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Blue Cross MedicareRx Gold (PDP) (S5596-035-0)
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 Cross MedicareRx Gold (PDP) (S5596-035-0)
Benefit Details           
The Blue Cross MedicareRx Gold (PDP) (S5596-035-0)
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   4 Tier 4 33%33%None
A-HYDROCORT 100MG VIAL   4 Tier 4 33%33%None
A-METHAPRED 40MG UNIVIAL   4 Tier 4 33%33%None
ABELCENT INJECTION SUSPENSION 5MG/ML   5 Tier 5 33%N/ANone
ABILIFY 10MG TABLET   2 Tier 2 $43.00$107.50Q:30
/30Days
ABILIFY 15MG TABLET   2 Tier 2 $43.00$107.50Q:30
/30Days
ABILIFY 1MG/ML SOLUTION   2 Tier 2 $43.00$107.50Q:900
/30Days
ABILIFY 20MG TABLET   2 Tier 2 $43.00$107.50Q:60
/30Days
ABILIFY 2MG TABLET   2 Tier 2 $43.00$107.50Q:30
/30Days
ABILIFY 30MG TABLET   2 Tier 2 $43.00$107.50Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ABILIFY 5MG TABLET (OTSUKA)   2 Tier 2 $43.00$107.50Q:30
/30Days
ABILIFY DISCMELT 10MG TABLET   2 Tier 2 $43.00$107.50Q:60
/30Days
ABILIFY DISCMELT 15MG TABLET   2 Tier 2 $43.00$107.50Q:60
/30Days
ABILIFY INJ 9.75MG   4 Tier 4 33%33%None
ABRAXANE 100MG VIAL   5 Tier 5 33%N/AP
ACARBOSE 100MG TABLET S   1 Tier 1 $6.00$9.00None
ACARBOSE 50MG TABLET S   1 Tier 1 $6.00$9.00None
ACARBOSE TABLETS   1 Tier 1 $6.00$9.00None
ACCOLATE 10MG TABLET   3 Tier 3 $85.00$212.50Q:60
/30Days
ACCOLATE 20MG TABLET   3 Tier 3 $85.00$212.50Q:60
/30Days
ACCUNEB 0.63MG/3ML INH TUBEX   3 Tier 3 $85.00$212.50P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACCUNEB 1.25MG/3ML INH TUBEX   3 Tier 3 $85.00$212.50P
ACCURETIC 10-12.5MG TABLET   3 Tier 3 $85.00$212.50None
ACCURETIC 20-12.5MG TABLET   3 Tier 3 $85.00$212.50None
ACCURETIC 20-25MG TABLET   3 Tier 3 $85.00$212.50None
ACEBUTOLOL 200MG CAPSULE   1 Tier 1 $6.00$9.00None
ACEBUTOLOL 400MG CAPSULE   1 Tier 1 $6.00$9.00None
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE   2 Tier 2 $43.00$107.50None
ACEON 2MG TABLET   3 Tier 3 $85.00$212.50None
ACEON 4MG TABLET   3 Tier 3 $85.00$212.50None
ACEON 8MG TABLET   3 Tier 3 $85.00$212.50None
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD   1 Tier 1 $6.00$9.00Q:4500
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT)   1 Tier 1 $6.00$9.00Q:390
/30Days
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT)   1 Tier 1 $6.00$9.00Q:390
/30Days
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT)   1 Tier 1 $6.00$9.00Q:390
/30Days
ACETAMINOPHEN CAFFEINE AND DIHYDROCODEINE BITARTRATE TABLETS 712.8;60;MG;MG;MG 100 BOT   3 Tier 3 $85.00$212.50Q:180
/30Days
ACETASOL HC SOLUTION 10ML 10 ML BOT   1 Tier 1 $6.00$9.00None
ACETAZOLAMIDE 125MG TABLET   1 Tier 1 $6.00$9.00None
ACETAZOLAMIDE 250MG TABLET (100 CT)   1 Tier 1 $6.00$9.00None
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT   1 Tier 1 $6.00$9.00None
ACETAZOLAMIDE SOD 500MG VL   4 Tier 4 33%33%None
ACETIC ACID 2% SOLUTION NON-ORAL   1 Tier 1 $6.00$9.00None
ACETYLCYSTEINE 10% VIAL   1 Tier 1 $6.00$9.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN   1 Tier 1 $6.00$9.00P
ACLOVATE ALCLOMETASONE DIPROPIONATE 0.05% OINTMENT(GM) TOPICAL   3 Tier 3 $85.00$212.50None
ACLOVATE CREAM 0.05% 15GM TUBE   3 Tier 3 $85.00$212.50None
ACTEMRA INJECTION 200MG/10ML   5 Tier 5 33%N/AP
ACTHIB VACCINE VIAL 10-24UNT/5ML   2 Tier 2 $43.00$107.50None
ACTICIN 5% CREAM   1 Tier 1 $6.00$9.00None
ACTIGALL 300MG CAPSULE   3 Tier 3 $85.00$212.50None
ACTIMMUNE SOLUTION FOR INJECTION 100MCG   5 Tier 5 33%N/AP
ACTIQ 1200MCG LOZENGE   5 Tier 5 33%N/AP Q:120
/30Days
ACTIQ 1600MCG LOZENGE   5 Tier 5 33%N/AP Q:120
/30Days
ACTIQ 200MCG LOZENGE   5 Tier 5 33%N/AP Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACTIQ 400MCG LOZENGE   5 Tier 5 33%N/AP Q:120
/30Days
ACTIQ 600MCG LOZENGE   5 Tier 5 33%N/AP Q:120
/30Days
ACTIQ 800MCG LOZENGE   5 Tier 5 33%N/AP Q:120
/30Days
ACTIVELLA 0.5-0.1MG TABLET 28 DLPK   3 Tier 3 $85.00$212.50None
ACTIVELLA 1-0.5MG TABLET 28 DLPK   3 Tier 3 $85.00$212.50None
ACTONEL 150MG TABLET   3 Tier 3 $85.00$212.50Q:1
/30Days
ACTONEL 30MG TABLET   3 Tier 3 $85.00$212.50Q:30
/30Days
ACTONEL 35MG TABLET   3 Tier 3 $85.00$212.50Q:4
/28Days
ACTONEL 5MG TABLET   3 Tier 3 $85.00$212.50Q:30
/30Days
ACTOPLUS MET 15MG/500MG TABLET   2 Tier 2 $43.00$107.50Q:90
/30Days
ACTOPLUS MET 15MG/850MG TABLET   2 Tier 2 $43.00$107.50Q:90
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACTOS 15MG TABLET   2 Tier 2 $43.00$107.50Q:30
/30Days
ACTOS 30MG TABLET (500 CT)   2 Tier 2 $43.00$107.50Q:30
/30Days
ACTOS 45MG TABLET   2 Tier 2 $43.00$107.50Q:30
/30Days
ACULAR 0.5% EYE DROPS   3 Tier 3 $85.00$212.50None
ACULAR LS 0.4% OPHTH SOL   3 Tier 3 $85.00$212.50None
ACYCLOVIR 200MG CAPSULE (1000 CT)   1 Tier 1 $6.00$9.00None
ACYCLOVIR 200MG/5ML SUSP   1 Tier 1 $6.00$9.00None
ACYCLOVIR 400MG TABLET (100 CT)   1 Tier 1 $6.00$9.00None
ACYCLOVIR 800 MG ORAL TABLET   1 Tier 1 $6.00$9.00None
ACYCLOVIR SODIUM 500MG VIAL   4 Tier 4 33%33%None
ADACEL VIAL 2UNT/5UNT   2 Tier 2 $43.00$107.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADAGEN 250U/ML VIAL   5 Tier 5 33%N/ANone
ADALAT CC 30MG TABLET   3 Tier 3 $85.00$212.50None
ADALAT CC 60MG TABLET   3 Tier 3 $85.00$212.50None
ADALAT CC 90MG TABLET   3 Tier 3 $85.00$212.50None
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA]   5 Tier 5 33%N/AP Q:2
/28Days
ADAPALENE CREAM   3 Tier 3 $85.00$212.50None
ADAPALENE GEL   3 Tier 3 $85.00$212.50None
ADCIRCA TABLETS 20MG 60 BOT   5 Tier 5 33%N/AP Q:60
/30Days
ADOXA 100MG TABLET   3 Tier 3 $85.00$212.50None
ADOXA 50MG TABLET   3 Tier 3 $85.00$212.50None
ADOXA PAK 100MG TABLET DSPK-31   3 Tier 3 $85.00$212.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADOXA PAK 100MG TABLET DSPK-60   3 Tier 3 $85.00$212.50None
ADOXA PAK 150MG TABLET   3 Tier 3 $85.00$212.50None
ADOXA PAK 75MG TABLET   3 Tier 3 $85.00$212.50None
ADVAIR DISKU MIS 100/50   2 Tier 2 $43.00$107.50Q:60
/30Days
ADVAIR DISKU MIS 250/50   2 Tier 2 $43.00$107.50Q:60
/30Days
ADVAIR DISKU MIS 500/50   2 Tier 2 $43.00$107.50Q:60
/30Days
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL   2 Tier 2 $43.00$107.50Q:12
/30Days
ADVAIR HFA INHALER 230;21MCG;MCG   2 Tier 2 $43.00$107.50Q:12
/30Days
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL   2 Tier 2 $43.00$107.50Q:12
/30Days
ADVICOR ER 20-750MG TABLET (90 CT)   3 Tier 3 $85.00$212.50None
ADVICOR EXTENDED RELEASE TABLETS 20;1000MG;MG 90 BOTPL   3 Tier 3 $85.00$212.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADVICOR EXTENDED RELEASE TABLETS 20;500MG;MG 90 BOTPL   3 Tier 3 $85.00$212.50None
ADVICOR EXTENDED RELEASE TABLETS 40;1000MG;MG 90 BOTPL   3 Tier 3 $85.00$212.50None
AEROBID-M AEROSOL W/ADAPTER   3 Tier 3 $85.00$212.50Q:21
/30Days
AFEDITAB CR 30MG TABLET SA   1 Tier 1 $6.00$9.00None
AFEDITAB CR 60MG TABLET SA   1 Tier 1 $6.00$9.00None
AFINITOR TABLETS   5 Tier 5 33%N/AP
AFINITOR TABLETS   5 Tier 5 33%N/AP
AFINITOR TABLETS 5 MG   5 Tier 5 33%N/AP
AGGRENOX 25-200MG CAPSULE   2 Tier 2 $43.00$107.50Q:60
/30Days
AGRYLIN 0.5MG CAPSULE   3 Tier 3 $85.00$212.50None
AK-CON 0.1% EYE DROPS   1 Tier 1 $6.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AKNE-MYCIN 2% OINTMENT   3 Tier 3 $85.00$212.50None
AKTOB 0.3% EYE DROPS   1 Tier 1 $6.00$9.00None
ALA-CORT 1% CREAM   3 Tier 3 $85.00$212.50None
ALA-CORT 1% LOTION   3 Tier 3 $85.00$212.50None
ALA-SCALP HP 2% LOTION   3 Tier 3 $85.00$212.50None
ALAMAST 0.1% DROPS   3 Tier 3 $85.00$212.50Q:20
/30Days
ALBENZA 200MG TABLET   3 Tier 3 $85.00$212.50None
ALBUTEROL SULFATE 0.63MG/3ML VIAL NEBULIZER   1 Tier 1 $6.00$9.00P
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER   1 Tier 1 $6.00$9.00P
ALBUTEROL SULFATE 4MG TABLET SR 12HR   1 Tier 1 $6.00$9.00None
ALBUTEROL SULFATE 8MG TABLET SR 12HR   1 Tier 1 $6.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   1 Tier 1 $6.00$9.00P
ALBUTEROL SULFATE SOLUTION FOR INHALATION   1 Tier 1 $6.00$9.00P
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT   1 Tier 1 $6.00$9.00None
ALBUTEROL SULFATE TABLET 2MG (500 CT)   1 Tier 1 $6.00$9.00None
ALBUTEROL TABLET 4MG (500 CT)   1 Tier 1 $6.00$9.00None
ALCAINE 0.5% EYE DROPS   3 Tier 3 $85.00$212.50None
ALCLOMETASONE DIPROPIONATE 0.05% CREAM   1 Tier 1 $6.00$9.00None
ALCLOMETASONE DIPROPIONATE 0.05% OINTMENT   1 Tier 1 $6.00$9.00None
ALCOHOL 5%/DEXTROSE 5%   4 Tier 4 33%33%None
ALDACTAZIDE 25/25 TABLET   3 Tier 3 $85.00$212.50None
ALDACTAZIDE 50/50 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
ALDACTONE 100MG TABLET   3 Tier 3 $85.00$212.50None
ALDACTONE 25MG TABLET   3 Tier 3 $85.00$212.50None
ALDACTONE 50MG TABLET   3 Tier 3 $85.00$212.50None
ALDARA IMIQUIMOD CREAM 5% 24 PKT X 250 MG CRTN   3 Tier 3 $85.00$212.50None
ALDURAZYME 2.9MG/5ML VIAL   5 Tier 5 33%N/ANone
ALENDRONATE SODIUM 10MG TABLET   1 Tier 1 $6.00$9.00Q:30
/30Days
ALENDRONATE SODIUM 40MG TABLET   1 Tier 1 $6.00$9.00Q:30
/30Days
ALENDRONATE SODIUM 5MG TABLET   1 Tier 1 $6.00$9.00Q:30
/30Days
ALENDRONATE SODIUM TABLET 35MG 20 CRTN   1 Tier 1 $6.00$9.00Q:4
/28Days
ALENDRONATE SODIUM TABLETS 70 MG   1 Tier 1 $6.00$9.00Q:4
/28Days
ALIMTA 500MG VIAL   5 Tier 5 33%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALINIA 100MG/5ML SUSPENSION   3 Tier 3 $85.00$212.50None
ALINIA 500MG TABLET   3 Tier 3 $85.00$212.50None
ALISKIREN 150 MG / VALSARTAN 160 MG ORAL TABLET [VALTURNA]   2 Tier 2 $43.00$107.50Q:30
/30Days
ALISKIREN 300 MG / VALSARTAN 320 MG ORAL TABLET [VALTURNA]   2 Tier 2 $43.00$107.50Q:30
/30Days
ALKERAN FOR INJECTION 50MG/VIAL 1 VIALSU   5 Tier 5 33%N/AP
ALLOPURINOL SODIUM 500MG VIAL   4 Tier 4 33%33%None
ALLOPURINOL TABLET 300MG (1000 CT)   1 Tier 1 $6.00$9.00None
ALLOPURINOL TABLETS   1 Tier 1 $6.00$9.00None
ALOCRIL 2% EYE DROPS   3 Tier 3 $85.00$212.50Q:10
/30Days
ALOMIDE 0.1% EYE DROPS   3 Tier 3 $85.00$212.50None
ALOPRIM SOLUTION FOR INJECTION 500MG/VIAL 30 ML VIALGL   4 Tier 4 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALORA 0.025MG PATCH   2 Tier 2 $43.00$107.50Q:8
/28Days
ALORA 0.05MG PATCH   2 Tier 2 $43.00$107.50Q:8
/28Days
ALORA 0.075MG PATCH   2 Tier 2 $43.00$107.50Q:8
/28Days
ALORA 0.1MG PATCH   2 Tier 2 $43.00$107.50Q:8
/28Days
ALOXI 0.25MG/5ML   5 Tier 5 33%N/ANone
ALPHA-1-PROTEINASE INHIBITOR,HUMAN 16 MG/ML INJECTABLE SOLUTION [ARALAST]   4 Tier 4 33%33%None
ALPHAGAN P 0.1% DROPS   2 Tier 2 $43.00$107.50None
ALPHAGAN P 0.15% EYE DROPS   3 Tier 3 $85.00$212.50None
ALREX 0.2% EYE DROPS   3 Tier 3 $85.00$212.50None
ALTOPREV 20MG TABLET SR 24HR   3 Tier 3 $85.00$212.50Q:30
/30Days
ALTOPREV 40MG TABLET SR 24HR   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
ALTOPREV 60MG TABLET SR 24HR   3 Tier 3 $85.00$212.50Q:30
/30Days
AMANTADINE 100MG CAPSULE   1 Tier 1 $6.00$9.00None
AMANTADINE 100MG TABLET   1 Tier 1 $6.00$9.00None
AMANTADINE HCL 50 MG/ 5 ML SYRUP   1 Tier 1 $6.00$9.00None
AMARYL 1MG TABLET   3 Tier 3 $85.00$212.50None
AMARYL 2MG TABLET   3 Tier 3 $85.00$212.50None
AMARYL 4MG TABLET   3 Tier 3 $85.00$212.50None
AMBIEN 10MG TABLET   3 Tier 3 $85.00$212.50P Q:30
/30Days
AMBIEN CR 12.5MG TABLET   3 Tier 3 $85.00$212.50P Q:30
/30Days
AMBIEN CR 6.25MG TABLET   3 Tier 3 $85.00$212.50P Q:30
/30Days
AMBIEN TABLETS 5MG 100 BOT   3 Tier 3 $85.00$212.50P Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMBISOME 50MG VIAL   5 Tier 5 33%N/ANone
AMCINONIDE 0.1% CREAM   1 Tier 1 $6.00$9.00None
AMCINONIDE 0.1% LOTION   1 Tier 1 $6.00$9.00None
AMCINONIDE 0.1% OINTMENT 60GM TUBE   1 Tier 1 $6.00$9.00None
AMERGE 1MG TABLET   3 Tier 3 $85.00$212.50Q:9
/30Days
AMERGE 2.5MG TABLET   3 Tier 3 $85.00$212.50Q:9
/30Days
AMEVIVE ADMISTRATION PACK FOR INTRAMUSCULAR ADMINISTRATION KIT 15MG 1 X 4 PKGCOM   5 Tier 5 33%N/AP
AMIFOSTINE FOR INJECTION 500MG/VIAL   5 Tier 5 33%N/ANone
AMIKACIN 250MG/ML VIAL   4 Tier 4 33%33%None
AMIKACIN 50MG/ML VIAL   4 Tier 4 33%33%None
AMILORIDE HCL W/HCTZ 5MG-50MG 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
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT   1 Tier 1 $6.00$9.00None
AMINOPHYLLINE 100MG TABLET   1 Tier 1 $6.00$9.00None
AMINOPHYLLINE 200MG TABLET (1000 CT)   1 Tier 1 $6.00$9.00None
AMINOPHYLLINE INJECTION 250MG 10ML X 25 VIALSD   4 Tier 4 33%33%None
AMINOSYN 10% IV SOLUTION   4 Tier 4 33%33%None
AMINOSYN 3.5% IV SOLUTION   4 Tier 4 33%33%None
AMINOSYN 5% IV SOLUTION   4 Tier 4 33%33%None
AMINOSYN 7% IV SOLUTION   4 Tier 4 33%33%None
AMINOSYN 7%-ELECTROLYTE SOL   4 Tier 4 33%33%None
AMINOSYN 8.5% IV SOLUTION   4 Tier 4 33%33%None
AMINOSYN HBC INJECTION SULFITE FREE 7%   4 Tier 4 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN II 10% IV SOLUTION   4 Tier 4 33%33%None
AMINOSYN II 15% IV SOLUTION   4 Tier 4 33%33%None
AMINOSYN II 3.5% IN D25W IV   4 Tier 4 33%33%None
AMINOSYN II 3.5% IN D5W IV   4 Tier 4 33%33%None
AMINOSYN II 3.5% M/D5W IV   4 Tier 4 33%33%None
AMINOSYN II 3.5% W/ELEC DEX   4 Tier 4 33%33%None
AMINOSYN II 4.25% IN D10W   4 Tier 4 33%33%None
AMINOSYN II 4.25% IN D20W   4 Tier 4 33%33%None
AMINOSYN II 4.25% W/ELEC DW   4 Tier 4 33%33%None
AMINOSYN II 4.25%-D25W IV   4 Tier 4 33%33%None
AMINOSYN II 5% IN D25W IV   4 Tier 4 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN II 7% IV SOLUTION   4 Tier 4 33%33%None
AMINOSYN II 8.5% ELECTROLYT   4 Tier 4 33%33%None
AMINOSYN II 8.5% IV SOLUTION   4 Tier 4 33%33%None
AMINOSYN M 3.5% IV SOLUTION   4 Tier 4 33%33%None
AMINOSYN PF INJECTION   4 Tier 4 33%33%None
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5%   4 Tier 4 33%33%None
AMINOSYN-HF 8% IV SOLUTION   4 Tier 4 33%33%None
AMINOSYN-PF 7% IV SOLUTION   4 Tier 4 33%33%None
AMIODARONE HCL 400MG TABLET   1 Tier 1 $6.00$9.00None
AMIODARONE HCL INJECTION   4 Tier 4 33%33%None
AMIODARONE HYDROCHLORIDE 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
AMITIZA 8MCG CAPSULE   2 Tier 2 $43.00$107.50None
AMITIZA CAPSULES 24MCG 60 CAP BOT   2 Tier 2 $43.00$107.50None
AMITRIP/CDP 25-10 TABLET   1 Tier 1 $6.00$9.00None
AMITRIP/PERPHEN 10-2 TABLET   1 Tier 1 $6.00$9.00None
AMITRIP/PERPHEN 10-4 TABLET   1 Tier 1 $6.00$9.00None
AMITRIP/PERPHEN 25-2 TABLET   1 Tier 1 $6.00$9.00None
AMITRIP/PERPHEN 25-4 TABLET   1 Tier 1 $6.00$9.00None
AMITRIP/PERPHEN 50-4 TABLET   1 Tier 1 $6.00$9.00None
AMITRIPTYLINE HCL 100MG TABLET   1 Tier 1 $6.00$9.00None
AMITRIPTYLINE HCL 10MG TABLET   1 Tier 1 $6.00$9.00None
AMITRIPTYLINE HCL 150 MG TAB   1 Tier 1 $6.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)   1 Tier 1 $6.00$9.00None
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)   1 Tier 1 $6.00$9.00None
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT   1 Tier 1 $6.00$9.00None
AMLODIPINE 10 MG / HYDROCHLOROTHIAZIDE 12.5 MG / VALSARTAN 160 MG ORAL TABLET [EXFORGE HCT 10/160/12   2 Tier 2 $43.00$107.50Q:30
/30Days
AMLODIPINE 10 MG / HYDROCHLOROTHIAZIDE 25 MG / VALSARTAN 160 MG ORAL TABLET [EXFORGE HCT 10/160/25]   2 Tier 2 $43.00$107.50Q:30
/30Days
AMLODIPINE 10 MG / HYDROCHLOROTHIAZIDE 25 MG / VALSARTAN 320 MG ORAL TABLET [EXFORGE HCT 10/320/25]   2 Tier 2 $43.00$107.50Q:30
/30Days
AMLODIPINE 5 MG / HYDROCHLOROTHIAZIDE 12.5 MG / VALSARTAN 160 MG ORAL TABLET [EXFORGE HCT 5/160/12.5   2 Tier 2 $43.00$107.50Q:30
/30Days
AMLODIPINE 5 MG / HYDROCHLOROTHIAZIDE 25 MG / VALSARTAN 160 MG ORAL TABLET [EXFORGE HCT 5/160/25]   2 Tier 2 $43.00$107.50Q:30
/30Days
AMLODIPINE BESYLATE 10MG TABLET (90 CT)   1 Tier 1 $6.00$9.00Q:30
/30Days
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)   1 Tier 1 $6.00$9.00Q:30
/30Days
AMLODIPINE BESYLATE 5MG TABLET (90 CT)   1 Tier 1 $6.00$9.00Q:45
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE CAPSULES   1 Tier 1 $6.00$9.00None
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE CAPSULES   1 Tier 1 $6.00$9.00None
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE   1 Tier 1 $6.00$9.00None
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE   1 Tier 1 $6.00$9.00None
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE   1 Tier 1 $6.00$9.00None
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE   1 Tier 1 $6.00$9.00None
AMMONIUM CHLORIDE 5 MEQ/ML   4 Tier 4 33%33%None
AMMONIUM LACTATE 12% CREAM   1 Tier 1 $6.00$9.00None
AMMONIUM LACTATE 12% LOTION   1 Tier 1 $6.00$9.00None
AMMONIUM LACTATE 120 MG/ML TOPICAL CREAM [LAC-HYDRIN]   3 Tier 3 $85.00$212.50None
AMMONIUM LACTATE 120 MG/ML TOPICAL LOTION [LAC-HYDRIN]   3 Tier 3 $85.00$212.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMNESTEEM 10MG CAPSULE   1 Tier 1 $6.00$9.00None
AMNESTEEM 20MG CAPSULE   1 Tier 1 $6.00$9.00None
AMNESTEEM 40MG CAPSULE   1 Tier 1 $6.00$9.00None
AMOX TR-K CLV 500-125 MG TAB   1 Tier 1 $6.00$9.00None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL   1 Tier 1 $6.00$9.00None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE   1 Tier 1 $6.00$9.00None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET   1 Tier 1 $6.00$9.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE   1 Tier 1 $6.00$9.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   1 Tier 1 $6.00$9.00None
AMOXAPINE 100MG TABLET   1 Tier 1 $6.00$9.00None
AMOXAPINE 150MG 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
AMOXAPINE 25MG TABLET   1 Tier 1 $6.00$9.00None
AMOXAPINE 50MG TABLET   1 Tier 1 $6.00$9.00None
AMOXICILLIN 125MG TABLET CHEW   1 Tier 1 $6.00$9.00None
AMOXICILLIN 200MG TABLET CHEW   1 Tier 1 $6.00$9.00None
AMOXICILLIN 250MG CAPSULE   1 Tier 1 $6.00$9.00None
AMOXICILLIN 400MG TABLET CHEW   1 Tier 1 $6.00$9.00None
AMOXICILLIN 50 MG/ML / CLAVULANATE 12.5 MG/ML ORAL SUSPENSION   1 Tier 1 $6.00$9.00None
AMOXICILLIN 500MG CAPSULE   1 Tier 1 $6.00$9.00None
AMOXICILLIN 500MG TABLET (100 CT)   1 Tier 1 $6.00$9.00None
AMOXICILLIN 875MG TABLET   1 Tier 1 $6.00$9.00None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 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
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS EXTENDED RELEASE 1000;62.5MG;MG   1 Tier 1 $6.00$9.00None
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT   1 Tier 1 $6.00$9.00None
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT   1 Tier 1 $6.00$9.00None
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL   1 Tier 1 $6.00$9.00None
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   1 Tier 1 $6.00$9.00None
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL   1 Tier 1 $6.00$9.00None
AMOXICILLIN TABLET USP CHEWABLE 250MG (250 CT)   1 Tier 1 $6.00$9.00None
AMPHETAMINE SALT COMBO 12.5MG TABLET   1 Tier 1 $6.00$9.00None
AMPHETAMINE SALT COMBO 15MG TABLET   1 Tier 1 $6.00$9.00None
AMPHETAMINE SALT COMBO 30MG TABLET   1 Tier 1 $6.00$9.00None
AMPHETAMINE SALT COMBO 7.5MG 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
AMPHETAMINE SALTS 20MG TABLET   1 Tier 1 $6.00$9.00None
AMPHETAMINE SALTS 5 MG TAB   1 Tier 1 $6.00$9.00None
AMPHOTEC FOR INJECTION 50MG/VIAL   4 Tier 4 33%33%None
AMPHOTERICIN B FOR INJECTION 50 MG   4 Tier 4 33%33%None
AMPICILLIN AND SULBACTAM FOR INJECTION 10-5 1 VIAL   4 Tier 4 33%33%None
AMPICILLIN AND SULBACTAM FOR INJECTION 2-1 10 VIAL   4 Tier 4 33%33%None
AMPICILLIN CAPSULES 250MG 100 BOT   1 Tier 1 $6.00$9.00None
AMPICILLIN CAPSULES 500MG 100 BOT   1 Tier 1 $6.00$9.00None
AMPICILLIN FOR INJECTION POWDER   4 Tier 4 33%33%None
AMPICILLIN FOR INJECTION USP 125MG/ML 1 VIAL   4 Tier 4 33%33%None
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML 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
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT   1 Tier 1 $6.00$9.00None
AMPICILLIN POWDER FOR INJECTION 1 GM/ML   4 Tier 4 33%33%None
AMPYRA ER 10 MG TABLET   5 Tier 5 33%N/AP Q:60
/30Days
AMYLASES 109000 UNT / ENDOPEPTIDASES 68000 UNT / LIPASE 20000 UNT ENTERIC COATED CAPSULE [ZENPEP 20]   3 Tier 3 $85.00$212.50None
AMYLASES 27000 UNT / ENDOPEPTIDASES 17000 UNT / LIPASE 5000 UNT ENTERIC COATED CAPSULE [ZENPEP 5]   3 Tier 3 $85.00$212.50None
AMYLASES 55000 UNT / ENDOPEPTIDASES 34000 UNT / LIPASE 10000 UNT ENTERIC COATED CAPSULE [ZENPEP 10]   3 Tier 3 $85.00$212.50None
AMYLASES 82000 UNT / ENDOPEPTIDASES 51000 UNT / LIPASE 15000 UNT ENTERIC COATED CAPSULE [ZENPEP 15]   3 Tier 3 $85.00$212.50None
ANADROL-50 50MG TABLET (100 CT)   5 Tier 5 33%N/AP
ANAFRANIL 25MG CAPSULE   3 Tier 3 $85.00$212.50None
ANAFRANIL 50MG CAPSULE   3 Tier 3 $85.00$212.50None
ANAFRANIL 75MG CAPSULE   3 Tier 3 $85.00$212.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANAGRELIDE HCL 0.5MG CAPSULE   1 Tier 1 $6.00$9.00None
ANAGRELIDE HCL 1MG CAPSULE   1 Tier 1 $6.00$9.00None
ANAPROX 275MG TABLET   3 Tier 3 $85.00$212.50None
ANAPROX DS 550MG TABLET   3 Tier 3 $85.00$212.50None
ANASTROZOLE TABLETS   1 Tier 1 $6.00$9.00None
ANCOBON 250MG CAPSULE   5 Tier 5 33%N/ANone
ANCOBON 500MG CAPSULE   5 Tier 5 33%N/ANone
ANDRODERM 2.5MG/24HR PATCH   2 Tier 2 $43.00$107.50P Q:60
/30Days
ANDRODERM 5MG/24HR PATCH   2 Tier 2 $43.00$107.50P Q:30
/30Days
ANDROGEL 1%(50MG) GEL PACKET   2 Tier 2 $43.00$107.50P Q:300
/30Days
ANDROID 10MG CAPSULE   3 Tier 3 $85.00$212.50P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANESTACON 15ML   3 Tier 3 $85.00$212.50None
ANTABUSE 250MG TABLET   2 Tier 2 $43.00$107.50None
ANTABUSE 500MG TABLET   2 Tier 2 $43.00$107.50None
ANTARA CAPSULES   3 Tier 3 $85.00$212.50None
ANTARA CAPSULES   3 Tier 3 $85.00$212.50None
ANTIVERT 12.5MG TABLET   3 Tier 3 $85.00$212.50None
ANTIVERT 25MG TABLET   3 Tier 3 $85.00$212.50None
ANTIVERT 50MG TABLET   3 Tier 3 $85.00$212.50None
ANTIZOL INJECTION 1GM 4 X 1.5ML VIAL CRTN   5 Tier 5 33%N/ANone
ANUSOL-HC 2.5% CREAM   3 Tier 3 $85.00$212.50None
ANZEMET 100MG TABLET   3 Tier 3 $85.00$212.50P Q:5
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANZEMET 20MG/ML VIAL   4 Tier 4 33%33%None
ANZEMET 50MG TABLET   3 Tier 3 $85.00$212.50P Q:5
/30Days
APAP-CAFFEINE-DIHYDROCODE TAB 30 EA   1 Tier 1 $6.00$9.00Q:180
/30Days
APHTHASOL 5% PASTE   3 Tier 3 $85.00$212.50None
APIDRA 100UNITS/ML VIAL   2 Tier 2 $43.00$107.50None
APOKYN 30 MG/3 ML CARTRIDGE   5 Tier 5 33%N/ANone
APRACLONIDINE 5 MG/ML OPHTHALMIC SOLUTION   1 Tier 1 $6.00$9.00Q:20
/30Days
APRI 0.15-0.03 TABLET   1 Tier 1 $6.00$9.00Q:28
/28Days
APTIVUS 250MG CAPSULE   5 Tier 5 33%N/ANone
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT   5 Tier 5 33%N/ANone
ARALEN PHOSPHATE 500MG 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
ARANELLE 7-9-5 TABLET   1 Tier 1 $6.00$9.00Q:28
/28Days
ARANESP 100MCG/ML VIAL   5 Tier 5 33%N/AP
ARANESP 200MCG/0.4ML SYRINGE   5 Tier 5 33%N/AP
ARANESP 200MCG/ML VIAL   5 Tier 5 33%N/AP
ARANESP 25MCG/ML VIAL   4 Tier 4 33%33%P
ARANESP 300MCG/ML VIAL   5 Tier 5 33%N/AP
ARANESP 500MCG/1ML SYRINGE   5 Tier 5 33%N/AP
ARANESP 60MCG/ML VIAL   5 Tier 5 33%N/AP
ARANESP PREFILLED SYRINGE SINGLE USE 100MCG/0.5ML 1 SYR   5 Tier 5 33%N/AP
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR   5 Tier 5 33%N/AP
ARANESP PREFILLED SYRINGE SINGLE USE 25MCG/0.42ML SYR   4 Tier 4 33%33%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR   5 Tier 5 33%N/AP
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR   4 Tier 4 33%33%P
ARANESP PREFILLED SYRINGE SINGLE USE 60MCG/0.3ML 60MCG/ 0.3ML SYR   5 Tier 5 33%N/AP
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD   4 Tier 4 33%33%P
ARAVA 10MG TABLET   3 Tier 3 $85.00$212.50None
ARAVA 20MG TABLET   3 Tier 3 $85.00$212.50None
ARCALYST INJECTION 220MG/VIAL   5 Tier 5 33%N/ANone
AREDIA 30MG VIAL   4 Tier 4 33%33%P
AREDIA 90MG VIAL   4 Tier 4 33%33%P
ARICEPT 10MG TABLET   2 Tier 2 $43.00$107.50Q:30
/30Days
ARICEPT 5MG TABLET   2 Tier 2 $43.00$107.50Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARICEPT ODT 10MG TABLET   2 Tier 2 $43.00$107.50Q:30
/30Days
ARICEPT ODT 5MG TABLET   2 Tier 2 $43.00$107.50Q:30
/30Days
ARICEPT TABLETS   2 Tier 2 $43.00$107.50S Q:30
/30Days
ARIMIDEX 1MG TABLET   2 Tier 2 $43.00$107.50None
ARIXTRA 10MG SYRINGE   5 Tier 5 33%N/ANone
ARIXTRA 2.5MG SYRINGE   4 Tier 4 33%33%None
ARIXTRA 5MG SYRINGE   5 Tier 5 33%N/ANone
ARIXTRA 7.5MG SYRINGE   5 Tier 5 33%N/ANone
AROMASIN 25MG TABLET   2 Tier 2 $43.00$107.50None
ARRANON 250MG VIAL   4 Tier 4 33%33%P
ARTHROTEC 50 50MG TABLET -200MCG (60 CT)   3 Tier 3 $85.00$212.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARTHROTEC 75 TABLET EC   3 Tier 3 $85.00$212.50None
ARZERRA INJECTION 100MG/5ML   5 Tier 5 33%N/AP
ASACOL 400MG TABLET EC   2 Tier 2 $43.00$107.50None
ASCOMP W/CODEINE 30-50-325 CAPSULE   1 Tier 1 $6.00$9.00None
ASENAPINE 10 MG SUBLINGUAL TABLET [SAPHRIS]   3 Tier 3 $85.00$212.50Q:60
/30Days
ASENAPINE 5 MG SUBLINGUAL TABLET [SAPHRIS]   3 Tier 3 $85.00$212.50Q:60
/30Days
ASMANEX 220MCG(14) AEROSOL POWDER BREATH ACTIVATED   2 Tier 2 $43.00$107.50None
ASMANEX TWISTHALER 110 MCG #30   2 Tier 2 $43.00$107.50None
ASMANEX TWISTHALER 220MCG #120   2 Tier 2 $43.00$107.50None
ASMANEX TWISTHALER 220MCG #30   2 Tier 2 $43.00$107.50None
ASMANEX TWISTHALER 220MCG #60   2 Tier 2 $43.00$107.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ASTELIN 137MCG AEROSOL SPRAY W/PUMP   3 Tier 3 $85.00$212.50Q:30
/25Days
ASTEPRO 0.15% NASAL SPRAY 30 ML   2 Tier 2 $43.00$107.50Q:30
/25Days
ASTRAMORPH PF INJECTION   4 Tier 4 33%33%None
ASTRAMORPH PF INJECTION 1MG/ML   4 Tier 4 33%33%None
ATACAND 16MG TABLET   3 Tier 3 $85.00$212.50None
ATACAND 32MG TABLET   3 Tier 3 $85.00$212.50None
ATACAND 4MG TABLET   3 Tier 3 $85.00$212.50None
ATACAND 8MG TABLET   3 Tier 3 $85.00$212.50None
ATACAND HCT 16/12.5MG TABLET   3 Tier 3 $85.00$212.50None
ATACAND HCT 32/12.5MG TABLET   3 Tier 3 $85.00$212.50None
ATACAND HCT TABLETS 32;25MG;MG 90 TABLETS 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
ATAMET   1 Tier 1 $6.00$9.00None
ATENOLOL 25MG TABLET (100 CT)   1 Tier 1 $6.00$9.00None
ATENOLOL TABLET USP 50MG (100 CT)   1 Tier 1 $6.00$9.00None
ATENOLOL TABLETS USP 100MG 1 BLPK   1 Tier 1 $6.00$9.00None
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT)   1 Tier 1 $6.00$9.00None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   1 Tier 1 $6.00$9.00None
ATRIPLA TABLET 600MG/200MG   5 Tier 5 33%N/ANone
ATROPINE 0.025 MG / DIPHENOXYLATE 2.5 MG ORAL TABLET   1 Tier 1 $6.00$9.00None
ATROPINE 0.025 MG / DIPHENOXYLATE 2.5 MG ORAL TABLET [LOMOTIL]   3 Tier 3 $85.00$212.50None
ATROPINE 0.05MG/ML SYRINGE   4 Tier 4 33%33%None
ATROPINE 0.1MG/ML SYRINGE   4 Tier 4 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATROVENT HFA AER 17MCG   2 Tier 2 $43.00$107.50Q:39
/30Days
ATROVENT NASAL SPRAY 0.03%   3 Tier 3 $85.00$212.50Q:30
/30Days
ATROVENT NASAL SPRAY 0.06%   3 Tier 3 $85.00$212.50Q:15
/30Days
ATTENUVAX VACCINE W/DILUENT 1 DOSE/0.5ML   2 Tier 2 $43.00$107.50None
AUGMENTIN ES-600 SUSPENSION 75 ML   3 Tier 3 $85.00$212.50None
AVALIDE 150-12.5MG TABLET   3 Tier 3 $85.00$212.50None
AVALIDE 300-12.5MG TABLET   3 Tier 3 $85.00$212.50None
AVALIDE 300-25MG TABLET   3 Tier 3 $85.00$212.50None
AVANDAMET 2MG/1000MG TABLET   2 Tier 2 $43.00$107.50Q:60
/30Days
AVANDAMET 2MG/500MG TABLET   2 Tier 2 $43.00$107.50Q:120
/30Days
AVANDAMET 4MG/500MG TABLET   2 Tier 2 $43.00$107.50Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVANDAMET TABLET 4-1000MG   2 Tier 2 $43.00$107.50Q:60
/30Days
AVANDARYL 4MG/1MG TABLET   2 Tier 2 $43.00$107.50Q:60
/30Days
AVANDARYL 4MG/2MG TABLET   2 Tier 2 $43.00$107.50Q:60
/30Days
AVANDARYL 4MG/4MG TABLET   2 Tier 2 $43.00$107.50Q:30
/30Days
AVANDARYL 8MG-2MG TABLET   2 Tier 2 $43.00$107.50Q:30
/30Days
AVANDARYL 8MG-4MG TABLET   2 Tier 2 $43.00$107.50Q:30
/30Days
AVANDIA 2MG TABLET   2 Tier 2 $43.00$107.50Q:60
/30Days
AVANDIA 4MG TABLET (90 CT)   2 Tier 2 $43.00$107.50Q:60
/30Days
AVANDIA 8MG TABLET (90 CT)   2 Tier 2 $43.00$107.50Q:30
/30Days
AVAPRO 150MG TABLET   3 Tier 3 $85.00$212.50None
AVAPRO 300MG 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
AVAPRO 75MG TABLET (30 CT)   3 Tier 3 $85.00$212.50None
AVASTIN 100MG/4ML VIAL   5 Tier 5 33%N/AP
AVELOX 400MG TABLET   3 Tier 3 $85.00$212.50Q:21
/1Days
AVELOX ABC PACK 400MG TABLET   3 Tier 3 $85.00$212.50Q:5
/1Days
AVELOX IV 400MG/250ML   4 Tier 4 33%33%None
AVIANE 0.1-0.02 TABLET   1 Tier 1 $6.00$9.00Q:28
/28Days
AVINZA 120MG CAPSULE MULTIPHASIC RELEASE 24 HR   3 Tier 3 $85.00$212.50Q:60
/30Days
AVINZA 30MG CAPSULE MULTIPHASIC RELEASE 24 HR   3 Tier 3 $85.00$212.50Q:60
/30Days
AVINZA 60MG CAPSULE MULTIPHASIC RELEASE 24 HR   3 Tier 3 $85.00$212.50Q:60
/30Days
AVINZA 90MG CAPSULE MULTIPHASIC RELEASE 24 HR   3 Tier 3 $85.00$212.50Q:60
/30Days
AVINZA CAPSULES EXTENDED RELEASE 45MG 100 BOTPL   3 Tier 3 $85.00$212.50Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVINZA CAPSULES EXTENDED RELEASE 75MG 100 BOTPL   3 Tier 3 $85.00$212.50Q:60
/30Days
AVITA 0.025% CREAM   3 Tier 3 $85.00$212.50Q:90
/30Days
AVODART 0.5MG SOFTGEL   2 Tier 2 $43.00$107.50None
AVONEX ADMIN PACK 30MCG SYR   5 Tier 5 33%N/AP
AVONEX ADMIN PACK 30MCG VL   5 Tier 5 33%N/AP
AXERT 12.5MG TABLET   3 Tier 3 $85.00$212.50Q:9
/30Days
AXERT 6.25MG TABLET   3 Tier 3 $85.00$212.50Q:9
/30Days
AXID 150MG PULVULE   3 Tier 3 $85.00$212.50None
AXID 15MG/ML ORAL SOLUTION   3 Tier 3 $85.00$212.50None
AXID 300MG PULVULE   3 Tier 3 $85.00$212.50None
AYGESTIN 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
AZACTAM INJECTION   4 Tier 4 33%33%None
AZACTAM INJECTION 1GM/50ML   4 Tier 4 33%33%None
AZACTAM INJECTION 2GM/VIL   4 Tier 4 33%33%None
AZASAN 100MG TABLET   3 Tier 3 $85.00$212.50P
AZASAN 75MG TABLET   3 Tier 3 $85.00$212.50P
AZATHIOPRINE 50MG TABLET   1 Tier 1 $6.00$9.00P
AZATHIOPRINE SOD 100MG VIAL   4 Tier 4 33%33%P
AZELASTINE 137 MCG NASAL SPRAY   1 Tier 1 $6.00$9.00Q:30
/25Days
AZELASTINE HYDROCHLORIDE OPHTHALMIC SOLUTION   3 Tier 3 $85.00$212.50Q:6
/30Days
AZELEX 20% CREAM 30GM TUBE   3 Tier 3 $85.00$212.50None
AZILECT 0.5MG 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
AZILECT 1MG TABLET   2 Tier 2 $43.00$107.50None
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Tier 1 $6.00$9.00Q:15
/1Days
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Tier 1 $6.00$9.00Q:46
/1Days
AZITHROMYCIN 250 MG TABLET   1 Tier 1 $6.00$9.00Q:6
/1Days
AZITHROMYCIN 33.3 MG/ML ER SUSPENSION [ZMAX]   2 Tier 2 $43.00$107.50None
AZITHROMYCIN 500MG TABLET (30 CT)   1 Tier 1 $6.00$9.00Q:3
/1Days
AZITHROMYCIN FOR INJECTION 500MG 10 VIALSD   4 Tier 4 33%33%None
AZITHROMYCIN TABLETS   1 Tier 1 $6.00$9.00Q:8
/1Days
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT   3 Tier 3 $85.00$212.50None
AZOR 10MG-20MG TABLET   3 Tier 3 $85.00$212.50Q:30
/30Days
AZOR 10MG-40MG TABLET (30 CT)   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
AZOR 5MG-20MG TABLET (30 CT)   3 Tier 3 $85.00$212.50Q:30
/30Days
AZOR 5MG-40MG TABLET   3 Tier 3 $85.00$212.50Q:30
/30Days
AZTREONAM FOR INJECTION   4 Tier 4 33%33%None
AZULFIDINE 500MG TABLET   3 Tier 3 $85.00$212.50None
AZULFIDINE EN TABLET S 500MG TABLET 6 X (300 CT)PL   3 Tier 3 $85.00$212.50None

Chart Legend:

Below are a few notes to help you understand the above 2011 Medicare Part D Blue Cross MedicareRx Gold (PDP) Plan Formulary.
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  • 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 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 wit 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 which tier the drug is in. 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.