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2010 Medicare Part D Plan Formulary Information
MedicareBlue Rx Premier (PDP) (S5743-004-0) Benefit Details
The MedicareBlue Rx Premier (PDP) (S5743-004-0) Formulary Drugs Starting with the Letter A in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY
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 METHAPRED METHLYPREDNISOLONE SODIUM SUCCINATE FOR INJECTION 125 MG	1	Level 1: Covered Generics	$4.00	$8.00	None
A-METHAPRED 40MG UNIVIAL	1	Level 1: Covered Generics	$4.00	$8.00	None
ABILIFY 10MG TABLET	3	Level 3: Covered Brand	50%	50%	S Q:30 /30Days
ABILIFY 15MG TABLET	3	Level 3: Covered Brand	50%	50%	S Q:30 /30Days
ABILIFY 1MG/ML SOLUTION	3	Level 3: Covered Brand	50%	50%	S Q:900 /30Days
ABILIFY 20MG TABLET	3	Level 3: Covered Brand	50%	50%	S Q:30 /30Days
ABILIFY 2MG TABLET	3	Level 3: Covered Brand	50%	50%	S Q:30 /30Days
ABILIFY 30MG TABLET	3	Level 3: Covered Brand	50%	50%	S Q:30 /30Days
ABILIFY 5MG TABLET (OTSUKA)	3	Level 3: Covered Brand	50%	50%	S Q:30 /30Days
ABILIFY DISCMELT 10MG TABLET	3	Level 3: Covered Brand	50%	50%	S Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ABILIFY DISCMELT 15MG TABLET	3	Level 3: Covered Brand	50%	50%	S Q:60 /30Days
ABILIFY INJ 9.75MG	3	Level 3: Covered Brand	50%	50%	S Q:120 /30Days
ABRAXANE 100MG VIAL	4	Covered Specialty	33%	33%	None
ACARBOSE 100MG TABLET S	1	Level 1: Covered Generics	$4.00	$8.00	None
ACARBOSE 25MG TABLET S	1	Level 1: Covered Generics	$4.00	$8.00	None
ACARBOSE 50MG TABLET S	1	Level 1: Covered Generics	$4.00	$8.00	None
ACCOLATE 10MG TABLET	2	Level 2: Covered Preferred Brand	$38.00	$76.00	None
ACCOLATE 20MG TABLET	2	Level 2: Covered Preferred Brand	$38.00	$76.00	S
ACEBUTOLOL 200MG CAPSULE	1	Level 1: Covered Generics	$4.00	$8.00	None
ACEBUTOLOL 400MG CAPSULE	1	Level 1: Covered Generics	$4.00	$8.00	None
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD	1	Level 1: Covered Generics	$4.00	$8.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
ACETAZOLAMIDE 125MG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
ACETAZOLAMIDE 250MG TABLET (100 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
ACETIC ACID 2% SOLUTION NON-ORAL	1	Level 1: Covered Generics	$4.00	$8.00	None
ACETIC ACID IN AQUEOUS ALUMINUM ACETATE OTIC SOLUTION 2% 60 ML BOT	1	Level 1: Covered Generics	$4.00	$8.00	None
ACTHIB VACCINE VIAL 10-24UNT/5ML	3	Level 3: Covered Brand	50%	50%	None
ACTICIN 5% CREAM	1	Level 1: Covered Generics	$4.00	$8.00	None
ACTIMMUNE SOLUTION FOR INJECTION 100MCG	4	Covered Specialty	33%	33%	None
ACTONEL 150MG TABLET	3	Level 3: Covered Brand	50%	50%	S Q:1 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ACTONEL 30MG TABLET	3	Level 3: Covered Brand	50%	50%	S Q:30 /30Days
ACTONEL 35MG TABLET	3	Level 3: Covered Brand	50%	50%	S Q:4 /28Days
ACTONEL 5MG TABLET	3	Level 3: Covered Brand	50%	50%	S Q:30 /30Days
ACTONEL 75MG TABLET	3	Level 3: Covered Brand	50%	50%	S Q:2 /30Days
ACTOPLUS MET 15MG/500MG TABLET	2	Level 2: Covered Preferred Brand	$38.00	$76.00	S
ACTOPLUS MET 15MG/850MG TABLET	2	Level 2: Covered Preferred Brand	$38.00	$76.00	S
ACTOS 15MG TABLET	2	Level 2: Covered Preferred Brand	$38.00	$76.00	S
ACTOS 30MG TABLET (500 CT)	2	Level 2: Covered Preferred Brand	$38.00	$76.00	S
ACTOS 45MG TABLET	2	Level 2: Covered Preferred Brand	$38.00	$76.00	S
ACULAR 0.5% EYE DROPS	3	Level 3: Covered Brand	50%	50%	None
ACULAR LS 0.4% OPHTH SOL	3	Level 3: Covered Brand	50%	50%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ACYCLOVIR 200MG CAPSULE (1000 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
ACYCLOVIR 200MG/5ML SUSP	1	Level 1: Covered Generics	$4.00	$8.00	None
ACYCLOVIR 400MG TABLET (100 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
ACYCLOVIR SODIUM 500MG VIAL	1	Level 1: Covered Generics	$4.00	$8.00	P
ACYCLOVIR TABLET USP 800MG (100 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
ADACEL VIAL 2UNT/5UNT	3	Level 3: Covered Brand	50%	50%	None
ADAGEN 250U/ML VIAL	4	Covered Specialty	33%	33%	None
ADVAIR DISKU MIS 100/50	2	Level 2: Covered Preferred Brand	$38.00	$76.00	Q:60 /30Days
ADVAIR DISKU MIS 250/50	2	Level 2: Covered Preferred Brand	$38.00	$76.00	Q:60 /30Days
ADVAIR DISKU MIS 500/50	2	Level 2: Covered Preferred Brand	$38.00	$76.00	Q:60 /30Days
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL	2	Level 2: Covered Preferred Brand	$38.00	$76.00	Q:12 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ADVAIR HFA INHALER 230;21MCG;MCG	2	Level 2: Covered Preferred Brand	$38.00	$76.00	Q:12 /30Days
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL	2	Level 2: Covered Preferred Brand	$38.00	$76.00	Q:12 /30Days
AFEDITAB CR 30MG TABLET SA	1	Level 1: Covered Generics	$4.00	$8.00	None
AFEDITAB CR 60MG TABLET SA	1	Level 1: Covered Generics	$4.00	$8.00	None
AGGRENOX 25-200MG CAPSULE	3	Level 3: Covered Brand	50%	50%	None
AK-CON 0.1% EYE DROPS	1	Level 1: Covered Generics	$4.00	$8.00	None
AK-POLY-BAC EYE OINTMENT 500UNT/1000UNT	1	Level 1: Covered Generics	$4.00	$8.00	None
AKTOB 0.3% EYE DROPS	1	Level 1: Covered Generics	$4.00	$8.00	None
ALA-CORT 1% CREAM	1	Level 1: Covered Generics	$4.00	$8.00	None
ALA-CORT 1% LOTION	1	Level 1: Covered Generics	$4.00	$8.00	None
ALBENZA 200MG TABLET	3	Level 3: Covered Brand	50%	50%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ALBUTEROL SULFATE 0.63MG/3ML VIAL NEBULIZER	1	Level 1: Covered Generics	$4.00	$8.00	P
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER	1	Level 1: Covered Generics	$4.00	$8.00	P
ALBUTEROL SULFATE 2.5MG/3ML VIAL NEBULIZER	1	Level 1: Covered Generics	$4.00	$8.00	P
ALBUTEROL SULFATE 4MG TABLET SR 12HR	1	Level 1: Covered Generics	$4.00	$8.00	None
ALBUTEROL SULFATE 8MG TABLET SR 12HR	1	Level 1: Covered Generics	$4.00	$8.00	None
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR	1	Level 1: Covered Generics	$4.00	$8.00	P
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT	1	Level 1: Covered Generics	$4.00	$8.00	None
ALBUTEROL SULFATE TABLET 2MG (500 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
ALBUTEROL TABLET 4MG (500 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
ALCLOMETASONE DIPROPIONATE 0.05% CREAM	1	Level 1: Covered Generics	$4.00	$8.00	None
ALCLOMETASONE DIPROPIONATE 0.05% OINTMENT	1	Level 1: Covered Generics	$4.00	$8.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ALDARA IMIQUIMOD CREAM 5% 24 PKT X 250 MG CRTN	3	Level 3: Covered Brand	50%	50%	P Q:12 /30Days
ALDURAZYME 2.9MG/5ML VIAL	4	Covered Specialty	33%	33%	None
ALENDRONATE SODIUM 10MG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	Q:30 /30Days
ALENDRONATE SODIUM 40MG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	Q:30 /30Days
ALENDRONATE SODIUM 5MG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	Q:30 /30Days
ALENDRONATE SODIUM 70MG TABLET 4 BLPK	1	Level 1: Covered Generics	$4.00	$8.00	Q:4 /28Days
ALENDRONATE SODIUM TABLET 35MG 20 CRTN	1	Level 1: Covered Generics	$4.00	$8.00	Q:4 /28Days
ALFERON N INJ 5MU/ML	4	Covered Specialty	33%	33%	None
ALIMTA 500MG VIAL	4	Covered Specialty	33%	33%	None
ALKERAN FOR INJECTION 50MG/VIAL 1 VIALSU	4	Covered Specialty	33%	33%	None
ALLOPURINOL SODIUM 500MG VIAL	1	Level 1: Covered Generics	$4.00	$8.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ALLOPURINOL TABLET 300MG (1000 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
ALLOPURINOL TABLET USP 100MG (1000 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
ALOXI 0.25MG/5ML	3	Level 3: Covered Brand	50%	50%	None
ALPHAGAN P 0.1% DROPS	3	Level 3: Covered Brand	50%	50%	None
ALREX 0.2% EYE DROPS	3	Level 3: Covered Brand	50%	50%	None
AMANTADINE 100MG CAPSULE	1	Level 1: Covered Generics	$4.00	$8.00	None
AMCINONIDE 0.1% CREAM	1	Level 1: Covered Generics	$4.00	$8.00	None
AMEVIVE ADMISTRATION PACK FOR INTRAMUSCULAR ADMINISTRATION KIT 15MG 1 X 4 PKGCOM	4	Covered Specialty	33%	33%	S
AMIKACIN 250MG/ML VIAL	1	Level 1: Covered Generics	$4.00	$8.00	None
AMIKACIN 50MG/ML VIAL	1	Level 1: Covered Generics	$4.00	$8.00	None
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT	1	Level 1: Covered Generics	$4.00	$8.00	None
AMINOPHYLLINE 100MG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
AMINOPHYLLINE 200MG TABLET (1000 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
AMINOSYN-HF 8% IV SOLUTION	1	Level 1: Covered Generics	$4.00	$8.00	P
AMIODARONE HCL 200MG TABLET (60 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
AMIODARONE HCL 400MG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
AMITRIPTYLINE HCL 100MG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
AMITRIPTYLINE HCL 10MG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
AMITRIPTYLINE HCL 150MG TABLET (100 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT	1	Level 1: Covered Generics	$4.00	$8.00	None
AMLODIPINE BESYLATE 10MG TABLET (90 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
AMLODIPINE BESYLATE 5MG TABLET (90 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE	1	Level 1: Covered Generics	$4.00	$8.00	None
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE	1	Level 1: Covered Generics	$4.00	$8.00	None
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE	1	Level 1: Covered Generics	$4.00	$8.00	None
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE	1	Level 1: Covered Generics	$4.00	$8.00	None
AMMONIUM LACTATE 12% CREAM	1	Level 1: Covered Generics	$4.00	$8.00	None
AMMONIUM LACTATE 12% LOTION	1	Level 1: Covered Generics	$4.00	$8.00	None
AMNESTEEM 10MG CAPSULE	1	Level 1: Covered Generics	$4.00	$8.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMNESTEEM 20MG CAPSULE	1	Level 1: Covered Generics	$4.00	$8.00	None
AMNESTEEM 40MG CAPSULE	1	Level 1: Covered Generics	$4.00	$8.00	None
AMOCLAN 200-28.5/5 SUSPENSION RECONSTITUTED ORAL	1	Level 1: Covered Generics	$4.00	$8.00	None
AMOCLAN 400-57MG/5 SUSPENSION RECONSTITUTED ORAL	1	Level 1: Covered Generics	$4.00	$8.00	None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL	1	Level 1: Covered Generics	$4.00	$8.00	None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE	1	Level 1: Covered Generics	$4.00	$8.00	None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE	1	Level 1: Covered Generics	$4.00	$8.00	None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL	1	Level 1: Covered Generics	$4.00	$8.00	None
AMOX TR-POTASSIUM CLAVULANATE 500-125MG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
AMOXAPINE 100MG TABLET	3	Level 3: Covered Brand	50%	50%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMOXAPINE 150MG TABLET	3	Level 3: Covered Brand	50%	50%	None
AMOXAPINE 25MG TABLET	3	Level 3: Covered Brand	50%	50%	None
AMOXAPINE 50MG TABLET	3	Level 3: Covered Brand	50%	50%	None
AMOXICILLIN 125MG TABLET CHEW	1	Level 1: Covered Generics	$4.00	$8.00	None
AMOXICILLIN 200MG TABLET CHEW	1	Level 1: Covered Generics	$4.00	$8.00	None
AMOXICILLIN 250MG CAPSULE	1	Level 1: Covered Generics	$4.00	$8.00	None
AMOXICILLIN 400MG TABLET CHEW	3	Level 3: Covered Brand	50%	50%	None
AMOXICILLIN 500MG CAPSULE	1	Level 1: Covered Generics	$4.00	$8.00	None
AMOXICILLIN 500MG TABLET (100 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
AMOXICILLIN 875MG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT	1	Level 1: Covered Generics	$4.00	$8.00	None
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	Level 1: Covered Generics	$4.00	$8.00	None
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT	1	Level 1: Covered Generics	$4.00	$8.00	None
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL	1	Level 1: Covered Generics	$4.00	$8.00	None
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT	1	Level 1: Covered Generics	$4.00	$8.00	None
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL	1	Level 1: Covered Generics	$4.00	$8.00	None
AMOXICILLIN TABLET USP CHEWABLE 250MG (250 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
AMOXIL 250MG/5ML SUSPENSION	1	Level 1: Covered Generics	$4.00	$8.00	None
AMOXIL CAPSULES 500MG	1	Level 1: Covered Generics	$4.00	$8.00	None
AMPHET ASP/ AMPHET/ D-AMPHET 5MG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
AMPHETAMINE SALT COMBO 12.5MG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
AMPHETAMINE SALT COMBO 15MG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMPHETAMINE SALT COMBO 30MG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
AMPHETAMINE SALT COMBO 7.5MG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
AMPHETAMINE SALTS 20MG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
AMPICILLIN CAPSULES 250MG 100 BOT	1	Level 1: Covered Generics	$4.00	$8.00	None
AMPICILLIN CAPSULES 500MG 100 BOT	1	Level 1: Covered Generics	$4.00	$8.00	None
AMPICILLIN FOR INJECTION POWDER	1	Level 1: Covered Generics	$4.00	$8.00	None
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT	3	Level 3: Covered Brand	50%	50%	None
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT	3	Level 3: Covered Brand	50%	50%	None
AMPICILLIN POWDER FOR INJECTION 1 GM/ML	1	Level 1: Covered Generics	$4.00	$8.00	None
ANADROL-50 50MG TABLET (100 CT)	3	Level 3: Covered Brand	50%	50%	None
ANAGRELIDE HCL 0.5MG CAPSULE	1	Level 1: Covered Generics	$4.00	$8.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ANAGRELIDE HCL 1MG CAPSULE	1	Level 1: Covered Generics	$4.00	$8.00	None
ANCOBON 250MG CAPSULE	3	Level 3: Covered Brand	50%	50%	None
ANCOBON 500MG CAPSULE	3	Level 3: Covered Brand	50%	50%	None
ANDRODERM 2.5MG/24HR PATCH	2	Level 2: Covered Preferred Brand	$38.00	$76.00	None
ANDRODERM 5MG/24HR PATCH	2	Level 2: Covered Preferred Brand	$38.00	$76.00	None
ANDROGEL 1%(50MG) GEL PACKET	2	Level 2: Covered Preferred Brand	$38.00	$76.00	None
ANESTACON 15ML	1	Level 1: Covered Generics	$4.00	$8.00	None
ANTABUSE 250MG TABLET	3	Level 3: Covered Brand	50%	50%	None
ANTABUSE 500MG TABLET	3	Level 3: Covered Brand	50%	50%	None
APAP-CAFFEINE-DIHYDROCODE TAB 30 EA	1	Level 1: Covered Generics	$4.00	$8.00	None
APOKYN FOR INJECTION 30MG 5 CTG	4	Covered Specialty	33%	33%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
APRI 0.15-0.03 TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
APTIVUS 250MG CAPSULE	3	Level 3: Covered Brand	50%	50%	None
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT	3	Level 3: Covered Brand	50%	50%	None
ARANELLE 7-9-5 TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
ARANESP 100MCG/ML VIAL	4	Covered Specialty	33%	33%	P
ARANESP 200MCG/0.4ML SYRINGE	4	Covered Specialty	33%	33%	P
ARANESP 200MCG/ML VIAL	4	Covered Specialty	33%	33%	P
ARANESP 25MCG/ML VIAL	2	Level 2: Covered Preferred Brand	$38.00	$76.00	P
ARANESP 300MCG/ML VIAL	4	Covered Specialty	33%	33%	P
ARANESP 500MCG/1ML SYRINGE	4	Covered Specialty	33%	33%	P
ARANESP 60MCG/ML VIAL	4	Covered Specialty	33%	33%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ARANESP PREFILLED SYRINGE SINGLE USE 100MCG/0.5ML 1 SYR	4	Covered Specialty	33%	33%	P
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR	4	Covered Specialty	33%	33%	P
ARANESP PREFILLED SYRINGE SINGLE USE 25MCG/0.42ML SYR	2	Level 2: Covered Preferred Brand	$38.00	$76.00	P
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR	4	Covered Specialty	33%	33%	P
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR	2	Level 2: Covered Preferred Brand	$38.00	$76.00	P
ARANESP PREFILLED SYRINGE SINGLE USE 60MCG/0.3ML 60MCG/ 0.3ML SYR	4	Covered Specialty	33%	33%	P
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD	2	Level 2: Covered Preferred Brand	$38.00	$76.00	P
ARICEPT 10MG TABLET	2	Level 2: Covered Preferred Brand	$38.00	$76.00	None
ARICEPT 5MG TABLET	2	Level 2: Covered Preferred Brand	$38.00	$76.00	None
ARICEPT ODT 10MG TABLET	2	Level 2: Covered Preferred Brand	$38.00	$76.00	None
ARICEPT ODT 5MG TABLET	2	Level 2: Covered Preferred Brand	$38.00	$76.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ARIMIDEX 1MG TABLET	3	Level 3: Covered Brand	50%	50%	None
ARIXTRA 10MG SYRINGE	4	Covered Specialty	33%	33%	Q:24 /90Days
ARIXTRA 2.5MG SYRINGE	3	Level 3: Covered Brand	50%	50%	Q:15 /90Days
ARIXTRA 5MG SYRINGE	4	Covered Specialty	33%	33%	Q:12 /90Days
ARIXTRA 7.5MG SYRINGE	4	Covered Specialty	33%	33%	Q:18 /90Days
AROMASIN 25MG TABLET	2	Level 2: Covered Preferred Brand	$38.00	$76.00	None
ARRANON 250MG VIAL	4	Covered Specialty	33%	33%	None
ASACOL 400MG TABLET EC	2	Level 2: Covered Preferred Brand	$38.00	$76.00	None
ASACOL HD DELAYED RELEASE TABLETS 800MG 180 BOT	2	Level 2: Covered Preferred Brand	$38.00	$76.00	None
ASTELIN 137MCG AEROSOL SPRAY W/PUMP	2	Level 2: Covered Preferred Brand	$38.00	$76.00	Q:60 /30Days
ASTEPRO NASAL SPRAY 137 MCG/SPRY	2	Level 2: Covered Preferred Brand	$38.00	$76.00	Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ASTRAMORPH-PF 0.5MG/ML VIAL	1	Level 1: Covered Generics	$4.00	$8.00	P
ASTRAMORPH-PF 1MG/ML VIAL	1	Level 1: Covered Generics	$4.00	$8.00	P
ATAMET	1	Level 1: Covered Generics	$4.00	$8.00	None
ATENOLOL 25MG TABLET (100 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
ATENOLOL TABLET USP 50MG (100 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
ATENOLOL TABLETS USP 100MG 1 BLPK	1	Level 1: Covered Generics	$4.00	$8.00	None
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
ATGAM 50MG/ML AMPUL	4	Covered Specialty	33%	33%	P
ATRIPLA TABLET 600MG/200MG	3	Level 3: Covered Brand	50%	50%	None
ATROVENT HFA AER 17MCG	3	Level 3: Covered Brand	50%	50%	Q:26 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ATTENUVAX VACCINE W/DILUENT 1 DOSE/0.5ML	3	Level 3: Covered Brand	50%	50%	None
AVANDAMET 2MG/1000MG TABLET	2	Level 2: Covered Preferred Brand	$38.00	$76.00	S
AVANDAMET 2MG/500MG TABLET	2	Level 2: Covered Preferred Brand	$38.00	$76.00	S
AVANDAMET 4MG/500MG TABLET	2	Level 2: Covered Preferred Brand	$38.00	$76.00	S
AVANDAMET TABLET 4-1000MG	2	Level 2: Covered Preferred Brand	$38.00	$76.00	S
AVANDARYL 4MG/1MG TABLET	2	Level 2: Covered Preferred Brand	$38.00	$76.00	S
AVANDARYL 4MG/2MG TABLET	2	Level 2: Covered Preferred Brand	$38.00	$76.00	S
AVANDARYL 4MG/4MG TABLET	2	Level 2: Covered Preferred Brand	$38.00	$76.00	S
AVANDARYL 8MG-2MG TABLET	2	Level 2: Covered Preferred Brand	$38.00	$76.00	S
AVANDARYL 8MG-4MG TABLET	2	Level 2: Covered Preferred Brand	$38.00	$76.00	S
AVANDIA 2MG TABLET	2	Level 2: Covered Preferred Brand	$38.00	$76.00	S
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AVANDIA 4MG TABLET (90 CT)	2	Level 2: Covered Preferred Brand	$38.00	$76.00	S
AVANDIA 8MG TABLET (90 CT)	2	Level 2: Covered Preferred Brand	$38.00	$76.00	S
AVASTIN 100MG/4ML VIAL	4	Covered Specialty	33%	33%	None
AVELOX IV 400MG/250ML	3	Level 3: Covered Brand	50%	50%	None
AVIANE 0.1-0.02 TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
AVINZA 120MG CAPSULE MULTIPHASIC RELEASE 24 HR	2	Level 2: Covered Preferred Brand	$38.00	$76.00	None
AVINZA 30MG CAPSULE MULTIPHASIC RELEASE 24 HR	2	Level 2: Covered Preferred Brand	$38.00	$76.00	None
AVINZA 60MG CAPSULE MULTIPHASIC RELEASE 24 HR	2	Level 2: Covered Preferred Brand	$38.00	$76.00	None
AVINZA 90MG CAPSULE MULTIPHASIC RELEASE 24 HR	2	Level 2: Covered Preferred Brand	$38.00	$76.00	None
AVINZA CAPSULES EXTENDED RELEASE 45MG 100 BOTPL	2	Level 2: Covered Preferred Brand	$38.00	$76.00	None
AVINZA CAPSULES EXTENDED RELEASE 75MG 100 BOTPL	2	Level 2: Covered Preferred Brand	$38.00	$76.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AVITA 0.025% CREAM	1	Level 1: Covered Generics	$4.00	$8.00	None
AVODART 0.5MG SOFTGEL	2	Level 2: Covered Preferred Brand	$38.00	$76.00	None
AVONEX ADMIN PACK 30MCG SYR	4	Covered Specialty	33%	33%	None
AVONEX ADMIN PACK 30MCG VL	4	Covered Specialty	33%	33%	None
AZACTAM 2GM VIAL	2	Level 2: Covered Preferred Brand	$38.00	$76.00	None
AZACTAM INJECTION 1GM 50ML BAG	2	Level 2: Covered Preferred Brand	$38.00	$76.00	None
AZACTAM/ISO-OSMOT 2GM/50ML	2	Level 2: Covered Preferred Brand	$38.00	$76.00	None
AZASAN 100MG TABLET	3	Level 3: Covered Brand	50%	50%	P
AZASAN 75MG TABLET	3	Level 3: Covered Brand	50%	50%	P
AZATHIOPRINE 50MG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	P
AZATHIOPRINE SOD 100MG VIAL	3	Level 3: Covered Brand	50%	50%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AZELEX 20% CREAM 30GM TUBE	3	Level 3: Covered Brand	50%	50%	None
AZILECT 0.5MG TABLET	2	Level 2: Covered Preferred Brand	$38.00	$76.00	None
AZILECT 1MG TABLET	2	Level 2: Covered Preferred Brand	$38.00	$76.00	None
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL	1	Level 1: Covered Generics	$4.00	$8.00	None
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL	1	Level 1: Covered Generics	$4.00	$8.00	None
AZITHROMYCIN 250MG TABLET (30 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
AZITHROMYCIN 500MG TABLET (30 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
AZITHROMYCIN FOR INJECTION 500MG 10 VIALSD	1	Level 1: Covered Generics	$4.00	$8.00	None
AZITHROMYCIN TABLET 600MG (30 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT	3	Level 3: Covered Brand	50%	50%	None
AZOR 10MG-20MG TABLET	2	Level 2: Covered Preferred Brand	$38.00	$76.00	S
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AZOR 10MG-40MG TABLET (30 CT)	2	Level 2: Covered Preferred Brand	$38.00	$76.00	S
AZOR 5MG-20MG TABLET (30 CT)	2	Level 2: Covered Preferred Brand	$38.00	$76.00	S
AZOR 5MG-40MG TABLET	2	Level 2: Covered Preferred Brand	$38.00	$76.00	S

Chart Legend:

Below are a few notes to help you understand the above 2010 Medicare Part D MedicareBlue Rx Premier (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.