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2011 Medicare Part D and Medicare Advantage Plan Formulary Browser
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.
Select your search style and criteria below or use this example to get started

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State & Plan   ZIP & Plan   PlanID   FormularyID

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PDP     MAPD
Scroll down to see formulary results.

CIGNA Medicare Rx Plan Two (PDP) (S5617-202-0)
Tier 1 (170)
Tier 2 (1309)
Tier 3 (1123)
Tier 4 (446)
Tier 5 (405)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
Yes No Show either
  *required
 
Cick on the first letter of your drug name to browse the formulary:

A B C D E F G H I J K L 
M N O P Q R S T U V W X Y Z 0-9 
2011 Medicare Part D Plan Formulary Information
CIGNA Medicare Rx Plan Two (PDP) (S5617-202-0)
Benefit Details           
The CIGNA Medicare Rx Plan Two (PDP) (S5617-202-0)
Formulary Drugs Starting with the Letter A
in CMS PDP Region 32 which includes: CA
Drugs Starting with Letter A

Drug Name		 Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order
A METHAPRED METHLYPREDNISOLONE SODIUM SUCCINATE FOR INJECTION 125 MG   2 Preferred Generic/Preferred Brand $3.00$7.50P
A-HYDROCORT 100MG VIAL   2 Preferred Generic/Preferred Brand $3.00$7.50P
A-METHAPRED 40MG UNIVIAL   2 Preferred Generic/Preferred Brand $3.00$7.50P
ABELCENT INJECTION SUSPENSION 5MG/ML   5 Specialty Tier 33%33%P
ABILIFY 10MG TABLET   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00P Q:30
/30Days
ABILIFY 15MG TABLET   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00P Q:30
/30Days
ABILIFY 1MG/ML SOLUTION   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00P Q:900
/30Days
ABILIFY 20MG TABLET   5 Specialty Tier 33%33%P Q:30
/30Days
ABILIFY 2MG TABLET   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00P Q:30
/30Days
ABILIFY 30MG TABLET   5 Specialty Tier 33%33%P Q:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ABILIFY 5MG TABLET (OTSUKA)   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00P Q:30
/30Days
ABILIFY DISCMELT 10MG TABLET   5 Specialty Tier 33%33%P Q:60
/30Days
ABILIFY DISCMELT 15MG TABLET   5 Specialty Tier 33%33%P Q:60
/30Days
ABILIFY INJ 9.75MG   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00P
ABRAXANE 100MG VIAL   5 Specialty Tier 33%33%P
ACARBOSE 100MG TABLET S   2 Preferred Generic/Preferred Brand $3.00$7.50None
ACARBOSE 50MG TABLET S   2 Preferred Generic/Preferred Brand $3.00$7.50None
ACARBOSE TABLETS   2 Preferred Generic/Preferred Brand $3.00$7.50None
ACCOLATE 10MG TABLET   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00Q:60
/30Days
ACCOLATE 20MG TABLET   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00Q:60
/30Days
ACEBUTOLOL 200MG CAPSULE   1 Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ACEBUTOLOL 400MG CAPSULE   1 Preferred Generic $0.00$0.00None
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD   2 Preferred Generic/Preferred Brand $3.00$7.50None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT)   2 Preferred Generic/Preferred Brand $3.00$7.50None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT)   2 Preferred Generic/Preferred Brand $3.00$7.50None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT)   2 Preferred Generic/Preferred Brand $3.00$7.50None
ACETASOL HC SOLUTION 10ML 10 ML BOT   2 Preferred Generic/Preferred Brand $3.00$7.50None
ACETAZOLAMIDE 125MG TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
ACETAZOLAMIDE 250MG TABLET (100 CT)   2 Preferred Generic/Preferred Brand $3.00$7.50None
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
ACETAZOLAMIDE SOD 500MG VL   2 Preferred Generic/Preferred Brand $3.00$7.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ACETIC ACID 2% SOLUTION NON-ORAL   2 Preferred Generic/Preferred Brand $3.00$7.50None
ACETYLCYSTEINE 10% VIAL   2 Preferred Generic/Preferred Brand $3.00$7.50P
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN   2 Preferred Generic/Preferred Brand $3.00$7.50P
ACTEMRA INJECTION 200MG/10ML   5 Specialty Tier 33%33%P
ACTHIB VACCINE VIAL 10-24UNT/5ML   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
ACTICIN 5% CREAM   2 Preferred Generic/Preferred Brand $3.00$7.50None
ACTIMMUNE SOLUTION FOR INJECTION 100MCG   5 Specialty Tier 33%33%P
ACTONEL 150MG TABLET   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00S Q:1
/30Days
ACTONEL 30MG TABLET   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00S Q:30
/30Days
ACTONEL 35MG TABLET   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00S Q:4
/28Days
ACTONEL 5MG TABLET   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00S Q:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ACTOPLUS MET 15MG/500MG TABLET   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:90
/30Days
ACTOPLUS MET 15MG/850MG TABLET   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:90
/30Days
ACTOS 15MG TABLET   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:30
/30Days
ACTOS 30MG TABLET (500 CT)   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:30
/30Days
ACTOS 45MG TABLET   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:30
/30Days
ACYCLOVIR 200MG CAPSULE (1000 CT)   2 Preferred Generic/Preferred Brand $3.00$7.50None
ACYCLOVIR 200MG/5ML SUSP   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
ACYCLOVIR 400MG TABLET (100 CT)   2 Preferred Generic/Preferred Brand $3.00$7.50None
ACYCLOVIR 800 MG ORAL TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
ACYCLOVIR SODIUM 500MG VIAL   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
ADACEL VIAL 2UNT/5UNT   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ADAGEN 250U/ML VIAL   5 Specialty Tier 33%33%P
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA]   5 Specialty Tier 33%33%P
ADCIRCA TABLETS 20MG 60 BOT   5 Specialty Tier 33%33%P Q:60
/30Days
ADDERALL XR 10MG CAPSULE SA   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00Q:30
/30Days
ADDERALL XR 15MG CAPSULE SA   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00Q:30
/30Days
ADDERALL XR 20MG CAPSULE SA   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00Q:60
/30Days
ADDERALL XR 25MG CAPSULE SA   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00Q:60
/30Days
ADDERALL XR 30MG CAPSULE SA   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00Q:60
/30Days
ADDERALL XR 5MG CAPSULE SA   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00Q:30
/30Days
ADVAIR DISKU MIS 100/50   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
ADVAIR DISKU MIS 250/50   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ADVAIR DISKU MIS 500/50   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
ADVAIR HFA INHALER 230;21MCG;MCG   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
AFEDITAB CR 30MG TABLET SA   2 Preferred Generic/Preferred Brand $3.00$7.50None
AFEDITAB CR 60MG TABLET SA   2 Preferred Generic/Preferred Brand $3.00$7.50None
AFINITOR TABLETS   5 Specialty Tier 33%33%P
AFINITOR TABLETS   5 Specialty Tier 33%33%P
AFINITOR TABLETS 5 MG   5 Specialty Tier 33%33%P
AGGRENOX 25-200MG CAPSULE   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00Q:60
/30Days
AK-CON 0.1% EYE DROPS   2 Preferred Generic/Preferred Brand $3.00$7.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
AKTOB 0.3% EYE DROPS   2 Preferred Generic/Preferred Brand $3.00$7.50None
ALA-CORT 1% CREAM   2 Preferred Generic/Preferred Brand $3.00$7.50None
ALA-CORT 1% LOTION   2 Preferred Generic/Preferred Brand $3.00$7.50None
ALAMAST 0.1% DROPS   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
ALBENZA 200MG TABLET   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
ALBUTEROL SULFATE 0.63MG/3ML VIAL NEBULIZER   2 Preferred Generic/Preferred Brand $3.00$7.50P
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER   2 Preferred Generic/Preferred Brand $3.00$7.50P
ALBUTEROL SULFATE 4MG TABLET SR 12HR   2 Preferred Generic/Preferred Brand $3.00$7.50None
ALBUTEROL SULFATE 8MG TABLET SR 12HR   2 Preferred Generic/Preferred Brand $3.00$7.50None
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   2 Preferred Generic/Preferred Brand $3.00$7.50P
ALBUTEROL SULFATE SOLUTION FOR INHALATION   2 Preferred Generic/Preferred Brand $3.00$7.50P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT   2 Preferred Generic/Preferred Brand $3.00$7.50None
ALBUTEROL SULFATE TABLET 2MG (500 CT)   2 Preferred Generic/Preferred Brand $3.00$7.50None
ALBUTEROL TABLET 4MG (500 CT)   2 Preferred Generic/Preferred Brand $3.00$7.50None
ALCLOMETASONE DIPROPIONATE 0.05% CREAM   2 Preferred Generic/Preferred Brand $3.00$7.50None
ALCLOMETASONE DIPROPIONATE 0.05% OINTMENT   2 Preferred Generic/Preferred Brand $3.00$7.50None
ALCOHOL 5%/DEXTROSE 5%   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
ALDARA IMIQUIMOD CREAM 5% 24 PKT X 250 MG CRTN   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
ALDURAZYME 2.9MG/5ML VIAL   5 Specialty Tier 33%33%P
ALENDRONATE SODIUM 10MG TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50Q:30
/30Days
ALENDRONATE SODIUM 40MG TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50Q:30
/30Days
ALENDRONATE SODIUM 5MG TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50Q:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ALENDRONATE SODIUM TABLET 35MG 20 CRTN   2 Preferred Generic/Preferred Brand $3.00$7.50Q:4
/28Days
ALENDRONATE SODIUM TABLETS 70 MG   2 Preferred Generic/Preferred Brand $3.00$7.50Q:4
/28Days
ALIMTA 500MG VIAL   5 Specialty Tier 33%33%P
ALINIA 100MG/5ML SUSPENSION   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
ALINIA 500MG TABLET   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
ALKERAN FOR INJECTION 50MG/VIAL 1 VIALSU   5 Specialty Tier 33%33%P
ALLOPURINOL SODIUM 500MG VIAL   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
ALLOPURINOL TABLET 300MG (1000 CT)   2 Preferred Generic/Preferred Brand $3.00$7.50None
ALLOPURINOL TABLETS   2 Preferred Generic/Preferred Brand $3.00$7.50None
ALOCRIL 2% EYE DROPS   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
ALOMIDE 0.1% EYE DROPS   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ALOPRIM SOLUTION FOR INJECTION 500MG/VIAL 30 ML VIALGL   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
ALORA 0.025MG PATCH   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:8
/28Days
ALORA 0.05MG PATCH   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:8
/28Days
ALORA 0.075MG PATCH   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:8
/28Days
ALORA 0.1MG PATCH   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:8
/28Days
ALPHA-1-PROTEINASE INHIBITOR,HUMAN 16 MG/ML INJECTABLE SOLUTION [ARALAST]   5 Specialty Tier 33%33%P
ALPHAGAN P 0.1% DROPS   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
ALPHAGAN P 0.15% EYE DROPS   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
ALVESCO 160MCG/ACT AERS   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
ALVESCO 80MCG/ACT AERS   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
AMANTADINE 100MG CAPSULE   2 Preferred Generic/Preferred Brand $3.00$7.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
AMANTADINE 100MG TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMANTADINE HCL 50 MG/ 5 ML SYRUP   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMBIEN CR 12.5MG TABLET   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00S Q:30
/30Days
AMBIEN CR 6.25MG TABLET   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00S Q:30
/30Days
AMBISOME 50MG VIAL   5 Specialty Tier 33%33%P
AMCINONIDE 0.1% CREAM   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMCINONIDE 0.1% LOTION   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMCINONIDE 0.1% OINTMENT 60GM TUBE   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMEVIVE ADMISTRATION PACK FOR INTRAMUSCULAR ADMINISTRATION KIT 15MG 1 X 4 PKGCOM   5 Specialty Tier 33%33%P
AMIFOSTINE FOR INJECTION 500MG/VIAL   5 Specialty Tier 33%33%P
AMIKACIN 250MG/ML VIAL   2 Preferred Generic/Preferred Brand $3.00$7.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
AMIKACIN 50MG/ML VIAL   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET   1 Preferred Generic $0.00$0.00None
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMINOPHYLLINE 100MG TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMINOPHYLLINE 200MG TABLET (1000 CT)   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMINOPHYLLINE INJECTION 250MG 10ML X 25 VIALSD   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMINOSYN 10% IV SOLUTION   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
AMINOSYN 3.5% IV SOLUTION   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
AMINOSYN 5% IV SOLUTION   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
AMINOSYN 7% IV SOLUTION   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
AMINOSYN 7%-ELECTROLYTE SOL   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
AMINOSYN 8.5% IV SOLUTION   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
AMINOSYN HBC INJECTION SULFITE FREE 7%   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
AMINOSYN II 10% IV SOLUTION   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
AMINOSYN II 15% IV SOLUTION   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
AMINOSYN II 3.5% IN D25W IV   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
AMINOSYN II 3.5% IN D5W IV   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
AMINOSYN II 3.5% M/D5W IV   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
AMINOSYN II 3.5% W/ELEC DEX   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
AMINOSYN II 4.25% IN D10W   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
AMINOSYN II 4.25% IN D20W   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
AMINOSYN II 4.25% W/ELEC DW   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
AMINOSYN II 4.25%-D25W IV   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
AMINOSYN II 5% IN D25W IV   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
AMINOSYN II 7% IV SOLUTION   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
AMINOSYN II 8.5% ELECTROLYT   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
AMINOSYN II 8.5% IV SOLUTION   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
AMINOSYN M 3.5% IV SOLUTION   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
AMINOSYN PF INJECTION   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5%   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
AMINOSYN-HF 8% IV SOLUTION   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
AMINOSYN-PF 7% IV SOLUTION   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
AMIODARONE HCL 400MG TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
AMIODARONE HCL INJECTION   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMIODARONE HYDROCHLORIDE TABLETS   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMITRIP/CDP 25-10 TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMITRIP/PERPHEN 10-2 TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMITRIP/PERPHEN 10-4 TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMITRIP/PERPHEN 25-2 TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMITRIP/PERPHEN 25-4 TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMITRIP/PERPHEN 50-4 TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMITRIPTYLINE HCL 100MG TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMITRIPTYLINE HCL 10MG TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMITRIPTYLINE HCL 150 MG TAB   2 Preferred Generic/Preferred Brand $3.00$7.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMLODIPINE 10 MG / HYDROCHLOROTHIAZIDE 12.5 MG / VALSARTAN 160 MG ORAL TABLET [EXFORGE HCT 10/160/12   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:30
/30Days
AMLODIPINE 10 MG / HYDROCHLOROTHIAZIDE 25 MG / VALSARTAN 160 MG ORAL TABLET [EXFORGE HCT 10/160/25]   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:30
/30Days
AMLODIPINE 10 MG / HYDROCHLOROTHIAZIDE 25 MG / VALSARTAN 320 MG ORAL TABLET [EXFORGE HCT 10/320/25]   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:30
/30Days
AMLODIPINE 10 MG / TELMISARTAN 40 MG ORAL TABLET [TWYNSTA 40/10]   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:30
/30Days
AMLODIPINE 10 MG / TELMISARTAN 80 MG ORAL TABLET [TWYNSTA 80/10]   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:30
/30Days
AMLODIPINE 5 MG / HYDROCHLOROTHIAZIDE 12.5 MG / VALSARTAN 160 MG ORAL TABLET [EXFORGE HCT 5/160/12.5   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:30
/30Days
AMLODIPINE 5 MG / HYDROCHLOROTHIAZIDE 25 MG / VALSARTAN 160 MG ORAL TABLET [EXFORGE HCT 5/160/25]   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:30
/30Days
AMLODIPINE 5 MG / TELMISARTAN 40 MG ORAL TABLET [TWYNSTA 40/5]   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
AMLODIPINE 5 MG / TELMISARTAN 80 MG ORAL TABLET [TWYNSTA 80/5]   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:30
/30Days
AMLODIPINE BESYLATE 10MG TABLET (90 CT)   2 Preferred Generic/Preferred Brand $3.00$7.50Q:30
/30Days
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)   2 Preferred Generic/Preferred Brand $3.00$7.50Q:30
/30Days
AMLODIPINE BESYLATE 5MG TABLET (90 CT)   2 Preferred Generic/Preferred Brand $3.00$7.50Q:30
/30Days
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE CAPSULES   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE CAPSULES   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
AMMONIUM CHLORIDE 5 MEQ/ML   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
AMMONIUM LACTATE 12% CREAM   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMMONIUM LACTATE 12% LOTION   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMNESTEEM 10MG CAPSULE   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
AMNESTEEM 20MG CAPSULE   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
AMNESTEEM 40MG CAPSULE   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
AMOX TR-K CLV 500-125 MG TAB   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   2 Preferred Generic/Preferred Brand $3.00$7.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
AMOXAPINE 100MG TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMOXAPINE 150MG TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMOXAPINE 25MG TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMOXAPINE 50MG TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMOXICILLIN 125MG TABLET CHEW   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMOXICILLIN 200MG TABLET CHEW   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMOXICILLIN 250MG CAPSULE   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMOXICILLIN 400MG TABLET CHEW   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMOXICILLIN 50 MG/ML / CLAVULANATE 12.5 MG/ML ORAL SUSPENSION   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMOXICILLIN 500MG CAPSULE   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMOXICILLIN 500MG TABLET (100 CT)   2 Preferred Generic/Preferred Brand $3.00$7.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
AMOXICILLIN 875MG TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMOXICILLIN TABLET USP CHEWABLE 250MG (250 CT)   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMPHETAMINE SALT COMBO 12.5MG TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMPHETAMINE SALT COMBO 15MG TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMPHETAMINE SALT COMBO 30MG TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
AMPHETAMINE SALT COMBO 7.5MG TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMPHETAMINE SALTS 20MG TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMPHETAMINE SALTS 5 MG TAB   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMPHOTEC FOR INJECTION 50MG/VIAL   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00P
AMPHOTERICIN B FOR INJECTION 50 MG   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
AMPICILLIN AND SULBACTAM FOR INJECTION 10-5 1 VIAL   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
AMPICILLIN AND SULBACTAM FOR INJECTION 2-1 10 VIAL   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
AMPICILLIN CAPSULES 250MG 100 BOT   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMPICILLIN CAPSULES 500MG 100 BOT   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMPICILLIN FOR INJECTION POWDER   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
AMPICILLIN FOR INJECTION USP 125MG/ML 1 VIAL   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT   2 Preferred Generic/Preferred Brand $3.00$7.50None
AMPICILLIN POWDER FOR INJECTION 1 GM/ML   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
AMPYRA ER 10 MG TABLET   5 Specialty Tier 33%33%P Q:60
/30Days
AMYLASES 109000 UNT / ENDOPEPTIDASES 68000 UNT / LIPASE 20000 UNT ENTERIC COATED CAPSULE [ZENPEP 20]   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
AMYLASES 27000 UNT / ENDOPEPTIDASES 17000 UNT / LIPASE 5000 UNT ENTERIC COATED CAPSULE [ZENPEP 5]   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
AMYLASES 55000 UNT / ENDOPEPTIDASES 34000 UNT / LIPASE 10000 UNT ENTERIC COATED CAPSULE [ZENPEP 10]   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
AMYLASES 82000 UNT / ENDOPEPTIDASES 51000 UNT / LIPASE 15000 UNT ENTERIC COATED CAPSULE [ZENPEP 15]   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
ANADROL-50 50MG TABLET (100 CT)   5 Specialty Tier 33%33%None
ANAGRELIDE HCL 0.5MG CAPSULE   2 Preferred Generic/Preferred Brand $3.00$7.50P
ANAGRELIDE HCL 1MG CAPSULE   2 Preferred Generic/Preferred Brand $3.00$7.50P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ANASTROZOLE TABLETS   2 Preferred Generic/Preferred Brand $3.00$7.50Q:30
/30Days
ANCOBON 250MG CAPSULE   5 Specialty Tier 33%33%None
ANCOBON 500MG CAPSULE   5 Specialty Tier 33%33%None
ANDROGEL 1%(50MG) GEL PACKET   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
ANGELIQ 1-0.5MG TABLET   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
ANIDULAFUNGIN 3.33 MG/ML INJECTABLE SOLUTION [ERAXIS]   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
ANTABUSE 250MG TABLET   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
ANTABUSE 500MG TABLET   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
ANTIZOL INJECTION 1GM 4 X 1.5ML VIAL CRTN   5 Specialty Tier 33%33%P
ANZEMET 100MG TABLET   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00P Q:5
/30Days
ANZEMET 20MG/ML VIAL   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ANZEMET 50MG TABLET   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00P Q:5
/30Days
APIDRA 100UNITS/ML VIAL   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
APOKYN 30 MG/3 ML CARTRIDGE   5 Specialty Tier 33%33%P
APRACLONIDINE 5 MG/ML OPHTHALMIC SOLUTION   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
APRI 0.15-0.03 TABLET   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
APTIVUS 250MG CAPSULE   5 Specialty Tier 33%33%None
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT   5 Specialty Tier 33%33%None
ARANELLE 7-9-5 TABLET   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
ARANESP 100MCG/ML VIAL   5 Specialty Tier 33%33%P
ARANESP 200MCG/0.4ML SYRINGE   5 Specialty Tier 33%33%P
ARANESP 200MCG/ML VIAL   5 Specialty Tier 33%33%P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ARANESP 25MCG/ML VIAL   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
ARANESP 300MCG/ML VIAL   5 Specialty Tier 33%33%P
ARANESP 500MCG/1ML SYRINGE   5 Specialty Tier 33%33%P
ARANESP 60MCG/ML VIAL   5 Specialty Tier 33%33%P
ARANESP PREFILLED SYRINGE SINGLE USE 100MCG/0.5ML 1 SYR   5 Specialty Tier 33%33%P
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR   5 Specialty Tier 33%33%P
ARANESP PREFILLED SYRINGE SINGLE USE 25MCG/0.42ML SYR   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR   5 Specialty Tier 33%33%P
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
ARANESP PREFILLED SYRINGE SINGLE USE 60MCG/0.3ML 60MCG/ 0.3ML SYR   5 Specialty Tier 33%33%P
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ARCALYST INJECTION 220MG/VIAL   5 Specialty Tier 33%33%P
ARICEPT 10MG TABLET   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:30
/30Days
ARICEPT 5MG TABLET   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:30
/30Days
ARICEPT ODT 10MG TABLET   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:30
/30Days
ARICEPT ODT 5MG TABLET   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:30
/30Days
ARICEPT TABLETS   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:30
/30Days
ARIMIDEX 1MG TABLET   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:30
/30Days
ARIXTRA 10MG SYRINGE   5 Specialty Tier 33%33%Q:24
/365Days
ARIXTRA 2.5MG SYRINGE   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:32
/365Days
ARIXTRA 5MG SYRINGE   5 Specialty Tier 33%33%Q:12
/365Days
ARIXTRA 7.5MG SYRINGE   5 Specialty Tier 33%33%Q:18
/365Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
AROMASIN 25MG TABLET   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
ARRANON 250MG VIAL   5 Specialty Tier 33%33%P
ARZERRA INJECTION 100MG/5ML   5 Specialty Tier 33%33%P
ASACOL 400MG TABLET EC   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00S
ASACOL HD DELAYED RELEASE TABLETS 800MG 180 BOT   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00S
ASCOMP W/CODEINE 30-50-325 CAPSULE   2 Preferred Generic/Preferred Brand $3.00$7.50None
ASENAPINE 10 MG SUBLINGUAL TABLET [SAPHRIS]   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00P
ASENAPINE 5 MG SUBLINGUAL TABLET [SAPHRIS]   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00P
ASMANEX 220MCG(14) AEROSOL POWDER BREATH ACTIVATED   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
ASMANEX TWISTHALER 110 MCG #30   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
ASMANEX TWISTHALER 220MCG #120   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ASMANEX TWISTHALER 220MCG #30   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
ASMANEX TWISTHALER 220MCG #60   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
ASTEPRO 0.15% NASAL SPRAY 30 ML   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
ATAMET   2 Preferred Generic/Preferred Brand $3.00$7.50None
ATENOLOL 25MG TABLET (100 CT)   1 Preferred Generic $0.00$0.00None
ATENOLOL TABLET USP 50MG (100 CT)   1 Preferred Generic $0.00$0.00None
ATENOLOL TABLETS USP 100MG 1 BLPK   1 Preferred Generic $0.00$0.00None
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT)   1 Preferred Generic $0.00$0.00None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   1 Preferred Generic $0.00$0.00None
ATGAM 50MG/ML AMPUL   5 Specialty Tier 33%33%P
ATRIPLA TABLET 600MG/200MG   5 Specialty Tier 33%33%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ATROPINE 0.025 MG / DIPHENOXYLATE 2.5 MG ORAL TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
ATROPINE 0.05MG/ML SYRINGE   2 Preferred Generic/Preferred Brand $3.00$7.50None
ATROPINE 0.1MG/ML SYRINGE   2 Preferred Generic/Preferred Brand $3.00$7.50None
ATROVENT HFA AER 17MCG   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00S
ATTENUVAX VACCINE W/DILUENT 1 DOSE/0.5ML   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
AVANDAMET 2MG/1000MG TABLET   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:60
/30Days
AVANDAMET 2MG/500MG TABLET   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:60
/30Days
AVANDAMET 4MG/500MG TABLET   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:60
/30Days
AVANDAMET TABLET 4-1000MG   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:60
/30Days
AVANDARYL 4MG/1MG TABLET   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:60
/30Days
AVANDARYL 4MG/2MG TABLET   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:60
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
AVANDARYL 4MG/4MG TABLET   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:60
/30Days
AVANDARYL 8MG-2MG TABLET   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:30
/30Days
AVANDARYL 8MG-4MG TABLET   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:30
/30Days
AVANDIA 2MG TABLET   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:60
/30Days
AVANDIA 4MG TABLET (90 CT)   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:60
/30Days
AVANDIA 8MG TABLET (90 CT)   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:30
/30Days
AVASTIN 100MG/4ML VIAL   5 Specialty Tier 33%33%P
AVELOX 400MG TABLET   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:30
/30Days
AVELOX ABC PACK 400MG TABLET   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:30
/30Days
AVELOX IV 400MG/250ML   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
AVIANE 0.1-0.02 TABLET   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
AVODART 0.5MG SOFTGEL   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:30
/30Days
AVONEX ADMIN PACK 30MCG SYR   5 Specialty Tier 33%33%P
AVONEX ADMIN PACK 30MCG VL   5 Specialty Tier 33%33%P
AZACTAM INJECTION   5 Specialty Tier 33%33%None
AZACTAM INJECTION 1GM/50ML   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
AZACTAM INJECTION 2GM/VIL   5 Specialty Tier 33%33%None
AZASAN 100MG TABLET   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
AZASAN 75MG TABLET   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
AZASITE 1% DROPS   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
AZATHIOPRINE 50MG TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50P
AZATHIOPRINE SOD 100MG VIAL   2 Preferred Generic/Preferred Brand $3.00$7.50P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
AZELASTINE 137 MCG NASAL SPRAY   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
AZELASTINE HYDROCHLORIDE OPHTHALMIC SOLUTION   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
AZILECT 0.5MG TABLET   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
AZILECT 1MG TABLET   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL   2 Preferred Generic/Preferred Brand $3.00$7.50None
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL   2 Preferred Generic/Preferred Brand $3.00$7.50None
AZITHROMYCIN 250 MG TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50Q:12
/30Days
AZITHROMYCIN 33.3 MG/ML ER SUSPENSION [ZMAX]   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00Q:120
/30Days
AZITHROMYCIN 500MG TABLET (30 CT)   2 Preferred Generic/Preferred Brand $3.00$7.50None
AZITHROMYCIN FOR INJECTION 500MG 10 VIALSD   2 Preferred Generic/Preferred Brand $3.00$7.50None
AZITHROMYCIN TABLETS   2 Preferred Generic/Preferred Brand $3.00$7.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
AZTREONAM FOR INJECTION   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None

Chart Legend:

Below are a few notes to help you understand the above 2011 Medicare Part D CIGNA Medicare Rx Plan Two (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.





 
 


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Tips & Disclaimers
  • Q1Medicare®, Q1Rx®, and Q1Group® are registered Service Marks of Q1Group LLC and may not be used in any advertising, publicity, or for commercial purposes without the express authorization of Q1Group.
  • 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 PDPCompare.com and MACompare.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.
    Statement required by Medicare:
    "We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options."
  • 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.
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