preferred Brand $25.00$60.00Q:31
/31Days

Chart Legend:

Below are a few notes to help you understand the above 2010 Medicare Part D AARP MedicareRx Saver (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.