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Blue Shield Medicare Rx Plan (PDP) (S2468-002-0)
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Cick on the first letter of your drug name to browse the formulary:

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M N O P Q R S T U V W X Y Z 0-9 
2011 Medicare Part D Plan Formulary Information
Blue Shield Medicare Rx Plan (PDP) (S2468-002-0)
Benefit Details           
The Blue Shield Medicare Rx Plan (PDP) (S2468-002-0)
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   5 Tier 5 33%33%P
A-HYDROCORT 100MG VIAL   5 Tier 5 33%33%P
A-METHAPRED 40MG UNIVIAL   5 Tier 5 33%33%P
ABELCENT INJECTION SUSPENSION 5MG/ML   5 Tier 5 33%33%P
ABILIFY 10MG TABLET   4 Tier 4 $80.50$161.00None
ABILIFY 15MG TABLET   4 Tier 4 $80.50$161.00None
ABILIFY 1MG/ML SOLUTION   4 Tier 4 $80.50$161.00None
ABILIFY 20MG TABLET   4 Tier 4 $80.50$161.00None
ABILIFY 2MG TABLET   4 Tier 4 $80.50$161.00None
ABILIFY 30MG TABLET   4 Tier 4 $80.50$161.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ABILIFY 5MG TABLET (OTSUKA)   4 Tier 4 $80.50$161.00None
ABILIFY DISCMELT 10MG TABLET   4 Tier 4 $80.50$161.00P
ABILIFY DISCMELT 15MG TABLET   4 Tier 4 $80.50$161.00P
ABILIFY INJ 9.75MG   5 Tier 5 33%33%P
ABRAXANE 100MG VIAL   5 Tier 5 33%33%P
ACARBOSE 100MG TABLET S   2 Tier 2 $20.00$40.00None
ACARBOSE 50MG TABLET S   2 Tier 2 $20.00$40.00None
ACARBOSE TABLETS   2 Tier 2 $20.00$40.00None
ACCOLATE 10MG TABLET   4 Tier 4 $80.50$161.00None
ACCOLATE 20MG TABLET   4 Tier 4 $80.50$161.00None
ACEBUTOLOL 200MG CAPSULE   1 Tier 1 $9.00$18.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACEBUTOLOL 400MG CAPSULE   1 Tier 1 $9.00$18.00None
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE   5 Tier 5 33%33%None
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD   1 Tier 1 $9.00$18.00None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT)   1 Tier 1 $9.00$18.00None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT)   1 Tier 1 $9.00$18.00None
ACETAZOLAMIDE 125MG TABLET   1 Tier 1 $9.00$18.00None
ACETAZOLAMIDE 250MG TABLET (100 CT)   1 Tier 1 $9.00$18.00None
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT   1 Tier 1 $9.00$18.00None
ACETAZOLAMIDE SOD 500MG VL   5 Tier 5 33%33%P
ACETIC ACID 2% SOLUTION NON-ORAL   1 Tier 1 $9.00$18.00None
ACETYLCYSTEINE 10% VIAL   1 Tier 1 $9.00$18.00P
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 $9.00$18.00P
ACTHIB VACCINE VIAL 10-24UNT/5ML   5 Tier 5 33%33%None
ACTICIN 5% CREAM   1 Tier 1 $9.00$18.00None
ACTIMMUNE SOLUTION FOR INJECTION 100MCG   6 Tier 6 33%33%P
ACTIVELLA 0.5-0.1MG TABLET 28 DLPK   3 Tier 3 $45.00$90.00None
ACTONEL 150MG TABLET   4 Tier 4 $80.50$161.00S Q:1
/28Days
ACTONEL 30MG TABLET   3 Tier 3 $45.00$90.00P
ACTONEL 35MG TABLET   4 Tier 4 $80.50$161.00S Q:4
/28Days
ACTONEL 5MG TABLET   4 Tier 4 $80.50$161.00S Q:30
/30Days
ACTOPLUS MET 15MG/500MG TABLET   3 Tier 3 $45.00$90.00S
ACTOPLUS MET 15MG/850MG TABLET   3 Tier 3 $45.00$90.00S
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACTOPLUS MET XR TABLETS EXTENDED RELEASE 15;1000 MG;MG   3 Tier 3 $45.00$90.00S
ACTOPLUS MET XR TABLETS EXTENDED RELEASE 30;1000 MG;MG   3 Tier 3 $45.00$90.00S
ACTOS 15MG TABLET   3 Tier 3 $45.00$90.00S
ACTOS 30MG TABLET (500 CT)   3 Tier 3 $45.00$90.00S
ACTOS 45MG TABLET   3 Tier 3 $45.00$90.00S
ACYCLOVIR 200MG CAPSULE (1000 CT)   1 Tier 1 $9.00$18.00None
ACYCLOVIR 200MG/5ML SUSP   2 Tier 2 $20.00$40.00None
ACYCLOVIR 400MG TABLET (100 CT)   1 Tier 1 $9.00$18.00None
ACYCLOVIR 800 MG ORAL TABLET   1 Tier 1 $9.00$18.00None
ACYCLOVIR SODIUM 500MG VIAL   5 Tier 5 33%33%P
ADACEL VIAL 2UNT/5UNT   5 Tier 5 33%33%None
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%33%P
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA]   6 Tier 6 33%33%P
ADAPALENE CREAM   2 Tier 2 $20.00$40.00P
ADAPALENE GEL   2 Tier 2 $20.00$40.00P
ADCIRCA TABLETS 20MG 60 BOT   3 Tier 3 $45.00$90.00P
ADDERALL XR 10MG CAPSULE SA   3 Tier 3 $45.00$90.00Q:30
/30Days
ADDERALL XR 15MG CAPSULE SA   3 Tier 3 $45.00$90.00Q:60
/30Days
ADDERALL XR 20MG CAPSULE SA   3 Tier 3 $45.00$90.00Q:30
/30Days
ADDERALL XR 25MG CAPSULE SA   3 Tier 3 $45.00$90.00Q:30
/30Days
ADDERALL XR 30MG CAPSULE SA   3 Tier 3 $45.00$90.00Q:30
/30Days
ADDERALL XR 5MG CAPSULE SA   3 Tier 3 $45.00$90.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADVAIR DISKU MIS 100/50   3 Tier 3 $45.00$90.00Q:60
/30Days
ADVAIR DISKU MIS 250/50   3 Tier 3 $45.00$90.00Q:60
/30Days
ADVAIR DISKU MIS 500/50   3 Tier 3 $45.00$90.00Q:60
/30Days
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL   3 Tier 3 $45.00$90.00Q:12
/30Days
ADVAIR HFA INHALER 230;21MCG;MCG   3 Tier 3 $45.00$90.00Q:12
/30Days
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL   3 Tier 3 $45.00$90.00Q:12
/30Days
ADVICOR ER 20-750MG TABLET (90 CT)   3 Tier 3 $45.00$90.00Q:60
/30Days
ADVICOR EXTENDED RELEASE TABLETS 20;1000MG;MG 90 BOTPL   3 Tier 3 $45.00$90.00Q:60
/30Days
ADVICOR EXTENDED RELEASE TABLETS 20;500MG;MG 90 BOTPL   3 Tier 3 $45.00$90.00Q:30
/30Days
ADVICOR EXTENDED RELEASE TABLETS 40;1000MG;MG 90 BOTPL   3 Tier 3 $45.00$90.00Q:30
/30Days
AEROBID-M AEROSOL W/ADAPTER   4 Tier 4 $80.50$161.00Q:21
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AFEDITAB CR 30MG TABLET SA   1 Tier 1 $9.00$18.00None
AFEDITAB CR 60MG TABLET SA   1 Tier 1 $9.00$18.00None
AFINITOR TABLETS   6 Tier 6 33%33%P Q:60
/30Days
AFINITOR TABLETS   6 Tier 6 33%33%P Q:30
/30Days
AFINITOR TABLETS 5 MG   6 Tier 6 33%33%P Q:30
/30Days
AGGRENOX 25-200MG CAPSULE   4 Tier 4 $80.50$161.00None
AK-CON 0.1% EYE DROPS   1 Tier 1 $9.00$18.00None
AKNE-MYCIN 2% OINTMENT   4 Tier 4 $80.50$161.00None
AKTOB 0.3% EYE DROPS   1 Tier 1 $9.00$18.00None
ALA-CORT 1% CREAM   1 Tier 1 $9.00$18.00None
ALA-CORT 1% LOTION   1 Tier 1 $9.00$18.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALA-SCALP HP 2% LOTION   4 Tier 4 $80.50$161.00None
ALAMAST 0.1% DROPS   3 Tier 3 $45.00$90.00None
ALBENZA 200MG TABLET   4 Tier 4 $80.50$161.00None
ALBUTEROL SULFATE 0.63MG/3ML VIAL NEBULIZER   1 Tier 1 $9.00$18.00P Q:375
/30Days
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER   1 Tier 1 $9.00$18.00P Q:180
/30Days
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   1 Tier 1 $9.00$18.00P Q:40
/30Days
ALBUTEROL SULFATE SOLUTION FOR INHALATION   1 Tier 1 $9.00$18.00P Q:360
/30Days
ALCLOMETASONE DIPROPIONATE 0.05% CREAM   1 Tier 1 $9.00$18.00None
ALCLOMETASONE DIPROPIONATE 0.05% OINTMENT   1 Tier 1 $9.00$18.00None
ALCOHOL 5%/DEXTROSE 5%   5 Tier 5 33%33%P
ALDACTAZIDE 50/50 TABLET   4 Tier 4 $80.50$161.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALDURAZYME 2.9MG/5ML VIAL   6 Tier 6 33%33%P
ALENDRONATE SODIUM 10MG TABLET   1 Tier 1 $9.00$18.00Q:30
/30Days
ALENDRONATE SODIUM 40MG TABLET   1 Tier 1 $9.00$18.00Q:30
/30Days
ALENDRONATE SODIUM 5MG TABLET   1 Tier 1 $9.00$18.00Q:30
/30Days
ALENDRONATE SODIUM TABLET 35MG 20 CRTN   1 Tier 1 $9.00$18.00Q:4
/28Days
ALENDRONATE SODIUM TABLETS 70 MG   1 Tier 1 $9.00$18.00Q:4
/28Days
ALIMTA 500MG VIAL   5 Tier 5 33%33%P
ALINIA 100MG/5ML SUSPENSION   4 Tier 4 $80.50$161.00Q:180
/3Days
ALINIA 500MG TABLET   4 Tier 4 $80.50$161.00Q:60
/30Days
ALISKIREN 150 MG / VALSARTAN 160 MG ORAL TABLET [VALTURNA]   4 Tier 4 $80.50$161.00S Q:30
/30Days
ALISKIREN 300 MG / VALSARTAN 320 MG ORAL TABLET [VALTURNA]   4 Tier 4 $80.50$161.00S Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALKERAN FOR INJECTION 50MG/VIAL 1 VIALSU   5 Tier 5 33%33%P
ALLEGRA 30MG/5ML SUSPENSION ORAL   4 Tier 4 $80.50$161.00P Q:300
/30Days
ALLEGRA-D 24 HOUR TABLET   4 Tier 4 $80.50$161.00S Q:30
/30Days
ALLOPURINOL SODIUM 500MG VIAL   5 Tier 5 33%33%P
ALLOPURINOL TABLET 300MG (1000 CT)   1 Tier 1 $9.00$18.00None
ALLOPURINOL TABLETS   1 Tier 1 $9.00$18.00None
ALOCRIL 2% EYE DROPS   4 Tier 4 $80.50$161.00None
ALOMIDE 0.1% EYE DROPS   3 Tier 3 $45.00$90.00None
ALORA 0.025MG PATCH   4 Tier 4 $80.50$161.00Q:8
/28Days
ALORA 0.05MG PATCH   4 Tier 4 $80.50$161.00Q:8
/28Days
ALORA 0.075MG PATCH   4 Tier 4 $80.50$161.00Q:8
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALORA 0.1MG PATCH   4 Tier 4 $80.50$161.00Q:8
/28Days
ALOXI 0.25MG/5ML   5 Tier 5 33%33%P
ALPHA-1-PROTEINASE INHIBITOR,HUMAN 16 MG/ML INJECTABLE SOLUTION [ARALAST]   6 Tier 6 33%33%P
ALPHAGAN P 0.1% DROPS   3 Tier 3 $45.00$90.00None
ALPHAGAN P 0.15% EYE DROPS   3 Tier 3 $45.00$90.00None
ALREX 0.2% EYE DROPS   3 Tier 3 $45.00$90.00None
ALTOPREV 20MG TABLET SR 24HR   4 Tier 4 $80.50$161.00None
ALTOPREV 40MG TABLET SR 24HR   4 Tier 4 $80.50$161.00None
ALTOPREV 60MG TABLET SR 24HR   4 Tier 4 $80.50$161.00None
AMANTADINE 100MG CAPSULE   1 Tier 1 $9.00$18.00None
AMANTADINE 100MG TABLET   1 Tier 1 $9.00$18.00None
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 $9.00$18.00None
AMBIEN CR 12.5MG TABLET   4 Tier 4 $80.50$161.00S Q:30
/30Days
AMBIEN CR 6.25MG TABLET   4 Tier 4 $80.50$161.00S Q:30
/30Days
AMBISOME 50MG VIAL   5 Tier 5 33%33%P
AMCINONIDE 0.1% CREAM   1 Tier 1 $9.00$18.00None
AMCINONIDE 0.1% LOTION   1 Tier 1 $9.00$18.00None
AMCINONIDE 0.1% OINTMENT 60GM TUBE   1 Tier 1 $9.00$18.00None
AMERGE 1MG TABLET   3 Tier 3 $45.00$90.00Q:18
/30Days
AMERGE 2.5MG TABLET   3 Tier 3 $45.00$90.00Q:18
/30Days
AMEVIVE ADMISTRATION PACK FOR INTRAMUSCULAR ADMINISTRATION KIT 15MG 1 X 4 PKGCOM   6 Tier 6 33%33%P
AMIFOSTINE FOR INJECTION 500MG/VIAL   5 Tier 5 33%33%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMIKACIN 250MG/ML VIAL   5 Tier 5 33%33%P
AMIKACIN 50MG/ML VIAL   5 Tier 5 33%33%P
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET   1 Tier 1 $9.00$18.00None
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT   1 Tier 1 $9.00$18.00None
AMINOPHYLLINE 100MG TABLET   1 Tier 1 $9.00$18.00None
AMINOPHYLLINE 200MG TABLET (1000 CT)   1 Tier 1 $9.00$18.00None
AMINOPHYLLINE INJECTION 250MG 10ML X 25 VIALSD   5 Tier 5 33%33%P
AMINOSYN 10% IV SOLUTION   5 Tier 5 33%33%P
AMINOSYN 3.5% IV SOLUTION   5 Tier 5 33%33%P
AMINOSYN 5% IV SOLUTION   5 Tier 5 33%33%P
AMINOSYN 7% IV SOLUTION   5 Tier 5 33%33%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN 7%-ELECTROLYTE SOL   5 Tier 5 33%33%P
AMINOSYN 8.5% IV SOLUTION   5 Tier 5 33%33%P
AMINOSYN HBC INJECTION SULFITE FREE 7%   5 Tier 5 33%33%P
AMINOSYN II 10% IV SOLUTION   5 Tier 5 33%33%P
AMINOSYN II 15% IV SOLUTION   5 Tier 5 33%33%P
AMINOSYN II 3.5% IN D25W IV   5 Tier 5 33%33%P
AMINOSYN II 3.5% IN D5W IV   5 Tier 5 33%33%P
AMINOSYN II 3.5% W/ELEC DEX   5 Tier 5 33%33%P
AMINOSYN II 4.25% IN D10W   5 Tier 5 33%33%P
AMINOSYN II 4.25% IN D20W   5 Tier 5 33%33%P
AMINOSYN II 4.25% W/ELEC DW   5 Tier 5 33%33%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN II 4.25%-D25W IV   5 Tier 5 33%33%P
AMINOSYN II 5% IN D25W IV   5 Tier 5 33%33%P
AMINOSYN II 7% IV SOLUTION   5 Tier 5 33%33%P
AMINOSYN II 8.5% ELECTROLYT   5 Tier 5 33%33%P
AMINOSYN II 8.5% IV SOLUTION   5 Tier 5 33%33%P
AMINOSYN M 3.5% IV SOLUTION   5 Tier 5 33%33%P
AMINOSYN PF INJECTION   5 Tier 5 33%33%P
AMINOSYN-HF 8% IV SOLUTION   5 Tier 5 33%33%P
AMINOSYN-PF 7% IV SOLUTION   5 Tier 5 33%33%P
AMIODARONE HCL 400MG TABLET   1 Tier 1 $9.00$18.00None
AMIODARONE HCL INJECTION   5 Tier 5 33%33%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMIODARONE HYDROCHLORIDE TABLETS   1 Tier 1 $9.00$18.00None
AMITIZA 8MCG CAPSULE   4 Tier 4 $80.50$161.00P Q:60
/30Days
AMITIZA CAPSULES 24MCG 60 CAP BOT   4 Tier 4 $80.50$161.00P Q:60
/30Days
AMITRIP/CDP 25-10 TABLET   1 Tier 1 $9.00$18.00None
AMITRIP/PERPHEN 10-2 TABLET   1 Tier 1 $9.00$18.00None
AMITRIP/PERPHEN 10-4 TABLET   1 Tier 1 $9.00$18.00None
AMITRIP/PERPHEN 25-2 TABLET   1 Tier 1 $9.00$18.00None
AMITRIP/PERPHEN 25-4 TABLET   1 Tier 1 $9.00$18.00None
AMITRIP/PERPHEN 50-4 TABLET   1 Tier 1 $9.00$18.00None
AMITRIPTYLINE HCL 100MG TABLET   1 Tier 1 $9.00$18.00None
AMITRIPTYLINE HCL 10MG TABLET   1 Tier 1 $9.00$18.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITRIPTYLINE HCL 150 MG TAB   1 Tier 1 $9.00$18.00None
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)   1 Tier 1 $9.00$18.00None
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)   1 Tier 1 $9.00$18.00None
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT   1 Tier 1 $9.00$18.00None
AMLODIPINE 10 MG / HYDROCHLOROTHIAZIDE 12.5 MG / VALSARTAN 160 MG ORAL TABLET [EXFORGE HCT 10/160/12   3 Tier 3 $45.00$90.00S Q:30
/30Days
AMLODIPINE 10 MG / HYDROCHLOROTHIAZIDE 25 MG / VALSARTAN 160 MG ORAL TABLET [EXFORGE HCT 10/160/25]   3 Tier 3 $45.00$90.00S Q:30
/30Days
AMLODIPINE 10 MG / HYDROCHLOROTHIAZIDE 25 MG / VALSARTAN 320 MG ORAL TABLET [EXFORGE HCT 10/320/25]   3 Tier 3 $45.00$90.00S Q:30
/30Days
AMLODIPINE 5 MG / HYDROCHLOROTHIAZIDE 12.5 MG / VALSARTAN 160 MG ORAL TABLET [EXFORGE HCT 5/160/12.5   3 Tier 3 $45.00$90.00S Q:30
/30Days
AMLODIPINE 5 MG / HYDROCHLOROTHIAZIDE 25 MG / VALSARTAN 160 MG ORAL TABLET [EXFORGE HCT 5/160/25]   3 Tier 3 $45.00$90.00S Q:30
/30Days
AMLODIPINE BESYLATE 10MG TABLET (90 CT)   1 Tier 1 $9.00$18.00None
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)   1 Tier 1 $9.00$18.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE BESYLATE 5MG TABLET (90 CT)   1 Tier 1 $9.00$18.00None
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE CAPSULES   2 Tier 2 $20.00$40.00Q:30
/30Days
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE CAPSULES   2 Tier 2 $20.00$40.00Q:60
/30Days
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE   1 Tier 1 $9.00$18.00Q:30
/30Days
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE   1 Tier 1 $9.00$18.00Q:30
/30Days
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE   1 Tier 1 $9.00$18.00Q:30
/30Days
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE   1 Tier 1 $9.00$18.00Q:30
/30Days
AMMONIUM LACTATE 12% CREAM   1 Tier 1 $9.00$18.00None
AMMONIUM LACTATE 12% LOTION   1 Tier 1 $9.00$18.00None
AMNESTEEM 10MG CAPSULE   2 Tier 2 $20.00$40.00None
AMNESTEEM 20MG CAPSULE   2 Tier 2 $20.00$40.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMNESTEEM 40MG CAPSULE   2 Tier 2 $20.00$40.00None
AMOX TR-K CLV 500-125 MG TAB   1 Tier 1 $9.00$18.00None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL   1 Tier 1 $9.00$18.00None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE   1 Tier 1 $9.00$18.00None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET   1 Tier 1 $9.00$18.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE   1 Tier 1 $9.00$18.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   1 Tier 1 $9.00$18.00None
AMOXAPINE 100MG TABLET   1 Tier 1 $9.00$18.00None
AMOXAPINE 150MG TABLET   1 Tier 1 $9.00$18.00None
AMOXAPINE 25MG TABLET   1 Tier 1 $9.00$18.00None
AMOXAPINE 50MG TABLET   1 Tier 1 $9.00$18.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN 125MG TABLET CHEW   1 Tier 1 $9.00$18.00None
AMOXICILLIN 200MG TABLET CHEW   1 Tier 1 $9.00$18.00None
AMOXICILLIN 250MG CAPSULE   1 Tier 1 $9.00$18.00None
AMOXICILLIN 400MG TABLET CHEW   1 Tier 1 $9.00$18.00None
AMOXICILLIN 50 MG/ML / CLAVULANATE 12.5 MG/ML ORAL SUSPENSION   1 Tier 1 $9.00$18.00None
AMOXICILLIN 500MG CAPSULE   1 Tier 1 $9.00$18.00None
AMOXICILLIN 500MG TABLET (100 CT)   1 Tier 1 $9.00$18.00None
AMOXICILLIN 875MG TABLET   1 Tier 1 $9.00$18.00None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT   1 Tier 1 $9.00$18.00None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS EXTENDED RELEASE 1000;62.5MG;MG   1 Tier 1 $9.00$18.00None
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT   1 Tier 1 $9.00$18.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT   1 Tier 1 $9.00$18.00None
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL   1 Tier 1 $9.00$18.00None
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   1 Tier 1 $9.00$18.00None
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL   1 Tier 1 $9.00$18.00None
AMOXICILLIN TABLET USP CHEWABLE 250MG (250 CT)   1 Tier 1 $9.00$18.00None
AMPHETAMINE SALT COMBO 12.5MG TABLET   1 Tier 1 $9.00$18.00None
AMPHETAMINE SALT COMBO 15MG TABLET   1 Tier 1 $9.00$18.00None
AMPHETAMINE SALT COMBO 30MG TABLET   1 Tier 1 $9.00$18.00None
AMPHETAMINE SALT COMBO 7.5MG TABLET   1 Tier 1 $9.00$18.00None
AMPHETAMINE SALTS 20MG TABLET   1 Tier 1 $9.00$18.00None
AMPHETAMINE SALTS 5 MG TAB   1 Tier 1 $9.00$18.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPHOTEC FOR INJECTION 50MG/VIAL   5 Tier 5 33%33%P
AMPHOTERICIN B FOR INJECTION 50 MG   5 Tier 5 33%33%P
AMPICILLIN AND SULBACTAM FOR INJECTION 10-5 1 VIAL   5 Tier 5 33%33%P
AMPICILLIN AND SULBACTAM FOR INJECTION 2-1 10 VIAL   5 Tier 5 33%33%P
AMPICILLIN CAPSULES 250MG 100 BOT   1 Tier 1 $9.00$18.00None
AMPICILLIN CAPSULES 500MG 100 BOT   1 Tier 1 $9.00$18.00None
AMPICILLIN FOR INJECTION POWDER   5 Tier 5 33%33%P
AMPICILLIN FOR INJECTION USP 125MG/ML 1 VIAL   5 Tier 5 33%33%P
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT   1 Tier 1 $9.00$18.00None
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT   1 Tier 1 $9.00$18.00None
AMPICILLIN POWDER FOR INJECTION 1 GM/ML   5 Tier 5 33%33%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPYRA ER 10 MG TABLET   6 Tier 6 33%33%P Q:60
/30Days
AMYLASES 109000 UNT / ENDOPEPTIDASES 68000 UNT / LIPASE 20000 UNT ENTERIC COATED CAPSULE [ZENPEP 20]   3 Tier 3 $45.00$90.00None
AMYLASES 27000 UNT / ENDOPEPTIDASES 17000 UNT / LIPASE 5000 UNT ENTERIC COATED CAPSULE [ZENPEP 5]   3 Tier 3 $45.00$90.00None
AMYLASES 55000 UNT / ENDOPEPTIDASES 34000 UNT / LIPASE 10000 UNT ENTERIC COATED CAPSULE [ZENPEP 10]   3 Tier 3 $45.00$90.00None
AMYLASES 82000 UNT / ENDOPEPTIDASES 51000 UNT / LIPASE 15000 UNT ENTERIC COATED CAPSULE [ZENPEP 15]   3 Tier 3 $45.00$90.00None
ANADROL-50 50MG TABLET (100 CT)   4 Tier 4 $80.50$161.00None
ANAGRELIDE HCL 0.5MG CAPSULE   1 Tier 1 $9.00$18.00None
ANAGRELIDE HCL 1MG CAPSULE   1 Tier 1 $9.00$18.00None
ANASTROZOLE TABLETS   1 Tier 1 $9.00$18.00None
ANCOBON 250MG CAPSULE   3 Tier 3 $45.00$90.00P
ANCOBON 500MG CAPSULE   3 Tier 3 $45.00$90.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANDRODERM 2.5MG/24HR PATCH   4 Tier 4 $80.50$161.00Q:60
/30Days
ANDRODERM 5MG/24HR PATCH   4 Tier 4 $80.50$161.00Q:60
/30Days
ANDROGEL 1%(50MG) GEL PACKET   3 Tier 3 $45.00$90.00Q:300
/30Days
ANDROID 10MG CAPSULE   4 Tier 4 $80.50$161.00None
ANTABUSE 250MG TABLET   3 Tier 3 $45.00$90.00None
ANTABUSE 500MG TABLET   3 Tier 3 $45.00$90.00None
ANTARA CAPSULES   4 Tier 4 $80.50$161.00None
ANTARA CAPSULES   4 Tier 4 $80.50$161.00None
ANTIVERT 50MG TABLET   4 Tier 4 $80.50$161.00None
ANUSOL-HC 2.5% CREAM   4 Tier 4 $80.50$161.00None
ANZEMET 100MG TABLET   3 Tier 3 $45.00$90.00P Q:1
/5Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANZEMET 20MG/ML VIAL   5 Tier 5 33%33%P
ANZEMET 50MG TABLET   3 Tier 3 $45.00$90.00P Q:1
/5Days
APHTHASOL 5% PASTE   4 Tier 4 $80.50$161.00None
APIDRA 100UNITS/ML VIAL   4 Tier 4 $80.50$161.00None
APOKYN 30 MG/3 ML CARTRIDGE   5 Tier 5 33%33%P
APRACLONIDINE 5 MG/ML OPHTHALMIC SOLUTION   2 Tier 2 $20.00$40.00None
APRI 0.15-0.03 TABLET   1 Tier 1 $9.00$18.00None
APTIVUS 250MG CAPSULE   3 Tier 3 $45.00$90.00None
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT   3 Tier 3 $45.00$90.00None
ARANELLE 7-9-5 TABLET   1 Tier 1 $9.00$18.00None
ARANESP 100MCG/ML VIAL   6 Tier 6 33%33%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP 200MCG/0.4ML SYRINGE   6 Tier 6 33%33%P
ARANESP 200MCG/ML VIAL   6 Tier 6 33%33%P
ARANESP 25MCG/ML VIAL   5 Tier 5 33%33%P
ARANESP 300MCG/ML VIAL   6 Tier 6 33%33%P
ARANESP 500MCG/1ML SYRINGE   6 Tier 6 33%33%P
ARANESP 60MCG/ML VIAL   6 Tier 6 33%33%P
ARANESP PREFILLED SYRINGE SINGLE USE 100MCG/0.5ML 1 SYR   6 Tier 6 33%33%P
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR   6 Tier 6 33%33%P
ARANESP PREFILLED SYRINGE SINGLE USE 25MCG/0.42ML SYR   5 Tier 5 33%33%P
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR   6 Tier 6 33%33%P
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR   5 Tier 5 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 60MCG/0.3ML 60MCG/ 0.3ML SYR   6 Tier 6 33%33%P
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD   5 Tier 5 33%33%P
ARCALYST INJECTION 220MG/VIAL   6 Tier 6 33%33%P
ARICEPT 10MG TABLET   3 Tier 3 $45.00$90.00None
ARICEPT 5MG TABLET   3 Tier 3 $45.00$90.00None
ARICEPT ODT 10MG TABLET   3 Tier 3 $45.00$90.00None
ARICEPT ODT 5MG TABLET   3 Tier 3 $45.00$90.00None
ARICEPT TABLETS   3 Tier 3 $45.00$90.00S
ARIMIDEX 1MG TABLET   3 Tier 3 $45.00$90.00None
ARIXTRA 10MG SYRINGE   6 Tier 6 33%33%Q:24
/30Days
ARIXTRA 2.5MG SYRINGE   5 Tier 5 33%33%Q:15
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARIXTRA 5MG SYRINGE   6 Tier 6 33%33%Q:12
/30Days
ARIXTRA 7.5MG SYRINGE   6 Tier 6 33%33%Q:18
/30Days
ARMODAFINIL 150 MG ORAL TABLET [NUVIGIL]   3 Tier 3 $45.00$90.00P Q:30
/30Days
ARMODAFINIL 250 MG ORAL TABLET [NUVIGIL]   3 Tier 3 $45.00$90.00P Q:30
/30Days
ARMODAFINIL 50 MG ORAL TABLET [NUVIGIL]   3 Tier 3 $45.00$90.00P Q:60
/30Days
AROMASIN 25MG TABLET   3 Tier 3 $45.00$90.00S
ARRANON 250MG VIAL   6 Tier 6 33%33%P
ARTHROTEC 50 50MG TABLET -200MCG (60 CT)   4 Tier 4 $80.50$161.00None
ARTHROTEC 75 TABLET EC   4 Tier 4 $80.50$161.00None
ARZERRA INJECTION 100MG/5ML   6 Tier 6 33%33%P
ASACOL 400MG TABLET EC   3 Tier 3 $45.00$90.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ASACOL HD DELAYED RELEASE TABLETS 800MG 180 BOT   3 Tier 3 $45.00$90.00None
ASCOMP W/CODEINE 30-50-325 CAPSULE   2 Tier 2 $20.00$40.00None
ASENAPINE 10 MG SUBLINGUAL TABLET [SAPHRIS]   4 Tier 4 $80.50$161.00Q:60
/30Days
ASENAPINE 5 MG SUBLINGUAL TABLET [SAPHRIS]   4 Tier 4 $80.50$161.00Q:60
/30Days
ASMANEX 220MCG(14) AEROSOL POWDER BREATH ACTIVATED   3 Tier 3 $45.00$90.00None
ASMANEX TWISTHALER 110 MCG #30   3 Tier 3 $45.00$90.00None
ASMANEX TWISTHALER 220MCG #120   3 Tier 3 $45.00$90.00None
ASMANEX TWISTHALER 220MCG #30   3 Tier 3 $45.00$90.00None
ASMANEX TWISTHALER 220MCG #60   3 Tier 3 $45.00$90.00None
ASTEPRO 0.15% NASAL SPRAY 30 ML   3 Tier 3 $45.00$90.00Q:30
/30Days
ASTRAMORPH PF INJECTION   5 Tier 5 33%33%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ASTRAMORPH PF INJECTION 1MG/ML   5 Tier 5 33%33%P
ATACAND 16MG TABLET   4 Tier 4 $80.50$161.00S Q:30
/30Days
ATACAND 32MG TABLET   4 Tier 4 $80.50$161.00S Q:30
/30Days
ATACAND 4MG TABLET   4 Tier 4 $80.50$161.00S Q:30
/30Days
ATACAND 8MG TABLET   4 Tier 4 $80.50$161.00S Q:30
/30Days
ATACAND HCT 16/12.5MG TABLET   4 Tier 4 $80.50$161.00S Q:30
/30Days
ATACAND HCT 32/12.5MG TABLET   4 Tier 4 $80.50$161.00S Q:30
/30Days
ATACAND HCT TABLETS 32;25MG;MG 90 TABLETS BOT   4 Tier 4 $80.50$161.00S Q:30
/30Days
ATAMET   1 Tier 1 $9.00$18.00None
ATENOLOL 25MG TABLET (100 CT)   1 Tier 1 $9.00$18.00None
ATENOLOL TABLET USP 50MG (100 CT)   1 Tier 1 $9.00$18.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATENOLOL TABLETS USP 100MG 1 BLPK   1 Tier 1 $9.00$18.00None
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT)   1 Tier 1 $9.00$18.00None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   1 Tier 1 $9.00$18.00None
ATGAM 50MG/ML AMPUL   6 Tier 6 33%33%P
ATRIPLA TABLET 600MG/200MG   6 Tier 6 33%33%None
ATROPINE 0.025 MG / DIPHENOXYLATE 2.5 MG ORAL TABLET   1 Tier 1 $9.00$18.00None
ATROPINE 0.05MG/ML SYRINGE   5 Tier 5 33%33%P
ATROPINE 0.1MG/ML SYRINGE   5 Tier 5 33%33%P
ATROVENT HFA AER 17MCG   3 Tier 3 $45.00$90.00Q:52
/30Days
ATTENUVAX VACCINE W/DILUENT 1 DOSE/0.5ML   5 Tier 5 33%33%P
AVALIDE 150-12.5MG TABLET   3 Tier 3 $45.00$90.00S Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVALIDE 300-12.5MG TABLET   3 Tier 3 $45.00$90.00S Q:30
/30Days
AVALIDE 300-25MG TABLET   3 Tier 3 $45.00$90.00S Q:30
/30Days
AVANDAMET 2MG/1000MG TABLET   3 Tier 3 $45.00$90.00S
AVANDAMET 2MG/500MG TABLET   3 Tier 3 $45.00$90.00S
AVANDAMET 4MG/500MG TABLET   3 Tier 3 $45.00$90.00S
AVANDAMET TABLET 4-1000MG   3 Tier 3 $45.00$90.00S
AVANDARYL 4MG/1MG TABLET   4 Tier 4 $80.50$161.00S
AVANDARYL 4MG/2MG TABLET   4 Tier 4 $80.50$161.00S
AVANDARYL 4MG/4MG TABLET   4 Tier 4 $80.50$161.00S
AVANDARYL 8MG-2MG TABLET   4 Tier 4 $80.50$161.00S
AVANDARYL 8MG-4MG TABLET   4 Tier 4 $80.50$161.00S
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVANDIA 2MG TABLET   3 Tier 3 $45.00$90.00S
AVANDIA 4MG TABLET (90 CT)   3 Tier 3 $45.00$90.00S
AVANDIA 8MG TABLET (90 CT)   3 Tier 3 $45.00$90.00S
AVAPRO 150MG TABLET   3 Tier 3 $45.00$90.00S Q:30
/30Days
AVAPRO 300MG TABLET   3 Tier 3 $45.00$90.00S Q:30
/30Days
AVAPRO 75MG TABLET (30 CT)   3 Tier 3 $45.00$90.00S Q:30
/30Days
AVASTIN 100MG/4ML VIAL   6 Tier 6 33%33%P
AVELOX 400MG TABLET   3 Tier 3 $45.00$90.00Q:10
/10Days
AVELOX ABC PACK 400MG TABLET   3 Tier 3 $45.00$90.00Q:10
/10Days
AVELOX IV 400MG/250ML   5 Tier 5 33%33%P
AVIANE 0.1-0.02 TABLET   1 Tier 1 $9.00$18.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVINZA 120MG CAPSULE MULTIPHASIC RELEASE 24 HR   4 Tier 4 $80.50$161.00Q:13
/1Days
AVINZA 30MG CAPSULE MULTIPHASIC RELEASE 24 HR   4 Tier 4 $80.50$161.00Q:30
/30Days
AVINZA 60MG CAPSULE MULTIPHASIC RELEASE 24 HR   4 Tier 4 $80.50$161.00Q:30
/30Days
AVINZA 90MG CAPSULE MULTIPHASIC RELEASE 24 HR   4 Tier 4 $80.50$161.00Q:90
/30Days
AVINZA CAPSULES EXTENDED RELEASE 45MG 100 BOTPL   4 Tier 4 $80.50$161.00Q:30
/30Days
AVINZA CAPSULES EXTENDED RELEASE 75MG 100 BOTPL   4 Tier 4 $80.50$161.00Q:30
/30Days
AVODART 0.5MG SOFTGEL   4 Tier 4 $80.50$161.00S Q:30
/30Days
AVONEX ADMIN PACK 30MCG SYR   6 Tier 6 33%33%P Q:4
/28Days
AVONEX ADMIN PACK 30MCG VL   6 Tier 6 33%33%P Q:4
/28Days
AXERT 12.5MG TABLET   4 Tier 4 $80.50$161.00Q:24
/30Days
AXERT 6.25MG TABLET   4 Tier 4 $80.50$161.00Q:24
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZACTAM INJECTION   5 Tier 5 33%33%P
AZACTAM INJECTION 1GM/50ML   5 Tier 5 33%33%P
AZACTAM INJECTION 2GM/VIL   5 Tier 5 33%33%P
AZASAN 100MG TABLET   4 Tier 4 $80.50$161.00P
AZASAN 75MG TABLET   4 Tier 4 $80.50$161.00P
AZATHIOPRINE 50MG TABLET   1 Tier 1 $9.00$18.00P
AZATHIOPRINE SOD 100MG VIAL   5 Tier 5 33%33%P
AZELASTINE 137 MCG NASAL SPRAY   2 Tier 2 $20.00$40.00Q:30
/30Days
AZELASTINE HYDROCHLORIDE OPHTHALMIC SOLUTION   2 Tier 2 $20.00$40.00None
AZELEX 20% CREAM 30GM TUBE   4 Tier 4 $80.50$161.00None
AZILECT 0.5MG TABLET   3 Tier 3 $45.00$90.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZILECT 1MG TABLET   3 Tier 3 $45.00$90.00None
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Tier 1 $9.00$18.00None
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Tier 1 $9.00$18.00None
AZITHROMYCIN 250 MG TABLET   1 Tier 1 $9.00$18.00Q:6
/5Days
AZITHROMYCIN 33.3 MG/ML ER SUSPENSION [ZMAX]   4 Tier 4 $80.50$161.00Q:60
/30Days
AZITHROMYCIN 500MG TABLET (30 CT)   1 Tier 1 $9.00$18.00Q:3
/3Days
AZITHROMYCIN FOR INJECTION 500MG 10 VIALSD   5 Tier 5 33%33%P
AZITHROMYCIN TABLETS   1 Tier 1 $9.00$18.00Q:8
/30Days
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT   3 Tier 3 $45.00$90.00None
AZTREONAM FOR INJECTION   5 Tier 5 33%33%P

Chart Legend:

Below are a few notes to help you understand the above 2011 Medicare Part D Blue Shield Medicare Rx Plan (PDP) Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region).

  • Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.

  • Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $310 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.

  • Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
    • Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.

    • No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.

  • Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
  • Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
    • Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
    • Drug Description - This is the Medicare Part D plan’s description of this particular drug tier.
  • Cost Sharing - Copay / Coinsurance - These figures apply to the initial coverage phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
    • Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $(2840)) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, on the 2011 Humana Walmart-Preferred Rx Plan the pricing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
    • Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
  • Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
    • None - This drug does not fall under any drug utilization management controls.
    • P - Prior Authorization -This drug is subject to prior authorization.
    • S - Step Therapy -This drug is subject to step therapy.
    • Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.




(Chart Source: Centers for Medicare and Medicaid files: CMS Data October 2011 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Part D plan provider.