Q1GROUP LLC | Q1Medicare.com - a non-government resource for the Medicare community
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

Select your search style and criteria below or use this example to get started

Search by:
State & Plan   ZIP & Plan   PlanID   FormularyID

Search Criteria
PDP     MAPD
Scroll down to see formulary results.

Aetna Medicare Rx Plus (PDP) (S5810-219-0)
Tier 1 (1470)
Tier 2 (494)
Tier 3 (340)
Tier 4 (810)
Tier 5 (334)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
Yes No Show either
Cick on the first letter of your drug name to browse the formulary:

A B C D E F G H I J K L 
M N O P Q R S T U V W X Y Z 0-9 
2010 Medicare Part D Plan Formulary Information
Aetna Medicare Rx Plus (PDP) (S5810-219-0)
Sanctioned Plan  
The Aetna Medicare Rx Plus (PDP) (S5810-219-0)
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
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
A METHAPRED METHLYPREDNISOLONE SODIUM SUCCINATE FOR INJECTION 125 MG   1 Tier 1 - Preferred Generic $5.00$15.00None
A-HYDROCORT 100MG VIAL   1 Tier 1 - Preferred Generic $5.00$15.00None
A-METHAPRED 40MG UNIVIAL   1 Tier 1 - Preferred Generic $5.00$15.00None
ABILIFY 10MG TABLET   4 Tier 4 - Non-Preferred Brand $80.00$225.00S Q:1
/1Days
ABILIFY 15MG TABLET   4 Tier 4 - Non-Preferred Brand $80.00$225.00S Q:1
/1Days
ABILIFY 1MG/ML SOLUTION   4 Tier 4 - Non-Preferred Brand $80.00$225.00S Q:30
/1Days
ABILIFY 20MG TABLET   4 Tier 4 - Non-Preferred Brand $80.00$225.00S Q:1
/1Days
ABILIFY 2MG TABLET   4 Tier 4 - Non-Preferred Brand $80.00$225.00S Q:1
/1Days
ABILIFY 30MG TABLET   4 Tier 4 - Non-Preferred Brand $80.00$225.00S Q:1
/1Days
ABILIFY 5MG TABLET (OTSUKA)   4 Tier 4 - Non-Preferred Brand $80.00$225.00S Q:1
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ABILIFY DISCMELT 10MG TABLET   4 Tier 4 - Non-Preferred Brand $80.00$225.00S Q:2
/1Days
ABILIFY DISCMELT 15MG TABLET   4 Tier 4 - Non-Preferred Brand $80.00$225.00S Q:2
/1Days
ABILIFY INJ 9.75MG   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
ABRAXANE 100MG VIAL   5 Tier 5 - Specialty 33%33%None
ACARBOSE 100MG TABLET S   2 Tier 2 - Non-Preferred Generic $32.00$81.00None
ACARBOSE 25MG TABLET S   2 Tier 2 - Non-Preferred Generic $32.00$81.00None
ACARBOSE 50MG TABLET S   2 Tier 2 - Non-Preferred Generic $32.00$81.00None
ACCOLATE 10MG TABLET   4 Tier 4 - Non-Preferred Brand $80.00$225.00Q:2
/1Days
ACCOLATE 20MG TABLET   4 Tier 4 - Non-Preferred Brand $80.00$225.00Q:2
/1Days
ACEBUTOLOL 200MG CAPSULE   1 Tier 1 - Preferred Generic $5.00$15.00S
ACEBUTOLOL 400MG CAPSULE   1 Tier 1 - Preferred Generic $5.00$15.00S
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACEON 2MG TABLET   4 Tier 4 - Non-Preferred Brand $80.00$225.00Q:2
/1Days
ACEON 4MG TABLET   4 Tier 4 - Non-Preferred Brand $80.00$225.00Q:2
/1Days
ACEON 8MG TABLET   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD   1 Tier 1 - Preferred Generic $5.00$15.00Q:167
/1Days
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT)   1 Tier 1 - Preferred Generic $5.00$15.00Q:13
/1Days
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT)   1 Tier 1 - Preferred Generic $5.00$15.00Q:13
/1Days
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT)   1 Tier 1 - Preferred Generic $5.00$15.00Q:13
/1Days
ACETASOL HC OTIC SOLUTION   1 Tier 1 - Preferred Generic $5.00$15.00None
ACETASOL HC SOLUTION 10ML 10 ML BOT   1 Tier 1 - Preferred Generic $5.00$15.00None
ACETAZOLAMIDE 125MG TABLET   1 Tier 1 - Preferred Generic $5.00$15.00None
ACETAZOLAMIDE 250MG TABLET (100 CT)   1 Tier 1 - Preferred Generic $5.00$15.00None
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 Tier 1 - Preferred Generic $5.00$15.00None
ACETAZOLAMIDE SOD 500MG VL   2 Tier 2 - Non-Preferred Generic $32.00$81.00None
ACETIC ACID 2% SOLUTION NON-ORAL   1 Tier 1 - Preferred Generic $5.00$15.00None
ACETIC ACID IN AQUEOUS ALUMINUM ACETATE OTIC SOLUTION 2% 60 ML BOT   1 Tier 1 - Preferred Generic $5.00$15.00None
ACETYLCYSTEINE 10% VIAL   1 Tier 1 - Preferred Generic $5.00$15.00P
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN   1 Tier 1 - Preferred Generic $5.00$15.00P
ACTHIB VACCINE VIAL 10-24UNT/5ML   3 Tier 3 - Preferred Brand $38.00$99.00None
ACTICIN 5% CREAM   1 Tier 1 - Preferred Generic $5.00$15.00None
ACTIMMUNE SOLUTION FOR INJECTION 100MCG   5 Tier 5 - Specialty 33%33%P
ACTIVELLA 0.5-0.1MG TABLET 28 DLPK   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
ACTONEL 150MG TABLET   3 Tier 3 - Preferred Brand $38.00$99.00Q:1
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACTONEL 30MG TABLET   3 Tier 3 - Preferred Brand $38.00$99.00None
ACTONEL 35MG TABLET   3 Tier 3 - Preferred Brand $38.00$99.00Q:4
/28Days
ACTONEL 5MG TABLET   3 Tier 3 - Preferred Brand $38.00$99.00None
ACTONEL 75MG TABLET   3 Tier 3 - Preferred Brand $38.00$99.00Q:2
/28Days
ACTONEL WITH CALCIUM TABLET   3 Tier 3 - Preferred Brand $38.00$99.00Q:1
/1Days
ACTOPLUS MET 15MG/500MG TABLET   3 Tier 3 - Preferred Brand $38.00$99.00None
ACTOPLUS MET 15MG/850MG TABLET   3 Tier 3 - Preferred Brand $38.00$99.00None
ACTOS 15MG TABLET   3 Tier 3 - Preferred Brand $38.00$99.00None
ACTOS 30MG TABLET (500 CT)   3 Tier 3 - Preferred Brand $38.00$99.00None
ACTOS 45MG TABLET   3 Tier 3 - Preferred Brand $38.00$99.00None
ACULAR 0.5% EYE DROPS   4 Tier 4 - Non-Preferred Brand $80.00$225.00S
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACULAR LS 0.4% OPHTH SOL   4 Tier 4 - Non-Preferred Brand $80.00$225.00S
ACYCLOVIR 200MG CAPSULE (1000 CT)   1 Tier 1 - Preferred Generic $5.00$15.00None
ACYCLOVIR 200MG/5ML SUSP   2 Tier 2 - Non-Preferred Generic $32.00$81.00None
ACYCLOVIR 400MG TABLET (100 CT)   1 Tier 1 - Preferred Generic $5.00$15.00None
ACYCLOVIR SODIUM 500MG VIAL   2 Tier 2 - Non-Preferred Generic $32.00$81.00None
ACYCLOVIR TABLET USP 800MG (100 CT)   1 Tier 1 - Preferred Generic $5.00$15.00None
ADACEL VIAL 2UNT/5UNT   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
ADAGEN 250U/ML VIAL   5 Tier 5 - Specialty 33%33%None
ADCIRCA TABLETS 20MG 60 BOT   5 Tier 5 - Specialty 33%33%P
ADVAIR DISKU MIS 100/50   3 Tier 3 - Preferred Brand $38.00$99.00None
ADVAIR DISKU MIS 250/50   3 Tier 3 - Preferred Brand $38.00$99.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADVAIR DISKU MIS 500/50   3 Tier 3 - Preferred Brand $38.00$99.00None
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL   3 Tier 3 - Preferred Brand $38.00$99.00None
ADVAIR HFA INHALER 230;21MCG;MCG   3 Tier 3 - Preferred Brand $38.00$99.00None
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL   3 Tier 3 - Preferred Brand $38.00$99.00None
ADVICOR ER 20-750MG TABLET (90 CT)   4 Tier 4 - Non-Preferred Brand $80.00$225.00Q:2
/1Days
ADVICOR EXTENDED RELEASE TABLETS 20;1000MG;MG 90 BOTPL   4 Tier 4 - Non-Preferred Brand $80.00$225.00Q:2
/1Days
ADVICOR EXTENDED RELEASE TABLETS 20;500MG;MG 90 BOTPL   4 Tier 4 - Non-Preferred Brand $80.00$225.00Q:2
/1Days
ADVICOR EXTENDED RELEASE TABLETS 40;1000MG;MG 90 BOTPL   4 Tier 4 - Non-Preferred Brand $80.00$225.00Q:2
/1Days
AEROBID-M AEROSOL W/ADAPTER   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
AFEDITAB CR 30MG TABLET SA   1 Tier 1 - Preferred Generic $5.00$15.00Q:1
/1Days
AFEDITAB CR 60MG TABLET SA   1 Tier 1 - Preferred Generic $5.00$15.00Q:2
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AGGRENOX 25-200MG CAPSULE   3 Tier 3 - Preferred Brand $38.00$99.00None
AK-CON 0.1% EYE DROPS   1 Tier 1 - Preferred Generic $5.00$15.00None
AK-POLY-BAC EYE OINTMENT 500UNT/1000UNT   1 Tier 1 - Preferred Generic $5.00$15.00None
AKNE-MYCIN 2% OINTMENT   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
AKTOB 0.3% EYE DROPS   1 Tier 1 - Preferred Generic $5.00$15.00None
ALA-CORT 1% CREAM   1 Tier 1 - Preferred Generic $5.00$15.00None
ALA-CORT 1% LOTION   1 Tier 1 - Preferred Generic $5.00$15.00None
ALA-SCALP HP 2% LOTION   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
ALAMAST 0.1% DROPS   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
ALBENZA 200MG TABLET   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
ALBUTEROL SULFATE 0.63MG/3ML VIAL NEBULIZER   1 Tier 1 - Preferred Generic $5.00$15.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER   1 Tier 1 - Preferred Generic $5.00$15.00P
ALBUTEROL SULFATE 2.5MG/3ML VIAL NEBULIZER   1 Tier 1 - Preferred Generic $5.00$15.00P
ALBUTEROL SULFATE 4MG TABLET SR 12HR   2 Tier 2 - Non-Preferred Generic $32.00$81.00None
ALBUTEROL SULFATE 8MG TABLET SR 12HR   2 Tier 2 - Non-Preferred Generic $32.00$81.00None
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   1 Tier 1 - Preferred Generic $5.00$15.00P
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT   1 Tier 1 - Preferred Generic $5.00$15.00None
ALBUTEROL SULFATE TABLET 2MG (500 CT)   1 Tier 1 - Preferred Generic $5.00$15.00None
ALBUTEROL TABLET 4MG (500 CT)   1 Tier 1 - Preferred Generic $5.00$15.00None
ALCLOMETASONE DIPROPIONATE 0.05% CREAM   1 Tier 1 - Preferred Generic $5.00$15.00None
ALCLOMETASONE DIPROPIONATE 0.05% OINTMENT   1 Tier 1 - Preferred Generic $5.00$15.00None
ALCOHOL 5%/DEXTROSE 5%   1 Tier 1 - Preferred Generic $5.00$15.00None
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 Tier 3 - Preferred Brand $38.00$99.00None
ALDURAZYME 2.9MG/5ML VIAL   5 Tier 5 - Specialty 33%33%None
ALENDRONATE SODIUM 10MG TABLET   1 Tier 1 - Preferred Generic $5.00$15.00None
ALENDRONATE SODIUM 40MG TABLET   1 Tier 1 - Preferred Generic $5.00$15.00None
ALENDRONATE SODIUM 5MG TABLET   1 Tier 1 - Preferred Generic $5.00$15.00None
ALENDRONATE SODIUM 70MG TABLET 4 BLPK   1 Tier 1 - Preferred Generic $5.00$15.00Q:4
/28Days
ALENDRONATE SODIUM TABLET 35MG 20 CRTN   1 Tier 1 - Preferred Generic $5.00$15.00Q:4
/28Days
ALIMTA 500MG VIAL   5 Tier 5 - Specialty 33%33%None
ALINIA 100MG/5ML SUSPENSION   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
ALINIA 500MG TABLET   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
ALKERAN FOR INJECTION 50MG/VIAL 1 VIALSU   5 Tier 5 - Specialty 33%33%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALLOPURINOL SODIUM 500MG VIAL   5 Tier 5 - Specialty 33%33%None
ALLOPURINOL TABLET 300MG (1000 CT)   1 Tier 1 - Preferred Generic $5.00$15.00None
ALLOPURINOL TABLET USP 100MG (1000 CT)   1 Tier 1 - Preferred Generic $5.00$15.00None
ALOCRIL 2% EYE DROPS   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
ALOMIDE 0.1% EYE DROPS   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
ALORA 0.025MG PATCH   4 Tier 4 - Non-Preferred Brand $80.00$225.00Q:8
/28Days
ALORA 0.05MG PATCH   4 Tier 4 - Non-Preferred Brand $80.00$225.00Q:8
/28Days
ALORA 0.075MG PATCH   4 Tier 4 - Non-Preferred Brand $80.00$225.00Q:8
/28Days
ALORA 0.1MG PATCH   4 Tier 4 - Non-Preferred Brand $80.00$225.00Q:8
/28Days
ALPHAGAN P 0.1% DROPS   3 Tier 3 - Preferred Brand $38.00$99.00None
ALPHAGAN P 0.15% EYE DROPS   3 Tier 3 - Preferred Brand $38.00$99.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALREX 0.2% EYE DROPS   4 Tier 4 - Non-Preferred Brand $80.00$225.00S
ALTABAX 1% OINTMENT   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
ALTOPREV 20MG TABLET SR 24HR   4 Tier 4 - Non-Preferred Brand $80.00$225.00S Q:1
/1Days
ALTOPREV 40MG TABLET SR 24HR   4 Tier 4 - Non-Preferred Brand $80.00$225.00S Q:1
/1Days
ALTOPREV 60MG TABLET SR 24HR   4 Tier 4 - Non-Preferred Brand $80.00$225.00S Q:1
/1Days
ALVESCO 160MCG/ACT AERS   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
ALVESCO 80MCG/ACT AERS   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
AMANTADINE 100MG CAPSULE   1 Tier 1 - Preferred Generic $5.00$15.00None
AMANTADINE 100MG TABLET   1 Tier 1 - Preferred Generic $5.00$15.00None
AMCINONIDE 0.1% CREAM   1 Tier 1 - Preferred Generic $5.00$15.00None
AMCINONIDE 0.1% LOTION   1 Tier 1 - Preferred Generic $5.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMCINONIDE 0.1% OINTMENT 60GM TUBE   1 Tier 1 - Preferred Generic $5.00$15.00None
AMERGE 1MG TABLET   3 Tier 3 - Preferred Brand $38.00$99.00Q:9
/30Days
AMERGE 2.5MG TABLET   3 Tier 3 - Preferred Brand $38.00$99.00Q:9
/30Days
AMEVIVE ADMISTRATION PACK FOR INTRAMUSCULAR ADMINISTRATION KIT 15MG 1 X 4 PKGCOM   5 Tier 5 - Specialty 33%33%None
AMIFOSTINE FOR INJECTION 500MG/VIAL   5 Tier 5 - Specialty 33%33%None
AMIKACIN 250MG/ML VIAL   2 Tier 2 - Non-Preferred Generic $32.00$81.00None
AMIKACIN 50MG/ML VIAL   1 Tier 1 - Preferred Generic $5.00$15.00None
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET   1 Tier 1 - Preferred Generic $5.00$15.00None
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT   1 Tier 1 - Preferred Generic $5.00$15.00None
AMINOPHYLLINE 100MG TABLET   1 Tier 1 - Preferred Generic $5.00$15.00None
AMINOPHYLLINE 200MG TABLET (1000 CT)   1 Tier 1 - Preferred Generic $5.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOPHYLLINE INJECTION 250MG 10ML X 25 VIALSD   1 Tier 1 - Preferred Generic $5.00$15.00None
AMINOSYN 10% IV SOLUTION   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
AMINOSYN 3.5% IV SOLUTION   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
AMINOSYN 5% IV SOLUTION   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
AMINOSYN 7% IV SOLUTION   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
AMINOSYN 7%-ELECTROLYTE SOL   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
AMINOSYN 8.5% IV SOLUTION   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
AMINOSYN II 10% IV SOLUTION   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
AMINOSYN II 15% IV SOLUTION   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
AMINOSYN II 3.5% IN D25W IV   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
AMINOSYN II 3.5% M/D5W IV   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN II 3.5% W/ELEC DEX   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
AMINOSYN II 4.25% IN D10W   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
AMINOSYN II 4.25% IN D20W   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
AMINOSYN II 4.25% W/ELEC DW   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
AMINOSYN II 4.25%-D25W IV   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
AMINOSYN II 5% IN D25W IV   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
AMINOSYN II 7% IV SOLUTION   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
AMINOSYN II 8.5% ELECTROLYT   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
AMINOSYN II 8.5% IV SOLUTION   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
AMINOSYN M 3.5% IV SOLUTION   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
AMINOSYN PF INJECTION   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN-HBC 7% IV SOLUTION   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
AMINOSYN-HF 8% IV SOLUTION   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
AMINOSYN-PF 7% IV SOLUTION   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
AMIODARONE HCL 200MG TABLET (60 CT)   1 Tier 1 - Preferred Generic $5.00$15.00None
AMIODARONE HCL 400MG TABLET   1 Tier 1 - Preferred Generic $5.00$15.00None
AMIODARONE HCL INJECTION   1 Tier 1 - Preferred Generic $5.00$15.00None
AMITIZA 8MCG CAPSULE   4 Tier 4 - Non-Preferred Brand $80.00$225.00P S Q:60
/30Days
AMITIZA CAPSULES 24MCG 60 CAP BOT   4 Tier 4 - Non-Preferred Brand $80.00$225.00S Q:60
/30Days
AMITRIP/CDP 25-10 TABLET   1 Tier 1 - Preferred Generic $5.00$15.00None
AMITRIP/PERPHEN 10-2 TABLET   1 Tier 1 - Preferred Generic $5.00$15.00None
AMITRIP/PERPHEN 10-4 TABLET   1 Tier 1 - Preferred Generic $5.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITRIP/PERPHEN 25-2 TABLET   1 Tier 1 - Preferred Generic $5.00$15.00None
AMITRIP/PERPHEN 25-4 TABLET   1 Tier 1 - Preferred Generic $5.00$15.00None
AMITRIP/PERPHEN 50-4 TABLET   1 Tier 1 - Preferred Generic $5.00$15.00None
AMITRIPTYLINE HCL 100MG TABLET   1 Tier 1 - Preferred Generic $5.00$15.00None
AMITRIPTYLINE HCL 10MG TABLET   1 Tier 1 - Preferred Generic $5.00$15.00None
AMITRIPTYLINE HCL 150MG TABLET (100 CT)   1 Tier 1 - Preferred Generic $5.00$15.00None
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)   1 Tier 1 - Preferred Generic $5.00$15.00None
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)   1 Tier 1 - Preferred Generic $5.00$15.00None
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT   1 Tier 1 - Preferred Generic $5.00$15.00None
AMLODIPINE BESYLATE 10MG TABLET (90 CT)   1 Tier 1 - Preferred Generic $5.00$15.00S
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)   1 Tier 1 - Preferred Generic $5.00$15.00S Q:1
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE BESYLATE 5MG TABLET (90 CT)   1 Tier 1 - Preferred Generic $5.00$15.00S Q:1
/1Days
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE   2 Tier 2 - Non-Preferred Generic $32.00$81.00None
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE   2 Tier 2 - Non-Preferred Generic $32.00$81.00None
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE   2 Tier 2 - Non-Preferred Generic $32.00$81.00None
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE   2 Tier 2 - Non-Preferred Generic $32.00$81.00None
AMMONIUM CHLORIDE 5 MEQ/ML   1 Tier 1 - Preferred Generic $5.00$15.00None
AMMONIUM LACTATE 12% CREAM   1 Tier 1 - Preferred Generic $5.00$15.00None
AMMONIUM LACTATE 12% LOTION   1 Tier 1 - Preferred Generic $5.00$15.00None
AMNESTEEM 10MG CAPSULE   2 Tier 2 - Non-Preferred Generic $32.00$81.00P
AMNESTEEM 20MG CAPSULE   2 Tier 2 - Non-Preferred Generic $32.00$81.00P
AMNESTEEM 40MG CAPSULE   2 Tier 2 - Non-Preferred Generic $32.00$81.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOCLAN 200-28.5/5 SUSPENSION RECONSTITUTED ORAL   1 Tier 1 - Preferred Generic $5.00$15.00None
AMOCLAN 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   1 Tier 1 - Preferred Generic $5.00$15.00None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL   1 Tier 1 - Preferred Generic $5.00$15.00None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE   1 Tier 1 - Preferred Generic $5.00$15.00None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET   1 Tier 1 - Preferred Generic $5.00$15.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE   1 Tier 1 - Preferred Generic $5.00$15.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   1 Tier 1 - Preferred Generic $5.00$15.00None
AMOX TR-POTASSIUM CLAVULANATE 500-125MG TABLET   1 Tier 1 - Preferred Generic $5.00$15.00None
AMOXAPINE 100MG TABLET   1 Tier 1 - Preferred Generic $5.00$15.00None
AMOXAPINE 150MG TABLET   1 Tier 1 - Preferred Generic $5.00$15.00None
AMOXAPINE 25MG TABLET   1 Tier 1 - Preferred Generic $5.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXAPINE 50MG TABLET   1 Tier 1 - Preferred Generic $5.00$15.00None
AMOXICILLIN 125MG TABLET CHEW   1 Tier 1 - Preferred Generic $5.00$15.00None
AMOXICILLIN 200MG TABLET CHEW   1 Tier 1 - Preferred Generic $5.00$15.00None
AMOXICILLIN 250MG CAPSULE   1 Tier 1 - Preferred Generic $5.00$15.00None
AMOXICILLIN 400MG TABLET CHEW   1 Tier 1 - Preferred Generic $5.00$15.00None
AMOXICILLIN 500MG CAPSULE   1 Tier 1 - Preferred Generic $5.00$15.00None
AMOXICILLIN 500MG TABLET (100 CT)   1 Tier 1 - Preferred Generic $5.00$15.00None
AMOXICILLIN 875MG TABLET   1 Tier 1 - Preferred Generic $5.00$15.00None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT   1 Tier 1 - Preferred Generic $5.00$15.00None
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT   1 Tier 1 - Preferred Generic $5.00$15.00None
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT   1 Tier 1 - Preferred Generic $5.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL   1 Tier 1 - Preferred Generic $5.00$15.00None
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   1 Tier 1 - Preferred Generic $5.00$15.00None
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL   1 Tier 1 - Preferred Generic $5.00$15.00None
AMOXICILLIN TABLET USP CHEWABLE 250MG (250 CT)   1 Tier 1 - Preferred Generic $5.00$15.00None
AMOXIL 250MG/5ML SUSPENSION   1 Tier 1 - Preferred Generic $5.00$15.00None
AMOXIL CAPSULES 500MG   1 Tier 1 - Preferred Generic $5.00$15.00None
AMPHET ASP/ AMPHET/ D-AMPHET 5MG TABLET   1 Tier 1 - Preferred Generic $5.00$15.00P Q:2
/1Days
AMPHETAMINE SALT COMBO 12.5MG TABLET   1 Tier 1 - Preferred Generic $5.00$15.00P Q:2
/1Days
AMPHETAMINE SALT COMBO 15MG TABLET   1 Tier 1 - Preferred Generic $5.00$15.00P Q:2
/1Days
AMPHETAMINE SALT COMBO 30MG TABLET   1 Tier 1 - Preferred Generic $5.00$15.00P Q:2
/1Days
AMPHETAMINE SALT COMBO 7.5MG TABLET   1 Tier 1 - Preferred Generic $5.00$15.00P Q:2
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPHETAMINE SALTS 20MG TABLET   1 Tier 1 - Preferred Generic $5.00$15.00P Q:3
/1Days
AMPHOTERICIN B FOR INJECTION 50 MG   2 Tier 2 - Non-Preferred Generic $32.00$81.00None
AMPICILLIN AND SULBACTAM FOR INJECTION 10-5 1 VIAL   2 Tier 2 - Non-Preferred Generic $32.00$81.00None
AMPICILLIN AND SULBACTAM FOR INJECTION 2-1 10 VIAL   2 Tier 2 - Non-Preferred Generic $32.00$81.00None
AMPICILLIN CAPSULES 250MG 100 BOT   1 Tier 1 - Preferred Generic $5.00$15.00None
AMPICILLIN CAPSULES 500MG 100 BOT   1 Tier 1 - Preferred Generic $5.00$15.00None
AMPICILLIN FOR INJECTION POWDER   2 Tier 2 - Non-Preferred Generic $32.00$81.00None
AMPICILLIN FOR INJECTION USP 125MG/ML 1 VIAL   2 Tier 2 - Non-Preferred Generic $32.00$81.00None
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT   1 Tier 1 - Preferred Generic $5.00$15.00None
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT   1 Tier 1 - Preferred Generic $5.00$15.00None
AMPICILLIN POWDER FOR INJECTION 1 GM/ML   2 Tier 2 - Non-Preferred Generic $32.00$81.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANADROL-50 50MG TABLET (100 CT)   5 Tier 5 - Specialty 33%33%P
ANAGRELIDE HCL 0.5MG CAPSULE   2 Tier 2 - Non-Preferred Generic $32.00$81.00None
ANAGRELIDE HCL 1MG CAPSULE   2 Tier 2 - Non-Preferred Generic $32.00$81.00None
ANCOBON 250MG CAPSULE   5 Tier 5 - Specialty 33%33%None
ANCOBON 500MG CAPSULE   5 Tier 5 - Specialty 33%33%None
ANDRODERM 2.5MG/24HR PATCH   3 Tier 3 - Preferred Brand $38.00$99.00None
ANDRODERM 5MG/24HR PATCH   3 Tier 3 - Preferred Brand $38.00$99.00None
ANDROGEL 1%(50MG) GEL PACKET   3 Tier 3 - Preferred Brand $38.00$99.00None
ANDROID 10MG CAPSULE   4 Tier 4 - Non-Preferred Brand $80.00$225.00P
ANESTACON 15ML   1 Tier 1 - Preferred Generic $5.00$15.00None
ANTABUSE 250MG TABLET   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANTABUSE 500MG TABLET   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
ANTARA 130MG CAPSULE   4 Tier 4 - Non-Preferred Brand $80.00$225.00S
ANTARA 43MG CAPSULE   4 Tier 4 - Non-Preferred Brand $80.00$225.00S
ANTIVERT 12.5MG TABLET   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
ANTIVERT 25MG TABLET   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
ANTIVERT 50MG TABLET   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
ANZEMET 100MG TABLET   4 Tier 4 - Non-Preferred Brand $80.00$225.00P S Q:5
/30Days
ANZEMET 50MG TABLET   4 Tier 4 - Non-Preferred Brand $80.00$225.00P S Q:5
/30Days
APAP-CAFFEINE-DIHYDROCODE TAB 30 EA   2 Tier 2 - Non-Preferred Generic $32.00$81.00Q:5
/1Days
APHTHASOL 5% PASTE   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
APIDRA 100UNITS/ML VIAL   3 Tier 3 - Preferred Brand $38.00$99.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
APOKYN FOR INJECTION 30MG 5 CTG   5 Tier 5 - Specialty 33%33%P
APRI 0.15-0.03 TABLET   1 Tier 1 - Preferred Generic $5.00$15.00None
APTIVUS 250MG CAPSULE   5 Tier 5 - Specialty 33%33%None
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT   5 Tier 5 - Specialty 33%33%None
ARALAST 500MG VIAL   5 Tier 5 - Specialty 33%33%None
ARANELLE 7-9-5 TABLET   1 Tier 1 - Preferred Generic $5.00$15.00None
ARANESP 100MCG/ML VIAL   5 Tier 5 - Specialty 33%33%P
ARANESP 200MCG/0.4ML SYRINGE   5 Tier 5 - Specialty 33%33%P
ARANESP 200MCG/ML VIAL   5 Tier 5 - Specialty 33%33%P
ARANESP 25MCG/ML VIAL   3 Tier 3 - Preferred Brand $38.00$99.00P
ARANESP 300MCG/ML VIAL   5 Tier 5 - Specialty 33%33%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP 500MCG/1ML SYRINGE   5 Tier 5 - Specialty 33%33%P
ARANESP 60MCG/ML VIAL   5 Tier 5 - Specialty 33%33%P
ARANESP PREFILLED SYRINGE SINGLE USE 100MCG/0.5ML 1 SYR   5 Tier 5 - Specialty 33%33%P
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR   5 Tier 5 - Specialty 33%33%P
ARANESP PREFILLED SYRINGE SINGLE USE 25MCG/0.42ML SYR   3 Tier 3 - Preferred Brand $38.00$99.00P
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR   5 Tier 5 - Specialty 33%33%P
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR   3 Tier 3 - Preferred Brand $38.00$99.00P
ARANESP PREFILLED SYRINGE SINGLE USE 60MCG/0.3ML 60MCG/ 0.3ML SYR   5 Tier 5 - Specialty 33%33%P
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD   3 Tier 3 - Preferred Brand $38.00$99.00P
ARCALYST INJECTION 220MG/VIAL   5 Tier 5 - Specialty 33%33%None
ARICEPT 10MG TABLET   3 Tier 3 - Preferred Brand $38.00$99.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARICEPT 5MG TABLET   3 Tier 3 - Preferred Brand $38.00$99.00None
ARICEPT ODT 10MG TABLET   3 Tier 3 - Preferred Brand $38.00$99.00None
ARICEPT ODT 5MG TABLET   3 Tier 3 - Preferred Brand $38.00$99.00None
ARIMIDEX 1MG TABLET   3 Tier 3 - Preferred Brand $38.00$99.00None
ARIXTRA 10MG SYRINGE   5 Tier 5 - Specialty 33%33%None
ARIXTRA 2.5MG SYRINGE   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
ARIXTRA 5MG SYRINGE   5 Tier 5 - Specialty 33%33%None
ARIXTRA 7.5MG SYRINGE   5 Tier 5 - Specialty 33%33%None
AROMASIN 25MG TABLET   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
ARRANON 250MG VIAL   5 Tier 5 - Specialty 33%33%None
ARTHROTEC 50 50MG TABLET -200MCG (60 CT)   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARTHROTEC 75 TABLET EC   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
ASACOL 400MG TABLET EC   4 Tier 4 - Non-Preferred Brand $80.00$225.00S Q:12
/1Days
ASACOL HD DELAYED RELEASE TABLETS 800MG 180 BOT   4 Tier 4 - Non-Preferred Brand $80.00$225.00S Q:6
/1Days
ASCOMP W/CODEINE 30-50-325 CAPSULE   2 Tier 2 - Non-Preferred Generic $32.00$81.00Q:6
/1Days
ASMANEX 220MCG(14) AEROSOL POWDER BREATH ACTIVATED   3 Tier 3 - Preferred Brand $38.00$99.00None
ASMANEX TWISTHALER 220MCG #120   3 Tier 3 - Preferred Brand $38.00$99.00None
ASMANEX TWISTHALER 220MCG #30   3 Tier 3 - Preferred Brand $38.00$99.00None
ASMANEX TWISTHALER 220MCG #60   3 Tier 3 - Preferred Brand $38.00$99.00None
ASTELIN 137MCG AEROSOL SPRAY W/PUMP   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
ASTEPRO NASAL SPRAY 137 MCG/SPRY   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
ASTRAMORPH-PF 0.5MG/ML VIAL   1 Tier 1 - Preferred Generic $5.00$15.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ASTRAMORPH-PF 1MG/ML VIAL   1 Tier 1 - Preferred Generic $5.00$15.00P
ATACAND 16MG TABLET   4 Tier 4 - Non-Preferred Brand $80.00$225.00S Q:2
/1Days
ATACAND 32MG TABLET   4 Tier 4 - Non-Preferred Brand $80.00$225.00S
ATACAND 4MG TABLET   4 Tier 4 - Non-Preferred Brand $80.00$225.00S Q:2
/1Days
ATACAND 8MG TABLET   4 Tier 4 - Non-Preferred Brand $80.00$225.00S Q:2
/1Days
ATACAND HCT 16/12.5MG TABLET   4 Tier 4 - Non-Preferred Brand $80.00$225.00S Q:2
/1Days
ATACAND HCT 32/12.5MG TABLET   4 Tier 4 - Non-Preferred Brand $80.00$225.00S
ATACAND HCT TABLETS 32;25MG;MG 90 TABLETS BOT   4 Tier 4 - Non-Preferred Brand $80.00$225.00S
ATAMET   1 Tier 1 - Preferred Generic $5.00$15.00None
ATENOLOL 25MG TABLET (100 CT)   1 Tier 1 - Preferred Generic $5.00$15.00None
ATENOLOL TABLET USP 50MG (100 CT)   1 Tier 1 - Preferred Generic $5.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATENOLOL TABLETS USP 100MG 1 BLPK   1 Tier 1 - Preferred Generic $5.00$15.00None
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT)   1 Tier 1 - Preferred Generic $5.00$15.00None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   1 Tier 1 - Preferred Generic $5.00$15.00None
ATGAM 50MG/ML AMPUL   5 Tier 5 - Specialty 33%33%P
ATRIPLA TABLET 600MG/200MG   5 Tier 5 - Specialty 33%33%None
ATROPINE 0.05MG/ML SYRINGE   1 Tier 1 - Preferred Generic $5.00$15.00P
ATROPINE 0.1MG/ML SYRINGE   1 Tier 1 - Preferred Generic $5.00$15.00P
ATROVENT HFA AER 17MCG   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
ATTENUVAX VACCINE W/DILUENT 1 DOSE/0.5ML   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
AUGMENTIN XR 1000-62.5 TABLET   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
AVANDAMET 2MG/1000MG TABLET   3 Tier 3 - Preferred Brand $38.00$99.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVANDAMET 2MG/500MG TABLET   3 Tier 3 - Preferred Brand $38.00$99.00None
AVANDAMET 4MG/500MG TABLET   3 Tier 3 - Preferred Brand $38.00$99.00None
AVANDAMET TABLET 4-1000MG   3 Tier 3 - Preferred Brand $38.00$99.00None
AVANDARYL 4MG/1MG TABLET   3 Tier 3 - Preferred Brand $38.00$99.00None
AVANDARYL 4MG/2MG TABLET   3 Tier 3 - Preferred Brand $38.00$99.00None
AVANDARYL 4MG/4MG TABLET   3 Tier 3 - Preferred Brand $38.00$99.00None
AVANDARYL 8MG-2MG TABLET   3 Tier 3 - Preferred Brand $38.00$99.00None
AVANDARYL 8MG-4MG TABLET   3 Tier 3 - Preferred Brand $38.00$99.00None
AVANDIA 2MG TABLET   3 Tier 3 - Preferred Brand $38.00$99.00None
AVANDIA 4MG TABLET (90 CT)   3 Tier 3 - Preferred Brand $38.00$99.00None
AVANDIA 8MG TABLET (90 CT)   3 Tier 3 - Preferred Brand $38.00$99.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVASTIN 100MG/4ML VIAL   5 Tier 5 - Specialty 33%33%None
AVELOX 400MG TABLET   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
AVELOX ABC PACK 400MG TABLET   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
AVELOX IV 400MG/250ML   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
AVIANE 0.1-0.02 TABLET   1 Tier 1 - Preferred Generic $5.00$15.00None
AVITA 0.025% CREAM   1 Tier 1 - Preferred Generic $5.00$15.00None
AVODART 0.5MG SOFTGEL   3 Tier 3 - Preferred Brand $38.00$99.00P
AVONEX ADMIN PACK 30MCG SYR   5 Tier 5 - Specialty 33%33%P
AVONEX ADMIN PACK 30MCG VL   5 Tier 5 - Specialty 33%33%P
AXID 15MG/ML ORAL SOLUTION   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
AZACTAM 2GM VIAL   3 Tier 3 - Preferred Brand $38.00$99.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZACTAM INJECTION 1GM 50ML BAG   3 Tier 3 - Preferred Brand $38.00$99.00None
AZACTAM/ISO-OSMOT 2GM/50ML   3 Tier 3 - Preferred Brand $38.00$99.00None
AZASAN 100MG TABLET   4 Tier 4 - Non-Preferred Brand $80.00$225.00P
AZASAN 75MG TABLET   4 Tier 4 - Non-Preferred Brand $80.00$225.00P
AZASITE 1% DROPS   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
AZATHIOPRINE 50MG TABLET   1 Tier 1 - Preferred Generic $5.00$15.00P
AZATHIOPRINE SOD 100MG VIAL   5 Tier 5 - Specialty 33%33%P
AZELEX 20% CREAM 30GM TUBE   4 Tier 4 - Non-Preferred Brand $80.00$225.00None
AZILECT 0.5MG TABLET   3 Tier 3 - Preferred Brand $38.00$99.00None
AZILECT 1MG TABLET   3 Tier 3 - Preferred Brand $38.00$99.00None
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Tier 1 - Preferred Generic $5.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Tier 1 - Preferred Generic $5.00$15.00None
AZITHROMYCIN 250MG TABLET (30 CT)   1 Tier 1 - Preferred Generic $5.00$15.00None
AZITHROMYCIN 500MG TABLET (30 CT)   1 Tier 1 - Preferred Generic $5.00$15.00None
AZITHROMYCIN FOR INJECTION 500MG 10 VIALSD   2 Tier 2 - Non-Preferred Generic $32.00$81.00None
AZITHROMYCIN TABLET 600MG (30 CT)   1 Tier 1 - Preferred Generic $5.00$15.00None
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT   4 Tier 4 - Non-Preferred Brand $80.00$225.00S

Chart Legend:

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