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.

First Health Part D-Premier (PDP) (S5768-082-0)
Tier 1 (1436)
Tier 2 (376)
Tier 3 (959)
Tier 4 (260)

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
First Health Part D-Premier (PDP) (S5768-082-0)
Benefit Details  
The First Health Part D-Premier (PDP) (S5768-082-0)
Formulary Drugs Starting with the Letter P
in CMS PDP Region 32 which includes: CA
Drugs Starting with Letter P

Drug Name		 Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order
PACERONE 100MG TABLET   2 Preferred Brand 12%12%None
PACERONE 200MG TABLET   1 Preferred Generic $7.00$21.00None
PACERONE 300MG TABLET   2 Preferred Brand 12%12%None
PACLITAXEL INJECTION SOLUTION 6MG 50ML VIALMD   3 Non-Preferred Generic/Non-Preferred Brand 42%42%P
PAMIDRONATE DISODIUM INJECTION 3MG 10ML VIALSD   3 Non-Preferred Generic/Non-Preferred Brand 42%42%P
PAMIDRONATE DISODIUM INJECTION 9MG 10ML VIALSD   3 Non-Preferred Generic/Non-Preferred Brand 42%42%P
PANRETIN 0.1% GEL 60GM TUBE   2 Preferred Brand 12%12%None
PARCAINE 0.5% DROPS   1 Preferred Generic $7.00$21.00None
PAROMOMYCIN 250MG CAPSULE   1 Preferred Generic $7.00$21.00None
PAROXETINE 40MG TABLET (500 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
PAROXETINE FILM COATED 20MG TABLET (100 CT)   1 Preferred Generic $7.00$21.00None
PAROXETINE HCL 10MG TABLET   1 Preferred Generic $7.00$21.00None
PAROXETINE HCL 10MG/5ML SUSPENSION ORAL   1 Preferred Generic $7.00$21.00None
PAROXETINE HCL TABLET 24 12.5MG   3 Non-Preferred Generic/Non-Preferred Brand 42%42%S Q:30
/30Days
PAROXETINE HCL TABLET 24 25MG   3 Non-Preferred Generic/Non-Preferred Brand 42%42%S Q:60
/30Days
PAROXETINE TABLETS 30MG 90 BOT   1 Preferred Generic $7.00$21.00None
PASER GRANULES 4GM PACKET   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
PATADAY 0.2% DROPS   3 Non-Preferred Generic/Non-Preferred Brand 42%42%Q:3
/30Days
PATANOL 0.1% EYE DROPS   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
PAXIL CR 37.5MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 42%42%S Q:60
/30Days
PCE 333MG DISPERTAB   2 Preferred Brand 12%12%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
PCE 500MG DISPERTAB   2 Preferred Brand 12%12%None
PEDIARIX SOLUTION INJECTION 25-25-10 10 X .5ML VIAL   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
PEDVAXHIB VACCINE VIAL   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
PEG 3350/ELECTROLYTE 240-22.72G SOLUTION RECONSTITUTED ORAL   1 Preferred Generic $7.00$21.00None
PEG-INTRON 100MCG KIT   4 Specialty - Generic and Brand 29%N/AP S
PEG-INTRON REDIPEN 120MCG   4 Specialty - Generic and Brand 29%N/AP S Q:4
/30Days
PEG-INTRON REDIPEN 150MCG   4 Specialty - Generic and Brand 29%N/AP S Q:4
/30Days
PEG-INTRON REDIPEN 80MCG   4 Specialty - Generic and Brand 29%N/AP S Q:4
/30Days
PEGANONE 250MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
PEGASYS 180MCG/0.5ML CONV.PK   4 Specialty - Generic and Brand 29%N/AP Q:1
/28Days
PENICILLIN G POTASSIUM FOR INJECTION   1 Preferred Generic $7.00$21.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
PENICILLIN G POTASSIUM FOR INJECTION   1 Preferred Generic $7.00$21.00None
PENICILLIN G PROCAINE 1200000UNT 2ML CTG   2 Preferred Brand 12%12%None
PENICILLIN G SODIUM FOR INJECTION 5000000UNT 1 VIAL   1 Preferred Generic $7.00$21.00None
PENICILLIN V POTASSIUM 250MG TABLET (1000 CT)   1 Preferred Generic $7.00$21.00None
PENICILLIN V POTASSIUM 250MG/5ML LIQUID   1 Preferred Generic $7.00$21.00None
PENICILLIN V POTASSIUM 500MG TABLET   1 Preferred Generic $7.00$21.00None
PENICILLIN V POTASSIUM FOR ORAL SOLUTION CONCENTRATE 125MG 200ML BOT   1 Preferred Generic $7.00$21.00None
PENTASA 250MG CAPSULE SA   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
PENTASA 500MG CAPSULE   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
PENTAZOCINE/ACETAMIN TABLET   1 Preferred Generic $7.00$21.00None
PENTAZOCINE/NALOXONE 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
PENTOXIFYLLINE 400MG TABLET SA   1 Preferred Generic $7.00$21.00None
PEPCID SOLUTION 40MG 24 X 400MG BOT   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
PERFOROMIST 20MCG/2ML VIAL NEBULIZER   3 Non-Preferred Generic/Non-Preferred Brand 42%42%P S Q:120
/30Days
PERMETHRIN 5% CREAM   1 Preferred Generic $7.00$21.00None
PERPHENAZINE TABLETS 16MG 100 BOT   1 Preferred Generic $7.00$21.00None
PERPHENAZINE TABLETS 4MG 100 BOXUD   1 Preferred Generic $7.00$21.00None
PERPHENAZINE TABLETS 8MG 100 BOT   1 Preferred Generic $7.00$21.00None
PERPHENAZINE TABLETS USP 2MG 100 BOT   1 Preferred Generic $7.00$21.00None
PHENYTEK 200MG CAPSULE   2 Preferred Brand 12%12%None
PHENYTEK 300MG CAPSULE   2 Preferred Brand 12%12%None
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ 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
PHENYTOIN SODIUM EXTENDED CAPSULES 100MG (100 CT)   1 Preferred Generic $7.00$21.00None
PHENYTOIN SODIUM INJECTION 50MG 25 X 2ML AMP   1 Preferred Generic $7.00$21.00None
PHOSPHOLINE IODIDE 0.125%   2 Preferred Brand 12%12%None
PILOCARPINE HCL 5MG TABLET (100 CT)   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
PILOCARPINE HCL 7.5MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
PILOPINE HS 4% EYE GEL   2 Preferred Brand 12%12%None
PINDOLOL 10MG TABLET   1 Preferred Generic $7.00$21.00None
PINDOLOL 5MG TABLET   1 Preferred Generic $7.00$21.00None
PIPERACILLIN 3GM VIAL   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
PIPERACILLIN 40GM BULK VIAL   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
PIROXICAM 10MG 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
PIROXICAM 20MG CAPSULE (500 CT)   1 Preferred Generic $7.00$21.00None
PLAN B 0.75MG TABLET 2 BLPK   2 Preferred Brand 12%12%None
PLAVIX 75MG TABLET   2 Preferred Brand 12%12%Q:30
/30Days
PLAVIX TABLETS 300MG   2 Preferred Brand 12%12%Q:1
/365Days
PODOFILOX 0.5% TOPICAL TUBEX   1 Preferred Generic $7.00$21.00None
POLY-DEX 0.1% SUSPENSION DROPS   1 Preferred Generic $7.00$21.00None
POLY-PRED EYE DROPS   2 Preferred Brand 12%12%None
POLYGAM S/D 10GM VL W/DILUENT   4 Specialty - Generic and Brand 29%N/AP
POLYMYXIN B SUL-TRIMETHOPRIM 10K U-0.1%   1 Preferred Generic $7.00$21.00None
POTASSIUM CHLORIDE 0.075%/D5W/SODIUM CHLORIDE 0.2%   1 Preferred Generic $7.00$21.00None
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.3%   1 Preferred Generic $7.00$21.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.45%   1 Preferred Generic $7.00$21.00None
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.9% 1000ML   1 Preferred Generic $7.00$21.00None
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.2%   1 Preferred Generic $7.00$21.00None
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.45% 1000ML BAG   1 Preferred Generic $7.00$21.00None
POTASSIUM CHLORIDE 10MEQ TABLET SA   1 Preferred Generic $7.00$21.00None
POTASSIUM CHLORIDE 10MEQ/100ML SOL   1 Preferred Generic $7.00$21.00None
POTASSIUM CHLORIDE 10MEQ/50ML SOL   1 Preferred Generic $7.00$21.00None
POTASSIUM CHLORIDE 20MEQ IN D5W LACT RNG   1 Preferred Generic $7.00$21.00None
POTASSIUM CHLORIDE 20MEQ IN D5W/NACL 0.225%   1 Preferred Generic $7.00$21.00None
POTASSIUM CHLORIDE 20MEQ TABLET SR PARTICLES/CRYSTALS   1 Preferred Generic $7.00$21.00None
POTASSIUM CHLORIDE 20MEQ/50ML SOL   1 Preferred Generic $7.00$21.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
POTASSIUM CHLORIDE 30MEQ/100ML SOL   1 Preferred Generic $7.00$21.00None
POTASSIUM CHLORIDE 40MEQ IN D5W LACT RNG   1 Preferred Generic $7.00$21.00None
POTASSIUM CHLORIDE 40MEQ/NS 1000ML IV SOLUTION   1 Preferred Generic $7.00$21.00None
POTASSIUM CHLORIDE 8MEQ TABLET SA   1 Preferred Generic $7.00$21.00None
POTASSIUM CHLORIDE ER CAPSULES 10MEQ   1 Preferred Generic $7.00$21.00None
POTASSIUM CHLORIDE ER CPCR 8MEQ   1 Preferred Generic $7.00$21.00None
POTASSIUM CHLORIDE FOR INJECTION CONCENTRATE   1 Preferred Generic $7.00$21.00None
POTASSIUM CHLORIDE IN 5% DEXTROSE AND 0.2% NACL SOLUTION FOR INJECTION USP 0.15% 250ML X 24 CASE   1 Preferred Generic $7.00$21.00None
POTASSIUM CHLORIDE IN 5% DEXTROSE AND NACL SOLUTION FOR INJECTION 0.075% 1000ML PLASTIC BAGS X 12 CA   1 Preferred Generic $7.00$21.00None
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION   1 Preferred Generic $7.00$21.00None
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION   1 Preferred Generic $7.00$21.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
POTASSIUM CHLORIDE IN 5% DEXTROSE INJECTION 40 12 X 1000ML CTR   1 Preferred Generic $7.00$21.00None
POTASSIUM CHLORIDE IN DEXTROSE AND SODIUM CHLORIDE INJECTION 5-30-.225 12 X 1000ML CTR   1 Preferred Generic $7.00$21.00None
POTASSIUM CHLORIDE IN DEXTROSE INJECTION 5GM/75MG   1 Preferred Generic $7.00$21.00None
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION 0.15%-0.9% 12 X 1000ML BAG   1 Preferred Generic $7.00$21.00None
POTASSIUM CITRATE 10MEQ TABLET SA   1 Preferred Generic $7.00$21.00None
POTASSIUM CITRATE 5MEQ TABLET SA   1 Preferred Generic $7.00$21.00None
PRAVASTATIN SODIUM 20MG TABLET 500 BOT   1 Preferred Generic $7.00$21.00None
PRAVASTATIN SODIUM 40MG TABLET (500 CT)   1 Preferred Generic $7.00$21.00None
PRAVASTATIN SODIUM 80MG TABLET (90 CT)   1 Preferred Generic $7.00$21.00None
PRAVASTATIN SODIUM TABLETS 10MG 90 BOT   1 Preferred Generic $7.00$21.00None
PRAZOSIN 5MG 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
PRAZOSIN HCL 1MG CAPSULE   1 Preferred Generic $7.00$21.00None
PRAZOSIN HCL 2MG CAPSULE   1 Preferred Generic $7.00$21.00None
PRED G OPHTHALMIC SUSPENSION 1;0.3%;% 5 ML BOTDR   2 Preferred Brand 12%12%None
PRED MILD 0.12% EYE DROPS   2 Preferred Brand 12%12%None
PRED-G S.O.P. EYE OINTMENT   2 Preferred Brand 12%12%None
PREDNICARBATE 0.1% CREAM   1 Preferred Generic $7.00$21.00None
PREDNICARBATE 0.1% OINTMENT   1 Preferred Generic $7.00$21.00None
PREDNISOLONE 5MG/5ML TUBEX   1 Preferred Generic $7.00$21.00None
PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION 1.0% STERILE 10ML BOTDR   1 Preferred Generic $7.00$21.00None
PREDNISOLONE SOD 1% EYE DROP   1 Preferred Generic $7.00$21.00None
PREDNISOLONE SODIUM PHOSPHATE 15MG/5ML SOLUTION ORAL   1 Preferred Generic $7.00$21.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
PREDNISONE 10MG TABLET (100 CT)   1 Preferred Generic $7.00$21.00None
PREDNISONE 1MG TABLET   1 Preferred Generic $7.00$21.00None
PREDNISONE 2.5MG TABLET   1 Preferred Generic $7.00$21.00None
PREDNISONE 20MG TABLET (1000 CT)   1 Preferred Generic $7.00$21.00None
PREDNISONE 50MG TABLET   1 Preferred Generic $7.00$21.00None
PREDNISONE 5MG TABLET (100 CT)   1 Preferred Generic $7.00$21.00None
PREDNISONE 5MG/5ML SOLUTION   1 Preferred Generic $7.00$21.00None
PREDNISONE 5MG/ML SOLUTION   1 Preferred Generic $7.00$21.00None
PREFEST TABLET 30 EA   3 Non-Preferred Generic/Non-Preferred Brand 42%42%Q:30
/30Days
PREMARIN 0.3MG (100 CT)   2 Preferred Brand 12%12%Q:30
/30Days
PREMARIN 0.45MG TABLET   2 Preferred Brand 12%12%Q:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
PREMARIN 0.625MG (100 CT)   2 Preferred Brand 12%12%Q:30
/30Days
PREMARIN 0.9MG TABLET   2 Preferred Brand 12%12%Q:30
/30Days
PREMARIN 1.25MG (100 CT)   2 Preferred Brand 12%12%Q:30
/30Days
PREMARIN VAGINAL CREAM /APPL   2 Preferred Brand 12%12%None
PREMPHASE 0.625/5MG TABLET   2 Preferred Brand 12%12%Q:30
/30Days
PREMPRO 0.3MG/1.5MG TABLET   2 Preferred Brand 12%12%Q:30
/30Days
PREMPRO 0.45/1.5MG TABLET   2 Preferred Brand 12%12%Q:30
/30Days
PREMPRO 0.625/2.5MG TABLET DIALPK   2 Preferred Brand 12%12%Q:30
/30Days
PREMPRO 0.625/5MG TABLET   2 Preferred Brand 12%12%Q:30
/30Days
PRENATABS OBN TABLETS 200;1;150;MG;MG;MCG; 90 BOT   1 Preferred Generic $7.00$21.00P
PREVACID SOLUTAB EXTENDED RELEASE ORALLY DISINTEGRATING 30MG 100 BOXUD   3 Non-Preferred Generic/Non-Preferred Brand 42%42%S Q:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
PREVACID SOLUTAB TABLETS DELAYED RELEASE ORALLY DISINTEGRATING 15MG 100 BOXUD   3 Non-Preferred Generic/Non-Preferred Brand 42%42%S Q:30
/30Days
PREVALITE POW 4GM PK   1 Preferred Generic $7.00$21.00None
PREZISTA TABLET 600MG   4 Specialty - Generic and Brand 29%N/ANone
PREZISTA TABLET 75MG   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
PREZISTA TABLETS 400MG 60 TABLETS BOT   4 Specialty - Generic and Brand 29%N/ANone
PRIFTIN 150MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
PRIMAQUINE 26.3MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
PRIMAXIN I.M. 500MG VIAL   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
PRIMAXIN IV 250MG VIAL   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
PRIMAXIN IV INJ 500MG   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
PRIMIDONE 250MG 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
PRIMIDONE 50MG TABLET (500 CT)   1 Preferred Generic $7.00$21.00None
PRIMSOL 50MG/5ML ORAL SOLUTION   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
PRISTIQ 100MG TABLET SR 24HR   3 Non-Preferred Generic/Non-Preferred Brand 42%42%S Q:30
/30Days
PRISTIQ 50MG TABLET SR 24HR   3 Non-Preferred Generic/Non-Preferred Brand 42%42%S Q:30
/30Days
PROAIR HFA 90MCG HFA AEROSOL WITH ADAPTER   2 Preferred Brand 12%12%Q:17
/30Days
PROBENECID 500MG TABLET   1 Preferred Generic $7.00$21.00None
PROBENECID/COLCHICINE TABLET S   1 Preferred Generic $7.00$21.00None
PROCAINAMIDE 100MG/ML VIAL   1 Preferred Generic $7.00$21.00None
PROCAINAMIDE 500MG/ML VIAL   1 Preferred Generic $7.00$21.00None
PROCHIEVE 4% GEL   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
PROCHIEVE GEL 8%   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
PROCHLORPERAZINE EDISYLATE INJECTION 10MG 10 X 2ML VIALS CRTN   1 Preferred Generic $7.00$21.00None
PROCHLORPERAZINE MALEATE 10MG TABLET (100 CT)   1 Preferred Generic $7.00$21.00None
PROCHLORPERAZINE MALEATE 5MG TABLET (100 CT)   1 Preferred Generic $7.00$21.00None
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX   1 Preferred Generic $7.00$21.00None
PROCRIT 10000U/ML VIAL   3 Non-Preferred Generic/Non-Preferred Brand 42%42%P Q:12
/28Days
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL   3 Non-Preferred Generic/Non-Preferred Brand 42%42%P Q:12
/28Days
PROCRIT 3000U/ML VIAL   3 Non-Preferred Generic/Non-Preferred Brand 42%42%P Q:12
/28Days
PROCRIT 40000U/ML VIAL PR   4 Specialty - Generic and Brand 29%N/AP Q:4
/28Days
PROCRIT 4000U/ML VIAL 25 X 1ML VIAL   3 Non-Preferred Generic/Non-Preferred Brand 42%42%P Q:12
/28Days
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY   4 Specialty - Generic and Brand 29%N/AP Q:12
/28Days
PROCTOSOL-HC 2.5% 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
PROCTOZONE-HC 2.5% CREAM   1 Preferred Generic $7.00$21.00None
PROGLYCEM 50MG/ML ORAL SUSP   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
PROGRAF 0.5MG CAPSULE   3 Non-Preferred Generic/Non-Preferred Brand 42%42%P
PROGRAF 1MG CAPSULE   3 Non-Preferred Generic/Non-Preferred Brand 42%42%P
PROGRAF 5MG CAPSULE   4 Specialty - Generic and Brand 29%N/AP
PROLASTIN 500MG VIAL   4 Specialty - Generic and Brand 29%N/AP
PROLEUKIN 22 MILLION UNITS VL   4 Specialty - Generic and Brand 29%N/AP
PROMACTA TABLETS   4 Specialty - Generic and Brand 29%N/AP Q:30
/30Days
PROMACTA TABLETS 25 MG   4 Specialty - Generic and Brand 29%N/AP Q:30
/30Days
PROMETHAZINE 50MG/ML VIAL   1 Preferred Generic $7.00$21.00None
PROMETHAZINE HCL 12.5MG 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
PROMETHAZINE HCL 25MG TABLET (1000 CT)   1 Preferred Generic $7.00$21.00None
PROMETHAZINE HCL 50MG TABLET (100 CT)   1 Preferred Generic $7.00$21.00None
PROMETHAZINE HCL 6.25MG/5ML SYRUP   1 Preferred Generic $7.00$21.00None
PROMETHAZINE HCL INJECTION 25MG 10 X 1ML VIAL   1 Preferred Generic $7.00$21.00None
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 12.5MG 12 BOX   1 Preferred Generic $7.00$21.00None
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 25MG 12 BOX   1 Preferred Generic $7.00$21.00None
PROMETHAZINE VC PLAIN 6.25-5MG 16 FL OZ BOT   1 Preferred Generic $7.00$21.00None
PROMETHEGAN 25MG SUPP   1 Preferred Generic $7.00$21.00None
PROMETHEGAN 50MG SUPPOS   1 Preferred Generic $7.00$21.00None
PROMETRIUM 100MG CAPSULE   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
PROMETRIUM 200MG CAPSULE   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
PROPAFENONE HCL 150MG TABLET (100 CT)   1 Preferred Generic $7.00$21.00None
PROPAFENONE HCL 225MG TABLET   1 Preferred Generic $7.00$21.00None
PROPAFENONE HCL 300MG TABLET (100 CT)   1 Preferred Generic $7.00$21.00None
PROPANTHELINE 15MG TABLET   1 Preferred Generic $7.00$21.00None
PROPARACAINE 0.5% EYE DROPS   1 Preferred Generic $7.00$21.00None
PROPOXY-N/APAP 100-500MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
PROPOXY-N/APAP 100-650 TABLET   1 Preferred Generic $7.00$21.00None
PROPOXY-N/APAP 50-325 TABLET   1 Preferred Generic $7.00$21.00None
PROPOXYPHENE HCL AND ACETAMINOPHEN TABLET 650/65MG (500 CT)   1 Preferred Generic $7.00$21.00None
PROPOXYPHENE HCL CAPSULES 65MG (100 CT)   1 Preferred Generic $7.00$21.00None
PROPRANOLOL 20MG/5ML TUBEX   1 Preferred Generic $7.00$21.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
PROPRANOLOL 40MG/5ML TUBEX   1 Preferred Generic $7.00$21.00None
PROPRANOLOL 60MG TABLET   1 Preferred Generic $7.00$21.00None
PROPRANOLOL 80MG TABLET   1 Preferred Generic $7.00$21.00None
PROPRANOLOL HCL 20MG TABLET (1000 CT)   1 Preferred Generic $7.00$21.00None
PROPRANOLOL HCL CAPSULES ER 120MG (1000 CT)   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
PROPRANOLOL HCL CAPSULES ER 160MG (1000 CT)   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
PROPRANOLOL HCL CAPSULES ER 60MG (100 CT)   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
PROPRANOLOL HCL CAPSULES ER 80MG (1000 CT)   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
PROPRANOLOL HCL INJECTION 1MG 10 PKG OF 10 CRTN   1 Preferred Generic $7.00$21.00None
PROPRANOLOL HCL TABLET USP 10MG (1000 CT)   1 Preferred Generic $7.00$21.00None
PROPRANOLOL HCL TABLET USP 40MG (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
PROPRANOLOL/HCTZ 40/25 TABLET   1 Preferred Generic $7.00$21.00None
PROPRANOLOL/HCTZ 80/25 TABLET   1 Preferred Generic $7.00$21.00None
PROPYLTHIOURACIL 50MG TABLET   1 Preferred Generic $7.00$21.00None
PROQUAD VIAL   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
PROTONIX 20MG TABLET EC   2 Preferred Brand 12%12%Q:30
/30Days
PROTONIX 40MG TABLET EC   2 Preferred Brand 12%12%Q:30
/30Days
PROTONIX IV 40MG VIAL   3 Non-Preferred Generic/Non-Preferred Brand 42%42%P
PROTOPIC 0.03% OINTMENT 100GM TUBE   3 Non-Preferred Generic/Non-Preferred Brand 42%42%S Q:30
/30Days
PROTOPIC 0.1% OINTMENT 60GM TUBE   3 Non-Preferred Generic/Non-Preferred Brand 42%42%S Q:30
/30Days
PROTRIPTYLINE HYDROCHLORIDE TABLETS   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
PROTRIPTYLINE HYDROCHLORIDE TABLETS 5MG   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
PROVENTIL HFA INHALER 90MCG AE   3 Non-Preferred Generic/Non-Preferred Brand 42%42%Q:13
/30Days
PROVIGIL 100MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 42%42%P Q:30
/30Days
PROVIGIL 200MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 42%42%P Q:30
/30Days
PROZAC WEEKLY 90MG CAPSULE   3 Non-Preferred Generic/Non-Preferred Brand 42%42%S Q:4
/28Days
PULMICORT FLEXHALER 180MCG AEROSOL POWDER BREATH ACTIVATED   3 Non-Preferred Generic/Non-Preferred Brand 42%42%Q:2
/30Days
PULMICORT FLEXHALER 90MCG AEROSOL POWDER BREATH ACTIVATED   3 Non-Preferred Generic/Non-Preferred Brand 42%42%Q:2
/30Days
PULMOZYME 1MG/ML AMPUL   4 Specialty - Generic and Brand 29%N/AP
PYRAZINAMIDE 500MG TABLET   1 Preferred Generic $7.00$21.00None
PYRIDOSTIGMINE BROMIDE 60MG TABLET   1 Preferred Generic $7.00$21.00None

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.