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Blue MedicareRx Premier (PDP) (S5596-003-0)
Tier 1 (1617)
Tier 2 (563)
Tier 3 (1426)
Tier 4 (554)
Tier 5 (339)
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2011 Medicare Part D Plan Formulary Information
Blue MedicareRx Premier (PDP) (S5596-003-0)
Benefit Details           
The Blue MedicareRx Premier (PDP) (S5596-003-0)
Formulary Drugs Starting with the Letter C

in CMS PDP Region 01 which includes: ME NH
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 0.5 MG TABLET   1 Tier 1 $6.00$9.00None
CADUET 10MG/10MG TABLET   3 Tier 3 $85.00$212.50Q:30
/30Days
CADUET 10MG/20MG TABLET   3 Tier 3 $85.00$212.50Q:30
/30Days
CADUET 10MG/40MG TABLET   3 Tier 3 $85.00$212.50Q:30
/30Days
CADUET 10MG/80MG TABLET   3 Tier 3 $85.00$212.50Q:30
/30Days
CADUET 2.5MG/10MG TABLET   3 Tier 3 $85.00$212.50Q:30
/30Days
CADUET 2.5MG/20MG TABLET   3 Tier 3 $85.00$212.50Q:30
/30Days
CADUET 2.5MG/40MG TABLET   3 Tier 3 $85.00$212.50Q:30
/30Days
CADUET 5MG/10MG TABLET   3 Tier 3 $85.00$212.50Q:30
/30Days
CADUET 5MG/20MG TABLET   3 Tier 3 $85.00$212.50Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CADUET 5MG/40MG TABLET   3 Tier 3 $85.00$212.50Q:30
/30Days
CADUET 5MG/80MG TABLET   3 Tier 3 $85.00$212.50Q:30
/30Days
CAFERGOT EROGOTAMINE TARTRATE AND CAFFINE TABLETS 1;100MG;MG 100 BOT   3 Tier 3 $85.00$212.50None
CALAN 120MG TABLET   3 Tier 3 $85.00$212.50None
CALAN 80MG TABLET   3 Tier 3 $85.00$212.50None
CALAN SR 120MG CAPLET SA   3 Tier 3 $85.00$212.50None
CALAN SR 180MG CAPLET SA   3 Tier 3 $85.00$212.50None
CALAN SR TABLET 240MG (500 CT)   3 Tier 3 $85.00$212.50None
CALCIJEX 1 MCG/ML AMPUL   4 Tier 4 33%33%P
CALCIPOTRIENE OINTMENT   1 Tier 1 $6.00$9.00Q:200
/30Days
CALCIPOTRIENE TOPICAL SOLUTION   1 Tier 1 $6.00$9.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY   1 Tier 1 $6.00$9.00Q:4
/30Days
CALCITRIOL 0.00025 MG ORAL CAPSULE [ROCALTROL]   3 Tier 3 $85.00$212.50None
CALCITRIOL 0.0005 MG ORAL CAPSULE [ROCALTROL]   3 Tier 3 $85.00$212.50None
CALCITRIOL 0.001 MG/ML ORAL SOLUTION [ROCALTROL]   3 Tier 3 $85.00$212.50None
CALCITRIOL 0.25MCG CAPSULE   1 Tier 1 $6.00$9.00None
CALCITRIOL 0.5MCG CAPSULE   1 Tier 1 $6.00$9.00None
CALCITRIOL 1MCG/ML SOLUTION ORAL   1 Tier 1 $6.00$9.00None
CALCITRIOL 2 MCG/ML VIAL   4 Tier 4 33%33%P
CALCITRIOL INJECTION SOLUTION 1MCG 50 X 01ML AMP   4 Tier 4 33%33%P
CALCIUM ACETATE CAPSULE 667 MG   1 Tier 1 $6.00$9.00None
CALCIUM CHLORIDE 0.0014 MEQ/ML / POTASSIUM CHLORIDE 0.004 MEQ/ML / SODIUM CHLORIDE 0.103 MEQ/ML / SO   4 Tier 4 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CAMILA 0.35MG TABLET   1 Tier 1 $6.00$9.00Q:28
/28Days
CAMPATH 30MG/ML VIAL   5 Tier 5 33%N/ANone
CAMPRAL 333MG DOSE PAK   2 Tier 2 $43.00$107.50None
CAMPTOSAR 20MG/ML VIAL   5 Tier 5 33%N/AP
CANASA RECTAL SUPPOSITORIES 1000MG 30 BOX   2 Tier 2 $43.00$107.50None
CANCIDAS IV 50MG VIAL   5 Tier 5 33%N/ANone
CANCIDAS IV 70MG VIAL   5 Tier 5 33%N/ANone
CANTIL 25MG TABLET   3 Tier 3 $85.00$212.50None
CAPEX SHA 0.01%   3 Tier 3 $85.00$212.50None
CAPITAL W/CODEINE ORAL SUSP   3 Tier 3 $85.00$212.50Q:2700
/30Days
CAPREOMYCIN 500 MG/ML INJECTABLE SOLUTION [CAPASTAT]   4 Tier 4 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CAPTOPRIL 100MG TABLET   1 Tier 1 $6.00$9.00None
CAPTOPRIL 12.5MG TABLET   1 Tier 1 $6.00$9.00None
CAPTOPRIL 25MG TABLET   1 Tier 1 $6.00$9.00None
CAPTOPRIL 50MG TABLET   1 Tier 1 $6.00$9.00None
CAPTOPRIL/HCTZ 25/15 TABLET   1 Tier 1 $6.00$9.00None
CAPTOPRIL/HCTZ 25/25 TABLET   1 Tier 1 $6.00$9.00None
CAPTOPRIL/HCTZ 50/15 TABLET   1 Tier 1 $6.00$9.00None
CAPTOPRIL/HCTZ 50/25 TABLET   1 Tier 1 $6.00$9.00None
CARAC CRE 0.5%   3 Tier 3 $85.00$212.50None
CARAFATE SUCRALFATE 1G TABLET ORAL   3 Tier 3 $85.00$212.50None
CARAFATE SUS 1GM/10ML   3 Tier 3 $85.00$212.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARBAMAZEPINE EXTENDED RELEASE TABLETS 200MG   1 Tier 1 $6.00$9.00None
CARBAMAZEPINE EXTENDED RELEASE TABLETS 400MG   1 Tier 1 $6.00$9.00None
CARBAMAZEPINE ORAL SUSPENSION 200 MG   1 Tier 1 $6.00$9.00None
CARBAMAZEPINE TABLET CHEWABLE 100MG (100 CT)   1 Tier 1 $6.00$9.00None
CARBAMAZEPINE TABLET USP 200MG (1000 CT)   1 Tier 1 $6.00$9.00None
CARBATROL 100MG CAPSULE SA   2 Tier 2 $43.00$107.50Q:60
/30Days
CARBATROL 200MG CAPSULE SA   2 Tier 2 $43.00$107.50Q:240
/30Days
CARBATROL 300MG CAPSULE SA   2 Tier 2 $43.00$107.50Q:150
/30Days
CARBIDOPA AND LEVEDOPA ORALLY DISINTEGRATING TABLETS 10;100MG;MG 100 BOT   1 Tier 1 $6.00$9.00None
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;100MG;MG 100 BOT   1 Tier 1 $6.00$9.00None
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;250MG;MG 100 BOT   1 Tier 1 $6.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARBIDOPA-LEVODOPA 25MG-100MG TABLET SA   1 Tier 1 $6.00$9.00None
CARBIDOPA-LEVODOPA 50MG-200MG TABLET SA   1 Tier 1 $6.00$9.00None
CARBIDOPA/LEVO 10/100 TABLET   1 Tier 1 $6.00$9.00None
CARBIDOPA/LEVO 25/100 TABLET   1 Tier 1 $6.00$9.00None
CARBIDOPA/LEVO 25/250 TABLET   1 Tier 1 $6.00$9.00None
CARBINOXAMINE 4 MG ORAL TABLET   1 Tier 1 $6.00$9.00None
CARBINOXAMINE MALEATE SOLUTION 4MG/5ML 16 OZ BOT   1 Tier 1 $6.00$9.00None
CARBOPLATIN INJECTION   4 Tier 4 33%33%P
CARDIZEM 120MG TABLET   3 Tier 3 $85.00$212.50None
CARDIZEM 30MG TABLET   3 Tier 3 $85.00$212.50None
CARDIZEM 60MG TABLET   3 Tier 3 $85.00$212.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARDIZEM 90MG TABLET   3 Tier 3 $85.00$212.50None
CARDIZEM CAPSULES 180MG (90 CT)   3 Tier 3 $85.00$212.50None
CARDIZEM CD 120MG CAPSULE SR 24 HR   3 Tier 3 $85.00$212.50None
CARDIZEM CD 240MG CAPSULE SR 24 HR   3 Tier 3 $85.00$212.50None
CARDIZEM CD 300MG CAPSULE SR 24 HR   3 Tier 3 $85.00$212.50None
CARDIZEM CD 360MG CAPSULE SR 24 HR   3 Tier 3 $85.00$212.50None
CARDIZEM LA EXTENDED RELEASE TABLETS 120MG 90 BOT   3 Tier 3 $85.00$212.50None
CARDIZEM LA EXTENDED RELEASE TABLETS 180MG 90 BOT   3 Tier 3 $85.00$212.50None
CARDIZEM LA EXTENDED RELEASE TABLETS 240MG 90 BOT   3 Tier 3 $85.00$212.50None
CARDIZEM LA EXTENDED RELEASE TABLETS 300MG 90 BOT   3 Tier 3 $85.00$212.50None
CARDIZEM LA EXTENDED RELEASE TABLETS 360MG 30 BOT   3 Tier 3 $85.00$212.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARDIZEM LA EXTENDED RELEASE TABLETS 420MG 30 BOT   3 Tier 3 $85.00$212.50None
CARDURA 1MG TABLET   3 Tier 3 $85.00$212.50None
CARDURA 2MG TABLET   3 Tier 3 $85.00$212.50None
CARDURA 4MG TABLET   3 Tier 3 $85.00$212.50None
CARDURA 8MG TABLET   3 Tier 3 $85.00$212.50None
CARDURA XL 4MG TABLET   3 Tier 3 $85.00$212.50None
CARDURA XL 8MG TABLET   3 Tier 3 $85.00$212.50None
CARIMUNE NF 3GM VIAL   5 Tier 5 33%N/AP
CARISOPRODOL AND ASPIRIN TABLETS USP 325;200MG;MG 100 BOTPL   1 Tier 1 $6.00$9.00None
CARISOPRODOL ASPIRIN AND CODEINE PHOSPHATE TABLETS USP 325;200;16MG;MG;MG 100 BOTPL   1 Tier 1 $6.00$9.00None
CARISOPRODOL TABLET USP 350MG (100 CT)   1 Tier 1 $6.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARMOL HC 1%-10% CREAM   3 Tier 3 $85.00$212.50None
CARNITOR 100MG/ML ORAL TUBEX   3 Tier 3 $85.00$212.50P
CARNITOR 1GM/5ML VIAL   4 Tier 4 33%33%P
CARNITOR 330MG TABLET   3 Tier 3 $85.00$212.50P
CARTEOLOL HCL OPHTHALMIC SOLUTION USP 1% 15ML BOT   1 Tier 1 $6.00$9.00None
CARTIA XT 120MG CAPSULE SA   1 Tier 1 $6.00$9.00None
CARTIA XT 180MG CAPSULE SA   1 Tier 1 $6.00$9.00None
CARTIA XT 240MG CAPSULE SA   1 Tier 1 $6.00$9.00None
CARTIA XT 300MG CAPSULE SR 24 HR   1 Tier 1 $6.00$9.00None
CARVEDILOL 12.5MG TABLET (100 CT)   1 Tier 1 $6.00$9.00None
CARVEDILOL 25MG TABLET (500 CT)   1 Tier 1 $6.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARVEDILOL 3.125MG TABLET (100 CT)   1 Tier 1 $6.00$9.00None
CARVEDILOL 6.25MG TABLET (500 CT)   1 Tier 1 $6.00$9.00None
CASODEX 50MG TABLET   3 Tier 3 $85.00$212.50None
CATAFLAM 50MG TABLET   3 Tier 3 $85.00$212.50None
CATAPRES 0.1MG TABLET   3 Tier 3 $85.00$212.50None
CATAPRES 0.2MG TABLET   3 Tier 3 $85.00$212.50None
CATAPRES 0.3MG TABLET   3 Tier 3 $85.00$212.50None
CATAPRES-TTS DIS 0.3/24HR   3 Tier 3 $85.00$212.50Q:4
/28Days
CATAPRES-TTS-1 PATCH 2.52.5MG/UNT 1 X 4 CRTN   3 Tier 3 $85.00$212.50Q:4
/28Days
CATAPRES-TTS-2 PATCH 52.5MG/UNT 1 X 4 CRTN   3 Tier 3 $85.00$212.50Q:4
/28Days
CAYSTON KIT   5 Tier 5 33%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEDAX 400MG CAPSULE   3 Tier 3 $85.00$212.50None
CEENU 100MG CAPSULE   2 Tier 2 $43.00$107.50None
CEENU 10MG CAPSULE   2 Tier 2 $43.00$107.50None
CEENU 40MG CAPSULE   2 Tier 2 $43.00$107.50None
CEFACLOR 250MG/5ML ORAL SUSP   1 Tier 1 $6.00$9.00None
CEFACLOR 375MG/5ML ORAL SUSP   1 Tier 1 $6.00$9.00None
CEFACLOR CAPSULES   1 Tier 1 $6.00$9.00None
CEFACLOR CAPSULES   1 Tier 1 $6.00$9.00None
CEFACLOR ER 500MG TABLET SR 12HR   1 Tier 1 $6.00$9.00None
CEFACLOR POWDER FOR ORAL SUSPENSION USP 125MG 75ML BOT   1 Tier 1 $6.00$9.00None
CEFADROXIL 1G TABLET   1 Tier 1 $6.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFADROXIL 500MG CAPSULE   1 Tier 1 $6.00$9.00None
CEFADROXIL 500MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Tier 1 $6.00$9.00None
CEFADROXIL FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   1 Tier 1 $6.00$9.00None
CEFAZOLIN 1 GM VIAL   4 Tier 4 33%33%None
CEFAZOLIN 1GM/D5W BAG   4 Tier 4 33%33%None
CEFAZOLIN 20GM BULK VIAL   4 Tier 4 33%33%None
CEFAZOLIN FOR INJECTION   4 Tier 4 33%33%None
CEFDINIR 250MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Tier 1 $6.00$9.00None
CEFDINIR CAPSULES 300MG (60 CT)   1 Tier 1 $6.00$9.00None
CEFDINIR FOR ORAL SUSPENSION 125MG/5ML (100 CT)   1 Tier 1 $6.00$9.00None
CEFEPIME HCL 2 GRAM VIAL   4 Tier 4 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFEPIME INJ 1GM 20ML APX 10x1G VIAL   4 Tier 4 33%33%None
CEFOTAXIME FOR INJECTION   4 Tier 4 33%33%None
CEFOTAXIME FOR INJECTION 1GM 50 BOX VIALGL   4 Tier 4 33%33%None
CEFOTAXIME FOR INJECTION 2GM 25 VIAL   4 Tier 4 33%33%None
CEFOTAXIME FOR INJECTION 500MG 10 VIAL   4 Tier 4 33%33%None
CEFOTETAN 10 GM SOLR   4 Tier 4 33%33%None
CEFOTETAN 1GM VIAL 1EA x 10   4 Tier 4 33%33%None
CEFOTETAN 2GM VIAL 1EA x 10   4 Tier 4 33%33%None
CEFOXITIN 180 MG/ML INJECTABLE SOLUTION   4 Tier 4 33%33%None
CEFOXITIN 95 MG/ML INJECTABLE SOLUTION   4 Tier 4 33%33%None
CEFOXITIN FOR INJECTION 1 GM/50ML   4 Tier 4 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFOXITIN FOR INJECTION 2MG/50ML 50 ML BOT   4 Tier 4 33%33%None
CEFOXITIN FOR INJECTION SOLUTION   4 Tier 4 33%33%None
CEFPODOXIME PROXETIL 200MG TABLET   1 Tier 1 $6.00$9.00None
CEFPODOXIME PROXETIL FILM COATED TABLET 100MG (20 CT)   1 Tier 1 $6.00$9.00None
CEFPODOXIME PROXETIL FOR ORAL SUSPENSION 100MG 50ML BOT   1 Tier 1 $6.00$9.00None
CEFPODOXIME PROXETIL FOR ORAL SUSPENSION 50MG 50ML BOT   1 Tier 1 $6.00$9.00None
CEFPROZIL 250MG TABLET (100 CT)   1 Tier 1 $6.00$9.00None
CEFPROZIL 250MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Tier 1 $6.00$9.00None
CEFPROZIL FOR ORAL SUSPENSION 125MG/5ML 75ML BOT   1 Tier 1 $6.00$9.00None
CEFPROZIL TABLETS 500MG 100 BOT   1 Tier 1 $6.00$9.00None
CEFTAZIDIME FOR INJECTION 1GM/VIAL 1 SINGLE VIAL VIAL   4 Tier 4 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFTAZIDIME FOR INJECTION 2GM/VIAL 10 X 2 CRTN   4 Tier 4 33%33%None
CEFTAZIDIME FOR INJECTION 6GM/VIAL 6 X 6 CRTN   4 Tier 4 33%33%None
CEFTIN 125MG/5ML ORAL SUSP   3 Tier 3 $85.00$212.50None
CEFTIN 250MG TABLET   3 Tier 3 $85.00$212.50None
CEFTIN 250MG/5ML ORAL SUSP   3 Tier 3 $85.00$212.50None
CEFTIN 500MG TABLET (20 CT)   3 Tier 3 $85.00$212.50None
CEFTRIAXONE 10GM VIAL   4 Tier 4 33%33%None
CEFTRIAXONE FOR INJECTION   4 Tier 4 33%33%None
CEFTRIAXONE FOR INJECTION   5 Tier 5 33%N/ANone
CEFTRIAXONE FOR INJECTION 250MG BOX OF 10 VIALGL   4 Tier 4 33%33%None
CEFTRIAXONE FOR INJECTION 500MG BOX OF 10 VIALGL   4 Tier 4 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFUROXIME 250MG TABLET   1 Tier 1 $6.00$9.00None
CEFUROXIME AXETIL 125MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Tier 1 $6.00$9.00None
CEFUROXIME AXETIL 500MG TABLET (20 CT)   1 Tier 1 $6.00$9.00None
CEFUROXIME FOR INJECTION   4 Tier 4 33%33%None
CEFUROXIME FOR INJECTION   4 Tier 4 33%33%None
CEFUROXIME FOR INJECTION   4 Tier 4 33%33%None
CEFUROXIME FOR INJECTION AND DEXTROSE INJECTION   4 Tier 4 33%33%None
CEFUROXIME FOR INJECTION AND DEXTROSE INJECTION   4 Tier 4 33%33%None
CELEBREX 100MG CAPSULE   3 Tier 3 $85.00$212.50P Q:60
/30Days
CELEBREX 200MG CAPSULE   3 Tier 3 $85.00$212.50P Q:60
/30Days
CELEBREX 400MG CAPSULE   3 Tier 3 $85.00$212.50P Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CELEBREX 50MG CAPSULE   3 Tier 3 $85.00$212.50P Q:60
/30Days
CELESTONE 0.6MG/5ML SYRUP   3 Tier 3 $85.00$212.50None
CELEXA 10MG TABLET   3 Tier 3 $85.00$212.50Q:45
/30Days
CELEXA 20MG TABLET   3 Tier 3 $85.00$212.50Q:45
/30Days
CELEXA 40MG TABLET   3 Tier 3 $85.00$212.50Q:30
/30Days
CELLCEPT 200MG/ML ORAL SUSP   5 Tier 5 33%N/AP
CELLCEPT 500MG TABLET   5 Tier 5 33%N/AP
CELLCEPT CAPSULES 250MG (500 CT)   3 Tier 3 $85.00$212.50P
CELLCEPT IV INJ 500MG   4 Tier 4 33%33%P
CELONTIN 300MG KAPSEAL   2 Tier 2 $43.00$107.50None
CENESTIN 0.3MG TABLET   3 Tier 3 $85.00$212.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CENESTIN 0.45MG TABLET   3 Tier 3 $85.00$212.50None
CENESTIN 0.625MG TABLET   3 Tier 3 $85.00$212.50None
CENESTIN 0.9MG TABLET   3 Tier 3 $85.00$212.50None
CENESTIN 1.25MG TABLET   3 Tier 3 $85.00$212.50None
CEPHALEXIN 250MG CAPSULE   1 Tier 1 $6.00$9.00None
CEPHALEXIN 250MG TABLET   1 Tier 1 $6.00$9.00None
CEPHALEXIN 250MG/5ML ORAL SUSP   1 Tier 1 $6.00$9.00None
CEPHALEXIN 500MG TABLET   1 Tier 1 $6.00$9.00None
CEPHALEXIN CAPSULES 500MG (500 CT)   1 Tier 1 $6.00$9.00None
CEPHALEXIN POWDER FOR SUSPENSION ORAL USP 125MG 200ML BOT   1 Tier 1 $6.00$9.00None
CEREBYX 100 MG PE/2 ML VIAL   4 Tier 4 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEREDASE 80UNITS/ML VIAL   5 Tier 5 33%N/AP
CEREZYME INJ 200UNIT   5 Tier 5 33%N/AP
CERUBIDINE 20MG VIAL   4 Tier 4 33%33%P
CESAMET CAPSULES   3 Tier 3 $85.00$212.50None
CESIA 7 DAYS X 3 TABLET   1 Tier 1 $6.00$9.00Q:28
/28Days
CETIRIZINE HCL 5MG/5ML   1 Tier 1 $6.00$9.00Q:300
/30Days
CHANTIX 0.5MG TABLET   3 Tier 3 $85.00$212.50None
CHANTIX 1MG TABLET   3 Tier 3 $85.00$212.50None
CHANTIX STARTING MONTH PAK   3 Tier 3 $85.00$212.50None
CHEMET 100MG CAPSULE   3 Tier 3 $85.00$212.50None
CHLORAMPHEN NA SUCC 1GM VL   4 Tier 4 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CHLORDIAZEPOXIDE AND AMITRIPTYLINE HCL TABLET 12.5-5MG (500 CT)   1 Tier 1 $6.00$9.00None
CHLORHEXIDINE GLUCONATE 0.12% MOUTHWASH   1 Tier 1 $6.00$9.00None
CHLOROQUINE PH 500MG TABLET   1 Tier 1 $6.00$9.00None
CHLOROQUINE PHOSPHATE 250MG TABLET (50 CT)   1 Tier 1 $6.00$9.00None
CHLOROTHIAZIDE 250MG TABLET   1 Tier 1 $6.00$9.00None
CHLOROTHIAZIDE 500MG TABLET   1 Tier 1 $6.00$9.00None
CHLOROTHIAZIDE SODIUM FOR INJECTION 500MG/VIAL   4 Tier 4 33%33%None
CHLORPROMAZINE 100MG TABLET   1 Tier 1 $6.00$9.00None
CHLORPROMAZINE 10MG TABLET   1 Tier 1 $6.00$9.00None
CHLORPROMAZINE 25MG TABLET   1 Tier 1 $6.00$9.00None
CHLORPROMAZINE 25MG/ML AMP   4 Tier 4 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CHLORPROMAZINE 50MG TABLET   1 Tier 1 $6.00$9.00None
CHLORPROMAZINE HCL 200MG TABLET   1 Tier 1 $6.00$9.00None
CHLORPROPAMIDE 100MG TABLET   1 Tier 1 $6.00$9.00None
CHLORPROPAMIDE 250MG TABLET (1000 CT)   1 Tier 1 $6.00$9.00None
CHLORTHALIDONE 25MG TABLET (100 CT)   1 Tier 1 $6.00$9.00None
CHLORTHALIDONE 50MG TABLET (1000 CT)   1 Tier 1 $6.00$9.00None
CHLORZOXAZONE 500MG TABLET   1 Tier 1 $6.00$9.00None
CHOLESTYRAMINE LIGHT POWDER FOR ORAL SUSPENSION   1 Tier 1 $6.00$9.00None
CICLOPIROX 0.77% CREAM   1 Tier 1 $6.00$9.00None
CICLOPIROX 0.77% TOPICAL SUSPENSION   1 Tier 1 $6.00$9.00None
CICLOPIROX 1% SHAMPOO   1 Tier 1 $6.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CICLOPIROX 8% TOPICAL SOLUTION NAIL LACQUER 6.6ML BOT   1 Tier 1 $6.00$9.00P
CICLOPIROX GEL   1 Tier 1 $6.00$9.00None
CILOSTAZOL 50MG TABLET (60 CT)   1 Tier 1 $6.00$9.00None
CILOSTAZOL TABLET 100MG (60 CT)   1 Tier 1 $6.00$9.00None
CILOXAN 0.3% OINTMENT   3 Tier 3 $85.00$212.50Q:8
/30Days
CILOXAN SOLUTION 0.3% 5ML BOT   3 Tier 3 $85.00$212.50None
CIMETIDINE 150MG/ML VIAL   4 Tier 4 33%33%None
CIMETIDINE 200MG TABLET   1 Tier 1 $6.00$9.00None
CIMETIDINE HCL 300MG/5ML SOL   1 Tier 1 $6.00$9.00None
CIMETIDINE TABLETS   1 Tier 1 $6.00$9.00None
CIMETIDINE TABLETS   1 Tier 1 $6.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CIMETIDINE TABLETS USP   1 Tier 1 $6.00$9.00None
CIMZIA 200 MG/ML SYRINGE KIT   5 Tier 5 33%N/AP Q:6
/28Days
CIMZIA KIT   5 Tier 5 33%N/AP Q:6
/28Days
CIPRO (10%) SUS 500MG/5   3 Tier 3 $85.00$212.50None
CIPRO (5%) SUS 250MG/5   3 Tier 3 $85.00$212.50None
CIPRO 250MG TABLET   3 Tier 3 $85.00$212.50Q:28
/1Days
CIPRO 500MG TABLET   3 Tier 3 $85.00$212.50Q:28
/1Days
CIPRO 750MG TABLET   3 Tier 3 $85.00$212.50Q:28
/1Days
CIPRO HC OTIC SUSPENSION   3 Tier 3 $85.00$212.50None
CIPRO IV INFUSION 200MG 100ML BAG   4 Tier 4 33%33%None
CIPRODEX OTIC SUSPENSION   2 Tier 2 $43.00$107.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CIPROFLOXACIN 250MG TABLET (100 CT)   1 Tier 1 $6.00$9.00Q:28
/1Days
CIPROFLOXACIN 400 MG/40 ML VL   4 Tier 4 33%33%None
CIPROFLOXACIN 500MG TABLET   1 Tier 1 $6.00$9.00Q:28
/1Days
CIPROFLOXACIN ER 1000MG TABLET (30 CT)   1 Tier 1 $6.00$9.00Q:14
/1Days
CIPROFLOXACIN ER 500MG TABLET (30 CT)   1 Tier 1 $6.00$9.00Q:3
/1Days
CIPROFLOXACIN HCL 0.3% DROPS   1 Tier 1 $6.00$9.00None
CIPROFLOXACIN HCL 100MG TABLET   1 Tier 1 $6.00$9.00None
CIPROFLOXACIN TABLETS 750MG 100 BOT   1 Tier 1 $6.00$9.00Q:28
/1Days
CISPLATIN 1 MG/ML INJECTABLE SOLUTION   4 Tier 4 33%33%P
CITALOPRAM HBR 20 MG TABLET   1 Tier 1 $6.00$9.00Q:45
/30Days
CITALOPRAM HBR ORAL SOLUTION 10MG 240ML BOTPL   1 Tier 1 $6.00$9.00Q:600
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CITALOPRAM HYDROBROMIDE TABLETS 40MG 30 BOT   1 Tier 1 $6.00$9.00Q:30
/30Days
CITOLOPRAM HBR 10MG TABLET (100 CT)   1 Tier 1 $6.00$9.00Q:45
/30Days
CLADRIBINE 1MG/ML VIAL   5 Tier 5 33%N/AP
CLAFORAN 10GM VIAL   4 Tier 4 33%33%None
CLAFORAN 500MG VIAL   4 Tier 4 33%33%None
CLAFORAN INJECTION ADD VANTAGE SYSTEM 1GM 25 X 1GM VIAL   4 Tier 4 33%33%None
CLAFORAN INJECTION STERILE 2GM 10 X 2GM VIAL   4 Tier 4 33%33%None
CLARAVIS 10MG CAPSULE   1 Tier 1 $6.00$9.00None
CLARAVIS 20MG CAPSULE   1 Tier 1 $6.00$9.00None
CLARAVIS 30MG CAPSULE   1 Tier 1 $6.00$9.00None
CLARAVIS 40MG CAPSULE   1 Tier 1 $6.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLARITHROMYCIN 250MG TABLET   1 Tier 1 $6.00$9.00Q:42
/1Days
CLARITHROMYCIN 500MG TABLET   1 Tier 1 $6.00$9.00Q:28
/1Days
CLARITHROMYCIN ER 500MG TABLET (60 CT)   1 Tier 1 $6.00$9.00Q:28
/1Days
CLARITHROMYCIN FOR ORAL SUSPENSION   1 Tier 1 $6.00$9.00Q:200
/1Days
CLARITHROMYCIN FOR ORAL SUSPENSION   1 Tier 1 $6.00$9.00None
CLEMASTINE FUM 2.68MG TABLET   1 Tier 1 $6.00$9.00None
CLEMASTINE FUMARATE SYRUP   1 Tier 1 $6.00$9.00None
CLEOCIN 100MG VAGINAL OVULE   3 Tier 3 $85.00$212.50None
CLEOCIN 2% VAGINAL CREAM   3 Tier 3 $85.00$212.50None
CLEOCIN 300MG/D5W/GALAXY   4 Tier 4 33%33%None
CLEOCIN 600MG/D5W/GALAXY   4 Tier 4 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLEOCIN 900MG/D5W/GALAXY   4 Tier 4 33%33%None
CLEOCIN HCL 150MG CAPSULE   3 Tier 3 $85.00$212.50None
CLEOCIN HCL 300MG CAPSULE   3 Tier 3 $85.00$212.50None
CLEOCIN HCL 75MG CAPSULE   3 Tier 3 $85.00$212.50None
CLEOCIN PED SOL 75MG/5ML   3 Tier 3 $85.00$212.50None
CLEOCIN PHOS 150MG/ML VIAL   4 Tier 4 33%33%None
CLEOCIN T 1% GEL   3 Tier 3 $85.00$212.50None
CLEOCIN T 1% LOTION   3 Tier 3 $85.00$212.50None
CLEOCIN T 1% PLEDGETS   3 Tier 3 $85.00$212.50None
CLEOCIN T 1% SOLUTION   3 Tier 3 $85.00$212.50None
CLIMARA 0.025MG/DAY PATCH   3 Tier 3 $85.00$212.50Q:4
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLIMARA 0.0375MG/DAY PATCH   3 Tier 3 $85.00$212.50Q:4
/28Days
CLIMARA 0.05MG/24H PATCH   3 Tier 3 $85.00$212.50Q:4
/28Days
CLIMARA 0.06/MG DAY PATCH   3 Tier 3 $85.00$212.50Q:4
/28Days
CLIMARA 0.075MG/DAY PATCH   3 Tier 3 $85.00$212.50Q:4
/28Days
CLIMARA 0.1MG/24H PATCH   3 Tier 3 $85.00$212.50Q:4
/28Days
CLIMARA PRO DIS WEEKLY 4.40MG/1.39MG   2 Tier 2 $43.00$107.50Q:4
/28Days
CLINDAGEL 1% GEL   3 Tier 3 $85.00$212.50None
CLINDAMYCIN 150MG/ML ADDVAN   4 Tier 4 33%33%None
CLINDAMYCIN HCL 150MG CAPSULE   1 Tier 1 $6.00$9.00None
CLINDAMYCIN HYDROCHLORIDE CAPSULES   1 Tier 1 $6.00$9.00None
CLINDAMYCIN PHOSP 1% LOTION   1 Tier 1 $6.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLINDAMYCIN PHOSPHATE 1% FOAM   3 Tier 3 $85.00$212.50None
CLINDAMYCIN PHOSPHATE 1% SOLUTION NON-ORAL   1 Tier 1 $6.00$9.00None
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE   1 Tier 1 $6.00$9.00None
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX   1 Tier 1 $6.00$9.00None
CLINDAMYCIN PHOSPHATE VAGINAL CREAM   1 Tier 1 $6.00$9.00None
CLINDESSE 2% VAGINAL CREAM   3 Tier 3 $85.00$212.50None
CLINIMIX 2.75%/5% INJECTION 1000ML BAG   4 Tier 4 33%33%None
CLINIMIX 4.25/10 SOLUTION   4 Tier 4 33%33%None
CLINIMIX 4.25/20 SOLUTION   4 Tier 4 33%33%None
CLINIMIX 4.25/25 SOLUTION   4 Tier 4 33%33%None
CLINIMIX 4.25/5 SOLUTION   4 Tier 4 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLINIMIX 5/15 SOLUTION   4 Tier 4 33%33%None
CLINIMIX 5/20 SOLUTION   4 Tier 4 33%33%None
CLINIMIX 5/25 SULFITE FREE INJECTIONS 1035MG-420MEQ 1000ML BAG   4 Tier 4 33%33%None
CLINIMIX E 2.75/10 SOLUTION   4 Tier 4 33%33%None
CLINIMIX E 2.75/5 SOLUTION   4 Tier 4 33%33%None
CLINIMIX E 4.25/25 SOLUTION   4 Tier 4 33%33%None
CLINIMIX E 4.25/5 SOLUTION   4 Tier 4 33%33%None
CLINIMIX E 5/20 SOLUTION   4 Tier 4 33%33%None
CLINIMIX E 5/25 SOLUTION   4 Tier 4 33%33%None
CLINIMIX E 5%/15% INJECTION 2000ML BAG   4 Tier 4 33%33%None
CLINISOL 15% SOLUTION   4 Tier 4 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLINORIL 200MG TABLET   3 Tier 3 $85.00$212.50None
CLOBETASOL 0.05% OINTMENT   1 Tier 1 $6.00$9.00None
CLOBETASOL 0.05% SOLUTION   1 Tier 1 $6.00$9.00None
CLOBETASOL E 0.05% CREAM   1 Tier 1 $6.00$9.00None
CLOBETASOL PROPIONATE 0.05% FOAM   1 Tier 1 $6.00$9.00None
CLOBETASOL PROPIONATE CRM 0.05% 15GM   3 Tier 3 $85.00$212.50None
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE   1 Tier 1 $6.00$9.00None
CLOBEX 0.05% SHAMPOO   3 Tier 3 $85.00$212.50None
CLOBEX 0.05% SPRAY NON-AEROSOL   3 Tier 3 $85.00$212.50None
CLOBEX 0.05% TOPICAL LOTION   3 Tier 3 $85.00$212.50None
CLODERM 0.1% CREAM   3 Tier 3 $85.00$212.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLOLAR 1MG/ML VIAL   5 Tier 5 33%N/AP
CLOMIPRAMINE HCL 25MG CAPSULE   1 Tier 1 $6.00$9.00None
CLOMIPRAMINE HCL 50MG CAPSULE   1 Tier 1 $6.00$9.00None
CLOMIPRAMINE HCL 75MG CAPSULE   1 Tier 1 $6.00$9.00None
CLONIDINE HCL 0.2MG TABLET (500 CT)   1 Tier 1 $6.00$9.00None
CLONIDINE HCL TABLET 0.1MG (500 CT)   1 Tier 1 $6.00$9.00None
CLONIDINE HCL TABLET 0.3MG (100 CT)   1 Tier 1 $6.00$9.00None
CLONIDINE PATCH 0.1MG/DAY   1 Tier 1 $6.00$9.00Q:4
/28Days
CLONIDINE PATCH 0.2MG/DAY   1 Tier 1 $6.00$9.00Q:4
/28Days
CLONIDINE PATCH 0.3MG/DAY   1 Tier 1 $6.00$9.00Q:4
/28Days
CLORPRES 0.1-15 TABLET   3 Tier 3 $85.00$212.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLORPRES 0.2-15 TABLET   3 Tier 3 $85.00$212.50None
CLORPRES 0.3-15 TABLET   3 Tier 3 $85.00$212.50None
CLOTRIMAZOLE 1% CREAM   1 Tier 1 $6.00$9.00None
CLOTRIMAZOLE 10MG TROCHE   1 Tier 1 $6.00$9.00None
CLOTRIMAZOLE SOLUTION TOPICAL 1% 30ML BOTPL   1 Tier 1 $6.00$9.00None
CLOTRIMAZOLE-BETAMETHASONE 1-0.05% LOTION   1 Tier 1 $6.00$9.00None
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE CREAM USP .5MG-10GM 45GM TUBE   1 Tier 1 $6.00$9.00None
CLOZAPINE 100 MG DISINTEGRATING TABLET [FAZACLO]   2 Tier 2 $43.00$107.50Q:270
/30Days
CLOZAPINE 100 MG ORAL TABLET   1 Tier 1 $6.00$9.00Q:270
/30Days
CLOZAPINE 12.5 MG DISINTEGRATING TABLET [FAZACLO]   2 Tier 2 $43.00$107.50Q:60
/30Days
CLOZAPINE 200MG TABLET (500 CT)   1 Tier 1 $6.00$9.00Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLOZAPINE 25 MG DISINTEGRATING TABLET [FAZACLO]   2 Tier 2 $43.00$107.50Q:90
/30Days
CLOZAPINE 25MG TABLET (100 CT)   1 Tier 1 $6.00$9.00Q:90
/30Days
CLOZAPINE 50MG TABLET (500 CT)   1 Tier 1 $6.00$9.00Q:90
/30Days
CLOZARIL 100MG TABLET   3 Tier 3 $85.00$212.50Q:270
/30Days
CLOZARIL 25MG TABLET   3 Tier 3 $85.00$212.50Q:90
/30Days
CO-GESIC 5/500 TABLET   1 Tier 1 $6.00$9.00Q:240
/30Days
CODEINE 60 MG ORAL TABLET   1 Tier 1 $6.00$9.00None
CODEINE SULFATE 30 MG TABLET 3100   1 Tier 1 $6.00$9.00None
CODEINE SULFATE TABLETS   1 Tier 1 $6.00$9.00None
COGENTIN 1MG/ML AMPUL   4 Tier 4 33%33%None
COGNEX 10MG CAPSULE   3 Tier 3 $85.00$212.50Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COGNEX 20MG CAPSULE   3 Tier 3 $85.00$212.50Q:120
/30Days
COGNEX 30MG CAPSULE   3 Tier 3 $85.00$212.50Q:120
/30Days
COGNEX 40MG CAPSULE   3 Tier 3 $85.00$212.50Q:120
/30Days
COLAZAL 750MG CAPSULE   3 Tier 3 $85.00$212.50None
COLCHICINE 0.6 MG ORAL TABLET [COLCRYS]   3 Tier 3 $85.00$212.50P
COLESTID 1GM TABLET   3 Tier 3 $85.00$212.50None
COLESTID GRANULES   3 Tier 3 $85.00$212.50None
COLESTIPOL HCL 1G TABLET   1 Tier 1 $6.00$9.00None
COLESTIPOL HCL 5G GRANULES   1 Tier 1 $6.00$9.00None
COLISTIMETHATE 150MG VIAL   5 Tier 5 33%N/ANone
COLLAGENASE SANTYL OINTMENT 250UNT 30GM TUBE   2 Tier 2 $43.00$107.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COLOCORT 100MG ENEMA   3 Tier 3 $85.00$212.50None
COLY MYCIN M FOR INJECTION 150MG/VIAL 5 ML VIALSD   5 Tier 5 33%N/ANone
COLY MYCIN S OTIC SUSPENSION 3;3.3;10MG/ML;MG/ 5 ML BOTDR   3 Tier 3 $85.00$212.50None
COLYTE WITH FLAVOR PACKETS   3 Tier 3 $85.00$212.50None
COMBIGAN 0.2%-0.5% DROPS   2 Tier 2 $43.00$107.50None
COMBIPATCH 0.05/0.14MG PTCH   3 Tier 3 $85.00$212.50Q:8
/28Days
COMBIPATCH 0.05/0.25MG PTCH   3 Tier 3 $85.00$212.50Q:8
/28Days
COMBIVENT INHALER   2 Tier 2 $43.00$107.50Q:45
/30Days
COMBIVIR TABLETS   5 Tier 5 33%N/ANone
COMBUNOX 5/400MG TABLET   3 Tier 3 $85.00$212.50None
COMPRO 25MG SUPPOSITORY   1 Tier 1 $6.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COMTAN 200MG TABLET   2 Tier 2 $43.00$107.50None
COMVAX VACCINE VIAL   2 Tier 2 $43.00$107.50None
CONDYLOX GEL 0.5% 3.5 GM CRTN   3 Tier 3 $85.00$212.50None
CONDYLOX TOPICAL SOLUTION .5% 3.5 ML CTR   3 Tier 3 $85.00$212.50None
CONSTULOSE 10GM/15ML SYRUP   1 Tier 1 $6.00$9.00None
COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN   5 Tier 5 33%N/AP
COPEGUS 200MG TABLET   5 Tier 5 33%N/ANone
CORDARONE 200MG TABLET   2 Tier 2 $43.00$107.50None
CORDRAN 0.05% LOTION   3 Tier 3 $85.00$212.50None
CORDRAN SP 0.05% CREAM   3 Tier 3 $85.00$212.50None
CORDRAN TAPE 4MCG/SQCM 1 X 80 X 3 CTR   3 Tier 3 $85.00$212.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COREG CR 10MG CAPSULE MULTIPHASIC RELEASE 24 HR   3 Tier 3 $85.00$212.50None
COREG CR 20MG CAPSULE MULTIPHASIC RELEASE 24 HR   3 Tier 3 $85.00$212.50None
COREG CR 40MG CAPSULE MULTIPHASIC RELEASE 24 HR   3 Tier 3 $85.00$212.50None
COREG CR 80MG CAPSULE MULTIPHASIC RELEASE 24 HR   3 Tier 3 $85.00$212.50None
CORGARD (NADOLOL) 80MG TABLET   3 Tier 3 $85.00$212.50None
CORGARD 20MG TABLET (100 CT)   3 Tier 3 $85.00$212.50None
CORGARD 40MG TABLET (100 CT)   3 Tier 3 $85.00$212.50None
CORTEF 10MG TABLET   3 Tier 3 $85.00$212.50None
CORTEF 20MG TABLET   3 Tier 3 $85.00$212.50None
CORTEF 5MG TABLET   3 Tier 3 $85.00$212.50None
CORTENEMA 100MG/60ML ENEMA   3 Tier 3 $85.00$212.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CORTIFOAM RECTAL FOAM   3 Tier 3 $85.00$212.50None
CORTISONE ACETATE 25MG TABLET (100 CT)   1 Tier 1 $6.00$9.00None
CORTISPORIN CRE 0.5%   3 Tier 3 $85.00$212.50None
CORTISPORIN EAR SOLUTION   3 Tier 3 $85.00$212.50None
CORTISPORIN OINTMENT   3 Tier 3 $85.00$212.50None
CORTISPORIN TC OTIC SUSPENSION 3;3.3;0.5MG/ML; 10 ML BOTDR   3 Tier 3 $85.00$212.50None
CORTOMYCIN EAR SOLUTION   1 Tier 1 $6.00$9.00None
CORTOMYCIN EAR SUSPENSION   1 Tier 1 $6.00$9.00None
CORZIDE 40-5MG TABLET   3 Tier 3 $85.00$212.50None
CORZIDE 80-5MG TABLET   3 Tier 3 $85.00$212.50None
COSMEGEN 0.5MG VIAL   5 Tier 5 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COSOPT PLUS EYE DROPS 22.3 MG/ML 6.8 MG/M   3 Tier 3 $85.00$212.50Q:20
/30Days
COUMADIN 10MG TABLET   2 Tier 2 $43.00$107.50None
COUMADIN 1MG TABLET   2 Tier 2 $43.00$107.50None
COUMADIN 2.5MG TABLET   2 Tier 2 $43.00$107.50None
COUMADIN 2MG TABLET   2 Tier 2 $43.00$107.50None
COUMADIN 3MG TABLET   2 Tier 2 $43.00$107.50None
COUMADIN 4MG TABLET   2 Tier 2 $43.00$107.50None
COUMADIN 5MG TABLET   2 Tier 2 $43.00$107.50None
COUMADIN 5MG VIAL   4 Tier 4 33%33%None
COUMADIN 6MG TABLET   2 Tier 2 $43.00$107.50None
COUMADIN 7.5MG TABLET   2 Tier 2 $43.00$107.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COVERA-HS 180MG SA TABLET   3 Tier 3 $85.00$212.50None
COVERA-HS 240MG SA TABLET   3 Tier 3 $85.00$212.50None
COZAAR 100MG TABLET   3 Tier 3 $85.00$212.50None
COZAAR 25MG TABLET (1000 CT)   3 Tier 3 $85.00$212.50None
COZAAR 50MG TABLET 10000 BOT   3 Tier 3 $85.00$212.50None
CREON DELAYED RELEASE CAPSULES 12000MG 100 BOT   2 Tier 2 $43.00$107.50None
CREON DELAYED RELEASE CAPSULES 24000MG 100 BOT   2 Tier 2 $43.00$107.50None
CREON DELAYED RELEASE CAPSULES 6000MG 100 BOT   2 Tier 2 $43.00$107.50None
CRESTOR 10MG TABLET   3 Tier 3 $85.00$212.50Q:30
/30Days
CRESTOR 20MG TABLET   3 Tier 3 $85.00$212.50Q:30
/30Days
CRESTOR 40MG TABLET   3 Tier 3 $85.00$212.50Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CRESTOR 5MG TABLET   3 Tier 3 $85.00$212.50Q:30
/30Days
CRINONE GEL 8%   3 Tier 3 $85.00$212.50None
CRIXIVAN 100MG CAPSULE   2 Tier 2 $43.00$107.50None
CRIXIVAN 200MG CAPSULE   2 Tier 2 $43.00$107.50None
CRIXIVAN 333MG CAPSULE   2 Tier 2 $43.00$107.50None
CRIXIVAN 400MG CAPSULE (120 CT)   2 Tier 2 $43.00$107.50None
CROMOLYN NEBULIZER SOLUTION   1 Tier 1 $6.00$9.00P
CROMOLYN SODIUM 4% 40MG 10ML BOT   1 Tier 1 $6.00$9.00None
CUBICIN 500MG VIAL   5 Tier 5 33%N/AP
CUPRIMINE CAPSULES 250MG (100 CT)   2 Tier 2 $43.00$107.50None
CUTIVATE CREAM 0.05%   3 Tier 3 $85.00$212.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CUTIVATE LOTION 0.05%   3 Tier 3 $85.00$212.50None
CUTIVATE OINTMENT 0.005% 60GM TUBE   3 Tier 3 $85.00$212.50None
CYCLESSA 28 DAY TABLET   3 Tier 3 $85.00$212.50Q:28
/28Days
CYCLOBENZAPRINE HCL 10MG TABLET (1000 CT)   1 Tier 1 $6.00$9.00None
CYCLOBENZAPRINE HCL 5MG TABLET (500 CT)   1 Tier 1 $6.00$9.00None
CYCLOPHOSPHAMIDE 25MG TABLET   1 Tier 1 $6.00$9.00P
CYCLOPHOSPHAMIDE 50MG TABLET   1 Tier 1 $6.00$9.00P
CYCLOSPORINE 100MG CAPSULE   1 Tier 1 $6.00$9.00P
CYCLOSPORINE 100MG CAPSULE   1 Tier 1 $6.00$9.00P
CYCLOSPORINE 25MG CAPSULE   1 Tier 1 $6.00$9.00P
CYCLOSPORINE 50MG CAPSULE   1 Tier 1 $6.00$9.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CYCLOSPORINE 50MG/ML AMP   4 Tier 4 33%33%P
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT   1 Tier 1 $6.00$9.00P
CYKLOKAPRON 100MG/ML AMPUL   4 Tier 4 33%33%None
CYMBALTA 20MG CAPSULE   2 Tier 2 $43.00$107.50Q:60
/30Days
CYMBALTA 60MG CAPSULE   2 Tier 2 $43.00$107.50Q:60
/30Days
CYMBALTA CAPSULES DELAYED RELEASE 30MG (30 CT)   2 Tier 2 $43.00$107.50Q:60
/30Days
CYPROHEPTADINE HCL 4 MG   1 Tier 1 $6.00$9.00None
CYPROHEPTADINE HYDROCHLORIDE SOLUTION USP SYRUP 2MG 473 ML BOTGL   1 Tier 1 $6.00$9.00None
CYSTADANE POWDER FOR ORAL SOLUTION 180GM   2 Tier 2 $43.00$107.50None
CYSTAGON 150MG CAPSULE   2 Tier 2 $43.00$107.50None
CYSTAGON 50MG CAPSULE   2 Tier 2 $43.00$107.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CYTARABINE 20MG/ML VIAL   4 Tier 4 33%33%P
CYTARABINE 500MG VIAL   4 Tier 4 33%33%P
CYTARABINE SOLUTION INJECTION 100MG 20ML VIALSD   4 Tier 4 33%33%P
CYTOMEL 25MCG TABLET   3 Tier 3 $85.00$212.50None
CYTOMEL 50MCG TABLET   3 Tier 3 $85.00$212.50None
CYTOMEL 5MCG TABLET   3 Tier 3 $85.00$212.50None
CYTOTEC TABLET 100MCG (120 CT)   3 Tier 3 $85.00$212.50None
CYTOTEC TABLET 200MCG (60 CT)   3 Tier 3 $85.00$212.50None
CYTOVENE IV INJECTION   4 Tier 4 33%33%None

Chart Legend:

Below are a few notes to help you understand the above 2011 Medicare Part D Blue MedicareRx 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 intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $(2840)) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, on the 2011 Humana Walmart-Preferred Rx Plan the pricing 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 2011 )

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.







Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.