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EnvisionRxPlus Silver (PDP) (S7694-032-0)
Tier 1 (1241)
Tier 2 (300)
Tier 3 (294)
Tier 4 (354)
Tier 5 (199)
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Uses Step Therapy:
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2011 Medicare Part D Plan Formulary Information
EnvisionRxPlus Silver (PDP) (S7694-032-0)
Benefit Details           
The EnvisionRxPlus Silver (PDP) (S7694-032-0)
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
ABILIFY 10MG TABLET   3 Tier 3 Preferred Brand 25%25%None
ABILIFY 15MG TABLET   3 Tier 3 Preferred Brand 25%25%None
ABILIFY 1MG/ML SOLUTION   3 Tier 3 Preferred Brand 25%25%None
ABILIFY 20MG TABLET   3 Tier 3 Preferred Brand 25%25%None
ABILIFY 2MG TABLET   3 Tier 3 Preferred Brand 25%25%None
ABILIFY 30MG TABLET   3 Tier 3 Preferred Brand 25%25%None
ABILIFY 5MG TABLET (OTSUKA)   3 Tier 3 Preferred Brand 25%25%None
ABILIFY DISCMELT 10MG TABLET   3 Tier 3 Preferred Brand 25%25%None
ABILIFY DISCMELT 15MG TABLET   3 Tier 3 Preferred Brand 25%25%None
ABILIFY INJ 9.75MG   3 Tier 3 Preferred Brand 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACARBOSE 100MG TABLET S   1 Tier 1 Preferred Generics 25%25%None
ACARBOSE 50MG TABLET S   1 Tier 1 Preferred Generics 25%25%None
ACARBOSE TABLETS   1 Tier 1 Preferred Generics 25%25%None
ACCOLATE 10MG TABLET   3 Tier 3 Preferred Brand 25%25%None
ACCOLATE 20MG TABLET   3 Tier 3 Preferred Brand 25%25%None
ACEBUTOLOL 200MG CAPSULE   1 Tier 1 Preferred Generics 25%25%None
ACEBUTOLOL 400MG CAPSULE   1 Tier 1 Preferred Generics 25%25%None
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE   4 Tier 4 Non-Preferred Brand 25%25%None
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD   1 Tier 1 Preferred Generics 25%25%None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT)   1 Tier 1 Preferred Generics 25%25%None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT)   1 Tier 1 Preferred Generics 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT)   1 Tier 1 Preferred Generics 25%25%None
ACETASOL HC SOLUTION 10ML 10 ML BOT   2 Tier 2 Non-Preferred Generics 25%25%None
ACETAZOLAMIDE 125MG TABLET   1 Tier 1 Preferred Generics 25%25%None
ACETAZOLAMIDE 250MG TABLET (100 CT)   1 Tier 1 Preferred Generics 25%25%None
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT   2 Tier 2 Non-Preferred Generics 25%25%None
ACETIC ACID 2% SOLUTION NON-ORAL   1 Tier 1 Preferred Generics 25%25%None
ACTHIB VACCINE VIAL 10-24UNT/5ML   4 Tier 4 Non-Preferred Brand 25%25%None
ACTICIN 5% CREAM   1 Tier 1 Preferred Generics 25%25%None
ACTIMMUNE SOLUTION FOR INJECTION 100MCG   5 Tier 5 Specialty Drugs 25%25%None
ACTOPLUS MET 15MG/500MG TABLET   3 Tier 3 Preferred Brand 25%25%None
ACTOPLUS MET 15MG/850MG TABLET   3 Tier 3 Preferred Brand 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACTOS 15MG TABLET   3 Tier 3 Preferred Brand 25%25%None
ACTOS 30MG TABLET (500 CT)   3 Tier 3 Preferred Brand 25%25%None
ACTOS 45MG TABLET   3 Tier 3 Preferred Brand 25%25%None
ACYCLOVIR 200MG CAPSULE (1000 CT)   1 Tier 1 Preferred Generics 25%25%None
ACYCLOVIR 200MG/5ML SUSP   1 Tier 1 Preferred Generics 25%25%None
ACYCLOVIR 400MG TABLET (100 CT)   1 Tier 1 Preferred Generics 25%25%None
ACYCLOVIR 800 MG ORAL TABLET   1 Tier 1 Preferred Generics 25%25%None
ACYCLOVIR SODIUM 500MG VIAL   1 Tier 1 Preferred Generics 25%25%None
ADACEL VIAL 2UNT/5UNT   4 Tier 4 Non-Preferred Brand 25%25%None
ADAGEN 250U/ML VIAL   5 Tier 5 Specialty Drugs 25%25%None
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA]   5 Tier 5 Specialty Drugs 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADVAIR DISKU MIS 100/50   4 Tier 4 Non-Preferred Brand 25%25%None
ADVAIR DISKU MIS 250/50   4 Tier 4 Non-Preferred Brand 25%25%None
ADVAIR DISKU MIS 500/50   4 Tier 4 Non-Preferred Brand 25%25%None
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL   4 Tier 4 Non-Preferred Brand 25%25%None
ADVAIR HFA INHALER 230;21MCG;MCG   4 Tier 4 Non-Preferred Brand 25%25%None
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL   4 Tier 4 Non-Preferred Brand 25%25%None
AFEDITAB CR 30MG TABLET SA   1 Tier 1 Preferred Generics 25%25%None
AFEDITAB CR 60MG TABLET SA   1 Tier 1 Preferred Generics 25%25%None
AFINITOR TABLETS   5 Tier 5 Specialty Drugs 25%25%None
AFINITOR TABLETS   5 Tier 5 Specialty Drugs 25%25%None
AFINITOR TABLETS 5 MG   5 Tier 5 Specialty Drugs 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AGGRENOX 25-200MG CAPSULE   3 Tier 3 Preferred Brand 25%25%None
AK-CON 0.1% EYE DROPS   1 Tier 1 Preferred Generics 25%25%None
AKTOB 0.3% EYE DROPS   1 Tier 1 Preferred Generics 25%25%None
ALA-CORT 1% CREAM   1 Tier 1 Preferred Generics 25%25%None
ALA-CORT 1% LOTION   1 Tier 1 Preferred Generics 25%25%None
ALBUTEROL SULFATE 0.63MG/3ML VIAL NEBULIZER   2 Tier 2 Non-Preferred Generics 25%25%P
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER   1 Tier 1 Preferred Generics 25%25%P
ALBUTEROL SULFATE 4MG TABLET SR 12HR   1 Tier 1 Preferred Generics 25%25%None
ALBUTEROL SULFATE 8MG TABLET SR 12HR   1 Tier 1 Preferred Generics 25%25%None
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   1 Tier 1 Preferred Generics 25%25%P
ALBUTEROL SULFATE SOLUTION FOR INHALATION   1 Tier 1 Preferred Generics 25%25%P
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   1 Tier 1 Preferred Generics 25%25%None
ALBUTEROL SULFATE TABLET 2MG (500 CT)   1 Tier 1 Preferred Generics 25%25%None
ALBUTEROL TABLET 4MG (500 CT)   1 Tier 1 Preferred Generics 25%25%None
ALCLOMETASONE DIPROPIONATE 0.05% CREAM   1 Tier 1 Preferred Generics 25%25%None
ALCLOMETASONE DIPROPIONATE 0.05% OINTMENT   1 Tier 1 Preferred Generics 25%25%None
ALCOHOL 5%/DEXTROSE 5%   1 Tier 1 Preferred Generics 25%25%None
ALDARA IMIQUIMOD CREAM 5% 24 PKT X 250 MG CRTN   3 Tier 3 Preferred Brand 25%25%None
ALDURAZYME 2.9MG/5ML VIAL   5 Tier 5 Specialty Drugs 25%25%None
ALENDRONATE SODIUM 10MG TABLET   1 Tier 1 Preferred Generics 25%25%None
ALENDRONATE SODIUM 40MG TABLET   1 Tier 1 Preferred Generics 25%25%None
ALENDRONATE SODIUM 5MG TABLET   1 Tier 1 Preferred Generics 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALENDRONATE SODIUM TABLET 35MG 20 CRTN   1 Tier 1 Preferred Generics 25%25%None
ALENDRONATE SODIUM TABLETS 70 MG   1 Tier 1 Preferred Generics 25%25%None
ALIMTA 500MG VIAL   5 Tier 5 Specialty Drugs 25%25%None
ALLEGRA-D 24 HOUR TABLET   3 Tier 3 Preferred Brand 25%25%None
ALLOPURINOL SODIUM 500MG VIAL   1 Tier 1 Preferred Generics 25%25%None
ALLOPURINOL TABLET 300MG (1000 CT)   1 Tier 1 Preferred Generics 25%25%None
ALLOPURINOL TABLETS   1 Tier 1 Preferred Generics 25%25%None
ALPHAGAN P 0.1% DROPS   3 Tier 3 Preferred Brand 25%25%None
ALPHAGAN P 0.15% EYE DROPS   3 Tier 3 Preferred Brand 25%25%None
AMANTADINE 100MG CAPSULE   1 Tier 1 Preferred Generics 25%25%None
AMANTADINE 100MG TABLET   1 Tier 1 Preferred Generics 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMANTADINE HCL 50 MG/ 5 ML SYRUP   1 Tier 1 Preferred Generics 25%25%None
AMCINONIDE 0.1% CREAM   1 Tier 1 Preferred Generics 25%25%None
AMCINONIDE 0.1% LOTION   1 Tier 1 Preferred Generics 25%25%None
AMCINONIDE 0.1% OINTMENT 60GM TUBE   1 Tier 1 Preferred Generics 25%25%None
AMIFOSTINE FOR INJECTION 500MG/VIAL   5 Tier 5 Specialty Drugs 25%25%None
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET   1 Tier 1 Preferred Generics 25%25%None
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT   1 Tier 1 Preferred Generics 25%25%None
AMINOPHYLLINE 100MG TABLET   1 Tier 1 Preferred Generics 25%25%None
AMINOPHYLLINE 200MG TABLET (1000 CT)   1 Tier 1 Preferred Generics 25%25%None
AMINOPHYLLINE INJECTION 250MG 10ML X 25 VIALSD   1 Tier 1 Preferred Generics 25%25%None
AMINOSYN 10% IV SOLUTION   4 Tier 4 Non-Preferred Brand 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN 3.5% IV SOLUTION   4 Tier 4 Non-Preferred Brand 25%25%P
AMINOSYN 5% IV SOLUTION   4 Tier 4 Non-Preferred Brand 25%25%P
AMINOSYN 7% IV SOLUTION   4 Tier 4 Non-Preferred Brand 25%25%P
AMINOSYN 7%-ELECTROLYTE SOL   4 Tier 4 Non-Preferred Brand 25%25%P
AMINOSYN 8.5% IV SOLUTION   4 Tier 4 Non-Preferred Brand 25%25%P
AMINOSYN HBC INJECTION SULFITE FREE 7%   4 Tier 4 Non-Preferred Brand 25%25%P
AMINOSYN II 10% IV SOLUTION   4 Tier 4 Non-Preferred Brand 25%25%P
AMINOSYN II 3.5% IN D25W IV   4 Tier 4 Non-Preferred Brand 25%25%P
AMINOSYN II 3.5% IN D5W IV   4 Tier 4 Non-Preferred Brand 25%25%P
AMINOSYN II 3.5% M/D5W IV   4 Tier 4 Non-Preferred Brand 25%25%None
AMINOSYN II 3.5% W/ELEC DEX   4 Tier 4 Non-Preferred Brand 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN II 4.25% IN D10W   4 Tier 4 Non-Preferred Brand 25%25%P
AMINOSYN II 4.25% IN D20W   4 Tier 4 Non-Preferred Brand 25%25%P
AMINOSYN II 4.25% W/ELEC DW   4 Tier 4 Non-Preferred Brand 25%25%P
AMINOSYN II 4.25%-D25W IV   4 Tier 4 Non-Preferred Brand 25%25%P
AMINOSYN II 5% IN D25W IV   4 Tier 4 Non-Preferred Brand 25%25%P
AMINOSYN II 7% IV SOLUTION   4 Tier 4 Non-Preferred Brand 25%25%P
AMINOSYN II 8.5% ELECTROLYT   4 Tier 4 Non-Preferred Brand 25%25%P
AMINOSYN II 8.5% IV SOLUTION   4 Tier 4 Non-Preferred Brand 25%25%P
AMINOSYN M 3.5% IV SOLUTION   4 Tier 4 Non-Preferred Brand 25%25%P
AMINOSYN PF INJECTION   4 Tier 4 Non-Preferred Brand 25%25%P
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5%   1 Tier 1 Preferred Generics 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN-HF 8% IV SOLUTION   4 Tier 4 Non-Preferred Brand 25%25%P
AMINOSYN-PF 7% IV SOLUTION   4 Tier 4 Non-Preferred Brand 25%25%P
AMIODARONE HCL 400MG TABLET   2 Tier 2 Non-Preferred Generics 25%25%None
AMIODARONE HCL INJECTION   1 Tier 1 Preferred Generics 25%25%None
AMIODARONE HYDROCHLORIDE TABLETS   2 Tier 2 Non-Preferred Generics 25%25%None
AMITIZA 8MCG CAPSULE   3 Tier 3 Preferred Brand 25%25%S
AMITIZA CAPSULES 24MCG 60 CAP BOT   3 Tier 3 Preferred Brand 25%25%S
AMITRIP/CDP 25-10 TABLET   1 Tier 1 Preferred Generics 25%25%None
AMITRIP/PERPHEN 10-2 TABLET   1 Tier 1 Preferred Generics 25%25%None
AMITRIP/PERPHEN 10-4 TABLET   1 Tier 1 Preferred Generics 25%25%None
AMITRIP/PERPHEN 25-2 TABLET   1 Tier 1 Preferred Generics 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITRIP/PERPHEN 25-4 TABLET   1 Tier 1 Preferred Generics 25%25%None
AMITRIP/PERPHEN 50-4 TABLET   1 Tier 1 Preferred Generics 25%25%None
AMITRIPTYLINE HCL 100MG TABLET   1 Tier 1 Preferred Generics 25%25%None
AMITRIPTYLINE HCL 10MG TABLET   1 Tier 1 Preferred Generics 25%25%None
AMITRIPTYLINE HCL 150 MG TAB   1 Tier 1 Preferred Generics 25%25%None
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)   1 Tier 1 Preferred Generics 25%25%None
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)   1 Tier 1 Preferred Generics 25%25%None
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT   1 Tier 1 Preferred Generics 25%25%None
AMLODIPINE BESYLATE 10MG TABLET (90 CT)   1 Tier 1 Preferred Generics 25%25%None
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)   1 Tier 1 Preferred Generics 25%25%None
AMLODIPINE BESYLATE 5MG TABLET (90 CT)   1 Tier 1 Preferred Generics 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE   1 Tier 1 Preferred Generics 25%25%None
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE   1 Tier 1 Preferred Generics 25%25%None
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE   1 Tier 1 Preferred Generics 25%25%None
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE   1 Tier 1 Preferred Generics 25%25%None
AMOX TR-K CLV 500-125 MG TAB   1 Tier 1 Preferred Generics 25%25%None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL   1 Tier 1 Preferred Generics 25%25%None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE   1 Tier 1 Preferred Generics 25%25%None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET   1 Tier 1 Preferred Generics 25%25%None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE   1 Tier 1 Preferred Generics 25%25%None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   1 Tier 1 Preferred Generics 25%25%None
AMOXAPINE 100MG TABLET   1 Tier 1 Preferred Generics 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXAPINE 150MG TABLET   1 Tier 1 Preferred Generics 25%25%None
AMOXAPINE 25MG TABLET   1 Tier 1 Preferred Generics 25%25%None
AMOXAPINE 50MG TABLET   1 Tier 1 Preferred Generics 25%25%None
AMOXICILLIN 125MG TABLET CHEW   1 Tier 1 Preferred Generics 25%25%None
AMOXICILLIN 200MG TABLET CHEW   1 Tier 1 Preferred Generics 25%25%None
AMOXICILLIN 250MG CAPSULE   1 Tier 1 Preferred Generics 25%25%None
AMOXICILLIN 400MG TABLET CHEW   1 Tier 1 Preferred Generics 25%25%None
AMOXICILLIN 500MG CAPSULE   1 Tier 1 Preferred Generics 25%25%None
AMOXICILLIN 500MG TABLET (100 CT)   1 Tier 1 Preferred Generics 25%25%None
AMOXICILLIN 875MG TABLET   1 Tier 1 Preferred Generics 25%25%None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT   1 Tier 1 Preferred Generics 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT   1 Tier 1 Preferred Generics 25%25%None
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT   1 Tier 1 Preferred Generics 25%25%None
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL   1 Tier 1 Preferred Generics 25%25%None
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   1 Tier 1 Preferred Generics 25%25%None
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL   1 Tier 1 Preferred Generics 25%25%None
AMOXICILLIN TABLET USP CHEWABLE 250MG (250 CT)   1 Tier 1 Preferred Generics 25%25%None
AMPHETAMINE SALT COMBO 12.5MG TABLET   1 Tier 1 Preferred Generics 25%25%None
AMPHETAMINE SALT COMBO 15MG TABLET   1 Tier 1 Preferred Generics 25%25%None
AMPHETAMINE SALT COMBO 30MG TABLET   1 Tier 1 Preferred Generics 25%25%None
AMPHETAMINE SALT COMBO 7.5MG TABLET   1 Tier 1 Preferred Generics 25%25%None
AMPHETAMINE SALTS 20MG TABLET   1 Tier 1 Preferred Generics 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPHETAMINE SALTS 5 MG TAB   1 Tier 1 Preferred Generics 25%25%None
AMPICILLIN CAPSULES 250MG 100 BOT   1 Tier 1 Preferred Generics 25%25%None
AMPICILLIN CAPSULES 500MG 100 BOT   1 Tier 1 Preferred Generics 25%25%None
AMPICILLIN FOR INJECTION POWDER   2 Tier 2 Non-Preferred Generics 25%25%None
AMPICILLIN FOR INJECTION USP 125MG/ML 1 VIAL   2 Tier 2 Non-Preferred Generics 25%25%None
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT   1 Tier 1 Preferred Generics 25%25%None
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT   1 Tier 1 Preferred Generics 25%25%None
AMPICILLIN POWDER FOR INJECTION 1 GM/ML   2 Tier 2 Non-Preferred Generics 25%25%None
AMPYRA ER 10 MG TABLET   5 Tier 5 Specialty Drugs 25%25%None
ANADROL-50 50MG TABLET (100 CT)   4 Tier 4 Non-Preferred Brand 25%25%None
ANASTROZOLE TABLETS   2 Tier 2 Non-Preferred Generics 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANCOBON 250MG CAPSULE   5 Tier 5 Specialty Drugs 25%25%None
ANCOBON 500MG CAPSULE   5 Tier 5 Specialty Drugs 25%25%None
ANDRODERM 2.5MG/24HR PATCH   4 Tier 4 Non-Preferred Brand 25%25%None
ANDRODERM 5MG/24HR PATCH   4 Tier 4 Non-Preferred Brand 25%25%None
ANIDULAFUNGIN 3.33 MG/ML INJECTABLE SOLUTION [ERAXIS]   4 Tier 4 Non-Preferred Brand 25%25%None
ANTABUSE 250MG TABLET   4 Tier 4 Non-Preferred Brand 25%25%None
ANTABUSE 500MG TABLET   4 Tier 4 Non-Preferred Brand 25%25%None
APIDRA 100UNITS/ML VIAL   3 Tier 3 Preferred Brand 25%25%None
APLENZIN TABLETS EXTENDED RELEASE 348 MG   4 Tier 4 Non-Preferred Brand 25%25%None
APLENZIN TABLETS EXTENDED RELEASE 522 MG   4 Tier 4 Non-Preferred Brand 25%25%None
APOKYN 30 MG/3 ML CARTRIDGE   5 Tier 5 Specialty Drugs 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
APRISO CP24   4 Tier 4 Non-Preferred Brand 25%25%None
APTIVUS 250MG CAPSULE   5 Tier 5 Specialty Drugs 25%25%None
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT   5 Tier 5 Specialty Drugs 25%25%None
ARCALYST INJECTION 220MG/VIAL   5 Tier 5 Specialty Drugs 25%25%None
ARICEPT 10MG TABLET   3 Tier 3 Preferred Brand 25%25%None
ARICEPT 5MG TABLET   3 Tier 3 Preferred Brand 25%25%None
ARICEPT ODT 10MG TABLET   3 Tier 3 Preferred Brand 25%25%None
ARICEPT ODT 5MG TABLET   3 Tier 3 Preferred Brand 25%25%None
ARICEPT TABLETS   3 Tier 3 Preferred Brand 25%25%None
ARIMIDEX 1MG TABLET   3 Tier 3 Preferred Brand 25%25%None
ARIXTRA 10MG SYRINGE   4 Tier 4 Non-Preferred Brand 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARIXTRA 2.5MG SYRINGE   4 Tier 4 Non-Preferred Brand 25%25%None
ARIXTRA 5MG SYRINGE   4 Tier 4 Non-Preferred Brand 25%25%None
ARIXTRA 7.5MG SYRINGE   4 Tier 4 Non-Preferred Brand 25%25%None
AROMASIN 25MG TABLET   4 Tier 4 Non-Preferred Brand 25%25%None
ARZERRA INJECTION 100MG/5ML   5 Tier 5 Specialty Drugs 25%25%P
ASACOL 400MG TABLET EC   3 Tier 3 Preferred Brand 25%25%None
ASACOL HD DELAYED RELEASE TABLETS 800MG 180 BOT   3 Tier 3 Preferred Brand 25%25%None
ASCOMP W/CODEINE 30-50-325 CAPSULE   1 Tier 1 Preferred Generics 25%25%None
ASENAPINE 10 MG SUBLINGUAL TABLET [SAPHRIS]   3 Tier 3 Preferred Brand 25%25%None
ASENAPINE 5 MG SUBLINGUAL TABLET [SAPHRIS]   3 Tier 3 Preferred Brand 25%25%None
ASTELIN 137MCG AEROSOL SPRAY W/PUMP   3 Tier 3 Preferred Brand 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ASTEPRO 0.15% NASAL SPRAY 30 ML   3 Tier 3 Preferred Brand 25%25%None
ASTRAMORPH PF INJECTION   1 Tier 1 Preferred Generics 25%25%None
ASTRAMORPH PF INJECTION 1MG/ML   1 Tier 1 Preferred Generics 25%25%None
ATENOLOL 25MG TABLET (100 CT)   1 Tier 1 Preferred Generics 25%25%None
ATENOLOL TABLET USP 50MG (100 CT)   1 Tier 1 Preferred Generics 25%25%None
ATENOLOL TABLETS USP 100MG 1 BLPK   1 Tier 1 Preferred Generics 25%25%None
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT)   1 Tier 1 Preferred Generics 25%25%None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   1 Tier 1 Preferred Generics 25%25%None
ATGAM 50MG/ML AMPUL   5 Tier 5 Specialty Drugs 25%25%P
ATRIPLA TABLET 600MG/200MG   5 Tier 5 Specialty Drugs 25%25%None
ATROPINE 0.025 MG / DIPHENOXYLATE 2.5 MG ORAL TABLET   1 Tier 1 Preferred Generics 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATROPINE 0.05MG/ML SYRINGE   1 Tier 1 Preferred Generics 25%25%None
ATROPINE 0.1MG/ML SYRINGE   1 Tier 1 Preferred Generics 25%25%None
ATROVENT HFA AER 17MCG   3 Tier 3 Preferred Brand 25%25%None
ATTENUVAX VACCINE W/DILUENT 1 DOSE/0.5ML   4 Tier 4 Non-Preferred Brand 25%25%None
AVANDAMET 2MG/1000MG TABLET   3 Tier 3 Preferred Brand 25%25%None
AVANDAMET 2MG/500MG TABLET   3 Tier 3 Preferred Brand 25%25%None
AVANDAMET 4MG/500MG TABLET   3 Tier 3 Preferred Brand 25%25%None
AVANDAMET TABLET 4-1000MG   3 Tier 3 Preferred Brand 25%25%None
AVANDARYL 4MG/1MG TABLET   3 Tier 3 Preferred Brand 25%25%None
AVANDARYL 4MG/2MG TABLET   3 Tier 3 Preferred Brand 25%25%None
AVANDARYL 4MG/4MG TABLET   3 Tier 3 Preferred Brand 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVANDARYL 8MG-2MG TABLET   3 Tier 3 Preferred Brand 25%25%None
AVANDARYL 8MG-4MG TABLET   3 Tier 3 Preferred Brand 25%25%None
AVANDIA 2MG TABLET   3 Tier 3 Preferred Brand 25%25%None
AVANDIA 4MG TABLET (90 CT)   3 Tier 3 Preferred Brand 25%25%None
AVANDIA 8MG TABLET (90 CT)   3 Tier 3 Preferred Brand 25%25%None
AVASTIN 100MG/4ML VIAL   5 Tier 5 Specialty Drugs 25%25%None
AVODART 0.5MG SOFTGEL   3 Tier 3 Preferred Brand 25%25%None
AVONEX ADMIN PACK 30MCG SYR   5 Tier 5 Specialty Drugs 25%25%None
AVONEX ADMIN PACK 30MCG VL   5 Tier 5 Specialty Drugs 25%25%None
AZACTAM INJECTION   5 Tier 5 Specialty Drugs 25%25%None
AZACTAM INJECTION 1GM/50ML   3 Tier 3 Preferred Brand 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZACTAM INJECTION 2GM/VIL   5 Tier 5 Specialty Drugs 25%25%None
AZATHIOPRINE 50MG TABLET   1 Tier 1 Preferred Generics 25%25%P
AZELASTINE 137 MCG NASAL SPRAY   2 Tier 2 Non-Preferred Generics 25%25%None
AZELASTINE HYDROCHLORIDE OPHTHALMIC SOLUTION   2 Tier 2 Non-Preferred Generics 25%25%None
AZILECT 0.5MG TABLET   3 Tier 3 Preferred Brand 25%25%None
AZILECT 1MG TABLET   3 Tier 3 Preferred Brand 25%25%None
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Tier 1 Preferred Generics 25%25%None
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Tier 1 Preferred Generics 25%25%None
AZITHROMYCIN 250 MG TABLET   1 Tier 1 Preferred Generics 25%25%None
AZITHROMYCIN 500MG TABLET (30 CT)   1 Tier 1 Preferred Generics 25%25%None
AZITHROMYCIN FOR INJECTION 500MG 10 VIALSD   2 Tier 2 Non-Preferred Generics 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZITHROMYCIN TABLETS   1 Tier 1 Preferred Generics 25%25%None
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT   3 Tier 3 Preferred Brand 25%25%None
AZTREONAM FOR INJECTION   2 Tier 2 Non-Preferred Generics 25%25%None

Chart Legend:

Below are a few notes to help you understand the above 2011 Medicare Part D EnvisionRxPlus Silver (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.





 
 

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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.