Q1Medicare.com 2011 Medicare Part D or Medicare Advantage Plan Formulary Browser

2011 Medicare Part D Plan Formulary Information
CVS Caremark Value (PDP) (S5601-022-0) Benefit Details
The CVS Caremark Value (PDP) (S5601-022-0) Formulary Drugs Starting with the Letter P in CMS PDP Region 11 which includes: FL
Drugs Starting with Letter P Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter P Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PACERONE 100MG TABLET	2	Preferred Brand Drugs	$42.00	$94.50	None
PACERONE 200MG TABLET	1	Generic Drugs	$5.00	$7.50	None
PACLITAXEL INJECTION SOLUTION 6MG 50ML VIALMD	1	Generic Drugs	$5.00	$7.50	P
PALIPERIDONE PALMITATE 156 MG/ML PREFILLED SYRINGE [INVEGA]	3	Non-Preferred Generic and Non-Preferred Brand Drugs	$95.00	$261.25	P
PALIPERIDONE PALMITATE 156 MG/ML PREFILLED SYRINGE [INVEGA]	4	Specialty Tier Drugs	25%	N/A	P
PALIPERIDONE PALMITATE 156 MG/ML PREFILLED SYRINGE [INVEGA]	3	Non-Preferred Generic and Non-Preferred Brand Drugs	$95.00	$261.25	P
PALIPERIDONE PALMITATE 156 MG/ML PREFILLED SYRINGE [INVEGA]	4	Specialty Tier Drugs	25%	N/A	P
PALIPERIDONE PALMITATE 156 MG/ML PREFILLED SYRINGE [INVEGA]	4	Specialty Tier Drugs	25%	N/A	P
PANCREAZE 10,500 UNIT CAP DR	2	Preferred Brand Drugs	$42.00	$94.50	None
PANCREAZE 16,800 UNIT CAP DR	2	Preferred Brand Drugs	$42.00	$94.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PANCREAZE 21,000 UNIT CAP DR	2	Preferred Brand Drugs	$42.00	$94.50	None
PANCREAZE 4,200 UNIT CAP DR	2	Preferred Brand Drugs	$42.00	$94.50	None
PANRETIN 0.1% GEL 60GM TUBE	4	Specialty Tier Drugs	25%	N/A	None
PAROMOMYCIN 250MG CAPSULE	1	Generic Drugs	$5.00	$7.50	None
PAROXETINE 40MG TABLET (500 CT)	1	Generic Drugs	$5.00	$7.50	None
PAROXETINE FILM COATED 20MG TABLET (100 CT)	1	Generic Drugs	$5.00	$7.50	Q:45 /30Days
PAROXETINE HCL 10MG/5ML SUSPENSION ORAL	1	Generic Drugs	$5.00	$7.50	None
PAROXETINE HCL TABLET 24 12.5MG	1	Generic Drugs	$5.00	$7.50	Q:30 /30Days
PAROXETINE HCL TABLET 24 25MG	1	Generic Drugs	$5.00	$7.50	None
PAROXETINE TABLETS	1	Generic Drugs	$5.00	$7.50	Q:45 /30Days
PAROXETINE TABLETS 30MG 90 BOT	1	Generic Drugs	$5.00	$7.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PASER GRANULES 4GM PACKET	3	Non-Preferred Generic and Non-Preferred Brand Drugs	$95.00	$261.25	None
PATADAY 0.2% DROPS	2	Preferred Brand Drugs	$42.00	$94.50	None
PATANOL 0.1% EYE DROPS	2	Preferred Brand Drugs	$42.00	$94.50	None
PAZOPANIB 200 MG ORAL TABLET [VOTRIENT]	4	Specialty Tier Drugs	25%	N/A	P
PEDI-DRI TOPICAL POWDER	1	Generic Drugs	$5.00	$7.50	None
PEDIARIX SOLUTION INJECTION 25-25-10 10 X .5ML VIAL	2	Preferred Brand Drugs	$42.00	$94.50	P
PEDVAXHIB VACCINE VIAL	2	Preferred Brand Drugs	$42.00	$94.50	None
PEG-INTRON 100MCG KIT	4	Specialty Tier Drugs	25%	N/A	P
PEG-INTRON REDIPEN 120MCG	4	Specialty Tier Drugs	25%	N/A	P
PEG-INTRON REDIPEN 150MCG	4	Specialty Tier Drugs	25%	N/A	P
PEG-INTRON REDIPEN 50MCG	4	Specialty Tier Drugs	25%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PEG-INTRON REDIPEN 80MCG	4	Specialty Tier Drugs	25%	N/A	P
PEGANONE 250MG TABLET	2	Preferred Brand Drugs	$42.00	$94.50	None
PEGASYS 180MCG/0.5ML CONV.PK	4	Specialty Tier Drugs	25%	N/A	P
PEGASYS INJECTION	4	Specialty Tier Drugs	25%	N/A	P
PENICILLIN G POTASSIUM FOR INJECTION	1	Generic Drugs	$5.00	$7.50	P
PENICILLIN G POTASSIUM FOR INJECTION 5000000UNIT/VIAL	1	Generic Drugs	$5.00	$7.50	P
PENICILLIN G PROCAINE 1200000UNT 2ML CTG	2	Preferred Brand Drugs	$42.00	$94.50	None
PENICILLIN V POTASSIUM 250MG TABLET (1000 CT)	1	Generic Drugs	$5.00	$7.50	None
PENICILLIN V POTASSIUM 250MG/5ML LIQUID	1	Generic Drugs	$5.00	$7.50	None
PENICILLIN V POTASSIUM 500MG TABLET	1	Generic Drugs	$5.00	$7.50	None
PENICILLIN V POTASSIUM FOR ORAL SOLUTION CONCENTRATE 125MG 200ML BOT	1	Generic Drugs	$5.00	$7.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PENTASA 250MG CAPSULE SA	2	Preferred Brand Drugs	$42.00	$94.50	None
PENTASA 500MG CAPSULE	2	Preferred Brand Drugs	$42.00	$94.50	None
PENTOPAK 400MG TABLET SA	1	Generic Drugs	$5.00	$7.50	None
PENTOSTATIN FOR INJECTION 10MG/VIAL	1	Generic Drugs	$5.00	$7.50	P
PENTOXIFYLLINE 400MG TABLET SA	1	Generic Drugs	$5.00	$7.50	None
PEPCID SOLUTION 40MG 24 X 400MG BOT	2	Preferred Brand Drugs	$42.00	$94.50	None
PERINDOPRIL ERBUMINE 2 MG ORAL TABLET	1	Generic Drugs	$5.00	$7.50	None
PERINDOPRIL ERBUMINE 4 MG ORAL TABLET	1	Generic Drugs	$5.00	$7.50	None
PERINDOPRIL ERBUMINE 8 MG ORAL TABLET	1	Generic Drugs	$5.00	$7.50	None
PERIOGARD 0.12% ORAL RINSE	1	Generic Drugs	$5.00	$7.50	None
PERMETHRIN 5% CREAM	1	Generic Drugs	$5.00	$7.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PERPHENAZINE TABLETS 16MG 100 BOT	1	Generic Drugs	$5.00	$7.50	None
PERPHENAZINE TABLETS 4MG 100 BOXUD	1	Generic Drugs	$5.00	$7.50	None
PERPHENAZINE TABLETS 8MG 100 BOT	1	Generic Drugs	$5.00	$7.50	None
PERPHENAZINE TABLETS USP 2MG 100 BOT	1	Generic Drugs	$5.00	$7.50	None
PHENADOZ 12.5MG SUPPOSITORY	1	Generic Drugs	$5.00	$7.50	None
PHENADOZ 25MG SUPPOSITORY	1	Generic Drugs	$5.00	$7.50	None
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT	1	Generic Drugs	$5.00	$7.50	None
PHENYTOIN SODIUM EXTENDED CAPSULES 100MG (100 CT)	1	Generic Drugs	$5.00	$7.50	None
PHENYTOIN SODIUM INJECTION 50MG 25 X 2ML AMP	1	Generic Drugs	$5.00	$7.50	None
PHOSLO 667MG CAPSULE	2	Preferred Brand Drugs	$42.00	$94.50	None
PHOTOFRIN 75MG VIAL	2	Preferred Brand Drugs	$42.00	$94.50	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PILOCARPINE HCL 5MG TABLET (100 CT)	1	Generic Drugs	$5.00	$7.50	None
PILOCARPINE HCL 7.5MG TABLET	1	Generic Drugs	$5.00	$7.50	None
PILOPINE HS 4% EYE GEL	2	Preferred Brand Drugs	$42.00	$94.50	None
PINDOLOL 10MG TABLET	1	Generic Drugs	$5.00	$7.50	None
PINDOLOL 5MG TABLET	1	Generic Drugs	$5.00	$7.50	None
PIPERACILLIN 200 MG/ML / TAZOBACTAM 25 MG/ML INJECTABLE SOLUTION	1	Generic Drugs	$5.00	$7.50	P
PIROXICAM 10 MG CAPSULE	1	Generic Drugs	$5.00	$7.50	None
PIROXICAM 20MG CAPSULE (500 CT)	1	Generic Drugs	$5.00	$7.50	None
PLASMA-LYTE 148 IV SOLUTION	2	Preferred Brand Drugs	$42.00	$94.50	None
PLASMA-LYTE 148/DEXTROSE 5%	2	Preferred Brand Drugs	$42.00	$94.50	None
PLASMA-LYTE 56 INJECTION 32;128 MG/100ML;	2	Preferred Brand Drugs	$42.00	$94.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PLASMA-LYTE 56/DEXTROSE 5%	2	Preferred Brand Drugs	$42.00	$94.50	None
PLASMA-LYTE A PH 7.4 SOLUTION 37;368; MG/100ML;	2	Preferred Brand Drugs	$42.00	$94.50	None
PLASMA-LYTE INJ-R	1	Generic Drugs	$5.00	$7.50	None
PLAVIX 75MG TABLET	2	Preferred Brand Drugs	$42.00	$94.50	None
PLAVIX TABLETS 300MG	2	Preferred Brand Drugs	$42.00	$94.50	Q:1 /30Days
PODOFILOX 0.5% TOPICAL TUBEX	1	Generic Drugs	$5.00	$7.50	None
POLY-DEX 0.1% SUSPENSION DROPS	1	Generic Drugs	$5.00	$7.50	None
POLY-DEX 3.5-10K-.1 OINTMENT	1	Generic Drugs	$5.00	$7.50	None
POLYCIN-B 500-10KU/G OINTMENT	1	Generic Drugs	$5.00	$7.50	None
POLYETH GLYC NF POWDER FOR ORAL SOLUTION 17GM (527 CT)	1	Generic Drugs	$5.00	$7.50	None
POLYETHYLENE GLYCOL 3350 105 MG/ML / POTASSIUM CHLORIDE 0.00497 MEQ/ML / SODIUM BICARBONATE 1.43 MG/	1	Generic Drugs	$5.00	$7.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
POLYETHYLENE GLYCOL 3350 105 MG/ML / POTASSIUM CHLORIDE 0.005 MEQ/ML / SODIUM BICARBONATE 0.017 MEQ/	1	Generic Drugs	$5.00	$7.50	None
POLYETHYLENE GLYCOL 3350 59 MG/ML / POTASSIUM CHLORIDE 0.1 MEQ/ML / SODIUM BICARBONATE 0.02 MEQ/ML /	1	Generic Drugs	$5.00	$7.50	None
POLYETHYLENE GLYCOL 3350 60 MG/ML / POTASSIUM CHLORIDE 0.01 MEQ/ML / SODIUM BICARBONATE 0.02 MEQ/ML	1	Generic Drugs	$5.00	$7.50	None
POLYMYXIN B SUL-TRIMETHOPRIM 10K U-0.1%	1	Generic Drugs	$5.00	$7.50	None
PORTIA 0.15-0.03 TABLET	1	Generic Drugs	$5.00	$7.50	None
POTASSIUM CHLORIDE 0.075%/D5W/SODIUM CHLORIDE 0.2%	1	Generic Drugs	$5.00	$7.50	None
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.3%	1	Generic Drugs	$5.00	$7.50	None
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.45%	1	Generic Drugs	$5.00	$7.50	None
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.9% 1000ML	1	Generic Drugs	$5.00	$7.50	None
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.2%	1	Generic Drugs	$5.00	$7.50	None
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.45% 1000ML BAG	1	Generic Drugs	$5.00	$7.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
POTASSIUM CHLORIDE 10MEQ/100ML SOL	1	Generic Drugs	$5.00	$7.50	None
POTASSIUM CHLORIDE 10MEQ/50ML SOL	1	Generic Drugs	$5.00	$7.50	None
POTASSIUM CHLORIDE 20MEQ IN D5W LACT RNG	2	Preferred Brand Drugs	$42.00	$94.50	None
POTASSIUM CHLORIDE 20MEQ IN D5W/NACL 0.225%	2	Preferred Brand Drugs	$42.00	$94.50	None
POTASSIUM CHLORIDE 20MEQ/50ML SOL	1	Generic Drugs	$5.00	$7.50	None
POTASSIUM CHLORIDE 30MEQ/100ML SOL	1	Generic Drugs	$5.00	$7.50	None
POTASSIUM CHLORIDE 40MEQ IN D5W LACT RNG	1	Generic Drugs	$5.00	$7.50	None
POTASSIUM CHLORIDE 40MEQ IN D5W/NACL 0.9%	2	Preferred Brand Drugs	$42.00	$94.50	None
POTASSIUM CHLORIDE 40MEQ/NS 1000ML IV SOLUTION	2	Preferred Brand Drugs	$42.00	$94.50	None
POTASSIUM CHLORIDE 8 MEQ EXTENDED RELEASE TABLET	1	Generic Drugs	$5.00	$7.50	None
POTASSIUM CHLORIDE ER CAPSULES 10MEQ	1	Generic Drugs	$5.00	$7.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
POTASSIUM CHLORIDE ER CPCR 8MEQ	1	Generic Drugs	$5.00	$7.50	None
POTASSIUM CHLORIDE EXTENDED RELEASE TABLETS	1	Generic Drugs	$5.00	$7.50	None
POTASSIUM CHLORIDE FOR INJECTION CONCENTRATE	1	Generic Drugs	$5.00	$7.50	None
POTASSIUM CHLORIDE IN 10% DEXTROSE AND NACL SOLUTION FOR INJECTION	2	Preferred Brand Drugs	$42.00	$94.50	None
POTASSIUM CHLORIDE IN 5% DEXTROSE AND 0.2% NACL SOLUTION FOR INJECTION USP 0.15% 250ML X 24 CASE	1	Generic Drugs	$5.00	$7.50	None
POTASSIUM CHLORIDE IN 5% DEXTROSE AND NACL SOLUTION FOR INJECTION 0.075% 1000ML PLASTIC BAGS X 12 CA	1	Generic Drugs	$5.00	$7.50	None
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION	1	Generic Drugs	$5.00	$7.50	None
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION	1	Generic Drugs	$5.00	$7.50	None
POTASSIUM CHLORIDE IN 5% DEXTROSE INJECTION 40 12 X 1000ML CTR	1	Generic Drugs	$5.00	$7.50	None
POTASSIUM CHLORIDE IN DEXTROSE INJECTION 5GM/75MG	2	Preferred Brand Drugs	$42.00	$94.50	None
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION	2	Preferred Brand Drugs	$42.00	$94.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION 0.15%-0.9% 12 X 1000ML BAG	1	Generic Drugs	$5.00	$7.50	None
POTASSIUM CHLORIDE TABLET EXTENED RELEASE	1	Generic Drugs	$5.00	$7.50	None
POTASSIUM CITRATE 10MEQ TABLET SA	1	Generic Drugs	$5.00	$7.50	None
POTASSIUM CITRATE 5MEQ TABLET SA	1	Generic Drugs	$5.00	$7.50	None
PRAMIPEXOLE 0.125 MG TABLET	1	Generic Drugs	$5.00	$7.50	None
PRAMIPEXOLE 0.25 MG TABLET	1	Generic Drugs	$5.00	$7.50	None
PRAMIPEXOLE 0.5 MG TABLET	1	Generic Drugs	$5.00	$7.50	None
PRAMIPEXOLE 1 MG TABLET	1	Generic Drugs	$5.00	$7.50	None
PRAMIPEXOLE 1.5 MG TABLET	1	Generic Drugs	$5.00	$7.50	None
PRAMIPEXOLE DIHYDROCHLORIDE TABLETS	1	Generic Drugs	$5.00	$7.50	None
PRANDIN 0.5MG TABLET	2	Preferred Brand Drugs	$42.00	$94.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PRANDIN 1MG TABLET	2	Preferred Brand Drugs	$42.00	$94.50	None
PRANDIN 2MG TABLET	2	Preferred Brand Drugs	$42.00	$94.50	None
PRASUGREL 10 MG ORAL TABLET	2	Preferred Brand Drugs	$42.00	$94.50	None
PRASUGREL 5 MG ORAL TABLET	2	Preferred Brand Drugs	$42.00	$94.50	None
PRAVASTATIN SODIUM 20MG TABLET 500 BOT	1	Generic Drugs	$5.00	$7.50	Q:30 /30Days
PRAVASTATIN SODIUM 40MG TABLET (500 CT)	1	Generic Drugs	$5.00	$7.50	Q:30 /30Days
PRAVASTATIN SODIUM 80MG TABLET (90 CT)	1	Generic Drugs	$5.00	$7.50	None
PRAVASTATIN SODIUM TABLETS 10MG 90 BOT	1	Generic Drugs	$5.00	$7.50	Q:30 /30Days
PRAZOSIN 5MG CAPSULE	1	Generic Drugs	$5.00	$7.50	None
PRAZOSIN HCL 1MG CAPSULE	1	Generic Drugs	$5.00	$7.50	None
PRAZOSIN HCL 2MG CAPSULE	1	Generic Drugs	$5.00	$7.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION 1.0% STERILE 10ML BOTDR	1	Generic Drugs	$5.00	$7.50	None
PREDNISOLONE SOD 1% EYE DROP	2	Preferred Brand Drugs	$42.00	$94.50	None
PREDNISOLONE SODIUM PHOSPHATE 15MG/5ML SOLUTION ORAL	1	Generic Drugs	$5.00	$7.50	None
PREDNISOLONE SODIUM PHOSPHATE ORAL SOLUTION	1	Generic Drugs	$5.00	$7.50	None
PREDNISONE 10MG TABLET (100 CT)	1	Generic Drugs	$5.00	$7.50	None
PREDNISONE 1MG TABLET	1	Generic Drugs	$5.00	$7.50	None
PREDNISONE 2.5MG TABLET	1	Generic Drugs	$5.00	$7.50	None
PREDNISONE 20MG TABLET (1000 CT)	1	Generic Drugs	$5.00	$7.50	None
PREDNISONE 5 MG TABLET	1	Generic Drugs	$5.00	$7.50	None
PREDNISONE 50MG TABLET	1	Generic Drugs	$5.00	$7.50	None
PREDNISONE 5MG/5ML SOLUTION	1	Generic Drugs	$5.00	$7.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PREDNISONE 5MG/ML SOLUTION	2	Preferred Brand Drugs	$42.00	$94.50	None
PREGNYL INJ 10000UNT	1	Generic Drugs	$5.00	$7.50	P
PREMARIN 0.3MG (100 CT)	2	Preferred Brand Drugs	$42.00	$94.50	None
PREMARIN 0.45MG TABLET	2	Preferred Brand Drugs	$42.00	$94.50	None
PREMARIN 0.625MG (100 CT)	2	Preferred Brand Drugs	$42.00	$94.50	None
PREMARIN 0.9MG TABLET	2	Preferred Brand Drugs	$42.00	$94.50	None
PREMARIN 1.25MG (100 CT)	2	Preferred Brand Drugs	$42.00	$94.50	None
PREMARIN 25MG VIAL	2	Preferred Brand Drugs	$42.00	$94.50	P
PREMARIN VAGINAL CREAM /APPL	2	Preferred Brand Drugs	$42.00	$94.50	None
PREMASOL 10% IV SOLUTION	2	Preferred Brand Drugs	$42.00	$94.50	P
PREMASOL 6% IV SOLUTION	1	Generic Drugs	$5.00	$7.50	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PREMPHASE 0.625/5MG TABLET	2	Preferred Brand Drugs	$42.00	$94.50	None
PREMPRO 0.3 MG-1.5 MG TABLET #28 EA	2	Preferred Brand Drugs	$42.00	$94.50	None
PREMPRO 0.45-1.5 MG TABLET 28 EA	2	Preferred Brand Drugs	$42.00	$94.50	None
PRENATABS OBN TABLETS 200;1;150;MG;MG;MCG; 90 BOT	1	Generic Drugs	$5.00	$7.50	None
PREVALITE POW 4GM	1	Generic Drugs	$5.00	$7.50	None
PREVIFEM TABLETS .035;.25MG;MG 28 BLPK	1	Generic Drugs	$5.00	$7.50	None
PREZISTA TABLET 600MG	4	Specialty Tier Drugs	25%	N/A	None
PREZISTA TABLET 75MG	2	Preferred Brand Drugs	$42.00	$94.50	None
PREZISTA TABLETS	2	Preferred Brand Drugs	$42.00	$94.50	None
PREZISTA TABLETS 400MG 60 TABLETS BOT	4	Specialty Tier Drugs	25%	N/A	None
PRIFTIN 150MG TABLET	3	Non-Preferred Generic and Non-Preferred Brand Drugs	$95.00	$261.25	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PRIMAXIN I.M. 500MG VIAL	2	Preferred Brand Drugs	$42.00	$94.50	None
PRIMAXIN IV 250MG VIAL	2	Preferred Brand Drugs	$42.00	$94.50	P
PRIMAXIN IV INJ 500MG	2	Preferred Brand Drugs	$42.00	$94.50	P
PRIMIDONE 250MG TABLET (100 CT)	1	Generic Drugs	$5.00	$7.50	None
PRIMIDONE 50MG TABLET (500 CT)	1	Generic Drugs	$5.00	$7.50	None
PRISTIQ 100MG TABLET SR 24HR	2	Preferred Brand Drugs	$42.00	$94.50	None
PRISTIQ 50MG TABLET SR 24HR	2	Preferred Brand Drugs	$42.00	$94.50	Q:30 /30Days
PROAIR HFA 90MCG HFA AEROSOL WITH ADAPTER	2	Preferred Brand Drugs	$42.00	$94.50	Q:18 /30Days
PROBENECID 500MG TABLET	1	Generic Drugs	$5.00	$7.50	None
PROBENECID/COLCHICINE TABLET S	1	Generic Drugs	$5.00	$7.50	None
PROCALAMINE INJECTION 210MG-290MG-26MG 6 X 1000ML BOT	2	Preferred Brand Drugs	$42.00	$94.50	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PROCHLORPERAZINE EDISYLATE INJECTION 10MG 10 X 2ML VIALS CRTN	1	Generic Drugs	$5.00	$7.50	None
PROCHLORPERAZINE MALEATE 10MG TABLET (100 CT)	1	Generic Drugs	$5.00	$7.50	None
PROCHLORPERAZINE MALEATE 5MG TABLET (100 CT)	1	Generic Drugs	$5.00	$7.50	None
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX	1	Generic Drugs	$5.00	$7.50	None
PROCRIT 10000U/ML VIAL	2	Preferred Brand Drugs	$42.00	$94.50	P Q:12 /30Days
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL	2	Preferred Brand Drugs	$42.00	$94.50	P Q:12 /30Days
PROCRIT 3000U/ML VIAL	2	Preferred Brand Drugs	$42.00	$94.50	P Q:12 /30Days
PROCRIT 40000U/ML VIAL PR	4	Specialty Tier Drugs	25%	N/A	P Q:6 /30Days
PROCRIT 4000U/ML VIAL 25 X 1ML VIAL	2	Preferred Brand Drugs	$42.00	$94.50	P Q:12 /30Days
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY	4	Specialty Tier Drugs	25%	N/A	P Q:12 /30Days
PROCTO-PAK 1% CREAM	1	Generic Drugs	$5.00	$7.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PROCTOCREAM-HC 2.5% CREAM	1	Generic Drugs	$5.00	$7.50	None
PROCTOSOL-HC 2.5% CREAM	1	Generic Drugs	$5.00	$7.50	None
PROCTOZONE-HC 2.5% CREAM	1	Generic Drugs	$5.00	$7.50	None
PROGLYCEM 50MG/ML ORAL SUSP	2	Preferred Brand Drugs	$42.00	$94.50	None
PROGRAF 0.5MG CAPSULE	2	Preferred Brand Drugs	$42.00	$94.50	P
PROGRAF 1MG CAPSULE	2	Preferred Brand Drugs	$42.00	$94.50	P
PROGRAF 5MG CAPSULE	4	Specialty Tier Drugs	25%	N/A	P
PROLEUKIN 22 MILLION UNITS VL	4	Specialty Tier Drugs	25%	N/A	P
PROMACTA TABLETS	4	Specialty Tier Drugs	25%	N/A	P
PROMACTA TABLETS	4	Specialty Tier Drugs	25%	N/A	P
PROMACTA TABLETS 25 MG	4	Specialty Tier Drugs	25%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PROMETHAZINE 50MG/ML VIAL	1	Generic Drugs	$5.00	$7.50	P
PROMETHAZINE HCL 12.5MG TABLET	1	Generic Drugs	$5.00	$7.50	None
PROMETHAZINE HCL 25MG TABLET (1000 CT)	1	Generic Drugs	$5.00	$7.50	None
PROMETHAZINE HCL 50MG TABLET (100 CT)	1	Generic Drugs	$5.00	$7.50	None
PROMETHAZINE HCL 6.25MG/5ML SYRUP	1	Generic Drugs	$5.00	$7.50	None
PROMETHAZINE HCL INJECTION 25MG 10 X 1ML VIAL	1	Generic Drugs	$5.00	$7.50	P
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 12.5MG 12 BOX	1	Generic Drugs	$5.00	$7.50	None
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 25MG 12 BOX	1	Generic Drugs	$5.00	$7.50	None
PROMETHAZINE VC PLAIN 6.25-5MG 16 FL OZ BOT	1	Generic Drugs	$5.00	$7.50	None
PROMETHEGAN 25MG SUPP	1	Generic Drugs	$5.00	$7.50	None
PROMETHEGAN 50MG SUPPOS	1	Generic Drugs	$5.00	$7.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PROPAFENONE HCL 150MG TABLET (100 CT)	1	Generic Drugs	$5.00	$7.50	None
PROPAFENONE HCL 225MG TABLET	1	Generic Drugs	$5.00	$7.50	None
PROPAFENONE HCL 300MG TABLET (100 CT)	1	Generic Drugs	$5.00	$7.50	None
PROPAFENONE HYDROCHLORIDE CAPSULES EXTENDED RELEASE	1	Generic Drugs	$5.00	$7.50	None
PROPAFENONE HYDROCHLORIDE CAPSULES EXTENDED RELEASE	1	Generic Drugs	$5.00	$7.50	None
PROPAFENONE HYDROCHLORIDE CAPSULES EXTENDED RELEASE	1	Generic Drugs	$5.00	$7.50	None
PROPARACAINE 0.5% EYE DROPS	1	Generic Drugs	$5.00	$7.50	None
PROPRANOLOL 20MG/5ML TUBEX	1	Generic Drugs	$5.00	$7.50	None
PROPRANOLOL 40MG/5ML TUBEX	1	Generic Drugs	$5.00	$7.50	None
PROPRANOLOL 60MG TABLET	1	Generic Drugs	$5.00	$7.50	None
PROPRANOLOL 80 MG TABLET	1	Generic Drugs	$5.00	$7.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PROPRANOLOL HCL 20MG TABLET (1000 CT)	1	Generic Drugs	$5.00	$7.50	None
PROPRANOLOL HCL CAPSULES ER 120MG (1000 CT)	1	Generic Drugs	$5.00	$7.50	None
PROPRANOLOL HCL CAPSULES ER 160MG (1000 CT)	1	Generic Drugs	$5.00	$7.50	None
PROPRANOLOL HCL CAPSULES ER 60MG (100 CT)	1	Generic Drugs	$5.00	$7.50	None
PROPRANOLOL HCL CAPSULES ER 80MG (1000 CT)	1	Generic Drugs	$5.00	$7.50	None
PROPRANOLOL HCL INJECTION 1MG 10 PKG OF 10 CRTN	1	Generic Drugs	$5.00	$7.50	P
PROPRANOLOL HCL TABLET USP 10MG (1000 CT)	1	Generic Drugs	$5.00	$7.50	None
PROPRANOLOL HCL TABLET USP 40MG (1000 CT)	1	Generic Drugs	$5.00	$7.50	None
PROPYLTHIOURACIL 50MG TABLET	1	Generic Drugs	$5.00	$7.50	None
PROQUAD VIAL	2	Preferred Brand Drugs	$42.00	$94.50	None
PROSOL 20% INJECTION	2	Preferred Brand Drugs	$42.00	$94.50	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PROTOPIC 0.03% OINTMENT 100GM TUBE	2	Preferred Brand Drugs	$42.00	$94.50	P
PROTOPIC 0.1% OINTMENT 60GM TUBE	2	Preferred Brand Drugs	$42.00	$94.50	P
PROTRIPTYLINE HYDROCHLORIDE TABLETS	1	Generic Drugs	$5.00	$7.50	None
PROTRIPTYLINE HYDROCHLORIDE TABLETS 5MG	1	Generic Drugs	$5.00	$7.50	None
PROVIGIL 100MG TABLET	2	Preferred Brand Drugs	$42.00	$94.50	P Q:90 /30Days
PROVIGIL 200MG TABLET	2	Preferred Brand Drugs	$42.00	$94.50	P Q:60 /30Days
PULMOZYME 1MG/ML AMPUL	4	Specialty Tier Drugs	25%	N/A	P
PYRAZINAMIDE 500MG TABLET	1	Generic Drugs	$5.00	$7.50	None
PYRIDOSTIGMINE BROMIDE 60MG TABLET	1	Generic Drugs	$5.00	$7.50	None

Chart Legend:

Below are a few notes to help you understand the above 2011 Medicare Part D CVS Caremark Value (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.