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2012 Medicare Part D and Medicare Advantage Plan Formulary Browser

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CVS Caremark Value (PDP) (S5601-064-0)
Tier 1 (1871)
Tier 2 (805)
Tier 3 (94)
Tier 4 (274)

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2012 Medicare Part D Plan Formulary Information
CVS Caremark Value (PDP) (S5601-064-0)
Benefit Details           
The CVS Caremark Value (PDP) (S5601-064-0)
Formulary Drugs Starting with the Letter P

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

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
PACERONE 100MG TABLET   2 Preferred Brand Drugs $45.00$101.25None
PACERONE 200MG TABLET   1 Generic Drugs $7.00$10.50None
PACLITAXEL INJECTION SOLUTION 6MG 50ML VIALMD   1 Generic Drugs $7.00$10.50P
PANCREAZE 10,500 UNIT CAP DR   2 Preferred Brand Drugs $45.00$101.25None
PANCREAZE 16,800 UNIT CAP DR   2 Preferred Brand Drugs $45.00$101.25None
PANCREAZE 21,000 UNIT CAP DR   2 Preferred Brand Drugs $45.00$101.25None
PANCREAZE 4,200 UNIT CAP DR   2 Preferred Brand Drugs $45.00$101.25None
PANRETIN 0.1% GEL 60GM TUBE   4 Specialty Tier Drugs 25%N/ANone
PAROMOMYCIN 250MG CAPSULE   1 Generic Drugs $7.00$10.50None
PAROXETINE FILM COATED 20MG TABLET (100 CT)   1 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
PAROXETINE HCL 10MG/5ML SUSPENSION ORAL   1 Generic Drugs $7.00$10.50None
PAROXETINE HCL TABLET 24 12.5MG   1 Generic Drugs $7.00$10.50Q:30
/30Days
PAROXETINE HCL TABLET 24 25MG   1 Generic Drugs $7.00$10.50None
Paroxetine Hydrochloride 37.5mg/1 30 BOTTLE in 1 BOTTLE / 30 TABLET, FILM COATED, EXTENDED RELEASE   1 Generic Drugs $7.00$10.50None
PAROXETINE HYDROCHLORIDE TABLETS 10 MG   1 Generic Drugs $7.00$10.50Q:45
/30Days
PAROXETINE TABLETS 30MG 90 BOT   1 Generic Drugs $7.00$10.50None
PAROXETINE40mg/1   1 Generic Drugs $7.00$10.50None
PASER GRANULES 4GM PACKET   3 Non-Preferred Brand Drugs $95.00$261.25None
PATADAY 0.2% DROPS   2 Preferred Brand Drugs $45.00$101.25None
PATANASE 665ug/1 240 SPRAY, METERED in 1 BOTTLE   3 Non-Preferred Brand Drugs $95.00$261.25None
PATANOL 0.1% EYE DROPS   2 Preferred Brand Drugs $45.00$101.25None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PEDI-DRI TOPICAL POWDER   1 Generic Drugs $7.00$10.50None
PEDVAXHIB VACCINE VIAL   2 Preferred Brand Drugs $45.00$101.25None
PEGANONE 250MG TABLET   2 Preferred Brand Drugs $45.00$101.25None
PEGASYS 180MCG/0.5ML CONV.PK   4 Specialty Tier Drugs 25%N/AP
PEGASYS INJECTION   4 Specialty Tier Drugs 25%N/AP
PEGASYS PROCLICK 135 MCG/0.5   4 Specialty Tier Drugs 25%N/AP
PEGINTRON 1 KIT in 1 CARTON   4 Specialty Tier Drugs 25%N/AP
PegIntron 120ug/0.5mL 1 CARTRIDGE in 1 CARTON / 0.5 mL in 1 CARTRIDGE   4 Specialty Tier Drugs 25%N/AP
PegIntron 150ug/0.5mL 1 CARTRIDGE in 1 CARTON / 0.5 mL in 1 CARTRIDGE   4 Specialty Tier Drugs 25%N/AP
PegIntron 50ug/0.5mL 1 CARTRIDGE in 1 CARTON / 0.5 mL in 1 CARTRIDGE   4 Specialty Tier Drugs 25%N/AP
PegIntron 80ug/0.5mL 1 CARTRIDGE in 1 CARTON / 0.5 mL in 1 CARTRIDGE   4 Specialty Tier Drugs 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PENICILLIN G POTASSIUM FOR INJECTION 5000000UNIT/VIAL   1 Generic Drugs $7.00$10.50None
PENICILLIN G PROCAINE 1200000UNT 2ML CTG   2 Preferred Brand Drugs $45.00$101.25None
PENICILLIN V POTASSIUM 250MG TABLET (1000 CT)   1 Generic Drugs $7.00$10.50None
PENICILLIN V POTASSIUM 250MG/5ML LIQUID   1 Generic Drugs $7.00$10.50None
PENICILLIN V POTASSIUM 500MG TABLET   1 Generic Drugs $7.00$10.50None
PENICILLIN V POTASSIUM FOR ORAL SOLUTION CONCENTRATE 125MG 200ML BOT   1 Generic Drugs $7.00$10.50None
PENNSAID SOLUTION   2 Preferred Brand Drugs $45.00$101.25None
PENTASA 250MG CAPSULE SA   2 Preferred Brand Drugs $45.00$101.25None
PENTASA 500MG CAPSULE   2 Preferred Brand Drugs $45.00$101.25None
PENTOPAK 400MG TABLET SA   1 Generic Drugs $7.00$10.50None
PENTOSTATIN FOR INJECTION 10MG/VIAL   1 Generic Drugs $7.00$10.50P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PENTOXIFYLLINE 400MG TABLET SA   1 Generic Drugs $7.00$10.50None
PERFOROMIST 20MCG/2ML VIAL NEBULIZER   3 Non-Preferred Brand Drugs $95.00$261.25P
Perindopril Erbumine 2mg/1 100 TABLET in 1 BOTTLE   1 Generic Drugs $7.00$10.50None
Perindopril Erbumine 4mg/1 100 TABLET in 1 BOTTLE   1 Generic Drugs $7.00$10.50None
Perindopril Erbumine 8mg/1 100 TABLET in 1 BOTTLE   1 Generic Drugs $7.00$10.50None
PERIOGARD 0.12% ORAL RINSE   1 Generic Drugs $7.00$10.50None
Permethrin 50mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE   1 Generic Drugs $7.00$10.50None
PERPHENAZINE 16 MG TABLET   1 Generic Drugs $7.00$10.50None
PERPHENAZINE TABLETS 4MG 100 BOXUD   1 Generic Drugs $7.00$10.50None
PERPHENAZINE TABLETS 8MG 100 BOT   1 Generic Drugs $7.00$10.50None
PERPHENAZINE TABLETS USP 2MG 100 BOT   1 Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PHENADOZ 12.5MG SUPPOSITORY   1 Generic Drugs $7.00$10.50P
PHENADOZ 25MG SUPPOSITORY   1 Generic Drugs $7.00$10.50P
Phenelzine Sulfate 15mg/1 60 TABLET in 1 BOTTLE   1 Generic Drugs $7.00$10.50None
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT   1 Generic Drugs $7.00$10.50None
PHENYTOIN SOD EXT 200 MG CAP   1 Generic Drugs $7.00$10.50None
PHENYTOIN SODIUM EXTENDED CAPSULES 100MG (100 CT)   1 Generic Drugs $7.00$10.50None
PHENYTOIN SODIUM INJECTION 50MG 25 X 2ML AMP   1 Generic Drugs $7.00$10.50None
PHOSLO 667MG CAPSULE   2 Preferred Brand Drugs $45.00$101.25None
Phoslyra 667mg/5mL 1 BOTTLE in 1 CARTON / 473 mL in 1 BOTTLE   2 Preferred Brand Drugs $45.00$101.25None
PILOCARPINE HCL 5MG TABLET (100 CT)   1 Generic Drugs $7.00$10.50None
Pilocarpine Hydrochloride 7.5mg/1 100 TABLET, FILM COATED in 1 BOTTLE   1 Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PILOPINE HS 4% EYE GEL   2 Preferred Brand Drugs $45.00$101.25None
PINDOLOL 10MG TABLET   1 Generic Drugs $7.00$10.50None
PINDOLOL 5MG TABLET   1 Generic Drugs $7.00$10.50None
PIPERACILLIN 200 MG/ML / TAZOBACTAM 25 MG/ML INJECTABLE SOLUTION   1 Generic Drugs $7.00$10.50None
Piperacillin and Tazobactam 4; 0.5g/1; g/1 10 VIAL, SINGLE-USE in 1 CARTON / 1 INJECTION, POWDER, L   1 Generic Drugs $7.00$10.50None
PIROXICAM 10 MG CAPSULE   1 Generic Drugs $7.00$10.50None
Piroxicam 20mg/1 500 CAPSULE in 1 BOTTLE   1 Generic Drugs $7.00$10.50None
PLASMA-LYTE 148 IV SOLUTION   2 Preferred Brand Drugs $45.00$101.25None
PLASMA-LYTE 148/DEXTROSE 5%   2 Preferred Brand Drugs $45.00$101.25None
PLASMA-LYTE 56 INJECTION 32;128 MG/100ML;   2 Preferred Brand Drugs $45.00$101.25None
PLASMA-LYTE 56/DEXTROSE 5%   2 Preferred Brand Drugs $45.00$101.25None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PLASMA-LYTE A PH 7.4 SOLUTION 37;368; MG/100ML;   2 Preferred Brand Drugs $45.00$101.25None
PLASMA-LYTE INJ-R   1 Generic Drugs $7.00$10.50None
PLAVIX 75MG TABLET   2 Preferred Brand Drugs $45.00$101.25None
PLAVIX TABLETS 300MG   2 Preferred Brand Drugs $45.00$101.25Q:1
/30Days
PODOFILOX 0.5% TOPICAL TUBEX   1 Generic Drugs $7.00$10.50None
POLY-DEX 0.1% SUSPENSION DROPS   1 Generic Drugs $7.00$10.50None
POLY-DEX 3.5-10K-.1 OINTMENT   1 Generic Drugs $7.00$10.50None
POLYETH GLYC NF POWDER FOR ORAL SOLUTION 17GM (527 CT)   1 Generic Drugs $7.00$10.50None
POLYETHYLENE GLYCOL 3350 105 MG/ML / POTASSIUM CHLORIDE 0.00497 MEQ/ML / SODIUM BICARBONATE 1.43 MG/   1 Generic Drugs $7.00$10.50None
POLYMYXIN B SUL-TRIMETHOPRIM 10K U-0.1%   1 Generic Drugs $7.00$10.50None
PORTIA 0.15-0.03 TABLET   1 Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
POTASSIUM CHLORIDE 0.075%/D5W/SODIUM CHLORIDE 0.2%   1 Generic Drugs $7.00$10.50None
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.3%   1 Generic Drugs $7.00$10.50None
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.45%   1 Generic Drugs $7.00$10.50None
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.9% 1000ML   1 Generic Drugs $7.00$10.50None
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.2%   1 Generic Drugs $7.00$10.50None
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.45% 1000ML BAG   1 Generic Drugs $7.00$10.50None
POTASSIUM CHLORIDE 10MEQ/100ML SOL   1 Generic Drugs $7.00$10.50None
POTASSIUM CHLORIDE 10MEQ/50ML SOL   1 Generic Drugs $7.00$10.50None
POTASSIUM CHLORIDE 149mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 5 mL in 1 VIAL, SINGLE-DOSE   1 Generic Drugs $7.00$10.50None
Potassium Chloride 20.000000meq/1   1 Generic Drugs $7.00$10.50None
POTASSIUM CHLORIDE 20MEQ IN D5W/NACL 0.225%   2 Preferred Brand Drugs $45.00$101.25None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
POTASSIUM CHLORIDE 20MEQ/50ML SOL   1 Generic Drugs $7.00$10.50None
POTASSIUM CHLORIDE 30MEQ/100ML SOL   1 Generic Drugs $7.00$10.50None
POTASSIUM CHLORIDE 40MEQ IN D5W/NACL 0.9%   2 Preferred Brand Drugs $45.00$101.25None
POTASSIUM CHLORIDE 40MEQ/NS 1000ML IV SOLUTION   2 Preferred Brand Drugs $45.00$101.25None
POTASSIUM CHLORIDE ER CAPSULES 10MEQ   1 Generic Drugs $7.00$10.50None
POTASSIUM CHLORIDE ER CPCR 8MEQ   1 Generic Drugs $7.00$10.50None
POTASSIUM CHLORIDE EXTENDED RELEASE TABLETS   1 Generic Drugs $7.00$10.50None
POTASSIUM CHLORIDE IN 10% DEXTROSE AND NACL SOLUTION FOR INJECTION   2 Preferred Brand Drugs $45.00$101.25None
POTASSIUM CHLORIDE IN 5% DEXTROSE AND 0.2% NACL SOLUTION FOR INJECTION USP 0.15% 250ML X 24 CASE   1 Generic Drugs $7.00$10.50None
POTASSIUM CHLORIDE IN 5% DEXTROSE AND NACL SOLUTION FOR INJECTION 0.075% 1000ML PLASTIC BAGS X 12 CA   1 Generic Drugs $7.00$10.50None
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION   1 Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION   1 Generic Drugs $7.00$10.50None
POTASSIUM CHLORIDE IN 5% DEXTROSE INJECTION 40 12 X 1000ML CTR   1 Generic Drugs $7.00$10.50None
POTASSIUM CHLORIDE IN DEXTROSE INJECTION 5GM/75MG   2 Preferred Brand Drugs $45.00$101.25None
Potassium Chloride in Lactated Ringers and Dextrose 20; 5; 179; 600; 310mg/100mL; g/100mL; mg/100mL   2 Preferred Brand Drugs $45.00$101.25None
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION   1 Generic Drugs $7.00$10.50None
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION 0.15%-0.9% 12 X 1000ML BAG   1 Generic Drugs $7.00$10.50None
POTASSIUM CITRATE 10MEQ TABLET SA   1 Generic Drugs $7.00$10.50None
POTASSIUM CITRATE 5MEQ TABLET SA   1 Generic Drugs $7.00$10.50None
POTIGA 200 MG TABLET   3 Non-Preferred Brand Drugs $95.00$261.25None
POTIGA 300 MG TABLET   3 Non-Preferred Brand Drugs $95.00$261.25None
POTIGA 400 MG TABLET   3 Non-Preferred Brand Drugs $95.00$261.25None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
POTIGA 50 MG TABLET   3 Non-Preferred Brand Drugs $95.00$261.25None
PRADAXA 150mg/1 1 BOTTLE in 1 CARTON / 60 CAPSULE in 1 BOTTLE   2 Preferred Brand Drugs $45.00$101.25None
PRADAXA 75mg/1 1 BOTTLE in 1 CARTON / 60 CAPSULE in 1 BOTTLE   2 Preferred Brand Drugs $45.00$101.25None
PRAMIPEXOLE 0.125 MG TABLET   1 Generic Drugs $7.00$10.50None
PRAMIPEXOLE 0.25 MG TABLET   1 Generic Drugs $7.00$10.50None
PRAMIPEXOLE 0.5 MG TABLET   1 Generic Drugs $7.00$10.50None
PRAMIPEXOLE 1 MG TABLET   1 Generic Drugs $7.00$10.50None
PRAMIPEXOLE 1.5 MG TABLET   1 Generic Drugs $7.00$10.50None
PRAMIPEXOLE DIHYDROCHLORIDE TABLETS   1 Generic Drugs $7.00$10.50None
PRANDIN 0.5MG TABLET   2 Preferred Brand Drugs $45.00$101.25None
PRANDIN 1MG TABLET   2 Preferred Brand Drugs $45.00$101.25None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PRANDIN 2MG TABLET   2 Preferred Brand Drugs $45.00$101.25None
PRAVASTATIN SODIUM 20MG TABLET 500 BOT   1 Generic Drugs $7.00$10.50Q:45
/30Days
PRAVASTATIN SODIUM 40MG TABLET (500 CT)   1 Generic Drugs $7.00$10.50Q:45
/30Days
PRAVASTATIN SODIUM 80MG TABLET (90 CT)   1 Generic Drugs $7.00$10.50None
PRAVASTATIN SODIUM TABLETS 10MG 90 BOT   1 Generic Drugs $7.00$10.50Q:45
/30Days
PRAZOSIN 5MG CAPSULE   1 Generic Drugs $7.00$10.50None
PRAZOSIN HCL 1MG CAPSULE   1 Generic Drugs $7.00$10.50None
PRAZOSIN HCL 2MG CAPSULE   1 Generic Drugs $7.00$10.50None
PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION 1.0% STERILE 10ML BOTDR   1 Generic Drugs $7.00$10.50None
PREDNISOLONE SOD 1% EYE DROP   2 Preferred Brand Drugs $45.00$101.25None
PREDNISOLONE SODIUM PHOSPHATE 15MG/5ML SOLUTION ORAL   1 Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PREDNISOLONE SODIUM PHOSPHATE ORAL SOLUTION   1 Generic Drugs $7.00$10.50None
PREDNISONE 10MG TABLET (100 CT)   1 Generic Drugs $7.00$10.50None
PREDNISONE 1MG TABLET   1 Generic Drugs $7.00$10.50None
PREDNISONE 2.5MG TABLET   1 Generic Drugs $7.00$10.50None
PREDNISONE 20MG TABLET (1000 CT)   1 Generic Drugs $7.00$10.50None
PREDNISONE 5 MG TABLET   1 Generic Drugs $7.00$10.50None
PREDNISONE 50MG TABLET   1 Generic Drugs $7.00$10.50None
PREDNISONE 5MG/5ML SOLUTION   1 Generic Drugs $7.00$10.50None
PREDNISONE 5MG/ML SOLUTION   2 Preferred Brand Drugs $45.00$101.25None
PREGNYL INJ 10000UNT   1 Generic Drugs $7.00$10.50P
PREMARIN 0.3MG (100 CT)   2 Preferred Brand Drugs $45.00$101.25P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PREMARIN 0.45MG TABLET   2 Preferred Brand Drugs $45.00$101.25P
PREMARIN 0.625MG (100 CT)   2 Preferred Brand Drugs $45.00$101.25P
Premarin 0.625mg/g   2 Preferred Brand Drugs $45.00$101.25None
PREMARIN 0.9MG TABLET   2 Preferred Brand Drugs $45.00$101.25P
PREMARIN 1.25MG (100 CT)   2 Preferred Brand Drugs $45.00$101.25P
PREMARIN 25MG VIAL   2 Preferred Brand Drugs $45.00$101.25None
PREMASOL 10% IV SOLUTION   2 Preferred Brand Drugs $45.00$101.25P
PREMASOL 6% IV SOLUTION   1 Generic Drugs $7.00$10.50P
Premphase 1 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK   2 Preferred Brand Drugs $45.00$101.25P
PREMPRO 0.3 MG-1.5 MG TABLET #28 EA   2 Preferred Brand Drugs $45.00$101.25P
PREMPRO 0.45-1.5 MG TABLET 28 EA   2 Preferred Brand Drugs $45.00$101.25P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Prempro 0.625; 2.5mg/1; mg/1 1 BLISTER PACK in 1 CARTON / 28 TABLET, SUGAR COATED in 1 BLISTER PACK   2 Preferred Brand Drugs $45.00$101.25P
PREVALITE POW 4GM   1 Generic Drugs $7.00$10.50None
Previfem 6 BLISTER PACK in 1 BLISTER PACK / 1 KIT in 1 BLISTER PACK   1 Generic Drugs $7.00$10.50None
PREVPAC (TRIPLE THERAPY) KIT 30;500;500MG;MG;MG; 14 PKGCOM   2 Preferred Brand Drugs $45.00$101.25Q:14
/365Days
PREZISTA TABLET 600MG   4 Specialty Tier Drugs 25%N/ANone
PREZISTA TABLET 75MG   2 Preferred Brand Drugs $45.00$101.25None
PREZISTA TABLETS   2 Preferred Brand Drugs $45.00$101.25None
PREZISTA TABLETS 400MG 60 TABLETS BOT   4 Specialty Tier Drugs 25%N/ANone
PRIFTIN 150MG TABLET   3 Non-Preferred Brand Drugs $95.00$261.25None
PRIMAXIN I.M. 500MG VIAL   2 Preferred Brand Drugs $45.00$101.25None
Primidone 250mg/1 100 TABLET in 1 BOTTLE   1 Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Primidone 50mg/1 500 TABLET in 1 BOTTLE   1 Generic Drugs $7.00$10.50None
PRISTIQ 100MG TABLET SR 24HR   2 Preferred Brand Drugs $45.00$101.25None
Pristiq Extended-Release 50mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC   2 Preferred Brand Drugs $45.00$101.25Q:30
/30Days
PRIVIGEN 10% VIAL   4 Specialty Tier Drugs 25%N/AP
PROAIR HFA 90MCG HFA AEROSOL WITH ADAPTER   2 Preferred Brand Drugs $45.00$101.25Q:18
/30Days
PROBENECID 500MG TABLET   1 Generic Drugs $7.00$10.50None
PROBENECID/COLCHICINE TABLET S   1 Generic Drugs $7.00$10.50None
ProcalAmine 0.21; 0.29; 0.026; 0.014; 3; 0.42; 0.085; 0.21; 0.27; 0.22; 0.054; 0.16; 0.17; 0.041; 0   2 Preferred Brand Drugs $45.00$101.25P
PROCHLORPERAZINE EDISYLATE INJECTION 10MG 10 X 2ML VIALS CRTN   1 Generic Drugs $7.00$10.50None
PROCHLORPERAZINE MALEATE 10MG TABLET (100 CT)   1 Generic Drugs $7.00$10.50None
PROCHLORPERAZINE MALEATE 5MG TABLET (100 CT)   1 Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX   1 Generic Drugs $7.00$10.50None
PROCRIT 10000U/ML VIAL   2 Preferred Brand Drugs $45.00$101.25P
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL   2 Preferred Brand Drugs $45.00$101.25P
PROCRIT 3000U/ML VIAL   2 Preferred Brand Drugs $45.00$101.25P
PROCRIT 40000U/ML VIAL PR   4 Specialty Tier Drugs 25%N/AP
PROCRIT 4000U/ML VIAL 25 X 1ML VIAL   2 Preferred Brand Drugs $45.00$101.25P
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY   4 Specialty Tier Drugs 25%N/AP
PROCTO-PAK 1% CREAM   1 Generic Drugs $7.00$10.50None
Proctocream HC 25mg/g   1 Generic Drugs $7.00$10.50None
PROCTOSOL-HC 2.5% CREAM   1 Generic Drugs $7.00$10.50None
PROCTOZONE-HC 2.5% CREAM   1 Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Proglycem 50mg/mL 1 BOTTLE, DROPPER in 1 BOX / 30 mL in 1 BOTTLE, DROPPER   2 Preferred Brand Drugs $45.00$101.25None
PROGRAF 0.5MG CAPSULE   2 Preferred Brand Drugs $45.00$101.25P
PROGRAF 1MG CAPSULE   2 Preferred Brand Drugs $45.00$101.25P
Prograf 5mg/1 1 BOTTLE in 1 CARTON / 100 CAPSULE, GELATIN COATED in 1 BOTTLE   4 Specialty Tier Drugs 25%N/AP
PROLEUKIN 1.1mg/mL 1 VIAL, SINGLE-USE in 1 BOX / 1 mL in 1 VIAL, SINGLE-USE   4 Specialty Tier Drugs 25%N/AP
PROLIA INJECTION   3 Non-Preferred Brand Drugs $95.00$261.25None
PROMACTA 12.5 MG TABLET   4 Specialty Tier Drugs 25%N/AP
PROMACTA 25 MG TABLET   4 Specialty Tier Drugs 25%N/AP
PROMACTA 50 MG TABLET   4 Specialty Tier Drugs 25%N/AP
PROMACTA 75 MG TABLET   4 Specialty Tier Drugs 25%N/AP
PROMETHAZINE 50MG/ML VIAL   1 Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PROMETHAZINE HCL 25MG TABLET (1000 CT)   1 Generic Drugs $7.00$10.50P
PROMETHAZINE HCL 50MG TABLET (100 CT)   1 Generic Drugs $7.00$10.50P
PROMETHAZINE HCL 6.25MG/5ML SYRUP   1 Generic Drugs $7.00$10.50P
PROMETHAZINE HCL INJECTION 25MG 10 X 1ML VIAL   1 Generic Drugs $7.00$10.50None
Promethazine Hydrochloride 12.5mg/1 100 TABLET in 1 BOTTLE   1 Generic Drugs $7.00$10.50P
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 12.5MG 12 BOX   1 Generic Drugs $7.00$10.50P
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 25MG 12 BOX   1 Generic Drugs $7.00$10.50P
PROMETHAZINE VC PLAIN 6.25-5MG 16 FL OZ BOT   1 Generic Drugs $7.00$10.50P
PROMETHEGAN 25MG SUPP   1 Generic Drugs $7.00$10.50P
PROMETHEGAN 50MG SUPPOS   1 Generic Drugs $7.00$10.50P
PROPAFENONE HCL 150MG TABLET (100 CT)   1 Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PROPAFENONE HCL 225MG TABLET   1 Generic Drugs $7.00$10.50None
PROPAFENONE HCL 300MG TABLET (100 CT)   1 Generic Drugs $7.00$10.50None
Propafenone Hydrochloride 225mg/1 60 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC   1 Generic Drugs $7.00$10.50None
PROPAFENONE HYDROCHLORIDE CAPSULES EXTENDED RELEASE   1 Generic Drugs $7.00$10.50None
PROPAFENONE HYDROCHLORIDE CAPSULES EXTENDED RELEASE   1 Generic Drugs $7.00$10.50None
PROPARACAINE 0.5% EYE DROPS   1 Generic Drugs $7.00$10.50None
PROPRANOLOL 20MG/5ML TUBEX   1 Generic Drugs $7.00$10.50None
PROPRANOLOL 40MG/5ML TUBEX   1 Generic Drugs $7.00$10.50None
PROPRANOLOL 60MG TABLET   1 Generic Drugs $7.00$10.50None
PROPRANOLOL 80 MG TABLET   1 Generic Drugs $7.00$10.50None
PROPRANOLOL HCL 20MG TABLET (1000 CT)   1 Generic Drugs $7.00$10.50None
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 Generic Drugs $7.00$10.50None
PROPRANOLOL HCL TABLET USP 10MG (1000 CT)   1 Generic Drugs $7.00$10.50None
PROPRANOLOL HCL TABLET USP 40MG (1000 CT)   1 Generic Drugs $7.00$10.50None
Propranolol Hydrochloride 120mg/1 100 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC   1 Generic Drugs $7.00$10.50None
Propranolol Hydrochloride 160mg/1 100 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC   1 Generic Drugs $7.00$10.50None
Propranolol Hydrochloride 60mg/1 1000 CAPSULE, EXTENDED RELEASE in 1 BOTTLE   1 Generic Drugs $7.00$10.50None
Propranolol Hydrochloride 80mg/1 100 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC   1 Generic Drugs $7.00$10.50None
PROPYLTHIOURACIL 50MG TABLET   1 Generic Drugs $7.00$10.50None
PROQUAD VIAL   2 Preferred Brand Drugs $45.00$101.25None
PROSOL 20% INJECTION   2 Preferred Brand Drugs $45.00$101.25P
PROTOPIC 0.03% OINTMENT 100GM TUBE   2 Preferred Brand Drugs $45.00$101.25P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PROTOPIC 0.1% OINTMENT 60GM TUBE   2 Preferred Brand Drugs $45.00$101.25P
PROTRIPTYLINE HYDROCHLORIDE TABLETS   1 Generic Drugs $7.00$10.50None
PROTRIPTYLINE HYDROCHLORIDE TABLETS 5MG   1 Generic Drugs $7.00$10.50None
PULMOZYME 1MG/ML AMPUL   4 Specialty Tier Drugs 25%N/AP
PYRAZINAMIDE 500MG TABLET   1 Generic Drugs $7.00$10.50None
PYRIDOSTIGMINE BROMIDE 60MG TABLET   1 Generic Drugs $7.00$10.50None

Chart Legend:

Below are a few notes to help you understand the above 2012 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 $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.