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First Health Part D-Premier (PDP) (S5768-122-0)
Tier 1 (1436)
Tier 2 (376)
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Tier 4 (260)

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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
First Health Part D-Premier (PDP) (S5768-122-0)
Benefit Details  
The First Health Part D-Premier (PDP) (S5768-122-0)
Formulary Drugs Starting with the Letter C
in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY
Drugs Starting with Letter C

Drug Name		 Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order
CABERGOLINE 0.5MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CADUET 10MG/10MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 46%46%S Q:30
/30Days
CADUET 10MG/20MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 46%46%S Q:30
/30Days
CADUET 10MG/40MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 46%46%S Q:30
/30Days
CADUET 10MG/80MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 46%46%S Q:30
/30Days
CADUET 2.5MG/10MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 46%46%S Q:30
/30Days
CADUET 2.5MG/20MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 46%46%S Q:30
/30Days
CADUET 2.5MG/40MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 46%46%S Q:30
/30Days
CADUET 5MG/10MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 46%46%S Q:30
/30Days
CADUET 5MG/20MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 46%46%S Q:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CADUET 5MG/40MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 46%46%S Q:30
/30Days
CADUET 5MG/80MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 46%46%S Q:30
/30Days
CALCIPOTRIENE TOPICAL SOLUTION   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CALCITRIOL 0.25MCG CAPSULE   1 Preferred Generic $7.00$21.00None
CALCITRIOL 0.5MCG CAPSULE   1 Preferred Generic $7.00$21.00None
CALCITRIOL 1MCG/ML SOLUTION ORAL   1 Preferred Generic $7.00$21.00None
CALCITRIOL 2 MCG/ML VIAL   1 Preferred Generic $7.00$21.00None
CALCITRIOL INJECTION SOLUTION 1MCG 50 X 01ML AMP   1 Preferred Generic $7.00$21.00None
CALCIUM ACETATE CAPSULE 667 MG   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CAMPATH 30MG/ML VIAL   4 Specialty - Generic and Brand 29%N/AP
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CAMPRAL 333MG DOSE PAK   3 Non-Preferred Generic/Non-Preferred Brand 46%46%Q:180
/30Days
CANASA RECTAL SUPPOSITORIES 1000MG 30 BOX   2 Preferred Brand 11%11%None
CANCIDAS IV 50MG VIAL   4 Specialty - Generic and Brand 29%N/AP
CANCIDAS IV 70MG VIAL   4 Specialty - Generic and Brand 29%N/AP
CANTIL 25MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CAPASTAT SULFATE 1GM VIAL   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CAPEX SHA 0.01%   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CAPITAL W/CODEINE ORAL SUSP   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CAPTOPRIL 100MG TABLET   1 Preferred Generic $7.00$21.00None
CAPTOPRIL 12.5MG TABLET   1 Preferred Generic $7.00$21.00None
CAPTOPRIL 25MG TABLET   1 Preferred Generic $7.00$21.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CAPTOPRIL 50MG TABLET   1 Preferred Generic $7.00$21.00None
CAPTOPRIL/HCTZ 25/15 TABLET   1 Preferred Generic $7.00$21.00None
CAPTOPRIL/HCTZ 25/25 TABLET   1 Preferred Generic $7.00$21.00None
CAPTOPRIL/HCTZ 50/15 TABLET   1 Preferred Generic $7.00$21.00None
CAPTOPRIL/HCTZ 50/25 TABLET   1 Preferred Generic $7.00$21.00None
CARAC CRE 0.5%   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CARBAMAZEPINE 100MG/5ML SUSPENSION ORAL   1 Preferred Generic $7.00$21.00None
CARBAMAZEPINE EXTENDED RELEASE TABLETS 200MG   1 Preferred Generic $7.00$21.00None
CARBAMAZEPINE EXTENDED RELEASE TABLETS 400MG   1 Preferred Generic $7.00$21.00None
CARBAMAZEPINE TABLET CHEWABLE 100MG (100 CT)   1 Preferred Generic $7.00$21.00None
CARBAMAZEPINE TABLET USP 200MG (1000 CT)   1 Preferred Generic $7.00$21.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CARBATROL 100MG CAPSULE SA   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CARBATROL 200MG CAPSULE SA   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CARBATROL 300MG CAPSULE SA   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CARBIDOPA AND LEVEDOPA ORALLY DISINTEGRATING TABLETS 10;100MG;MG 100 BOT   1 Preferred Generic $7.00$21.00None
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;100MG;MG 100 BOT   1 Preferred Generic $7.00$21.00None
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;250MG;MG 100 BOT   1 Preferred Generic $7.00$21.00None
CARBIDOPA-LEVODOPA 25MG-100MG TABLET SA   1 Preferred Generic $7.00$21.00None
CARBIDOPA-LEVODOPA 50MG-200MG TABLET SA   1 Preferred Generic $7.00$21.00None
CARBIDOPA/LEVO 10/100 TABLET   1 Preferred Generic $7.00$21.00None
CARBIDOPA/LEVO 25/100 TABLET   1 Preferred Generic $7.00$21.00None
CARBIDOPA/LEVO 25/250 TABLET   1 Preferred Generic $7.00$21.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CARBINOXAMINE MALEATE SOLUTION 4MG/5ML 16 OZ BOT   1 Preferred Generic $7.00$21.00None
CARBINOXAMINE MALEATE TABLETS 4MG 100 BOT   1 Preferred Generic $7.00$21.00None
CARDIZEM LA EXTENDED RELEASE TABLETS 120MG 90 BOT   3 Non-Preferred Generic/Non-Preferred Brand 46%46%Q:30
/30Days
CARDIZEM LA EXTENDED RELEASE TABLETS 180MG 90 BOT   3 Non-Preferred Generic/Non-Preferred Brand 46%46%Q:30
/30Days
CARDIZEM LA EXTENDED RELEASE TABLETS 240MG 90 BOT   3 Non-Preferred Generic/Non-Preferred Brand 46%46%Q:60
/30Days
CARDIZEM LA EXTENDED RELEASE TABLETS 300MG 90 BOT   3 Non-Preferred Generic/Non-Preferred Brand 46%46%Q:30
/30Days
CARDIZEM LA EXTENDED RELEASE TABLETS 360MG 30 BOT   3 Non-Preferred Generic/Non-Preferred Brand 46%46%Q:30
/30Days
CARDIZEM LA EXTENDED RELEASE TABLETS 420MG 30 BOT   3 Non-Preferred Generic/Non-Preferred Brand 46%46%Q:30
/30Days
CARISOPRODOL AND ASPIRIN TABLETS USP 325;200MG;MG 100 BOTPL   1 Preferred Generic $7.00$21.00None
CARISOPRODOL ASPIRIN AND CODEINE PHOSPHATE TABLETS USP 325;200;16MG;MG;MG 100 BOTPL   1 Preferred Generic $7.00$21.00None
CARISOPRODOL TABLET USP 350MG (100 CT)   1 Preferred Generic $7.00$21.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CARTEOLOL HCL OPHTHALMIC SOLUTION USP 1% 15ML BOT   1 Preferred Generic $7.00$21.00None
CARTIA XT 120MG CAPSULE SA   1 Preferred Generic $7.00$21.00None
CARTIA XT 180MG CAPSULE SA   1 Preferred Generic $7.00$21.00None
CARTIA XT 240MG CAPSULE SA   1 Preferred Generic $7.00$21.00None
CARTIA XT 300MG CAPSULE SR 24 HR   1 Preferred Generic $7.00$21.00None
CARVEDILOL 12.5MG TABLET (100 CT)   1 Preferred Generic $7.00$21.00None
CARVEDILOL 25MG TABLET (500 CT)   1 Preferred Generic $7.00$21.00None
CARVEDILOL 3.125MG TABLET (100 CT)   1 Preferred Generic $7.00$21.00None
CARVEDILOL 6.25MG TABLET (500 CT)   1 Preferred Generic $7.00$21.00None
CATAPRES-TTS DIS 0.3/24HR   3 Non-Preferred Generic/Non-Preferred Brand 46%46%S Q:5
/30Days
CATAPRES-TTS-1 PATCH 2.52.5MG/UNT 1 X 4 CRTN   3 Non-Preferred Generic/Non-Preferred Brand 46%46%S Q:5
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CATAPRES-TTS-2 PATCH 52.5MG/UNT 1 X 4 CRTN   3 Non-Preferred Generic/Non-Preferred Brand 46%46%S Q:5
/30Days
CEDAX 400MG CAPSULE   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CEDAX 90MG/5ML SUSPENSION RECONSTITUTED ORAL   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CEENU 100MG CAPSULE   2 Preferred Brand 11%11%None
CEENU 10MG CAPSULE   2 Preferred Brand 11%11%None
CEENU 40MG CAPSULE   2 Preferred Brand 11%11%None
CEFACLOR 250MG/5ML ORAL SUSP   1 Preferred Generic $7.00$21.00None
CEFACLOR 375MG/5ML ORAL SUSP   1 Preferred Generic $7.00$21.00None
CEFACLOR CAPSULES USP 250MG (100 CT)   1 Preferred Generic $7.00$21.00None
CEFACLOR CAPSULES USP 500MG (100 CT)   1 Preferred Generic $7.00$21.00None
CEFACLOR ER 500MG TABLET SR 12HR   1 Preferred Generic $7.00$21.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CEFACLOR POWDER FOR ORAL SUSPENSION USP 125MG 75ML BOT   1 Preferred Generic $7.00$21.00None
CEFADROXIL 1G TABLET   1 Preferred Generic $7.00$21.00None
CEFADROXIL 500MG CAPSULE   1 Preferred Generic $7.00$21.00None
CEFADROXIL 500MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Preferred Generic $7.00$21.00None
CEFADROXIL FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   1 Preferred Generic $7.00$21.00None
CEFAZOLIN 20GM BULK VIAL   1 Preferred Generic $7.00$21.00None
CEFAZOLIN FOR INJECTION   1 Preferred Generic $7.00$21.00None
CEFAZOLIN FOR INJECTION 1MG 25 VIALGL   1 Preferred Generic $7.00$21.00None
CEFDINIR 250MG/5ML SUSPENSION RECONSTITUTED ORAL   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CEFDINIR CAPSULES 300MG (60 CT)   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CEFDINIR FOR ORAL SUSPENSION 125MG/5ML (100 CT)   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CEFEPIME HCL 2 GRAM VIAL   1 Preferred Generic $7.00$21.00None
CEFEPIME INJ 1GM 20ML APX 10x1G VIAL   1 Preferred Generic $7.00$21.00None
CEFOTAXIME FOR INJECTION   1 Preferred Generic $7.00$21.00None
CEFOTAXIME FOR INJECTION 1GM 50 BOX VIALGL   1 Preferred Generic $7.00$21.00None
CEFOTAXIME FOR INJECTION 2GM 25 VIAL   1 Preferred Generic $7.00$21.00None
CEFOTAXIME FOR INJECTION 500MG 10 VIAL   1 Preferred Generic $7.00$21.00None
CEFOXITIN FOR INJECTION 10GM 10 X 100ML VIAL   1 Preferred Generic $7.00$21.00None
CEFOXITIN FOR INJECTION 1GM 25 X 20ML VIAL   1 Preferred Generic $7.00$21.00None
CEFOXITIN FOR INJECTION 2GM 20ML VIAL   1 Preferred Generic $7.00$21.00None
CEFPODOXIME PROXETIL 200MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CEFPODOXIME PROXETIL FILM COATED TABLET 100MG (20 CT)   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CEFPODOXIME PROXETIL FOR ORAL SUSPENSION 100MG 50ML BOT   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CEFPODOXIME PROXETIL FOR ORAL SUSPENSION 50MG 50ML BOT   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CEFPROZIL 250MG TABLET (100 CT)   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CEFPROZIL 250MG/5ML SUSPENSION RECONSTITUTED ORAL   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CEFPROZIL FOR ORAL SUSPENSION 125MG/5ML 75ML BOT   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CEFPROZIL TABLETS 500MG 100 BOT   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CEFTRIAXONE 10GM VIAL   1 Preferred Generic $7.00$21.00None
CEFTRIAXONE FOR INJECTION 250MG BOX OF 10 VIALGL   1 Preferred Generic $7.00$21.00None
CEFTRIAXONE FOR INJECTION 500MG BOX OF 10 VIALGL   1 Preferred Generic $7.00$21.00None
CEFTRIAXONE FOR INJECTION AND DEXTROSE INJECTION 1 GM/50ML   1 Preferred Generic $7.00$21.00None
CEFTRIAXONE FOR INJECTION AND DEXTROSE INJECTION 2 GM/50ML   1 Preferred Generic $7.00$21.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CEFUROXIME 250MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CEFUROXIME AXETIL 125MG/5ML SUSPENSION RECONSTITUTED ORAL   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CEFUROXIME AXETIL 250MG/5ML SUSPENSION RECONSTITUTED ORAL   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CEFUROXIME AXETIL 500MG TABLET (20 CT)   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CEFUROXIME FOR INJECTION   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CEFUROXIME FOR INJECTION   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CEFUROXIME FOR INJECTION 7.5GM 10 X 7.5 VIALPHR   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CELEBREX 100MG CAPSULE   3 Non-Preferred Generic/Non-Preferred Brand 46%46%S Q:30
/30Days
CELEBREX 200MG CAPSULE   3 Non-Preferred Generic/Non-Preferred Brand 46%46%S Q:60
/30Days
CELEBREX 400MG CAPSULE   3 Non-Preferred Generic/Non-Preferred Brand 46%46%S Q:60
/30Days
CELEBREX 50MG CAPSULE   3 Non-Preferred Generic/Non-Preferred Brand 46%46%S Q:60
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CELESTONE 0.6MG/5ML SYRUP   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CELLCEPT 200MG/ML ORAL SUSP   3 Non-Preferred Generic/Non-Preferred Brand 46%46%P
CELONTIN 300MG KAPSEAL   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CENESTIN 0.3MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 46%46%Q:30
/30Days
CENESTIN 0.45MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 46%46%Q:30
/30Days
CENESTIN 0.625MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 46%46%Q:30
/30Days
CENESTIN 0.9MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 46%46%Q:30
/30Days
CENESTIN 1.25MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 46%46%Q:30
/30Days
CEPHALEXIN 250MG CAPSULE   1 Preferred Generic $7.00$21.00None
CEPHALEXIN 250MG TABLET   1 Preferred Generic $7.00$21.00None
CEPHALEXIN 250MG/5ML ORAL SUSP   1 Preferred Generic $7.00$21.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CEPHALEXIN 500MG TABLET   1 Preferred Generic $7.00$21.00None
CEPHALEXIN CAPSULES 500MG (500 CT)   1 Preferred Generic $7.00$21.00None
CEPHALEXIN POWDER FOR SUSPENSION ORAL USP 125MG 200ML BOT   1 Preferred Generic $7.00$21.00None
CEREDASE 80UNITS/ML VIAL   4 Specialty - Generic and Brand 29%N/AP
CEREZYME INJ 200UNIT   4 Specialty - Generic and Brand 29%N/AP
CHANTIX 1MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 46%46%P Q:60
/30Days
CHANTIX STARTING MONTH PAK   3 Non-Preferred Generic/Non-Preferred Brand 46%46%P Q:53
/30Days
CHLORAMPHEN NA SUCC 1GM VL   1 Preferred Generic $7.00$21.00None
CHLORDIAZEPOXIDE AND AMITRIPTYLINE HCL TABLET 12.5-5MG (500 CT)   1 Preferred Generic $7.00$21.00None
CHLORHEXIDINE GLUCONATE 0.12% MOUTHWASH   1 Preferred Generic $7.00$21.00None
CHLOROQUINE PH 500MG TABLET   1 Preferred Generic $7.00$21.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CHLOROQUINE PHOSPHATE 250MG TABLET (50 CT)   1 Preferred Generic $7.00$21.00None
CHLOROTHIAZIDE 250MG TABLET   1 Preferred Generic $7.00$21.00None
CHLOROTHIAZIDE 500MG TABLET   1 Preferred Generic $7.00$21.00None
CHLORPROMAZINE 100MG TABLET   1 Preferred Generic $7.00$21.00None
CHLORPROMAZINE 10MG TABLET   1 Preferred Generic $7.00$21.00None
CHLORPROMAZINE 25MG TABLET   1 Preferred Generic $7.00$21.00None
CHLORPROMAZINE 25MG/ML AMP   1 Preferred Generic $7.00$21.00None
CHLORPROMAZINE 50MG TABLET   1 Preferred Generic $7.00$21.00None
CHLORPROMAZINE HCL 200MG TABLET   1 Preferred Generic $7.00$21.00None
CHLORPROPAMIDE 100MG TABLET   1 Preferred Generic $7.00$21.00None
CHLORPROPAMIDE 250MG TABLET (1000 CT)   1 Preferred Generic $7.00$21.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CHLORTHALIDONE 25MG TABLET (100 CT)   1 Preferred Generic $7.00$21.00None
CHLORTHALIDONE 50MG TABLET (1000 CT)   1 Preferred Generic $7.00$21.00None
CHLORZOXAZONE 250MG TABLET   1 Preferred Generic $7.00$21.00None
CHLORZOXAZONE 500MG TABLET   1 Preferred Generic $7.00$21.00None
CHOLESTYRAMINE LIGHT ORAL SUSP USP POWDER 4GM 210GM CAN   1 Preferred Generic $7.00$21.00None
CHOLESTYRAMINE POWDER FOR ORAL SUSPENSION USP 4GM 60 X 9GM SINGLE DOSE CRTN   1 Preferred Generic $7.00$21.00None
CHOLESTYRAMINE POWDER FOR ORAL SUSPENSION USP 4GM 378GM CAN   1 Preferred Generic $7.00$21.00None
CHORIONIC GONAD 10000U VIAL   1 Preferred Generic $7.00$21.00None
CICLOPIROX 0.77% CREAM   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CICLOPIROX 0.77% TOPICAL SUSPENSION   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CICLOPIROX 8% TOPICAL SOLUTION NAIL LACQUER 6.6ML BOT   1 Preferred Generic $7.00$21.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CILOSTAZOL 50MG TABLET (60 CT)   1 Preferred Generic $7.00$21.00None
CILOSTAZOL TABLET 100MG (60 CT)   1 Preferred Generic $7.00$21.00None
CILOXAN 0.3% OINTMENT   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CIMETIDINE 150MG/ML VIAL   1 Preferred Generic $7.00$21.00None
CIMETIDINE 200MG TABLET   1 Preferred Generic $7.00$21.00None
CIMETIDINE HCL 300MG/5ML SOL   1 Preferred Generic $7.00$21.00None
CIMETIDINE TABLET USP 300MG (1000 CT)   1 Preferred Generic $7.00$21.00None
CIMETIDINE TABLET USP 400MG (1000 CT)   1 Preferred Generic $7.00$21.00None
CIMETIDINE TABLET USP 800MG (30 CT)   1 Preferred Generic $7.00$21.00None
CIMZIA KIT   4 Specialty - Generic and Brand 29%N/AP Q:3
/28Days
CIPRO (10%) SUS 500MG/5   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CIPRO (5%) SUS 250MG/5   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CIPRO HC OTIC SUSPENSION   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CIPRODEX OTIC SUSPENSION   2 Preferred Brand 11%11%None
CIPROFLOXACIN 10MG/ML VIAL   1 Preferred Generic $7.00$21.00None
CIPROFLOXACIN 250MG TABLET (100 CT)   1 Preferred Generic $7.00$21.00None
CIPROFLOXACIN 500MG TABLET   1 Preferred Generic $7.00$21.00None
CIPROFLOXACIN HCL 0.3% DROPS   1 Preferred Generic $7.00$21.00None
CIPROFLOXACIN HCL 100MG TABLET   1 Preferred Generic $7.00$21.00None
CIPROFLOXACIN TABLETS 750MG 100 BOT   1 Preferred Generic $7.00$21.00None
CISPLATIN INJECTION 1MG   1 Preferred Generic $7.00$21.00None
CITALOPRAM HBR 20MG TABLET (100 CT)   1 Preferred Generic $7.00$21.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CITALOPRAM HBR ORAL SOLUTION 10MG 240ML BOTPL   1 Preferred Generic $7.00$21.00None
CITALOPRAM HYDROBROMIDE TABLETS 40MG 30 BOT   1 Preferred Generic $7.00$21.00None
CITOLOPRAM HBR 10MG TABLET (100 CT)   1 Preferred Generic $7.00$21.00None
CLARINEX 0.5MG/ML SYRUP   3 Non-Preferred Generic/Non-Preferred Brand 46%46%S Q:300
/30Days
CLARINEX 2.5MG REDITABS   3 Non-Preferred Generic/Non-Preferred Brand 46%46%S Q:30
/30Days
CLARINEX 5MG REDITABS   3 Non-Preferred Generic/Non-Preferred Brand 46%46%S Q:30
/30Days
CLARINEX 5MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 46%46%S Q:30
/30Days
CLARINEX-D 12 HOUR TABLET   3 Non-Preferred Generic/Non-Preferred Brand 46%46%S Q:60
/30Days
CLARINEX-D 24 HOUR TABLET   3 Non-Preferred Generic/Non-Preferred Brand 46%46%S Q:30
/30Days
CLARITHROMYCIN 250MG TABLET   1 Preferred Generic $7.00$21.00None
CLARITHROMYCIN 250MG/5ML. SUS. 100ML   1 Preferred Generic $7.00$21.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CLARITHROMYCIN 500MG TABLET   1 Preferred Generic $7.00$21.00None
CLARITHROMYCIN ER 500MG TABLET (60 CT)   3 Non-Preferred Generic/Non-Preferred Brand 46%46%Q:28
/14Days
CLARITHROMYCIN FOR ORAL SUSPENSION 125/5ML 125MG BOT   1 Preferred Generic $7.00$21.00None
CLEMASTINE FUM 2.68MG TABLET   1 Preferred Generic $7.00$21.00None
CLEMASTINE FUMARATE 0.67MG/5ML SYRUP   1 Preferred Generic $7.00$21.00None
CLEOCIN 100MG VAGINAL OVULE   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CLEOCIN HCL 75MG CAPSULE   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CLEOCIN PED SOL 75MG/5ML   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CLIMARA PRO DIS WEEKLY 4.40MG/1.39MG   3 Non-Preferred Generic/Non-Preferred Brand 46%46%Q:4
/28Days
CLINDAMYCIN 150MG/ML ADDVAN   1 Preferred Generic $7.00$21.00None
CLINDAMYCIN HCL 150MG CAPSULE   1 Preferred Generic $7.00$21.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CLINDAMYCIN HCL 300MG CAPS   1 Preferred Generic $7.00$21.00None
CLINDAMYCIN PHOSP 1% LOTION   1 Preferred Generic $7.00$21.00None
CLINDAMYCIN PHOSPHATE 1% SOLUTION NON-ORAL   1 Preferred Generic $7.00$21.00None
CLINDAMYCIN PHOSPHATE 2% CREAM WITH APPLICATOR   1 Preferred Generic $7.00$21.00None
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE   1 Preferred Generic $7.00$21.00None
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX   1 Preferred Generic $7.00$21.00None
CLINDESSE 2% VAGINAL CREAM   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CLINISOL 15% SOLUTION   3 Non-Preferred Generic/Non-Preferred Brand 46%46%P
CLOBETASOL 0.05% OINTMENT   1 Preferred Generic $7.00$21.00None
CLOBETASOL 0.05% SOLUTION   1 Preferred Generic $7.00$21.00None
CLOBETASOL E 0.05% CREAM   1 Preferred Generic $7.00$21.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE   1 Preferred Generic $7.00$21.00None
CLOBEX 0.05% SHAMPOO   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CLOBEX 0.05% TOPICAL LOTION   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CLODERM 0.1% CREAM   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CLOMIPRAMINE HCL 25MG CAPSULE   1 Preferred Generic $7.00$21.00None
CLOMIPRAMINE HCL 50MG CAPSULE   1 Preferred Generic $7.00$21.00None
CLOMIPRAMINE HCL 75MG CAPSULE   1 Preferred Generic $7.00$21.00None
CLONIDINE HCL 0.2MG TABLET (500 CT)   1 Preferred Generic $7.00$21.00None
CLONIDINE HCL TABLET 0.1MG (500 CT)   1 Preferred Generic $7.00$21.00None
CLONIDINE HCL TABLET 0.3MG (100 CT)   1 Preferred Generic $7.00$21.00None
CLORPRES 0.1/15 TABLET   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CLORPRES 0.2/15MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CLORPRES 0.3/15MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CLOTRIMAZOLE 10MG TROCHE   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CLOTRIMAZOLE SOLUTION TOPICAL 1% 30ML BOTPL   1 Preferred Generic $7.00$21.00None
CLOTRIMAZOLE-BETAMETHASONE 1-0.05% LOTION   1 Preferred Generic $7.00$21.00None
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE CREAM USP .5MG-10GM 45GM TUBE   1 Preferred Generic $7.00$21.00None
CLOZAPINE 200MG TABLET (500 CT)   2 Preferred Brand 11%11%None
CLOZAPINE 25MG TABLET (100 CT)   1 Preferred Generic $7.00$21.00None
CLOZAPINE 50MG TABLET (500 CT)   1 Preferred Generic $7.00$21.00None
CLOZAPINE TABLETS 100MG 100 BOT   1 Preferred Generic $7.00$21.00None
COGNEX 10MG CAPSULE   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
COGNEX 20MG CAPSULE   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
COGNEX 30MG CAPSULE   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
COGNEX 40MG CAPSULE   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
COLCHICINE TABLET USP 0.6MG (100 CT)   1 Preferred Generic $7.00$21.00None
COLESTIPOL HCL 1G TABLET   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
COLESTIPOL HCL 5G GRANULES   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
COLISTIMETHATE 150MG VIAL   4 Specialty - Generic and Brand 29%N/ANone
COLLAGENASE SANTYL OINTMENT 250UNT 30GM TUBE   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
COLY MYCIN S OTIC SUSPENSION 3;3.3;10MG/ML;MG/ 5 ML BOTDR   2 Preferred Brand 11%11%None
COMBIGAN 0.2%-0.5% DROPS   2 Preferred Brand 11%11%Q:5
/25Days
COMBIPATCH 0.05/0.14MG PTCH   3 Non-Preferred Generic/Non-Preferred Brand 46%46%Q:8
/28Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
COMBIPATCH 0.05/0.25MG PTCH   3 Non-Preferred Generic/Non-Preferred Brand 46%46%Q:8
/28Days
COMBIVENT INHALER   3 Non-Preferred Generic/Non-Preferred Brand 46%46%Q:29
/30Days
COMBIVIR TABLET   4 Specialty - Generic and Brand 29%N/ANone
COMTAN 200MG TABLET   2 Preferred Brand 11%11%None
COMVAX VACCINE VIAL   3 Non-Preferred Generic/Non-Preferred Brand 46%46%P
CONCERTA ER TABLETS 18MG 100 TABLETS BOT   3 Non-Preferred Generic/Non-Preferred Brand 46%46%S Q:30
/30Days
CONCERTA ER TABLETS 27MG 100 TABLETS BOT   3 Non-Preferred Generic/Non-Preferred Brand 46%46%S Q:30
/30Days
CONCERTA ER TABLETS 36MG 100 TABLETS BOT   3 Non-Preferred Generic/Non-Preferred Brand 46%46%S Q:30
/30Days
CONCERTA ER TABLETS 54MG 100 BOT   3 Non-Preferred Generic/Non-Preferred Brand 46%46%S Q:30
/30Days
CONDYLOX GEL 0.5% 3.5 GM CRTN   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CONSTULOSE 10GM/15ML SYRUP   1 Preferred Generic $7.00$21.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN   4 Specialty - Generic and Brand 29%N/AP Q:30
/30Days
CORDRAN 0.05% LOTION   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CORDRAN SP 0.05% CREAM   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
CORDRAN TAPE 4MCG/SQCM 1 X 80 X 3 CTR   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
COREG CR 10MG CAPSULE MULTIPHASIC RELEASE 24 HR   3 Non-Preferred Generic/Non-Preferred Brand 46%46%Q:30
/30Days
COREG CR 20MG CAPSULE MULTIPHASIC RELEASE 24 HR   3 Non-Preferred Generic/Non-Preferred Brand 46%46%Q:30
/30Days
COREG CR 40MG CAPSULE MULTIPHASIC RELEASE 24 HR   3 Non-Preferred Generic/Non-Preferred Brand 46%46%Q:30
/30Days
COREG CR 80MG CAPSULE MULTIPHASIC RELEASE 24 HR   3 Non-Preferred Generic/Non-Preferred Brand 46%46%Q:30
/30Days
CORTIFOAM 10% FOAM   2 Preferred Brand 11%11%None
CORTISONE ACETATE 25MG TABLET (100 CT)   1 Preferred Generic $7.00$21.00None
CORTOMYCIN EAR SOLUTION   1 Preferred Generic $7.00$21.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CORTOMYCIN EAR SUSPENSION   1 Preferred Generic $7.00$21.00None
COUMADIN 10MG TABLET   2 Preferred Brand 11%11%None
COUMADIN 1MG TABLET   2 Preferred Brand 11%11%None
COUMADIN 2.5MG TABLET   2 Preferred Brand 11%11%None
COUMADIN 2MG TABLET   2 Preferred Brand 11%11%None
COUMADIN 3MG TABLET   2 Preferred Brand 11%11%None
COUMADIN 4MG TABLET   2 Preferred Brand 11%11%None
COUMADIN 5MG TABLET   2 Preferred Brand 11%11%None
COUMADIN 6MG TABLET   2 Preferred Brand 11%11%None
COUMADIN 7.5MG TABLET   2 Preferred Brand 11%11%None
COVERA-HS 180MG SA TABLET   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
COVERA-HS 240MG SA TABLET   3 Non-Preferred Generic/Non-Preferred Brand 46%46%None
COZAAR 100MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 46%46%Q:60
/30Days
COZAAR 25MG TABLET (1000 CT)   3 Non-Preferred Generic/Non-Preferred Brand 46%46%Q:30
/30Days
COZAAR 50MG TABLET 10000 BOT   3 Non-Preferred Generic/Non-Preferred Brand 46%46%Q:30
/30Days
CRESTOR 10MG TABLET   2 Preferred Brand 11%11%Q:30
/30Days
CRESTOR 20MG TABLET   2 Preferred Brand 11%11%Q:30
/30Days
CRESTOR 40MG TABLET   2 Preferred Brand 11%11%Q:30
/30Days
CRESTOR 5MG TABLET   2 Preferred Brand 11%11%Q:30
/30Days
CRIXIVAN 100MG CAPSULE   2 Preferred Brand 11%11%None
CRIXIVAN 200MG CAPSULE   2 Preferred Brand 11%11%None
CRIXIVAN 333MG CAPSULE   2 Preferred Brand 11%11%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CRIXIVAN 400MG CAPSULE (120 CT)   2 Preferred Brand 11%11%None
CROMOLYN NEBULIZER SOLUTION   1 Preferred Generic $7.00$21.00P
CROMOLYN SODIUM 4% 40MG 10ML BOT   1 Preferred Generic $7.00$21.00None
CUBICIN 500MG VIAL   4 Specialty - Generic and Brand 29%N/ANone
CUPRIMINE 125MG CAPSULE   2 Preferred Brand 11%11%None
CUPRIMINE CAPSULES 250MG (100 CT)   2 Preferred Brand 11%11%None
CYCLOBENZAPRINE HCL 10MG TABLET (1000 CT)   1 Preferred Generic $7.00$21.00None
CYCLOBENZAPRINE HCL 5MG TABLET (500 CT)   1 Preferred Generic $7.00$21.00None
CYCLOPHOSPHAMIDE 25MG TABLET   1 Preferred Generic $7.00$21.00P
CYCLOPHOSPHAMIDE 50MG TABLET   1 Preferred Generic $7.00$21.00P
CYCLOSPORINE 100MG CAPSULE   1 Preferred Generic $7.00$21.00P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CYCLOSPORINE 25MG CAPSULE   1 Preferred Generic $7.00$21.00P
CYCLOSPORINE 50MG CAPSULE   1 Preferred Generic $7.00$21.00P
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT   1 Preferred Generic $7.00$21.00P
CYKLOKAPRON 100MG/ML AMPUL   2 Preferred Brand 11%11%None
CYMBALTA 20MG CAPSULE   3 Non-Preferred Generic/Non-Preferred Brand 46%46%P Q:60
/30Days
CYMBALTA 60MG CAPSULE   3 Non-Preferred Generic/Non-Preferred Brand 46%46%P Q:30
/30Days
CYMBALTA CAPSULES DELAYED RELEASE 30MG (30 CT)   3 Non-Preferred Generic/Non-Preferred Brand 46%46%P Q:60
/30Days
CYPROHEPTADINE 4MG TABLET   1 Preferred Generic $7.00$21.00None
CYPROHEPTADINE HYDROCHLORIDE SOLUTION USP SYRUP 2MG 473 ML BOTGL   1 Preferred Generic $7.00$21.00None
CYSTADANE POWDER FOR ORAL SOLUTION 180GM   3 Non-Preferred Generic/Non-Preferred Brand 46%46%P
CYSTAGON 150MG CAPSULE   3 Non-Preferred Generic/Non-Preferred Brand 46%46%P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CYSTAGON 50MG CAPSULE   3 Non-Preferred Generic/Non-Preferred Brand 46%46%P

Chart Legend:

Below are a few notes to help you understand the above 2010 Medicare Part D First Health Part D-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.