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Blue Shield Medicare Rx Enhanced Plan (PDP (S2468-001-0)
Tier 1 (1633)
Tier 2 (526)
Tier 3 (606)
Tier 4 (610)
Tier 5 (183)
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2010 Medicare Part D Plan Formulary Information
Blue Shield Medicare Rx Enhanced Plan (PDP (S2468-001-0)
Benefit Details  
The Blue Shield Medicare Rx Enhanced Plan (PDP (S2468-001-0)
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   4 Injectables 33%33%P
A-HYDROCORT 100MG VIAL   4 Injectables 33%33%P
A-METHAPRED 40MG UNIVIAL   4 Injectables 33%33%P
ABELCENT INJECTION SUSPENSION 5MG/ML   4 Injectables 33%33%P
ABILIFY 10MG TABLET   3 Non-Preferred Brand $75.00$150.00None
ABILIFY 15MG TABLET   3 Non-Preferred Brand $75.00$150.00None
ABILIFY 1MG/ML SOLUTION   3 Non-Preferred Brand $75.00$150.00None
ABILIFY 20MG TABLET   3 Non-Preferred Brand $75.00$150.00None
ABILIFY 2MG TABLET   3 Non-Preferred Brand $75.00$150.00None
ABILIFY 30MG TABLET   3 Non-Preferred Brand $75.00$150.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ABILIFY 5MG TABLET (OTSUKA)   3 Non-Preferred Brand $75.00$150.00None
ABILIFY DISCMELT 10MG TABLET   3 Non-Preferred Brand $75.00$150.00P
ABILIFY DISCMELT 15MG TABLET   3 Non-Preferred Brand $75.00$150.00P
ABILIFY INJ 9.75MG   4 Injectables 33%33%P
ABRAXANE 100MG VIAL   4 Injectables 33%33%P
ACARBOSE 100MG TABLET S   1 Formulary Generic $9.00$18.00None
ACARBOSE 25MG TABLET S   1 Formulary Generic $9.00$18.00None
ACARBOSE 50MG TABLET S   1 Formulary Generic $9.00$18.00None
ACCOLATE 10MG TABLET   3 Non-Preferred Brand $75.00$150.00None
ACCOLATE 20MG TABLET   3 Non-Preferred Brand $75.00$150.00None
ACEBUTOLOL 200MG CAPSULE   1 Formulary Generic $9.00$18.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACEBUTOLOL 400MG CAPSULE   1 Formulary Generic $9.00$18.00None
ACEON 2MG TABLET   3 Non-Preferred Brand $75.00$150.00Q:30
/30Days
ACEON 4MG TABLET   3 Non-Preferred Brand $75.00$150.00Q:30
/30Days
ACEON 8MG TABLET   3 Non-Preferred Brand $75.00$150.00Q:60
/30Days
ACETADOTE 200MG/ML VIAL   4 Injectables 33%33%P
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD   1 Formulary Generic $9.00$18.00None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT)   1 Formulary Generic $9.00$18.00None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT)   1 Formulary Generic $9.00$18.00None
ACETASOL HC OTIC SOLUTION   1 Formulary Generic $9.00$18.00None
ACETAZOLAMIDE 125MG TABLET   1 Formulary Generic $9.00$18.00None
ACETAZOLAMIDE 250MG TABLET (100 CT)   1 Formulary Generic $9.00$18.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT   1 Formulary Generic $9.00$18.00None
ACETAZOLAMIDE SOD 500MG VL   4 Injectables 33%33%P
ACETIC ACID 2% SOLUTION NON-ORAL   1 Formulary Generic $9.00$18.00None
ACETYLCYSTEINE 10% VIAL   1 Formulary Generic $9.00$18.00P
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN   1 Formulary Generic $9.00$18.00P
ACIPHEX 20MG TABLET EC   2 Formulary Brand $35.00$70.00None
ACTHIB VACCINE VIAL 10-24UNT/5ML   4 Injectables 33%33%P
ACTICIN 5% CREAM   1 Formulary Generic $9.00$18.00None
ACTIMMUNE SOLUTION FOR INJECTION 100MCG   5 Formulary Specialty (Unique High Cost Drugs) 33%33%P
ACTIVELLA 0.5-0.1MG TABLET 28 DLPK   2 Formulary Brand $35.00$70.00None
ACTONEL 150MG TABLET   3 Non-Preferred Brand $75.00$150.00S Q:1
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACTONEL 30MG TABLET   2 Formulary Brand $35.00$70.00P
ACTONEL 35MG TABLET   3 Non-Preferred Brand $75.00$150.00S Q:4
/28Days
ACTONEL 5MG TABLET   3 Non-Preferred Brand $75.00$150.00S Q:30
/30Days
ACTONEL 75MG TABLET   3 Non-Preferred Brand $75.00$150.00S Q:2
/28Days
ACTONEL WITH CALCIUM TABLET   3 Non-Preferred Brand $75.00$150.00S Q:28
/28Days
ACTOPLUS MET 15MG/500MG TABLET   2 Formulary Brand $35.00$70.00S
ACTOPLUS MET 15MG/850MG TABLET   2 Formulary Brand $35.00$70.00S
ACTOS 15MG TABLET   2 Formulary Brand $35.00$70.00S
ACTOS 30MG TABLET (500 CT)   2 Formulary Brand $35.00$70.00S
ACTOS 45MG TABLET   2 Formulary Brand $35.00$70.00S
ACULAR 0.5% EYE DROPS   2 Formulary Brand $35.00$70.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACULAR LS 0.4% OPHTH SOL   2 Formulary Brand $35.00$70.00None
ACYCLOVIR 200MG CAPSULE (1000 CT)   1 Formulary Generic $9.00$18.00None
ACYCLOVIR 200MG/5ML SUSP   1 Formulary Generic $9.00$18.00None
ACYCLOVIR 400MG TABLET (100 CT)   1 Formulary Generic $9.00$18.00None
ACYCLOVIR SODIUM 500MG VIAL   4 Injectables 33%33%P
ACYCLOVIR TABLET USP 800MG (100 CT)   1 Formulary Generic $9.00$18.00None
ADACEL VIAL 2UNT/5UNT   4 Injectables 33%33%P
ADAGEN 250U/ML VIAL   4 Injectables 33%33%P
ADDERALL XR 10MG CAPSULE SA   2 Formulary Brand $35.00$70.00Q:30
/30Days
ADDERALL XR 15MG CAPSULE SA   2 Formulary Brand $35.00$70.00Q:60
/30Days
ADDERALL XR 20MG CAPSULE SA   2 Formulary Brand $35.00$70.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADDERALL XR 25MG CAPSULE SA   2 Formulary Brand $35.00$70.00Q:30
/30Days
ADDERALL XR 30MG CAPSULE SA   2 Formulary Brand $35.00$70.00Q:30
/30Days
ADDERALL XR 5MG CAPSULE SA   2 Formulary Brand $35.00$70.00Q:30
/30Days
ADVAIR DISKU MIS 100/50   2 Formulary Brand $35.00$70.00Q:60
/30Days
ADVAIR DISKU MIS 250/50   2 Formulary Brand $35.00$70.00Q:60
/30Days
ADVAIR DISKU MIS 500/50   2 Formulary Brand $35.00$70.00Q:60
/30Days
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL   2 Formulary Brand $35.00$70.00Q:12
/30Days
ADVAIR HFA INHALER 230;21MCG;MCG   2 Formulary Brand $35.00$70.00Q:12
/30Days
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL   2 Formulary Brand $35.00$70.00Q:12
/30Days
ADVICOR ER 20-750MG TABLET (90 CT)   2 Formulary Brand $35.00$70.00Q:60
/30Days
ADVICOR EXTENDED RELEASE TABLETS 20;1000MG;MG 90 BOTPL   2 Formulary Brand $35.00$70.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADVICOR EXTENDED RELEASE TABLETS 20;500MG;MG 90 BOTPL   2 Formulary Brand $35.00$70.00Q:30
/30Days
ADVICOR EXTENDED RELEASE TABLETS 40;1000MG;MG 90 BOTPL   2 Formulary Brand $35.00$70.00Q:30
/30Days
AEROBID-M AEROSOL W/ADAPTER   3 Non-Preferred Brand $75.00$150.00Q:21
/30Days
AFEDITAB CR 30MG TABLET SA   1 Formulary Generic $9.00$18.00None
AFEDITAB CR 60MG TABLET SA   1 Formulary Generic $9.00$18.00None
AGGRENOX 25-200MG CAPSULE   3 Non-Preferred Brand $75.00$150.00None
AK-CON 0.1% EYE DROPS   1 Formulary Generic $9.00$18.00None
AK-POLY-BAC EYE OINTMENT 500UNT/1000UNT   1 Formulary Generic $9.00$18.00None
AKNE-MYCIN 2% OINTMENT   3 Non-Preferred Brand $75.00$150.00None
AKTOB 0.3% EYE DROPS   1 Formulary Generic $9.00$18.00None
ALA-CORT 1% CREAM   1 Formulary Generic $9.00$18.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALA-CORT 1% LOTION   1 Formulary Generic $9.00$18.00None
ALA-SCALP HP 2% LOTION   3 Non-Preferred Brand $75.00$150.00None
ALAMAST 0.1% DROPS   2 Formulary Brand $35.00$70.00None
ALBENZA 200MG TABLET   3 Non-Preferred Brand $75.00$150.00None
ALBUTEROL SULFATE 0.63MG/3ML VIAL NEBULIZER   1 Formulary Generic $9.00$18.00P Q:375
/30Days
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER   1 Formulary Generic $9.00$18.00P Q:180
/30Days
ALBUTEROL SULFATE 2.5MG/3ML VIAL NEBULIZER   1 Formulary Generic $9.00$18.00P Q:360
/30Days
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   1 Formulary Generic $9.00$18.00P Q:40
/30Days
ALCLOMETASONE DIPROPIONATE 0.05% CREAM   1 Formulary Generic $9.00$18.00None
ALCLOMETASONE DIPROPIONATE 0.05% OINTMENT   1 Formulary Generic $9.00$18.00None
ALCOHOL 5%/DEXTROSE 5%   4 Injectables 33%33%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALDACTAZIDE 50/50 TABLET   3 Non-Preferred Brand $75.00$150.00None
ALDARA IMIQUIMOD CREAM 5% 24 PKT X 250 MG CRTN   2 Formulary Brand $35.00$70.00None
ALDURAZYME 2.9MG/5ML VIAL   5 Formulary Specialty (Unique High Cost Drugs) 33%33%P
ALENDRONATE SODIUM 10MG TABLET   1 Formulary Generic $9.00$18.00Q:30
/30Days
ALENDRONATE SODIUM 40MG TABLET   1 Formulary Generic $9.00$18.00Q:30
/30Days
ALENDRONATE SODIUM 5MG TABLET   1 Formulary Generic $9.00$18.00Q:30
/30Days
ALENDRONATE SODIUM 70MG TABLET 4 BLPK   1 Formulary Generic $9.00$18.00Q:4
/28Days
ALENDRONATE SODIUM TABLET 35MG 20 CRTN   1 Formulary Generic $9.00$18.00Q:4
/28Days
ALFERON N INJ 5MU/ML   5 Formulary Specialty (Unique High Cost Drugs) 33%33%P
ALIMTA 500MG VIAL   4 Injectables 33%33%P
ALINIA 100MG/5ML SUSPENSION   3 Non-Preferred Brand $75.00$150.00Q:180
/3Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALINIA 500MG TABLET   3 Non-Preferred Brand $75.00$150.00Q:60
/30Days
ALKERAN FOR INJECTION 50MG/VIAL 1 VIALSU   4 Injectables 33%33%P
ALLEGRA 30MG/5ML SUSPENSION ORAL   3 Non-Preferred Brand $75.00$150.00P Q:300
/30Days
ALLEGRA-D 12 HOUR TABLET 60-120MG (500 CT)   3 Non-Preferred Brand $75.00$150.00S Q:60
/30Days
ALLEGRA-D 24 HOUR TABLET   3 Non-Preferred Brand $75.00$150.00S Q:30
/30Days
ALLOPURINOL SODIUM 500MG VIAL   4 Injectables 33%33%P
ALLOPURINOL TABLET 300MG (1000 CT)   1 Formulary Generic $9.00$18.00None
ALLOPURINOL TABLET USP 100MG (1000 CT)   1 Formulary Generic $9.00$18.00None
ALOCRIL 2% EYE DROPS   3 Non-Preferred Brand $75.00$150.00None
ALOMIDE 0.1% EYE DROPS   2 Formulary Brand $35.00$70.00None
ALORA 0.025MG PATCH   3 Non-Preferred Brand $75.00$150.00Q: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 $75.00$150.00Q:8
/28Days
ALORA 0.075MG PATCH   3 Non-Preferred Brand $75.00$150.00Q:8
/28Days
ALORA 0.1MG PATCH   3 Non-Preferred Brand $75.00$150.00Q:8
/28Days
ALOXI 0.25MG/5ML   4 Injectables 33%33%P
ALPHAGAN P 0.1% DROPS   2 Formulary Brand $35.00$70.00None
ALPHAGAN P 0.15% EYE DROPS   2 Formulary Brand $35.00$70.00None
ALREX 0.2% EYE DROPS   2 Formulary Brand $35.00$70.00None
ALTOPREV 20MG TABLET SR 24HR   3 Non-Preferred Brand $75.00$150.00None
ALTOPREV 40MG TABLET SR 24HR   3 Non-Preferred Brand $75.00$150.00None
ALTOPREV 60MG TABLET SR 24HR   3 Non-Preferred Brand $75.00$150.00None
AMANTADINE 100MG CAPSULE   1 Formulary Generic $9.00$18.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMANTADINE 100MG TABLET   1 Formulary Generic $9.00$18.00None
AMBIEN CR 12.5MG TABLET   3 Non-Preferred Brand $75.00$150.00S Q:30
/30Days
AMBIEN CR 6.25MG TABLET   3 Non-Preferred Brand $75.00$150.00S Q:30
/30Days
AMBISOME 50MG VIAL   4 Injectables 33%33%P
AMCINONIDE 0.1% CREAM   1 Formulary Generic $9.00$18.00None
AMCINONIDE 0.1% LOTION   1 Formulary Generic $9.00$18.00None
AMCINONIDE 0.1% OINTMENT 60GM TUBE   1 Formulary Generic $9.00$18.00None
AMERGE 1MG TABLET   2 Formulary Brand $35.00$70.00Q:9
/30Days
AMERGE 2.5MG TABLET   2 Formulary Brand $35.00$70.00Q:9
/30Days
AMEVIVE ADMISTRATION PACK FOR INTRAMUSCULAR ADMINISTRATION KIT 15MG 1 X 4 PKGCOM   5 Formulary Specialty (Unique High Cost Drugs) 33%33%P
AMIFOSTINE FOR INJECTION 500MG/VIAL   4 Injectables 33%33%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMIKACIN 250MG/ML VIAL   4 Injectables 33%33%P
AMIKACIN 50MG/ML VIAL   4 Injectables 33%33%P
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET   1 Formulary Generic $9.00$18.00None
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT   1 Formulary Generic $9.00$18.00None
AMINESS 5.2% IV SOLUTION   4 Injectables 33%33%P
AMINOPHYLLINE 100MG TABLET   1 Formulary Generic $9.00$18.00None
AMINOPHYLLINE 200MG TABLET (1000 CT)   1 Formulary Generic $9.00$18.00None
AMINOPHYLLINE INJECTION 250MG 10ML X 25 VIALSD   4 Injectables 33%33%P
AMINOSYN 10% IV SOLUTION   4 Injectables 33%33%P
AMINOSYN 3.5% IV SOLUTION   4 Injectables 33%33%P
AMINOSYN 5% IV SOLUTION   4 Injectables 33%33%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN 7% IV SOLUTION   4 Injectables 33%33%P
AMINOSYN 7%-ELECTROLYTE SOL   4 Injectables 33%33%P
AMINOSYN 8.5% IV SOLUTION   4 Injectables 33%33%P
AMINOSYN II 10% IV SOLUTION   4 Injectables 33%33%P
AMINOSYN II 15% IV SOLUTION   4 Injectables 33%33%P
AMINOSYN II 3.5% IN D25W IV   4 Injectables 33%33%P
AMINOSYN II 3.5% M/D5W IV   4 Injectables 33%33%P
AMINOSYN II 3.5% W/ELEC DEX   4 Injectables 33%33%P
AMINOSYN II 4.25% IN D10W   4 Injectables 33%33%P
AMINOSYN II 4.25% IN D20W   4 Injectables 33%33%P
AMINOSYN II 4.25% W/ELEC DW   4 Injectables 33%33%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN II 4.25%-D25W IV   4 Injectables 33%33%P
AMINOSYN II 5% IN D25W IV   4 Injectables 33%33%P
AMINOSYN II 7% IV SOLUTION   4 Injectables 33%33%P
AMINOSYN II 8.5% ELECTROLYT   4 Injectables 33%33%P
AMINOSYN II 8.5% IV SOLUTION   4 Injectables 33%33%P
AMINOSYN M 3.5% IV SOLUTION   4 Injectables 33%33%P
AMINOSYN PF INJECTION   4 Injectables 33%33%P
AMINOSYN-HBC 7% IV SOLUTION   4 Injectables 33%33%P
AMINOSYN-HF 8% IV SOLUTION   4 Injectables 33%33%P
AMINOSYN-PF 7% IV SOLUTION   4 Injectables 33%33%P
AMIODARONE HCL 200MG TABLET (60 CT)   1 Formulary Generic $9.00$18.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMIODARONE HCL 400MG TABLET   1 Formulary Generic $9.00$18.00None
AMIODARONE HCL INJECTION   4 Injectables 33%33%P
AMITIZA 8MCG CAPSULE   3 Non-Preferred Brand $75.00$150.00P Q:60
/30Days
AMITIZA CAPSULES 24MCG 60 CAP BOT   3 Non-Preferred Brand $75.00$150.00P Q:60
/30Days
AMITRIP/CDP 25-10 TABLET   1 Formulary Generic $9.00$18.00None
AMITRIP/PERPHEN 10-2 TABLET   1 Formulary Generic $9.00$18.00None
AMITRIP/PERPHEN 10-4 TABLET   1 Formulary Generic $9.00$18.00None
AMITRIP/PERPHEN 25-2 TABLET   1 Formulary Generic $9.00$18.00None
AMITRIP/PERPHEN 25-4 TABLET   1 Formulary Generic $9.00$18.00None
AMITRIP/PERPHEN 50-4 TABLET   1 Formulary Generic $9.00$18.00None
AMITRIPTYLINE HCL 100MG TABLET   1 Formulary Generic $9.00$18.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITRIPTYLINE HCL 10MG TABLET   1 Formulary Generic $9.00$18.00None
AMITRIPTYLINE HCL 150MG TABLET (100 CT)   1 Formulary Generic $9.00$18.00None
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)   1 Formulary Generic $9.00$18.00None
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)   1 Formulary Generic $9.00$18.00None
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT   1 Formulary Generic $9.00$18.00None
AMLODIPINE BESYLATE 10MG TABLET (90 CT)   1 Formulary Generic $9.00$18.00None
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)   1 Formulary Generic $9.00$18.00None
AMLODIPINE BESYLATE 5MG TABLET (90 CT)   1 Formulary Generic $9.00$18.00None
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE   1 Formulary Generic $9.00$18.00Q:30
/30Days
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE   1 Formulary Generic $9.00$18.00Q:30
/30Days
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE   1 Formulary Generic $9.00$18.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE   1 Formulary Generic $9.00$18.00Q:30
/30Days
AMMONIUM LACTATE 12% CREAM   1 Formulary Generic $9.00$18.00None
AMMONIUM LACTATE 12% LOTION   1 Formulary Generic $9.00$18.00None
AMNESTEEM 10MG CAPSULE   1 Formulary Generic $9.00$18.00None
AMNESTEEM 20MG CAPSULE   1 Formulary Generic $9.00$18.00None
AMNESTEEM 40MG CAPSULE   1 Formulary Generic $9.00$18.00None
AMOCLAN 200-28.5/5 SUSPENSION RECONSTITUTED ORAL   1 Formulary Generic $9.00$18.00None
AMOCLAN 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   1 Formulary Generic $9.00$18.00None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL   1 Formulary Generic $9.00$18.00None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE   1 Formulary Generic $9.00$18.00None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET   1 Formulary Generic $9.00$18.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE   1 Formulary Generic $9.00$18.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   1 Formulary Generic $9.00$18.00None
AMOX TR-POTASSIUM CLAVULANATE 500-125MG TABLET   1 Formulary Generic $9.00$18.00None
AMOXAPINE 100MG TABLET   1 Formulary Generic $9.00$18.00None
AMOXAPINE 150MG TABLET   1 Formulary Generic $9.00$18.00None
AMOXAPINE 25MG TABLET   1 Formulary Generic $9.00$18.00None
AMOXAPINE 50MG TABLET   1 Formulary Generic $9.00$18.00None
AMOXICILLIN 125MG TABLET CHEW   1 Formulary Generic $9.00$18.00None
AMOXICILLIN 200MG TABLET CHEW   1 Formulary Generic $9.00$18.00None
AMOXICILLIN 250MG CAPSULE   1 Formulary Generic $9.00$18.00None
AMOXICILLIN 400MG TABLET CHEW   1 Formulary Generic $9.00$18.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN 500MG CAPSULE   1 Formulary Generic $9.00$18.00None
AMOXICILLIN 500MG TABLET (100 CT)   1 Formulary Generic $9.00$18.00None
AMOXICILLIN 875MG TABLET   1 Formulary Generic $9.00$18.00None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT   1 Formulary Generic $9.00$18.00None
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT   1 Formulary Generic $9.00$18.00None
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT   1 Formulary Generic $9.00$18.00None
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL   1 Formulary Generic $9.00$18.00None
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   1 Formulary Generic $9.00$18.00None
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL   1 Formulary Generic $9.00$18.00None
AMOXICILLIN TABLET USP CHEWABLE 250MG (250 CT)   1 Formulary Generic $9.00$18.00None
AMPHET ASP/ AMPHET/ D-AMPHET 5MG TABLET   1 Formulary Generic $9.00$18.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPHETAMINE SALT COMBO 12.5MG TABLET   1 Formulary Generic $9.00$18.00None
AMPHETAMINE SALT COMBO 15MG TABLET   1 Formulary Generic $9.00$18.00None
AMPHETAMINE SALT COMBO 30MG TABLET   1 Formulary Generic $9.00$18.00None
AMPHETAMINE SALT COMBO 7.5MG TABLET   1 Formulary Generic $9.00$18.00None
AMPHETAMINE SALTS 20MG TABLET   1 Formulary Generic $9.00$18.00None
AMPHOTEC INJ 50MG   4 Injectables 33%33%P
AMPHOTERICIN B FOR INJECTION 50 MG   4 Injectables 33%33%P
AMPICILLIN AND SULBACTAM FOR INJECTION 10-5 1 VIAL   4 Injectables 33%33%P
AMPICILLIN AND SULBACTAM FOR INJECTION 2-1 10 VIAL   4 Injectables 33%33%P
AMPICILLIN CAPSULES 250MG 100 BOT   1 Formulary Generic $9.00$18.00None
AMPICILLIN CAPSULES 500MG 100 BOT   1 Formulary Generic $9.00$18.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPICILLIN FOR INJECTION POWDER   4 Injectables 33%33%P
AMPICILLIN FOR INJECTION USP 125MG/ML 1 VIAL   4 Injectables 33%33%P
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT   1 Formulary Generic $9.00$18.00None
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT   1 Formulary Generic $9.00$18.00None
AMPICILLIN POWDER FOR INJECTION 1 GM/ML   4 Injectables 33%33%P
ANADROL-50 50MG TABLET (100 CT)   3 Non-Preferred Brand $75.00$150.00None
ANAGRELIDE HCL 0.5MG CAPSULE   1 Formulary Generic $9.00$18.00None
ANAGRELIDE HCL 1MG CAPSULE   1 Formulary Generic $9.00$18.00None
ANCOBON 250MG CAPSULE   2 Formulary Brand $35.00$70.00P
ANCOBON 500MG CAPSULE   2 Formulary Brand $35.00$70.00P
ANDRODERM 2.5MG/24HR PATCH   3 Non-Preferred Brand $75.00$150.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANDRODERM 5MG/24HR PATCH   3 Non-Preferred Brand $75.00$150.00Q:60
/30Days
ANDROGEL 1%(50MG) GEL PACKET   2 Formulary Brand $35.00$70.00Q:300
/30Days
ANDROID 10MG CAPSULE   3 Non-Preferred Brand $75.00$150.00None
ANTABUSE 250MG TABLET   2 Formulary Brand $35.00$70.00None
ANTABUSE 500MG TABLET   2 Formulary Brand $35.00$70.00None
ANTARA 130MG CAPSULE   3 Non-Preferred Brand $75.00$150.00None
ANTARA 43MG CAPSULE   3 Non-Preferred Brand $75.00$150.00None
ANTIVERT 50MG TABLET   3 Non-Preferred Brand $75.00$150.00None
ANZEMET 100MG TABLET   2 Formulary Brand $35.00$70.00P Q:1
/5Days
ANZEMET 20MG/ML VIAL   4 Injectables 33%33%P
ANZEMET 50MG TABLET   2 Formulary Brand $35.00$70.00P Q:1
/5Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
APHTHASOL 5% PASTE   3 Non-Preferred Brand $75.00$150.00None
APIDRA 100UNITS/ML VIAL   3 Non-Preferred Brand $75.00$150.00None
APOKYN FOR INJECTION 30MG 5 CTG   4 Injectables 33%33%P
APRI 0.15-0.03 TABLET   1 Formulary Generic $9.00$18.00None
APTIVUS 250MG CAPSULE   2 Formulary Brand $35.00$70.00None
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT   2 Formulary Brand $35.00$70.00None
ARALAST 500MG VIAL   5 Formulary Specialty (Unique High Cost Drugs) 33%33%P
ARANELLE 7-9-5 TABLET   1 Formulary Generic $9.00$18.00None
ARANESP 100MCG/ML VIAL   5 Formulary Specialty (Unique High Cost Drugs) 33%33%P
ARANESP 200MCG/0.4ML SYRINGE   5 Formulary Specialty (Unique High Cost Drugs) 33%33%P
ARANESP 200MCG/ML VIAL   5 Formulary Specialty (Unique High Cost Drugs) 33%33%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP 25MCG/ML VIAL   4 Injectables 33%33%P
ARANESP 300MCG/ML VIAL   5 Formulary Specialty (Unique High Cost Drugs) 33%33%P
ARANESP 500MCG/1ML SYRINGE   5 Formulary Specialty (Unique High Cost Drugs) 33%33%P
ARANESP 60MCG/ML VIAL   5 Formulary Specialty (Unique High Cost Drugs) 33%33%P
ARANESP PREFILLED SYRINGE SINGLE USE 100MCG/0.5ML 1 SYR   5 Formulary Specialty (Unique High Cost Drugs) 33%33%P
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR   5 Formulary Specialty (Unique High Cost Drugs) 33%33%P
ARANESP PREFILLED SYRINGE SINGLE USE 25MCG/0.42ML SYR   4 Injectables 33%33%P
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR   5 Formulary Specialty (Unique High Cost Drugs) 33%33%P
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR   4 Injectables 33%33%P
ARANESP PREFILLED SYRINGE SINGLE USE 60MCG/0.3ML 60MCG/ 0.3ML SYR   5 Formulary Specialty (Unique High Cost Drugs) 33%33%P
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD   4 Injectables 33%33%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARCALYST INJECTION 220MG/VIAL   5 Formulary Specialty (Unique High Cost Drugs) 33%33%P
ARICEPT 10MG TABLET   2 Formulary Brand $35.00$70.00None
ARICEPT 5MG TABLET   2 Formulary Brand $35.00$70.00None
ARICEPT ODT 10MG TABLET   2 Formulary Brand $35.00$70.00None
ARICEPT ODT 5MG TABLET   2 Formulary Brand $35.00$70.00None
ARIMIDEX 1MG TABLET   2 Formulary Brand $35.00$70.00None
ARIXTRA 10MG SYRINGE   5 Formulary Specialty (Unique High Cost Drugs) 33%33%Q:24
/30Days
ARIXTRA 2.5MG SYRINGE   4 Injectables 33%33%Q:15
/30Days
ARIXTRA 5MG SYRINGE   5 Formulary Specialty (Unique High Cost Drugs) 33%33%Q:12
/30Days
ARIXTRA 7.5MG SYRINGE   5 Formulary Specialty (Unique High Cost Drugs) 33%33%Q:18
/30Days
AROMASIN 25MG TABLET   2 Formulary Brand $35.00$70.00S
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARRANON 250MG VIAL   5 Formulary Specialty (Unique High Cost Drugs) 33%33%P
ARTHROTEC 50 50MG TABLET -200MCG (60 CT)   3 Non-Preferred Brand $75.00$150.00None
ARTHROTEC 75 TABLET EC   3 Non-Preferred Brand $75.00$150.00None
ASACOL 400MG TABLET EC   2 Formulary Brand $35.00$70.00None
ASACOL HD DELAYED RELEASE TABLETS 800MG 180 BOT   2 Formulary Brand $35.00$70.00None
ASCOMP W/CODEINE 30-50-325 CAPSULE   1 Formulary Generic $9.00$18.00None
ASMANEX 220MCG(14) AEROSOL POWDER BREATH ACTIVATED   2 Formulary Brand $35.00$70.00Q:1
/30Days
ASMANEX TWISTHALER 220MCG #120   2 Formulary Brand $35.00$70.00Q:1
/30Days
ASMANEX TWISTHALER 220MCG #30   2 Formulary Brand $35.00$70.00Q:1
/30Days
ASMANEX TWISTHALER 220MCG #60   2 Formulary Brand $35.00$70.00Q:1
/30Days
ASTELIN 137MCG AEROSOL SPRAY W/PUMP   2 Formulary Brand $35.00$70.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ASTEPRO NASAL SPRAY 137 MCG/SPRY   2 Formulary Brand $35.00$70.00Q:30
/25Days
ASTRAMORPH-PF 0.5MG/ML VIAL   4 Injectables 33%33%P
ASTRAMORPH-PF 1MG/ML VIAL   4 Injectables 33%33%P
ATACAND 16MG TABLET   3 Non-Preferred Brand $75.00$150.00S Q:30
/30Days
ATACAND 32MG TABLET   3 Non-Preferred Brand $75.00$150.00S Q:30
/30Days
ATACAND 4MG TABLET   3 Non-Preferred Brand $75.00$150.00S Q:30
/30Days
ATACAND 8MG TABLET   3 Non-Preferred Brand $75.00$150.00S Q:30
/30Days
ATACAND HCT 16/12.5MG TABLET   3 Non-Preferred Brand $75.00$150.00S Q:30
/30Days
ATACAND HCT 32/12.5MG TABLET   3 Non-Preferred Brand $75.00$150.00S Q:30
/30Days
ATACAND HCT TABLETS 32;25MG;MG 90 TABLETS BOT   3 Non-Preferred Brand $75.00$150.00S Q:30
/30Days
ATAMET   1 Formulary Generic $9.00$18.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATENOLOL 25MG TABLET (100 CT)   1 Formulary Generic $9.00$18.00None
ATENOLOL TABLET USP 50MG (100 CT)   1 Formulary Generic $9.00$18.00None
ATENOLOL TABLETS USP 100MG 1 BLPK   1 Formulary Generic $9.00$18.00None
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT)   1 Formulary Generic $9.00$18.00None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   1 Formulary Generic $9.00$18.00None
ATGAM 50MG/ML AMPUL   5 Formulary Specialty (Unique High Cost Drugs) 33%33%P
ATRIPLA TABLET 600MG/200MG   5 Formulary Specialty (Unique High Cost Drugs) 33%33%None
ATROPINE 0.05MG/ML SYRINGE   4 Injectables 33%33%P
ATROPINE 0.1MG/ML SYRINGE   4 Injectables 33%33%P
ATROVENT HFA AER 17MCG   2 Formulary Brand $35.00$70.00Q:52
/30Days
ATTENUVAX VACCINE W/DILUENT 1 DOSE/0.5ML   4 Injectables 33%33%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AUGMENTIN 125 SUSPENSION   2 Formulary Brand $35.00$70.00None
AUGMENTIN 250 SUSPENSION   2 Formulary Brand $35.00$70.00None
AUGMENTIN TABLETS COMBO   3 Non-Preferred Brand $75.00$150.00None
AUGMENTIN XR 1000-62.5 TABLET   3 Non-Preferred Brand $75.00$150.00None
AVALIDE 150-12.5MG TABLET   2 Formulary Brand $35.00$70.00S Q:60
/30Days
AVALIDE 300-12.5MG TABLET   2 Formulary Brand $35.00$70.00S Q:30
/30Days
AVALIDE 300-25MG TABLET   2 Formulary Brand $35.00$70.00S Q:30
/30Days
AVANDAMET 2MG/1000MG TABLET   2 Formulary Brand $35.00$70.00S
AVANDAMET 2MG/500MG TABLET   2 Formulary Brand $35.00$70.00S
AVANDAMET 4MG/500MG TABLET   2 Formulary Brand $35.00$70.00S
AVANDAMET TABLET 4-1000MG   2 Formulary Brand $35.00$70.00S
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVANDARYL 4MG/1MG TABLET   3 Non-Preferred Brand $75.00$150.00S
AVANDARYL 4MG/2MG TABLET   3 Non-Preferred Brand $75.00$150.00S
AVANDARYL 4MG/4MG TABLET   3 Non-Preferred Brand $75.00$150.00S
AVANDARYL 8MG-2MG TABLET   3 Non-Preferred Brand $75.00$150.00S
AVANDARYL 8MG-4MG TABLET   3 Non-Preferred Brand $75.00$150.00S
AVANDIA 2MG TABLET   2 Formulary Brand $35.00$70.00S
AVANDIA 4MG TABLET (90 CT)   2 Formulary Brand $35.00$70.00S
AVANDIA 8MG TABLET (90 CT)   2 Formulary Brand $35.00$70.00S
AVAPRO 150MG TABLET   2 Formulary Brand $35.00$70.00S Q:30
/30Days
AVAPRO 300MG TABLET   2 Formulary Brand $35.00$70.00S Q:30
/30Days
AVAPRO 75MG TABLET (30 CT)   2 Formulary Brand $35.00$70.00S Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVASTIN 100MG/4ML VIAL   5 Formulary Specialty (Unique High Cost Drugs) 33%33%P
AVELOX 400MG TABLET   2 Formulary Brand $35.00$70.00Q:10
/10Days
AVELOX ABC PACK 400MG TABLET   2 Formulary Brand $35.00$70.00Q:10
/10Days
AVELOX IV 400MG/250ML   4 Injectables 33%33%P
AVIANE 0.1-0.02 TABLET   1 Formulary Generic $9.00$18.00None
AVINZA 120MG CAPSULE MULTIPHASIC RELEASE 24 HR   3 Non-Preferred Brand $75.00$150.00Q:13
/1Days
AVINZA 30MG CAPSULE MULTIPHASIC RELEASE 24 HR   3 Non-Preferred Brand $75.00$150.00Q:30
/30Days
AVINZA 60MG CAPSULE MULTIPHASIC RELEASE 24 HR   3 Non-Preferred Brand $75.00$150.00Q:30
/30Days
AVINZA 90MG CAPSULE MULTIPHASIC RELEASE 24 HR   3 Non-Preferred Brand $75.00$150.00Q:90
/30Days
AVINZA CAPSULES EXTENDED RELEASE 45MG 100 BOTPL   3 Non-Preferred Brand $75.00$150.00Q:30
/30Days
AVINZA CAPSULES EXTENDED RELEASE 75MG 100 BOTPL   3 Non-Preferred Brand $75.00$150.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVODART 0.5MG SOFTGEL   3 Non-Preferred Brand $75.00$150.00S Q:30
/30Days
AVONEX ADMIN PACK 30MCG SYR   5 Formulary Specialty (Unique High Cost Drugs) 33%33%P Q:4
/28Days
AVONEX ADMIN PACK 30MCG VL   5 Formulary Specialty (Unique High Cost Drugs) 33%33%P Q:4
/28Days
AXERT 12.5MG TABLET   3 Non-Preferred Brand $75.00$150.00Q:12
/30Days
AXERT 6.25MG TABLET   3 Non-Preferred Brand $75.00$150.00Q:12
/30Days
AXID 15MG/ML ORAL SOLUTION   3 Non-Preferred Brand $75.00$150.00None
AZACTAM 2GM VIAL   4 Injectables 33%33%P
AZACTAM INJECTION 1GM 50ML BAG   4 Injectables 33%33%P
AZACTAM/ISO-OSMOT 2GM/50ML   4 Injectables 33%33%P
AZASAN 100MG TABLET   3 Non-Preferred Brand $75.00$150.00P
AZASAN 75MG TABLET   3 Non-Preferred Brand $75.00$150.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZATHIOPRINE 50MG TABLET   1 Formulary Generic $9.00$18.00P
AZATHIOPRINE SOD 100MG VIAL   4 Injectables 33%33%P
AZELEX 20% CREAM 30GM TUBE   3 Non-Preferred Brand $75.00$150.00None
AZILECT 0.5MG TABLET   2 Formulary Brand $35.00$70.00None
AZILECT 1MG TABLET   2 Formulary Brand $35.00$70.00None
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Formulary Generic $9.00$18.00None
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Formulary Generic $9.00$18.00None
AZITHROMYCIN 250MG TABLET (30 CT)   1 Formulary Generic $9.00$18.00Q:6
/5Days
AZITHROMYCIN 500MG TABLET (30 CT)   1 Formulary Generic $9.00$18.00Q:3
/3Days
AZITHROMYCIN FOR INJECTION 500MG 10 VIALSD   4 Injectables 33%33%P
AZITHROMYCIN TABLET 600MG (30 CT)   1 Formulary Generic $9.00$18.00Q:8
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT   2 Formulary Brand $35.00$70.00None

Chart Legend:

Below are a few notes to help you understand the above 2010 Medicare Part D Blue Shield Medicare Rx Enhanced Plan (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.





 
 

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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.