2011 Medicare Part D Plan Formulary Information |
Passport Advantage (HMO SNP) (H1807-001-0)
Benefit Details
|
The Passport Advantage (HMO SNP) (H1807-001-0) Formulary Drugs Starting with the Letter P in Shelby County, KY: CMS MA Region 13 which includes: KY
|
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 |
PAMIDRONATE 60MG/10ML VIAL |
1 |
Tier 1 |
15% | N/A | P |
PAMIDRONATE DISODIUM INJECTION 3MG 10ML VIALSD |
1 |
Tier 1 |
15% | N/A | P |
PAMIDRONATE DISODIUM INJECTION 9MG 10ML VIALSD |
1 |
Tier 1 |
15% | N/A | P |
PANRETIN 0.1% GEL 60GM TUBE |
2 |
Tier 2 |
15% | N/A | P |
PANTOPRAZOLE SODIUM 20MG TABLET DELAYED RELEASE |
1 |
Tier 1 |
15% | N/A | S |
PANTOPRAZOLE SODIUM 40MG TABLET DELAYED RELEASE 90 CRC BOT |
1 |
Tier 1 |
15% | N/A | S |
PARCAINE 0.5% DROPS |
1 |
Tier 1 |
15% | N/A | None |
PAROMOMYCIN 250MG CAPSULE |
1 |
Tier 1 |
15% | N/A | None |
PAROXETINE 40MG TABLET (500 CT) |
1 |
Tier 1 |
15% | N/A | None |
PAROXETINE FILM COATED 20MG TABLET (100 CT) |
1 |
Tier 1 |
15% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PAROXETINE HCL 10MG/5ML SUSPENSION ORAL |
1 |
Tier 1 |
15% | N/A | None |
PAROXETINE HCL TABLET 24 12.5MG |
1 |
Tier 1 |
15% | N/A | None |
PAROXETINE HCL TABLET 24 25MG |
1 |
Tier 1 |
15% | N/A | None |
PAROXETINE TABLETS |
1 |
Tier 1 |
15% | N/A | None |
PAROXETINE TABLETS 30MG 90 BOT |
1 |
Tier 1 |
15% | N/A | None |
PATADAY 0.2% DROPS |
2 |
Tier 2 |
15% | N/A | None |
PATANOL 0.1% EYE DROPS |
2 |
Tier 2 |
15% | N/A | None |
PEDI-DRI TOPICAL POWDER |
1 |
Tier 1 |
15% | N/A | None |
PEDIARIX SOLUTION INJECTION 25-25-10 10 X .5ML VIAL |
2 |
Tier 2 |
15% | N/A | P |
PEDVAXHIB VACCINE VIAL |
2 |
Tier 2 |
15% | N/A | None |
PENICILLIN G POTASSIUM FOR INJECTION |
1 |
Tier 1 |
15% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PENICILLIN G PROCAINE 1200000UNT 2ML CTG |
1 |
Tier 1 |
15% | N/A | None |
PENICILLIN G SODIUM FOR INJECTION 5000000UNT 1 VIAL |
1 |
Tier 1 |
15% | N/A | None |
PENICILLIN V POTASSIUM 250MG TABLET (1000 CT) |
1 |
Tier 1 |
15% | N/A | None |
PENICILLIN V POTASSIUM 250MG/5ML LIQUID |
1 |
Tier 1 |
15% | N/A | None |
PENICILLIN V POTASSIUM 500MG TABLET |
1 |
Tier 1 |
15% | N/A | None |
PENICILLIN V POTASSIUM FOR ORAL SOLUTION CONCENTRATE 125MG 200ML BOT |
1 |
Tier 1 |
15% | N/A | None |
PENTASA 250MG CAPSULE SA |
2 |
Tier 2 |
15% | N/A | None |
PENTASA 500MG CAPSULE |
2 |
Tier 2 |
15% | N/A | None |
PENTAZOCINE/ACETAMIN TABLET |
1 |
Tier 1 |
15% | N/A | None |
PENTAZOCINE/NALOXONE TABLET |
1 |
Tier 1 |
15% | N/A | None |
PENTOPAK 400MG TABLET SA |
1 |
Tier 1 |
15% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PENTOXIFYLLINE 400MG TABLET SA |
1 |
Tier 1 |
15% | N/A | None |
PERIOGARD 0.12% ORAL RINSE |
1 |
Tier 1 |
15% | N/A | None |
PERMETHRIN 5% CREAM |
1 |
Tier 1 |
15% | N/A | None |
PERPHENAZINE TABLETS 16MG 100 BOT |
1 |
Tier 1 |
15% | N/A | None |
PERPHENAZINE TABLETS 4MG 100 BOXUD |
1 |
Tier 1 |
15% | N/A | None |
PERPHENAZINE TABLETS 8MG 100 BOT |
1 |
Tier 1 |
15% | N/A | None |
PERPHENAZINE TABLETS USP 2MG 100 BOT |
1 |
Tier 1 |
15% | N/A | None |
PHENADOZ 12.5MG SUPPOSITORY |
1 |
Tier 1 |
15% | N/A | None |
PHENADOZ 25MG SUPPOSITORY |
1 |
Tier 1 |
15% | N/A | None |
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT |
1 |
Tier 1 |
15% | N/A | None |
PHENYTOIN SOD EXT 200 MG CAP |
1 |
Tier 1 |
15% | N/A | None |
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 |
Tier 1 |
15% | N/A | None |
PHENYTOIN SODIUM INJECTION 50MG 25 X 2ML AMP |
1 |
Tier 1 |
15% | N/A | None |
PHOSPHOLINE IODIDE 0.125% |
2 |
Tier 2 |
15% | N/A | None |
PILOCARPINE HCL 5MG TABLET (100 CT) |
1 |
Tier 1 |
15% | N/A | None |
PILOCARPINE HCL 7.5MG TABLET |
1 |
Tier 1 |
15% | N/A | None |
PILOPINE HS 4% EYE GEL |
2 |
Tier 2 |
15% | N/A | None |
PINDOLOL 10MG TABLET |
1 |
Tier 1 |
15% | N/A | None |
PINDOLOL 5MG TABLET |
1 |
Tier 1 |
15% | N/A | None |
PIPERACILLIN 3GM VIAL |
1 |
Tier 1 |
15% | N/A | None |
PIROXICAM 10 MG CAPSULE |
1 |
Tier 1 |
15% | N/A | None |
PIROXICAM 20MG CAPSULE (500 CT) |
1 |
Tier 1 |
15% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PLAVIX 75MG TABLET |
2 |
Tier 2 |
15% | N/A | None |
PLAVIX TABLETS 300MG |
2 |
Tier 2 |
15% | N/A | None |
PODOFILOX 0.5% TOPICAL TUBEX |
1 |
Tier 1 |
15% | N/A | None |
POLY-DEX 0.1% SUSPENSION DROPS |
1 |
Tier 1 |
15% | N/A | None |
POLY-DEX 3.5-10K-.1 OINTMENT |
1 |
Tier 1 |
15% | N/A | None |
POLYCIN-B 500-10KU/G OINTMENT |
1 |
Tier 1 |
15% | N/A | None |
POLYETH GLYC NF POWDER FOR ORAL SOLUTION 17GM (527 CT) |
1 |
Tier 1 |
15% | N/A | None |
POLYETHYLENE GLYCOL 3350 105 MG/ML / POTASSIUM CHLORIDE 0.00497 MEQ/ML / SODIUM BICARBONATE 1.43 MG/ |
1 |
Tier 1 |
15% | N/A | None |
POLYETHYLENE GLYCOL 3350 59 MG/ML / POTASSIUM CHLORIDE 0.1 MEQ/ML / SODIUM BICARBONATE 0.02 MEQ/ML / |
1 |
Tier 1 |
15% | N/A | None |
POLYETHYLENE GLYCOL 3350 60 MG/ML / POTASSIUM CHLORIDE 0.01 MEQ/ML / SODIUM BICARBONATE 0.02 MEQ/ML |
1 |
Tier 1 |
15% | N/A | None |
POLYMYXIN B SUL-TRIMETHOPRIM 10K U-0.1% |
1 |
Tier 1 |
15% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PORTIA 0.15-0.03 TABLET |
1 |
Tier 1 |
15% | N/A | None |
POTASSIUM CHLORIDE 20MEQ/50ML SOL |
1 |
Tier 1 |
15% | N/A | None |
POTASSIUM CHLORIDE 40MEQ IN D5W LACT RNG |
1 |
Tier 1 |
15% | N/A | None |
POTASSIUM CHLORIDE 8 MEQ EXTENDED RELEASE TABLET |
1 |
Tier 1 |
15% | N/A | None |
POTASSIUM CHLORIDE ER CAPSULES 10MEQ |
1 |
Tier 1 |
15% | N/A | None |
POTASSIUM CHLORIDE ER CPCR 8MEQ |
1 |
Tier 1 |
15% | N/A | None |
POTASSIUM CHLORIDE EXTENDED RELEASE TABLETS |
1 |
Tier 1 |
15% | N/A | None |
POTASSIUM CHLORIDE TABLET EXTENED RELEASE |
1 |
Tier 1 |
15% | N/A | None |
POTASSIUM CITRATE 10MEQ TABLET SA |
1 |
Tier 1 |
15% | N/A | None |
POTASSIUM CITRATE 5MEQ TABLET SA |
1 |
Tier 1 |
15% | N/A | None |
PRAMIPEXOLE 0.125 MG TABLET |
1 |
Tier 1 |
15% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRAMIPEXOLE 0.25 MG TABLET |
1 |
Tier 1 |
15% | N/A | None |
PRAMIPEXOLE 0.5 MG TABLET |
1 |
Tier 1 |
15% | N/A | None |
PRAMIPEXOLE 1 MG TABLET |
1 |
Tier 1 |
15% | N/A | None |
PRAMIPEXOLE 1.5 MG TABLET |
1 |
Tier 1 |
15% | N/A | None |
PRAMIPEXOLE DIHYDROCHLORIDE TABLETS |
1 |
Tier 1 |
15% | N/A | None |
PRASUGREL 10 MG ORAL TABLET |
2 |
Tier 2 |
15% | N/A | None |
PRASUGREL 5 MG ORAL TABLET |
2 |
Tier 2 |
15% | N/A | None |
PRAVASTATIN SODIUM 20MG TABLET 500 BOT |
1 |
Tier 1 |
15% | N/A | None |
PRAVASTATIN SODIUM 40MG TABLET (500 CT) |
1 |
Tier 1 |
15% | N/A | None |
PRAVASTATIN SODIUM 80MG TABLET (90 CT) |
1 |
Tier 1 |
15% | N/A | None |
PRAVASTATIN SODIUM TABLETS 10MG 90 BOT |
1 |
Tier 1 |
15% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRAZOSIN 5MG CAPSULE |
1 |
Tier 1 |
15% | N/A | None |
PRAZOSIN HCL 1MG CAPSULE |
1 |
Tier 1 |
15% | N/A | None |
PRAZOSIN HCL 2MG CAPSULE |
1 |
Tier 1 |
15% | N/A | None |
PREDNICARBATE 0.1% OINTMENT |
1 |
Tier 1 |
15% | N/A | None |
PREDNICARBATE 1 MG/ML TOPICAL CREAM |
1 |
Tier 1 |
15% | N/A | None |
PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION 1.0% STERILE 10ML BOTDR |
1 |
Tier 1 |
15% | N/A | None |
PREDNISOLONE SOD 1% EYE DROP |
1 |
Tier 1 |
15% | N/A | None |
PREDNISOLONE SODIUM PHOSPHATE 15MG/5ML SOLUTION ORAL |
1 |
Tier 1 |
15% | N/A | None |
PREDNISOLONE SODIUM PHOSPHATE ORAL SOLUTION |
1 |
Tier 1 |
15% | N/A | None |
PREDNISONE 10MG TABLET (100 CT) |
1 |
Tier 1 |
15% | N/A | None |
PREDNISONE 1MG TABLET |
1 |
Tier 1 |
15% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREDNISONE 2.5MG TABLET |
1 |
Tier 1 |
15% | N/A | None |
PREDNISONE 20MG TABLET (1000 CT) |
1 |
Tier 1 |
15% | N/A | None |
PREDNISONE 5 MG TABLET |
1 |
Tier 1 |
15% | N/A | None |
PREDNISONE 50MG TABLET |
1 |
Tier 1 |
15% | N/A | None |
PREDNISONE 5MG/5ML SOLUTION |
1 |
Tier 1 |
15% | N/A | None |
PREMARIN 0.3MG (100 CT) |
2 |
Tier 2 |
15% | N/A | None |
PREMARIN 0.45MG TABLET |
2 |
Tier 2 |
15% | N/A | None |
PREMARIN 0.625MG (100 CT) |
2 |
Tier 2 |
15% | N/A | None |
PREMARIN 0.9MG TABLET |
2 |
Tier 2 |
15% | N/A | None |
PREMARIN 1.25MG (100 CT) |
2 |
Tier 2 |
15% | N/A | None |
PREMARIN 25MG VIAL |
2 |
Tier 2 |
15% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREMARIN VAGINAL CREAM /APPL |
2 |
Tier 2 |
15% | N/A | None |
PREMPHASE 0.625/5MG TABLET |
2 |
Tier 2 |
15% | N/A | None |
PREMPRO 0.3 MG-1.5 MG TABLET #28 EA |
2 |
Tier 2 |
15% | N/A | None |
PREMPRO 0.45-1.5 MG TABLET 28 EA |
2 |
Tier 2 |
15% | N/A | None |
PREVALITE POW 4GM |
1 |
Tier 1 |
15% | N/A | None |
PREVIFEM TABLETS .035;.25MG;MG 28 BLPK |
1 |
Tier 1 |
15% | N/A | None |
PREZISTA TABLET 600MG |
2 |
Tier 2 |
15% | N/A | None |
PREZISTA TABLET 75MG |
2 |
Tier 2 |
15% | N/A | None |
PREZISTA TABLETS |
2 |
Tier 2 |
15% | N/A | None |
PREZISTA TABLETS 400MG 60 TABLETS BOT |
2 |
Tier 2 |
15% | N/A | None |
PRIMIDONE 250MG TABLET (100 CT) |
1 |
Tier 1 |
15% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRIMIDONE 50MG TABLET (500 CT) |
1 |
Tier 1 |
15% | N/A | None |
PRISTIQ 100MG TABLET SR 24HR |
2 |
Tier 2 |
15% | N/A | None |
PRISTIQ 50MG TABLET SR 24HR |
2 |
Tier 2 |
15% | N/A | None |
PROBENECID 500MG TABLET |
1 |
Tier 1 |
15% | N/A | None |
PROBENECID/COLCHICINE TABLET S |
1 |
Tier 1 |
15% | N/A | None |
PROCHLORPERAZINE EDISYLATE INJECTION 10MG 10 X 2ML VIALS CRTN |
1 |
Tier 1 |
15% | N/A | None |
PROCHLORPERAZINE MALEATE 10MG TABLET (100 CT) |
1 |
Tier 1 |
15% | N/A | None |
PROCHLORPERAZINE MALEATE 5MG TABLET (100 CT) |
1 |
Tier 1 |
15% | N/A | None |
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX |
1 |
Tier 1 |
15% | N/A | None |
PROCRIT 10000U/ML VIAL |
2 |
Tier 2 |
15% | N/A | P |
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL |
2 |
Tier 2 |
15% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROCRIT 3000U/ML VIAL |
2 |
Tier 2 |
15% | N/A | P |
PROCRIT 4000U/ML VIAL 25 X 1ML VIAL |
2 |
Tier 2 |
15% | N/A | P |
PROCTO-PAK 1% CREAM |
1 |
Tier 1 |
15% | N/A | None |
PROCTOCREAM-HC 2.5% CREAM |
1 |
Tier 1 |
15% | N/A | None |
PROCTOSOL-HC 2.5% CREAM |
1 |
Tier 1 |
15% | N/A | None |
PROCTOZONE-HC 2.5% CREAM |
1 |
Tier 1 |
15% | N/A | None |
PROMETHAZINE HCL 12.5MG TABLET |
1 |
Tier 1 |
15% | N/A | None |
PROMETHAZINE HCL 25MG TABLET (1000 CT) |
1 |
Tier 1 |
15% | N/A | None |
PROMETHAZINE HCL 50MG TABLET (100 CT) |
1 |
Tier 1 |
15% | N/A | None |
PROMETHAZINE HCL 6.25MG/5ML SYRUP |
1 |
Tier 1 |
15% | N/A | None |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 12.5MG 12 BOX |
1 |
Tier 1 |
15% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 25MG 12 BOX |
1 |
Tier 1 |
15% | N/A | None |
PROMETHAZINE VC PLAIN 6.25-5MG 16 FL OZ BOT |
1 |
Tier 1 |
15% | N/A | None |
PROMETHEGAN 25MG SUPP |
1 |
Tier 1 |
15% | N/A | None |
PROMETHEGAN 50MG SUPPOS |
1 |
Tier 1 |
15% | N/A | None |
PROPAFENONE HCL 150MG TABLET (100 CT) |
1 |
Tier 1 |
15% | N/A | None |
PROPAFENONE HCL 225MG TABLET |
1 |
Tier 1 |
15% | N/A | None |
PROPAFENONE HCL 300MG TABLET (100 CT) |
1 |
Tier 1 |
15% | N/A | None |
PROPARACAINE 0.5% EYE DROPS |
1 |
Tier 1 |
15% | N/A | None |
PROPRANOLOL 20MG/5ML TUBEX |
1 |
Tier 1 |
15% | N/A | None |
PROPRANOLOL 40MG/5ML TUBEX |
1 |
Tier 1 |
15% | N/A | None |
PROPRANOLOL 60MG TABLET |
1 |
Tier 1 |
15% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROPRANOLOL 80 MG TABLET |
1 |
Tier 1 |
15% | N/A | None |
PROPRANOLOL HCL 20MG TABLET (1000 CT) |
1 |
Tier 1 |
15% | N/A | None |
PROPRANOLOL HCL CAPSULES ER 120MG (1000 CT) |
1 |
Tier 1 |
15% | N/A | None |
PROPRANOLOL HCL CAPSULES ER 160MG (1000 CT) |
1 |
Tier 1 |
15% | N/A | None |
PROPRANOLOL HCL CAPSULES ER 60MG (100 CT) |
1 |
Tier 1 |
15% | N/A | None |
PROPRANOLOL HCL CAPSULES ER 80MG (1000 CT) |
1 |
Tier 1 |
15% | N/A | None |
PROPRANOLOL HCL TABLET USP 10MG (1000 CT) |
1 |
Tier 1 |
15% | N/A | None |
PROPRANOLOL HCL TABLET USP 40MG (1000 CT) |
1 |
Tier 1 |
15% | N/A | None |
PROPRANOLOL/HCTZ 40/25 TABLET |
1 |
Tier 1 |
15% | N/A | None |
PROPRANOLOL/HCTZ 80/25 TABLET |
1 |
Tier 1 |
15% | N/A | None |
PROPYLTHIOURACIL 50MG TABLET |
1 |
Tier 1 |
15% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROQUAD VIAL |
2 |
Tier 2 |
15% | N/A | None |
PROTOPIC 0.03% OINTMENT 100GM TUBE |
2 |
Tier 2 |
15% | N/A | None |
PROTOPIC 0.1% OINTMENT 60GM TUBE |
2 |
Tier 2 |
15% | N/A | None |
PROTRIPTYLINE HYDROCHLORIDE TABLETS |
1 |
Tier 1 |
15% | N/A | None |
PROTRIPTYLINE HYDROCHLORIDE TABLETS 5MG |
1 |
Tier 1 |
15% | N/A | None |
PROVENTIL HFA INHALER 90MCG AE |
2 |
Tier 2 |
15% | N/A | None |
PROVIGIL 100MG TABLET |
2 |
Tier 2 |
15% | N/A | None |
PROVIGIL 200MG TABLET |
2 |
Tier 2 |
15% | N/A | None |
PYRAZINAMIDE 500MG TABLET |
1 |
Tier 1 |
15% | N/A | None |
PYRIDOSTIGMINE BROMIDE 60MG TABLET |
1 |
Tier 1 |
15% | N/A | None |