2011 Medicare Part D Plan Formulary Information |
Geisinger Gold Classic 2 $0 Deductible Rx (HMO) (H3954-039-0)
Benefit Details
|
The Geisinger Gold Classic 2 $0 Deductible Rx (HMO) (H3954-039-0) Formulary Drugs Starting with the Letter P in Monroe County, PA: CMS MA Region 6 which includes: PA
|
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 |
PALIPERIDONE PALMITATE 156 MG/ML PREFILLED SYRINGE [INVEGA] |
2 |
Tier 2 |
$39.00 | $97.50 | None |
PALIPERIDONE PALMITATE 156 MG/ML PREFILLED SYRINGE [INVEGA] |
2 |
Tier 2 |
$39.00 | $97.50 | None |
PALIPERIDONE PALMITATE 156 MG/ML PREFILLED SYRINGE [INVEGA] |
2 |
Tier 2 |
$39.00 | $97.50 | None |
PALIPERIDONE PALMITATE 156 MG/ML PREFILLED SYRINGE [INVEGA] |
2 |
Tier 2 |
$39.00 | $97.50 | None |
PALIPERIDONE PALMITATE 156 MG/ML PREFILLED SYRINGE [INVEGA] |
2 |
Tier 2 |
$39.00 | $97.50 | None |
PANRETIN 0.1% GEL 60GM TUBE |
2 |
Tier 2 |
$39.00 | $97.50 | None |
PANTOPRAZOLE SODIUM 20MG TABLET DELAYED RELEASE |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PANTOPRAZOLE SODIUM 40MG TABLET DELAYED RELEASE 90 CRC BOT |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PAROXETINE 40MG TABLET (500 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PAROXETINE FILM COATED 20MG TABLET (100 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | 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 |
$6.00 | $15.00 | None |
PAROXETINE HCL TABLET 24 12.5MG |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PAROXETINE HCL TABLET 24 25MG |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PAROXETINE TABLETS |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PAROXETINE TABLETS 30MG 90 BOT |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PASER GRANULES 4GM PACKET |
3 |
Tier 3 |
$69.00 | $172.50 | None |
PATADAY 0.2% DROPS |
2 |
Tier 2 |
$39.00 | $97.50 | None |
PAZOPANIB 200 MG ORAL TABLET [VOTRIENT] |
2 |
Tier 2 |
$39.00 | $97.50 | P |
PEDIARIX SOLUTION INJECTION 25-25-10 10 X .5ML VIAL |
2 |
Tier 2 |
$39.00 | $97.50 | None |
PEDVAXHIB VACCINE VIAL |
2 |
Tier 2 |
$39.00 | $97.50 | None |
PEG-INTRON 100MCG KIT |
4 |
Tier 4 |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PEGANONE 250MG TABLET |
2 |
Tier 2 |
$39.00 | $97.50 | None |
PEGASYS 180MCG/0.5ML CONV.PK |
4 |
Tier 4 |
33% | 33% | P |
PENICILLIN G POTASSIUM 2MMUNITS/50ML ISO-OSM |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PENICILLIN G POTASSIUM 3MMUNITS/50ML ISO-OSM |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PENICILLIN G POTASSIUM FOR INJECTION |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PENICILLIN V POTASSIUM 250MG TABLET (1000 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PENICILLIN V POTASSIUM 250MG/5ML LIQUID |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PENICILLIN V POTASSIUM 500MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PENICILLIN V POTASSIUM FOR ORAL SOLUTION CONCENTRATE 125MG 200ML BOT |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PENTAM 300 INJ 300MG |
3 |
Tier 3 |
$69.00 | $172.50 | None |
PENTOXIFYLLINE 400MG TABLET SA |
1 |
Tier 1 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PERCOCET 10/650MG TABLET |
3 |
Tier 3 |
$69.00 | $172.50 | None |
PERMETHRIN 5% CREAM |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PERPHENAZINE TABLETS 16MG 100 BOT |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PERPHENAZINE TABLETS 4MG 100 BOXUD |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PERPHENAZINE TABLETS 8MG 100 BOT |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PERPHENAZINE TABLETS USP 2MG 100 BOT |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PHENYTEK 200 MG CAPSULE |
3 |
Tier 3 |
$69.00 | $172.50 | None |
PHENYTEK 300 MG CAPSULE |
3 |
Tier 3 |
$69.00 | $172.50 | None |
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PHENYTOIN SODIUM EXTENDED CAPSULES 100MG (100 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PHENYTOIN SODIUM INJECTION 50MG 25 X 2ML AMP |
1 |
Tier 1 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PILOCARPINE HCL 5MG TABLET (100 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PILOPINE HS 4% EYE GEL |
2 |
Tier 2 |
$39.00 | $97.50 | None |
PINDOLOL 10MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PIPERACILLIN 3GM VIAL |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PIPERACILLIN 40GM BULK VIAL |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PIROXICAM 10 MG CAPSULE |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PIROXICAM 20MG CAPSULE (500 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PLAVIX 75MG TABLET |
2 |
Tier 2 |
$39.00 | $97.50 | Q:30 /30Days |
PORTIA 0.15-0.03 TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
POTASSIUM CHLORIDE 40MEQ IN D5W LACT RNG |
1 |
Tier 1 |
$6.00 | $15.00 | None |
POTASSIUM CHLORIDE 8 MEQ EXTENDED RELEASE TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTASSIUM CHLORIDE ER CAPSULES 10MEQ |
1 |
Tier 1 |
$6.00 | $15.00 | None |
POTASSIUM CHLORIDE EXTENDED RELEASE TABLETS |
1 |
Tier 1 |
$6.00 | $15.00 | None |
POTASSIUM CHLORIDE FOR INJECTION CONCENTRATE |
1 |
Tier 1 |
$6.00 | $15.00 | None |
POTASSIUM CHLORIDE TABLET EXTENED RELEASE |
1 |
Tier 1 |
$6.00 | $15.00 | None |
POTASSIUM CITRATE 10MEQ TABLET SA |
1 |
Tier 1 |
$6.00 | $15.00 | None |
POTASSIUM CITRATE 5MEQ TABLET SA |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PRANDIN 0.5MG TABLET |
2 |
Tier 2 |
$39.00 | $97.50 | None |
PRANDIN 1MG TABLET |
2 |
Tier 2 |
$39.00 | $97.50 | None |
PRANDIN 2MG TABLET |
2 |
Tier 2 |
$39.00 | $97.50 | None |
PRASUGREL 10 MG ORAL TABLET |
3 |
Tier 3 |
$69.00 | $172.50 | P |
PRASUGREL 5 MG ORAL TABLET |
3 |
Tier 3 |
$69.00 | $172.50 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRAVASTATIN SODIUM 20MG TABLET 500 BOT |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PRAVASTATIN SODIUM 40MG TABLET (500 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PRAVASTATIN SODIUM TABLETS 10MG 90 BOT |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PRAZOSIN 5MG CAPSULE |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PRAZOSIN HCL 1MG CAPSULE |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PRAZOSIN HCL 2MG CAPSULE |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PREDNICARBATE 1 MG/ML TOPICAL CREAM |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION 1.0% STERILE 10ML BOTDR |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PREDNISOLONE SOD 1% EYE DROP |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PREDNISOLONE SODIUM PHOSPHATE 15MG/5ML SOLUTION ORAL |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PREDNISOLONE SODIUM PHOSPHATE ORAL SOLUTION |
1 |
Tier 1 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREDNISONE 10MG TABLET (100 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PREDNISONE 1MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PREDNISONE 2.5MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PREDNISONE 20MG TABLET (1000 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PREDNISONE 5 MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PREDNISONE 50MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PREDNISONE 5MG/5ML SOLUTION |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PREMARIN 0.3MG (100 CT) |
2 |
Tier 2 |
$39.00 | $97.50 | None |
PREMARIN 0.45MG TABLET |
2 |
Tier 2 |
$39.00 | $97.50 | None |
PREMARIN 0.625MG (100 CT) |
2 |
Tier 2 |
$39.00 | $97.50 | None |
PREMARIN 0.9MG TABLET |
2 |
Tier 2 |
$39.00 | $97.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREMARIN 1.25MG (100 CT) |
2 |
Tier 2 |
$39.00 | $97.50 | None |
PREMARIN 25MG VIAL |
2 |
Tier 2 |
$39.00 | $97.50 | None |
PREMARIN VAGINAL CREAM /APPL |
2 |
Tier 2 |
$39.00 | $97.50 | None |
PREMPHASE 0.625/5MG TABLET |
2 |
Tier 2 |
$39.00 | $97.50 | None |
PREMPRO 0.3 MG-1.5 MG TABLET #28 EA |
2 |
Tier 2 |
$39.00 | $97.50 | None |
PREMPRO 0.45-1.5 MG TABLET 28 EA |
2 |
Tier 2 |
$39.00 | $97.50 | None |
PRENATABS OBN TABLETS 200;1;150;MG;MG;MCG; 90 BOT |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PREVACID CAPSULES DELAYED RELEASE 15 MG |
2 |
Tier 2 |
$39.00 | $97.50 | None |
PREVACID CAPSULES DELAYED RELEASE 30 MG |
2 |
Tier 2 |
$39.00 | $97.50 | None |
PREVACID SOLUTAB EXTENDED RELEASE ORALLY DISINTEGRATING 30MG 100 BOXUD |
2 |
Tier 2 |
$39.00 | $97.50 | None |
PREVACID SOLUTAB TABLETS DELAYED RELEASE ORALLY DISINTEGRATING 15MG 100 BOXUD |
2 |
Tier 2 |
$39.00 | $97.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREZISTA TABLET 600MG |
3 |
Tier 3 |
$69.00 | $172.50 | None |
PREZISTA TABLET 75MG |
3 |
Tier 3 |
$69.00 | $172.50 | None |
PREZISTA TABLETS 400MG 60 TABLETS BOT |
3 |
Tier 3 |
$69.00 | $172.50 | None |
PRIFTIN 150MG TABLET |
2 |
Tier 2 |
$39.00 | $97.50 | None |
PRIMAQUINE 26.3MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PRIMAXIN I.M. 500MG VIAL |
2 |
Tier 2 |
$39.00 | $97.50 | None |
PRIMAXIN IV 250MG VIAL |
2 |
Tier 2 |
$39.00 | $97.50 | None |
PRIMAXIN IV INJ 500MG |
2 |
Tier 2 |
$39.00 | $97.50 | None |
PRIMIDONE 250MG TABLET (100 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PRIMIDONE 50MG TABLET (500 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PRISTIQ 100MG TABLET SR 24HR |
3 |
Tier 3 |
$69.00 | $172.50 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRISTIQ 50MG TABLET SR 24HR |
3 |
Tier 3 |
$69.00 | $172.50 | P |
PRIVIGEN 10% VIAL |
2 |
Tier 2 |
$39.00 | $97.50 | None |
PROBENECID 500MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PROCAINAMIDE 100MG/ML VIAL |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PROCAINAMIDE 500MG/ML VIAL |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PROCHLORPERAZINE EDISYLATE INJECTION 10MG 10 X 2ML VIALS CRTN |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PROCHLORPERAZINE MALEATE 10MG TABLET (100 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PROCHLORPERAZINE MALEATE 5MG TABLET (100 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PROCRIT 10000U/ML VIAL |
2 |
Tier 2 |
$39.00 | $97.50 | P |
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL |
2 |
Tier 2 |
$39.00 | $97.50 | 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 |
$39.00 | $97.50 | P |
PROCRIT 40000U/ML VIAL PR |
2 |
Tier 2 |
$39.00 | $97.50 | P |
PROCRIT 4000U/ML VIAL 25 X 1ML VIAL |
2 |
Tier 2 |
$39.00 | $97.50 | P |
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY |
2 |
Tier 2 |
$39.00 | $97.50 | P |
PROCTOSOL-HC 2.5% CREAM |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PROGLYCEM 50MG/ML ORAL SUSP |
2 |
Tier 2 |
$39.00 | $97.50 | None |
PROGRAF 0.5MG CAPSULE |
2 |
Tier 2 |
$39.00 | $97.50 | None |
PROGRAF 1MG CAPSULE |
2 |
Tier 2 |
$39.00 | $97.50 | None |
PROGRAF 5MG CAPSULE |
2 |
Tier 2 |
$39.00 | $97.50 | None |
PROGRAF 5MG/ML AMPULE |
2 |
Tier 2 |
$39.00 | $97.50 | None |
PROLASTIN 500MG VIAL |
4 |
Tier 4 |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROLEUKIN 22 MILLION UNITS VL |
2 |
Tier 2 |
$39.00 | $97.50 | None |
PROMACTA TABLETS |
4 |
Tier 4 |
33% | 33% | P |
PROMACTA TABLETS 25 MG |
4 |
Tier 4 |
33% | 33% | P |
PROMETHAZINE 50MG/ML VIAL |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PROMETHAZINE HCL 12.5MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PROMETHAZINE HCL 25MG TABLET (1000 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PROMETHAZINE HCL 50MG TABLET (100 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PROMETHAZINE HCL 6.25MG/5ML SYRUP |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PROMETHAZINE HCL INJECTION 25MG 10 X 1ML VIAL |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 12.5MG 12 BOX |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 25MG 12 BOX |
1 |
Tier 1 |
$6.00 | $15.00 | 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 |
Tier 1 |
$6.00 | $15.00 | None |
PROPAFENONE HCL 225MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PROPAFENONE HCL 300MG TABLET (100 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PROPRANOLOL 20MG/5ML TUBEX |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PROPRANOLOL 40MG/5ML TUBEX |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PROPRANOLOL 60MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PROPRANOLOL 80 MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PROPRANOLOL HCL 20MG TABLET (1000 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PROPRANOLOL HCL CAPSULES ER 120MG (1000 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PROPRANOLOL HCL CAPSULES ER 160MG (1000 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PROPRANOLOL HCL CAPSULES ER 60MG (100 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROPRANOLOL HCL CAPSULES ER 80MG (1000 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PROPRANOLOL HCL INJECTION 1MG 10 PKG OF 10 CRTN |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PROPRANOLOL HCL TABLET USP 10MG (1000 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PROPRANOLOL HCL TABLET USP 40MG (1000 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PROPRANOLOL/HCTZ 80/25 TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PROPYLTHIOURACIL 50MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PROQUAD VIAL |
2 |
Tier 2 |
$39.00 | $97.50 | None |
PROTONIX IV 40MG VIAL |
3 |
Tier 3 |
$69.00 | $172.50 | None |
PROTRIPTYLINE HYDROCHLORIDE TABLETS |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PROTRIPTYLINE HYDROCHLORIDE TABLETS 5MG |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PROVIGIL 100MG TABLET |
2 |
Tier 2 |
$39.00 | $97.50 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROVIGIL 200MG TABLET |
2 |
Tier 2 |
$39.00 | $97.50 | P |
PULMICORT .25MG/2ML RESPULE |
3 |
Tier 3 |
$69.00 | $172.50 | None |
PULMICORT 0.5MG/2ML RESPULE |
3 |
Tier 3 |
$69.00 | $172.50 | None |
PULMOZYME 1MG/ML AMPUL |
3 |
Tier 3 |
$69.00 | $172.50 | None |
PYRAZINAMIDE 500MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
PYRIDOSTIGMINE BROMIDE 60MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |