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2012 Medicare Part D and Medicare Advantage Plan Formulary Browser

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Blue Cross MedicareRx Plus (PDP) (S5596-034-0)
Tier 1 (407)
Tier 2 (1277)
Tier 3 (451)
Tier 4 (270)
Tier 5 (604)
Tier 6 (434)
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Cick on the first letter of your drug name to browse the formulary:

A B C D E F G H I J K L 
M N O P Q R S T U V W X Y Z 0-9 
2012 Medicare Part D Plan Formulary Information
Blue Cross MedicareRx Plus (PDP) (S5596-034-0)
Benefit Details           
The Blue Cross MedicareRx Plus (PDP) (S5596-034-0)
Formulary Drugs Starting with the Letter C

in CMS PDP Region 32 which includes: CA
Drugs Starting with Letter C

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
CABERGOLINE 0.5 MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
CALCIJEX 1 MCG/ML AMPUL   5 Injectable Drug 33%33%P
Calcipotriene 50ug/g 60 g in 1 CARTON   2 Non-Preferred Generic Drugs $7.00$10.50Q:200
/30Days
CALCIPOTRIENE TOPICAL SOLUTION   2 Non-Preferred Generic Drugs $7.00$10.50Q:60
/30Days
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY   2 Non-Preferred Generic Drugs $7.00$10.50Q:4
/30Days
CALCITRIOL 0.25MCG CAPSULE   2 Non-Preferred Generic Drugs $7.00$10.50P
CALCITRIOL 0.5MCG CAPSULE   2 Non-Preferred Generic Drugs $7.00$10.50P
CALCITRIOL 1MCG/ML SOLUTION ORAL   2 Non-Preferred Generic Drugs $7.00$10.50P
CALCITRIOL INJ 1MCG/ML   5 Injectable Drug 33%33%P
CALCIUM ACETATE CAPSULE 667 MG   2 Non-Preferred Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CAMILA 0.35MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
CAMPATH INJECTION 30 MG/ML   6 Specialty Tier Drugs 33%N/ANone
Camptosar 20mg/mL 1 VIAL, SINGLE-DOSE in 1 CARTON / 5 mL in 1 VIAL, SINGLE-DOSE   5 Injectable Drug 33%33%P
CANASA RECTAL SUPPOSITORIES 1000MG 30 BOX   3 Preferred Brand Drugs $45.00$112.50None
CANCIDAS IV 50MG VIAL   6 Specialty Tier Drugs 33%N/ANone
CANCIDAS IV 70MG VIAL   6 Specialty Tier Drugs 33%N/ANone
CAPASTAT SULFATE 1g/1 1 INJECTION, POWDER, FOR SOLUTION in 1 CARTON   5 Injectable Drug 33%33%None
CAPRELSA 100mg/1 30 TABLET in 1 BOTTLE, PLASTIC   6 Specialty Tier Drugs 33%N/AP
CAPRELSA 300mg/1 30 TABLET in 1 BOTTLE, PLASTIC   6 Specialty Tier Drugs 33%N/AP
CAPTOPRIL 100MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
CAPTOPRIL 12.5MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CAPTOPRIL 25MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
CAPTOPRIL 50MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
Captopril and Hydrochlorothiazide 25; 15mg/1; mg/1 100 TABLET in 1 BOTTLE, PLASTIC   2 Non-Preferred Generic Drugs $7.00$10.50None
Captopril and Hydrochlorothiazide 25; 25mg/1; mg/1 100 TABLET in 1 BOTTLE, PLASTIC   2 Non-Preferred Generic Drugs $7.00$10.50None
Captopril and Hydrochlorothiazide 50; 15mg/1; mg/1 100 TABLET in 1 BOTTLE, PLASTIC   2 Non-Preferred Generic Drugs $7.00$10.50None
Captopril and Hydrochlorothiazide 50; 25mg/1; mg/1 100 TABLET in 1 BOTTLE, PLASTIC   2 Non-Preferred Generic Drugs $7.00$10.50None
CARAC CRE 0.5%   4 Non-Preferred Brand Drugs $90.00$225.00None
Carbaglu 200mg/1 5 TABLET in 1 BOTTLE   6 Specialty Tier Drugs 33%N/AP
Carbamazepine 100mg/1 100 TABLET, CHEWABLE in 1 BOTTLE   1 Preferred Generic Drugs $2.00$3.00None
Carbamazepine 100mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE   3 Preferred Brand Drugs $45.00$112.50Q:60
/30Days
Carbamazepine 200mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE   3 Preferred Brand Drugs $45.00$112.50Q:240
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Carbamazepine 300mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE   3 Preferred Brand Drugs $45.00$112.50Q:150
/30Days
CARBAMAZEPINE EXTENDED RELEASE TABLETS 200MG   2 Non-Preferred Generic Drugs $7.00$10.50None
CARBAMAZEPINE EXTENDED RELEASE TABLETS 400MG   2 Non-Preferred Generic Drugs $7.00$10.50None
CARBAMAZEPINE ORAL SUSPENSION 100 MG/5ML   1 Preferred Generic Drugs $2.00$3.00None
CARBAMAZEPINE TABLET USP 200MG (1000 CT)   1 Preferred Generic Drugs $2.00$3.00None
CARBIDOPA AND LEVEDOPA ORALLY DISINTEGRATING TABLETS 10;100MG;MG 100 BOT   2 Non-Preferred Generic Drugs $7.00$10.50None
Carbidopa and Levodopa 25; 100mg/1; mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, EXTENDED   2 Non-Preferred Generic Drugs $7.00$10.50None
Carbidopa and Levodopa 50; 200mg/1; mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, EXTENDED   2 Non-Preferred Generic Drugs $7.00$10.50None
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;100MG;MG 100 BOT   2 Non-Preferred Generic Drugs $7.00$10.50None
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;250MG;MG 100 BOT   2 Non-Preferred Generic Drugs $7.00$10.50None
CARBIDOPA/LEVO 10/100 TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARBIDOPA/LEVO 25/100 TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
CARBIDOPA/LEVO 25/250 TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
Carbinoxamine Maleate 4mg/1 100 TABLET in 1 BOTTLE   1 Preferred Generic Drugs $2.00$3.00None
Carbinoxamine Maleate 4mg/5mL 118 mL in 1 BOTTLE   1 Preferred Generic Drugs $2.00$3.00None
Carboplatin 10mg/mL   5 Injectable Drug 33%33%P
CARIMUNE NF 3GM VIAL   6 Specialty Tier Drugs 33%N/AP
CARISOPRODOL AND ASPIRIN TABLETS USP 325;200MG;MG 100 BOTPL   2 Non-Preferred Generic Drugs $7.00$10.50None
CARISOPRODOL ASPIRIN AND CODEINE PHOSPHATE TABLETS USP 325;200;16MG;MG;MG 100 BOTPL   2 Non-Preferred Generic Drugs $7.00$10.50None
CARISOPRODOL TABLET USP 350MG (100 CT)   2 Non-Preferred Generic Drugs $7.00$10.50None
CARNITOR 1GM/5ML VIAL   5 Injectable Drug 33%33%P
CARTEOLOL HCL OPHTHALMIC SOLUTION USP 1% 15ML BOT   1 Preferred Generic Drugs $2.00$3.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARTIA XT 120MG CAPSULE SA   2 Non-Preferred Generic Drugs $7.00$10.50None
CARTIA XT 180MG CAPSULE SA   2 Non-Preferred Generic Drugs $7.00$10.50None
CARTIA XT 240MG CAPSULE SA   2 Non-Preferred Generic Drugs $7.00$10.50None
CARTIA XT 300MG CAPSULE SR 24 HR   2 Non-Preferred Generic Drugs $7.00$10.50None
Carvedilol 12.5mg/1   2 Non-Preferred Generic Drugs $7.00$10.50None
Carvedilol 25mg/1   2 Non-Preferred Generic Drugs $7.00$10.50None
Carvedilol 3.125mg/1   2 Non-Preferred Generic Drugs $7.00$10.50None
Carvedilol 6.25mg/1 500 TABLET, FILM COATED in 1 BOTTLE   2 Non-Preferred Generic Drugs $7.00$10.50None
CAYSTON KIT   6 Specialty Tier Drugs 33%N/ANone
CEENU 100MG CAPSULE   3 Preferred Brand Drugs $45.00$112.50None
CEENU 10MG CAPSULE   3 Preferred Brand Drugs $45.00$112.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEENU 40MG CAPSULE   3 Preferred Brand Drugs $45.00$112.50None
CEFACLOR CAPSULES   2 Non-Preferred Generic Drugs $7.00$10.50None
CEFACLOR CAPSULES   2 Non-Preferred Generic Drugs $7.00$10.50None
CEFACLOR ER 500MG TABLET SR 12HR   2 Non-Preferred Generic Drugs $7.00$10.50None
CEFADROXIL 1G TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
Cefadroxil 500mg/1   2 Non-Preferred Generic Drugs $7.00$10.50None
Cefadroxil 500mg/5mL   2 Non-Preferred Generic Drugs $7.00$10.50None
CEFADROXIL FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   2 Non-Preferred Generic Drugs $7.00$10.50None
Cefazolin 10g/1 10 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 PACKAGE   5 Injectable Drug 33%33%None
Cefazolin 1g/1   5 Injectable Drug 33%33%None
CEFAZOLIN 1GM/D5W BAG   5 Injectable Drug 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFAZOLIN FOR INJECTION   5 Injectable Drug 33%33%None
CEFDINIR 250MG/5ML SUSPENSION RECONSTITUTED ORAL   2 Non-Preferred Generic Drugs $7.00$10.50None
CEFDINIR CAPSULES 300MG (60 CT)   2 Non-Preferred Generic Drugs $7.00$10.50None
CEFDINIR FOR ORAL SUSPENSION 125MG/5ML (100 CT)   2 Non-Preferred Generic Drugs $7.00$10.50None
CEFEPIME HCL 2 GRAM VIAL   5 Injectable Drug 33%33%None
CEFEPIME INJ 1GM 20ML APX 10x1G VIAL   5 Injectable Drug 33%33%None
CEFOTAXIME FOR INJECTION   5 Injectable Drug 33%33%None
CEFOTAXIME FOR INJECTION 1GM 50 BOX VIALGL   5 Injectable Drug 33%33%None
CEFOTAXIME FOR INJECTION 2GM 25 VIAL   5 Injectable Drug 33%33%None
CEFOTAXIME FOR INJECTION 500MG 10 VIAL   5 Injectable Drug 33%33%None
CEFOTETAN 10 GM SOLR   5 Injectable Drug 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFOTETAN 1GM VIAL 1EA x 10   5 Injectable Drug 33%33%None
CEFOTETAN 2GM VIAL 1EA x 10   5 Injectable Drug 33%33%None
Cefoxitin 1g/1 10 POWDER in 1 CARTON   5 Injectable Drug 33%33%None
Cefoxitin 2g/1 10 POWDER in 1 CARTON   5 Injectable Drug 33%33%None
CEFOXITIN FOR INJECTION 1 GM/50ML   5 Injectable Drug 33%33%None
CEFOXITIN FOR INJECTION 2MG/50ML 50 ML BOT   5 Injectable Drug 33%33%None
CEFOXITIN FOR INJECTION SOLUTION   5 Injectable Drug 33%33%None
Cefpodoxime Proxetil 100mg/5mL 1 BOTTLE in 1 CARTON / 100 mL in 1 BOTTLE   2 Non-Preferred Generic Drugs $7.00$10.50None
Cefpodoxime Proxetil 50mg/5mL 1 BOTTLE in 1 CARTON / 100 mL in 1 BOTTLE   2 Non-Preferred Generic Drugs $7.00$10.50None
CEFPODOXIME PROXETIL FILM COATED TABLET 100MG (20 CT)   2 Non-Preferred Generic Drugs $7.00$10.50None
CEFPODOXIME TAB 200MG   2 Non-Preferred Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFPROZIL 125mg/5mL   2 Non-Preferred Generic Drugs $7.00$10.50None
Cefprozil 250mg/1 100 TABLET, FILM COATED in 1 BOTTLE   2 Non-Preferred Generic Drugs $7.00$10.50None
CEFPROZIL 250MG/5ML SUSPENSION RECONSTITUTED ORAL   2 Non-Preferred Generic Drugs $7.00$10.50None
CEFPROZIL TABLETS 500MG 100 BOT   2 Non-Preferred Generic Drugs $7.00$10.50None
Ceftazidime 1g/1 25 VIAL in 1 CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL   5 Injectable Drug 33%33%None
Ceftazidime and Dextrose 1g/50mL 24 CONTAINER in 1 CASE / 50 mL in 1 CONTAINER   5 Injectable Drug 33%33%None
Ceftazidime and Dextrose 2g/50mL 24 CONTAINER in 1 CASE / 50 mL in 1 CONTAINER   5 Injectable Drug 33%33%None
CEFTAZIDIME FOR INJECTION 2GM/VIAL 10 X 2 CRTN   5 Injectable Drug 33%33%None
CEFTAZIDIME FOR INJECTION 6GM/VIAL 6 X 6 CRTN   5 Injectable Drug 33%33%None
CEFTRIAXONE 10GM VIAL   5 Injectable Drug 33%33%None
CEFTRIAXONE FOR INJECTION   5 Injectable Drug 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFTRIAXONE FOR INJECTION   5 Injectable Drug 33%33%None
CEFTRIAXONE FOR INJECTION 250MG BOX OF 10 VIALGL   5 Injectable Drug 33%33%None
Ceftriaxone Sodium 500mg/1   5 Injectable Drug 33%33%None
CEFUROXIME 250MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
CEFUROXIME AXETIL 125MG/5ML SUSPENSION RECONSTITUTED ORAL   2 Non-Preferred Generic Drugs $7.00$10.50None
CEFUROXIME AXETIL 500MG TABLET (20 CT)   2 Non-Preferred Generic Drugs $7.00$10.50None
CEFUROXIME FOR INJECTION   5 Injectable Drug 33%33%None
CEFUROXIME FOR INJECTION   5 Injectable Drug 33%33%None
CEFUROXIME FOR INJECTION   5 Injectable Drug 33%33%None
CELLCEPT 200MG/ML ORAL SUSP   6 Specialty Tier Drugs 33%N/AP
CELLCEPT 500MG TABLET   6 Specialty Tier Drugs 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CELLCEPT IV INJ 500MG   5 Injectable Drug 33%33%P
CELONTIN 300MG KAPSEAL   3 Preferred Brand Drugs $45.00$112.50None
Cephalexin 125mg/5mL 200 mL in 1 BOTTLE   1 Preferred Generic Drugs $2.00$3.00None
CEPHALEXIN 250MG CAPSULE   1 Preferred Generic Drugs $2.00$3.00None
CEPHALEXIN 250MG TABLET   1 Preferred Generic Drugs $2.00$3.00None
CEPHALEXIN 250MG/5ML ORAL SUSP   1 Preferred Generic Drugs $2.00$3.00None
CEPHALEXIN 500MG TABLET   1 Preferred Generic Drugs $2.00$3.00None
CEPHALEXIN CAPSULES 500MG (500 CT)   1 Preferred Generic Drugs $2.00$3.00None
CEREDASE 80UNITS/ML VIAL   6 Specialty Tier Drugs 33%N/AP
CEREZYME INJ 200UNIT   6 Specialty Tier Drugs 33%N/AP
CERUBIDINE 20MG VIAL   5 Injectable Drug 33%33%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CESIA 7 DAYS X 3 TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
CETIRIZINE HCL 5MG/5ML   2 Non-Preferred Generic Drugs $7.00$10.50Q:300
/30Days
CHANTIX 0.5MG TABLET   4 Non-Preferred Brand Drugs $90.00$225.00None
CHANTIX 1MG TABLET   4 Non-Preferred Brand Drugs $90.00$225.00None
CHANTIX STARTING MONTH PAK   4 Non-Preferred Brand Drugs $90.00$225.00None
CHLORAMPHEN NA SUCC 1GM VL   5 Injectable Drug 33%33%None
CHLORDIAZEPOXIDE AND AMITRIPTYLINE HCL TABLET 12.5-5MG (500 CT)   2 Non-Preferred Generic Drugs $7.00$10.50None
CHLORHEXIDINE GLUCONATE 0.12% MOUTHWASH   1 Preferred Generic Drugs $2.00$3.00None
CHLOROQUINE PH 500MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
CHLOROQUINE PHOSPHATE 250MG TABLET (50 CT)   2 Non-Preferred Generic Drugs $7.00$10.50None
CHLOROTHIAZIDE 250MG TABLET   1 Preferred Generic Drugs $2.00$3.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CHLOROTHIAZIDE 500MG TABLET   1 Preferred Generic Drugs $2.00$3.00None
CHLOROTHIAZIDE SODIUM FOR INJECTION 500MG/VIAL   5 Injectable Drug 33%33%None
CHLORPROMAZINE 10MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
CHLORPROMAZINE 25MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
CHLORPROMAZINE 25MG/ML AMP   5 Injectable Drug 33%33%None
CHLORPROMAZINE 50MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
CHLORPROMAZINE HCL 200MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
Chlorpromazine Hydrochloride 100mg/1 1000 TABLET, SUGAR COATED in 1 BOTTLE   2 Non-Preferred Generic Drugs $7.00$10.50None
CHLORPROPAMIDE 100MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
Chlorpropamide 250mg/1 1000 TABLET in 1 BOTTLE, PLASTIC   2 Non-Preferred Generic Drugs $7.00$10.50None
CHLORTHALIDONE 25MG TABLET (100 CT)   1 Preferred Generic Drugs $2.00$3.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CHLORTHALIDONE 50MG TABLET (1000 CT)   1 Preferred Generic Drugs $2.00$3.00None
CHLORZOXAZONE 500 MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
CHOLESTYRAMINE LIGHT POWDER FOR ORAL SUSPENSION   2 Non-Preferred Generic Drugs $7.00$10.50None
Cialis 2.5mg/1 2 BLISTER PACK in 1 CARTON / 15 TABLET, FILM COATED in 1 BLISTER PACK   4 Non-Preferred Brand Drugs $90.00$225.00P Q:30
/30Days
Cialis 5mg/1 30 TABLET, FILM COATED in 1 BOTTLE   4 Non-Preferred Brand Drugs $90.00$225.00P Q:30
/30Days
CICLOPIROX 1% SHAMPOO   2 Non-Preferred Generic Drugs $7.00$10.50None
Ciclopirox 7.7mg/mL 60 mL in 1 BOTTLE   2 Non-Preferred Generic Drugs $7.00$10.50None
CICLOPIROX 8% TOPICAL SOLUTION NAIL LACQUER 6.6ML BOT   2 Non-Preferred Generic Drugs $7.00$10.50P
CICLOPIROX GEL   2 Non-Preferred Generic Drugs $7.00$10.50None
Ciclopirox Olamine 7.7mg/g 1 TUBE in 1 TUBE / 15 g in 1 TUBE   2 Non-Preferred Generic Drugs $7.00$10.50None
CILOSTAZOL 50 MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CILOSTAZOL TABLET 100MG (60 CT)   2 Non-Preferred Generic Drugs $7.00$10.50None
CIMETIDINE 150MG/ML VIAL   5 Injectable Drug 33%33%None
Cimetidine 200mg/1 100 TABLET, FILM COATED in 1 BOTTLE, PLASTIC   2 Non-Preferred Generic Drugs $7.00$10.50None
Cimetidine 400mg/1 100 TABLET, FILM COATED in 1 BOTTLE   1 Preferred Generic Drugs $2.00$3.00None
Cimetidine 800mg/1 100 TABLET, FILM COATED in 1 BOTTLE   1 Preferred Generic Drugs $2.00$3.00None
Cimetidine Hydrochloride Oral Solution 300mg/5mL 237 mL in 1 BOTTLE   2 Non-Preferred Generic Drugs $7.00$10.50None
CIMETIDINE TABLETS   1 Preferred Generic Drugs $2.00$3.00None
Cimzia 2 KIT in 1 CARTON / 1 KIT in 1 KIT   6 Specialty Tier Drugs 33%N/AP Q:6
/28Days
CIMZIA 200 MG/ML SYRINGE KIT   6 Specialty Tier Drugs 33%N/AP Q:6
/28Days
Cinryze 500[iU]/5mL 1 VIAL in 1 CARTON / 5 mL in 1 VIAL   6 Specialty Tier Drugs 33%N/AP
CIPRO IV INFUSION 200MG 100ML BAG   5 Injectable Drug 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CIPRODEX OTIC SUSPENSION   3 Preferred Brand Drugs $45.00$112.50None
CIPROFLOXACIN 0.3% EYE DROP   2 Non-Preferred Generic Drugs $7.00$10.50None
CIPROFLOXACIN 250MG TABLET (100 CT)   2 Non-Preferred Generic Drugs $7.00$10.50None
Ciprofloxacin 400mg/40mL 1 VIAL in 1 CARTON / 40 mL in 1 VIAL   5 Injectable Drug 33%33%None
CIPROFLOXACIN 500MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
Ciprofloxacin ER 212.6; 287.5mg/1; mg/1 50 TABLET, FILM COATED, in 1 BOTTLE, PLASTIC   2 Non-Preferred Generic Drugs $7.00$10.50Q:3
/1Days
Ciprofloxacin ER 425.2; 574.9mg/1; mg/1 50 TABLET, FILM COATED, in 1 BOTTLE, PLASTIC   2 Non-Preferred Generic Drugs $7.00$10.50Q:14
/1Days
CIPROFLOXACIN HCL 100MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
CIPROFLOXACIN TABLETS 750MG 100 BOT   2 Non-Preferred Generic Drugs $7.00$10.50None
Cisplatin 100mg/100mL 1 VIAL in 1 CARTON / 100 mL in 1 VIAL   5 Injectable Drug 33%33%P
CITALOPRAM HBR 20 MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50Q:45
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CITALOPRAM HBR ORAL SOLUTION 10MG 240ML BOTPL   2 Non-Preferred Generic Drugs $7.00$10.50Q:600
/30Days
CITALOPRAM HYDROBROMIDE TABLETS 40MG 30 BOT   2 Non-Preferred Generic Drugs $7.00$10.50Q:30
/30Days
CITOLOPRAM HBR 10MG TABLET (100 CT)   2 Non-Preferred Generic Drugs $7.00$10.50Q:45
/30Days
CLADRIBINE 1MG/ML VIAL   6 Specialty Tier Drugs 33%N/AP
CLAFORAN 10GM VIAL   5 Injectable Drug 33%33%None
CLAFORAN 500MG VIAL   5 Injectable Drug 33%33%None
CLAFORAN INJECTION ADD VANTAGE SYSTEM 1GM 25 X 1GM VIAL   5 Injectable Drug 33%33%None
CLAFORAN INJECTION STERILE 2GM 10 X 2GM VIAL   5 Injectable Drug 33%33%None
CLARAVIS 10MG CAPSULE   2 Non-Preferred Generic Drugs $7.00$10.50None
CLARAVIS 20MG CAPSULE   2 Non-Preferred Generic Drugs $7.00$10.50None
Claravis 30mg/1 3 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK   2 Non-Preferred Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLARAVIS 40MG CAPSULE   2 Non-Preferred Generic Drugs $7.00$10.50None
CLARITHROMYCIN 250MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
CLARITHROMYCIN 500MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
CLARITHROMYCIN ER 500MG TABLET (60 CT)   2 Non-Preferred Generic Drugs $7.00$10.50Q:28
/1Days
CLARITHROMYCIN FOR ORAL SUSPENSION   2 Non-Preferred Generic Drugs $7.00$10.50None
CLARITHROMYCIN FOR ORAL SUSPENSION   2 Non-Preferred Generic Drugs $7.00$10.50None
CLEMASTINE FUM 2.68MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
CLEMASTINE FUMARATE SYRUP   2 Non-Preferred Generic Drugs $7.00$10.50None
CLEOCIN 300MG/D5W/GALAXY   5 Injectable Drug 33%33%None
CLEOCIN 600MG/D5W/GALAXY   5 Injectable Drug 33%33%None
CLEOCIN 900MG/D5W/GALAXY   5 Injectable Drug 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLEOCIN PHOS 150MG/ML VIAL   5 Injectable Drug 33%33%None
CLINDAMYCIN 150MG/ML ADDVAN   5 Injectable Drug 33%33%None
CLINDAMYCIN HCL 150MG CAPSULE   2 Non-Preferred Generic Drugs $7.00$10.50None
CLINDAMYCIN HYDROCHLORIDE CAPSULES   2 Non-Preferred Generic Drugs $7.00$10.50None
CLINDAMYCIN PHOSP 1% LOTION   2 Non-Preferred Generic Drugs $7.00$10.50None
clindamycin phosphate 10mg/mL 1 BOTTLE in 1 CARTON / 60 mL in 1 BOTTLE   2 Non-Preferred Generic Drugs $7.00$10.50None
Clindamycin Phosphate and Benzoyl Peroxide 1 KIT   2 Non-Preferred Generic Drugs $7.00$10.50None
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE   2 Non-Preferred Generic Drugs $7.00$10.50None
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX   2 Non-Preferred Generic Drugs $7.00$10.50None
CLINDAMYCIN PHOSPHATE VAGINAL CREAM   2 Non-Preferred Generic Drugs $7.00$10.50None
CLINIMIX 2.75%/5% INJECTION 1000ML BAG   5 Injectable Drug 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLINIMIX 4.25/10 SOLUTION   5 Injectable Drug 33%33%None
CLINIMIX 4.25/20 SOLUTION   5 Injectable Drug 33%33%None
CLINIMIX 4.25/25 SOLUTION   5 Injectable Drug 33%33%None
CLINIMIX 4.25/5 SOLUTION   5 Injectable Drug 33%33%None
CLINIMIX 5/15 SOLUTION   5 Injectable Drug 33%33%None
CLINIMIX 5/20 SOLUTION   5 Injectable Drug 33%33%None
CLINIMIX 5/25 SULFITE FREE INJECTIONS 1035MG-420MEQ 1000ML BAG   5 Injectable Drug 33%33%None
CLINIMIX E 2.75/10 SOLUTION   5 Injectable Drug 33%33%None
CLINIMIX E 2.75/5 SOLUTION   5 Injectable Drug 33%33%None
CLINIMIX E 4.25/25 SOLUTION   5 Injectable Drug 33%33%None
CLINIMIX E 4.25/5 SOLUTION   5 Injectable Drug 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLINIMIX E 5/20 SOLUTION   5 Injectable Drug 33%33%None
CLINIMIX E 5/25 SOLUTION   5 Injectable Drug 33%33%None
CLINIMIX E 5%/15% INJECTION 2000ML BAG   5 Injectable Drug 33%33%None
CLINISOL 15% SOLUTION   5 Injectable Drug 33%33%None
CLOBETASOL 0.05% OINTMENT   2 Non-Preferred Generic Drugs $7.00$10.50None
CLOBETASOL E 0.05% CREAM   2 Non-Preferred Generic Drugs $7.00$10.50None
Clobetasol Propionate 0.5mg/g 1 CAN in 1 CARTON / 100 g in 1 CAN   2 Non-Preferred Generic Drugs $7.00$10.50None
Clobetasol Propionate 0.5mg/mL 50 mL in 1 BOTTLE, PLASTIC   2 Non-Preferred Generic Drugs $7.00$10.50None
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE   2 Non-Preferred Generic Drugs $7.00$10.50None
CLOLAR 1MG/ML VIAL   6 Specialty Tier Drugs 33%N/AP
CLOMIPRAMINE HCL 25MG CAPSULE   2 Non-Preferred Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLOMIPRAMINE HCL 50MG CAPSULE   2 Non-Preferred Generic Drugs $7.00$10.50None
CLOMIPRAMINE HCL 75MG CAPSULE   2 Non-Preferred Generic Drugs $7.00$10.50None
Clonidine 0.1mg/d 4 POUCH in 1 CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH   2 Non-Preferred Generic Drugs $7.00$10.50Q:4
/28Days
Clonidine 0.2mg/d 4 POUCH in 1 CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH   2 Non-Preferred Generic Drugs $7.00$10.50Q:4
/28Days
Clonidine 0.3mg/d 4 POUCH in 1 CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH   2 Non-Preferred Generic Drugs $7.00$10.50Q:4
/28Days
CLONIDINE HCL 0.2MG TABLET (500 CT)   2 Non-Preferred Generic Drugs $7.00$10.50None
CLONIDINE HCL TABLET 0.1MG (500 CT)   2 Non-Preferred Generic Drugs $7.00$10.50None
CLONIDINE HCL TABLET 0.3MG (100 CT)   2 Non-Preferred Generic Drugs $7.00$10.50None
CLOPIDOGREL 300 MG tablet   3 Preferred Brand Drugs $45.00$112.50None
CLOPIDOGREL TAB 75MG   2 Non-Preferred Generic Drugs $7.00$10.50Q:30
/30Days
CLOTRIMAZOLE 1% CREAM   2 Non-Preferred Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLOTRIMAZOLE 10MG TROCHE   2 Non-Preferred Generic Drugs $7.00$10.50None
CLOTRIMAZOLE SOLUTION TOPICAL 1% 30ML BOTPL   2 Non-Preferred Generic Drugs $7.00$10.50None
CLOTRIMAZOLE-BETAMETHASONE 1-0.05% LOTION   2 Non-Preferred Generic Drugs $7.00$10.50None
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE 0.64; 10mg/g; mg/g 45 g in 1 TUBE   2 Non-Preferred Generic Drugs $7.00$10.50None
CLOZAPINE 100mg/1 100 TABLET in 1 BOTTLE   2 Non-Preferred Generic Drugs $7.00$10.50Q:270
/30Days
CLOZAPINE 200MG TABLET (500 CT)   2 Non-Preferred Generic Drugs $7.00$10.50Q:120
/30Days
CLOZAPINE 25MG TABLET (100 CT)   2 Non-Preferred Generic Drugs $7.00$10.50Q:90
/30Days
CLOZAPINE 50MG TABLET (500 CT)   2 Non-Preferred Generic Drugs $7.00$10.50Q:90
/30Days
CO-GESIC 5/500 TABLET   2 Non-Preferred Generic Drugs $7.00$10.50Q:240
/30Days
COARTEM 20MG-120MG   4 Non-Preferred Brand Drugs $90.00$225.00None
CODEINE SULFATE 30 MG TABLET 3100   2 Non-Preferred Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Codeine sulfate 60mg/1 100 TABLET in 1 BOTTLE   2 Non-Preferred Generic Drugs $7.00$10.50None
CODEINE SULFATE TABLETS   2 Non-Preferred Generic Drugs $7.00$10.50None
COGENTIN 1MG/ML AMPUL   5 Injectable Drug 33%33%None
Colcrys 0.6mg/1 100 TABLET, FILM COATED in 1 BOTTLE, PLASTIC   4 Non-Preferred Brand Drugs $90.00$225.00P
COLESTIPOL HCL 1G TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
COLESTIPOL HYDROCHLORIDE 5g/1 100 SUSPENSION in 1 BOTTLE   2 Non-Preferred Generic Drugs $7.00$10.50None
colistimethate 150mg/2mL 1 VIAL in 1 CARTON / 2 mL in 1 VIAL   5 Injectable Drug 33%33%None
COLLAGENASE SANTYL OINTMENT 250UNT 30GM TUBE   3 Preferred Brand Drugs $45.00$112.50None
COLY MYCIN M FOR INJECTION 150MG/VIAL 5 ML VIALSD   6 Specialty Tier Drugs 33%N/ANone
Colyte with flavor packs 240; 2.98; 6.72; 5.84; 22.72g/4L; g/4L; g/4L; g/4L; g/4L   4 Non-Preferred Brand Drugs $90.00$225.00None
COMBIGAN 0.2%-0.5% DROPS   3 Preferred Brand Drugs $45.00$112.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COMBIVENT INHALER   4 Non-Preferred Brand Drugs $90.00$225.00Q:45
/30Days
COMBIVIR 150; 300mg/1; mg/1 120 TABLET, FILM COATED in 1 DOSE PACK   6 Specialty Tier Drugs 33%N/ANone
COMPLERA 200; 27.5; 300mg/1; mg/1; mg/1   6 Specialty Tier Drugs 33%N/ANone
COMPRO 25MG SUPPOSITORY   2 Non-Preferred Generic Drugs $7.00$10.50None
COMTAN 200MG TABLET   4 Non-Preferred Brand Drugs $90.00$225.00None
COMVAX VACCINE VIAL   3 Preferred Brand Drugs $45.00$112.50None
CONSTULOSE 10GM/15ML SYRUP   2 Non-Preferred Generic Drugs $7.00$10.50None
COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN   6 Specialty Tier Drugs 33%N/AP
COPEGUS 200MG TABLET   6 Specialty Tier Drugs 33%N/ANone
CORTISONE ACETATE 25MG TABLET (100 CT)   1 Preferred Generic Drugs $2.00$3.00None
Cortomycin 10; 3.5; 10000mg/mL; mg/mL; [USP'U]/mL 1 10 mL BOTTLE, DROPPER   1 Preferred Generic Drugs $2.00$3.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Cortomycin 10; 3.5; 10000mg/mL; mg/mL; [USP'U]/mL 1 10 mL BOTTLE, DROPPER   1 Preferred Generic Drugs $2.00$3.00None
COSMEGEN 0.5MG VIAL   6 Specialty Tier Drugs 33%N/AP
COUMADIN 10MG TABLET   4 Non-Preferred Brand Drugs $90.00$225.00None
COUMADIN 1MG TABLET   4 Non-Preferred Brand Drugs $90.00$225.00None
COUMADIN 2.5MG TABLET   4 Non-Preferred Brand Drugs $90.00$225.00None
COUMADIN 2MG TABLET   4 Non-Preferred Brand Drugs $90.00$225.00None
COUMADIN 3mg/1 1 BOTTLE in 1 CARTON / 100 TABLET in 1 BOTTLE   4 Non-Preferred Brand Drugs $90.00$225.00None
COUMADIN 4mg/1 1 BOTTLE in 1 CARTON / 100 TABLET in 1 BOTTLE   4 Non-Preferred Brand Drugs $90.00$225.00None
COUMADIN 5MG TABLET   4 Non-Preferred Brand Drugs $90.00$225.00None
COUMADIN 5MG VIAL   5 Injectable Drug 33%33%None
COUMADIN 6MG TABLET   4 Non-Preferred Brand Drugs $90.00$225.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COUMADIN 7.5MG TABLET   4 Non-Preferred Brand Drugs $90.00$225.00None
Creon 256.11mg/1 1 BOTTLE in 1 CARTON / 70 CAPSULE, DELAYED RELEASE in 1 BOTTLE   3 Preferred Brand Drugs $45.00$112.50None
CREON DELAYED RELEASE CAPSULES 12000MG 100 BOT   3 Preferred Brand Drugs $45.00$112.50None
CREON DELAYED RELEASE CAPSULES 24000MG 100 BOT   3 Preferred Brand Drugs $45.00$112.50None
CREON DELAYED RELEASE CAPSULES 6000MG 100 BOT   3 Preferred Brand Drugs $45.00$112.50None
CRESTOR 10MG TABLET   3 Preferred Brand Drugs $45.00$112.50S Q:30
/30Days
CRESTOR 20MG TABLET   3 Preferred Brand Drugs $45.00$112.50S Q:30
/30Days
CRESTOR 40mg/1 30 TABLET, FILM COATED in 1 BOTTLE, PLASTIC   3 Preferred Brand Drugs $45.00$112.50S Q:30
/30Days
CRESTOR 5MG TABLET   3 Preferred Brand Drugs $45.00$112.50S Q:30
/30Days
CRIXIVAN 100MG CAPSULE   3 Preferred Brand Drugs $45.00$112.50None
CRIXIVAN 200MG CAPSULE   3 Preferred Brand Drugs $45.00$112.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CRIXIVAN 400mg/1 90 CAPSULE in 1 BOTTLE   3 Preferred Brand Drugs $45.00$112.50None
CROMOLYN NEBULIZER SOLUTION   1 Preferred Generic Drugs $2.00$3.00P Q:240
/30Days
CROMOLYN SODIUM 100 MG/5 ML   3 Preferred Brand Drugs $45.00$112.50None
CROMOLYN SODIUM 4% 40MG 10ML BOT   1 Preferred Generic Drugs $2.00$3.00None
CUBICIN 500MG VIAL   6 Specialty Tier Drugs 33%N/AP
CUPRIMINE CAPSULES 250MG (100 CT)   3 Preferred Brand Drugs $45.00$112.50None
Cyclafem 1/35 6 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK   2 Non-Preferred Generic Drugs $7.00$10.50None
Cyclafem 7/7/7 6 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK   2 Non-Preferred Generic Drugs $7.00$10.50None
CYCLOBENZAPRINE HCL 10MG TABLET (1000 CT)   2 Non-Preferred Generic Drugs $7.00$10.50None
CYCLOBENZAPRINE HCL 5MG TABLET (500 CT)   2 Non-Preferred Generic Drugs $7.00$10.50None
CYCLOPHOSPHAMIDE 25MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CYCLOPHOSPHAMIDE 50MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50P
CYCLOSPORINE 100MG CAPSULE   2 Non-Preferred Generic Drugs $7.00$10.50P
Cyclosporine 100mg/1 30 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK   2 Non-Preferred Generic Drugs $7.00$10.50P
CYCLOSPORINE 25MG CAPSULE   2 Non-Preferred Generic Drugs $7.00$10.50P
Cyclosporine 50mg/1 30 BLISTER PACK in 1 CARTON / 1 CAPSULE, LIQUID FILLED in 1 BLISTER PACK   2 Non-Preferred Generic Drugs $7.00$10.50P
Cyclosporine 50mg/mL 10 VIAL in 1 BOX / 5 mL in 1 VIAL   5 Injectable Drug 33%33%P
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT   2 Non-Preferred Generic Drugs $7.00$10.50P
CYKLOKAPRON 100MG/ML AMPUL   5 Injectable Drug 33%33%None
CYMBALTA 20MG CAPSULE   3 Preferred Brand Drugs $45.00$112.50Q:60
/30Days
Cymbalta 60mg/1 1000 CAPSULE, DELAYED RELEASE in 1 BOTTLE   3 Preferred Brand Drugs $45.00$112.50Q:60
/30Days
CYMBALTA CAPSULES DELAYED RELEASE 30MG (30 CT)   3 Preferred Brand Drugs $45.00$112.50Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CYPROHEPTADINE HCL 4 MG   2 Non-Preferred Generic Drugs $7.00$10.50None
CYPROHEPTADINE HYDROCHLORIDE SOLUTION USP SYRUP 2MG 473 ML BOTGL   2 Non-Preferred Generic Drugs $7.00$10.50None
CYSTADANE POWDER FOR ORAL SOLUTION 180GM   3 Preferred Brand Drugs $45.00$112.50None
CYSTAGON 150MG CAPSULE   3 Preferred Brand Drugs $45.00$112.50None
CYSTAGON 50MG CAPSULE   3 Preferred Brand Drugs $45.00$112.50None
CYTARABINE 20MG/ML VIAL   5 Injectable Drug 33%33%P
CYTARABINE 500MG VIAL   5 Injectable Drug 33%33%P
CYTARABINE SOLUTION INJECTION 100MG 20ML VIALSD   5 Injectable Drug 33%33%P
CYTOVENE IV INJECTION   5 Injectable Drug 33%33%None

Chart Legend:

Below are a few notes to help you understand the above 2012 Medicare Part D Blue Cross MedicareRx 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 $320 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 $2930) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2012 Humana Walmart-Preferred Rx Plan the cost-sharing 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 September 2012 )

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







Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.