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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 P

in CMS PDP Region 01 which includes: ME NH
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 Tier 2 $43.00$107.50None
PACERONE 200MG TABLET   1 Tier 1 $6.00$9.00None
PACERONE 400MG TABLET   3 Tier 3 $85.00$212.50None
PACLITAXEL INJECTION SOLUTION 6MG 50ML VIALMD   4 Tier 4 33%33%P
PALGIC 4MG/5ML LIQUID   1 Tier 1 $6.00$9.00None
PALGIC TABLETS 4GM 100 CTR   1 Tier 1 $6.00$9.00None
PALIPERIDONE PALMITATE 156 MG/ML PREFILLED SYRINGE [INVEGA]   4 Tier 4 33%33%Q:2
/28Days
PALIPERIDONE PALMITATE 156 MG/ML PREFILLED SYRINGE [INVEGA]   4 Tier 4 33%33%Q:2
/28Days
PALIPERIDONE PALMITATE 156 MG/ML PREFILLED SYRINGE [INVEGA]   4 Tier 4 33%33%Q:2
/28Days
PALIPERIDONE PALMITATE 156 MG/ML PREFILLED SYRINGE [INVEGA]   4 Tier 4 33%33%Q:2
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PALIPERIDONE PALMITATE 156 MG/ML PREFILLED SYRINGE [INVEGA]   4 Tier 4 33%33%Q:2
/28Days
PAMELOR 25MG CAPSULE   3 Tier 3 $85.00$212.50None
PAMELOR 50MG CAPSULE   3 Tier 3 $85.00$212.50None
PAMELOR CAPSULES 10   3 Tier 3 $85.00$212.50None
PAMELOR CAPSULES 75MG   3 Tier 3 $85.00$212.50None
PAMIDRONATE 60MG/10ML VIAL   4 Tier 4 33%33%P
PAMIDRONATE DISODIUM INJECTION 3MG 10ML VIALSD   4 Tier 4 33%33%P
PAMIDRONATE DISODIUM INJECTION 9MG 10ML VIALSD   4 Tier 4 33%33%P
PAMINE 2.5MG TABLET   3 Tier 3 $85.00$212.50None
PAMINE FORTE 5MG TABLET   3 Tier 3 $85.00$212.50None
PANDEL 0.1% CREAM45GM   3 Tier 3 $85.00$212.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PANITUMUMAB 20 MG/ML INJECTABLE SOLUTION [VECTIBIX]   5 Tier 5 33%N/AP
PANLOR DC CAPSULE   3 Tier 3 $85.00$212.50Q:330
/30Days
PANRETIN 0.1% GEL 60GM TUBE   5 Tier 5 33%N/ANone
PANTOPRAZOLE SODIUM 20MG TABLET DELAYED RELEASE   1 Tier 1 $6.00$9.00Q:30
/30Days
PANTOPRAZOLE SODIUM 40MG TABLET DELAYED RELEASE 90 CRC BOT   1 Tier 1 $6.00$9.00Q:30
/30Days
PARAFON FORTE DSC 500MG CPT   3 Tier 3 $85.00$212.50None
PARCAINE 0.5% DROPS   1 Tier 1 $6.00$9.00None
PARCOPA 10MG/100MG TABLET   3 Tier 3 $85.00$212.50None
PARCOPA 25MG/100MG TABLET   3 Tier 3 $85.00$212.50None
PARCOPA 25MG/250MG TABLET   3 Tier 3 $85.00$212.50None
PARLODEL 2.5MG 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
PARLODEL 5MG CAPSULE   3 Tier 3 $85.00$212.50None
PARNATE 10MG TABLET   3 Tier 3 $85.00$212.50None
PAROMOMYCIN 250MG CAPSULE   1 Tier 1 $6.00$9.00None
PAROXETINE 40MG TABLET (500 CT)   1 Tier 1 $6.00$9.00Q:60
/30Days
PAROXETINE FILM COATED 20MG TABLET (100 CT)   1 Tier 1 $6.00$9.00Q:30
/30Days
PAROXETINE HCL 10MG/5ML SUSPENSION ORAL   1 Tier 1 $6.00$9.00Q:1200
/30Days
PAROXETINE HCL TABLET 24 12.5MG   1 Tier 1 $6.00$9.00Q:30
/30Days
PAROXETINE HCL TABLET 24 25MG   1 Tier 1 $6.00$9.00Q:90
/30Days
PAROXETINE TABLETS   1 Tier 1 $6.00$9.00Q:45
/30Days
PAROXETINE TABLETS 30MG 90 BOT   1 Tier 1 $6.00$9.00Q:60
/30Days
PASER GRANULES 4GM PACKET   3 Tier 3 $85.00$212.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PATADAY 0.2% DROPS   2 Tier 2 $43.00$107.50Q:5
/30Days
PATANOL 0.1% EYE DROPS   2 Tier 2 $43.00$107.50Q:5
/30Days
PAXIL 10MG TABLET   3 Tier 3 $85.00$212.50Q:45
/30Days
PAXIL 10MG/5ML SUSPENSION   3 Tier 3 $85.00$212.50Q:1200
/30Days
PAXIL 20MG TABLET   3 Tier 3 $85.00$212.50Q:30
/30Days
PAXIL 30MG TABLET   3 Tier 3 $85.00$212.50Q:60
/30Days
PAXIL 40MG TABLET   3 Tier 3 $85.00$212.50Q:60
/30Days
PAXIL CR 12.5MG TABLET   3 Tier 3 $85.00$212.50Q:30
/30Days
PAXIL CR 25MG TABLET   3 Tier 3 $85.00$212.50Q:60
/30Days
PAXIL CR 37.5MG TABLET   3 Tier 3 $85.00$212.50Q:60
/30Days
PAZOPANIB 200 MG ORAL TABLET [VOTRIENT]   5 Tier 5 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PCE 333MG DISPERTAB   3 Tier 3 $85.00$212.50None
PCE 500MG DISPERTAB   3 Tier 3 $85.00$212.50None
PEDI-DRI TOPICAL POWDER   1 Tier 1 $6.00$9.00None
PEDIAPRED 6.7MG/5ML TUBEX   3 Tier 3 $85.00$212.50None
PEDIARIX SOLUTION INJECTION 25-25-10 10 X .5ML VIAL   2 Tier 2 $43.00$107.50None
PEDVAXHIB VACCINE VIAL   2 Tier 2 $43.00$107.50None
PEG-INTRON 100MCG KIT   5 Tier 5 33%N/AP
PEG-INTRON REDIPEN 120MCG   5 Tier 5 33%N/AP
PEG-INTRON REDIPEN 150MCG   5 Tier 5 33%N/AP
PEG-INTRON REDIPEN 50MCG   5 Tier 5 33%N/AP
PEG-INTRON REDIPEN 80MCG   5 Tier 5 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PEGANONE 250MG TABLET   2 Tier 2 $43.00$107.50None
PEGASYS 180MCG/0.5ML CONV.PK   5 Tier 5 33%N/AP
PEGASYS INJECTION   5 Tier 5 33%N/AP
PENICILLIN G POTASSIUM 2MMUNITS/50ML ISO-OSM   4 Tier 4 33%33%None
PENICILLIN G POTASSIUM 3MMUNITS/50ML ISO-OSM   4 Tier 4 33%33%None
PENICILLIN G POTASSIUM FOR INJECTION   4 Tier 4 33%33%None
PENICILLIN G POTASSIUM FOR INJECTION 5000000UNIT/VIAL   4 Tier 4 33%33%None
PENICILLIN G PROCAINE 1200000UNT 2ML CTG   4 Tier 4 33%33%None
PENICILLIN G SODIUM FOR INJECTION 5000000UNT 1 VIAL   4 Tier 4 33%33%None
PENICILLIN V POTASSIUM 250MG TABLET (1000 CT)   1 Tier 1 $6.00$9.00None
PENICILLIN V POTASSIUM 250MG/5ML LIQUID   1 Tier 1 $6.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PENICILLIN V POTASSIUM 500MG TABLET   1 Tier 1 $6.00$9.00None
PENICILLIN V POTASSIUM FOR ORAL SOLUTION CONCENTRATE 125MG 200ML BOT   1 Tier 1 $6.00$9.00None
PENLAC 8% SOLUTION   3 Tier 3 $85.00$212.50P
PENTAM 300 INJ 300MG   4 Tier 4 33%33%None
PENTASA 250MG CAPSULE SA   2 Tier 2 $43.00$107.50None
PENTASA 500MG CAPSULE   2 Tier 2 $43.00$107.50None
PENTAZOCINE/ACETAMIN TABLET   1 Tier 1 $6.00$9.00Q:180
/30Days
PENTAZOCINE/NALOXONE TABLET   1 Tier 1 $6.00$9.00None
PENTOPAK 400MG TABLET SA   1 Tier 1 $6.00$9.00None
PENTOSTATIN FOR INJECTION 10MG/VIAL   5 Tier 5 33%N/AP
PENTOXIFYLLINE 400MG TABLET SA   1 Tier 1 $6.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PEPCID 20MG TABLET   3 Tier 3 $85.00$212.50None
PEPCID 40MG TABLET   3 Tier 3 $85.00$212.50None
PEPCID PREMX SOL 20MG/50M   4 Tier 4 33%33%None
PEPCID SOLUTION 40MG 24 X 400MG BOT   3 Tier 3 $85.00$212.50None
PERCOCET 10/325MG TABLET   3 Tier 3 $85.00$212.50Q:360
/30Days
PERCOCET 10/650MG TABLET   3 Tier 3 $85.00$212.50Q:180
/30Days
PERCOCET 2.5/325MG TABLET   3 Tier 3 $85.00$212.50Q:360
/30Days
PERCOCET 7.5/325MG TABLET   3 Tier 3 $85.00$212.50Q:360
/30Days
PERCOCET 7.5/500MG TABLET   3 Tier 3 $85.00$212.50Q:240
/30Days
PERCOCET TABLET 5-325MG   3 Tier 3 $85.00$212.50Q:360
/30Days
PERCODAN 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
PERFOROMIST 20MCG/2ML VIAL NEBULIZER   3 Tier 3 $85.00$212.50P Q:120
/30Days
PERINDOPRIL ERBUMINE 2 MG ORAL TABLET   1 Tier 1 $6.00$9.00None
PERINDOPRIL ERBUMINE 4 MG ORAL TABLET   1 Tier 1 $6.00$9.00None
PERINDOPRIL ERBUMINE 8 MG ORAL TABLET   1 Tier 1 $6.00$9.00None
PERIOGARD 0.12% ORAL RINSE   1 Tier 1 $6.00$9.00None
PERIOSTAT DOXYCYCLINE HYCLATE TABLETS 20MG 100 BOT   3 Tier 3 $85.00$212.50None
PERMETHRIN 5% CREAM   1 Tier 1 $6.00$9.00None
PERPHENAZINE TABLETS 16MG 100 BOT   1 Tier 1 $6.00$9.00None
PERPHENAZINE TABLETS 4MG 100 BOXUD   1 Tier 1 $6.00$9.00None
PERPHENAZINE TABLETS 8MG 100 BOT   1 Tier 1 $6.00$9.00None
PERPHENAZINE TABLETS USP 2MG 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
PERSANTINE 25MG TABLET   3 Tier 3 $85.00$212.50None
PERSANTINE 50MG TABLET   3 Tier 3 $85.00$212.50None
PERSANTINE 75MG TABLET   3 Tier 3 $85.00$212.50None
PEXEVA 10MG TABLET   3 Tier 3 $85.00$212.50Q:45
/30Days
PEXEVA 20MG TABLET   3 Tier 3 $85.00$212.50Q:30
/30Days
PEXEVA 30MG TABLET   3 Tier 3 $85.00$212.50Q:60
/30Days
PEXEVA 40MG TABLET   3 Tier 3 $85.00$212.50Q:60
/30Days
PFIZERPEN 20MMU VIAL   4 Tier 4 33%33%None
PHENADOZ 12.5MG SUPPOSITORY   1 Tier 1 $6.00$9.00None
PHENADOZ 25MG SUPPOSITORY   1 Tier 1 $6.00$9.00None
PHENERGAN 25MG/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
PHENERGAN 50MG/ML VIAL   4 Tier 4 33%33%None
PHENYTEK 200 MG CAPSULE   2 Tier 2 $43.00$107.50None
PHENYTEK 300 MG CAPSULE   2 Tier 2 $43.00$107.50None
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT   1 Tier 1 $6.00$9.00None
PHENYTOIN SOD EXT 200 MG CAP   2 Tier 2 $43.00$107.50None
PHENYTOIN SODIUM EXTENDED CAPSULES 100MG (100 CT)   1 Tier 1 $6.00$9.00None
PHENYTOIN SODIUM INJECTION 50MG 25 X 2ML AMP   4 Tier 4 33%33%None
PHISOHEX 3% CLEANSER   3 Tier 3 $85.00$212.50None
PHOSLO 667MG CAPSULE   3 Tier 3 $85.00$212.50None
PHOSPHOLINE IODIDE 0.125%   3 Tier 3 $85.00$212.50None
PHOTOFRIN 75MG VIAL   5 Tier 5 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PHYSIOLYTE SOLUTION FOR IRRIGATION   4 Tier 4 33%33%P
PHYSIOSOL IRRIGATION SOL   4 Tier 4 33%33%P
PILOCARPINE HCL 5MG TABLET (100 CT)   1 Tier 1 $6.00$9.00None
PILOCARPINE HCL 7.5MG TABLET   1 Tier 1 $6.00$9.00None
PILOPINE HS 4% EYE GEL   3 Tier 3 $85.00$212.50None
PINDOLOL 10MG TABLET   1 Tier 1 $6.00$9.00None
PINDOLOL 5MG TABLET   1 Tier 1 $6.00$9.00None
PIPERACILLIN 200 MG/ML / TAZOBACTAM 25 MG/ML INJECTABLE SOLUTION   4 Tier 4 33%33%None
PIPERACILLIN 3GM VIAL   4 Tier 4 33%33%None
PIPERACILLIN 40GM BULK VIAL   4 Tier 4 33%33%None
PIROXICAM 10 MG 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
PIROXICAM 20MG CAPSULE (500 CT)   1 Tier 1 $6.00$9.00None
PLAQUENIL 200MG TABLET   3 Tier 3 $85.00$212.50None
PLASMA-LYTE 148 IV SOLUTION   4 Tier 4 33%33%None
PLASMA-LYTE 148/DEXTROSE 5%   4 Tier 4 33%33%None
PLASMA-LYTE 56 INJECTION 32;128 MG/100ML;   4 Tier 4 33%33%None
PLASMA-LYTE 56/DEXTROSE 5%   4 Tier 4 33%33%None
PLASMA-LYTE A PH 7.4 SOLUTION 37;368; MG/100ML;   4 Tier 4 33%33%None
PLASMA-LYTE INJ-R   4 Tier 4 33%33%None
PLAVIX 75MG TABLET   2 Tier 2 $43.00$107.50Q:30
/30Days
PLAVIX TABLETS 300MG   2 Tier 2 $43.00$107.50None
PLETAL 100MG 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
PLETAL 50MG TABLET   3 Tier 3 $85.00$212.50None
PODOFILOX 0.5% TOPICAL TUBEX   1 Tier 1 $6.00$9.00None
POLY-DEX 0.1% SUSPENSION DROPS   1 Tier 1 $6.00$9.00None
POLY-DEX 3.5-10K-.1 OINTMENT   1 Tier 1 $6.00$9.00None
POLY-PRED EYE DROPS   3 Tier 3 $85.00$212.50None
POLYCIN-B 500-10KU/G OINTMENT   1 Tier 1 $6.00$9.00None
POLYETH GLYC NF POWDER FOR ORAL SOLUTION 17GM (527 CT)   1 Tier 1 $6.00$9.00None
POLYETHYLENE GLYCOL 3350 105 MG/ML / POTASSIUM CHLORIDE 0.00497 MEQ/ML / SODIUM BICARBONATE 1.43 MG/   1 Tier 1 $6.00$9.00None
POLYETHYLENE GLYCOL 3350 105 MG/ML / POTASSIUM CHLORIDE 0.005 MEQ/ML / SODIUM BICARBONATE 0.017 MEQ/   1 Tier 1 $6.00$9.00None
POLYETHYLENE GLYCOL 3350 59 MG/ML / POTASSIUM CHLORIDE 0.1 MEQ/ML / SODIUM BICARBONATE 0.02 MEQ/ML /   1 Tier 1 $6.00$9.00None
POLYETHYLENE GLYCOL 3350 60 MG/ML / POTASSIUM CHLORIDE 0.01 MEQ/ML / SODIUM BICARBONATE 0.02 MEQ/ML   1 Tier 1 $6.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
POLYMYXIN B SUL-TRIMETHOPRIM 10K U-0.1%   1 Tier 1 $6.00$9.00None
POLYMYXIN B SULFATE VIAL   4 Tier 4 33%33%None
POLYTRIM EYE DROP   3 Tier 3 $85.00$212.50None
PONSTEL 250 MG KAPSEALS   3 Tier 3 $85.00$212.50None
PORTIA 0.15-0.03 TABLET   1 Tier 1 $6.00$9.00Q:28
/28Days
POTASSIUM CHLORIDE 0.075%/D5W/SODIUM CHLORIDE 0.2%   4 Tier 4 33%33%None
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.3%   4 Tier 4 33%33%None
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.45%   4 Tier 4 33%33%None
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.9% 1000ML   4 Tier 4 33%33%None
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.2%   4 Tier 4 33%33%None
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.45% 1000ML BAG   4 Tier 4 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
POTASSIUM CHLORIDE 10MEQ/100ML SOL   4 Tier 4 33%33%None
POTASSIUM CHLORIDE 10MEQ/50ML SOL   4 Tier 4 33%33%None
POTASSIUM CHLORIDE 20MEQ IN D5W LACT RNG   4 Tier 4 33%33%None
POTASSIUM CHLORIDE 20MEQ IN D5W/NACL 0.225%   4 Tier 4 33%33%None
POTASSIUM CHLORIDE 20MEQ/50ML SOL   4 Tier 4 33%33%None
POTASSIUM CHLORIDE 30MEQ/100ML SOL   4 Tier 4 33%33%None
POTASSIUM CHLORIDE 40MEQ IN D5W LACT RNG   4 Tier 4 33%33%None
POTASSIUM CHLORIDE 40MEQ IN D5W/NACL 0.9%   4 Tier 4 33%33%None
POTASSIUM CHLORIDE 40MEQ/NS 1000ML IV SOLUTION   4 Tier 4 33%33%None
POTASSIUM CHLORIDE 8 MEQ EXTENDED RELEASE TABLET   1 Tier 1 $6.00$9.00None
POTASSIUM CHLORIDE ER CAPSULES 10MEQ   1 Tier 1 $6.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
POTASSIUM CHLORIDE ER CPCR 8MEQ   1 Tier 1 $6.00$9.00None
POTASSIUM CHLORIDE EXTENDED RELEASE TABLETS   1 Tier 1 $6.00$9.00None
POTASSIUM CHLORIDE FOR INJECTION CONCENTRATE   4 Tier 4 33%33%None
POTASSIUM CHLORIDE IN 10% DEXTROSE AND NACL SOLUTION FOR INJECTION   4 Tier 4 33%33%None
POTASSIUM CHLORIDE IN 5% DEXTROSE AND 0.2% NACL SOLUTION FOR INJECTION USP 0.15% 250ML X 24 CASE   4 Tier 4 33%33%None
POTASSIUM CHLORIDE IN 5% DEXTROSE AND NACL SOLUTION FOR INJECTION 0.075% 1000ML PLASTIC BAGS X 12 CA   4 Tier 4 33%33%None
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION   4 Tier 4 33%33%None
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION   4 Tier 4 33%33%None
POTASSIUM CHLORIDE IN 5% DEXTROSE INJECTION 40 12 X 1000ML CTR   4 Tier 4 33%33%None
POTASSIUM CHLORIDE IN DEXTROSE INJECTION 5GM/75MG   4 Tier 4 33%33%None
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION   4 Tier 4 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION 0.15%-0.9% 12 X 1000ML BAG   4 Tier 4 33%33%None
POTASSIUM CHLORIDE TABLET EXTENED RELEASE   1 Tier 1 $6.00$9.00None
POTASSIUM CITRATE 10MEQ TABLET SA   1 Tier 1 $6.00$9.00None
POTASSIUM CITRATE 5MEQ TABLET SA   1 Tier 1 $6.00$9.00None
PRAMIPEXOLE 0.125 MG TABLET   1 Tier 1 $6.00$9.00None
PRAMIPEXOLE 0.25 MG TABLET   1 Tier 1 $6.00$9.00None
PRAMIPEXOLE 0.5 MG TABLET   1 Tier 1 $6.00$9.00None
PRAMIPEXOLE 1 MG TABLET   1 Tier 1 $6.00$9.00None
PRAMIPEXOLE 1.5 MG TABLET   1 Tier 1 $6.00$9.00None
PRAMIPEXOLE DIHYDROCHLORIDE TABLETS   1 Tier 1 $6.00$9.00None
PRANDIN 0.5MG 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
PRANDIN 1MG TABLET   3 Tier 3 $85.00$212.50None
PRANDIN 2MG TABLET   3 Tier 3 $85.00$212.50None
PRASUGREL 10 MG ORAL TABLET   2 Tier 2 $43.00$107.50Q:30
/30Days
PRASUGREL 5 MG ORAL TABLET   2 Tier 2 $43.00$107.50Q:30
/30Days
PRAVACHOL 10MG TABLET   3 Tier 3 $85.00$212.50Q:30
/30Days
PRAVACHOL 20MG TABLET   3 Tier 3 $85.00$212.50Q:30
/30Days
PRAVACHOL 40MG TABLET   3 Tier 3 $85.00$212.50Q:30
/30Days
PRAVACHOL 80MG TABLET   3 Tier 3 $85.00$212.50Q:30
/30Days
PRAVASTATIN SODIUM 20MG TABLET 500 BOT   1 Tier 1 $6.00$9.00Q:30
/30Days
PRAVASTATIN SODIUM 40MG TABLET (500 CT)   1 Tier 1 $6.00$9.00Q:30
/30Days
PRAVASTATIN SODIUM 80MG TABLET (90 CT)   1 Tier 1 $6.00$9.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PRAVASTATIN SODIUM TABLETS 10MG 90 BOT   1 Tier 1 $6.00$9.00Q:30
/30Days
PRAZOSIN 5MG CAPSULE   1 Tier 1 $6.00$9.00None
PRAZOSIN HCL 1MG CAPSULE   1 Tier 1 $6.00$9.00None
PRAZOSIN HCL 2MG CAPSULE   1 Tier 1 $6.00$9.00None
PRECOSE 50 MG TABLET   3 Tier 3 $85.00$212.50None
PRECOSE TABLETS 100MG 100 BOT   3 Tier 3 $85.00$212.50None
PRECOSE TABLETS 25MG 100 BOT   3 Tier 3 $85.00$212.50None
PRED FORTE 1% EYE DROPS   3 Tier 3 $85.00$212.50None
PRED G OPHTHALMIC SUSPENSION 1;0.3%;% 5 ML BOTDR   3 Tier 3 $85.00$212.50None
PRED MILD 0.12% EYE DROPS   3 Tier 3 $85.00$212.50None
PRED-G S.O.P. EYE OINTMENT   3 Tier 3 $85.00$212.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PREDNICARBATE 0.1% OINTMENT   1 Tier 1 $6.00$9.00None
PREDNICARBATE 1 MG/ML TOPICAL CREAM   1 Tier 1 $6.00$9.00None
PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION 1.0% STERILE 10ML BOTDR   1 Tier 1 $6.00$9.00None
PREDNISOLONE SOD 1% EYE DROP   1 Tier 1 $6.00$9.00None
PREDNISOLONE SODIUM PHOSPHATE 15MG/5ML SOLUTION ORAL   1 Tier 1 $6.00$9.00None
PREDNISOLONE SODIUM PHOSPHATE ORAL SOLUTION   1 Tier 1 $6.00$9.00None
PREDNISONE 10MG TABLET (100 CT)   1 Tier 1 $6.00$9.00None
PREDNISONE 1MG TABLET   1 Tier 1 $6.00$9.00None
PREDNISONE 2.5MG TABLET   1 Tier 1 $6.00$9.00None
PREDNISONE 20MG TABLET (1000 CT)   1 Tier 1 $6.00$9.00None
PREDNISONE 5 MG 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
PREDNISONE 50MG TABLET   1 Tier 1 $6.00$9.00None
PREDNISONE 5MG/5ML SOLUTION   1 Tier 1 $6.00$9.00None
PREDNISONE 5MG/ML SOLUTION   1 Tier 1 $6.00$9.00None
PREFEST TABLET 30 EA   3 Tier 3 $85.00$212.50None
PREGNYL INJ 10000UNT   4 Tier 4 33%33%P
PRELONE 15MG/5ML SOLUTION ORAL   3 Tier 3 $85.00$212.50None
PREMARIN 0.3MG (100 CT)   2 Tier 2 $43.00$107.50None
PREMARIN 0.45MG TABLET   2 Tier 2 $43.00$107.50None
PREMARIN 0.625MG (100 CT)   2 Tier 2 $43.00$107.50None
PREMARIN 0.9MG TABLET   2 Tier 2 $43.00$107.50None
PREMARIN 1.25MG (100 CT)   2 Tier 2 $43.00$107.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PREMARIN 25MG VIAL   4 Tier 4 33%33%None
PREMARIN VAGINAL CREAM /APPL   2 Tier 2 $43.00$107.50Q:86
/30Days
PREMASOL 10% IV SOLUTION   4 Tier 4 33%33%None
PREMASOL 6% IV SOLUTION   4 Tier 4 33%33%None
PREMPHASE 0.625/5MG TABLET   2 Tier 2 $43.00$107.50None
PREMPRO 0.3 MG-1.5 MG TABLET #28 EA   2 Tier 2 $43.00$107.50None
PREMPRO 0.45-1.5 MG TABLET 28 EA   2 Tier 2 $43.00$107.50None
PRENATABS OBN TABLETS 200;1;150;MG;MG;MCG; 90 BOT   1 Tier 1 $6.00$9.00None
PREVACID CAPSULES DELAYED RELEASE 15 MG   3 Tier 3 $85.00$212.50Q:30
/30Days
PREVACID CAPSULES DELAYED RELEASE 30 MG   3 Tier 3 $85.00$212.50Q:30
/30Days
PREVACID SOLUTAB EXTENDED RELEASE ORALLY DISINTEGRATING 30MG 100 BOXUD   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
PREVACID SOLUTAB TABLETS DELAYED RELEASE ORALLY DISINTEGRATING 15MG 100 BOXUD   3 Tier 3 $85.00$212.50Q:30
/30Days
PREVALITE POW 4GM   1 Tier 1 $6.00$9.00None
PREVIFEM TABLETS .035;.25MG;MG 28 BLPK   1 Tier 1 $6.00$9.00Q:28
/28Days
PREZISTA TABLET 600MG   5 Tier 5 33%N/ANone
PREZISTA TABLET 75MG   3 Tier 3 $85.00$212.50None
PREZISTA TABLETS   5 Tier 5 33%N/ANone
PREZISTA TABLETS 400MG 60 TABLETS BOT   5 Tier 5 33%N/ANone
PRIFTIN 150MG TABLET   2 Tier 2 $43.00$107.50None
PRIMAQUINE 26.3MG TABLET   2 Tier 2 $43.00$107.50None
PRIMAXIN I.M. 500MG VIAL   5 Tier 5 33%N/ANone
PRIMAXIN IV 250MG VIAL   4 Tier 4 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PRIMAXIN IV INJ 500MG   5 Tier 5 33%N/ANone
PRIMIDONE 250MG TABLET (100 CT)   1 Tier 1 $6.00$9.00None
PRIMIDONE 50MG TABLET (500 CT)   1 Tier 1 $6.00$9.00None
PRIMSOL 50MG/5ML ORAL SOLUTION   3 Tier 3 $85.00$212.50None
PRISTIQ 100MG TABLET SR 24HR   3 Tier 3 $85.00$212.50P Q:30
/30Days
PRISTIQ 50MG TABLET SR 24HR   3 Tier 3 $85.00$212.50P Q:30
/30Days
PRIVIGEN 10% VIAL   5 Tier 5 33%N/AP
PROAIR HFA 90MCG HFA AEROSOL WITH ADAPTER   2 Tier 2 $43.00$107.50Q:27
/30Days
PROAMATINE 10MG TABLET   3 Tier 3 $85.00$212.50None
PROAMATINE 2.5MG TABLET   3 Tier 3 $85.00$212.50None
PROAMATINE 5MG 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
PROBENECID 500MG TABLET   1 Tier 1 $6.00$9.00None
PROBENECID/COLCHICINE TABLET S   1 Tier 1 $6.00$9.00None
PROCAINAMIDE 100MG/ML VIAL   4 Tier 4 33%33%None
PROCAINAMIDE 500MG/ML VIAL   4 Tier 4 33%33%None
PROCALAMINE INJECTION 210MG-290MG-26MG 6 X 1000ML BOT   4 Tier 4 33%33%None
PROCARDIA 10MG CAPSULE   3 Tier 3 $85.00$212.50None
PROCARDIA XL 30MG TABLET (300 CT)   3 Tier 3 $85.00$212.50None
PROCARDIA XL 60MG TABLET SA   3 Tier 3 $85.00$212.50None
PROCARDIA XL 90MG TABLET SA   3 Tier 3 $85.00$212.50None
PROCHIEVE 4% GEL   3 Tier 3 $85.00$212.50None
PROCHIEVE GEL 8%   3 Tier 3 $85.00$212.50None
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   4 Tier 4 33%33%None
PROCHLORPERAZINE MALEATE 10MG TABLET (100 CT)   1 Tier 1 $6.00$9.00None
PROCHLORPERAZINE MALEATE 5MG TABLET (100 CT)   1 Tier 1 $6.00$9.00None
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX   1 Tier 1 $6.00$9.00None
PROCRIT 10000U/ML VIAL   4 Tier 4 33%33%P
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL   4 Tier 4 33%33%P
PROCRIT 3000U/ML VIAL   4 Tier 4 33%33%P
PROCRIT 40000U/ML VIAL PR   5 Tier 5 33%N/AP
PROCRIT 4000U/ML VIAL 25 X 1ML VIAL   4 Tier 4 33%33%P
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY   5 Tier 5 33%N/AP
PROCTO-PAK 1% CREAM   1 Tier 1 $6.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PROCTOCORT 1% CREAM   3 Tier 3 $85.00$212.50None
PROCTOCREAM-HC 2.5% CREAM   3 Tier 3 $85.00$212.50None
PROCTOSOL-HC 2.5% CREAM   1 Tier 1 $6.00$9.00None
PROCTOZONE-HC 2.5% CREAM   1 Tier 1 $6.00$9.00None
PROGLYCEM 50MG/ML ORAL SUSP   5 Tier 5 33%N/ANone
PROGRAF 0.5MG CAPSULE   2 Tier 2 $43.00$107.50P
PROGRAF 1MG CAPSULE   2 Tier 2 $43.00$107.50P
PROGRAF 5MG CAPSULE   2 Tier 2 $43.00$107.50P
PROGRAF 5MG/ML AMPULE   4 Tier 4 33%33%P
PROLASTIN 500MG VIAL   5 Tier 5 33%N/ANone
PROLEUKIN 22 MILLION UNITS VL   5 Tier 5 33%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PROLIA INJECTION   4 Tier 4 33%33%P Q:2
/365Days
PROMACTA TABLETS   5 Tier 5 33%N/AP
PROMACTA TABLETS   5 Tier 5 33%N/AP
PROMACTA TABLETS 25 MG   5 Tier 5 33%N/AP
PROMETHAZINE 50MG/ML VIAL   4 Tier 4 33%33%None
PROMETHAZINE HCL 12.5MG TABLET   1 Tier 1 $6.00$9.00None
PROMETHAZINE HCL 25MG TABLET (1000 CT)   1 Tier 1 $6.00$9.00None
PROMETHAZINE HCL 50MG TABLET (100 CT)   1 Tier 1 $6.00$9.00None
PROMETHAZINE HCL 6.25MG/5ML SYRUP   1 Tier 1 $6.00$9.00None
PROMETHAZINE HCL INJECTION 25MG 10 X 1ML VIAL   4 Tier 4 33%33%None
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 12.5MG 12 BOX   1 Tier 1 $6.00$9.00None
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 $6.00$9.00None
PROMETHEGAN 25MG SUPP   1 Tier 1 $6.00$9.00None
PROMETHEGAN 50MG SUPPOS   1 Tier 1 $6.00$9.00None
PROMETRIUM 100MG CAPSULE   2 Tier 2 $43.00$107.50None
PROMETRIUM 200MG CAPSULE   2 Tier 2 $43.00$107.50None
PROPAFENONE HCL 150MG TABLET (100 CT)   1 Tier 1 $6.00$9.00None
PROPAFENONE HCL 225MG TABLET   1 Tier 1 $6.00$9.00None
PROPAFENONE HCL 300MG TABLET (100 CT)   1 Tier 1 $6.00$9.00None
PROPAFENONE HYDROCHLORIDE CAPSULES EXTENDED RELEASE   3 Tier 3 $85.00$212.50None
PROPAFENONE HYDROCHLORIDE CAPSULES EXTENDED RELEASE   3 Tier 3 $85.00$212.50None
PROPAFENONE HYDROCHLORIDE CAPSULES EXTENDED RELEASE   3 Tier 3 $85.00$212.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PROPARACAINE 0.5% EYE DROPS   1 Tier 1 $6.00$9.00None
PROPINE 0.1% EYE DROPS   3 Tier 3 $85.00$212.50None
PROPRANOLOL 20MG/5ML TUBEX   1 Tier 1 $6.00$9.00None
PROPRANOLOL 40MG/5ML TUBEX   1 Tier 1 $6.00$9.00None
PROPRANOLOL 60MG TABLET   1 Tier 1 $6.00$9.00None
PROPRANOLOL 80 MG TABLET   1 Tier 1 $6.00$9.00None
PROPRANOLOL HCL 20MG TABLET (1000 CT)   1 Tier 1 $6.00$9.00None
PROPRANOLOL HCL CAPSULES ER 120MG (1000 CT)   1 Tier 1 $6.00$9.00None
PROPRANOLOL HCL CAPSULES ER 160MG (1000 CT)   1 Tier 1 $6.00$9.00None
PROPRANOLOL HCL CAPSULES ER 60MG (100 CT)   1 Tier 1 $6.00$9.00None
PROPRANOLOL HCL CAPSULES ER 80MG (1000 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
PROPRANOLOL HCL INJECTION 1MG 10 PKG OF 10 CRTN   4 Tier 4 33%33%None
PROPRANOLOL HCL TABLET USP 10MG (1000 CT)   1 Tier 1 $6.00$9.00None
PROPRANOLOL HCL TABLET USP 40MG (1000 CT)   1 Tier 1 $6.00$9.00None
PROPRANOLOL/HCTZ 40/25 TABLET   1 Tier 1 $6.00$9.00None
PROPRANOLOL/HCTZ 80/25 TABLET   1 Tier 1 $6.00$9.00None
PROPYLTHIOURACIL 50MG TABLET   1 Tier 1 $6.00$9.00None
PROQUAD VIAL   2 Tier 2 $43.00$107.50None
PROQUIN XR ER TABLET 582MG   3 Tier 3 $85.00$212.50Q:3
/1Days
PROSCAR TABLETS 5MG 30 BOT   3 Tier 3 $85.00$212.50None
PROSOL 20% INJECTION   4 Tier 4 33%33%None
PROTONIX IV 40MG VIAL   4 Tier 4 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PROTOPIC 0.03% OINTMENT 100GM TUBE   3 Tier 3 $85.00$212.50P
PROTOPIC 0.1% OINTMENT 60GM TUBE   3 Tier 3 $85.00$212.50P
PROTRIPTYLINE HYDROCHLORIDE TABLETS   1 Tier 1 $6.00$9.00None
PROTRIPTYLINE HYDROCHLORIDE TABLETS 5MG   1 Tier 1 $6.00$9.00None
PROVENTIL HFA INHALER 90MCG AE   2 Tier 2 $43.00$107.50Q:21
/30Days
PROVERA 10MG TABLET   3 Tier 3 $85.00$212.50None
PROVERA 2.5MG TABLET (100 CT)   3 Tier 3 $85.00$212.50None
PROVERA 5MG TABLET   3 Tier 3 $85.00$212.50None
PROVIGIL 100MG TABLET   2 Tier 2 $43.00$107.50P Q:30
/30Days
PROVIGIL 200MG TABLET   2 Tier 2 $43.00$107.50P Q:60
/30Days
PROZAC 10MG PULVULE   3 Tier 3 $85.00$212.50Q:45
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PROZAC 40MG PULVULE   3 Tier 3 $85.00$212.50Q:60
/30Days
PROZAC CAPSULES 20MG (2000 CT)   3 Tier 3 $85.00$212.50Q:120
/30Days
PROZAC WEEKLY 90MG CAPSULE   3 Tier 3 $85.00$212.50Q:4
/28Days
PULMICORT .25MG/2ML RESPULE   3 Tier 3 $85.00$212.50P Q:120
/30Days
PULMICORT 0.5MG/2ML RESPULE   3 Tier 3 $85.00$212.50P Q:120
/30Days
PULMICORT 1MG/2ML AMPUL FOR NEBULIZATION   3 Tier 3 $85.00$212.50P Q:120
/30Days
PULMICORT FLEXHALER 180MCG AEROSOL POWDER BREATH ACTIVATED   3 Tier 3 $85.00$212.50Q:1
/25Days
PULMICORT FLEXHALER 90MCG AEROSOL POWDER BREATH ACTIVATED   3 Tier 3 $85.00$212.50Q:1
/25Days
PULMOZYME 1MG/ML AMPUL   5 Tier 5 33%N/AP
PURINETHOL 50MG TABLET   3 Tier 3 $85.00$212.50None
PYRAZINAMIDE 500MG 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
PYRIDOSTIGMINE BROMIDE 60MG TABLET   1 Tier 1 $6.00$9.00None

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.