2011 Medicare Part D Plan Formulary Information |
Optimum Emerald Full (HMO SNP) (H5594-017-0)
Benefit Details
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The Optimum Emerald Full (HMO SNP) (H5594-017-0) Formulary Drugs Starting with the Letter P in Pinellas County, FL: CMS MA Region 9 which includes: FL
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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 |
PANCREAZE 10,500 UNIT CAP DR |
2 |
Tier 2 |
N/A | N/A | None |
PANCREAZE 16,800 UNIT CAP DR |
2 |
Tier 2 |
N/A | N/A | None |
PANCREAZE 21,000 UNIT CAP DR |
2 |
Tier 2 |
N/A | N/A | None |
PANCREAZE 4,200 UNIT CAP DR |
2 |
Tier 2 |
N/A | N/A | None |
PANRETIN 0.1% GEL 60GM TUBE |
2 |
Tier 2 |
N/A | N/A | None |
PANTOPRAZOLE SODIUM 20MG TABLET DELAYED RELEASE |
2 |
Tier 2 |
N/A | N/A | Q:30 /30Days |
PANTOPRAZOLE SODIUM 40MG TABLET DELAYED RELEASE 90 CRC BOT |
2 |
Tier 2 |
N/A | N/A | Q:60 /30Days |
PAROXETINE 40MG TABLET (500 CT) |
1 |
Tier 1 |
N/A | N/A | Q:30 /30Days |
PAROXETINE FILM COATED 20MG TABLET (100 CT) |
1 |
Tier 1 |
N/A | N/A | Q:30 /30Days |
PAROXETINE TABLETS |
1 |
Tier 1 |
N/A | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PAROXETINE TABLETS 30MG 90 BOT |
1 |
Tier 1 |
N/A | N/A | Q:30 /30Days |
PASER GRANULES 4GM PACKET |
2 |
Tier 2 |
N/A | N/A | None |
PAXIL 10MG/5ML SUSPENSION |
2 |
Tier 2 |
N/A | N/A | Q:900 /30Days |
PEDIARIX SOLUTION INJECTION 25-25-10 10 X .5ML VIAL |
2 |
Tier 2 |
N/A | N/A | None |
PEDVAXHIB VACCINE VIAL |
2 |
Tier 2 |
N/A | N/A | None |
PENICILLIN G POTASSIUM FOR INJECTION |
1 |
Tier 1 |
N/A | N/A | P |
PENICILLIN G POTASSIUM FOR INJECTION 5000000UNIT/VIAL |
1 |
Tier 1 |
N/A | N/A | P |
PENICILLIN V POTASSIUM 250MG TABLET (1000 CT) |
1 |
Tier 1 |
N/A | N/A | None |
PENICILLIN V POTASSIUM 250MG/5ML LIQUID |
1 |
Tier 1 |
N/A | N/A | None |
PENICILLIN V POTASSIUM 500MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
PENICILLIN V POTASSIUM FOR ORAL SOLUTION CONCENTRATE 125MG 200ML BOT |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PENTAM 300 INJ 300MG |
1 |
Tier 1 |
N/A | N/A | P |
PENTOXIFYLLINE 400MG TABLET SA |
1 |
Tier 1 |
N/A | N/A | None |
PERMETHRIN 5% CREAM |
1 |
Tier 1 |
N/A | N/A | None |
PERPHENAZINE TABLETS 16MG 100 BOT |
1 |
Tier 1 |
N/A | N/A | None |
PERPHENAZINE TABLETS 4MG 100 BOXUD |
1 |
Tier 1 |
N/A | N/A | None |
PERPHENAZINE TABLETS 8MG 100 BOT |
1 |
Tier 1 |
N/A | N/A | None |
PERPHENAZINE TABLETS USP 2MG 100 BOT |
1 |
Tier 1 |
N/A | N/A | None |
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT |
1 |
Tier 1 |
N/A | N/A | None |
PHENYTOIN SODIUM EXTENDED CAPSULES 100MG (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
PHENYTOIN SODIUM INJECTION 50MG 25 X 2ML AMP |
1 |
Tier 1 |
N/A | N/A | None |
PILOCARPINE HCL 5MG TABLET (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PILOCARPINE HCL 7.5MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
PINDOLOL 10MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
PINDOLOL 5MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
PIPERACILLIN 3GM VIAL |
2 |
Tier 2 |
N/A | N/A | P |
PIPERACILLIN 40GM BULK VIAL |
2 |
Tier 2 |
N/A | N/A | P |
PIROXICAM 10 MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
PIROXICAM 20MG CAPSULE (500 CT) |
1 |
Tier 1 |
N/A | N/A | None |
PODOFILOX 0.5% TOPICAL TUBEX |
1 |
Tier 1 |
N/A | N/A | None |
POLYETH GLYC NF POWDER FOR ORAL SOLUTION 17GM (527 CT) |
1 |
Tier 1 |
N/A | N/A | None |
POLYETHYLENE GLYCOL 3350 105 MG/ML / POTASSIUM CHLORIDE 0.00497 MEQ/ML / SODIUM BICARBONATE 1.43 MG/ |
1 |
Tier 1 |
N/A | N/A | None |
POLYMYXIN B SUL-TRIMETHOPRIM 10K U-0.1% |
1 |
Tier 1 |
N/A | 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 |
N/A | N/A | None |
POTASSIUM CHLORIDE 0.075%/D5W/SODIUM CHLORIDE 0.2% |
2 |
Tier 2 |
N/A | N/A | None |
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.3% |
2 |
Tier 2 |
N/A | N/A | None |
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.45% |
2 |
Tier 2 |
N/A | N/A | None |
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.9% 1000ML |
2 |
Tier 2 |
N/A | N/A | None |
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.2% |
2 |
Tier 2 |
N/A | N/A | None |
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.45% 1000ML BAG |
2 |
Tier 2 |
N/A | N/A | None |
POTASSIUM CHLORIDE 20MEQ IN D5W LACT RNG |
1 |
Tier 1 |
N/A | N/A | None |
POTASSIUM CHLORIDE 20MEQ IN D5W/NACL 0.225% |
2 |
Tier 2 |
N/A | N/A | None |
POTASSIUM CHLORIDE 40MEQ IN D5W LACT RNG |
1 |
Tier 1 |
N/A | N/A | None |
POTASSIUM CHLORIDE 40MEQ IN D5W/NACL 0.9% |
2 |
Tier 2 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTASSIUM CHLORIDE 8 MEQ EXTENDED RELEASE TABLET |
1 |
Tier 1 |
N/A | N/A | None |
POTASSIUM CHLORIDE ER CAPSULES 10MEQ |
1 |
Tier 1 |
N/A | N/A | None |
POTASSIUM CHLORIDE ER CPCR 8MEQ |
1 |
Tier 1 |
N/A | N/A | None |
POTASSIUM CHLORIDE EXTENDED RELEASE TABLETS |
1 |
Tier 1 |
N/A | N/A | None |
POTASSIUM CHLORIDE FOR INJECTION CONCENTRATE |
1 |
Tier 1 |
N/A | N/A | None |
POTASSIUM CHLORIDE IN 10% DEXTROSE AND NACL SOLUTION FOR INJECTION |
2 |
Tier 2 |
N/A | N/A | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND 0.2% NACL SOLUTION FOR INJECTION USP 0.15% 250ML X 24 CASE |
2 |
Tier 2 |
N/A | N/A | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND NACL SOLUTION FOR INJECTION 0.075% 1000ML PLASTIC BAGS X 12 CA |
2 |
Tier 2 |
N/A | N/A | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION |
2 |
Tier 2 |
N/A | N/A | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION |
1 |
Tier 1 |
N/A | N/A | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE INJECTION 40 12 X 1000ML CTR |
2 |
Tier 2 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTASSIUM CHLORIDE TABLET EXTENED RELEASE |
1 |
Tier 1 |
N/A | N/A | None |
POTASSIUM CITRATE 10MEQ TABLET SA |
1 |
Tier 1 |
N/A | N/A | None |
POTASSIUM CITRATE 5MEQ TABLET SA |
1 |
Tier 1 |
N/A | N/A | None |
PRAMIPEXOLE 0.125 MG TABLET |
1 |
Tier 1 |
N/A | N/A | Q:90 /30Days |
PRAMIPEXOLE 0.25 MG TABLET |
1 |
Tier 1 |
N/A | N/A | Q:90 /30Days |
PRAMIPEXOLE 0.5 MG TABLET |
1 |
Tier 1 |
N/A | N/A | Q:90 /30Days |
PRAMIPEXOLE 1 MG TABLET |
1 |
Tier 1 |
N/A | N/A | Q:90 /30Days |
PRAMIPEXOLE 1.5 MG TABLET |
1 |
Tier 1 |
N/A | N/A | Q:90 /30Days |
PRAMIPEXOLE DIHYDROCHLORIDE TABLETS |
1 |
Tier 1 |
N/A | N/A | Q:90 /30Days |
PRAVASTATIN SODIUM 20MG TABLET 500 BOT |
1 |
Tier 1 |
N/A | N/A | Q:30 /30Days |
PRAVASTATIN SODIUM 40MG TABLET (500 CT) |
1 |
Tier 1 |
N/A | N/A | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRAVASTATIN SODIUM 80MG TABLET (90 CT) |
1 |
Tier 1 |
N/A | N/A | Q:30 /30Days |
PRAVASTATIN SODIUM TABLETS 10MG 90 BOT |
1 |
Tier 1 |
N/A | N/A | Q:30 /30Days |
PRAZOSIN 5MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
PRAZOSIN HCL 1MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
PRAZOSIN HCL 2MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
PREDNICARBATE 0.1% OINTMENT |
1 |
Tier 1 |
N/A | N/A | None |
PREDNICARBATE 1 MG/ML TOPICAL CREAM |
1 |
Tier 1 |
N/A | N/A | None |
PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION 1.0% STERILE 10ML BOTDR |
1 |
Tier 1 |
N/A | N/A | None |
PREDNISOLONE SOD 1% EYE DROP |
1 |
Tier 1 |
N/A | N/A | None |
PREDNISOLONE SODIUM PHOSPHATE 15MG/5ML SOLUTION ORAL |
1 |
Tier 1 |
N/A | N/A | None |
PREDNISOLONE SODIUM PHOSPHATE ORAL SOLUTION |
1 |
Tier 1 |
N/A | N/A | 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 |
N/A | N/A | None |
PREDNISONE 1MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
PREDNISONE 2.5MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
PREDNISONE 20MG TABLET (1000 CT) |
1 |
Tier 1 |
N/A | N/A | None |
PREDNISONE 5 MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
PREDNISONE 50MG TABLET |
1 |
Tier 1 |
N/A | N/A | P |
PREDNISONE 5MG/5ML SOLUTION |
1 |
Tier 1 |
N/A | N/A | None |
PREDNISONE 5MG/ML SOLUTION |
1 |
Tier 1 |
N/A | N/A | None |
PREGNYL INJ 10000UNT |
1 |
Tier 1 |
N/A | N/A | P |
PREMARIN 0.3MG (100 CT) |
2 |
Tier 2 |
N/A | N/A | Q:30 /30Days |
PREMARIN 0.45MG TABLET |
2 |
Tier 2 |
N/A | N/A | 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 |
Tier 2 |
N/A | N/A | Q:30 /30Days |
PREMARIN 0.9MG TABLET |
2 |
Tier 2 |
N/A | N/A | Q:30 /30Days |
PREMARIN 1.25MG (100 CT) |
2 |
Tier 2 |
N/A | N/A | Q:30 /30Days |
PREMPHASE 0.625/5MG TABLET |
2 |
Tier 2 |
N/A | N/A | Q:30 /30Days |
PREMPRO 0.3 MG-1.5 MG TABLET #28 EA |
2 |
Tier 2 |
N/A | N/A | Q:30 /30Days |
PREMPRO 0.45-1.5 MG TABLET 28 EA |
2 |
Tier 2 |
N/A | N/A | Q:30 /30Days |
PRENATABS OBN TABLETS 200;1;150;MG;MG;MCG; 90 BOT |
1 |
Tier 1 |
N/A | N/A | None |
PREVIFEM TABLETS .035;.25MG;MG 28 BLPK |
1 |
Tier 1 |
N/A | N/A | None |
PRIMIDONE 250MG TABLET (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
PRIMIDONE 50MG TABLET (500 CT) |
1 |
Tier 1 |
N/A | N/A | None |
PROBENECID 500MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROBENECID/COLCHICINE TABLET S |
1 |
Tier 1 |
N/A | N/A | None |
PROCHLORPERAZINE EDISYLATE INJECTION 10MG 10 X 2ML VIALS CRTN |
1 |
Tier 1 |
N/A | N/A | None |
PROCHLORPERAZINE MALEATE 10MG TABLET (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
PROCHLORPERAZINE MALEATE 5MG TABLET (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX |
1 |
Tier 1 |
N/A | N/A | None |
PROCTOZONE-HC 2.5% CREAM |
1 |
Tier 1 |
N/A | N/A | None |
PROGLYCEM 50MG/ML ORAL SUSP |
2 |
Tier 2 |
N/A | N/A | None |
PROMETHAZINE HCL 12.5MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
PROMETHAZINE HCL 25MG TABLET (1000 CT) |
1 |
Tier 1 |
N/A | N/A | None |
PROMETHAZINE HCL 50MG TABLET (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
PROMETHAZINE HCL 6.25MG/5ML SYRUP |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROMETHAZINE HCL INJECTION 25MG 10 X 1ML VIAL |
1 |
Tier 1 |
N/A | N/A | P |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 12.5MG 12 BOX |
1 |
Tier 1 |
N/A | N/A | None |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 25MG 12 BOX |
1 |
Tier 1 |
N/A | N/A | None |
PROPAFENONE HCL 225MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
PROPAFENONE HCL 300MG TABLET (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
PROPRANOLOL 20MG/5ML TUBEX |
1 |
Tier 1 |
N/A | N/A | None |
PROPRANOLOL 40MG/5ML TUBEX |
1 |
Tier 1 |
N/A | N/A | None |
PROPRANOLOL 60MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
PROPRANOLOL 80 MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
PROPRANOLOL HCL 20MG TABLET (1000 CT) |
1 |
Tier 1 |
N/A | N/A | None |
PROPRANOLOL HCL CAPSULES ER 120MG (1000 CT) |
1 |
Tier 1 |
N/A | N/A | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROPRANOLOL HCL CAPSULES ER 160MG (1000 CT) |
1 |
Tier 1 |
N/A | N/A | Q:120 /30Days |
PROPRANOLOL HCL CAPSULES ER 60MG (100 CT) |
1 |
Tier 1 |
N/A | N/A | Q:30 /30Days |
PROPRANOLOL HCL CAPSULES ER 80MG (1000 CT) |
1 |
Tier 1 |
N/A | N/A | Q:30 /30Days |
PROPRANOLOL HCL INJECTION 1MG 10 PKG OF 10 CRTN |
1 |
Tier 1 |
N/A | N/A | P |
PROPRANOLOL HCL TABLET USP 10MG (1000 CT) |
1 |
Tier 1 |
N/A | N/A | None |
PROPRANOLOL HCL TABLET USP 40MG (1000 CT) |
1 |
Tier 1 |
N/A | N/A | None |
PROPRANOLOL/HCTZ 40/25 TABLET |
1 |
Tier 1 |
N/A | N/A | None |
PROPRANOLOL/HCTZ 80/25 TABLET |
1 |
Tier 1 |
N/A | N/A | None |
PROPYLTHIOURACIL 50MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
PROQUAD VIAL |
2 |
Tier 2 |
N/A | N/A | None |
PROTRIPTYLINE HYDROCHLORIDE TABLETS |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROTRIPTYLINE HYDROCHLORIDE TABLETS 5MG |
1 |
Tier 1 |
N/A | N/A | None |
PYRAZINAMIDE 500MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
PYRIDOSTIGMINE BROMIDE 60MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |