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BravoRx (PDP) (S5998-013-0)
Tier 1 (2082)
Tier 2 (982)
Tier 3 (57)


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2012 Medicare Part D Plan Formulary Information
BravoRx (PDP) (S5998-013-0)
Benefit Details           
The BravoRx (PDP) (S5998-013-0)
Formulary Drugs Starting with the Letter A

in CMS PDP Region 32 which includes: CA
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   1 Tier 1 25%25%None
A-HYDROCORT 100MG VIAL   1 Tier 1 25%25%None
A-METHAPRED INJ 40MG   1 Tier 1 25%25%None
ABACAVIR TAB 300MG   1 Tier 1 25%25%None
ABELCENT INJECTION SUSPENSION 5MG/ML   2 Tier 2 25%25%P
ABILIFY 10MG TABLET   2 Tier 2 25%25%P Q:30
/30Days
ABILIFY 15MG TABLET   2 Tier 2 25%25%P Q:30
/30Days
ABILIFY 1MG/ML SOLUTION   2 Tier 2 25%25%P Q:900
/30Days
ABILIFY 20MG TABLET   2 Tier 2 25%25%P Q:30
/30Days
ABILIFY 2MG TABLET   2 Tier 2 25%25%P Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ABILIFY 30MG TABLET   2 Tier 2 25%25%P Q:30
/30Days
ABILIFY 5MG TABLET (OTSUKA)   2 Tier 2 25%25%P Q:30
/30Days
ABILIFY DISCMELT 10MG TABLET   2 Tier 2 25%25%P Q:60
/30Days
ABILIFY DISCMELT 15MG TABLET   2 Tier 2 25%25%P Q:60
/30Days
ABILIFY INJ 9.75MG   2 Tier 2 25%25%P
ABRAXANE 100MG VIAL   2 Tier 2 25%25%P
Acarbose 100mg/1 90 TABLET in 1 BOTTLE,   1 Tier 1 25%25%Q:90
/30Days
acarbose 50 mg tablet   1 Tier 1 25%25%Q:90
/30Days
ACARBOSE TABLETS   1 Tier 1 25%25%Q:90
/30Days
ACEBUTOLOL 200MG CAPSULE   1 Tier 1 25%25%None
ACEBUTOLOL 400MG CAPSULE   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE   2 Tier 2 25%25%None
Acetaminophen and Codeine Phosphate 300; 60mg/1; mg/1 500 TABLET in 1 BOTTLE   1 Tier 1 25%25%Q:240
/30Days
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD   1 Tier 1 25%25%Q:5000
/30Days
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT)   1 Tier 1 25%25%Q:360
/30Days
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT)   1 Tier 1 25%25%Q:360
/30Days
ACETASOL HC SOLUTION 10ML 10 ML BOT   1 Tier 1 25%25%None
ACETAZOLAMIDE 125MG TABLET   1 Tier 1 25%25%None
ACETAZOLAMIDE 250MG TABLET (100 CT)   1 Tier 1 25%25%None
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT   1 Tier 1 25%25%None
ACETAZOLAMIDE SOD 500MG VL   1 Tier 1 25%25%None
ACETIC ACID 2% SOLUTION NON-ORAL   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETYLCYSTEINE 10% VIAL   1 Tier 1 25%25%P
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN   1 Tier 1 25%25%P
ACTHIB VACCINE VIAL 10-24UNT/5ML   2 Tier 2 25%25%None
ACTICIN 5% CREAM   1 Tier 1 25%25%None
ACTIMMUNE SOLUTION FOR INJECTION 100MCG   2 Tier 2 25%25%P
Actonel 150mg/1 36 DOSE PACK in 1 CASE / 1 TRAY in 1 DOSE PACK / 1 TABLET, FILM COATED in 1 TRAY   2 Tier 2 25%25%Q:1
/28Days
Actonel 30mg/1 12 BOTTLE in 1 CASE / 30 TABLET, FILM COATED in 1 BOTTLE   2 Tier 2 25%25%Q:30
/30Days
Actonel 35mg/1 36 DOSE PACK in 1 CASE / 1 TRAY in 1 DOSE PACK / 4 TABLET, FILM COATED in 1 TRAY   2 Tier 2 25%25%Q:4
/28Days
Actonel 5mg/1 12 BOTTLE in 1 CASE / 30 TABLET, FILM COATED in 1 BOTTLE   2 Tier 2 25%25%Q:30
/30Days
ACTOPLUS MET 15MG/500MG TABLET   2 Tier 2 25%25%S Q:90
/30Days
ACTOPLUS MET 15MG/850MG TABLET   2 Tier 2 25%25%S Q:90
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACTOS 15MG TABLET   2 Tier 2 25%25%S Q:30
/30Days
ACTOS 30MG TABLET (500 CT)   2 Tier 2 25%25%S Q:30
/30Days
ACTOS 45MG TABLET   2 Tier 2 25%25%S Q:30
/30Days
Acyclovir 200mg/1   1 Tier 1 25%25%None
Acyclovir 200mg/5mL 473 mL in 1 BOTTLE   1 Tier 1 25%25%None
Acyclovir 400mg/1 100 BLISTER PACK in 1 BOX / 1 TABLET in 1 BLISTER PACK   1 Tier 1 25%25%None
Acyclovir 800mg/1 100 BLISTER PACK in 1 BOX / 1 TABLET in 1 BLISTER PACK   1 Tier 1 25%25%None
ACYCLOVIR SODIUM 500MG VIAL   1 Tier 1 25%25%None
ADACEL VIAL 2UNT/5UNT   2 Tier 2 25%25%None
ADAGEN 250U/ML VIAL   2 Tier 2 25%25%P
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA]   2 Tier 2 25%25%P Q:2
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADVAIR DISKUS MIS 100/50   2 Tier 2 25%25%Q:60
/30Days
ADVAIR DISKUS MIS 250/50   2 Tier 2 25%25%Q:60
/30Days
ADVAIR DISKUS MIS 500/50   2 Tier 2 25%25%Q:60
/30Days
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER   2 Tier 2 25%25%Q:24
/30Days
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL   2 Tier 2 25%25%Q:24
/30Days
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL   2 Tier 2 25%25%Q:24
/30Days
AFEDITAB CR 30MG TABLET SA   1 Tier 1 25%25%None
AFEDITAB CR 60MG TABLET SA   1 Tier 1 25%25%None
Afinitor 7.5mg/1 28 BLISTER PACK in 1 CARTON / 1 TABLET in 1 BLISTER PACK   2 Tier 2 25%25%P Q:30
/30Days
AFINITOR TABLETS 10 MG   2 Tier 2 25%25%P Q:30
/30Days
AFINITOR TABLETS 2.5 MG   2 Tier 2 25%25%P Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AFINITOR TABLETS 5 MG   2 Tier 2 25%25%P Q:30
/30Days
AGGRENOX 25-200MG CAPSULE   2 Tier 2 25%25%Q:60
/30Days
AK-CON 0.1% EYE DROPS   1 Tier 1 25%25%None
AKTOB 0.3% EYE DROPS   1 Tier 1 25%25%None
ALA-CORT 1% CREAM   1 Tier 1 25%25%None
ALA-CORT 1% LOTION   1 Tier 1 25%25%None
ALA-SCALP HP 2% LOTION   2 Tier 2 25%25%None
ALBENZA 200 MG TABLET   2 Tier 2 25%25%None
Albuterol Sulfate 0.63mg/3mL 25 POUCH in 1 CARTON / 5 VIAL in 1 POUCH / 3 mL in 1 VIAL   1 Tier 1 25%25%P Q:375
/30Days
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER   1 Tier 1 25%25%P Q:375
/30Days
ALBUTEROL SULFATE 4MG TABLET SR 12HR   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALBUTEROL SULFATE 8MG TABLET SR 12HR   1 Tier 1 25%25%None
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   1 Tier 1 25%25%P Q:360
/30Days
ALBUTEROL SULFATE SOLUTION FOR INHALATION   1 Tier 1 25%25%P Q:375
/30Days
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT   1 Tier 1 25%25%None
ALBUTEROL SULFATE TABLET 2MG (500 CT)   1 Tier 1 25%25%None
ALBUTEROL TABLET 4MG (500 CT)   1 Tier 1 25%25%None
ALCLOMETASONE DIPROPIONATE 0.05% CREAM   1 Tier 1 25%25%None
Alclometasone Dipropionate 0.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE   1 Tier 1 25%25%None
ALDURAZYME 2.9MG/5ML VIAL   2 Tier 2 25%25%P
ALENDRONATE SODIUM 10MG TABLET   1 Tier 1 25%25%Q:30
/30Days
ALENDRONATE SODIUM 40MG TABLET   1 Tier 1 25%25%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALENDRONATE SODIUM 5MG TABLET   1 Tier 1 25%25%Q:30
/30Days
ALENDRONATE SODIUM 70mg/1   1 Tier 1 25%25%Q:4
/28Days
ALENDRONATE SODIUM TABLET 35MG 20 CRTN   1 Tier 1 25%25%Q:4
/28Days
ALIMTA 500MG VIAL   2 Tier 2 25%25%P
ALINIA 100MG/5ML SUSPENSION   2 Tier 2 25%25%None
ALINIA 500MG TABLET   2 Tier 2 25%25%None
ALKERAN 1 KIT in 1 CARTON   2 Tier 2 25%25%P
Allopurinol 300mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET in 1 BLISTER PACK   1 Tier 1 25%25%None
ALLOPURINOL SODIUM 500MG VIAL   1 Tier 1 25%25%None
ALLOPURINOL TABLETS   1 Tier 1 25%25%None
ALOCRIL 2% EYE DROPS   2 Tier 2 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALOXI 0.25MG/5ML   3 Tier 3 25%25%P
AMANTADINE 100MG CAPSULE   1 Tier 1 25%25%None
AMANTADINE 100MG TABLET   1 Tier 1 25%25%None
Amantadine Hydrochloride 50mg/5mL   1 Tier 1 25%25%None
AMBISOME 50MG VIAL   2 Tier 2 25%25%P
AMCINONIDE 0.1% CREAM   1 Tier 1 25%25%None
AMCINONIDE 0.1% LOTION   1 Tier 1 25%25%None
AMCINONIDE 0.1% OINTMENT 60GM TUBE   1 Tier 1 25%25%None
AMIFOSTINE FOR INJECTION 500MG/VIAL   1 Tier 1 25%25%P
AMIKACIN 250MG/ML VIAL   1 Tier 1 25%25%None
AMIKACIN 50MG/ML VIAL   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET   1 Tier 1 25%25%None
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT   1 Tier 1 25%25%None
AMINOPHYLLINE 100MG TABLET   1 Tier 1 25%25%None
AMINOPHYLLINE 200MG TABLET (1000 CT)   1 Tier 1 25%25%None
Aminophylline 25mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 10 mL in 1 VIA   1 Tier 1 25%25%None
AMINOSYN 10% IV SOLUTION   2 Tier 2 25%25%P
AMINOSYN 3.5% IV SOLUTION   2 Tier 2 25%25%P
AMINOSYN 5% IV SOLUTION   2 Tier 2 25%25%P
AMINOSYN 7% IV SOLUTION   2 Tier 2 25%25%P
AMINOSYN 8.5% IV SOLUTION   2 Tier 2 25%25%P
AMINOSYN HBC INJECTION SULFITE FREE 7%   2 Tier 2 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN II 10% IV SOLUTION   2 Tier 2 25%25%P
AMINOSYN II 15% IV SOLUTION   2 Tier 2 25%25%P
AMINOSYN II 3.5% IN D25W IV   2 Tier 2 25%25%P
AMINOSYN II 3.5% IN D5W IV   2 Tier 2 25%25%P
AMINOSYN II 3.5% W/ELEC DEX   2 Tier 2 25%25%P
AMINOSYN II 4.25% IN D10W   2 Tier 2 25%25%P
AMINOSYN II 4.25% IN D20W   2 Tier 2 25%25%P
AMINOSYN II 4.25% W/ELEC DW   2 Tier 2 25%25%P
AMINOSYN II 4.25%-D25W IV   2 Tier 2 25%25%P
AMINOSYN II 5% IN D25W IV   2 Tier 2 25%25%P
AMINOSYN II 7% IV SOLUTION   2 Tier 2 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN II 8.5% ELECTROLYT   2 Tier 2 25%25%P
AMINOSYN II 8.5% IV SOLUTION   2 Tier 2 25%25%P
AMINOSYN M 3.5% IV SOLUTION   2 Tier 2 25%25%P
AMINOSYN PF INJECTION   2 Tier 2 25%25%P
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5%   2 Tier 2 25%25%P
AMINOSYN-HF 8% IV SOLUTION   2 Tier 2 25%25%P
AMINOSYN-PF 7% IV SOLUTION   2 Tier 2 25%25%P
AMIODARONE HCL 400MG TABLET   1 Tier 1 25%25%None
AMIODARONE HCL INJECTION   1 Tier 1 25%25%None
Amiodarone hydrochloride 200mg/1   1 Tier 1 25%25%None
AMITIZA 8MCG CAPSULE   2 Tier 2 25%25%Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITIZA CAPSULES 24MCG 60 CAP BOT   2 Tier 2 25%25%Q:60
/30Days
AMITRIP/CDP 25-10 TABLET   1 Tier 1 25%25%None
AMITRIP/PERPHEN 10-2 TABLET   1 Tier 1 25%25%None
AMITRIP/PERPHEN 10-4 TABLET   1 Tier 1 25%25%None
AMITRIP/PERPHEN 25-2 TABLET   1 Tier 1 25%25%None
AMITRIP/PERPHEN 25-4 TABLET   1 Tier 1 25%25%None
AMITRIP/PERPHEN 50-4 TABLET   1 Tier 1 25%25%None
AMITRIPTYLINE HCL 100MG TABLET   1 Tier 1 25%25%None
AMITRIPTYLINE HCL 10MG TABLET   1 Tier 1 25%25%None
AMITRIPTYLINE HCL 150 MG TAB   1 Tier 1 25%25%None
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)   1 Tier 1 25%25%None
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT   1 Tier 1 25%25%None
AMLODIPINE BESYLATE 10MG TABLET (90 CT)   1 Tier 1 25%25%None
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)   1 Tier 1 25%25%None
AMLODIPINE BESYLATE 5MG TABLET (90 CT)   1 Tier 1 25%25%None
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE CAPSULES   1 Tier 1 25%25%None
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE CAPSULES   1 Tier 1 25%25%None
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE   1 Tier 1 25%25%None
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE   1 Tier 1 25%25%None
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE   1 Tier 1 25%25%None
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMMONIUM LACTATE 12% CREAM   1 Tier 1 25%25%None
AMMONIUM LACTATE 12% LOTION   1 Tier 1 25%25%None
Amnesteem 10mg/1 3 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK   1 Tier 1 25%25%None
Amnesteem 20mg/1 3 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK   1 Tier 1 25%25%None
Amnesteem 40mg/1 3 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK   1 Tier 1 25%25%None
AMOX TR-K CLV 500-125 MG TAB   1 Tier 1 25%25%None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL   1 Tier 1 25%25%None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE   1 Tier 1 25%25%None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET   1 Tier 1 25%25%None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE   1 Tier 1 25%25%None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXAPINE 100MG TABLET   1 Tier 1 25%25%None
AMOXAPINE 150MG TABLET   1 Tier 1 25%25%None
AMOXAPINE 25MG TABLET   1 Tier 1 25%25%None
AMOXAPINE 50MG TABLET   1 Tier 1 25%25%None
AMOXICILLIN 125MG TABLET CHEW   1 Tier 1 25%25%None
AMOXICILLIN 200MG TABLET CHEW   1 Tier 1 25%25%None
AMOXICILLIN 250MG CAPSULE   1 Tier 1 25%25%None
Amoxicillin 250mg/1 500 TABLET, CHEWABLE in 1 BOTTLE   1 Tier 1 25%25%None
AMOXICILLIN 50 MG/ML / CLAVULANATE 12.5 MG/ML ORAL SUSPENSION   1 Tier 1 25%25%None
AMOXICILLIN 500MG TABLET (100 CT)   1 Tier 1 25%25%None
AMOXICILLIN 875MG TABLET   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT   1 Tier 1 25%25%None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS EXTENDED RELEASE 1000;62.5MG;MG   1 Tier 1 25%25%None
AMOXICILLIN CAP 500MG   1 Tier 1 25%25%None
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT   1 Tier 1 25%25%None
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT   1 Tier 1 25%25%None
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL   1 Tier 1 25%25%None
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   1 Tier 1 25%25%None
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL   1 Tier 1 25%25%None
AMPHETAMINE SALT COMBO 12.5MG TABLET   1 Tier 1 25%25%Q:90
/30Days
AMPHETAMINE SALT COMBO 15MG TABLET   1 Tier 1 25%25%Q:90
/30Days
AMPHETAMINE SALT COMBO 30MG TABLET   1 Tier 1 25%25%Q:90
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPHETAMINE SALT COMBO 7.5MG TABLET   1 Tier 1 25%25%Q:90
/30Days
AMPHETAMINE SALTS 20MG TABLET   1 Tier 1 25%25%Q:90
/30Days
AMPHETAMINE SALTS 5 MG TAB   1 Tier 1 25%25%Q:90
/30Days
AMPHOTEC FOR INJECTION 50MG/VIAL   2 Tier 2 25%25%P
amphotericin b 50mg/10mL 10 mL in 1 VIAL   1 Tier 1 25%25%P
Ampicillin 125mg/1 10 VIAL in 1 BOX / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL   1 Tier 1 25%25%None
AMPICILLIN AND SULBACTAM FOR INJECTION 2-1 10 VIAL   1 Tier 1 25%25%None
AMPICILLIN CAPSULES 250MG 100 BOT   1 Tier 1 25%25%None
AMPICILLIN CAPSULES 500MG 100 BOT   1 Tier 1 25%25%None
AMPICILLIN FOR INJECTION POWDER   1 Tier 1 25%25%None
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPICILLIN POWDER FOR INJECTION 1 GM/ML   1 Tier 1 25%25%None
ampicillin-sulbactam 15 gm vl   1 Tier 1 25%25%None
AMPYRA ER 10 MG TABLET   2 Tier 2 25%25%P
ANADROL-50 50MG TABLET (100 CT)   2 Tier 2 25%25%P
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE in 1 BOTTLE   1 Tier 1 25%25%None
Anagrelide Hydrochloride 1mg/1 100 CAPSULE in 1 BOTTLE   1 Tier 1 25%25%None
ANASTROZOLE TABLETS   1 Tier 1 25%25%Q:30
/30Days
ANCOBON 250MG CAPSULE   2 Tier 2 25%25%None
ANCOBON 500MG CAPSULE   2 Tier 2 25%25%None
ANDROGEL 1%(50MG) GEL PACKET   2 Tier 2 25%25%P
Androgel 16.2mg/g 1 BOTTLE, PUMP in 1 CARTON / 88 g in 1 BOTTLE, PUMP   2 Tier 2 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANZEMET 20MG/ML VIAL   2 Tier 2 25%25%None
APOKYN 30mg/3mL 5 CARTRIDGE in 1 CARTON / 3 mL in 1 CARTRIDGE   2 Tier 2 25%25%P Q:60
/30Days
Apraclonidine Ophthalmic 5mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 10 mL in 1 BOTTLE, DROPPER   1 Tier 1 25%25%None
APRI 0.15-0.03 TABLET   1 Tier 1 25%25%None
APRISO CP24   2 Tier 2 25%25%None
APTIVUS 250MG CAPSULE   2 Tier 2 25%25%None
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT   2 Tier 2 25%25%Q:300
/30Days
ARANELLE 7-9-5 TABLET   1 Tier 1 25%25%None
ARANESP 100ug/0.5mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE in 1 BLISTER PACK / 0.5 mL in 1 SYRINGE   2 Tier 2 25%25%P
ARANESP 100ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE   2 Tier 2 25%25%P
ARANESP 200MCG/0.4ML SYRINGE   2 Tier 2 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP 200MCG/ML VIAL   2 Tier 2 25%25%P
ARANESP 25ug/0.42mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE in 1 BLISTER PACK / 0.42 mL in 1 SYRING   2 Tier 2 25%25%P
ARANESP 25ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE   2 Tier 2 25%25%P
ARANESP 300MCG/ML VIAL   2 Tier 2 25%25%P
ARANESP 500MCG/1ML SYRINGE   2 Tier 2 25%25%P
ARANESP 60MCG/ML VIAL   2 Tier 2 25%25%P
ARANESP 60ug/0.3mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE in 1 BLISTER PACK / 0.3 mL in 1 SYRINGE   2 Tier 2 25%25%P
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR   2 Tier 2 25%25%P
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR   2 Tier 2 25%25%P
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR   2 Tier 2 25%25%P
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD   2 Tier 2 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARCALYST INJECTION 220MG/VIAL   2 Tier 2 25%25%P
AROMASIN 25MG TABLET   2 Tier 2 25%25%None
ARTHROTEC 50 50MG TABLET -200MCG (60 CT)   2 Tier 2 25%25%None
ARTHROTEC 75 TABLET EC   2 Tier 2 25%25%None
ARZERRA 20mg/mL 3 VIAL in 1 CARTON / 5 mL in 1 VIAL   2 Tier 2 25%25%P
ASACOL 400mg/1 12 BOTTLE in 1 CASE / 180 TABLET, DELAYED RELEASE in 1 BOTTLE   2 Tier 2 25%25%None
Ascomp with Codeine 325; 50; 40; 30mg/1; mg/1; mg/1; mg/1 500 CAPSULE in 1 BOTTLE, PLASTIC   1 Tier 1 25%25%Q:360
/30Days
ASTRAMORPH PF INJECTION 0.5MG/ML   1 Tier 1 25%25%None
ASTRAMORPH PF INJECTION 1MG/ML   1 Tier 1 25%25%None
Atelvia 35mg/1 36 DOSE PACK in 1 CASE / 4 TABLET, DELAYED RELEASE in 1 DOSE PACK   2 Tier 2 25%25%Q:4
/28Days
ATENOLOL 100mg/1 100 TABLET in 1 BOTTLE, PLASTIC   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Atenolol 25mg/1 100 TABLET in 1 BOTTLE, PLASTIC   1 Tier 1 25%25%None
ATENOLOL TABLET USP 50MG (100 CT)   1 Tier 1 25%25%None
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT)   1 Tier 1 25%25%None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   1 Tier 1 25%25%None
ATGAM 50MG/ML AMPUL   2 Tier 2 25%25%P
ATORVASTATIN 10 MG TABLET   1 Tier 1 25%25%Q:30
/30Days
ATORVASTATIN 20 MG TABLET   1 Tier 1 25%25%Q:30
/30Days
ATORVASTATIN 40 MG TABLET   1 Tier 1 25%25%Q:30
/30Days
ATORVASTATIN 80 MG TABLET   1 Tier 1 25%25%Q:30
/30Days
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE, PLASTIC   2 Tier 2 25%25%None
ATROPINE 0.05MG/ML SYRINGE   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATROPINE 0.1MG/ML SYRINGE   1 Tier 1 25%25%None
ATROVENT HFA AER 17MCG   2 Tier 2 25%25%Q:26
/30Days
AUGMENTED BETAMETHASONE DIPROPIONATE OINTMENT   1 Tier 1 25%25%None
AVASTIN 100MG/4ML VIAL   2 Tier 2 25%25%P
AVELOX 400MG TABLET   2 Tier 2 25%25%None
AVELOX ABC PACK 400MG TABLET   2 Tier 2 25%25%None
AVELOX IV 400MG/250ML   2 Tier 2 25%25%None
AVIANE 0.1-0.02 TABLET   1 Tier 1 25%25%None
AVITA 0.025% CREAM   1 Tier 1 25%25%P
Avita 0.25mg/g 45 g in 1 TUBE   1 Tier 1 25%25%P
AVODART 0.5MG SOFTGEL   2 Tier 2 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVONEX ADMIN PACK 30MCG SYR   3 Tier 3 25%25%P Q:4
/28Days
AVONEX ADMIN PACK 30MCG VL   3 Tier 3 25%25%P Q:4
/28Days
AZACTAM INJECTION 1GM/50ML   2 Tier 2 25%25%None
AZACTAM INJECTION 2GM/50ML   2 Tier 2 25%25%None
AZASAN 100MG TABLET   2 Tier 2 25%25%P
AZASAN 75MG TABLET   2 Tier 2 25%25%P
AZASITE 1% DROPS   2 Tier 2 25%25%None
AZATHIOPRINE 50MG TABLET   1 Tier 1 25%25%None
AZELASTINE 137 MCG NASAL SPRAY   1 Tier 1 25%25%Q:60
/30Days
AZELASTINE HYDROCHLORIDE OPHTHALMIC SOLUTION   1 Tier 1 25%25%None
AZILECT 0.5MG TABLET   2 Tier 2 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZILECT 1MG TABLET   2 Tier 2 25%25%None
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Tier 1 25%25%Q:150
/30Days
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Tier 1 25%25%Q:75
/30Days
AZITHROMYCIN 250 MG TABLET   1 Tier 1 25%25%Q:12
/28Days
Azithromycin 500mg/1 10 VIAL, SINGLE-USE in 1 TRAY / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION   1 Tier 1 25%25%None
Azithromycin 500mg/1 30 TABLET, FILM COATED in 1 BOTTLE   1 Tier 1 25%25%Q:12
/28Days
Azithromycin 600mg/1 30 TABLET, FILM COATED in 1 BOTTLE   1 Tier 1 25%25%Q:12
/28Days
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT   2 Tier 2 25%25%None
AZTREONAM FOR INJECTION   1 Tier 1 25%25%None

Chart Legend:

Below are a few notes to help you understand the above 2012 Medicare Part D BravoRx (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 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 wit 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 which tier the drug is in. 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.