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2011 Medicare Part D and Medicare Advantage Plan Formulary Browser

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Health Net Orange Option 1 (PDP) (S5678-002-0)
Tier 1 (1401)
Tier 2 (633)
Tier 3 (558)
Tier 4 (668)
Tier 5 (286)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
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Has Quantity Limits:
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  *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
Health Net Orange Option 1 (PDP) (S5678-002-0)
Sanctioned Plan           
The Health Net Orange Option 1 (PDP) (S5678-002-0)
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 Injectable 25%25%None
A-HYDROCORT 100MG VIAL   4 Tier 4 Injectable 25%25%None
A-METHAPRED 40MG UNIVIAL   4 Tier 4 Injectable 25%25%None
ABELCENT INJECTION SUSPENSION 5MG/ML   5 Tier 5 Specialty 25%25%None
ABILIFY 10MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00Q:1
/1Days
ABILIFY 15MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00Q:1
/1Days
ABILIFY 1MG/ML SOLUTION   2 Tier 2 Preferred Brand $34.00$68.00Q:30
/1Days
ABILIFY 20MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00Q:1
/1Days
ABILIFY 2MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00Q:2
/1Days
ABILIFY 30MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00Q:1
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ABILIFY 5MG TABLET (OTSUKA)   2 Tier 2 Preferred Brand $34.00$68.00Q:2
/1Days
ABILIFY DISCMELT 10MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00Q:2
/1Days
ABILIFY DISCMELT 15MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00Q:2
/1Days
ABILIFY INJ 9.75MG   4 Tier 4 Injectable 25%25%None
ABRAXANE 100MG VIAL   5 Tier 5 Specialty 25%25%None
ACARBOSE 100MG TABLET S   1 Tier 1 Preferred Generic $4.00$8.00None
ACARBOSE 25MG TABLET S   1 Tier 1 Preferred Generic $4.00$8.00None
ACARBOSE 50MG TABLET S   1 Tier 1 Preferred Generic $4.00$8.00None
ACCOLATE 10MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00S Q:2
/1Days
ACCOLATE 20MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00S Q:2
/1Days
ACEBUTOLOL 200MG CAPSULE   1 Tier 1 Preferred Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACEBUTOLOL 400MG CAPSULE   1 Tier 1 Preferred Generic $4.00$8.00None
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE   4 Tier 4 Injectable 25%25%None
ACETADOTE 200MG/ML VIAL   4 Tier 4 Injectable 25%25%None
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD   1 Tier 1 Preferred Generic $4.00$8.00None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT)   1 Tier 1 Preferred Generic $4.00$8.00None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT)   1 Tier 1 Preferred Generic $4.00$8.00None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT)   1 Tier 1 Preferred Generic $4.00$8.00None
ACETASOL HC SOLUTION 10ML 10 ML BOT   1 Tier 1 Preferred Generic $4.00$8.00None
ACETAZOLAMIDE 125MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
ACETAZOLAMIDE 250MG TABLET (100 CT)   1 Tier 1 Preferred Generic $4.00$8.00None
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT   1 Tier 1 Preferred Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETAZOLAMIDE SOD 500MG VL   4 Tier 4 Injectable 25%25%None
ACETIC ACID 2% SOLUTION NON-ORAL   1 Tier 1 Preferred Generic $4.00$8.00None
ACETIC ACID 20 MG/ML / HYDROCORTISONE 10 MG/ML OTIC SOLUTION   1 Tier 1 Preferred Generic $4.00$8.00None
ACETYLCYSTEINE 10% VIAL   1 Tier 1 Preferred Generic $4.00$8.00P
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN   1 Tier 1 Preferred Generic $4.00$8.00P
ACIPHEX 20MG TABLET EC   2 Tier 2 Preferred Brand $34.00$68.00Q:1
/1Days
ACLOVATE ALCLOMETASONE DIPROPIONATE 0.05% OINTMENT(GM) TOPICAL   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
ACTEMRA INJECTION 200MG/10ML   5 Tier 5 Specialty 25%25%P
ACTHIB VACCINE VIAL 10-24UNT/5ML   4 Tier 4 Injectable 25%25%None
ACTICIN 5% CREAM   1 Tier 1 Preferred Generic $4.00$8.00None
ACTIMMUNE SOLUTION FOR INJECTION 100MCG   5 Tier 5 Specialty 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACTIVELLA 0.5-0.1MG TABLET 28 DLPK   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
ACTONEL 150MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00None
ACTONEL 30MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00Q:1
/1Days
ACTONEL 35MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00None
ACTONEL 5MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00Q:1
/1Days
ACTOPLUS MET 15MG/500MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00None
ACTOPLUS MET 15MG/850MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00None
ACTOS 15MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00None
ACTOS 30MG TABLET (500 CT)   2 Tier 2 Preferred Brand $34.00$68.00None
ACTOS 45MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00None
ACYCLOVIR 200MG CAPSULE (1000 CT)   1 Tier 1 Preferred Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACYCLOVIR 200MG/5ML SUSP   1 Tier 1 Preferred Generic $4.00$8.00None
ACYCLOVIR 400MG TABLET (100 CT)   1 Tier 1 Preferred Generic $4.00$8.00None
ACYCLOVIR 800 MG ORAL TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
ACYCLOVIR SODIUM 500MG VIAL   4 Tier 4 Injectable 25%25%None
ADACEL VIAL 2UNT/5UNT   4 Tier 4 Injectable 25%25%None
ADAGEN 250U/ML VIAL   5 Tier 5 Specialty 25%25%None
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA]   5 Tier 5 Specialty 25%25%P
ADCIRCA TABLETS 20MG 60 BOT   5 Tier 5 Specialty 25%25%None
ADVAIR DISKU MIS 100/50   2 Tier 2 Preferred Brand $34.00$68.00Q:2
/1Days
ADVAIR DISKU MIS 250/50   2 Tier 2 Preferred Brand $34.00$68.00Q:2
/1Days
ADVAIR DISKU MIS 500/50   2 Tier 2 Preferred Brand $34.00$68.00Q:2
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL   2 Tier 2 Preferred Brand $34.00$68.00None
ADVAIR HFA INHALER 230;21MCG;MCG   2 Tier 2 Preferred Brand $34.00$68.00None
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL   2 Tier 2 Preferred Brand $34.00$68.00None
AEROBID-M AEROSOL W/ADAPTER   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00Q:1
/1Days
AFEDITAB CR 30MG TABLET SA   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
AFEDITAB CR 60MG TABLET SA   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
AFINITOR TABLETS   5 Tier 5 Specialty 25%25%P
AFINITOR TABLETS 5 MG   5 Tier 5 Specialty 25%25%P
AGGRENOX 25-200MG CAPSULE   2 Tier 2 Preferred Brand $34.00$68.00None
AK-CON 0.1% EYE DROPS   1 Tier 1 Preferred Generic $4.00$8.00None
AKTOB 0.3% EYE DROPS   1 Tier 1 Preferred Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALA-CORT 1% CREAM   1 Tier 1 Preferred Generic $4.00$8.00None
ALA-CORT 1% LOTION   1 Tier 1 Preferred Generic $4.00$8.00None
ALAMAST 0.1% DROPS   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00Q:1
/1Days
ALBENZA 200MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
ALBUTEROL SULFATE 0.63MG/3ML VIAL NEBULIZER   1 Tier 1 Preferred Generic $4.00$8.00P
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER   1 Tier 1 Preferred Generic $4.00$8.00P
ALBUTEROL SULFATE 2.5MG/3ML VIAL NEBULIZER   1 Tier 1 Preferred Generic $4.00$8.00P
ALBUTEROL SULFATE 4MG TABLET SR 12HR   1 Tier 1 Preferred Generic $4.00$8.00None
ALBUTEROL SULFATE 8MG TABLET SR 12HR   1 Tier 1 Preferred Generic $4.00$8.00None
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   1 Tier 1 Preferred Generic $4.00$8.00P
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT   1 Tier 1 Preferred Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALBUTEROL SULFATE TABLET 2MG (500 CT)   1 Tier 1 Preferred Generic $4.00$8.00None
ALBUTEROL TABLET 4MG (500 CT)   1 Tier 1 Preferred Generic $4.00$8.00None
ALCAINE 0.5% EYE DROPS   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
ALCLOMETASONE DIPROPIONATE 0.05% CREAM   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
ALCLOMETASONE DIPROPIONATE 0.05% OINTMENT   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
ALCOHOL 5%/DEXTROSE 5%   4 Tier 4 Injectable 25%25%None
ALDACTAZIDE 50/50 TABLET   2 Tier 2 Preferred Brand $34.00$68.00None
ALDARA IMIQUIMOD CREAM 5% 24 PKT X 250 MG CRTN   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00P
ALDURAZYME 2.9MG/5ML VIAL   5 Tier 5 Specialty 25%25%None
ALENDRONATE SODIUM 10MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00Q:1
/1Days
ALENDRONATE SODIUM 40MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00Q:1
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALENDRONATE SODIUM 5MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00Q:1
/1Days
ALENDRONATE SODIUM TABLET 35MG 20 CRTN   1 Tier 1 Preferred Generic $4.00$8.00None
ALENDRONATE SODIUM TABLETS 70 MG   1 Tier 1 Preferred Generic $4.00$8.00None
ALFERON N INJ 5MU/ML   5 Tier 5 Specialty 25%25%None
ALIMTA 500MG VIAL   5 Tier 5 Specialty 25%25%None
ALINIA 100MG/5ML SUSPENSION   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00P
ALINIA 500MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00P
ALISKIREN 150 MG / VALSARTAN 160 MG ORAL TABLET [VALTURNA]   2 Tier 2 Preferred Brand $34.00$68.00Q:1
/1Days
ALISKIREN 300 MG / VALSARTAN 320 MG ORAL TABLET [VALTURNA]   2 Tier 2 Preferred Brand $34.00$68.00Q:1
/1Days
ALKERAN FOR INJECTION 50MG/VIAL 1 VIALSU   4 Tier 4 Injectable 25%25%None
ALLEGRA 30MG/5ML SUSPENSION ORAL   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00Q:20
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALLEGRA-D 12 HOUR TABLET 60-120MG (500 CT)   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00Q:2
/1Days
ALLEGRA-D 24 HOUR TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00Q:1
/1Days
ALLOPURINOL 100MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
ALLOPURINOL SODIUM 500MG VIAL   4 Tier 4 Injectable 25%25%None
ALLOPURINOL TABLET 300MG (1000 CT)   1 Tier 1 Preferred Generic $4.00$8.00None
ALOCRIL 2% EYE DROPS   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
ALOMIDE 0.1% EYE DROPS   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
ALOPRIM SOLUTION FOR INJECTION 500MG/VIAL 30 ML VIALGL   4 Tier 4 Injectable 25%25%None
ALORA 0.025MG PATCH   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
ALORA 0.05MG PATCH   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
ALORA 0.075MG PATCH   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALORA 0.1MG PATCH   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
ALOXI 0.25MG/5ML   5 Tier 5 Specialty 25%25%P
ALPHA-1-PROTEINASE INHIBITOR,HUMAN 16 MG/ML INJECTABLE SOLUTION [ARALAST]   5 Tier 5 Specialty 25%25%P
ALPHAGAN P 0.1% DROPS   2 Tier 2 Preferred Brand $34.00$68.00None
ALREX 0.2% EYE DROPS   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00Q:1
/1Days
AMANTADINE 100MG CAPSULE   1 Tier 1 Preferred Generic $4.00$8.00None
AMANTADINE 100MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
AMANTADINE HCL 50 MG/ 5 ML SYRUP   1 Tier 1 Preferred Generic $4.00$8.00None
AMBIEN CR 12.5MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00S Q:1
/1Days
AMBIEN CR 6.25MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00S Q:1
/1Days
AMBISOME 50MG VIAL   5 Tier 5 Specialty 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMCINONIDE 0.1% CREAM   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
AMCINONIDE 0.1% LOTION   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
AMCINONIDE 0.1% OINTMENT 60GM TUBE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
AMERGE 1MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00None
AMERGE 2.5MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00None
AMEVIVE ADMISTRATION PACK FOR INTRAMUSCULAR ADMINISTRATION KIT 15MG 1 X 4 PKGCOM   5 Tier 5 Specialty 25%25%P
AMIFOSTINE FOR INJECTION 500MG/VIAL   4 Tier 4 Injectable 25%25%None
AMIKACIN 250MG/ML VIAL   4 Tier 4 Injectable 25%25%None
AMIKACIN 50MG/ML VIAL   4 Tier 4 Injectable 25%25%None
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT   1 Tier 1 Preferred Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOPHYLLINE INJECTION 250MG 10ML X 25 VIALSD   4 Tier 4 Injectable 25%25%None
AMINOSYN 10% IV SOLUTION   4 Tier 4 Injectable 25%25%P
AMINOSYN 3.5% IV SOLUTION   4 Tier 4 Injectable 25%25%P
AMINOSYN 5% IV SOLUTION   4 Tier 4 Injectable 25%25%P
AMINOSYN 7% IV SOLUTION   4 Tier 4 Injectable 25%25%P
AMINOSYN 7%-ELECTROLYTE SOL   4 Tier 4 Injectable 25%25%P
AMINOSYN 8.5% IV SOLUTION   4 Tier 4 Injectable 25%25%P
AMINOSYN HBC INJECTION SULFITE FREE 7%   4 Tier 4 Injectable 25%25%P
AMINOSYN II 10% IV SOLUTION   4 Tier 4 Injectable 25%25%P
AMINOSYN II 15% IV SOLUTION   4 Tier 4 Injectable 25%25%P
AMINOSYN II 3.5% IN D25W IV   4 Tier 4 Injectable 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN II 3.5% IN D5W IV   4 Tier 4 Injectable 25%25%P
AMINOSYN II 3.5% M/D5W IV   4 Tier 4 Injectable 25%25%P
AMINOSYN II 3.5% W/ELEC DEX   4 Tier 4 Injectable 25%25%P
AMINOSYN II 4.25% IN D10W   4 Tier 4 Injectable 25%25%P
AMINOSYN II 4.25% IN D20W   4 Tier 4 Injectable 25%25%P
AMINOSYN II 4.25% W/ELEC DW   4 Tier 4 Injectable 25%25%P
AMINOSYN II 4.25%-D25W IV   4 Tier 4 Injectable 25%25%P
AMINOSYN II 5% IN D25W IV   4 Tier 4 Injectable 25%25%P
AMINOSYN II 7% IV SOLUTION   4 Tier 4 Injectable 25%25%P
AMINOSYN II 8.5% ELECTROLYT   4 Tier 4 Injectable 25%25%P
AMINOSYN II 8.5% IV SOLUTION   4 Tier 4 Injectable 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN M 3.5% IV SOLUTION   4 Tier 4 Injectable 25%25%P
AMINOSYN PF INJECTION   4 Tier 4 Injectable 25%25%P
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5%   4 Tier 4 Injectable 25%25%P
AMINOSYN-HF 8% IV SOLUTION   4 Tier 4 Injectable 25%25%P
AMINOSYN-PF 7% IV SOLUTION   4 Tier 4 Injectable 25%25%P
AMIODARONE HCL 200MG TABLET (60 CT)   1 Tier 1 Preferred Generic $4.00$8.00None
AMIODARONE HCL 400MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
AMIODARONE HCL INJECTION   4 Tier 4 Injectable 25%25%None
AMITIZA 8MCG CAPSULE   2 Tier 2 Preferred Brand $34.00$68.00None
AMITIZA CAPSULES 24MCG 60 CAP BOT   2 Tier 2 Preferred Brand $34.00$68.00None
AMITRIP/PERPHEN 10-2 TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITRIP/PERPHEN 10-4 TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
AMITRIP/PERPHEN 25-2 TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
AMITRIP/PERPHEN 25-4 TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
AMITRIP/PERPHEN 50-4 TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
AMITRIPTYLINE HCL 100MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
AMITRIPTYLINE HCL 10MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
AMITRIPTYLINE HCL 150 MG TAB   1 Tier 1 Preferred Generic $4.00$8.00None
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)   1 Tier 1 Preferred Generic $4.00$8.00None
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)   1 Tier 1 Preferred Generic $4.00$8.00None
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT   1 Tier 1 Preferred Generic $4.00$8.00None
AMLODIPINE 10 MG / HYDROCHLOROTHIAZIDE 12.5 MG / VALSARTAN 160 MG ORAL TABLET [EXFORGE HCT 10/160/12   2 Tier 2 Preferred Brand $34.00$68.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE 10 MG / HYDROCHLOROTHIAZIDE 25 MG / VALSARTAN 160 MG ORAL TABLET [EXFORGE HCT 10/160/25]   2 Tier 2 Preferred Brand $34.00$68.00None
AMLODIPINE 10 MG / HYDROCHLOROTHIAZIDE 25 MG / VALSARTAN 320 MG ORAL TABLET [EXFORGE HCT 10/320/25]   2 Tier 2 Preferred Brand $34.00$68.00None
AMLODIPINE 5 MG / HYDROCHLOROTHIAZIDE 12.5 MG / VALSARTAN 160 MG ORAL TABLET [EXFORGE HCT 5/160/12.5   2 Tier 2 Preferred Brand $34.00$68.00None
AMLODIPINE 5 MG / HYDROCHLOROTHIAZIDE 25 MG / VALSARTAN 160 MG ORAL TABLET [EXFORGE HCT 5/160/25]   2 Tier 2 Preferred Brand $34.00$68.00None
AMLODIPINE BESYLATE 10MG TABLET (90 CT)   1 Tier 1 Preferred Generic $4.00$8.00Q:1
/1Days
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)   1 Tier 1 Preferred Generic $4.00$8.00Q:1
/1Days
AMLODIPINE BESYLATE 5MG TABLET (90 CT)   1 Tier 1 Preferred Generic $4.00$8.00Q:2
/1Days
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00Q:1
/1Days
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00Q:1
/1Days
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00Q:1
/1Days
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00Q:1
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMMONIUM CHLORIDE 5 MEQ/ML   4 Tier 4 Injectable 25%25%None
AMMONIUM LACTATE 12% CREAM   1 Tier 1 Preferred Generic $4.00$8.00None
AMMONIUM LACTATE 12% LOTION   1 Tier 1 Preferred Generic $4.00$8.00None
AMNESTEEM 10MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
AMNESTEEM 20MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
AMNESTEEM 40MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
AMOX TR-K CLV 500-125 MG TAB   1 Tier 1 Preferred Generic $4.00$8.00None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL   1 Tier 1 Preferred Generic $4.00$8.00None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE   1 Tier 1 Preferred Generic $4.00$8.00None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE   1 Tier 1 Preferred Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   1 Tier 1 Preferred Generic $4.00$8.00None
AMOXAPINE 100MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
AMOXAPINE 150MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
AMOXAPINE 25MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
AMOXAPINE 50MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
AMOXICILLIN 125MG TABLET CHEW   1 Tier 1 Preferred Generic $4.00$8.00None
AMOXICILLIN 200MG TABLET CHEW   1 Tier 1 Preferred Generic $4.00$8.00None
AMOXICILLIN 250MG CAPSULE   1 Tier 1 Preferred Generic $4.00$8.00None
AMOXICILLIN 400MG TABLET CHEW   1 Tier 1 Preferred Generic $4.00$8.00None
AMOXICILLIN 50 MG/ML / CLAVULANATE 12.5 MG/ML ORAL SUSPENSION   1 Tier 1 Preferred Generic $4.00$8.00None
AMOXICILLIN 500MG CAPSULE   1 Tier 1 Preferred Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN 500MG TABLET (100 CT)   1 Tier 1 Preferred Generic $4.00$8.00None
AMOXICILLIN 875MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT   1 Tier 1 Preferred Generic $4.00$8.00None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS EXTENDED RELEASE 1000;62.5MG;MG   1 Tier 1 Preferred Generic $4.00$8.00None
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT   1 Tier 1 Preferred Generic $4.00$8.00None
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT   1 Tier 1 Preferred Generic $4.00$8.00None
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL   1 Tier 1 Preferred Generic $4.00$8.00None
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   1 Tier 1 Preferred Generic $4.00$8.00None
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL   1 Tier 1 Preferred Generic $4.00$8.00None
AMOXICILLIN TABLET USP CHEWABLE 250MG (250 CT)   1 Tier 1 Preferred Generic $4.00$8.00None
AMPHETAMINE SALT COMBO 12.5MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPHETAMINE SALT COMBO 15MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
AMPHETAMINE SALT COMBO 30MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
AMPHETAMINE SALT COMBO 7.5MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
AMPHETAMINE SALTS 20MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
AMPHETAMINE SALTS 5 MG TAB   1 Tier 1 Preferred Generic $4.00$8.00None
AMPHOTEC FOR INJECTION 50MG/VIAL   4 Tier 4 Injectable 25%25%None
AMPHOTERICIN B FOR INJECTION 50 MG   4 Tier 4 Injectable 25%25%None
AMPICILLIN AND SULBACTAM FOR INJECTION 10-5 1 VIAL   4 Tier 4 Injectable 25%25%None
AMPICILLIN AND SULBACTAM FOR INJECTION 2-1 10 VIAL   4 Tier 4 Injectable 25%25%None
AMPICILLIN CAPSULES 250MG 100 BOT   1 Tier 1 Preferred Generic $4.00$8.00None
AMPICILLIN CAPSULES 500MG 100 BOT   1 Tier 1 Preferred Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPICILLIN FOR INJECTION POWDER   4 Tier 4 Injectable 25%25%None
AMPICILLIN FOR INJECTION USP 125MG/ML 1 VIAL   4 Tier 4 Injectable 25%25%None
AMPICILLIN POWDER FOR INJECTION 1 GM/ML   4 Tier 4 Injectable 25%25%None
AMYLASES 109000 UNT / ENDOPEPTIDASES 68000 UNT / LIPASE 20000 UNT ENTERIC COATED CAPSULE [ZENPEP 20]   2 Tier 2 Preferred Brand $34.00$68.00None
AMYLASES 27000 UNT / ENDOPEPTIDASES 17000 UNT / LIPASE 5000 UNT ENTERIC COATED CAPSULE [ZENPEP 5]   2 Tier 2 Preferred Brand $34.00$68.00None
AMYLASES 55000 UNT / ENDOPEPTIDASES 34000 UNT / LIPASE 10000 UNT ENTERIC COATED CAPSULE [ZENPEP 10]   2 Tier 2 Preferred Brand $34.00$68.00None
AMYLASES 82000 UNT / ENDOPEPTIDASES 51000 UNT / LIPASE 15000 UNT ENTERIC COATED CAPSULE [ZENPEP 15]   2 Tier 2 Preferred Brand $34.00$68.00None
ANADROL-50 50MG TABLET (100 CT)   5 Tier 5 Specialty 25%25%None
ANAGRELIDE HCL 0.5MG CAPSULE   1 Tier 1 Preferred Generic $4.00$8.00None
ANAGRELIDE HCL 1MG CAPSULE   1 Tier 1 Preferred Generic $4.00$8.00None
ANCOBON 250MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANCOBON 500MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
ANDRODERM 2.5MG/24HR PATCH   2 Tier 2 Preferred Brand $34.00$68.00Q:2
/1Days
ANDRODERM 5MG/24HR PATCH   2 Tier 2 Preferred Brand $34.00$68.00Q:1
/1Days
ANDROGEL 1%(50MG) GEL PACKET   2 Tier 2 Preferred Brand $34.00$68.00Q:10
/1Days
ANDROID 10MG CAPSULE   2 Tier 2 Preferred Brand $34.00$68.00None
ANESTACON 15ML   1 Tier 1 Preferred Generic $4.00$8.00None
ANGELIQ 1-0.5MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
ANIDULAFUNGIN 3.33 MG/ML INJECTABLE SOLUTION [ERAXIS]   4 Tier 4 Injectable 25%25%None
ANTABUSE 250MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00None
ANTABUSE 500MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00None
ANTARA 43MG CAPSULE   2 Tier 2 Preferred Brand $34.00$68.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANTIZOL INJECTION 1GM 4 X 1.5ML VIAL CRTN   4 Tier 4 Injectable 25%25%None
ANZEMET 20MG/ML VIAL   4 Tier 4 Injectable 25%25%P
APAP-CAFFEINE-DIHYDROCODE TAB 30 EA   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
APOKYN 30 MG/3 ML CARTRIDGE   5 Tier 5 Specialty 25%25%P
APRACLONIDINE 5 MG/ML OPHTHALMIC SOLUTION   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00Q:10
/30Days
APRI 0.15-0.03 TABLET   1 Tier 1 Preferred Generic $4.00$8.00Q:1
/1Days
APRISO CP24   2 Tier 2 Preferred Brand $34.00$68.00None
APTIVUS 250MG CAPSULE   5 Tier 5 Specialty 25%25%None
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT   2 Tier 2 Preferred Brand $34.00$68.00None
ARANELLE 7-9-5 TABLET   1 Tier 1 Preferred Generic $4.00$8.00Q:1
/1Days
ARANESP 100MCG/ML VIAL   4 Tier 4 Injectable 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP 200MCG/0.4ML SYRINGE   5 Tier 5 Specialty 25%25%P
ARANESP 200MCG/ML VIAL   5 Tier 5 Specialty 25%25%P
ARANESP 25MCG/ML VIAL   4 Tier 4 Injectable 25%25%P
ARANESP 300MCG/ML VIAL   5 Tier 5 Specialty 25%25%P
ARANESP 500MCG/1ML SYRINGE   5 Tier 5 Specialty 25%25%P
ARANESP 60MCG/ML VIAL   4 Tier 4 Injectable 25%25%P
ARANESP PREFILLED SYRINGE SINGLE USE 100MCG/0.5ML 1 SYR   5 Tier 5 Specialty 25%25%P
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR   5 Tier 5 Specialty 25%25%P
ARANESP PREFILLED SYRINGE SINGLE USE 25MCG/0.42ML SYR   4 Tier 4 Injectable 25%25%P
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR   5 Tier 5 Specialty 25%25%P
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR   4 Tier 4 Injectable 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP PREFILLED SYRINGE SINGLE USE 60MCG/0.3ML 60MCG/ 0.3ML SYR   5 Tier 5 Specialty 25%25%P
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD   4 Tier 4 Injectable 25%25%P
ARCALYST INJECTION 220MG/VIAL   5 Tier 5 Specialty 25%25%P
AREDIA 30MG VIAL   4 Tier 4 Injectable 25%25%None
AREDIA 90MG VIAL   4 Tier 4 Injectable 25%25%None
ARICEPT 10MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00Q:1
/1Days
ARICEPT 5MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00Q:1
/1Days
ARICEPT ODT 10MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00Q:1
/1Days
ARICEPT ODT 5MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00Q:1
/1Days
ARIMIDEX 1MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00None
ARIXTRA 10MG SYRINGE   4 Tier 4 Injectable 25%25%Q:8
/10Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARIXTRA 2.5MG SYRINGE   4 Tier 4 Injectable 25%25%Q:5
/10Days
ARIXTRA 5MG SYRINGE   4 Tier 4 Injectable 25%25%Q:8
/10Days
ARIXTRA 7.5MG SYRINGE   4 Tier 4 Injectable 25%25%Q:8
/10Days
ARMODAFINIL 50 MG ORAL TABLET [NUVIGIL]   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00P
AROMASIN 25MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00None
ARRANON 250MG VIAL   5 Tier 5 Specialty 25%25%None
ARZERRA INJECTION 100MG/5ML   5 Tier 5 Specialty 25%25%P
ASACOL 400MG TABLET EC   2 Tier 2 Preferred Brand $34.00$68.00None
ASACOL HD DELAYED RELEASE TABLETS 800MG 180 BOT   2 Tier 2 Preferred Brand $34.00$68.00None
ASCOMP W/CODEINE 30-50-325 CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
ASENAPINE 10 MG SUBLINGUAL TABLET [SAPHRIS]   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00Q:2
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ASENAPINE 5 MG SUBLINGUAL TABLET [SAPHRIS]   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00Q:2
/1Days
ASMANEX 220MCG(14) AEROSOL POWDER BREATH ACTIVATED   2 Tier 2 Preferred Brand $34.00$68.00None
ASMANEX TWISTHALER 110 MCG #30   2 Tier 2 Preferred Brand $34.00$68.00None
ASMANEX TWISTHALER 220MCG #120   2 Tier 2 Preferred Brand $34.00$68.00None
ASMANEX TWISTHALER 220MCG #30   2 Tier 2 Preferred Brand $34.00$68.00None
ASMANEX TWISTHALER 220MCG #60   2 Tier 2 Preferred Brand $34.00$68.00None
ASTEPRO 0.15% NASAL SPRAY 30 ML   2 Tier 2 Preferred Brand $34.00$68.00Q:2
/1Days
ASTRAMORPH PF INJECTION 1MG/ML   4 Tier 4 Injectable 25%25%None
ASTRAMORPH-PF 0.5MG/ML VIAL   4 Tier 4 Injectable 25%25%None
ATACAND 16MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00Q:1
/1Days
ATACAND 32MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00Q:1
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATACAND 4MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00Q:1
/1Days
ATACAND 8MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00Q:1
/1Days
ATACAND HCT 16/12.5MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00Q:1
/1Days
ATACAND HCT 32/12.5MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00Q:1
/1Days
ATACAND HCT TABLETS 32;25MG;MG 90 TABLETS BOT   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00Q:1
/1Days
ATAMET   1 Tier 1 Preferred Generic $4.00$8.00None
ATENOLOL 25MG TABLET (100 CT)   1 Tier 1 Preferred Generic $4.00$8.00None
ATENOLOL TABLET USP 50MG (100 CT)   1 Tier 1 Preferred Generic $4.00$8.00None
ATENOLOL TABLETS USP 100MG 1 BLPK   1 Tier 1 Preferred Generic $4.00$8.00None
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT)   1 Tier 1 Preferred Generic $4.00$8.00None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   1 Tier 1 Preferred Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATGAM 50MG/ML AMPUL   4 Tier 4 Injectable 25%25%P
ATRIPLA TABLET 600MG/200MG   5 Tier 5 Specialty 25%25%None
ATROPINE 0.025 MG / DIPHENOXYLATE 2.5 MG ORAL TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
ATROPINE 0.05MG/ML SYRINGE   4 Tier 4 Injectable 25%25%None
ATROPINE 0.1MG/ML SYRINGE   4 Tier 4 Injectable 25%25%None
ATROVENT HFA AER 17MCG   2 Tier 2 Preferred Brand $34.00$68.00Q:1
/1Days
ATTENUVAX VACCINE W/DILUENT 1 DOSE/0.5ML   4 Tier 4 Injectable 25%25%None
AVALIDE 150-12.5MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00Q:1
/1Days
AVALIDE 300-12.5MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00Q:1
/1Days
AVALIDE 300-25MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00Q:1
/1Days
AVANDAMET 2MG/1000MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVANDAMET 2MG/500MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00None
AVANDAMET 4MG/500MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00None
AVANDAMET TABLET 4-1000MG   2 Tier 2 Preferred Brand $34.00$68.00None
AVANDARYL 4MG/1MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00None
AVANDARYL 4MG/2MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00None
AVANDARYL 4MG/4MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00None
AVANDARYL 8MG-2MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00None
AVANDARYL 8MG-4MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00None
AVANDIA 2MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00None
AVANDIA 4MG TABLET (90 CT)   2 Tier 2 Preferred Brand $34.00$68.00None
AVANDIA 8MG TABLET (90 CT)   2 Tier 2 Preferred Brand $34.00$68.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVAPRO 150MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00Q:1
/1Days
AVAPRO 300MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00Q:1
/1Days
AVAPRO 75MG TABLET (30 CT)   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00Q:1
/1Days
AVASTIN 100MG/4ML VIAL   5 Tier 5 Specialty 25%25%P
AVELOX 400MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00Q:1
/1Days
AVELOX ABC PACK 400MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00Q:1
/1Days
AVELOX IV 400MG/250ML   4 Tier 4 Injectable 25%25%None
AVIANE 0.1-0.02 TABLET   1 Tier 1 Preferred Generic $4.00$8.00Q:1
/1Days
AVINZA 120MG CAPSULE MULTIPHASIC RELEASE 24 HR   2 Tier 2 Preferred Brand $34.00$68.00Q:13
/1Days
AVINZA 30MG CAPSULE MULTIPHASIC RELEASE 24 HR   2 Tier 2 Preferred Brand $34.00$68.00Q:1
/1Days
AVINZA 60MG CAPSULE MULTIPHASIC RELEASE 24 HR   2 Tier 2 Preferred Brand $34.00$68.00Q:1
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVINZA 90MG CAPSULE MULTIPHASIC RELEASE 24 HR   2 Tier 2 Preferred Brand $34.00$68.00Q:17
/1Days
AVINZA CAPSULES EXTENDED RELEASE 45MG 100 BOTPL   2 Tier 2 Preferred Brand $34.00$68.00Q:1
/1Days
AVINZA CAPSULES EXTENDED RELEASE 75MG 100 BOTPL   2 Tier 2 Preferred Brand $34.00$68.00Q:1
/1Days
AVITA 0.025% CREAM   1 Tier 1 Preferred Generic $4.00$8.00P Q:1
/1Days
AVODART 0.5MG SOFTGEL   2 Tier 2 Preferred Brand $34.00$68.00None
AVONEX ADMIN PACK 30MCG SYR   5 Tier 5 Specialty 25%25%P
AVONEX ADMIN PACK 30MCG VL   5 Tier 5 Specialty 25%25%P
AZACTAM INJECTION 1GM/50ML   4 Tier 4 Injectable 25%25%None
AZACTAM INJECTION 2GM/VIL   5 Tier 5 Specialty 25%25%None
AZACTAM/ISO-OSMOT 2GM/50ML   4 Tier 4 Injectable 25%25%None
AZASAN 100MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZASAN 75MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00P
AZASITE 1% DROPS   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00S Q:3
/7Days
AZATHIOPRINE 50MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00P
AZATHIOPRINE SOD 100MG VIAL   4 Tier 4 Injectable 25%25%P
AZELASTINE 137 MCG NASAL SPRAY   1 Tier 1 Preferred Generic $4.00$8.00Q:1
/1Days
AZELASTINE HYDROCHLORIDE 0.5 MG/ML OPHTHALMIC SOLUTION   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00S
AZELEX 20% CREAM 30GM TUBE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
AZILECT 0.5MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00None
AZILECT 1MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00None
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Tier 1 Preferred Generic $4.00$8.00Q:15
/5Days
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Tier 1 Preferred Generic $4.00$8.00Q:30
/5Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZITHROMYCIN 250 MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00Q:6
/5Days
AZITHROMYCIN 33.3 MG/ML ER SUSPENSION [ZMAX]   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00Q:2
/1Days
AZITHROMYCIN 500MG TABLET (30 CT)   1 Tier 1 Preferred Generic $4.00$8.00Q:3
/3Days
AZITHROMYCIN FOR INJECTION 500MG 10 VIALSD   4 Tier 4 Injectable 25%25%None
AZITHROMYCIN TABLET 600MG (30 CT)   1 Tier 1 Preferred Generic $4.00$8.00None
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT   2 Tier 2 Preferred Brand $34.00$68.00None
AZOR 10MG-20MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00Q:1
/1Days
AZOR 10MG-40MG TABLET (30 CT)   2 Tier 2 Preferred Brand $34.00$68.00Q:1
/1Days
AZOR 5MG-20MG TABLET (30 CT)   2 Tier 2 Preferred Brand $34.00$68.00Q:1
/1Days
AZOR 5MG-40MG TABLET   2 Tier 2 Preferred Brand $34.00$68.00Q:1
/1Days

Chart Legend:

Below are a few notes to help you understand the above 2011 Medicare Part D Health Net Orange Option 1 (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 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.