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2012 Medicare Part D and Medicare Advantage Plan Formulary Browser

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Health Net Orange Option 2 (PDP) (S5678-008-0)
Tier 1 (1987)
Tier 2 (678)
Tier 3 (1448)
Tier 4 (695)
Tier 5 (362)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
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Has Quantity Limits:
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Cick on the first letter of your drug name to browse the formulary:

A B C D E F G H I J K L 
M N O P Q R S T U V W X Y Z 0-9 
2012 Medicare Part D Plan Formulary Information
Health Net Orange Option 2 (PDP) (S5678-008-0)
Sanctioned Plan           
The Health Net Orange Option 2 (PDP) (S5678-008-0)
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   4 Injectable Drugs 33%33%None
A-HYDROCORT 100MG VIAL   4 Injectable Drugs 33%33%None
A-METHAPRED INJ 40MG   4 Injectable Drugs 33%33%None
ABACAVIR TAB 300MG   1 Preferred Generic Drugs $0.00$0.00None
ABELCENT INJECTION SUSPENSION 5MG/ML   5 Specialty Tier Drugs 33%33%None
ABILIFY 10MG TABLET   2 Preferred Brand Drugs $38.00$76.00None
ABILIFY 15MG TABLET   2 Preferred Brand Drugs $38.00$76.00None
ABILIFY 1MG/ML SOLUTION   2 Preferred Brand Drugs $38.00$76.00None
ABILIFY 20MG TABLET   2 Preferred Brand Drugs $38.00$76.00None
ABILIFY 2MG TABLET   2 Preferred Brand Drugs $38.00$76.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ABILIFY 30MG TABLET   2 Preferred Brand Drugs $38.00$76.00None
ABILIFY 5MG TABLET (OTSUKA)   2 Preferred Brand Drugs $38.00$76.00None
ABILIFY DISCMELT 10MG TABLET   2 Preferred Brand Drugs $38.00$76.00None
ABILIFY DISCMELT 15MG TABLET   2 Preferred Brand Drugs $38.00$76.00None
ABILIFY INJ 9.75MG   4 Injectable Drugs 33%33%None
ABRAXANE 100MG VIAL   5 Specialty Tier Drugs 33%33%None
Abstral 100ug/1 32 TABLET in 1 BLISTER PACK   5 Specialty Tier Drugs 33%33%None
Abstral 200ug/1 32 TABLET in 1 BLISTER PACK   5 Specialty Tier Drugs 33%33%None
Abstral 300ug/1 32 TABLET in 1 BLISTER PACK   5 Specialty Tier Drugs 33%33%None
Abstral 400ug/1 32 TABLET in 1 BLISTER PACK   5 Specialty Tier Drugs 33%33%None
Abstral 600ug/1 32 TABLET in 1 BLISTER PACK   5 Specialty Tier Drugs 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Abstral 800ug/1 32 TABLET in 1 BLISTER PACK   5 Specialty Tier Drugs 33%33%None
ACANYA 25; 10mg/g; mg/g 1 BOTTLE, PUMP in 1 CARTON / 50 g in 1 BOTTLE, PUMP   3 Non-Preferred Brand Drugs $75.00$188.00None
Acarbose 100mg/1 90 TABLET in 1 BOTTLE,   1 Preferred Generic Drugs $0.00$0.00None
acarbose 50 mg tablet   1 Preferred Generic Drugs $0.00$0.00None
ACARBOSE TABLETS   1 Preferred Generic Drugs $0.00$0.00None
ACCOLATE 10MG TABLET   2 Preferred Brand Drugs $38.00$76.00None
ACCOLATE 20MG TABLET   2 Preferred Brand Drugs $38.00$76.00None
ACCUNEB 0.63MG/3ML INH TUBEX   3 Non-Preferred Brand Drugs $75.00$188.00P
ACCUNEB 1.25MG/3ML INH TUBEX   3 Non-Preferred Brand Drugs $75.00$188.00P
ACCUPRIL 10MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
ACCUPRIL 20MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACCUPRIL 40MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
ACCUPRIL 5MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
ACCURETIC 10-12.5MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
ACCURETIC 20-12.5MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
ACCURETIC 20-25MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
ACEBUTOLOL 200MG CAPSULE   1 Preferred Generic Drugs $0.00$0.00None
ACEBUTOLOL 400MG CAPSULE   1 Preferred Generic Drugs $0.00$0.00None
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE   4 Injectable Drugs 33%33%None
ACEON 2MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
ACEON 4MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
ACEON 8MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
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   1 Preferred Generic Drugs $0.00$0.00None
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD   1 Preferred Generic Drugs $0.00$0.00None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT)   1 Preferred Generic Drugs $0.00$0.00None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT)   1 Preferred Generic Drugs $0.00$0.00None
ACETASOL HC SOLUTION 10ML 10 ML BOT   1 Preferred Generic Drugs $0.00$0.00None
ACETAZOLAMIDE 125MG TABLET   1 Preferred Generic Drugs $0.00$0.00None
ACETAZOLAMIDE 250MG TABLET (100 CT)   1 Preferred Generic Drugs $0.00$0.00None
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT   1 Preferred Generic Drugs $0.00$0.00None
ACETAZOLAMIDE SOD 500MG VL   4 Injectable Drugs 33%33%None
ACETIC ACID 2% SOLUTION NON-ORAL   1 Preferred Generic Drugs $0.00$0.00None
ACETYLCYSTEINE 10% VIAL   1 Preferred Generic Drugs $0.00$0.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN   1 Preferred Generic Drugs $0.00$0.00P
ACIPHEX 20MG TABLET EC   2 Preferred Brand Drugs $38.00$76.00None
Aclovate 0.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE   3 Non-Preferred Brand Drugs $75.00$188.00None
Aclovate 0.5mg/g 60 g in 1 TUBE   3 Non-Preferred Brand Drugs $75.00$188.00None
ACTEMRA INJECTION 200MG/10ML   5 Specialty Tier Drugs 33%33%P
ACTHIB VACCINE VIAL 10-24UNT/5ML   4 Injectable Drugs 33%33%None
ACTICIN 5% CREAM   1 Preferred Generic Drugs $0.00$0.00None
ACTIGALL 300MG CAPSULE   3 Non-Preferred Brand Drugs $75.00$188.00None
ACTIMMUNE SOLUTION FOR INJECTION 100MCG   5 Specialty Tier Drugs 33%33%None
ACTIQ 1200MCG LOZENGE   5 Specialty Tier Drugs 33%33%P
ACTIQ 1600MCG LOZENGE   5 Specialty Tier Drugs 33%33%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACTIQ 200MCG LOZENGE   5 Specialty Tier Drugs 33%33%P
ACTIQ 400MCG LOZENGE   5 Specialty Tier Drugs 33%33%P
ACTIQ 600MCG LOZENGE   5 Specialty Tier Drugs 33%33%P
ACTIQ 800MCG LOZENGE   5 Specialty Tier Drugs 33%33%P
ACTIVELLA 0.5-0.1MG TABLET 28 DLPK   3 Non-Preferred Brand Drugs $75.00$188.00None
ACTIVELLA 1-0.5MG TABLET 28 DLPK   3 Non-Preferred Brand Drugs $75.00$188.00None
Actonel 150mg/1 36 DOSE PACK in 1 CASE / 1 TRAY in 1 DOSE PACK / 1 TABLET, FILM COATED in 1 TRAY   2 Preferred Brand Drugs $38.00$76.00None
Actonel 30mg/1 12 BOTTLE in 1 CASE / 30 TABLET, FILM COATED in 1 BOTTLE   2 Preferred Brand Drugs $38.00$76.00None
Actonel 35mg/1 36 DOSE PACK in 1 CASE / 1 TRAY in 1 DOSE PACK / 4 TABLET, FILM COATED in 1 TRAY   2 Preferred Brand Drugs $38.00$76.00None
Actonel 5mg/1 12 BOTTLE in 1 CASE / 30 TABLET, FILM COATED in 1 BOTTLE   2 Preferred Brand Drugs $38.00$76.00None
ACTOPLUS MET 15MG/500MG TABLET   2 Preferred Brand Drugs $38.00$76.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACTOPLUS MET 15MG/850MG TABLET   2 Preferred Brand Drugs $38.00$76.00None
ACTOPLUS MET XR TABLETS EXTENDED RELEASE 15;1000 MG;MG   2 Preferred Brand Drugs $38.00$76.00None
ACTOPLUS MET XR TABLETS EXTENDED RELEASE 30;1000 MG;MG   2 Preferred Brand Drugs $38.00$76.00None
ACTOS 15MG TABLET   2 Preferred Brand Drugs $38.00$76.00None
ACTOS 30MG TABLET (500 CT)   2 Preferred Brand Drugs $38.00$76.00None
ACTOS 45MG TABLET   2 Preferred Brand Drugs $38.00$76.00None
ACULAR 0.5% EYE DROPS   3 Non-Preferred Brand Drugs $75.00$188.00None
ACULAR LS 0.4% OPHTH SOL   3 Non-Preferred Brand Drugs $75.00$188.00None
ACUVAIL 0.45% OPHTH SOLUTION #30X0.4 EA   3 Non-Preferred Brand Drugs $75.00$188.00None
Acyclovir 200mg/1   1 Preferred Generic Drugs $0.00$0.00None
Acyclovir 200mg/5mL 473 mL in 1 BOTTLE   1 Preferred Generic Drugs $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Acyclovir 400mg/1 100 BLISTER PACK in 1 BOX / 1 TABLET in 1 BLISTER PACK   1 Preferred Generic Drugs $0.00$0.00None
Acyclovir 800mg/1 100 BLISTER PACK in 1 BOX / 1 TABLET in 1 BLISTER PACK   1 Preferred Generic Drugs $0.00$0.00None
ACYCLOVIR SODIUM 500MG VIAL   4 Injectable Drugs 33%33%None
ADACEL VIAL 2UNT/5UNT   4 Injectable Drugs 33%33%None
ADAGEN 250U/ML VIAL   5 Specialty Tier Drugs 33%33%None
ADALAT CC 30MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
ADALAT CC 60MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
ADALAT CC 90MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA]   5 Specialty Tier Drugs 33%33%P
ADAPALENE CREAM   1 Preferred Generic Drugs $0.00$0.00None
ADAPALENE GEL   1 Preferred Generic Drugs $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADCIRCA TABLETS 20MG 60 BOT   5 Specialty Tier Drugs 33%33%None
ADDERALL XR 10MG CAPSULE SA   3 Non-Preferred Brand Drugs $75.00$188.00None
ADDERALL XR 15MG CAPSULE SA   3 Non-Preferred Brand Drugs $75.00$188.00None
ADDERALL XR 20MG CAPSULE SA   3 Non-Preferred Brand Drugs $75.00$188.00None
ADDERALL XR 25MG CAPSULE SA   3 Non-Preferred Brand Drugs $75.00$188.00None
ADDERALL XR 30MG CAPSULE SA   3 Non-Preferred Brand Drugs $75.00$188.00None
ADDERALL XR 5MG CAPSULE SA   3 Non-Preferred Brand Drugs $75.00$188.00None
ADOXA 100MG TABLET   1 Preferred Generic Drugs $0.00$0.00None
ADOXA 50MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
ADOXA PAK 100MG TABLET DSPK-31   1 Preferred Generic Drugs $0.00$0.00None
ADOXA PAK 100MG TABLET DSPK-60   1 Preferred Generic Drugs $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADOXA PAK 150MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
ADVAIR DISKUS MIS 100/50   2 Preferred Brand Drugs $38.00$76.00None
ADVAIR DISKUS MIS 250/50   2 Preferred Brand Drugs $38.00$76.00None
ADVAIR DISKUS MIS 500/50   2 Preferred Brand Drugs $38.00$76.00None
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER   2 Preferred Brand Drugs $38.00$76.00None
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL   2 Preferred Brand Drugs $38.00$76.00None
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL   2 Preferred Brand Drugs $38.00$76.00None
ADVICOR ER 20-750MG TABLET (90 CT)   3 Non-Preferred Brand Drugs $75.00$188.00None
ADVICOR EXTENDED RELEASE TABLETS 20;1000MG;MG 90 BOTPL   3 Non-Preferred Brand Drugs $75.00$188.00None
ADVICOR EXTENDED RELEASE TABLETS 20;500MG;MG 90 BOTPL   3 Non-Preferred Brand Drugs $75.00$188.00None
ADVICOR EXTENDED RELEASE TABLETS 40;1000MG;MG 90 BOTPL   3 Non-Preferred Brand Drugs $75.00$188.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AFEDITAB CR 30MG TABLET SA   1 Preferred Generic Drugs $0.00$0.00None
AFEDITAB CR 60MG TABLET SA   1 Preferred Generic Drugs $0.00$0.00None
Afinitor 7.5mg/1 28 BLISTER PACK in 1 CARTON / 1 TABLET in 1 BLISTER PACK   5 Specialty Tier Drugs 33%33%None
AFINITOR TABLETS 10 MG   5 Specialty Tier Drugs 33%33%None
AFINITOR TABLETS 2.5 MG   5 Specialty Tier Drugs 33%33%None
AFINITOR TABLETS 5 MG   5 Specialty Tier Drugs 33%33%None
AGGRENOX 25-200MG CAPSULE   2 Preferred Brand Drugs $38.00$76.00None
AGRYLIN 0.5MG CAPSULE   3 Non-Preferred Brand Drugs $75.00$188.00None
AK-CON 0.1% EYE DROPS   1 Preferred Generic Drugs $0.00$0.00None
AKNE-MYCIN 2% OINTMENT   3 Non-Preferred Brand Drugs $75.00$188.00None
AKTOB 0.3% EYE DROPS   1 Preferred Generic Drugs $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALA-CORT 1% CREAM   1 Preferred Generic Drugs $0.00$0.00None
ALA-CORT 1% LOTION   1 Preferred Generic Drugs $0.00$0.00None
ALA-SCALP HP 2% LOTION   3 Non-Preferred Brand Drugs $75.00$188.00None
ALAMAST 0.1% DROPS   3 Non-Preferred Brand Drugs $75.00$188.00None
ALBENZA 200 MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
Albuterol Sulfate 0.63mg/3mL 25 POUCH in 1 CARTON / 5 VIAL in 1 POUCH / 3 mL in 1 VIAL   1 Preferred Generic Drugs $0.00$0.00P
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER   1 Preferred Generic Drugs $0.00$0.00P
ALBUTEROL SULFATE 4MG TABLET SR 12HR   1 Preferred Generic Drugs $0.00$0.00None
ALBUTEROL SULFATE 8MG TABLET SR 12HR   1 Preferred Generic Drugs $0.00$0.00None
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   1 Preferred Generic Drugs $0.00$0.00P
ALBUTEROL SULFATE SOLUTION FOR INHALATION   1 Preferred Generic Drugs $0.00$0.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT   1 Preferred Generic Drugs $0.00$0.00None
ALBUTEROL SULFATE TABLET 2MG (500 CT)   1 Preferred Generic Drugs $0.00$0.00None
ALBUTEROL TABLET 4MG (500 CT)   1 Preferred Generic Drugs $0.00$0.00None
ALCAINE 0.5% EYE DROPS   1 Preferred Generic Drugs $0.00$0.00None
ALCLOMETASONE DIPROPIONATE 0.05% CREAM   1 Preferred Generic Drugs $0.00$0.00None
Alclometasone Dipropionate 0.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE   1 Preferred Generic Drugs $0.00$0.00None
ALDACTAZIDE 25/25 TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
ALDACTAZIDE 50/50 TABLET   2 Preferred Brand Drugs $38.00$76.00None
ALDACTONE 100MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
ALDACTONE 25MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
ALDACTONE 50MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALDARA 5% CREAM   3 Non-Preferred Brand Drugs $75.00$188.00None
ALDURAZYME 2.9MG/5ML VIAL   5 Specialty Tier Drugs 33%33%None
ALENDRONATE SODIUM 10MG TABLET   1 Preferred Generic Drugs $0.00$0.00None
ALENDRONATE SODIUM 40MG TABLET   1 Preferred Generic Drugs $0.00$0.00None
ALENDRONATE SODIUM 5MG TABLET   1 Preferred Generic Drugs $0.00$0.00None
ALENDRONATE SODIUM 70mg/1   1 Preferred Generic Drugs $0.00$0.00None
ALENDRONATE SODIUM TABLET 35MG 20 CRTN   1 Preferred Generic Drugs $0.00$0.00None
ALFUZOSIN HYDROCHLORIDE 10mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE   1 Preferred Generic Drugs $0.00$0.00None
ALIMTA 500MG VIAL   5 Specialty Tier Drugs 33%33%None
ALINIA 100MG/5ML SUSPENSION   3 Non-Preferred Brand Drugs $75.00$188.00None
ALINIA 500MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALKERAN 1 KIT in 1 CARTON   4 Injectable Drugs 33%33%None
ALLEGRA 30MG/5ML SUSPENSION ORAL   3 Non-Preferred Brand Drugs $75.00$188.00None
Allopurinol 300mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET in 1 BLISTER PACK   1 Preferred Generic Drugs $0.00$0.00None
ALLOPURINOL SODIUM 500MG VIAL   4 Injectable Drugs 33%33%None
ALLOPURINOL TABLETS   1 Preferred Generic Drugs $0.00$0.00None
ALOCRIL 2% EYE DROPS   3 Non-Preferred Brand Drugs $75.00$188.00None
ALOMIDE 0.1% EYE DROPS   3 Non-Preferred Brand Drugs $75.00$188.00None
ALOPRIM SOLUTION FOR INJECTION 500MG/VIAL 30 ML VIALGL   4 Injectable Drugs 33%33%None
ALORA 0.025MG PATCH   3 Non-Preferred Brand Drugs $75.00$188.00None
ALORA 0.05MG PATCH   3 Non-Preferred Brand Drugs $75.00$188.00None
ALORA 0.075MG PATCH   3 Non-Preferred Brand Drugs $75.00$188.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALORA 0.1MG PATCH   3 Non-Preferred Brand Drugs $75.00$188.00None
ALOXI 0.25MG/5ML   4 Injectable Drugs 33%33%None
ALPHAGAN P 0.1% DROPS   2 Preferred Brand Drugs $38.00$76.00None
ALPHAGAN P 0.15% EYE DROPS   3 Non-Preferred Brand Drugs $75.00$188.00None
ALREX 0.2% EYE DROPS   3 Non-Preferred Brand Drugs $75.00$188.00None
ALTABAX 10mg/g 30 g in 1 TUBE   3 Non-Preferred Brand Drugs $75.00$188.00None
ALTACE 1.25MG CAPSULE   3 Non-Preferred Brand Drugs $75.00$188.00None
ALTACE 10MG CAPSULE (100 CT)   3 Non-Preferred Brand Drugs $75.00$188.00None
ALTACE 2.5 MG CAPSULE   3 Non-Preferred Brand Drugs $75.00$188.00None
ALTACE 5MG CAPSULE   3 Non-Preferred Brand Drugs $75.00$188.00None
ALTOPREV 20MG TABLET SR 24HR   3 Non-Preferred Brand Drugs $75.00$188.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALTOPREV 40MG TABLET SR 24HR   3 Non-Preferred Brand Drugs $75.00$188.00None
ALTOPREV 60MG TABLET SR 24HR   3 Non-Preferred Brand Drugs $75.00$188.00None
ALVESCO 160MCG/ACT AERS   3 Non-Preferred Brand Drugs $75.00$188.00None
ALVESCO 80MCG/ACT AERS   3 Non-Preferred Brand Drugs $75.00$188.00None
AMANTADINE 100MG CAPSULE   1 Preferred Generic Drugs $0.00$0.00None
AMANTADINE 100MG TABLET   1 Preferred Generic Drugs $0.00$0.00None
Amantadine Hydrochloride 50mg/5mL   1 Preferred Generic Drugs $0.00$0.00None
AMARYL 1MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
AMARYL 2MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
AMARYL 4MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
AMBIEN 10MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMBIEN CR 12.5MG TABLET   2 Preferred Brand Drugs $38.00$76.00None
AMBIEN CR 6.25MG TABLET   2 Preferred Brand Drugs $38.00$76.00None
AMBIEN TABLETS 5MG 100 BOT   3 Non-Preferred Brand Drugs $75.00$188.00None
AMBISOME 50MG VIAL   5 Specialty Tier Drugs 33%33%None
AMCINONIDE 0.1% CREAM   1 Preferred Generic Drugs $0.00$0.00None
AMCINONIDE 0.1% LOTION   1 Preferred Generic Drugs $0.00$0.00None
AMCINONIDE 0.1% OINTMENT 60GM TUBE   1 Preferred Generic Drugs $0.00$0.00None
AMERGE 1MG TABLET   2 Preferred Brand Drugs $38.00$76.00None
AMERGE 2.5MG TABLET   2 Preferred Brand Drugs $38.00$76.00None
Amethia 2 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK   1 Preferred Generic Drugs $0.00$0.00None
Amethyst 20; 90ug/1; ug/1 1 BLISTER PACK in 1 CARTON / 28 TABLET in 1 BLISTER PACK   1 Preferred Generic Drugs $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMEVIVE ADMISTRATION PACK FOR INTRAMUSCULAR ADMINISTRATION KIT 15MG 1 X 4 PKGCOM   5 Specialty Tier Drugs 33%33%P
AMIFOSTINE FOR INJECTION 500MG/VIAL   1 Preferred Generic Drugs $0.00$0.00None
AMIKACIN 250MG/ML VIAL   4 Injectable Drugs 33%33%None
AMIKACIN 50MG/ML VIAL   4 Injectable Drugs 33%33%None
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET   1 Preferred Generic Drugs $0.00$0.00None
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT   1 Preferred Generic Drugs $0.00$0.00None
AMINOPHYLLINE 100MG TABLET   1 Preferred Generic Drugs $0.00$0.00None
AMINOPHYLLINE 200MG TABLET (1000 CT)   1 Preferred Generic Drugs $0.00$0.00None
Aminophylline 25mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 10 mL in 1 VIA   4 Injectable Drugs 33%33%None
AMINOSYN 10% IV SOLUTION   4 Injectable Drugs 33%33%P
AMINOSYN 3.5% IV SOLUTION   4 Injectable Drugs 33%33%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN 5% IV SOLUTION   4 Injectable Drugs 33%33%P
AMINOSYN 7% IV SOLUTION   4 Injectable Drugs 33%33%P
AMINOSYN 8.5% IV SOLUTION   4 Injectable Drugs 33%33%P
AMINOSYN HBC INJECTION SULFITE FREE 7%   4 Injectable Drugs 33%33%P
AMINOSYN II 10% IV SOLUTION   4 Injectable Drugs 33%33%P
AMINOSYN II 15% IV SOLUTION   4 Injectable Drugs 33%33%P
AMINOSYN II 3.5% IN D25W IV   4 Injectable Drugs 33%33%P
AMINOSYN II 3.5% IN D5W IV   4 Injectable Drugs 33%33%P
AMINOSYN II 3.5% M/D5W IV   4 Injectable Drugs 33%33%P
AMINOSYN II 3.5% W/ELEC DEX   4 Injectable Drugs 33%33%P
AMINOSYN II 4.25% IN D10W   4 Injectable Drugs 33%33%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN II 4.25% IN D20W   4 Injectable Drugs 33%33%P
AMINOSYN II 4.25% W/ELEC DW   4 Injectable Drugs 33%33%P
AMINOSYN II 4.25%-D25W IV   4 Injectable Drugs 33%33%P
AMINOSYN II 5% IN D25W IV   4 Injectable Drugs 33%33%P
AMINOSYN II 7% IV SOLUTION   4 Injectable Drugs 33%33%P
AMINOSYN II 8.5% ELECTROLYT   4 Injectable Drugs 33%33%P
AMINOSYN II 8.5% IV SOLUTION   4 Injectable Drugs 33%33%P
AMINOSYN M 3.5% IV SOLUTION   4 Injectable Drugs 33%33%P
AMINOSYN PF INJECTION   4 Injectable Drugs 33%33%P
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5%   4 Injectable Drugs 33%33%P
AMINOSYN-HF 8% IV SOLUTION   4 Injectable Drugs 33%33%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN-PF 7% IV SOLUTION   4 Injectable Drugs 33%33%P
AMIODARONE HCL 400MG TABLET   1 Preferred Generic Drugs $0.00$0.00None
AMIODARONE HCL INJECTION   4 Injectable Drugs 33%33%None
Amiodarone hydrochloride 200mg/1   1 Preferred Generic Drugs $0.00$0.00None
AMITIZA 8MCG CAPSULE   2 Preferred Brand Drugs $38.00$76.00None
AMITIZA CAPSULES 24MCG 60 CAP BOT   2 Preferred Brand Drugs $38.00$76.00None
AMITRIP/CDP 25-10 TABLET   1 Preferred Generic Drugs $0.00$0.00None
AMITRIP/PERPHEN 10-2 TABLET   1 Preferred Generic Drugs $0.00$0.00None
AMITRIP/PERPHEN 10-4 TABLET   1 Preferred Generic Drugs $0.00$0.00None
AMITRIP/PERPHEN 25-2 TABLET   1 Preferred Generic Drugs $0.00$0.00None
AMITRIP/PERPHEN 25-4 TABLET   1 Preferred Generic Drugs $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITRIP/PERPHEN 50-4 TABLET   1 Preferred Generic Drugs $0.00$0.00None
AMITRIPTYLINE HCL 100MG TABLET   1 Preferred Generic Drugs $0.00$0.00None
AMITRIPTYLINE HCL 10MG TABLET   1 Preferred Generic Drugs $0.00$0.00None
AMITRIPTYLINE HCL 150 MG TAB   1 Preferred Generic Drugs $0.00$0.00None
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)   1 Preferred Generic Drugs $0.00$0.00None
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)   1 Preferred Generic Drugs $0.00$0.00None
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT   1 Preferred Generic Drugs $0.00$0.00None
AMLODIPINE BESYLATE 10MG TABLET (90 CT)   1 Preferred Generic Drugs $0.00$0.00None
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)   1 Preferred Generic Drugs $0.00$0.00None
AMLODIPINE BESYLATE 5MG TABLET (90 CT)   1 Preferred Generic Drugs $0.00$0.00None
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE CAPSULES   1 Preferred Generic Drugs $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE CAPSULES   1 Preferred Generic Drugs $0.00$0.00None
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE   1 Preferred Generic Drugs $0.00$0.00None
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE   1 Preferred Generic Drugs $0.00$0.00None
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE   1 Preferred Generic Drugs $0.00$0.00None
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE   1 Preferred Generic Drugs $0.00$0.00None
AMMONIUM CHLORIDE 5 MEQ/ML   4 Injectable Drugs 33%33%None
AMMONIUM LACTATE 12% CREAM   1 Preferred Generic Drugs $0.00$0.00None
AMMONIUM LACTATE 12% LOTION   1 Preferred Generic Drugs $0.00$0.00None
Amnesteem 10mg/1 3 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK   1 Preferred Generic Drugs $0.00$0.00None
Amnesteem 20mg/1 3 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK   1 Preferred Generic Drugs $0.00$0.00None
Amnesteem 40mg/1 3 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK   1 Preferred Generic Drugs $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOX TR-K CLV 500-125 MG TAB   1 Preferred Generic Drugs $0.00$0.00None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL   1 Preferred Generic Drugs $0.00$0.00None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE   1 Preferred Generic Drugs $0.00$0.00None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET   1 Preferred Generic Drugs $0.00$0.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE   1 Preferred Generic Drugs $0.00$0.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   1 Preferred Generic Drugs $0.00$0.00None
AMOXAPINE 100MG TABLET   1 Preferred Generic Drugs $0.00$0.00None
AMOXAPINE 150MG TABLET   1 Preferred Generic Drugs $0.00$0.00None
AMOXAPINE 25MG TABLET   1 Preferred Generic Drugs $0.00$0.00None
AMOXAPINE 50MG TABLET   1 Preferred Generic Drugs $0.00$0.00None
AMOXICILLIN 125MG TABLET CHEW   1 Preferred Generic Drugs $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN 200MG TABLET CHEW   1 Preferred Generic Drugs $0.00$0.00None
AMOXICILLIN 250MG CAPSULE   1 Preferred Generic Drugs $0.00$0.00None
Amoxicillin 250mg/1 500 TABLET, CHEWABLE in 1 BOTTLE   1 Preferred Generic Drugs $0.00$0.00None
AMOXICILLIN 50 MG/ML / CLAVULANATE 12.5 MG/ML ORAL SUSPENSION   1 Preferred Generic Drugs $0.00$0.00None
AMOXICILLIN 500MG TABLET (100 CT)   1 Preferred Generic Drugs $0.00$0.00None
AMOXICILLIN 875MG TABLET   1 Preferred Generic Drugs $0.00$0.00None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT   1 Preferred Generic Drugs $0.00$0.00None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS EXTENDED RELEASE 1000;62.5MG;MG   1 Preferred Generic Drugs $0.00$0.00None
AMOXICILLIN CAP 500MG   1 Preferred Generic Drugs $0.00$0.00None
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT   1 Preferred Generic Drugs $0.00$0.00None
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT   1 Preferred Generic Drugs $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL   1 Preferred Generic Drugs $0.00$0.00None
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   1 Preferred Generic Drugs $0.00$0.00None
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL   1 Preferred Generic Drugs $0.00$0.00None
AMPHETAMINE CAP 10MG ER   1 Preferred Generic Drugs $0.00$0.00None
AMPHETAMINE CAP 15MG ER   1 Preferred Generic Drugs $0.00$0.00None
AMPHETAMINE CAP 20MG ER   1 Preferred Generic Drugs $0.00$0.00None
AMPHETAMINE CAP 25MG ER   1 Preferred Generic Drugs $0.00$0.00None
AMPHETAMINE CAP 30MG ER   1 Preferred Generic Drugs $0.00$0.00None
AMPHETAMINE CAP 5MG ER   1 Preferred Generic Drugs $0.00$0.00None
AMPHETAMINE SALT COMBO 12.5MG TABLET   1 Preferred Generic Drugs $0.00$0.00None
AMPHETAMINE SALT COMBO 15MG TABLET   1 Preferred Generic Drugs $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPHETAMINE SALT COMBO 30MG TABLET   1 Preferred Generic Drugs $0.00$0.00None
AMPHETAMINE SALT COMBO 7.5MG TABLET   1 Preferred Generic Drugs $0.00$0.00None
AMPHETAMINE SALTS 20MG TABLET   1 Preferred Generic Drugs $0.00$0.00None
AMPHETAMINE SALTS 5 MG TAB   1 Preferred Generic Drugs $0.00$0.00None
AMPHOTEC FOR INJECTION 50MG/VIAL   4 Injectable Drugs 33%33%None
amphotericin b 50mg/10mL 10 mL in 1 VIAL   4 Injectable Drugs 33%33%None
Ampicillin 125mg/1 10 VIAL in 1 BOX / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL   4 Injectable Drugs 33%33%None
AMPICILLIN AND SULBACTAM FOR INJECTION 2-1 10 VIAL   4 Injectable Drugs 33%33%None
AMPICILLIN CAPSULES 250MG 100 BOT   1 Preferred Generic Drugs $0.00$0.00None
AMPICILLIN CAPSULES 500MG 100 BOT   1 Preferred Generic Drugs $0.00$0.00None
AMPICILLIN FOR INJECTION POWDER   4 Injectable Drugs 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT   1 Preferred Generic Drugs $0.00$0.00None
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT   1 Preferred Generic Drugs $0.00$0.00None
AMPICILLIN POWDER FOR INJECTION 1 GM/ML   4 Injectable Drugs 33%33%None
ampicillin-sulbactam 15 gm vl   4 Injectable Drugs 33%33%None
AMPYRA ER 10 MG TABLET   5 Specialty Tier Drugs 33%33%None
AMRIX 30mg/1   3 Non-Preferred Brand Drugs $75.00$188.00None
AMRIX CAPSULES EXTENDED RELEASE 15MG 60 CAPSULES BOT   3 Non-Preferred Brand Drugs $75.00$188.00None
Amturnide 150; 5; 12.5mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   2 Preferred Brand Drugs $38.00$76.00None
Amturnide 300; 10; 12.5mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   2 Preferred Brand Drugs $38.00$76.00None
Amturnide 300; 10; 25mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   2 Preferred Brand Drugs $38.00$76.00None
Amturnide 300; 5; 12.5mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   2 Preferred Brand Drugs $38.00$76.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Amturnide 300; 5; 25mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   2 Preferred Brand Drugs $38.00$76.00None
ANADROL-50 50MG TABLET (100 CT)   5 Specialty Tier Drugs 33%33%None
ANAFRANIL 25mg/1 30 CAPSULE in 1 BOTTLE   3 Non-Preferred Brand Drugs $75.00$188.00None
ANAFRANIL 50mg/1 30 CAPSULE in 1 BOTTLE   3 Non-Preferred Brand Drugs $75.00$188.00None
ANAFRANIL 75mg/1 30 CAPSULE in 1 BOTTLE   3 Non-Preferred Brand Drugs $75.00$188.00None
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE in 1 BOTTLE   1 Preferred Generic Drugs $0.00$0.00None
Anagrelide Hydrochloride 1mg/1 100 CAPSULE in 1 BOTTLE   1 Preferred Generic Drugs $0.00$0.00None
ANAPROX 275MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
ANAPROX DS 550MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
ANASTROZOLE TABLETS   1 Preferred Generic Drugs $0.00$0.00None
ANCOBON 250MG CAPSULE   3 Non-Preferred Brand Drugs $75.00$188.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANCOBON 500MG CAPSULE   3 Non-Preferred Brand Drugs $75.00$188.00None
ANDRODERM 2 MG/24HR PATCH   2 Preferred Brand Drugs $38.00$76.00None
ANDRODERM 2.5MG/24HR PATCH   2 Preferred Brand Drugs $38.00$76.00None
ANDRODERM 4 MG/24HR PATCH   2 Preferred Brand Drugs $38.00$76.00None
ANDRODERM 5MG/24HR PATCH   2 Preferred Brand Drugs $38.00$76.00None
ANDROGEL 1%(50MG) GEL PACKET   2 Preferred Brand Drugs $38.00$76.00None
Androgel 16.2mg/g 1 BOTTLE, PUMP in 1 CARTON / 88 g in 1 BOTTLE, PUMP   2 Preferred Brand Drugs $38.00$76.00None
ANDROID 10MG CAPSULE   1 Preferred Generic Drugs $0.00$0.00None
ANGELIQ 1-0.5MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
ANTABUSE 250MG TABLET   1 Preferred Generic Drugs $0.00$0.00None
ANTABUSE 500MG TABLET   1 Preferred Generic Drugs $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANTARA CAPSULES   2 Preferred Brand Drugs $38.00$76.00None
ANTARA CAPSULES   2 Preferred Brand Drugs $38.00$76.00None
ANTIVERT 12.5MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
ANTIVERT 25MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
ANTIVERT 50MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
ANTIZOL INJECTION 1GM 4 X 1.5ML VIAL CRTN   4 Injectable Drugs 33%33%None
ANUSOL-HC 2.5% CREAM   1 Preferred Generic Drugs $0.00$0.00None
ANZEMET 100MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00P
ANZEMET 20MG/ML VIAL   4 Injectable Drugs 33%33%None
ANZEMET 50MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00P
APAP-CAFFEINE-DIHYDROCODE TAB 30 EA   1 Preferred Generic Drugs $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
APIDRA 100UNITS/ML VIAL   3 Non-Preferred Brand Drugs $75.00$188.00None
Aplenzin 174mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE   3 Non-Preferred Brand Drugs $75.00$188.00None
APLENZIN TABLETS EXTENDED RELEASE 348 MG   3 Non-Preferred Brand Drugs $75.00$188.00None
APLENZIN TABLETS EXTENDED RELEASE 522 MG   3 Non-Preferred Brand Drugs $75.00$188.00None
APOKYN 30mg/3mL 5 CARTRIDGE in 1 CARTON / 3 mL in 1 CARTRIDGE   5 Specialty Tier Drugs 33%33%None
Apraclonidine Ophthalmic 5mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 10 mL in 1 BOTTLE, DROPPER   1 Preferred Generic Drugs $0.00$0.00None
APRI 0.15-0.03 TABLET   1 Preferred Generic Drugs $0.00$0.00None
APRISO CP24   2 Preferred Brand Drugs $38.00$76.00None
APTIVUS 250MG CAPSULE   5 Specialty Tier Drugs 33%33%None
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT   2 Preferred Brand Drugs $38.00$76.00None
Aralast NP 1 KIT in 1 CARTON   5 Specialty Tier Drugs 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARALEN PHOSPHATE 500MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
ARANELLE 7-9-5 TABLET   1 Preferred Generic Drugs $0.00$0.00None
ARANESP 100ug/0.5mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE in 1 BLISTER PACK / 0.5 mL in 1 SYRINGE   4 Injectable Drugs 33%33%P
ARANESP 100ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE   4 Injectable Drugs 33%33%P
ARANESP 200MCG/0.4ML SYRINGE   5 Specialty Tier Drugs 33%33%P
ARANESP 200MCG/ML VIAL   5 Specialty Tier Drugs 33%33%P
ARANESP 25ug/0.42mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE in 1 BLISTER PACK / 0.42 mL in 1 SYRING   4 Injectable Drugs 33%33%P
ARANESP 25ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE   4 Injectable Drugs 33%33%P
ARANESP 300MCG/ML VIAL   5 Specialty Tier Drugs 33%33%P
ARANESP 500MCG/1ML SYRINGE   5 Specialty Tier Drugs 33%33%P
ARANESP 60MCG/ML VIAL   4 Injectable Drugs 33%33%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP 60ug/0.3mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE in 1 BLISTER PACK / 0.3 mL in 1 SYRINGE   4 Injectable Drugs 33%33%P
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR   5 Specialty Tier Drugs 33%33%P
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR   5 Specialty Tier Drugs 33%33%P
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR   4 Injectable Drugs 33%33%P
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD   4 Injectable Drugs 33%33%P
ARAVA 10MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
ARAVA 20MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
ARCALYST INJECTION 220MG/VIAL   5 Specialty Tier Drugs 33%33%None
Arcapta Neohaler 75ug/1 30 BLISTER PACK in 1 BOX / 1 CAPSULE in 1 BLISTER PACK   3 Non-Preferred Brand Drugs $75.00$188.00None
AREDIA 30MG VIAL   4 Injectable Drugs 33%33%P
AREDIA 90MG VIAL   4 Injectable Drugs 33%33%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARGATROBAN 100mg/mL 1 VIAL in 1 CARTON / 2.5 mL in 1 VIAL   4 Injectable Drugs 33%33%None
ARICEPT 10MG TABLET   2 Preferred Brand Drugs $38.00$76.00None
ARICEPT 5MG TABLET   2 Preferred Brand Drugs $38.00$76.00None
ARICEPT ODT 10MG TABLET   2 Preferred Brand Drugs $38.00$76.00None
ARICEPT ODT 5MG TABLET   2 Preferred Brand Drugs $38.00$76.00None
ARICEPT TABLETS   2 Preferred Brand Drugs $38.00$76.00None
ARIMIDEX 1MG TABLET   2 Preferred Brand Drugs $38.00$76.00None
ARIXTRA 10MG SYRINGE   4 Injectable Drugs 33%33%None
ARIXTRA 2.5MG SYRINGE   4 Injectable Drugs 33%33%None
ARIXTRA 5MG SYRINGE   4 Injectable Drugs 33%33%None
ARIXTRA 7.5MG SYRINGE   4 Injectable Drugs 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AROMASIN 25MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
ARRANON 250MG VIAL   5 Specialty Tier Drugs 33%33%None
ARTHROTEC 50 50MG TABLET -200MCG (60 CT)   3 Non-Preferred Brand Drugs $75.00$188.00None
ARTHROTEC 75 TABLET EC   3 Non-Preferred Brand Drugs $75.00$188.00None
ARZERRA 20mg/mL 3 VIAL in 1 CARTON / 5 mL in 1 VIAL   5 Specialty Tier Drugs 33%33%None
ASACOL 400mg/1 12 BOTTLE in 1 CASE / 180 TABLET, DELAYED RELEASE in 1 BOTTLE   2 Preferred Brand Drugs $38.00$76.00None
ASACOL HD 800mg/1 12 BOTTLE in 1 CASE / 180 TABLET, DELAYED RELEASE in 1 BOTTLE   2 Preferred Brand Drugs $38.00$76.00None
Ascomp with Codeine 325; 50; 40; 30mg/1; mg/1; mg/1; mg/1 500 CAPSULE in 1 BOTTLE, PLASTIC   1 Preferred Generic Drugs $0.00$0.00None
ASMANEX 220ug/1 1 POUCH in 1 POUCH / 1 INHALER in 1 POUCH / 14 INHALANT in 1 INHALER   2 Preferred Brand Drugs $38.00$76.00None
ASMANEX TWISTHALER 110 MCG #30   2 Preferred Brand Drugs $38.00$76.00None
ASMANEX TWISTHALER 220MCG #120   2 Preferred Brand Drugs $38.00$76.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ASMANEX TWISTHALER 220MCG #30   2 Preferred Brand Drugs $38.00$76.00None
ASMANEX TWISTHALER 220MCG #60   2 Preferred Brand Drugs $38.00$76.00None
ASTELIN 137MCG AEROSOL SPRAY W/PUMP   3 Non-Preferred Brand Drugs $75.00$188.00None
ASTEPRO 0.15% NASAL SPRAY 30 ML   2 Preferred Brand Drugs $38.00$76.00None
ASTRAMORPH PF INJECTION 0.5MG/ML   4 Injectable Drugs 33%33%None
ASTRAMORPH PF INJECTION 1MG/ML   4 Injectable Drugs 33%33%None
ATACAND 16MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
ATACAND 32MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
ATACAND 4MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
ATACAND 8MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
ATACAND HCT 16/12.5MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATACAND HCT 32/12.5MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
ATACAND HCT TABLETS 32;25MG;MG 90 TABLETS BOT   3 Non-Preferred Brand Drugs $75.00$188.00None
Atelvia 35mg/1 36 DOSE PACK in 1 CASE / 4 TABLET, DELAYED RELEASE in 1 DOSE PACK   2 Preferred Brand Drugs $38.00$76.00None
ATENOLOL 100mg/1 100 TABLET in 1 BOTTLE, PLASTIC   1 Preferred Generic Drugs $0.00$0.00None
Atenolol 25mg/1 100 TABLET in 1 BOTTLE, PLASTIC   1 Preferred Generic Drugs $0.00$0.00None
ATENOLOL TABLET USP 50MG (100 CT)   1 Preferred Generic Drugs $0.00$0.00None
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT)   1 Preferred Generic Drugs $0.00$0.00None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   1 Preferred Generic Drugs $0.00$0.00None
ATGAM 50MG/ML AMPUL   4 Injectable Drugs 33%33%P
ATORVASTATIN 10 MG TABLET   1 Preferred Generic Drugs $0.00$0.00None
ATORVASTATIN 20 MG TABLET   1 Preferred Generic Drugs $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATORVASTATIN 40 MG TABLET   1 Preferred Generic Drugs $0.00$0.00None
ATORVASTATIN 80 MG TABLET   1 Preferred Generic Drugs $0.00$0.00None
Atovaquone and Proguanil Hydrochloride 250; 100mg/1; mg/1   1 Preferred Generic Drugs $0.00$0.00None
ATRALIN 0.05% GEL   3 Non-Preferred Brand Drugs $75.00$188.00None
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE, PLASTIC   5 Specialty Tier Drugs 33%33%None
ATROPINE 0.05MG/ML SYRINGE   4 Injectable Drugs 33%33%None
ATROPINE 0.1MG/ML SYRINGE   4 Injectable Drugs 33%33%None
ATROVENT HFA AER 17MCG   2 Preferred Brand Drugs $38.00$76.00None
ATROVENT NASAL SPRAY 0.03%   3 Non-Preferred Brand Drugs $75.00$188.00None
ATROVENT NASAL SPRAY 0.06%   3 Non-Preferred Brand Drugs $75.00$188.00None
AUGMENTED BETAMETHASONE DIPROPIONATE OINTMENT   1 Preferred Generic Drugs $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVALIDE 12.5; 150mg/1; mg/1 90 TABLET, FILM COATED in 1 BOTTLE   3 Non-Preferred Brand Drugs $75.00$188.00None
AVALIDE 12.5; 300mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   3 Non-Preferred Brand Drugs $75.00$188.00None
AVALIDE 300-25MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
AVANDAMET 1000; 2mg/1; mg/1 60 TABLET, FILM COATED in 1 BOTTLE   2 Preferred Brand Drugs $38.00$76.00None
AVANDAMET 1000; 4mg/1; mg/1 60 TABLET, FILM COATED in 1 BOTTLE   2 Preferred Brand Drugs $38.00$76.00None
AVANDAMET 500; 2mg/1; mg/1 60 TABLET, FILM COATED in 1 BOTTLE   2 Preferred Brand Drugs $38.00$76.00None
AVANDAMET 500; 4mg/1; mg/1 60 TABLET, FILM COATED in 1 BOTTLE   2 Preferred Brand Drugs $38.00$76.00None
AVANDARYL 1; 4mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   2 Preferred Brand Drugs $38.00$76.00None
AVANDARYL 2; 4mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   2 Preferred Brand Drugs $38.00$76.00None
AVANDARYL 2; 8mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   2 Preferred Brand Drugs $38.00$76.00None
AVANDARYL 4; 4mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   2 Preferred Brand Drugs $38.00$76.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVANDARYL 4; 8mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   2 Preferred Brand Drugs $38.00$76.00None
AVANDIA 2mg/1 60 TABLET, FILM COATED in 1 BOTTLE   2 Preferred Brand Drugs $38.00$76.00None
AVANDIA 4mg/1 30 TABLET, FILM COATED in 1 BOTTLE   2 Preferred Brand Drugs $38.00$76.00None
AVANDIA 8mg/1 30 TABLET, FILM COATED in 1 BOTTLE   2 Preferred Brand Drugs $38.00$76.00None
AVAPRO 150MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
AVAPRO 300MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
AVAPRO 75MG TABLET (30 CT)   3 Non-Preferred Brand Drugs $75.00$188.00None
AVASTIN 100MG/4ML VIAL   5 Specialty Tier Drugs 33%33%None
AVELOX 400MG TABLET   2 Preferred Brand Drugs $38.00$76.00None
AVELOX ABC PACK 400MG TABLET   2 Preferred Brand Drugs $38.00$76.00None
AVELOX IV 400MG/250ML   4 Injectable Drugs 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVIANE 0.1-0.02 TABLET   1 Preferred Generic Drugs $0.00$0.00None
AVINZA 120MG CAPSULE MULTIPHASIC RELEASE 24 HR   2 Preferred Brand Drugs $38.00$76.00None
AVINZA 30MG CAPSULE MULTIPHASIC RELEASE 24 HR   2 Preferred Brand Drugs $38.00$76.00None
AVINZA 60MG CAPSULE MULTIPHASIC RELEASE 24 HR   2 Preferred Brand Drugs $38.00$76.00None
AVINZA 90MG CAPSULE MULTIPHASIC RELEASE 24 HR   2 Preferred Brand Drugs $38.00$76.00None
AVINZA CAPSULES EXTENDED RELEASE 45MG 100 BOTPL   2 Preferred Brand Drugs $38.00$76.00None
AVINZA CAPSULES EXTENDED RELEASE 75MG 100 BOTPL   2 Preferred Brand Drugs $38.00$76.00None
AVITA 0.025% CREAM   1 Preferred Generic Drugs $0.00$0.00None
Avita 0.25mg/g 45 g in 1 TUBE   1 Preferred Generic Drugs $0.00$0.00None
AVODART 0.5MG SOFTGEL   2 Preferred Brand Drugs $38.00$76.00None
AVONEX ADMIN PACK 30MCG SYR   5 Specialty Tier Drugs 33%33%None
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 33%33%None
AXERT 12.5MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
AXERT 6.25MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
AXID 15MG/ML ORAL SOLUTION   3 Non-Preferred Brand Drugs $75.00$188.00None
AXIRON 30mg/1.5mL 1 BOTTLE, WITH APPLICATOR in 1 CARTON / 90 mL in 1 BOTTLE, WITH APPLICATOR   3 Non-Preferred Brand Drugs $75.00$188.00None
Aygestin 5mg/1 50 TABLET in 1 BOTTLE   1 Preferred Generic Drugs $0.00$0.00None
AZACTAM INJECTION 1GM/50ML   4 Injectable Drugs 33%33%None
AZACTAM INJECTION 2GM/50ML   4 Injectable Drugs 33%33%None
AZACTAM INJECTION 2GM/VIL   4 Injectable Drugs 33%33%None
AZASAN 100MG TABLET   1 Preferred Generic Drugs $0.00$0.00P
AZASAN 75MG TABLET   1 Preferred Generic Drugs $0.00$0.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZASITE 1% DROPS   3 Non-Preferred Brand Drugs $75.00$188.00None
AZATHIOPRINE 50MG TABLET   1 Preferred Generic Drugs $0.00$0.00P
AZATHIOPRINE SOD 100MG VIAL   4 Injectable Drugs 33%33%P
AZELASTINE 137 MCG NASAL SPRAY   1 Preferred Generic Drugs $0.00$0.00None
AZELASTINE HYDROCHLORIDE OPHTHALMIC SOLUTION   1 Preferred Generic Drugs $0.00$0.00None
AZELEX 20% CREAM 30GM TUBE   3 Non-Preferred Brand Drugs $75.00$188.00None
AZILECT 0.5MG TABLET   2 Preferred Brand Drugs $38.00$76.00None
AZILECT 1MG TABLET   2 Preferred Brand Drugs $38.00$76.00None
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Preferred Generic Drugs $0.00$0.00None
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Preferred Generic Drugs $0.00$0.00None
AZITHROMYCIN 250 MG TABLET   1 Preferred Generic Drugs $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Azithromycin 500mg/1 10 VIAL, SINGLE-USE in 1 TRAY / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION   4 Injectable Drugs 33%33%None
Azithromycin 500mg/1 30 TABLET, FILM COATED in 1 BOTTLE   1 Preferred Generic Drugs $0.00$0.00None
Azithromycin 600mg/1 30 TABLET, FILM COATED in 1 BOTTLE   1 Preferred Generic Drugs $0.00$0.00None
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT   2 Preferred Brand Drugs $38.00$76.00None
AZOR 10MG-20MG TABLET   2 Preferred Brand Drugs $38.00$76.00None
AZOR 10MG-40MG TABLET (30 CT)   2 Preferred Brand Drugs $38.00$76.00None
AZOR 5MG-20MG TABLET (30 CT)   2 Preferred Brand Drugs $38.00$76.00None
AZOR 5MG-40MG TABLET   2 Preferred Brand Drugs $38.00$76.00None
AZTREONAM FOR INJECTION   4 Injectable Drugs 33%33%None
AZULFIDINE 500MG TABLET   3 Non-Preferred Brand Drugs $75.00$188.00None
AZULFIDINE EN TABLET S 500MG TABLET 6 X (300 CT)PL   3 Non-Preferred Brand Drugs $75.00$188.00None

Chart Legend:

Below are a few notes to help you understand the above 2012 Medicare Part D Health Net Orange Option 2 (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.