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2012 Medicare Part D and Medicare Advantage Plan Formulary Browser

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EnvisionRxPlus Silver (PDP) (S7694-032-0)
Tier 1 (556)
Tier 2 (1128)
Tier 3 (355)
Tier 4 (327)
Tier 5 (252)
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2012 Medicare Part D Plan Formulary Information
EnvisionRxPlus Silver (PDP) (S7694-032-0)
Benefit Details           
The EnvisionRxPlus Silver (PDP) (S7694-032-0)
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 Non-Preferred Generic Drugs 25%N/ANone
PACERONE 200MG TABLET   2 Non-Preferred Generic Drugs 25%N/ANone
PALGIC 4MG/5ML LIQUID   1 Preferred Generic Drugs 25%N/ANone
PANRETIN 0.1% GEL 60GM TUBE   4 Non-Preferred Brand Drugs 25%N/ANone
PARCAINE 0.5% DROPS   1 Preferred Generic Drugs 25%N/ANone
PAROMOMYCIN 250MG CAPSULE   2 Non-Preferred Generic Drugs 25%N/ANone
PAROXETINE FILM COATED 20MG TABLET (100 CT)   1 Preferred Generic Drugs 25%N/ANone
PAROXETINE HCL 10MG/5ML SUSPENSION ORAL   2 Non-Preferred Generic Drugs 25%N/ANone
PAROXETINE HCL TABLET 24 12.5MG   2 Non-Preferred Generic Drugs 25%N/ANone
PAROXETINE HCL TABLET 24 25MG   2 Non-Preferred Generic Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Paroxetine Hydrochloride 37.5mg/1 30 BOTTLE in 1 BOTTLE / 30 TABLET, FILM COATED, EXTENDED RELEASE   2 Non-Preferred Generic Drugs 25%N/ANone
PAROXETINE HYDROCHLORIDE TABLETS 10 MG   1 Preferred Generic Drugs 25%N/ANone
PAROXETINE TABLETS 30MG 90 BOT   2 Non-Preferred Generic Drugs 25%N/ANone
PAROXETINE40mg/1   2 Non-Preferred Generic Drugs 25%N/ANone
PASER GRANULES 4GM PACKET   4 Non-Preferred Brand Drugs 25%N/ANone
PATADAY 0.2% DROPS   3 Preferred Brand Drugs 25%N/ANone
PATANOL 0.1% EYE DROPS   4 Non-Preferred Brand Drugs 25%N/ANone
PEDI-DRI TOPICAL POWDER   2 Non-Preferred Generic Drugs 25%N/ANone
PEDVAXHIB VACCINE VIAL   4 Non-Preferred Brand Drugs 25%N/ANone
PEGANONE 250MG TABLET   4 Non-Preferred Brand Drugs 25%N/ANone
PEGASYS 180MCG/0.5ML CONV.PK   5 Specialty Tier Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PEGASYS INJECTION   5 Specialty Tier Drugs 25%N/ANone
PEGASYS PROCLICK 135 MCG/0.5   5 Specialty Tier Drugs 25%N/ANone
PEGINTRON 1 KIT in 1 CARTON   5 Specialty Tier Drugs 25%N/ANone
PegIntron 120ug/0.5mL 1 CARTRIDGE in 1 CARTON / 0.5 mL in 1 CARTRIDGE   5 Specialty Tier Drugs 25%N/ANone
PegIntron 150ug/0.5mL 1 CARTRIDGE in 1 CARTON / 0.5 mL in 1 CARTRIDGE   5 Specialty Tier Drugs 25%N/ANone
PegIntron 50ug/0.5mL 1 CARTRIDGE in 1 CARTON / 0.5 mL in 1 CARTRIDGE   5 Specialty Tier Drugs 25%N/ANone
PegIntron 80ug/0.5mL 1 CARTRIDGE in 1 CARTON / 0.5 mL in 1 CARTRIDGE   5 Specialty Tier Drugs 25%N/ANone
PENICILLIN G POTASSIUM FOR INJECTION 5000000UNIT/VIAL   1 Preferred Generic Drugs 25%N/ANone
Penicillin G Sodium 5000000[iU]/1 10 VIAL in 1 CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL   1 Preferred Generic Drugs 25%N/ANone
PENICILLIN V POTASSIUM 250MG TABLET (1000 CT)   1 Preferred Generic Drugs 25%N/ANone
PENICILLIN V POTASSIUM 250MG/5ML LIQUID   1 Preferred Generic Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PENICILLIN V POTASSIUM 500MG TABLET   2 Non-Preferred Generic Drugs 25%N/ANone
PENICILLIN V POTASSIUM FOR ORAL SOLUTION CONCENTRATE 125MG 200ML BOT   1 Preferred Generic Drugs 25%N/ANone
PENTAZOCINE/ACETAMIN TABLET   2 Non-Preferred Generic Drugs 25%N/ANone
PENTAZOCINE/NALOXONE TABLET   2 Non-Preferred Generic Drugs 25%N/ANone
PENTOPAK 400MG TABLET SA   2 Non-Preferred Generic Drugs 25%N/ANone
PENTOXIFYLLINE 400MG TABLET SA   2 Non-Preferred Generic Drugs 25%N/ANone
Permethrin 50mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE   2 Non-Preferred Generic Drugs 25%N/ANone
PERPHENAZINE 16 MG TABLET   2 Non-Preferred Generic Drugs 25%N/ANone
PERPHENAZINE TABLETS 4MG 100 BOXUD   2 Non-Preferred Generic Drugs 25%N/ANone
PERPHENAZINE TABLETS 8MG 100 BOT   2 Non-Preferred Generic Drugs 25%N/ANone
PERPHENAZINE TABLETS USP 2MG 100 BOT   2 Non-Preferred Generic Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PEXEVA 10MG TABLET   4 Non-Preferred Brand Drugs 25%N/ANone
PEXEVA 20MG TABLET   4 Non-Preferred Brand Drugs 25%N/ANone
PEXEVA 30MG TABLET   4 Non-Preferred Brand Drugs 25%N/ANone
PEXEVA 40MG TABLET   4 Non-Preferred Brand Drugs 25%N/ANone
Phenelzine Sulfate 15mg/1 60 TABLET in 1 BOTTLE   2 Non-Preferred Generic Drugs 25%N/ANone
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT   2 Non-Preferred Generic Drugs 25%N/ANone
PHENYTOIN SOD EXT 200 MG CAP   2 Non-Preferred Generic Drugs 25%N/ANone
PHENYTOIN SODIUM EXTENDED CAPSULES 100MG (100 CT)   2 Non-Preferred Generic Drugs 25%N/ANone
PHENYTOIN SODIUM INJECTION 50MG 25 X 2ML AMP   1 Preferred Generic Drugs 25%N/ANone
PHOSPHOLINE IODIDE 0.125%   3 Preferred Brand Drugs 25%N/ANone
PHYSIOLYTE SOLUTION FOR IRRIGATION   1 Preferred Generic Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PHYSIOSOL IRRIGATION SOL   1 Preferred Generic Drugs 25%N/ANone
PICATO 0.015% GEL   5 Specialty Tier Drugs 25%N/ANone
PICATO 0.05% GEL   5 Specialty Tier Drugs 25%N/ANone
PILOCARPINE HCL 5MG TABLET (100 CT)   2 Non-Preferred Generic Drugs 25%N/ANone
Pilocarpine Hydrochloride 7.5mg/1 100 TABLET, FILM COATED in 1 BOTTLE   2 Non-Preferred Generic Drugs 25%N/ANone
PILOPINE HS 4% EYE GEL   3 Preferred Brand Drugs 25%N/ANone
PINDOLOL 10MG TABLET   1 Preferred Generic Drugs 25%N/ANone
PINDOLOL 5MG TABLET   1 Preferred Generic Drugs 25%N/ANone
PIPERACILLIN 3GM VIAL   2 Non-Preferred Generic Drugs 25%N/ANone
PIPERACILLIN 40GM BULK VIAL   2 Non-Preferred Generic Drugs 25%N/ANone
PIROXICAM 10 MG CAPSULE   2 Non-Preferred Generic Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Piroxicam 20mg/1 500 CAPSULE in 1 BOTTLE   1 Preferred Generic Drugs 25%N/ANone
PLASMA-LYTE 148 IV SOLUTION   3 Preferred Brand Drugs 25%N/ANone
PLASMA-LYTE 148/DEXTROSE 5%   3 Preferred Brand Drugs 25%N/ANone
PLASMA-LYTE 56 INJECTION 32;128 MG/100ML;   3 Preferred Brand Drugs 25%N/ANone
PLASMA-LYTE 56/DEXTROSE 5%   3 Preferred Brand Drugs 25%N/ANone
PLASMA-LYTE A PH 7.4 SOLUTION 37;368; MG/100ML;   3 Preferred Brand Drugs 25%N/ANone
PLASMA-LYTE INJ-R   2 Non-Preferred Generic Drugs 25%N/ANone
PLAVIX 75MG TABLET   3 Preferred Brand Drugs 25%N/ANone
PLAVIX TABLETS 300MG   3 Preferred Brand Drugs 25%N/ANone
PODOFILOX 0.5% TOPICAL TUBEX   1 Preferred Generic Drugs 25%N/ANone
POLY-DEX 3.5-10K-.1 OINTMENT   1 Preferred Generic Drugs 25%N/ANone
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)   2 Non-Preferred Generic Drugs 25%N/ANone
POLYMYXIN B SUL-TRIMETHOPRIM 10K U-0.1%   2 Non-Preferred Generic Drugs 25%N/ANone
POTASSIUM CHLORIDE 0.075%/D5W/SODIUM CHLORIDE 0.2%   1 Preferred Generic Drugs 25%N/ANone
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.3%   1 Preferred Generic Drugs 25%N/ANone
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.45%   1 Preferred Generic Drugs 25%N/ANone
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.2%   1 Preferred Generic Drugs 25%N/ANone
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.45% 1000ML BAG   1 Preferred Generic Drugs 25%N/ANone
POTASSIUM CHLORIDE 10MEQ/100ML SOL   1 Preferred Generic Drugs 25%N/ANone
POTASSIUM CHLORIDE 10MEQ/50ML SOL   1 Preferred Generic Drugs 25%N/ANone
POTASSIUM CHLORIDE 149mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 5 mL in 1 VIAL, SINGLE-DOSE   2 Non-Preferred Generic Drugs 25%N/ANone
Potassium Chloride 20.000000meq/1   2 Non-Preferred Generic Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
POTASSIUM CHLORIDE 20MEQ IN D5W/NACL 0.225%   1 Preferred Generic Drugs 25%N/ANone
POTASSIUM CHLORIDE 20MEQ/50ML SOL   1 Preferred Generic Drugs 25%N/ANone
POTASSIUM CHLORIDE 30MEQ/100ML SOL   1 Preferred Generic Drugs 25%N/ANone
POTASSIUM CHLORIDE ER CAPSULES 10MEQ   2 Non-Preferred Generic Drugs 25%N/ANone
POTASSIUM CHLORIDE ER CPCR 8MEQ   2 Non-Preferred Generic Drugs 25%N/ANone
POTASSIUM CHLORIDE EXTENDED RELEASE TABLETS   1 Preferred Generic Drugs 25%N/ANone
POTASSIUM CHLORIDE IN 5% DEXTROSE AND 0.2% NACL SOLUTION FOR INJECTION USP 0.15% 250ML X 24 CASE   2 Non-Preferred Generic Drugs 25%N/ANone
POTASSIUM CHLORIDE IN 5% DEXTROSE AND NACL SOLUTION FOR INJECTION 0.075% 1000ML PLASTIC BAGS X 12 CA   1 Preferred Generic Drugs 25%N/ANone
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION   1 Preferred Generic Drugs 25%N/ANone
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION   1 Preferred Generic Drugs 25%N/ANone
POTASSIUM CHLORIDE IN 5% DEXTROSE INJECTION 40 12 X 1000ML CTR   1 Preferred Generic Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
POTASSIUM CHLORIDE IN DEXTROSE INJECTION 5GM/75MG   1 Preferred Generic Drugs 25%N/ANone
Potassium Chloride in Lactated Ringers and Dextrose 20; 5; 179; 600; 310mg/100mL; g/100mL; mg/100mL   2 Non-Preferred Generic Drugs 25%N/ANone
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION   1 Preferred Generic Drugs 25%N/ANone
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION 0.15%-0.9% 12 X 1000ML BAG   1 Preferred Generic Drugs 25%N/ANone
POTASSIUM CITRATE 10MEQ TABLET SA   2 Non-Preferred Generic Drugs 25%N/ANone
POTASSIUM CITRATE 5MEQ TABLET SA   2 Non-Preferred Generic Drugs 25%N/ANone
POTIGA 200 MG TABLET   4 Non-Preferred Brand Drugs 25%N/ANone
POTIGA 300 MG TABLET   4 Non-Preferred Brand Drugs 25%N/ANone
POTIGA 400 MG TABLET   4 Non-Preferred Brand Drugs 25%N/ANone
POTIGA 50 MG TABLET   4 Non-Preferred Brand Drugs 25%N/ANone
PRADAXA 150mg/1 1 BOTTLE in 1 CARTON / 60 CAPSULE in 1 BOTTLE   3 Preferred Brand Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PRADAXA 75mg/1 1 BOTTLE in 1 CARTON / 60 CAPSULE in 1 BOTTLE   3 Preferred Brand Drugs 25%N/ANone
PRAMIPEXOLE 0.125 MG TABLET   2 Non-Preferred Generic Drugs 25%N/ANone
PRAMIPEXOLE 0.25 MG TABLET   2 Non-Preferred Generic Drugs 25%N/ANone
PRAMIPEXOLE 0.5 MG TABLET   2 Non-Preferred Generic Drugs 25%N/ANone
PRAMIPEXOLE 1 MG TABLET   2 Non-Preferred Generic Drugs 25%N/ANone
PRAMIPEXOLE 1.5 MG TABLET   2 Non-Preferred Generic Drugs 25%N/ANone
PRAMIPEXOLE DIHYDROCHLORIDE TABLETS   2 Non-Preferred Generic Drugs 25%N/ANone
PRANDIN 0.5MG TABLET   3 Preferred Brand Drugs 25%N/ANone
PRANDIN 1MG TABLET   3 Preferred Brand Drugs 25%N/ANone
PRANDIN 2MG TABLET   3 Preferred Brand Drugs 25%N/ANone
PRAVASTATIN SODIUM 20MG TABLET 500 BOT   1 Preferred Generic Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PRAVASTATIN SODIUM 40MG TABLET (500 CT)   1 Preferred Generic Drugs 25%N/ANone
PRAVASTATIN SODIUM 80MG TABLET (90 CT)   2 Non-Preferred Generic Drugs 25%N/ANone
PRAVASTATIN SODIUM TABLETS 10MG 90 BOT   1 Preferred Generic Drugs 25%N/ANone
PRAZOSIN 5MG CAPSULE   1 Preferred Generic Drugs 25%N/ANone
PRAZOSIN HCL 1MG CAPSULE   1 Preferred Generic Drugs 25%N/ANone
PRAZOSIN HCL 2MG CAPSULE   1 Preferred Generic Drugs 25%N/ANone
PREDNICARBATE 0.1% OINTMENT   1 Preferred Generic Drugs 25%N/ANone
PREDNICARBATE 1 MG/ML TOPICAL CREAM   2 Non-Preferred Generic Drugs 25%N/ANone
PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION 1.0% STERILE 10ML BOTDR   2 Non-Preferred Generic Drugs 25%N/ANone
PREDNISOLONE SOD 1% EYE DROP   2 Non-Preferred Generic Drugs 25%N/ANone
PREDNISOLONE SODIUM PHOSPHATE 15MG/5ML SOLUTION ORAL   2 Non-Preferred Generic Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PREDNISOLONE SODIUM PHOSPHATE ORAL SOLUTION   2 Non-Preferred Generic Drugs 25%N/ANone
PREDNISONE 10MG TABLET (100 CT)   1 Preferred Generic Drugs 25%N/ANone
PREDNISONE 1MG TABLET   2 Non-Preferred Generic Drugs 25%N/ANone
PREDNISONE 2.5MG TABLET   1 Preferred Generic Drugs 25%N/ANone
PREDNISONE 20MG TABLET (1000 CT)   1 Preferred Generic Drugs 25%N/ANone
PREDNISONE 5 MG TABLET   1 Preferred Generic Drugs 25%N/ANone
PREDNISONE 50MG TABLET   2 Non-Preferred Generic Drugs 25%N/ANone
PREDNISONE 5MG/5ML SOLUTION   2 Non-Preferred Generic Drugs 25%N/ANone
PREMARIN 0.3MG (100 CT)   3 Preferred Brand Drugs 25%N/ANone
PREMARIN 0.45MG TABLET   3 Preferred Brand Drugs 25%N/ANone
PREMARIN 0.625MG (100 CT)   3 Preferred Brand Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Premarin 0.625mg/g   3 Preferred Brand Drugs 25%N/ANone
PREMARIN 0.9MG TABLET   3 Preferred Brand Drugs 25%N/ANone
PREMARIN 1.25MG (100 CT)   3 Preferred Brand Drugs 25%N/ANone
PREMARIN 25MG VIAL   3 Preferred Brand Drugs 25%N/ANone
PREMASOL 6% IV SOLUTION   1 Preferred Generic Drugs 25%N/AP
Premphase 1 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK   3 Preferred Brand Drugs 25%N/ANone
PREMPRO 0.3 MG-1.5 MG TABLET #28 EA   3 Preferred Brand Drugs 25%N/ANone
PREMPRO 0.45-1.5 MG TABLET 28 EA   3 Preferred Brand Drugs 25%N/ANone
Prempro 0.625; 2.5mg/1; mg/1 1 BLISTER PACK in 1 CARTON / 28 TABLET, SUGAR COATED in 1 BLISTER PACK   3 Preferred Brand Drugs 25%N/ANone
PREVALITE POW 4GM   2 Non-Preferred Generic Drugs 25%N/ANone
PREZISTA TABLET 600MG   5 Specialty Tier Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PREZISTA TABLET 75MG   4 Non-Preferred Brand Drugs 25%N/ANone
PREZISTA TABLETS   4 Non-Preferred Brand Drugs 25%N/ANone
PREZISTA TABLETS 400MG 60 TABLETS BOT   5 Specialty Tier Drugs 25%N/ANone
PRIFTIN 150MG TABLET   4 Non-Preferred Brand Drugs 25%N/ANone
Primidone 250mg/1 100 TABLET in 1 BOTTLE   2 Non-Preferred Generic Drugs 25%N/ANone
Primidone 50mg/1 500 TABLET in 1 BOTTLE   2 Non-Preferred Generic Drugs 25%N/ANone
PRISTIQ 100MG TABLET SR 24HR   3 Preferred Brand Drugs 25%N/ANone
Pristiq Extended-Release 50mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC   3 Preferred Brand Drugs 25%N/ANone
PROAIR HFA 90MCG HFA AEROSOL WITH ADAPTER   3 Preferred Brand Drugs 25%N/ANone
PROBENECID 500MG TABLET   2 Non-Preferred Generic Drugs 25%N/ANone
PROCAINAMIDE 100MG/ML VIAL   1 Preferred Generic Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PROCAINAMIDE 500MG/ML VIAL   1 Preferred Generic Drugs 25%N/ANone
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   3 Preferred Brand Drugs 25%N/AP
PROCHLORPERAZINE EDISYLATE INJECTION 10MG 10 X 2ML VIALS CRTN   2 Non-Preferred Generic Drugs 25%N/ANone
PROCHLORPERAZINE MALEATE 10MG TABLET (100 CT)   1 Preferred Generic Drugs 25%N/ANone
PROCHLORPERAZINE MALEATE 5MG TABLET (100 CT)   2 Non-Preferred Generic Drugs 25%N/ANone
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX   2 Non-Preferred Generic Drugs 25%N/ANone
PROCRIT 10000U/ML VIAL   4 Non-Preferred Brand Drugs 25%N/AP
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL   3 Preferred Brand Drugs 25%N/AP Q:23
/30Days
PROCRIT 3000U/ML VIAL   3 Preferred Brand Drugs 25%N/AP Q:16
/30Days
PROCRIT 40000U/ML VIAL PR   5 Specialty Tier Drugs 25%N/AP
PROCRIT 4000U/ML VIAL 25 X 1ML VIAL   4 Non-Preferred Brand Drugs 25%N/AP Q:12
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY   5 Specialty Tier Drugs 25%N/AP
PROCTO-PAK 1% CREAM   1 Preferred Generic Drugs 25%N/ANone
Proctocream HC 25mg/g   1 Preferred Generic Drugs 25%N/ANone
PROCTOSOL-HC 2.5% CREAM   1 Preferred Generic Drugs 25%N/ANone
PROCTOZONE-HC 2.5% CREAM   1 Preferred Generic Drugs 25%N/ANone
Proglycem 50mg/mL 1 BOTTLE, DROPPER in 1 BOX / 30 mL in 1 BOTTLE, DROPPER   3 Preferred Brand Drugs 25%N/ANone
PROGRAF 5MG/ML AMPULE   4 Non-Preferred Brand Drugs 25%N/AP
PROLASTIN 500MG VIAL   5 Specialty Tier Drugs 25%N/ANone
PROLASTIN-C 1 KIT in 1 CARTON   5 Specialty Tier Drugs 25%N/ANone
PROLEUKIN 1.1mg/mL 1 VIAL, SINGLE-USE in 1 BOX / 1 mL in 1 VIAL, SINGLE-USE   5 Specialty Tier Drugs 25%N/ANone
PROLIA INJECTION   4 Non-Preferred Brand Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PROMACTA 12.5 MG TABLET   5 Specialty Tier Drugs 25%N/ANone
PROMACTA 25 MG TABLET   5 Specialty Tier Drugs 25%N/ANone
PROMACTA 50 MG TABLET   5 Specialty Tier Drugs 25%N/ANone
PROMACTA 75 MG TABLET   5 Specialty Tier Drugs 25%N/ANone
PROPAFENONE HCL 150MG TABLET (100 CT)   2 Non-Preferred Generic Drugs 25%N/ANone
PROPAFENONE HCL 225MG TABLET   2 Non-Preferred Generic Drugs 25%N/ANone
PROPAFENONE HCL 300MG TABLET (100 CT)   2 Non-Preferred Generic Drugs 25%N/ANone
PROPRANOLOL 20MG/5ML TUBEX   1 Preferred Generic Drugs 25%N/ANone
PROPRANOLOL 40MG/5ML TUBEX   1 Preferred Generic Drugs 25%N/ANone
PROPRANOLOL 60MG TABLET   2 Non-Preferred Generic Drugs 25%N/ANone
PROPRANOLOL 80 MG TABLET   1 Preferred Generic Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PROPRANOLOL HCL 20MG TABLET (1000 CT)   1 Preferred Generic Drugs 25%N/ANone
PROPRANOLOL HCL INJECTION 1MG 10 PKG OF 10 CRTN   1 Preferred Generic Drugs 25%N/ANone
PROPRANOLOL HCL TABLET USP 10MG (1000 CT)   1 Preferred Generic Drugs 25%N/ANone
PROPRANOLOL HCL TABLET USP 40MG (1000 CT)   1 Preferred Generic Drugs 25%N/ANone
Propranolol Hydrochloride 120mg/1 100 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC   2 Non-Preferred Generic Drugs 25%N/ANone
Propranolol Hydrochloride 160mg/1 100 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC   2 Non-Preferred Generic Drugs 25%N/ANone
Propranolol Hydrochloride 60mg/1 1000 CAPSULE, EXTENDED RELEASE in 1 BOTTLE   2 Non-Preferred Generic Drugs 25%N/ANone
Propranolol Hydrochloride 80mg/1 100 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC   2 Non-Preferred Generic Drugs 25%N/ANone
PROPRANOLOL/HCTZ 40/25 TABLET   1 Preferred Generic Drugs 25%N/ANone
PROPRANOLOL/HCTZ 80/25 TABLET   2 Non-Preferred Generic Drugs 25%N/ANone
PROPYLTHIOURACIL 50MG TABLET   2 Non-Preferred Generic Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PROQUAD VIAL   4 Non-Preferred Brand Drugs 25%N/ANone
Protonix I.V. 40mg/10mL 10 CARTON in 1 PACKAGE / 1 VIAL in 1 CARTON / 40 mL in 1 VIAL   4 Non-Preferred Brand Drugs 25%N/ANone
PROTRIPTYLINE HYDROCHLORIDE TABLETS   2 Non-Preferred Generic Drugs 25%N/ANone
PROTRIPTYLINE HYDROCHLORIDE TABLETS 5MG   2 Non-Preferred Generic Drugs 25%N/ANone
PROVIGIL 100MG TABLET   3 Preferred Brand Drugs 25%N/AP
PROVIGIL 200MG TABLET   3 Preferred Brand Drugs 25%N/AP
PULMICORT .25MG/2ML RESPULE   3 Preferred Brand Drugs 25%N/ANone
PULMICORT 1MG/2ML AMPUL FOR NEBULIZATION   3 Preferred Brand Drugs 25%N/ANone
PULMICORT FLEXHALER 180MCG AEROSOL POWDER BREATH ACTIVATED   3 Preferred Brand Drugs 25%N/ANone
PULMICORT FLEXHALER 90MCG AEROSOL POWDER BREATH ACTIVATED   3 Preferred Brand Drugs 25%N/ANone
PULMICORT RESPULES 0.5mg/2mL 6 POUCH in 1 CARTON / 5 AMPULE in 1 POUCH / 2 mL in 1 AMPULE   3 Preferred Brand Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PULMOZYME 1MG/ML AMPUL   5 Specialty Tier Drugs 25%N/AP
PYRAZINAMIDE 500MG TABLET   2 Non-Preferred Generic Drugs 25%N/ANone
PYRIDOSTIGMINE BROMIDE 60MG TABLET   2 Non-Preferred Generic Drugs 25%N/ANone

Chart Legend:

Below are a few notes to help you understand the above 2012 Medicare Part D EnvisionRxPlus Silver (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.





 
 

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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.