Q1Medicare.com 2012 Medicare Part D or Medicare Advantage Plan Formulary Browser

2012 Medicare Part D Plan Formulary Information
Blue Cross MedicareRx Plus (PDP) (S5596-034-0) Benefit Details
The Blue Cross MedicareRx Plus (PDP) (S5596-034-0) Formulary Drugs Starting with the Letter P in CMS PDP Region 32 which includes: CA
Drugs Starting with Letter P Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter P Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PACERONE 100MG TABLET	3	Preferred Brand Drugs	$45.00	$112.50	None
PACERONE 200MG TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PACLITAXEL INJECTION SOLUTION 6MG 50ML VIALMD	5	Injectable Drug	33%	33%	P
PALGIC 4MG/5ML LIQUID	1	Preferred Generic Drugs	$2.00	$3.00	None
PALGIC TABLETS 4GM 100 CTR	1	Preferred Generic Drugs	$2.00	$3.00	None
PAMIDRONATE 60MG/10ML VIAL	5	Injectable Drug	33%	33%	P
PAMIDRONATE DISODIUM INJECTION 3MG 10ML VIALSD	5	Injectable Drug	33%	33%	P
PAMIDRONATE DISODIUM INJECTION 9MG 10ML VIALSD	5	Injectable Drug	33%	33%	P
PANRETIN 0.1% GEL 60GM TUBE	6	Specialty Tier Drugs	33%	N/A	None
Pantoprazole 40mg/1 90 TABLET, DELAYED RELEASE in 1 BOTTLE	2	Non-Preferred Generic Drugs	$7.00	$10.50	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PANTOPRAZOLE SODIUM 20MG TABLET DELAYED RELEASE	2	Non-Preferred Generic Drugs	$7.00	$10.50	Q:30 /30Days
PARCAINE 0.5% DROPS	1	Preferred Generic Drugs	$2.00	$3.00	None
PAROMOMYCIN 250MG CAPSULE	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PAROXETINE FILM COATED 20MG TABLET (100 CT)	2	Non-Preferred Generic Drugs	$7.00	$10.50	Q:30 /30Days
PAROXETINE HCL 10MG/5ML SUSPENSION ORAL	2	Non-Preferred Generic Drugs	$7.00	$10.50	Q:1200 /30Days
PAROXETINE HCL TABLET 24 12.5MG	2	Non-Preferred Generic Drugs	$7.00	$10.50	Q:30 /30Days
PAROXETINE HCL TABLET 24 25MG	2	Non-Preferred Generic Drugs	$7.00	$10.50	Q:90 /30Days
Paroxetine Hydrochloride 37.5mg/1 30 BOTTLE in 1 BOTTLE / 30 TABLET, FILM COATED, EXTENDED RELEASE	2	Non-Preferred Generic Drugs	$7.00	$10.50	Q:60 /30Days
PAROXETINE HYDROCHLORIDE TABLETS 10 MG	2	Non-Preferred Generic Drugs	$7.00	$10.50	Q:45 /30Days
PAROXETINE TABLETS 30MG 90 BOT	2	Non-Preferred Generic Drugs	$7.00	$10.50	Q:60 /30Days
PAROXETINE40mg/1	2	Non-Preferred Generic Drugs	$7.00	$10.50	Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PASER GRANULES 4GM PACKET	4	Non-Preferred Brand Drugs	$90.00	$225.00	None
PATADAY 0.2% DROPS	3	Preferred Brand Drugs	$45.00	$112.50	None
PATANASE 665ug/1 240 SPRAY, METERED in 1 BOTTLE	4	Non-Preferred Brand Drugs	$90.00	$225.00	Q:31 /30Days
PATANOL 0.1% EYE DROPS	3	Preferred Brand Drugs	$45.00	$112.50	None
PEDI-DRI TOPICAL POWDER	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PEDVAXHIB VACCINE VIAL	3	Preferred Brand Drugs	$45.00	$112.50	None
PEGANONE 250MG TABLET	3	Preferred Brand Drugs	$45.00	$112.50	None
PEGASYS 180MCG/0.5ML CONV.PK	6	Specialty Tier Drugs	33%	N/A	P
PEGASYS INJECTION	6	Specialty Tier Drugs	33%	N/A	P
PEGASYS PROCLICK 135 MCG/0.5	6	Specialty Tier Drugs	33%	N/A	P
PEGINTRON 1 KIT in 1 CARTON	6	Specialty Tier Drugs	33%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PegIntron 120ug/0.5mL 1 CARTRIDGE in 1 CARTON / 0.5 mL in 1 CARTRIDGE	6	Specialty Tier Drugs	33%	N/A	P
PegIntron 150ug/0.5mL 1 CARTRIDGE in 1 CARTON / 0.5 mL in 1 CARTRIDGE	6	Specialty Tier Drugs	33%	N/A	P
PegIntron 50ug/0.5mL 1 CARTRIDGE in 1 CARTON / 0.5 mL in 1 CARTRIDGE	6	Specialty Tier Drugs	33%	N/A	P
PegIntron 80ug/0.5mL 1 CARTRIDGE in 1 CARTON / 0.5 mL in 1 CARTRIDGE	6	Specialty Tier Drugs	33%	N/A	P
PENICILLIN G POTASSIUM 2MMUNITS/50ML ISO-OSM	5	Injectable Drug	33%	33%	None
PENICILLIN G POTASSIUM 3MMUNITS/50ML ISO-OSM	5	Injectable Drug	33%	33%	None
PENICILLIN G POTASSIUM FOR INJECTION 5000000UNIT/VIAL	5	Injectable Drug	33%	33%	None
PENICILLIN G PROCAINE 1200000UNT 2ML CTG	5	Injectable Drug	33%	33%	None
Penicillin G Sodium 5000000[iU]/1 10 VIAL in 1 CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL	5	Injectable Drug	33%	33%	None
PENICILLIN V POTASSIUM 250MG TABLET (1000 CT)	1	Preferred Generic Drugs	$2.00	$3.00	None
PENICILLIN V POTASSIUM 250MG/5ML LIQUID	1	Preferred Generic Drugs	$2.00	$3.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PENICILLIN V POTASSIUM 500MG TABLET	1	Preferred Generic Drugs	$2.00	$3.00	None
PENICILLIN V POTASSIUM FOR ORAL SOLUTION CONCENTRATE 125MG 200ML BOT	1	Preferred Generic Drugs	$2.00	$3.00	None
PENTAM 300 INJ 300MG	5	Injectable Drug	33%	33%	None
PENTASA 250MG CAPSULE SA	3	Preferred Brand Drugs	$45.00	$112.50	None
PENTASA 500MG CAPSULE	3	Preferred Brand Drugs	$45.00	$112.50	None
PENTAZOCINE/ACETAMIN TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	Q:180 /30Days
PENTAZOCINE/NALOXONE TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PENTOPAK 400MG TABLET SA	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PENTOSTATIN FOR INJECTION 10MG/VIAL	6	Specialty Tier Drugs	33%	N/A	P
PENTOXIFYLLINE 400MG TABLET SA	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PERFOROMIST 20MCG/2ML VIAL NEBULIZER	4	Non-Preferred Brand Drugs	$90.00	$225.00	P Q:120 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Perindopril Erbumine 2mg/1 100 TABLET in 1 BOTTLE	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
Perindopril Erbumine 4mg/1 100 TABLET in 1 BOTTLE	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
Perindopril Erbumine 8mg/1 100 TABLET in 1 BOTTLE	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PERIOGARD 0.12% ORAL RINSE	1	Preferred Generic Drugs	$2.00	$3.00	None
Permethrin 50mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE	1	Preferred Generic Drugs	$2.00	$3.00	None
PERPHENAZINE 16 MG TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PERPHENAZINE TABLETS 4MG 100 BOXUD	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PERPHENAZINE TABLETS 8MG 100 BOT	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PERPHENAZINE TABLETS USP 2MG 100 BOT	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PFIZERPEN 20MMU VIAL	5	Injectable Drug	33%	33%	None
PHENADOZ 12.5MG SUPPOSITORY	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PHENADOZ 25MG SUPPOSITORY	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
Phenelzine Sulfate 15mg/1 60 TABLET in 1 BOTTLE	3	Preferred Brand Drugs	$45.00	$112.50	None
PHENERGAN 25 MG/ML VIAL	5	Injectable Drug	33%	33%	None
PHENERGAN 50 MG/ML VIAL	5	Injectable Drug	33%	33%	None
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT	1	Preferred Generic Drugs	$2.00	$3.00	None
PHENYTOIN SOD EXT 200 MG CAP	3	Preferred Brand Drugs	$45.00	$112.50	None
PHENYTOIN SODIUM EXTENDED CAPSULES 100MG (100 CT)	1	Preferred Generic Drugs	$2.00	$3.00	None
PHENYTOIN SODIUM INJECTION 50MG 25 X 2ML AMP	5	Injectable Drug	33%	33%	None
PHYSIOLYTE SOLUTION FOR IRRIGATION	5	Injectable Drug	33%	33%	P
PHYSIOSOL IRRIGATION SOL	5	Injectable Drug	33%	33%	P
PILOCARPINE HCL 5MG TABLET (100 CT)	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Pilocarpine Hydrochloride 7.5mg/1 100 TABLET, FILM COATED in 1 BOTTLE	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PILOPINE HS 4% EYE GEL	4	Non-Preferred Brand Drugs	$90.00	$225.00	None
PINDOLOL 10MG TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PINDOLOL 5MG TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PIPERACILLIN 200 MG/ML / TAZOBACTAM 25 MG/ML INJECTABLE SOLUTION	5	Injectable Drug	33%	33%	None
PIPERACILLIN 3GM VIAL	5	Injectable Drug	33%	33%	None
PIPERACILLIN 40GM BULK VIAL	5	Injectable Drug	33%	33%	None
Piperacillin and Tazobactam 4; 0.5g/1; g/1 10 VIAL, SINGLE-USE in 1 CARTON / 1 INJECTION, POWDER, L	5	Injectable Drug	33%	33%	None
PIROXICAM 10 MG CAPSULE	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
Piroxicam 20mg/1 500 CAPSULE in 1 BOTTLE	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PLASMA-LYTE 148 IV SOLUTION	5	Injectable Drug	33%	33%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PLASMA-LYTE 148/DEXTROSE 5%	5	Injectable Drug	33%	33%	None
PLASMA-LYTE 56 INJECTION 32;128 MG/100ML;	5	Injectable Drug	33%	33%	None
PLASMA-LYTE 56/DEXTROSE 5%	5	Injectable Drug	33%	33%	None
PLASMA-LYTE A PH 7.4 SOLUTION 37;368; MG/100ML;	5	Injectable Drug	33%	33%	None
PLASMA-LYTE INJ-R	5	Injectable Drug	33%	33%	None
PLAVIX 75MG TABLET	3	Preferred Brand Drugs	$45.00	$112.50	Q:30 /30Days
PLAVIX TABLETS 300MG	3	Preferred Brand Drugs	$45.00	$112.50	None
PODOFILOX 0.5% TOPICAL TUBEX	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
POLY-DEX 0.1% SUSPENSION DROPS	1	Preferred Generic Drugs	$2.00	$3.00	None
POLY-DEX 3.5-10K-.1 OINTMENT	1	Preferred Generic Drugs	$2.00	$3.00	None
POLYETH GLYC NF POWDER FOR ORAL SOLUTION 17GM (527 CT)	1	Preferred Generic Drugs	$2.00	$3.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
POLYETHYLENE GLYCOL 3350 105 MG/ML / POTASSIUM CHLORIDE 0.00497 MEQ/ML / SODIUM BICARBONATE 1.43 MG/	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
POLYMYXIN B SUL-TRIMETHOPRIM 10K U-0.1%	1	Preferred Generic Drugs	$2.00	$3.00	None
POLYMYXIN B SULFATE VIAL	5	Injectable Drug	33%	33%	None
PORTIA 0.15-0.03 TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
POTASSIUM CHLORIDE 0.075%/D5W/SODIUM CHLORIDE 0.2%	5	Injectable Drug	33%	33%	None
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.3%	5	Injectable Drug	33%	33%	None
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.45%	5	Injectable Drug	33%	33%	None
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.9% 1000ML	5	Injectable Drug	33%	33%	None
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.2%	5	Injectable Drug	33%	33%	None
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.45% 1000ML BAG	5	Injectable Drug	33%	33%	None
POTASSIUM CHLORIDE 10MEQ/100ML SOL	5	Injectable Drug	33%	33%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
POTASSIUM CHLORIDE 10MEQ/50ML SOL	5	Injectable Drug	33%	33%	None
POTASSIUM CHLORIDE 149mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 5 mL in 1 VIAL, SINGLE-DOSE	5	Injectable Drug	33%	33%	None
Potassium Chloride 20.000000meq/1	1	Preferred Generic Drugs	$2.00	$3.00	None
POTASSIUM CHLORIDE 20MEQ IN D5W/NACL 0.225%	5	Injectable Drug	33%	33%	None
POTASSIUM CHLORIDE 20MEQ/50ML SOL	5	Injectable Drug	33%	33%	None
POTASSIUM CHLORIDE 30MEQ/100ML SOL	5	Injectable Drug	33%	33%	None
POTASSIUM CHLORIDE 40MEQ IN D5W/NACL 0.9%	5	Injectable Drug	33%	33%	None
POTASSIUM CHLORIDE 40MEQ/NS 1000ML IV SOLUTION	5	Injectable Drug	33%	33%	None
POTASSIUM CHLORIDE ER CAPSULES 10MEQ	1	Preferred Generic Drugs	$2.00	$3.00	None
POTASSIUM CHLORIDE ER CPCR 8MEQ	1	Preferred Generic Drugs	$2.00	$3.00	None
POTASSIUM CHLORIDE EXTENDED RELEASE TABLETS	1	Preferred Generic Drugs	$2.00	$3.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
POTASSIUM CHLORIDE IN 10% DEXTROSE AND NACL SOLUTION FOR INJECTION	5	Injectable Drug	33%	33%	None
POTASSIUM CHLORIDE IN 5% DEXTROSE AND 0.2% NACL SOLUTION FOR INJECTION USP 0.15% 250ML X 24 CASE	5	Injectable Drug	33%	33%	None
POTASSIUM CHLORIDE IN 5% DEXTROSE AND NACL SOLUTION FOR INJECTION 0.075% 1000ML PLASTIC BAGS X 12 CA	5	Injectable Drug	33%	33%	None
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION	5	Injectable Drug	33%	33%	None
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION	5	Injectable Drug	33%	33%	None
POTASSIUM CHLORIDE IN 5% DEXTROSE INJECTION 40 12 X 1000ML CTR	5	Injectable Drug	33%	33%	None
POTASSIUM CHLORIDE IN DEXTROSE INJECTION 5GM/75MG	5	Injectable Drug	33%	33%	None
Potassium Chloride in Lactated Ringers and Dextrose 20; 5; 179; 600; 310mg/100mL; g/100mL; mg/100mL	5	Injectable Drug	33%	33%	None
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION	5	Injectable Drug	33%	33%	None
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION 0.15%-0.9% 12 X 1000ML BAG	5	Injectable Drug	33%	33%	None
POTASSIUM CITRATE 10MEQ TABLET SA	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
POTASSIUM CITRATE 5MEQ TABLET SA	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
POTIGA 200 MG TABLET	4	Non-Preferred Brand Drugs	$90.00	$225.00	Q:90 /30Days
POTIGA 300 MG TABLET	4	Non-Preferred Brand Drugs	$90.00	$225.00	Q:90 /30Days
POTIGA 400 MG TABLET	4	Non-Preferred Brand Drugs	$90.00	$225.00	Q:90 /30Days
POTIGA 50 MG TABLET	4	Non-Preferred Brand Drugs	$90.00	$225.00	Q:270 /30Days
PRAMIPEXOLE 0.125 MG TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PRAMIPEXOLE 0.25 MG TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PRAMIPEXOLE 0.5 MG TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PRAMIPEXOLE 1 MG TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PRAMIPEXOLE 1.5 MG TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PRAMIPEXOLE DIHYDROCHLORIDE TABLETS	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PRAVASTATIN SODIUM 20MG TABLET 500 BOT	2	Non-Preferred Generic Drugs	$7.00	$10.50	Q:30 /30Days
PRAVASTATIN SODIUM 40MG TABLET (500 CT)	2	Non-Preferred Generic Drugs	$7.00	$10.50	Q:30 /30Days
PRAVASTATIN SODIUM 80MG TABLET (90 CT)	2	Non-Preferred Generic Drugs	$7.00	$10.50	Q:30 /30Days
PRAVASTATIN SODIUM TABLETS 10MG 90 BOT	2	Non-Preferred Generic Drugs	$7.00	$10.50	Q:30 /30Days
PRAZOSIN 5MG CAPSULE	1	Preferred Generic Drugs	$2.00	$3.00	None
PRAZOSIN HCL 1MG CAPSULE	1	Preferred Generic Drugs	$2.00	$3.00	None
PRAZOSIN HCL 2MG CAPSULE	1	Preferred Generic Drugs	$2.00	$3.00	None
PREDNICARBATE 0.1% OINTMENT	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PREDNICARBATE 1 MG/ML TOPICAL CREAM	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION 1.0% STERILE 10ML BOTDR	1	Preferred Generic Drugs	$2.00	$3.00	None
PREDNISOLONE SOD 1% EYE DROP	1	Preferred Generic Drugs	$2.00	$3.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PREDNISOLONE SODIUM PHOSPHATE 15MG/5ML SOLUTION ORAL	1	Preferred Generic Drugs	$2.00	$3.00	None
PREDNISOLONE SODIUM PHOSPHATE ORAL SOLUTION	1	Preferred Generic Drugs	$2.00	$3.00	None
PREDNISONE 10MG TABLET (100 CT)	1	Preferred Generic Drugs	$2.00	$3.00	None
PREDNISONE 1MG TABLET	1	Preferred Generic Drugs	$2.00	$3.00	None
PREDNISONE 2.5MG TABLET	1	Preferred Generic Drugs	$2.00	$3.00	None
PREDNISONE 20MG TABLET (1000 CT)	1	Preferred Generic Drugs	$2.00	$3.00	None
PREDNISONE 5 MG TABLET	1	Preferred Generic Drugs	$2.00	$3.00	None
PREDNISONE 50MG TABLET	1	Preferred Generic Drugs	$2.00	$3.00	None
PREDNISONE 5MG/5ML SOLUTION	1	Preferred Generic Drugs	$2.00	$3.00	None
PREDNISONE 5MG/ML SOLUTION	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PREMARIN 0.3MG (100 CT)	3	Preferred Brand Drugs	$45.00	$112.50	S
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PREMARIN 0.45MG TABLET	3	Preferred Brand Drugs	$45.00	$112.50	S
PREMARIN 0.625MG (100 CT)	3	Preferred Brand Drugs	$45.00	$112.50	S
Premarin 0.625mg/g	4	Non-Preferred Brand Drugs	$90.00	$225.00	None
PREMARIN 0.9MG TABLET	3	Preferred Brand Drugs	$45.00	$112.50	S
PREMARIN 1.25MG (100 CT)	3	Preferred Brand Drugs	$45.00	$112.50	S
PREMARIN 25MG VIAL	5	Injectable Drug	33%	33%	None
PREMASOL 10% IV SOLUTION	5	Injectable Drug	33%	33%	None
PREMASOL 6% IV SOLUTION	5	Injectable Drug	33%	33%	None
Premphase 1 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK	3	Preferred Brand Drugs	$45.00	$112.50	None
PREMPRO 0.3 MG-1.5 MG TABLET #28 EA	3	Preferred Brand Drugs	$45.00	$112.50	None
PREMPRO 0.45-1.5 MG TABLET 28 EA	3	Preferred Brand Drugs	$45.00	$112.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Prempro 0.625; 2.5mg/1; mg/1 1 BLISTER PACK in 1 CARTON / 28 TABLET, SUGAR COATED in 1 BLISTER PACK	3	Preferred Brand Drugs	$45.00	$112.50	None
PREVALITE POW 4GM	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
Previfem 6 BLISTER PACK in 1 BLISTER PACK / 1 KIT in 1 BLISTER PACK	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PREZISTA TABLET 600MG	6	Specialty Tier Drugs	33%	N/A	None
PREZISTA TABLET 75MG	4	Non-Preferred Brand Drugs	$90.00	$225.00	None
PREZISTA TABLETS	6	Specialty Tier Drugs	33%	N/A	None
PREZISTA TABLETS 400MG 60 TABLETS BOT	6	Specialty Tier Drugs	33%	N/A	None
PRIFTIN 150MG TABLET	3	Preferred Brand Drugs	$45.00	$112.50	None
PRIMAQUINE 26.3MG TABLET	3	Preferred Brand Drugs	$45.00	$112.50	None
PRIMAXIN I.M. 500MG VIAL	5	Injectable Drug	33%	33%	None
PRIMAXIN IV 250MG VIAL	5	Injectable Drug	33%	33%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PRIMAXIN IV 500; 500mg/100mL; mg/100mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 100 mL in 1 VIAL, SINGLE-DOS	5	Injectable Drug	33%	33%	None
Primidone 250mg/1 100 TABLET in 1 BOTTLE	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
Primidone 50mg/1 500 TABLET in 1 BOTTLE	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PRISTIQ 100MG TABLET SR 24HR	4	Non-Preferred Brand Drugs	$90.00	$225.00	P Q:30 /30Days
Pristiq Extended-Release 50mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC	4	Non-Preferred Brand Drugs	$90.00	$225.00	P Q:30 /30Days
PRIVIGEN 10% VIAL	6	Specialty Tier Drugs	33%	N/A	P
PROAIR HFA 90MCG HFA AEROSOL WITH ADAPTER	3	Preferred Brand Drugs	$45.00	$112.50	Q:27 /30Days
PROBENECID 500MG TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PROBENECID/COLCHICINE TABLET S	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PROCAINAMIDE 100MG/ML VIAL	5	Injectable Drug	33%	33%	None
PROCAINAMIDE 500MG/ML VIAL	5	Injectable Drug	33%	33%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ProcalAmine 0.21; 0.29; 0.026; 0.014; 3; 0.42; 0.085; 0.21; 0.27; 0.22; 0.054; 0.16; 0.17; 0.041; 0	5	Injectable Drug	33%	33%	None
PROCHLORPERAZINE EDISYLATE INJECTION 10MG 10 X 2ML VIALS CRTN	5	Injectable Drug	33%	33%	None
PROCHLORPERAZINE MALEATE 10MG TABLET (100 CT)	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PROCHLORPERAZINE MALEATE 5MG TABLET (100 CT)	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PROCRIT 10000U/ML VIAL	5	Injectable Drug	33%	33%	P
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL	5	Injectable Drug	33%	33%	P
PROCRIT 3000U/ML VIAL	5	Injectable Drug	33%	33%	P
PROCRIT 40000U/ML VIAL PR	6	Specialty Tier Drugs	33%	N/A	P
PROCRIT 4000U/ML VIAL 25 X 1ML VIAL	5	Injectable Drug	33%	33%	P
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY	6	Specialty Tier Drugs	33%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PROCTO-PAK 1% CREAM	1	Preferred Generic Drugs	$2.00	$3.00	None
PROCTOSOL-HC 2.5% CREAM	1	Preferred Generic Drugs	$2.00	$3.00	None
PROCTOZONE-HC 2.5% CREAM	1	Preferred Generic Drugs	$2.00	$3.00	None
Proglycem 50mg/mL 1 BOTTLE, DROPPER in 1 BOX / 30 mL in 1 BOTTLE, DROPPER	6	Specialty Tier Drugs	33%	N/A	None
PROGRAF 5MG/ML AMPULE	5	Injectable Drug	33%	33%	P
PROLASTIN 500MG VIAL	6	Specialty Tier Drugs	33%	N/A	None
PROLASTIN-C 1 KIT in 1 CARTON	6	Specialty Tier Drugs	33%	N/A	None
PROLEUKIN 1.1mg/mL 1 VIAL, SINGLE-USE in 1 BOX / 1 mL in 1 VIAL, SINGLE-USE	6	Specialty Tier Drugs	33%	N/A	None
PROLIA INJECTION	5	Injectable Drug	33%	33%	P Q:2 /365Days
PROMACTA 12.5 MG TABLET	6	Specialty Tier Drugs	33%	N/A	P
PROMACTA 25 MG TABLET	6	Specialty Tier Drugs	33%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PROMACTA 50 MG TABLET	6	Specialty Tier Drugs	33%	N/A	P
PROMACTA 75 MG TABLET	6	Specialty Tier Drugs	33%	N/A	P
PROMETHAZINE 50MG/ML VIAL	5	Injectable Drug	33%	33%	None
PROMETHAZINE HCL 25MG TABLET (1000 CT)	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PROMETHAZINE HCL 50MG TABLET (100 CT)	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PROMETHAZINE HCL 6.25MG/5ML SYRUP	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PROMETHAZINE HCL INJECTION 25MG 10 X 1ML VIAL	5	Injectable Drug	33%	33%	None
Promethazine Hydrochloride 12.5mg/1 100 TABLET in 1 BOTTLE	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 12.5MG 12 BOX	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 25MG 12 BOX	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PROMETHEGAN 25MG SUPP	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PROMETHEGAN 50MG SUPPOS	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PROPAFENONE HCL 150MG TABLET (100 CT)	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PROPAFENONE HCL 225MG TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PROPAFENONE HCL 300MG TABLET (100 CT)	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
Propantheline Bromide 15mg/1 100 TABLET, FILM COATED in 1 BOTTLE, PLASTIC	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PROPARACAINE 0.5% EYE DROPS	1	Preferred Generic Drugs	$2.00	$3.00	None
PROPRANOLOL 20MG/5ML TUBEX	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PROPRANOLOL 40MG/5ML TUBEX	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PROPRANOLOL 60MG TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PROPRANOLOL 80 MG TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PROPRANOLOL HCL 20MG TABLET (1000 CT)	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PROPRANOLOL HCL INJECTION 1MG 10 PKG OF 10 CRTN	5	Injectable Drug	33%	33%	None
PROPRANOLOL HCL TABLET USP 10MG (1000 CT)	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PROPRANOLOL HCL TABLET USP 40MG (1000 CT)	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
Propranolol Hydrochloride 120mg/1 100 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
Propranolol Hydrochloride 160mg/1 100 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
Propranolol Hydrochloride 60mg/1 1000 CAPSULE, EXTENDED RELEASE in 1 BOTTLE	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
Propranolol Hydrochloride 80mg/1 100 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PROPRANOLOL/HCTZ 40/25 TABLET	1	Preferred Generic Drugs	$2.00	$3.00	None
PROPRANOLOL/HCTZ 80/25 TABLET	1	Preferred Generic Drugs	$2.00	$3.00	None
PROPYLTHIOURACIL 50MG TABLET	1	Preferred Generic Drugs	$2.00	$3.00	None
PROQUAD VIAL	3	Preferred Brand Drugs	$45.00	$112.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PROSOL 20% INJECTION	5	Injectable Drug	33%	33%	None
Protonix I.V. 40mg/10mL 10 CARTON in 1 PACKAGE / 1 VIAL in 1 CARTON / 40 mL in 1 VIAL	5	Injectable Drug	33%	33%	None
PROTRIPTYLINE HYDROCHLORIDE TABLETS	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PROTRIPTYLINE HYDROCHLORIDE TABLETS 5MG	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PROVENTIL HFA INHALER 90MCG AE	3	Preferred Brand Drugs	$45.00	$112.50	Q:21 /30Days
PROVIGIL 100MG TABLET	3	Preferred Brand Drugs	$45.00	$112.50	P Q:30 /30Days
PROVIGIL 200MG TABLET	3	Preferred Brand Drugs	$45.00	$112.50	P Q:60 /30Days
PULMOZYME 1MG/ML AMPUL	6	Specialty Tier Drugs	33%	N/A	P
PYRAZINAMIDE 500MG TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
PYRIDOSTIGMINE BROMIDE 60MG TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	None

Chart Legend:

Below are a few notes to help you understand the above 2012 Medicare Part D Blue Cross MedicareRx Plus (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.