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United American - Preferred (PDP) (S5755-006-0)
Tier 1 (190)
Tier 2 (1786)
Tier 3 (1093)
Tier 4 (198)
Tier 5 (232)
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2012 Medicare Part D Plan Formulary Information
United American - Preferred (PDP) (S5755-006-0)
Benefit Details           
The United American - Preferred (PDP) (S5755-006-0)
Formulary Drugs Starting with the Letter A

in CMS PDP Region 2 which includes: CT MA RI VT
Drugs Starting with Letter A

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
A METHAPRED METHLYPREDNISOLONE SODIUM SUCCINATE FOR INJECTION 125 MG   2* Non-Preferred Generic Drugs $9.00$21.00P
A-HYDROCORT 100MG VIAL   2* Non-Preferred Generic Drugs $9.00$21.00None
A-METHAPRED INJ 40MG   2* Non-Preferred Generic Drugs $9.00$21.00P
ABACAVIR TAB 300MG   2* Non-Preferred Generic Drugs $9.00$21.00None
ABILIFY 10MG TABLET   3 Preferred Brand Drugs $45.00$90.00Q:270
/90Days
ABILIFY 15MG TABLET   3 Preferred Brand Drugs $45.00$90.00Q:180
/90Days
ABILIFY 1MG/ML SOLUTION   3 Preferred Brand Drugs $45.00$90.00None
ABILIFY 20MG TABLET   3 Preferred Brand Drugs $45.00$90.00Q:90
/90Days
ABILIFY 2MG TABLET   3 Preferred Brand Drugs $45.00$90.00Q:90
/90Days
ABILIFY 30MG TABLET   3 Preferred Brand Drugs $45.00$90.00Q:90
/90Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ABILIFY 5MG TABLET (OTSUKA)   3 Preferred Brand Drugs $45.00$90.00Q:90
/90Days
ABILIFY DISCMELT 10MG TABLET   3 Preferred Brand Drugs $45.00$90.00Q:270
/90Days
ABILIFY DISCMELT 15MG TABLET   3 Preferred Brand Drugs $45.00$90.00Q:180
/90Days
ABILIFY INJ 9.75MG   3 Preferred Brand Drugs $45.00$90.00None
ABRAXANE 100MG VIAL   4 Non-Preferred Brand Drugs $95.00$190.00None
Acarbose 100mg/1 90 TABLET in 1 BOTTLE,   2* Non-Preferred Generic Drugs $9.00$21.00Q:270
/90Days
acarbose 50 mg tablet   2* Non-Preferred Generic Drugs $9.00$21.00Q:270
/90Days
ACARBOSE TABLETS   2* Non-Preferred Generic Drugs $9.00$21.00Q:270
/90Days
ACEBUTOLOL 200MG CAPSULE   2* Non-Preferred Generic Drugs $9.00$21.00None
ACEBUTOLOL 400MG CAPSULE   2* Non-Preferred Generic Drugs $9.00$21.00None
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE   3 Preferred Brand Drugs $45.00$90.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Acetaminophen and Codeine Phosphate 300; 60mg/1; mg/1 500 TABLET in 1 BOTTLE   2* Non-Preferred Generic Drugs $9.00$21.00None
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD   2* Non-Preferred Generic Drugs $9.00$21.00None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT)   2* Non-Preferred Generic Drugs $9.00$21.00None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT)   2* Non-Preferred Generic Drugs $9.00$21.00None
ACETASOL HC SOLUTION 10ML 10 ML BOT   2* Non-Preferred Generic Drugs $9.00$21.00None
ACETAZOLAMIDE 125MG TABLET   2* Non-Preferred Generic Drugs $9.00$21.00None
ACETAZOLAMIDE 250MG TABLET (100 CT)   2* Non-Preferred Generic Drugs $9.00$21.00None
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT   2* Non-Preferred Generic Drugs $9.00$21.00None
ACETAZOLAMIDE SOD 500MG VL   2* Non-Preferred Generic Drugs $9.00$21.00None
ACETIC ACID 2% SOLUTION NON-ORAL   2* Non-Preferred Generic Drugs $9.00$21.00None
ACETYLCYSTEINE 10% VIAL   2* Non-Preferred Generic Drugs $9.00$21.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN   2* Non-Preferred Generic Drugs $9.00$21.00P
ACTHIB VACCINE VIAL 10-24UNT/5ML   3 Preferred Brand Drugs $45.00$90.00None
ACTICIN 5% CREAM   2* Non-Preferred Generic Drugs $9.00$21.00None
ACTIMMUNE SOLUTION FOR INJECTION 100MCG   5 Specialty Tier Drugs 29%29%P
ACTIVELLA 0.5-0.1MG TABLET 28 DLPK   3 Preferred Brand Drugs $45.00$90.00None
Actonel 150mg/1 36 DOSE PACK in 1 CASE / 1 TRAY in 1 DOSE PACK / 1 TABLET, FILM COATED in 1 TRAY   4 Non-Preferred Brand Drugs $95.00$190.00S Q:3
/90Days
Actonel 30mg/1 12 BOTTLE in 1 CASE / 30 TABLET, FILM COATED in 1 BOTTLE   4 Non-Preferred Brand Drugs $95.00$190.00P Q:60
/120Days
Actonel 35mg/1 36 DOSE PACK in 1 CASE / 1 TRAY in 1 DOSE PACK / 4 TABLET, FILM COATED in 1 TRAY   4 Non-Preferred Brand Drugs $95.00$190.00S Q:12
/90Days
Actonel 5mg/1 12 BOTTLE in 1 CASE / 30 TABLET, FILM COATED in 1 BOTTLE   4 Non-Preferred Brand Drugs $95.00$190.00S Q:90
/90Days
ACTOPLUS MET 15MG/500MG TABLET   3 Preferred Brand Drugs $45.00$90.00Q:270
/90Days
ACTOPLUS MET 15MG/850MG TABLET   3 Preferred Brand Drugs $45.00$90.00Q:270
/90Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACTOS 15MG TABLET   3 Preferred Brand Drugs $45.00$90.00Q:90
/90Days
ACTOS 30MG TABLET (500 CT)   3 Preferred Brand Drugs $45.00$90.00Q:90
/90Days
ACTOS 45MG TABLET   3 Preferred Brand Drugs $45.00$90.00Q:90
/90Days
ACUVAIL 0.45% OPHTH SOLUTION #30X0.4 EA   3 Preferred Brand Drugs $45.00$90.00None
Acyclovir 200mg/1   2* Non-Preferred Generic Drugs $9.00$21.00None
Acyclovir 200mg/5mL 473 mL in 1 BOTTLE   2* Non-Preferred Generic Drugs $9.00$21.00None
Acyclovir 400mg/1 100 BLISTER PACK in 1 BOX / 1 TABLET in 1 BLISTER PACK   2* Non-Preferred Generic Drugs $9.00$21.00None
Acyclovir 800mg/1 100 BLISTER PACK in 1 BOX / 1 TABLET in 1 BLISTER PACK   2* Non-Preferred Generic Drugs $9.00$21.00None
ACYCLOVIR SODIUM 500MG VIAL   2* Non-Preferred Generic Drugs $9.00$21.00None
ADACEL VIAL 2UNT/5UNT   3 Preferred Brand Drugs $45.00$90.00None
ADAGEN 250U/ML VIAL   5 Specialty Tier Drugs 29%29%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA]   5 Specialty Tier Drugs 29%29%P Q:2
/90Days
ADAPALENE CREAM   2* Non-Preferred Generic Drugs $9.00$21.00None
ADAPALENE GEL   2* Non-Preferred Generic Drugs $9.00$21.00None
ADVAIR DISKUS MIS 100/50   3 Preferred Brand Drugs $45.00$90.00Q:180
/90Days
ADVAIR DISKUS MIS 250/50   3 Preferred Brand Drugs $45.00$90.00Q:180
/90Days
ADVAIR DISKUS MIS 500/50   3 Preferred Brand Drugs $45.00$90.00Q:180
/90Days
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER   3 Preferred Brand Drugs $45.00$90.00Q:36
/90Days
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL   3 Preferred Brand Drugs $45.00$90.00Q:36
/90Days
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL   3 Preferred Brand Drugs $45.00$90.00Q:36
/90Days
ADVICOR ER 20-750MG TABLET (90 CT)   4 Non-Preferred Brand Drugs $95.00$190.00None
ADVICOR EXTENDED RELEASE TABLETS 20;500MG;MG 90 BOTPL   4 Non-Preferred Brand Drugs $95.00$190.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADVICOR EXTENDED RELEASE TABLETS 40;1000MG;MG 90 BOTPL   4 Non-Preferred Brand Drugs $95.00$190.00None
AFEDITAB CR 30MG TABLET SA   2* Non-Preferred Generic Drugs $9.00$21.00None
AFEDITAB CR 60MG TABLET SA   2* Non-Preferred Generic Drugs $9.00$21.00None
Afinitor 7.5mg/1 28 BLISTER PACK in 1 CARTON / 1 TABLET in 1 BLISTER PACK   5 Specialty Tier Drugs 29%29%P
AFINITOR TABLETS 10 MG   5 Specialty Tier Drugs 29%29%P Q:180
/90Days
AFINITOR TABLETS 2.5 MG   5 Specialty Tier Drugs 29%29%P Q:270
/90Days
AFINITOR TABLETS 5 MG   5 Specialty Tier Drugs 29%29%P Q:270
/90Days
AGGRENOX 25-200MG CAPSULE   3 Preferred Brand Drugs $45.00$90.00None
AK-CON 0.1% EYE DROPS   1* Preferred Generic Drugs $3.00$0.00None
AKTOB 0.3% EYE DROPS   1* Preferred Generic Drugs $3.00$0.00None
ALA-CORT 1% CREAM   2* Non-Preferred Generic Drugs $9.00$21.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALA-CORT 1% LOTION   1* Preferred Generic Drugs $3.00$0.00None
ALAMAST 0.1% DROPS   3 Preferred Brand Drugs $45.00$90.00None
ALBENZA 200 MG TABLET   3 Preferred Brand Drugs $45.00$90.00None
Albuterol Sulfate 0.63mg/3mL 25 POUCH in 1 CARTON / 5 VIAL in 1 POUCH / 3 mL in 1 VIAL   2* Non-Preferred Generic Drugs $9.00$21.00P
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER   2* Non-Preferred Generic Drugs $9.00$21.00P
ALBUTEROL SULFATE 4MG TABLET SR 12HR   2* Non-Preferred Generic Drugs $9.00$21.00None
ALBUTEROL SULFATE 8MG TABLET SR 12HR   2* Non-Preferred Generic Drugs $9.00$21.00None
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   2* Non-Preferred Generic Drugs $9.00$21.00P
ALBUTEROL SULFATE SOLUTION FOR INHALATION   2* Non-Preferred Generic Drugs $9.00$21.00P
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT   2* Non-Preferred Generic Drugs $9.00$21.00None
ALBUTEROL SULFATE TABLET 2MG (500 CT)   2* Non-Preferred Generic Drugs $9.00$21.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALBUTEROL TABLET 4MG (500 CT)   2* Non-Preferred Generic Drugs $9.00$21.00None
ALCLOMETASONE DIPROPIONATE 0.05% CREAM   2* Non-Preferred Generic Drugs $9.00$21.00None
Alclometasone Dipropionate 0.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE   2* Non-Preferred Generic Drugs $9.00$21.00None
ALDURAZYME 2.9MG/5ML VIAL   5 Specialty Tier Drugs 29%29%None
ALENDRONATE SODIUM 10MG TABLET   2* Non-Preferred Generic Drugs $9.00$21.00Q:90
/90Days
ALENDRONATE SODIUM 40MG TABLET   2* Non-Preferred Generic Drugs $9.00$21.00Q:180
/365Days
ALENDRONATE SODIUM 5MG TABLET   2* Non-Preferred Generic Drugs $9.00$21.00Q:90
/90Days
ALENDRONATE SODIUM 70mg/1   2* Non-Preferred Generic Drugs $9.00$21.00Q:12
/90Days
ALENDRONATE SODIUM TABLET 35MG 20 CRTN   2* Non-Preferred Generic Drugs $9.00$21.00Q:12
/90Days
ALFUZOSIN HYDROCHLORIDE 10mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE   2* Non-Preferred Generic Drugs $9.00$21.00Q:90
/90Days
ALIMTA 500MG VIAL   4 Non-Preferred Brand Drugs $95.00$190.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALINIA 100MG/5ML SUSPENSION   3 Preferred Brand Drugs $45.00$90.00None
ALINIA 500MG TABLET   3 Preferred Brand Drugs $45.00$90.00None
ALKERAN 1 KIT in 1 CARTON   4 Non-Preferred Brand Drugs $95.00$190.00None
Allopurinol 300mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET in 1 BLISTER PACK   1* Preferred Generic Drugs $3.00$0.00None
ALLOPURINOL TABLETS   1* Preferred Generic Drugs $3.00$0.00None
ALOCRIL 2% EYE DROPS   4 Non-Preferred Brand Drugs $95.00$190.00None
ALORA 0.025MG PATCH   3 Preferred Brand Drugs $45.00$90.00None
ALORA 0.05MG PATCH   3 Preferred Brand Drugs $45.00$90.00None
ALORA 0.075MG PATCH   3 Preferred Brand Drugs $45.00$90.00None
ALORA 0.1MG PATCH   3 Preferred Brand Drugs $45.00$90.00None
ALPHAGAN P 0.1% DROPS   3 Preferred Brand Drugs $45.00$90.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALPHAGAN P 0.15% EYE DROPS   3 Preferred Brand Drugs $45.00$90.00None
ALREX 0.2% EYE DROPS   3 Preferred Brand Drugs $45.00$90.00None
ALTABAX 10mg/g 30 g in 1 TUBE   3 Preferred Brand Drugs $45.00$90.00None
ALVESCO 160MCG/ACT AERS   4 Non-Preferred Brand Drugs $95.00$190.00Q:37
/90Days
ALVESCO 80MCG/ACT AERS   4 Non-Preferred Brand Drugs $95.00$190.00Q:37
/90Days
AMANTADINE 100MG CAPSULE   2* Non-Preferred Generic Drugs $9.00$21.00None
AMANTADINE 100MG TABLET   2* Non-Preferred Generic Drugs $9.00$21.00None
Amantadine Hydrochloride 50mg/5mL   2* Non-Preferred Generic Drugs $9.00$21.00None
AMCINONIDE 0.1% CREAM   2* Non-Preferred Generic Drugs $9.00$21.00None
AMCINONIDE 0.1% LOTION   2* Non-Preferred Generic Drugs $9.00$21.00None
AMCINONIDE 0.1% OINTMENT 60GM TUBE   2* Non-Preferred Generic Drugs $9.00$21.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Amethia 2 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK   2* Non-Preferred Generic Drugs $9.00$21.00None
Amethyst 20; 90ug/1; ug/1 1 BLISTER PACK in 1 CARTON / 28 TABLET in 1 BLISTER PACK   2* Non-Preferred Generic Drugs $9.00$21.00None
AMIFOSTINE FOR INJECTION 500MG/VIAL   5 Specialty Tier Drugs 29%29%None
AMIKACIN 250MG/ML VIAL   2* Non-Preferred Generic Drugs $9.00$21.00None
AMIKACIN 50MG/ML VIAL   2* Non-Preferred Generic Drugs $9.00$21.00None
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET   2* Non-Preferred Generic Drugs $9.00$21.00None
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT   2* Non-Preferred Generic Drugs $9.00$21.00None
AMINOPHYLLINE 100MG TABLET   2* Non-Preferred Generic Drugs $9.00$21.00None
AMINOPHYLLINE 200MG TABLET (1000 CT)   2* Non-Preferred Generic Drugs $9.00$21.00None
Aminophylline 25mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 10 mL in 1 VIA   2* Non-Preferred Generic Drugs $9.00$21.00None
AMINOSYN 10% IV SOLUTION   3 Preferred Brand Drugs $45.00$90.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN 3.5% IV SOLUTION   3 Preferred Brand Drugs $45.00$90.00None
AMINOSYN 5% IV SOLUTION   3 Preferred Brand Drugs $45.00$90.00None
AMINOSYN 7% IV SOLUTION   3 Preferred Brand Drugs $45.00$90.00None
AMINOSYN 8.5% IV SOLUTION   3 Preferred Brand Drugs $45.00$90.00None
AMINOSYN HBC INJECTION SULFITE FREE 7%   3 Preferred Brand Drugs $45.00$90.00None
AMINOSYN II 10% IV SOLUTION   3 Preferred Brand Drugs $45.00$90.00None
AMINOSYN II 15% IV SOLUTION   3 Preferred Brand Drugs $45.00$90.00None
AMINOSYN II 3.5% IN D25W IV   3 Preferred Brand Drugs $45.00$90.00None
AMINOSYN II 3.5% IN D5W IV   3 Preferred Brand Drugs $45.00$90.00None
AMINOSYN II 3.5% M/D5W IV   3 Preferred Brand Drugs $45.00$90.00None
AMINOSYN II 4.25% IN D10W   3 Preferred Brand Drugs $45.00$90.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN II 4.25% IN D20W   3 Preferred Brand Drugs $45.00$90.00None
AMINOSYN II 4.25%-D25W IV   3 Preferred Brand Drugs $45.00$90.00None
AMINOSYN II 7% IV SOLUTION   3 Preferred Brand Drugs $45.00$90.00None
AMINOSYN II 8.5% ELECTROLYT   3 Preferred Brand Drugs $45.00$90.00None
AMINOSYN II 8.5% IV SOLUTION   3 Preferred Brand Drugs $45.00$90.00None
AMINOSYN PF INJECTION   3 Preferred Brand Drugs $45.00$90.00None
AMINOSYN-HF 8% IV SOLUTION   3 Preferred Brand Drugs $45.00$90.00None
AMINOSYN-PF 7% IV SOLUTION   3 Preferred Brand Drugs $45.00$90.00None
AMIODARONE HCL 400MG TABLET   2* Non-Preferred Generic Drugs $9.00$21.00None
AMIODARONE HCL INJECTION   2* Non-Preferred Generic Drugs $9.00$21.00None
Amiodarone hydrochloride 200mg/1   2* Non-Preferred Generic Drugs $9.00$21.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITIZA 8MCG CAPSULE   3 Preferred Brand Drugs $45.00$90.00None
AMITIZA CAPSULES 24MCG 60 CAP BOT   3 Preferred Brand Drugs $45.00$90.00None
AMITRIP/CDP 25-10 TABLET   2* Non-Preferred Generic Drugs $9.00$21.00None
AMITRIPTYLINE HCL 100MG TABLET   1* Preferred Generic Drugs $3.00$0.00None
AMITRIPTYLINE HCL 10MG TABLET   1* Preferred Generic Drugs $3.00$0.00None
AMITRIPTYLINE HCL 150 MG TAB   1* Preferred Generic Drugs $3.00$0.00None
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)   1* Preferred Generic Drugs $3.00$0.00None
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)   1* Preferred Generic Drugs $3.00$0.00None
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT   1* Preferred Generic Drugs $3.00$0.00None
AMLODIPINE BESYLATE 10MG TABLET (90 CT)   2* Non-Preferred Generic Drugs $9.00$21.00None
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)   2* Non-Preferred Generic Drugs $9.00$21.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE BESYLATE 5MG TABLET (90 CT)   2* Non-Preferred Generic Drugs $9.00$21.00None
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE CAPSULES   2* Non-Preferred Generic Drugs $9.00$21.00Q:90
/90Days
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE CAPSULES   2* Non-Preferred Generic Drugs $9.00$21.00Q:90
/90Days
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE   2* Non-Preferred Generic Drugs $9.00$21.00Q:90
/90Days
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE   2* Non-Preferred Generic Drugs $9.00$21.00Q:90
/90Days
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE   2* Non-Preferred Generic Drugs $9.00$21.00Q:90
/90Days
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE   2* Non-Preferred Generic Drugs $9.00$21.00Q:90
/90Days
AMMONIUM LACTATE 12% CREAM   2* Non-Preferred Generic Drugs $9.00$21.00None
AMMONIUM LACTATE 12% LOTION   2* Non-Preferred Generic Drugs $9.00$21.00None
Amnesteem 10mg/1 3 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK   2* Non-Preferred Generic Drugs $9.00$21.00None
Amnesteem 20mg/1 3 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK   2* Non-Preferred Generic Drugs $9.00$21.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Amnesteem 40mg/1 3 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK   2* Non-Preferred Generic Drugs $9.00$21.00None
AMOX TR-K CLV 500-125 MG TAB   2* Non-Preferred Generic Drugs $9.00$21.00None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL   2* Non-Preferred Generic Drugs $9.00$21.00None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE   2* Non-Preferred Generic Drugs $9.00$21.00None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET   2* Non-Preferred Generic Drugs $9.00$21.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE   2* Non-Preferred Generic Drugs $9.00$21.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   2* Non-Preferred Generic Drugs $9.00$21.00None
AMOXAPINE 100MG TABLET   2* Non-Preferred Generic Drugs $9.00$21.00None
AMOXAPINE 150MG TABLET   2* Non-Preferred Generic Drugs $9.00$21.00None
AMOXAPINE 25MG TABLET   2* Non-Preferred Generic Drugs $9.00$21.00None
AMOXAPINE 50MG TABLET   2* Non-Preferred Generic Drugs $9.00$21.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN 125MG TABLET CHEW   2* Non-Preferred Generic Drugs $9.00$21.00None
AMOXICILLIN 200MG TABLET CHEW   2* Non-Preferred Generic Drugs $9.00$21.00None
AMOXICILLIN 250MG CAPSULE   2* Non-Preferred Generic Drugs $9.00$21.00None
Amoxicillin 250mg/1 500 TABLET, CHEWABLE in 1 BOTTLE   2* Non-Preferred Generic Drugs $9.00$21.00None
AMOXICILLIN 50 MG/ML / CLAVULANATE 12.5 MG/ML ORAL SUSPENSION   2* Non-Preferred Generic Drugs $9.00$21.00None
AMOXICILLIN 500MG TABLET (100 CT)   1* Preferred Generic Drugs $3.00$0.00None
AMOXICILLIN 875MG TABLET   1* Preferred Generic Drugs $3.00$0.00None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT   2* Non-Preferred Generic Drugs $9.00$21.00None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS EXTENDED RELEASE 1000;62.5MG;MG   2* Non-Preferred Generic Drugs $9.00$21.00None
AMOXICILLIN CAP 500MG   1* Preferred Generic Drugs $3.00$0.00None
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT   2* Non-Preferred Generic Drugs $9.00$21.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT   2* Non-Preferred Generic Drugs $9.00$21.00None
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL   2* Non-Preferred Generic Drugs $9.00$21.00None
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   1* Preferred Generic Drugs $3.00$0.00None
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL   2* Non-Preferred Generic Drugs $9.00$21.00None
amphotericin b 50mg/10mL 10 mL in 1 VIAL   2* Non-Preferred Generic Drugs $9.00$21.00P
Ampicillin 125mg/1 10 VIAL in 1 BOX / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL   2* Non-Preferred Generic Drugs $9.00$21.00None
AMPICILLIN AND SULBACTAM FOR INJECTION 2-1 10 VIAL   2* Non-Preferred Generic Drugs $9.00$21.00None
AMPICILLIN CAPSULES 250MG 100 BOT   2* Non-Preferred Generic Drugs $9.00$21.00None
AMPICILLIN CAPSULES 500MG 100 BOT   2* Non-Preferred Generic Drugs $9.00$21.00None
AMPICILLIN FOR INJECTION POWDER   2* Non-Preferred Generic Drugs $9.00$21.00None
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT   2* Non-Preferred Generic Drugs $9.00$21.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT   2* Non-Preferred Generic Drugs $9.00$21.00None
AMPICILLIN POWDER FOR INJECTION 1 GM/ML   2* Non-Preferred Generic Drugs $9.00$21.00None
ampicillin-sulbactam 15 gm vl   2* Non-Preferred Generic Drugs $9.00$21.00None
Amturnide 150; 5; 12.5mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   3 Preferred Brand Drugs $45.00$90.00Q:90
/90Days
Amturnide 300; 10; 12.5mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   3 Preferred Brand Drugs $45.00$90.00Q:90
/90Days
Amturnide 300; 10; 25mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   3 Preferred Brand Drugs $45.00$90.00Q:90
/90Days
Amturnide 300; 5; 12.5mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   3 Preferred Brand Drugs $45.00$90.00Q:90
/90Days
Amturnide 300; 5; 25mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   3 Preferred Brand Drugs $45.00$90.00Q:90
/90Days
ANADROL-50 50MG TABLET (100 CT)   4 Non-Preferred Brand Drugs $95.00$190.00P
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE in 1 BOTTLE   2* Non-Preferred Generic Drugs $9.00$21.00None
Anagrelide Hydrochloride 1mg/1 100 CAPSULE in 1 BOTTLE   2* Non-Preferred Generic Drugs $9.00$21.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANASTROZOLE TABLETS   2* Non-Preferred Generic Drugs $9.00$21.00None
ANCOBON 250MG CAPSULE   3 Preferred Brand Drugs $45.00$90.00None
ANCOBON 500MG CAPSULE   3 Preferred Brand Drugs $45.00$90.00None
ANDRODERM 2 MG/24HR PATCH   3 Preferred Brand Drugs $45.00$90.00P
ANDRODERM 2.5MG/24HR PATCH   3 Preferred Brand Drugs $45.00$90.00P
ANDRODERM 4 MG/24HR PATCH   3 Preferred Brand Drugs $45.00$90.00P
ANDRODERM 5MG/24HR PATCH   3 Preferred Brand Drugs $45.00$90.00P
ANDROGEL 1%(50MG) GEL PACKET   3 Preferred Brand Drugs $45.00$90.00P
Androgel 16.2mg/g 1 BOTTLE, PUMP in 1 CARTON / 88 g in 1 BOTTLE, PUMP   3 Preferred Brand Drugs $45.00$90.00P
ANDROID 10MG CAPSULE   3 Preferred Brand Drugs $45.00$90.00P
ANTABUSE 250MG TABLET   3 Preferred Brand Drugs $45.00$90.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANTARA CAPSULES   3 Preferred Brand Drugs $45.00$90.00None
ANTARA CAPSULES   3 Preferred Brand Drugs $45.00$90.00None
APIDRA 100UNITS/ML VIAL   3 Preferred Brand Drugs $45.00$90.00None
APOKYN 30mg/3mL 5 CARTRIDGE in 1 CARTON / 3 mL in 1 CARTRIDGE   3 Preferred Brand Drugs $45.00$90.00None
Apraclonidine Ophthalmic 5mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 10 mL in 1 BOTTLE, DROPPER   2* Non-Preferred Generic Drugs $9.00$21.00None
APRI 0.15-0.03 TABLET   2* Non-Preferred Generic Drugs $9.00$21.00None
APRISO CP24   3 Preferred Brand Drugs $45.00$90.00None
APTIVUS 250MG CAPSULE   5 Specialty Tier Drugs 29%29%None
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT   5 Specialty Tier Drugs 29%29%None
Aralast NP 1 KIT in 1 CARTON   5 Specialty Tier Drugs 29%29%None
ARANELLE 7-9-5 TABLET   2* Non-Preferred Generic Drugs $9.00$21.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP 100ug/0.5mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE in 1 BLISTER PACK / 0.5 mL in 1 SYRINGE   3 Preferred Brand Drugs $45.00$90.00P Q:6
/90Days
ARANESP 100ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE   3 Preferred Brand Drugs $45.00$90.00P Q:12
/90Days
ARANESP 200MCG/0.4ML SYRINGE   3 Preferred Brand Drugs $45.00$90.00P Q:5
/90Days
ARANESP 200MCG/ML VIAL   3 Preferred Brand Drugs $45.00$90.00P Q:12
/90Days
ARANESP 25ug/0.42mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE in 1 BLISTER PACK / 0.42 mL in 1 SYRING   3 Preferred Brand Drugs $45.00$90.00P Q:10
/90Days
ARANESP 25ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE   3 Preferred Brand Drugs $45.00$90.00P Q:24
/90Days
ARANESP 300MCG/ML VIAL   3 Preferred Brand Drugs $45.00$90.00P Q:12
/90Days
ARANESP 500MCG/1ML SYRINGE   3 Preferred Brand Drugs $45.00$90.00P Q:3
/90Days
ARANESP 60MCG/ML VIAL   3 Preferred Brand Drugs $45.00$90.00P Q:24
/90Days
ARANESP 60ug/0.3mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE in 1 BLISTER PACK / 0.3 mL in 1 SYRINGE   3 Preferred Brand Drugs $45.00$90.00P Q:7
/90Days
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR   3 Preferred Brand Drugs $45.00$90.00P Q:4
/90Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR   3 Preferred Brand Drugs $45.00$90.00P Q:7
/90Days
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR   3 Preferred Brand Drugs $45.00$90.00P Q:10
/90Days
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD   3 Preferred Brand Drugs $45.00$90.00P Q:24
/90Days
ARCALYST INJECTION 220MG/VIAL   5 Specialty Tier Drugs 29%29%None
Arcapta Neohaler 75ug/1 30 BLISTER PACK in 1 BOX / 1 CAPSULE in 1 BLISTER PACK   4 Non-Preferred Brand Drugs $95.00$190.00Q:90
/90Days
ARICEPT ODT 10MG TABLET   3 Preferred Brand Drugs $45.00$90.00Q:90
/90Days
ARICEPT ODT 5MG TABLET   3 Preferred Brand Drugs $45.00$90.00Q:90
/90Days
ARICEPT TABLETS   3 Preferred Brand Drugs $45.00$90.00Q:90
/90Days
ARIXTRA 10MG SYRINGE   3 Preferred Brand Drugs $45.00$90.00None
ARIXTRA 2.5MG SYRINGE   3 Preferred Brand Drugs $45.00$90.00None
ARIXTRA 5MG SYRINGE   3 Preferred Brand Drugs $45.00$90.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARIXTRA 7.5MG SYRINGE   3 Preferred Brand Drugs $45.00$90.00None
ARRANON 250MG VIAL   4 Non-Preferred Brand Drugs $95.00$190.00None
ARTHROTEC 50 50MG TABLET -200MCG (60 CT)   4 Non-Preferred Brand Drugs $95.00$190.00None
ARTHROTEC 75 TABLET EC   4 Non-Preferred Brand Drugs $95.00$190.00None
ARZERRA 20mg/mL 3 VIAL in 1 CARTON / 5 mL in 1 VIAL   3 Preferred Brand Drugs $45.00$90.00None
ASACOL 400mg/1 12 BOTTLE in 1 CASE / 180 TABLET, DELAYED RELEASE in 1 BOTTLE   3 Preferred Brand Drugs $45.00$90.00None
ASACOL HD 800mg/1 12 BOTTLE in 1 CASE / 180 TABLET, DELAYED RELEASE in 1 BOTTLE   3 Preferred Brand Drugs $45.00$90.00None
Ascomp with Codeine 325; 50; 40; 30mg/1; mg/1; mg/1; mg/1 500 CAPSULE in 1 BOTTLE, PLASTIC   2* Non-Preferred Generic Drugs $9.00$21.00None
ASMANEX 220ug/1 1 POUCH in 1 POUCH / 1 INHALER in 1 POUCH / 14 INHALANT in 1 INHALER   3 Preferred Brand Drugs $45.00$90.00Q:3
/90Days
ASMANEX TWISTHALER 110 MCG #30   3 Preferred Brand Drugs $45.00$90.00Q:3
/90Days
ASMANEX TWISTHALER 220MCG #120   3 Preferred Brand Drugs $45.00$90.00Q:3
/90Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ASMANEX TWISTHALER 220MCG #30   3 Preferred Brand Drugs $45.00$90.00Q:3
/90Days
ASMANEX TWISTHALER 220MCG #60   3 Preferred Brand Drugs $45.00$90.00Q:3
/90Days
ASTEPRO 0.15% NASAL SPRAY 30 ML   3 Preferred Brand Drugs $45.00$90.00None
ATENOLOL 100mg/1 100 TABLET in 1 BOTTLE, PLASTIC   2* Non-Preferred Generic Drugs $9.00$21.00None
Atenolol 25mg/1 100 TABLET in 1 BOTTLE, PLASTIC   2* Non-Preferred Generic Drugs $9.00$21.00None
ATENOLOL TABLET USP 50MG (100 CT)   1* Preferred Generic Drugs $3.00$0.00None
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT)   1* Preferred Generic Drugs $3.00$0.00None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   1* Preferred Generic Drugs $3.00$0.00None
ATORVASTATIN 10 MG TABLET   2* Non-Preferred Generic Drugs $9.00$21.00Q:90
/90Days
ATORVASTATIN 20 MG TABLET   2* Non-Preferred Generic Drugs $9.00$21.00Q:90
/90Days
ATORVASTATIN 40 MG TABLET   2* Non-Preferred Generic Drugs $9.00$21.00Q:90
/90Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATORVASTATIN 80 MG TABLET   2* Non-Preferred Generic Drugs $9.00$21.00Q:90
/90Days
Atovaquone and Proguanil Hydrochloride 250; 100mg/1; mg/1   2* Non-Preferred Generic Drugs $9.00$21.00None
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE, PLASTIC   5 Specialty Tier Drugs 29%29%None
ATROPINE 0.05MG/ML SYRINGE   3 Preferred Brand Drugs $45.00$90.00None
ATROPINE 0.1MG/ML SYRINGE   2* Non-Preferred Generic Drugs $9.00$21.00None
ATROVENT HFA AER 17MCG   3 Preferred Brand Drugs $45.00$90.00Q:77
/90Days
AUGMENTED BETAMETHASONE DIPROPIONATE OINTMENT   2* Non-Preferred Generic Drugs $9.00$21.00None
AVALIDE 12.5; 150mg/1; mg/1 90 TABLET, FILM COATED in 1 BOTTLE   3 Preferred Brand Drugs $45.00$90.00Q:90
/90Days
AVALIDE 12.5; 300mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   3 Preferred Brand Drugs $45.00$90.00Q:90
/90Days
AVALIDE 300-25MG TABLET   3 Preferred Brand Drugs $45.00$90.00Q:90
/90Days
AVANDAMET 1000; 2mg/1; mg/1 60 TABLET, FILM COATED in 1 BOTTLE   3 Preferred Brand Drugs $45.00$90.00Q:180
/90Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVANDAMET 1000; 4mg/1; mg/1 60 TABLET, FILM COATED in 1 BOTTLE   3 Preferred Brand Drugs $45.00$90.00Q:180
/90Days
AVANDAMET 500; 2mg/1; mg/1 60 TABLET, FILM COATED in 1 BOTTLE   3 Preferred Brand Drugs $45.00$90.00Q:180
/90Days
AVANDAMET 500; 4mg/1; mg/1 60 TABLET, FILM COATED in 1 BOTTLE   3 Preferred Brand Drugs $45.00$90.00Q:180
/90Days
AVANDARYL 1; 4mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   3 Preferred Brand Drugs $45.00$90.00Q:180
/90Days
AVANDARYL 2; 4mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   3 Preferred Brand Drugs $45.00$90.00Q:180
/90Days
AVANDARYL 2; 8mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   3 Preferred Brand Drugs $45.00$90.00Q:90
/90Days
AVANDARYL 4; 4mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   3 Preferred Brand Drugs $45.00$90.00Q:90
/90Days
AVANDARYL 4; 8mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   3 Preferred Brand Drugs $45.00$90.00Q:90
/90Days
AVANDIA 2mg/1 60 TABLET, FILM COATED in 1 BOTTLE   3 Preferred Brand Drugs $45.00$90.00Q:180
/90Days
AVANDIA 4mg/1 30 TABLET, FILM COATED in 1 BOTTLE   3 Preferred Brand Drugs $45.00$90.00Q:180
/90Days
AVANDIA 8mg/1 30 TABLET, FILM COATED in 1 BOTTLE   3 Preferred Brand Drugs $45.00$90.00Q:90
/90Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVAPRO 150MG TABLET   3 Preferred Brand Drugs $45.00$90.00Q:90
/90Days
AVAPRO 300MG TABLET   3 Preferred Brand Drugs $45.00$90.00Q:90
/90Days
AVAPRO 75MG TABLET (30 CT)   3 Preferred Brand Drugs $45.00$90.00Q:90
/90Days
AVASTIN 100MG/4ML VIAL   4 Non-Preferred Brand Drugs $95.00$190.00None
AVELOX 400MG TABLET   3 Preferred Brand Drugs $45.00$90.00None
AVELOX ABC PACK 400MG TABLET   3 Preferred Brand Drugs $45.00$90.00None
AVELOX IV 400MG/250ML   3 Preferred Brand Drugs $45.00$90.00None
AVIANE 0.1-0.02 TABLET   2* Non-Preferred Generic Drugs $9.00$21.00None
AVITA 0.025% CREAM   2* Non-Preferred Generic Drugs $9.00$21.00None
AVODART 0.5MG SOFTGEL   3 Preferred Brand Drugs $45.00$90.00Q:90
/90Days
AVONEX ADMIN PACK 30MCG SYR   5 Specialty Tier Drugs 29%29%P Q:12
/90Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVONEX ADMIN PACK 30MCG VL   5 Specialty Tier Drugs 29%29%P Q:12
/90Days
AZACTAM INJECTION 1GM/50ML   3 Preferred Brand Drugs $45.00$90.00None
AZACTAM INJECTION 2GM/50ML   3 Preferred Brand Drugs $45.00$90.00None
AZACTAM INJECTION 2GM/VIL   3 Preferred Brand Drugs $45.00$90.00None
AZASITE 1% DROPS   3 Preferred Brand Drugs $45.00$90.00None
AZATHIOPRINE 50MG TABLET   2* Non-Preferred Generic Drugs $9.00$21.00P
AZATHIOPRINE SOD 100MG VIAL   2* Non-Preferred Generic Drugs $9.00$21.00None
AZELASTINE 137 MCG NASAL SPRAY   2* Non-Preferred Generic Drugs $9.00$21.00None
AZELASTINE HYDROCHLORIDE OPHTHALMIC SOLUTION   2* Non-Preferred Generic Drugs $9.00$21.00None
AZELEX 20% CREAM 30GM TUBE   3 Preferred Brand Drugs $45.00$90.00None
AZILECT 0.5MG TABLET   3 Preferred Brand Drugs $45.00$90.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZILECT 1MG TABLET   3 Preferred Brand Drugs $45.00$90.00None
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL   2* Non-Preferred Generic Drugs $9.00$21.00None
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL   2* Non-Preferred Generic Drugs $9.00$21.00None
AZITHROMYCIN 250 MG TABLET   2* Non-Preferred Generic Drugs $9.00$21.00None
Azithromycin 500mg/1 10 VIAL, SINGLE-USE in 1 TRAY / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION   2* Non-Preferred Generic Drugs $9.00$21.00None
Azithromycin 500mg/1 30 TABLET, FILM COATED in 1 BOTTLE   2* Non-Preferred Generic Drugs $9.00$21.00None
Azithromycin 600mg/1 30 TABLET, FILM COATED in 1 BOTTLE   2* Non-Preferred Generic Drugs $9.00$21.00None
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT   3 Preferred Brand Drugs $45.00$90.00None
AZTREONAM FOR INJECTION   2* Non-Preferred Generic Drugs $9.00$21.00None

Chart Legend:

Below are a few notes to help you understand the above 2012 Medicare Part D United American - Preferred (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.