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

2011 Medicare Part D Plan Formulary Information
First Health Part D Premier Plus (PDP) (S5674-035-0) Benefit Details
The First Health Part D Premier Plus (PDP) (S5674-035-0) Formulary Drugs Starting with the Letter P in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY
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	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	None
PACERONE 200MG TABLET	1	Preferred Generic	$0.00	$0.00	None
PACLITAXEL INJECTION SOLUTION 6MG 50ML VIALMD	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	P
PALGIC 4MG/5ML LIQUID	1	Preferred Generic	$0.00	$0.00	None
PALIPERIDONE PALMITATE 156 MG/ML PREFILLED SYRINGE [INVEGA]	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	Q:2 /28Days
PALIPERIDONE PALMITATE 156 MG/ML PREFILLED SYRINGE [INVEGA]	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	Q:1 /28Days
PALIPERIDONE PALMITATE 156 MG/ML PREFILLED SYRINGE [INVEGA]	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	Q:1 /28Days
PALIPERIDONE PALMITATE 156 MG/ML PREFILLED SYRINGE [INVEGA]	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	Q:1 /28Days
PALIPERIDONE PALMITATE 156 MG/ML PREFILLED SYRINGE [INVEGA]	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	None
PAMIDRONATE 60MG/10ML VIAL	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PAMIDRONATE DISODIUM INJECTION 3MG 10ML VIALSD	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	P
PAMIDRONATE DISODIUM INJECTION 9MG 10ML VIALSD	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	P
PANRETIN 0.1% GEL 60GM TUBE	3	Preferred Brand	30%	27%	None
PANTOPRAZOLE SODIUM 20MG TABLET DELAYED RELEASE	2	Generic	$25.00	$62.50	Q:30 /30Days
PANTOPRAZOLE SODIUM 40MG TABLET DELAYED RELEASE 90 CRC BOT	2	Generic	$25.00	$62.50	Q:30 /30Days
PAROMOMYCIN 250MG CAPSULE	1	Preferred Generic	$0.00	$0.00	None
PAROXETINE 40MG TABLET (500 CT)	1	Preferred Generic	$0.00	$0.00	None
PAROXETINE FILM COATED 20MG TABLET (100 CT)	1	Preferred Generic	$0.00	$0.00	None
PAROXETINE HCL 10MG/5ML SUSPENSION ORAL	1	Preferred Generic	$0.00	$0.00	None
PAROXETINE HCL TABLET 24 12.5MG	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	S Q:90 /30Days
PAROXETINE HCL TABLET 24 25MG	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	S Q:90 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PAROXETINE TABLETS	1	Preferred Generic	$0.00	$0.00	None
PAROXETINE TABLETS 30MG 90 BOT	1	Preferred Generic	$0.00	$0.00	None
PASER GRANULES 4GM PACKET	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	None
PATADAY 0.2% DROPS	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	Q:3 /30Days
PATANOL 0.1% EYE DROPS	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	None
PAXIL CR 37.5MG TABLET	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	S Q:60 /30Days
PAZOPANIB 200 MG ORAL TABLET [VOTRIENT]	5	Specialty Tier	33%	N/A	P Q:120 /30Days
PCE 333MG DISPERTAB	3	Preferred Brand	30%	27%	None
PCE 500MG DISPERTAB	3	Preferred Brand	30%	27%	None
PEDI-DRI TOPICAL POWDER	1	Preferred Generic	$0.00	$0.00	None
PEDIARIX SOLUTION INJECTION 25-25-10 10 X .5ML VIAL	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PEDVAXHIB VACCINE VIAL	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	None
PEGANONE 250MG TABLET	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	None
PEGASYS 180MCG/0.5ML CONV.PK	5	Specialty Tier	33%	N/A	P Q:1 /28Days
PENICILLIN G POTASSIUM FOR INJECTION	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	None
PENICILLIN G POTASSIUM FOR INJECTION 5000000UNIT/VIAL	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	None
PENICILLIN G PROCAINE 1200000UNT 2ML CTG	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	None
PENICILLIN G SODIUM FOR INJECTION 5000000UNT 1 VIAL	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	None
PENICILLIN V POTASSIUM 250MG TABLET (1000 CT)	1	Preferred Generic	$0.00	$0.00	None
PENICILLIN V POTASSIUM 250MG/5ML LIQUID	1	Preferred Generic	$0.00	$0.00	None
PENICILLIN V POTASSIUM 500MG TABLET	1	Preferred Generic	$0.00	$0.00	None
PENICILLIN V POTASSIUM FOR ORAL SOLUTION CONCENTRATE 125MG 200ML BOT	1	Preferred Generic	$0.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PENTASA 250MG CAPSULE SA	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	None
PENTASA 500MG CAPSULE	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	None
PENTAZOCINE/ACETAMIN TABLET	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	None
PENTAZOCINE/NALOXONE TABLET	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	None
PENTOPAK 400MG TABLET SA	1	Preferred Generic	$0.00	$0.00	None
PENTOXIFYLLINE 400MG TABLET SA	1	Preferred Generic	$0.00	$0.00	None
PEPCID SOLUTION 40MG 24 X 400MG BOT	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	None
PERFOROMIST 20MCG/2ML VIAL NEBULIZER	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	P Q:120 /30Days
PERINDOPRIL ERBUMINE 2 MG ORAL TABLET	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	Q:30 /30Days
PERINDOPRIL ERBUMINE 4 MG ORAL TABLET	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	Q:30 /30Days
PERINDOPRIL ERBUMINE 8 MG ORAL TABLET	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PERIOGARD 0.12% ORAL RINSE	1	Preferred Generic	$0.00	$0.00	None
PERMETHRIN 5% CREAM	1	Preferred Generic	$0.00	$0.00	None
PERPHENAZINE TABLETS 16MG 100 BOT	2	Generic	$25.00	$62.50	None
PERPHENAZINE TABLETS 4MG 100 BOXUD	2	Generic	$25.00	$62.50	None
PERPHENAZINE TABLETS 8MG 100 BOT	2	Generic	$25.00	$62.50	None
PERPHENAZINE TABLETS USP 2MG 100 BOT	2	Generic	$25.00	$62.50	None
PFIZERPEN 20MMU VIAL	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	None
PHENADOZ 12.5MG SUPPOSITORY	1	Preferred Generic	$0.00	$0.00	None
PHENADOZ 25MG SUPPOSITORY	1	Preferred Generic	$0.00	$0.00	None
PHENYTEK 200 MG CAPSULE	3	Preferred Brand	30%	27%	None
PHENYTEK 300 MG CAPSULE	3	Preferred Brand	30%	27%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT	1	Preferred Generic	$0.00	$0.00	None
PHENYTOIN SOD EXT 200 MG CAP	1	Preferred Generic	$0.00	$0.00	None
PHENYTOIN SODIUM EXTENDED CAPSULES 100MG (100 CT)	1	Preferred Generic	$0.00	$0.00	None
PHENYTOIN SODIUM INJECTION 50MG 25 X 2ML AMP	1	Preferred Generic	$0.00	$0.00	None
PHOSPHOLINE IODIDE 0.125%	3	Preferred Brand	30%	27%	None
PILOCARPINE HCL 5MG TABLET (100 CT)	2	Generic	$25.00	$62.50	None
PILOCARPINE HCL 7.5MG TABLET	2	Generic	$25.00	$62.50	None
PILOPINE HS 4% EYE GEL	3	Preferred Brand	30%	27%	None
PINDOLOL 10MG TABLET	1	Preferred Generic	$0.00	$0.00	None
PINDOLOL 5MG TABLET	1	Preferred Generic	$0.00	$0.00	None
PIPERACILLIN 200 MG/ML / TAZOBACTAM 25 MG/ML INJECTABLE SOLUTION	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PIPERACILLIN 3GM VIAL	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	None
PIPERACILLIN 40GM BULK VIAL	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	None
PIROXICAM 10 MG CAPSULE	1	Preferred Generic	$0.00	$0.00	None
PIROXICAM 20MG CAPSULE (500 CT)	1	Preferred Generic	$0.00	$0.00	None
PLAVIX 75MG TABLET	3	Preferred Brand	30%	27%	Q:30 /30Days
PLAVIX TABLETS 300MG	3	Preferred Brand	30%	27%	Q:1 /365Days
PODOFILOX 0.5% TOPICAL TUBEX	2	Generic	$25.00	$62.50	None
POLY-DEX 0.1% SUSPENSION DROPS	1	Preferred Generic	$0.00	$0.00	None
POLY-DEX 3.5-10K-.1 OINTMENT	1	Preferred Generic	$0.00	$0.00	None
POLY-PRED EYE DROPS	3	Preferred Brand	30%	27%	None
POLYCIN-B 500-10KU/G OINTMENT	1	Preferred Generic	$0.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
POLYETH GLYC NF POWDER FOR ORAL SOLUTION 17GM (527 CT)	1	Preferred Generic	$0.00	$0.00	None
POLYETHYLENE GLYCOL 3350 105 MG/ML / POTASSIUM CHLORIDE 0.00497 MEQ/ML / SODIUM BICARBONATE 1.43 MG/	1	Preferred Generic	$0.00	$0.00	None
POLYETHYLENE GLYCOL 3350 105 MG/ML / POTASSIUM CHLORIDE 0.005 MEQ/ML / SODIUM BICARBONATE 0.017 MEQ/	1	Preferred Generic	$0.00	$0.00	None
POLYETHYLENE GLYCOL 3350 59 MG/ML / POTASSIUM CHLORIDE 0.1 MEQ/ML / SODIUM BICARBONATE 0.02 MEQ/ML /	1	Preferred Generic	$0.00	$0.00	None
POLYETHYLENE GLYCOL 3350 60 MG/ML / POTASSIUM CHLORIDE 0.01 MEQ/ML / SODIUM BICARBONATE 0.02 MEQ/ML	1	Preferred Generic	$0.00	$0.00	None
POLYMYXIN B SUL-TRIMETHOPRIM 10K U-0.1%	1	Preferred Generic	$0.00	$0.00	None
PORTIA 0.15-0.03 TABLET	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	None
POTASSIUM CHLORIDE 0.075%/D5W/SODIUM CHLORIDE 0.2%	1	Preferred Generic	$0.00	$0.00	None
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.3%	1	Preferred Generic	$0.00	$0.00	None
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.45%	1	Preferred Generic	$0.00	$0.00	None
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.9% 1000ML	1	Preferred Generic	$0.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.2%	1	Preferred Generic	$0.00	$0.00	None
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.45% 1000ML BAG	1	Preferred Generic	$0.00	$0.00	None
POTASSIUM CHLORIDE 10MEQ/100ML SOL	1	Preferred Generic	$0.00	$0.00	None
POTASSIUM CHLORIDE 10MEQ/50ML SOL	1	Preferred Generic	$0.00	$0.00	None
POTASSIUM CHLORIDE 20MEQ IN D5W LACT RNG	1	Preferred Generic	$0.00	$0.00	None
POTASSIUM CHLORIDE 20MEQ IN D5W/NACL 0.225%	1	Preferred Generic	$0.00	$0.00	None
POTASSIUM CHLORIDE 20MEQ/50ML SOL	1	Preferred Generic	$0.00	$0.00	None
POTASSIUM CHLORIDE 30MEQ/100ML SOL	1	Preferred Generic	$0.00	$0.00	None
POTASSIUM CHLORIDE 40MEQ IN D5W LACT RNG	1	Preferred Generic	$0.00	$0.00	None
POTASSIUM CHLORIDE 40MEQ IN D5W/NACL 0.9%	1	Preferred Generic	$0.00	$0.00	None
POTASSIUM CHLORIDE 40MEQ/NS 1000ML IV SOLUTION	1	Preferred Generic	$0.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
POTASSIUM CHLORIDE 8 MEQ EXTENDED RELEASE TABLET	1	Preferred Generic	$0.00	$0.00	None
POTASSIUM CHLORIDE ER CAPSULES 10MEQ	1	Preferred Generic	$0.00	$0.00	None
POTASSIUM CHLORIDE ER CPCR 8MEQ	1	Preferred Generic	$0.00	$0.00	None
POTASSIUM CHLORIDE EXTENDED RELEASE TABLETS	1	Preferred Generic	$0.00	$0.00	None
POTASSIUM CHLORIDE FOR INJECTION CONCENTRATE	1	Preferred Generic	$0.00	$0.00	None
POTASSIUM CHLORIDE IN 5% DEXTROSE AND 0.2% NACL SOLUTION FOR INJECTION USP 0.15% 250ML X 24 CASE	1	Preferred Generic	$0.00	$0.00	None
POTASSIUM CHLORIDE IN 5% DEXTROSE AND NACL SOLUTION FOR INJECTION 0.075% 1000ML PLASTIC BAGS X 12 CA	1	Preferred Generic	$0.00	$0.00	None
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION	1	Preferred Generic	$0.00	$0.00	None
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION	1	Preferred Generic	$0.00	$0.00	None
POTASSIUM CHLORIDE IN 5% DEXTROSE INJECTION 40 12 X 1000ML CTR	1	Preferred Generic	$0.00	$0.00	None
POTASSIUM CHLORIDE IN DEXTROSE INJECTION 5GM/75MG	1	Preferred Generic	$0.00	$0.00	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	Preferred Generic	$0.00	$0.00	None
POTASSIUM CHLORIDE TABLET EXTENED RELEASE	1	Preferred Generic	$0.00	$0.00	None
POTASSIUM CITRATE 10MEQ TABLET SA	1	Preferred Generic	$0.00	$0.00	None
POTASSIUM CITRATE 5MEQ TABLET SA	1	Preferred Generic	$0.00	$0.00	None
PRAMIPEXOLE 0.125 MG TABLET	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	Q:90 /30Days
PRAMIPEXOLE 0.25 MG TABLET	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	Q:90 /30Days
PRAMIPEXOLE 0.5 MG TABLET	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	Q:90 /30Days
PRAMIPEXOLE 1 MG TABLET	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	Q:90 /30Days
PRAMIPEXOLE 1.5 MG TABLET	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	Q:90 /30Days
PRAMIPEXOLE DIHYDROCHLORIDE TABLETS	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	Q:90 /30Days
PRANDIN 0.5MG TABLET	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	Q:120 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PRANDIN 1MG TABLET	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	Q:120 /30Days
PRANDIN 2MG TABLET	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	Q:120 /30Days
PRASUGREL 10 MG ORAL TABLET	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	Q:30 /30Days
PRASUGREL 5 MG ORAL TABLET	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	Q:30 /30Days
PRAVASTATIN SODIUM 20MG TABLET 500 BOT	1	Preferred Generic	$0.00	$0.00	None
PRAVASTATIN SODIUM 40MG TABLET (500 CT)	1	Preferred Generic	$0.00	$0.00	None
PRAVASTATIN SODIUM 80MG TABLET (90 CT)	1	Preferred Generic	$0.00	$0.00	None
PRAVASTATIN SODIUM TABLETS 10MG 90 BOT	1	Preferred Generic	$0.00	$0.00	None
PRAZOSIN 5MG CAPSULE	1	Preferred Generic	$0.00	$0.00	None
PRAZOSIN HCL 1MG CAPSULE	1	Preferred Generic	$0.00	$0.00	None
PRAZOSIN HCL 2MG CAPSULE	1	Preferred Generic	$0.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PRED G OPHTHALMIC SUSPENSION 1;0.3%;% 5 ML BOTDR	3	Preferred Brand	30%	27%	None
PRED MILD 0.12% EYE DROPS	3	Preferred Brand	30%	27%	None
PRED-G S.O.P. EYE OINTMENT	3	Preferred Brand	30%	27%	None
PREDNICARBATE 0.1% OINTMENT	1	Preferred Generic	$0.00	$0.00	None
PREDNICARBATE 1 MG/ML TOPICAL CREAM	1	Preferred Generic	$0.00	$0.00	None
PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION 1.0% STERILE 10ML BOTDR	1	Preferred Generic	$0.00	$0.00	None
PREDNISOLONE SOD 1% EYE DROP	1	Preferred Generic	$0.00	$0.00	None
PREDNISOLONE SODIUM PHOSPHATE 15MG/5ML SOLUTION ORAL	2	Generic	$25.00	$62.50	None
PREDNISOLONE SODIUM PHOSPHATE ORAL SOLUTION	2	Generic	$25.00	$62.50	None
PREDNISONE 10MG TABLET (100 CT)	1	Preferred Generic	$0.00	$0.00	None
PREDNISONE 1MG TABLET	1	Preferred Generic	$0.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PREDNISONE 2.5MG TABLET	1	Preferred Generic	$0.00	$0.00	None
PREDNISONE 20MG TABLET (1000 CT)	1	Preferred Generic	$0.00	$0.00	None
PREDNISONE 5 MG TABLET	1	Preferred Generic	$0.00	$0.00	None
PREDNISONE 50MG TABLET	1	Preferred Generic	$0.00	$0.00	None
PREDNISONE 5MG/5ML SOLUTION	1	Preferred Generic	$0.00	$0.00	None
PREDNISONE 5MG/ML SOLUTION	1	Preferred Generic	$0.00	$0.00	None
PREFEST TABLET 30 EA	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	None
PREMARIN 0.3MG (100 CT)	3	Preferred Brand	30%	27%	Q:30 /30Days
PREMARIN 0.45MG TABLET	3	Preferred Brand	30%	27%	Q:30 /30Days
PREMARIN 0.625MG (100 CT)	3	Preferred Brand	30%	27%	Q:30 /30Days
PREMARIN 0.9MG TABLET	3	Preferred Brand	30%	27%	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PREMARIN 1.25MG (100 CT)	3	Preferred Brand	30%	27%	Q:30 /30Days
PREMARIN VAGINAL CREAM /APPL	3	Preferred Brand	30%	27%	None
PREMASOL 10% IV SOLUTION	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	P
PREMASOL 6% IV SOLUTION	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	P
PREMPHASE 0.625/5MG TABLET	3	Preferred Brand	30%	27%	Q:30 /30Days
PREMPRO 0.3 MG-1.5 MG TABLET #28 EA	3	Preferred Brand	30%	27%	Q:30 /30Days
PREMPRO 0.45-1.5 MG TABLET 28 EA	3	Preferred Brand	30%	27%	Q:30 /30Days
PRENATABS OBN TABLETS 200;1;150;MG;MG;MCG; 90 BOT	1	Preferred Generic	$0.00	$0.00	P
PREVALITE POW 4GM	2	Generic	$25.00	$62.50	None
PREVIFEM TABLETS .035;.25MG;MG 28 BLPK	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	None
PREZISTA TABLET 600MG	5	Specialty Tier	33%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PREZISTA TABLET 75MG	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	None
PREZISTA TABLETS	5	Specialty Tier	33%	N/A	None
PREZISTA TABLETS 400MG 60 TABLETS BOT	5	Specialty Tier	33%	N/A	None
PRIFTIN 150MG TABLET	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	None
PRIMAQUINE 26.3MG TABLET	3	Preferred Brand	30%	27%	None
PRIMAXIN I.M. 500MG VIAL	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	None
PRIMAXIN IV 250MG VIAL	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	None
PRIMAXIN IV INJ 500MG	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	None
PRIMIDONE 250MG TABLET (100 CT)	1	Preferred Generic	$0.00	$0.00	None
PRIMIDONE 50MG TABLET (500 CT)	1	Preferred Generic	$0.00	$0.00	None
PRIMSOL 50MG/5ML ORAL SOLUTION	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PRISTIQ 100MG TABLET SR 24HR	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	S Q:30 /30Days
PRISTIQ 50MG TABLET SR 24HR	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	S Q:30 /30Days
PROAIR HFA 90MCG HFA AEROSOL WITH ADAPTER	3	Preferred Brand	30%	27%	Q:17 /30Days
PROBENECID 500MG TABLET	1	Preferred Generic	$0.00	$0.00	None
PROBENECID/COLCHICINE TABLET S	1	Preferred Generic	$0.00	$0.00	None
PROCAINAMIDE 100MG/ML VIAL	1	Preferred Generic	$0.00	$0.00	None
PROCAINAMIDE 500MG/ML VIAL	1	Preferred Generic	$0.00	$0.00	None
PROCALAMINE INJECTION 210MG-290MG-26MG 6 X 1000ML BOT	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	P
PROCHIEVE 4% GEL	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	None
PROCHIEVE GEL 8%	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	None
PROCHLORPERAZINE EDISYLATE INJECTION 10MG 10 X 2ML VIALS CRTN	1	Preferred Generic	$0.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PROCHLORPERAZINE MALEATE 10MG TABLET (100 CT)	1	Preferred Generic	$0.00	$0.00	None
PROCHLORPERAZINE MALEATE 5MG TABLET (100 CT)	1	Preferred Generic	$0.00	$0.00	None
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX	1	Preferred Generic	$0.00	$0.00	None
PROCRIT 10000U/ML VIAL	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	P Q:12 /28Days
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	P Q:12 /28Days
PROCRIT 3000U/ML VIAL	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	P Q:12 /28Days
PROCRIT 40000U/ML VIAL PR	5	Specialty Tier	33%	N/A	P Q:8 /28Days
PROCRIT 4000U/ML VIAL 25 X 1ML VIAL	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	P Q:12 /28Days
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY	5	Specialty Tier	33%	N/A	P Q:12 /28Days
PROCTOSOL-HC 2.5% CREAM	1	Preferred Generic	$0.00	$0.00	None
PROCTOZONE-HC 2.5% CREAM	1	Preferred Generic	$0.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PROGLYCEM 50MG/ML ORAL SUSP	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	None
PROLASTIN 500MG VIAL	5	Specialty Tier	33%	N/A	P
PROMACTA TABLETS	5	Specialty Tier	33%	N/A	P Q:30 /30Days
PROMACTA TABLETS	5	Specialty Tier	33%	N/A	P Q:30 /30Days
PROMACTA TABLETS 25 MG	5	Specialty Tier	33%	N/A	P Q:30 /30Days
PROMETHAZINE 50MG/ML VIAL	1	Preferred Generic	$0.00	$0.00	None
PROMETHAZINE HCL 12.5MG TABLET	1	Preferred Generic	$0.00	$0.00	None
PROMETHAZINE HCL 25MG TABLET (1000 CT)	1	Preferred Generic	$0.00	$0.00	None
PROMETHAZINE HCL 50MG TABLET (100 CT)	1	Preferred Generic	$0.00	$0.00	None
PROMETHAZINE HCL 6.25MG/5ML SYRUP	1	Preferred Generic	$0.00	$0.00	None
PROMETHAZINE HCL INJECTION 25MG 10 X 1ML VIAL	1	Preferred Generic	$0.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 12.5MG 12 BOX	1	Preferred Generic	$0.00	$0.00	None
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 25MG 12 BOX	1	Preferred Generic	$0.00	$0.00	None
PROMETHAZINE VC PLAIN 6.25-5MG 16 FL OZ BOT	1	Preferred Generic	$0.00	$0.00	None
PROMETHEGAN 25MG SUPP	1	Preferred Generic	$0.00	$0.00	None
PROMETHEGAN 50MG SUPPOS	1	Preferred Generic	$0.00	$0.00	None
PROMETRIUM 100MG CAPSULE	3	Preferred Brand	30%	27%	None
PROMETRIUM 200MG CAPSULE	3	Preferred Brand	30%	27%	None
PROPAFENONE HCL 150MG TABLET (100 CT)	2	Generic	$25.00	$62.50	None
PROPAFENONE HCL 225MG TABLET	2	Generic	$25.00	$62.50	None
PROPAFENONE HCL 300MG TABLET (100 CT)	2	Generic	$25.00	$62.50	None
PROPAFENONE HYDROCHLORIDE CAPSULES EXTENDED RELEASE	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PROPAFENONE HYDROCHLORIDE CAPSULES EXTENDED RELEASE	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	Q:60 /30Days
PROPAFENONE HYDROCHLORIDE CAPSULES EXTENDED RELEASE	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	Q:60 /30Days
PROPRANOLOL 20MG/5ML TUBEX	1	Preferred Generic	$0.00	$0.00	None
PROPRANOLOL 40MG/5ML TUBEX	1	Preferred Generic	$0.00	$0.00	None
PROPRANOLOL 60MG TABLET	1	Preferred Generic	$0.00	$0.00	None
PROPRANOLOL 80 MG TABLET	1	Preferred Generic	$0.00	$0.00	None
PROPRANOLOL HCL 20MG TABLET (1000 CT)	1	Preferred Generic	$0.00	$0.00	None
PROPRANOLOL HCL CAPSULES ER 120MG (1000 CT)	2	Generic	$25.00	$62.50	Q:60 /30Days
PROPRANOLOL HCL CAPSULES ER 160MG (1000 CT)	2	Generic	$25.00	$62.50	Q:30 /30Days
PROPRANOLOL HCL CAPSULES ER 60MG (100 CT)	2	Generic	$25.00	$62.50	Q:30 /30Days
PROPRANOLOL HCL CAPSULES ER 80MG (1000 CT)	2	Generic	$25.00	$62.50	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PROPRANOLOL HCL INJECTION 1MG 10 PKG OF 10 CRTN	1	Preferred Generic	$0.00	$0.00	None
PROPRANOLOL HCL TABLET USP 10MG (1000 CT)	1	Preferred Generic	$0.00	$0.00	None
PROPRANOLOL HCL TABLET USP 40MG (1000 CT)	1	Preferred Generic	$0.00	$0.00	None
PROPRANOLOL/HCTZ 40/25 TABLET	1	Preferred Generic	$0.00	$0.00	None
PROPRANOLOL/HCTZ 80/25 TABLET	1	Preferred Generic	$0.00	$0.00	None
PROPYLTHIOURACIL 50MG TABLET	1	Preferred Generic	$0.00	$0.00	None
PROQUAD VIAL	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	None
PROSOL 20% INJECTION	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	P
PROTOPIC 0.03% OINTMENT 100GM TUBE	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	S Q:30 /30Days
PROTOPIC 0.1% OINTMENT 60GM TUBE	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	S Q:30 /30Days
PROTRIPTYLINE HYDROCHLORIDE TABLETS	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PROTRIPTYLINE HYDROCHLORIDE TABLETS 5MG	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	None
PROVENTIL HFA INHALER 90MCG AE	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	Q:13 /30Days
PROVIGIL 100MG TABLET	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	P Q:30 /30Days
PROVIGIL 200MG TABLET	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	P Q:30 /30Days
PULMICORT FLEXHALER 180MCG AEROSOL POWDER BREATH ACTIVATED	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	Q:2 /30Days
PULMICORT FLEXHALER 90MCG AEROSOL POWDER BREATH ACTIVATED	4	Non-Preferred Generic and Non-Preferred Brand	59%	59%	Q:2 /30Days
PYRAZINAMIDE 500MG TABLET	1	Preferred Generic	$0.00	$0.00	None
PYRIDOSTIGMINE BROMIDE 60MG TABLET	2	Generic	$25.00	$62.50	None

Chart Legend:

Below are a few notes to help you understand the above 2011 Medicare Part D First Health Part D Premier Plus (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.