Q1Medicare.com 2010 Medicare Part D or Medicare Advantage Plan Formulary Browser

2010 Medicare Part D Plan Formulary Information
Advantage Freedom Plan by RxAmerica (PDP) (S5644-176-0) Benefit Details
The Advantage Freedom Plan by RxAmerica (PDP) (S5644-176-0) Formulary Drugs Starting with the Letter A in CMS PDP Region 15 which includes: IN KY
Drugs Starting with Letter A Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter A Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
A-HYDROCORT 100MG VIAL	2	Generic	$5.00	$10.00	None
ABILIFY 10MG TABLET	5	Non-Preferred	45%	45%	S
ABILIFY 15MG TABLET	5	Non-Preferred	45%	45%	S
ABILIFY 1MG/ML SOLUTION	5	Non-Preferred	45%	45%	S
ABILIFY 20MG TABLET	5	Non-Preferred	45%	45%	S
ABILIFY 2MG TABLET	5	Non-Preferred	45%	45%	S
ABILIFY 30MG TABLET	5	Non-Preferred	45%	45%	S
ABILIFY 5MG TABLET (OTSUKA)	5	Non-Preferred	45%	45%	S
ABILIFY DISCMELT 10MG TABLET	5	Non-Preferred	45%	45%	P S
ABILIFY DISCMELT 15MG TABLET	5	Non-Preferred	45%	45%	P S
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ABILIFY INJ 9.75MG	5	Non-Preferred	45%	45%	P S
ACARBOSE 100MG TABLET S	2	Generic	$5.00	$10.00	None
ACARBOSE 25MG TABLET S	2	Generic	$5.00	$10.00	None
ACARBOSE 50MG TABLET S	2	Generic	$5.00	$10.00	None
ACCOLATE 10MG TABLET	3	Preferred Brand	33%	33%	None
ACCOLATE 20MG TABLET	3	Preferred Brand	33%	33%	None
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD	2	Generic	$5.00	$10.00	None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT)	2	Generic	$5.00	$10.00	None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT)	2	Generic	$5.00	$10.00	None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT)	2	Generic	$5.00	$10.00	None
ACETASOL HC OTIC SOLUTION	2	Generic	$5.00	$10.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ACETAZOLAMIDE 125MG TABLET	2	Generic	$5.00	$10.00	None
ACETAZOLAMIDE 250MG TABLET (100 CT)	2	Generic	$5.00	$10.00	None
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT	2	Generic	$5.00	$10.00	None
ACETIC ACID 2% SOLUTION NON-ORAL	2	Generic	$5.00	$10.00	None
ACETYLCYSTEINE 10% VIAL	2	Generic	$5.00	$10.00	P
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN	2	Generic	$5.00	$10.00	P
ACTHIB VACCINE VIAL 10-24UNT/5ML	3	Preferred Brand	33%	33%	None
ACTICIN 5% CREAM	2	Generic	$5.00	$10.00	None
ACTIMMUNE SOLUTION FOR INJECTION 100MCG	4	Specialty	33%	N/A	P
ACTOPLUS MET 15MG/500MG TABLET	3	Preferred Brand	33%	33%	Q:90 /30Days
ACTOPLUS MET 15MG/850MG TABLET	3	Preferred Brand	33%	33%	Q:90 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ACTOS 15MG TABLET	3	Preferred Brand	33%	33%	None
ACTOS 30MG TABLET (500 CT)	3	Preferred Brand	33%	33%	None
ACTOS 45MG TABLET	3	Preferred Brand	33%	33%	None
ACULAR 0.5% EYE DROPS	3	Preferred Brand	33%	33%	None
ACULAR LS 0.4% OPHTH SOL	3	Preferred Brand	33%	33%	None
ACYCLOVIR 200MG CAPSULE (1000 CT)	2	Generic	$5.00	$10.00	None
ACYCLOVIR 200MG/5ML SUSP	2	Generic	$5.00	$10.00	None
ACYCLOVIR 400MG TABLET (100 CT)	2	Generic	$5.00	$10.00	None
ACYCLOVIR TABLET USP 800MG (100 CT)	2	Generic	$5.00	$10.00	None
ADACEL VIAL 2UNT/5UNT	3	Preferred Brand	33%	33%	None
ADAGEN 250U/ML VIAL	3	Preferred Brand	33%	33%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ADVAIR DISKU MIS 100/50	3	Preferred Brand	33%	33%	Q:60 /30Days
ADVAIR DISKU MIS 250/50	3	Preferred Brand	33%	33%	Q:60 /30Days
ADVAIR DISKU MIS 500/50	3	Preferred Brand	33%	33%	Q:60 /30Days
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL	3	Preferred Brand	33%	33%	Q:12 /30Days
ADVAIR HFA INHALER 230;21MCG;MCG	3	Preferred Brand	33%	33%	Q:12 /30Days
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL	3	Preferred Brand	33%	33%	Q:12 /30Days
AFEDITAB CR 30MG TABLET SA	2	Generic	$5.00	$10.00	None
AFEDITAB CR 60MG TABLET SA	2	Generic	$5.00	$10.00	None
AGGRENOX 25-200MG CAPSULE	3	Preferred Brand	33%	33%	None
AK-CON 0.1% EYE DROPS	2	Generic	$5.00	$10.00	None
AKNE-MYCIN 2% OINTMENT	3	Preferred Brand	33%	33%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ALA-CORT 1% CREAM	2	Generic	$5.00	$10.00	None
ALA-CORT 1% LOTION	2	Generic	$5.00	$10.00	None
ALA-SCALP HP 2% LOTION	2	Generic	$5.00	$10.00	None
ALAMAST 0.1% DROPS	3	Preferred Brand	33%	33%	None
ALBUTEROL SULFATE 0.63MG/3ML VIAL NEBULIZER	2	Generic	$5.00	$10.00	P
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER	2	Generic	$5.00	$10.00	P
ALBUTEROL SULFATE 2.5MG/3ML VIAL NEBULIZER	2	Generic	$5.00	$10.00	P
ALBUTEROL SULFATE 4MG TABLET SR 12HR	2	Generic	$5.00	$10.00	None
ALBUTEROL SULFATE 8MG TABLET SR 12HR	2	Generic	$5.00	$10.00	None
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR	2	Generic	$5.00	$10.00	P
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT	2	Generic	$5.00	$10.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ALBUTEROL SULFATE TABLET 2MG (500 CT)	2	Generic	$5.00	$10.00	None
ALBUTEROL TABLET 4MG (500 CT)	2	Generic	$5.00	$10.00	None
ALDACTAZIDE 50/50 TABLET	3	Preferred Brand	33%	33%	None
ALDARA IMIQUIMOD CREAM 5% 24 PKT X 250 MG CRTN	3	Preferred Brand	33%	33%	None
ALDURAZYME 2.9MG/5ML VIAL	3	Preferred Brand	33%	33%	P
ALENDRONATE SODIUM 10MG TABLET	2	Generic	$5.00	$10.00	None
ALENDRONATE SODIUM 40MG TABLET	2	Generic	$5.00	$10.00	None
ALENDRONATE SODIUM 5MG TABLET	2	Generic	$5.00	$10.00	None
ALENDRONATE SODIUM 70MG TABLET 4 BLPK	2	Generic	$5.00	$10.00	Q:4 /28Days
ALENDRONATE SODIUM TABLET 35MG 20 CRTN	2	Generic	$5.00	$10.00	Q:4 /28Days
ALFERON N INJ 5MU/ML	4	Specialty	33%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ALKERAN FOR INJECTION 50MG/VIAL 1 VIALSU	3	Preferred Brand	33%	33%	P
ALLEGRA-D 12 HOUR TABLET 60-120MG (500 CT)	3	Preferred Brand	33%	33%	S Q:60 /30Days
ALLEGRA-D 24 HOUR TABLET	3	Preferred Brand	33%	33%	S Q:30 /30Days
ALLOPURINOL TABLET 300MG (1000 CT)	1	Value Generic	$2.50	$5.00	None
ALLOPURINOL TABLET USP 100MG (1000 CT)	1	Value Generic	$2.50	$5.00	None
ALORA 0.025MG PATCH	3	Preferred Brand	33%	33%	None
ALORA 0.05MG PATCH	3	Preferred Brand	33%	33%	None
ALORA 0.075MG PATCH	3	Preferred Brand	33%	33%	None
ALORA 0.1MG PATCH	3	Preferred Brand	33%	33%	None
ALPHAGAN P 0.15% EYE DROPS	3	Preferred Brand	33%	33%	None
ALREX 0.2% EYE DROPS	5	Non-Preferred	45%	45%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMANTADINE 100MG CAPSULE	2	Generic	$5.00	$10.00	None
AMANTADINE 100MG TABLET	2	Generic	$5.00	$10.00	None
AMIFOSTINE FOR INJECTION 500MG/VIAL	2	Generic	$5.00	$10.00	P
AMIKACIN 250MG/ML VIAL	5	Non-Preferred	45%	45%	P
AMIKACIN 50MG/ML VIAL	5	Non-Preferred	45%	45%	P
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET	1	Value Generic	$2.50	$5.00	None
AMINESS 5.2% IV SOLUTION	3	Preferred Brand	33%	33%	P
AMINOPHYLLINE 100MG TABLET	1	Value Generic	$2.50	$5.00	None
AMINOPHYLLINE 200MG TABLET (1000 CT)	1	Value Generic	$2.50	$5.00	None
AMINOPHYLLINE INJECTION 250MG 10ML X 25 VIALSD	2	Generic	$5.00	$10.00	P
AMINOSYN 10% IV SOLUTION	3	Preferred Brand	33%	33%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMINOSYN 3.5% IV SOLUTION	3	Preferred Brand	33%	33%	P
AMINOSYN 5% IV SOLUTION	3	Preferred Brand	33%	33%	P
AMINOSYN 7% IV SOLUTION	3	Preferred Brand	33%	33%	P
AMINOSYN 8.5% IV SOLUTION	3	Preferred Brand	33%	33%	P
AMINOSYN II 10% IV SOLUTION	3	Preferred Brand	33%	33%	P
AMINOSYN II 15% IV SOLUTION	3	Preferred Brand	33%	33%	P
AMINOSYN II 4.25% IN D10W	3	Preferred Brand	33%	33%	P
AMINOSYN II 7% IV SOLUTION	3	Preferred Brand	33%	33%	P
AMINOSYN II 8.5% ELECTROLYT	3	Preferred Brand	33%	33%	P
AMINOSYN II 8.5% IV SOLUTION	3	Preferred Brand	33%	33%	P
AMINOSYN PF INJECTION	3	Preferred Brand	33%	33%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMINOSYN-HBC 7% IV SOLUTION	3	Preferred Brand	33%	33%	P
AMINOSYN-HF 8% IV SOLUTION	2	Generic	$5.00	$10.00	P
AMINOSYN-PF 7% IV SOLUTION	3	Preferred Brand	33%	33%	P
AMIODARONE HCL 200MG TABLET (60 CT)	2	Generic	$5.00	$10.00	None
AMIODARONE HCL 400MG TABLET	2	Generic	$5.00	$10.00	None
AMIODARONE HCL INJECTION	2	Generic	$5.00	$10.00	P
AMITIZA 8MCG CAPSULE	3	Preferred Brand	33%	33%	P Q:60 /30Days
AMITIZA CAPSULES 24MCG 60 CAP BOT	3	Preferred Brand	33%	33%	P Q:60 /30Days
AMITRIPTYLINE HCL 100MG TABLET	1	Value Generic	$2.50	$5.00	None
AMITRIPTYLINE HCL 10MG TABLET	1	Value Generic	$2.50	$5.00	None
AMITRIPTYLINE HCL 150MG TABLET (100 CT)	1	Value Generic	$2.50	$5.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)	1	Value Generic	$2.50	$5.00	None
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)	1	Value Generic	$2.50	$5.00	None
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT	1	Value Generic	$2.50	$5.00	None
AMLODIPINE BESYLATE 10MG TABLET (90 CT)	2	Generic	$5.00	$10.00	None
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)	2	Generic	$5.00	$10.00	None
AMLODIPINE BESYLATE 5MG TABLET (90 CT)	2	Generic	$5.00	$10.00	None
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE	2	Generic	$5.00	$10.00	None
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE	2	Generic	$5.00	$10.00	None
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE	2	Generic	$5.00	$10.00	None
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE	2	Generic	$5.00	$10.00	None
AMMONIUM LACTATE 12% CREAM	2	Generic	$5.00	$10.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMMONIUM LACTATE 12% LOTION	2	Generic	$5.00	$10.00	None
AMNESTEEM 10MG CAPSULE	5	Non-Preferred	45%	45%	P
AMNESTEEM 20MG CAPSULE	5	Non-Preferred	45%	45%	P
AMNESTEEM 40MG CAPSULE	5	Non-Preferred	45%	45%	P
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL	2	Generic	$5.00	$10.00	None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE	2	Generic	$5.00	$10.00	None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE	2	Generic	$5.00	$10.00	None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL	2	Generic	$5.00	$10.00	None
AMOX TR-POTASSIUM CLAVULANATE 500-125MG TABLET	2	Generic	$5.00	$10.00	None
AMOXAPINE 100MG TABLET	2	Generic	$5.00	$10.00	None
AMOXAPINE 150MG TABLET	2	Generic	$5.00	$10.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMOXAPINE 25MG TABLET	2	Generic	$5.00	$10.00	None
AMOXAPINE 50MG TABLET	2	Generic	$5.00	$10.00	None
AMOXICILLIN 125MG TABLET CHEW	2	Generic	$5.00	$10.00	None
AMOXICILLIN 200MG TABLET CHEW	1	Value Generic	$2.50	$5.00	None
AMOXICILLIN 250MG CAPSULE	1	Value Generic	$2.50	$5.00	None
AMOXICILLIN 400MG TABLET CHEW	1	Value Generic	$2.50	$5.00	None
AMOXICILLIN 500MG CAPSULE	1	Value Generic	$2.50	$5.00	None
AMOXICILLIN 500MG TABLET (100 CT)	1	Value Generic	$2.50	$5.00	None
AMOXICILLIN 875MG TABLET	1	Value Generic	$2.50	$5.00	None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT	2	Generic	$5.00	$10.00	None
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT	2	Generic	$5.00	$10.00	None
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	Value Generic	$2.50	$5.00	None
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL	1	Value Generic	$2.50	$5.00	None
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT	1	Value Generic	$2.50	$5.00	None
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL	1	Value Generic	$2.50	$5.00	None
AMOXICILLIN TABLET USP CHEWABLE 250MG (250 CT)	1	Value Generic	$2.50	$5.00	None
AMOXIL 250MG/5ML SUSPENSION	2	Generic	$5.00	$10.00	None
AMOXIL CAPSULES 500MG	2	Generic	$5.00	$10.00	None
AMPHET ASP/ AMPHET/ D-AMPHET 5MG TABLET	2	Generic	$5.00	$10.00	None
AMPHETAMINE SALT COMBO 12.5MG TABLET	2	Generic	$5.00	$10.00	None
AMPHETAMINE SALT COMBO 15MG TABLET	2	Generic	$5.00	$10.00	None
AMPHETAMINE SALT COMBO 30MG TABLET	2	Generic	$5.00	$10.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMPHETAMINE SALT COMBO 7.5MG TABLET	2	Generic	$5.00	$10.00	None
AMPHETAMINE SALTS 20MG TABLET	2	Generic	$5.00	$10.00	None
AMPHOTERICIN B FOR INJECTION 50 MG	2	Generic	$5.00	$10.00	P
AMPICILLIN AND SULBACTAM FOR INJECTION 10-5 1 VIAL	2	Generic	$5.00	$10.00	P
AMPICILLIN AND SULBACTAM FOR INJECTION 2-1 10 VIAL	2	Generic	$5.00	$10.00	P
AMPICILLIN CAPSULES 250MG 100 BOT	2	Generic	$5.00	$10.00	None
AMPICILLIN CAPSULES 500MG 100 BOT	2	Generic	$5.00	$10.00	None
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT	2	Generic	$5.00	$10.00	None
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT	2	Generic	$5.00	$10.00	None
AMPICILLIN POWDER FOR INJECTION 1 GM/ML	2	Generic	$5.00	$10.00	P
ANAGRELIDE HCL 0.5MG CAPSULE	2	Generic	$5.00	$10.00	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ANAGRELIDE HCL 1MG CAPSULE	2	Generic	$5.00	$10.00	P
ANCOBON 250MG CAPSULE	3	Preferred Brand	33%	33%	None
ANCOBON 500MG CAPSULE	3	Preferred Brand	33%	33%	None
ANDRODERM 2.5MG/24HR PATCH	3	Preferred Brand	33%	33%	Q:30 /30Days
ANDRODERM 5MG/24HR PATCH	3	Preferred Brand	33%	33%	Q:30 /30Days
ANDROID 10MG CAPSULE	3	Preferred Brand	33%	33%	None
ANTABUSE 250MG TABLET	3	Preferred Brand	33%	33%	None
ANTABUSE 500MG TABLET	3	Preferred Brand	33%	33%	None
ANTIVERT 50MG TABLET	3	Preferred Brand	33%	33%	None
ANZEMET 100MG TABLET	3	Preferred Brand	33%	33%	P Q:3 /28Days
ANZEMET 20MG/ML VIAL	3	Preferred Brand	33%	33%	P Q:13 /28Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ANZEMET 50MG TABLET	3	Preferred Brand	33%	33%	P Q:3 /28Days
APIDRA 100UNITS/ML VIAL	5	Non-Preferred	45%	45%	None
APRI 0.15-0.03 TABLET	2	Generic	$5.00	$10.00	None
APRISO CP24	3	Preferred Brand	33%	33%	None
APTIVUS 250MG CAPSULE	3	Preferred Brand	33%	33%	None
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT	3	Preferred Brand	33%	33%	None
ARALAST 500MG VIAL	3	Preferred Brand	33%	33%	P
ARANELLE 7-9-5 TABLET	2	Generic	$5.00	$10.00	None
ARANESP 100MCG/ML VIAL	4	Specialty	33%	N/A	P
ARANESP 200MCG/0.4ML SYRINGE	4	Specialty	33%	N/A	P
ARANESP 200MCG/ML VIAL	4	Specialty	33%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ARANESP 25MCG/ML VIAL	5	Non-Preferred	45%	45%	P
ARANESP 300MCG/ML VIAL	4	Specialty	33%	N/A	P
ARANESP 500MCG/1ML SYRINGE	4	Specialty	33%	N/A	P
ARANESP 60MCG/ML VIAL	4	Specialty	33%	N/A	P
ARANESP PREFILLED SYRINGE SINGLE USE 100MCG/0.5ML 1 SYR	4	Specialty	33%	N/A	P
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR	4	Specialty	33%	N/A	P
ARANESP PREFILLED SYRINGE SINGLE USE 25MCG/0.42ML SYR	5	Non-Preferred	45%	45%	P
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR	4	Specialty	33%	N/A	P
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR	5	Non-Preferred	45%	45%	P
ARANESP PREFILLED SYRINGE SINGLE USE 60MCG/0.3ML 60MCG/ 0.3ML SYR	4	Specialty	33%	N/A	P
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD	5	Non-Preferred	45%	45%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ARICEPT 10MG TABLET	3	Preferred Brand	33%	33%	None
ARICEPT 5MG TABLET	3	Preferred Brand	33%	33%	None
ARICEPT ODT 10MG TABLET	3	Preferred Brand	33%	33%	None
ARICEPT ODT 5MG TABLET	3	Preferred Brand	33%	33%	None
ARIMIDEX 1MG TABLET	3	Preferred Brand	33%	33%	None
ARIXTRA 10MG SYRINGE	4	Specialty	33%	N/A	Q:16 /10Days
ARIXTRA 2.5MG SYRINGE	5	Non-Preferred	45%	45%	Q:10 /10Days
ARIXTRA 5MG SYRINGE	4	Specialty	33%	N/A	Q:8 /10Days
ARIXTRA 7.5MG SYRINGE	4	Specialty	33%	N/A	Q:12 /10Days
AROMASIN 25MG TABLET	3	Preferred Brand	33%	33%	None
ARTHROTEC 50 50MG TABLET -200MCG (60 CT)	3	Preferred Brand	33%	33%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ARTHROTEC 75 TABLET EC	3	Preferred Brand	33%	33%	None
ASCOMP W/CODEINE 30-50-325 CAPSULE	2	Generic	$5.00	$10.00	None
ASMANEX 220MCG(14) AEROSOL POWDER BREATH ACTIVATED	3	Preferred Brand	33%	33%	None
ASMANEX TWISTHALER 220MCG #120	3	Preferred Brand	33%	33%	None
ASMANEX TWISTHALER 220MCG #30	3	Preferred Brand	33%	33%	None
ASMANEX TWISTHALER 220MCG #60	3	Preferred Brand	33%	33%	None
ASTELIN 137MCG AEROSOL SPRAY W/PUMP	3	Preferred Brand	33%	33%	None
ASTEPRO NASAL SPRAY 137 MCG/SPRY	3	Preferred Brand	33%	33%	None
ASTRAMORPH-PF 0.5MG/ML VIAL	2	Generic	$5.00	$10.00	P
ASTRAMORPH-PF 1MG/ML VIAL	2	Generic	$5.00	$10.00	P
ATAMET	2	Generic	$5.00	$10.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ATENOLOL 25MG TABLET (100 CT)	1	Value Generic	$2.50	$5.00	None
ATENOLOL TABLET USP 50MG (100 CT)	1	Value Generic	$2.50	$5.00	None
ATENOLOL TABLETS USP 100MG 1 BLPK	1	Value Generic	$2.50	$5.00	None
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT)	1	Value Generic	$2.50	$5.00	None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)	1	Value Generic	$2.50	$5.00	None
ATGAM 50MG/ML AMPUL	3	Preferred Brand	33%	33%	P
ATRIPLA TABLET 600MG/200MG	3	Preferred Brand	33%	33%	None
ATROVENT HFA AER 17MCG	3	Preferred Brand	33%	33%	None
ATTENUVAX VACCINE W/DILUENT 1 DOSE/0.5ML	3	Preferred Brand	33%	33%	None
AUGMENTIN 125 SUSPENSION	3	Preferred Brand	33%	33%	None
AUGMENTIN 250 SUSPENSION	3	Preferred Brand	33%	33%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AUGMENTIN TABLETS COMBO	3	Preferred Brand	33%	33%	None
AUGMENTIN XR 1000-62.5 TABLET	3	Preferred Brand	33%	33%	None
AVANDAMET 2MG/1000MG TABLET	3	Preferred Brand	33%	33%	Q:60 /30Days
AVANDAMET 2MG/500MG TABLET	3	Preferred Brand	33%	33%	Q:120 /30Days
AVANDAMET 4MG/500MG TABLET	3	Preferred Brand	33%	33%	Q:60 /30Days
AVANDAMET TABLET 4-1000MG	3	Preferred Brand	33%	33%	Q:60 /30Days
AVANDARYL 4MG/1MG TABLET	3	Preferred Brand	33%	33%	Q:60 /30Days
AVANDARYL 4MG/2MG TABLET	3	Preferred Brand	33%	33%	Q:60 /30Days
AVANDARYL 4MG/4MG TABLET	3	Preferred Brand	33%	33%	Q:30 /30Days
AVANDARYL 8MG-2MG TABLET	3	Preferred Brand	33%	33%	Q:30 /30Days
AVANDARYL 8MG-4MG TABLET	3	Preferred Brand	33%	33%	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AVANDIA 2MG TABLET	3	Preferred Brand	33%	33%	None
AVANDIA 4MG TABLET (90 CT)	3	Preferred Brand	33%	33%	None
AVANDIA 8MG TABLET (90 CT)	3	Preferred Brand	33%	33%	None
AVIANE 0.1-0.02 TABLET	2	Generic	$5.00	$10.00	None
AVITA 0.025% CREAM	2	Generic	$5.00	$10.00	P
AVODART 0.5MG SOFTGEL	3	Preferred Brand	33%	33%	None
AZASAN 100MG TABLET	2	Generic	$5.00	$10.00	P
AZASAN 75MG TABLET	2	Generic	$5.00	$10.00	P
AZASITE 1% DROPS	3	Preferred Brand	33%	33%	None
AZATHIOPRINE 50MG TABLET	2	Generic	$5.00	$10.00	P
AZATHIOPRINE SOD 100MG VIAL	2	Generic	$5.00	$10.00	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL	2	Generic	$5.00	$10.00	None
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL	2	Generic	$5.00	$10.00	None
AZITHROMYCIN 250MG TABLET (30 CT)	2	Generic	$5.00	$10.00	None
AZITHROMYCIN 500MG TABLET (30 CT)	2	Generic	$5.00	$10.00	None
AZITHROMYCIN TABLET 600MG (30 CT)	2	Generic	$5.00	$10.00	None
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT	3	Preferred Brand	33%	33%	None

Chart Legend:

Below are a few notes to help you understand the above 2010 Medicare Part D Advantage Freedom Plan by RxAmerica (PDP) Plan Formulary.

Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region).
Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.
Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $310 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.
Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
- Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.
- No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.
Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
- Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
- Drug Description - This is the Medicare Part D plan’s description of this particular drug tier.
Cost Sharing - Copay / Coinsurance - These figures apply to the initial coverage phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
- Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the initial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $2830) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2013 Humana Walmart-Preferred Rx Plan the cost-sharing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
- Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
- None - This drug does not fall under any drug utilization management controls.
- P - Prior Authorization -This drug is subject to prior authorization.
- S - Step Therapy -This drug is subject to step therapy.
- Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.

(Chart Source: Centers for Medicare and Medicaid files: CMS Data October 2010 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Part D plan provider.