Q1Medicare.com 2013 Medicare Part D or Medicare Advantage Plan Formulary Browser

2013 Medicare Part D Plan Formulary Information
EnvisionRxPlus Gold (PDP) (S7694-082-0) Benefit Details
The EnvisionRxPlus Gold (PDP) (S7694-082-0) Formulary Drugs Starting with the Letter C in CMS PDP Region 11 which includes: FL
Drugs Starting with Letter C Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter C Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CALCIPOTRIENE TOPICAL SOLUTION	2	Non-Preferred Generic	1%	1%	None
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY	2	Non-Preferred Generic	1%	1%	P
CALCITRIOL 0.25MCG CAPSULE	2	Non-Preferred Generic	1%	1%	P
CALCITRIOL 0.5MCG CAPSULE	2	Non-Preferred Generic	1%	1%	P
CALCITRIOL 1MCG/ML SOLUTION ORAL	2	Non-Preferred Generic	1%	1%	P
CALCITRIOL INJ 1MCG/ML	2	Non-Preferred Generic	1%	1%	P
CALCIUM ACETATE CAPSULE 667 MG	2	Non-Preferred Generic	1%	1%	None
CAMPATH INJECTION 30 MG/ML	5	Specialty Tier	29%	N/A	None
Camptosar 20mg/mL 1 VIAL, SINGLE-DOSE in 1 CARTON / 5 mL in 1 VIAL, SINGLE-DOSE	4	Non-Preferred Brand	30%	30%	P
CAPASTAT SULFATE 1g/1 1 INJECTION, POWDER, FOR SOLUTION in 1 CARTON	4	Non-Preferred Brand	30%	30%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CAPRELSA 100mg/1 30 TABLET BOTTLE, PLASTIC	5	Specialty Tier	29%	N/A	None
CAPRELSA 300mg/1 30 TABLET BOTTLE, PLASTIC	5	Specialty Tier	29%	N/A	None
CAPTOPRIL 100MG TABLET	1	Preferred Generic	1%	1%	None
CAPTOPRIL 12.5MG TABLET	1	Preferred Generic	1%	1%	None
CAPTOPRIL 25MG TABLET	1	Preferred Generic	1%	1%	None
CAPTOPRIL 50MG TABLET	1	Preferred Generic	1%	1%	None
Captopril and Hydrochlorothiazide 25; 15mg 100 TABLET BOTTLE	1	Preferred Generic	1%	1%	None
Captopril and Hydrochlorothiazide 25; 25mg 100 TABLET BOTTLE	1	Preferred Generic	1%	1%	None
Captopril and Hydrochlorothiazide 50; 15mg 100 TABLET BOTTLE	1	Preferred Generic	1%	1%	None
Captopril and Hydrochlorothiazide 50; 25mg 100 TABLET BOTTLE	1	Preferred Generic	1%	1%	None
CARAFATE SUS 1GM/10ML	4	Non-Preferred Brand	30%	30%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Carbaglu 200mg/1 5 TABLET BOTTLE	5	Specialty Tier	29%	N/A	None
CARBAMAZEPINE 100 MG/5 ML SUSP	2	Non-Preferred Generic	1%	1%	None
Carbamazepine 100mg, CHEWABLE 100 TABLET BOTTLE	2	Non-Preferred Generic	1%	1%	None
Carbamazepine 100mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE	2	Non-Preferred Generic	1%	1%	None
Carbamazepine 200mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE	2	Non-Preferred Generic	1%	1%	None
Carbamazepine 300mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE	2	Non-Preferred Generic	1%	1%	None
CARBAMAZEPINE TABLET USP 200MG (1000 CT)	2	Non-Preferred Generic	1%	1%	None
CARBAMAZEPINE XR 200 MG TABLET	2	Non-Preferred Generic	1%	1%	None
CARBAMAZEPINE XR 400 MG TABLET	2	Non-Preferred Generic	1%	1%	None
Carbatrol 100mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE	4	Non-Preferred Brand	30%	30%	None
CARBATROL 200MG CAPSULE SA	4	Non-Preferred Brand	30%	30%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CARBATROL 300MG CAPSULE SA	4	Non-Preferred Brand	30%	30%	None
CARBIDOPA AND LEVEDOPA ORALLY DISINTEGRATING TABLETS 10;100MG;MG 100 BOT	2	Non-Preferred Generic	1%	1%	None
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;100MG;MG 100 BOT	2	Non-Preferred Generic	1%	1%	None
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;250MG;MG 100 BOT	2	Non-Preferred Generic	1%	1%	None
CARBIDOPA-LEVODOPA ER 25-100 TAB	2	Non-Preferred Generic	1%	1%	None
CARBIDOPA-LEVODOPA ER 50-200 TAB	2	Non-Preferred Generic	1%	1%	None
CARBIDOPA/LEVO 10/100 TABLET	2	Non-Preferred Generic	1%	1%	None
CARBIDOPA/LEVO 25/100 TABLET	2	Non-Preferred Generic	1%	1%	None
CARBIDOPA/LEVO 25/250 TABLET	2	Non-Preferred Generic	1%	1%	None
Carboplatin 10mg/mL	2	Non-Preferred Generic	1%	1%	P
CARIMUNE NF 3GM VIAL	5	Specialty Tier	29%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CARTEOLOL HCL OPHTHALMIC SOLUTION USP 1% 15ML BOT	1	Preferred Generic	1%	1%	None
CARTIA XT 120MG CAPSULE SA	2	Non-Preferred Generic	1%	1%	None
CARTIA XT 180MG CAPSULE SA	2	Non-Preferred Generic	1%	1%	None
CARTIA XT 240MG CAPSULE SA	2	Non-Preferred Generic	1%	1%	None
CARTIA XT 300MG CAPSULE SR 24 HR	2	Non-Preferred Generic	1%	1%	None
Carvedilol 12.5mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC	1	Preferred Generic	1%	1%	None
Carvedilol 25mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC	1	Preferred Generic	1%	1%	None
Carvedilol 3.125mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC	1	Preferred Generic	1%	1%	None
Carvedilol 6.25mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC	1	Preferred Generic	1%	1%	None
CAYSTON KIT	5	Specialty Tier	29%	N/A	None
CEENU 100MG CAPSULE	4	Non-Preferred Brand	30%	30%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CEENU 10MG CAPSULE	4	Non-Preferred Brand	30%	30%	None
CEENU 40MG CAPSULE	4	Non-Preferred Brand	30%	30%	None
CEFACLOR CAPSULES	2	Non-Preferred Generic	1%	1%	None
CEFACLOR CAPSULES	2	Non-Preferred Generic	1%	1%	None
CEFACLOR ER 500MG TABLET SR 12HR	1	Preferred Generic	1%	1%	None
CEFAZOLIN 1 GM VIAL	2	Non-Preferred Generic	1%	1%	None
Cefazolin 10g/1 10 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 PACKAGE	1	Preferred Generic	1%	1%	None
CEFAZOLIN 1GM/D5W BAG	1	Preferred Generic	1%	1%	None
CEFAZOLIN FOR INJECTION	1	Preferred Generic	1%	1%	None
CEFDINIR 250MG/5ML SUSPENSION RECONSTITUTED ORAL	1	Preferred Generic	1%	1%	None
CEFDINIR CAPSULES 300MG (60 CT)	2	Non-Preferred Generic	1%	1%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CEFDINIR FOR ORAL SUSPENSION 125MG/5ML (100 CT)	1	Preferred Generic	1%	1%	None
CEFEPIME HCL 2 GRAM VIAL	2	Non-Preferred Generic	1%	1%	None
CEFEPIME INJ 1GM 20ML APX 10x1G VIAL	2	Non-Preferred Generic	1%	1%	None
Cefoxitin 1g/1 10 POWDER in 1 CARTON	2	Non-Preferred Generic	1%	1%	None
Cefoxitin 2g/1 10 POWDER in 1 CARTON	2	Non-Preferred Generic	1%	1%	None
CEFOXITIN FOR INJECTION SOLUTION	2	Non-Preferred Generic	1%	1%	None
CEFPODOXIME 100 MG/5 ML SUSP	2	Non-Preferred Generic	1%	1%	None
CEFPODOXIME 200 MG TABLET	2	Non-Preferred Generic	1%	1%	None
CEFPODOXIME 50 MG/5 ML SUSP	2	Non-Preferred Generic	1%	1%	None
CEFPODOXIME PROXETIL FILM COATED TABLET 100MG (20 CT)	2	Non-Preferred Generic	1%	1%	None
cefprozil 125 mg/5 ml susp	2	Non-Preferred Generic	1%	1%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
cefprozil 250 mg/5 ml susp	2	Non-Preferred Generic	1%	1%	None
Cefprozil 250mg/1 100 FILM COATED TABLETS in BOTTLE	2	Non-Preferred Generic	1%	1%	None
CEFPROZIL TABLETS 500MG 100 BOT	2	Non-Preferred Generic	1%	1%	None
Ceftriaxone Sodium 500mg/1	2	Non-Preferred Generic	1%	1%	None
CEFUROXIME FOR INJECTION	1	Preferred Generic	1%	1%	None
CEFUROXIME FOR INJECTION	1	Preferred Generic	1%	1%	None
CEFUROXIME FOR INJECTION	1	Preferred Generic	1%	1%	None
CELEBREX 100MG CAPSULE	3	Preferred Brand	1%	1%	None
CELEBREX 200MG CAPSULE	3	Preferred Brand	1%	1%	None
CELEBREX 400MG CAPSULE	3	Preferred Brand	1%	1%	None
CELEBREX 50MG CAPSULE	3	Preferred Brand	1%	1%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CELLCEPT 200MG/ML ORAL SUSP	3	Preferred Brand	1%	1%	P
CELLCEPT 500MG TABLET	4	Non-Preferred Brand	30%	30%	P
CELLCEPT CAPSULES 250MG (500 CT)	4	Non-Preferred Brand	30%	30%	P
CELLCEPT IV INJ 500MG	3	Preferred Brand	1%	1%	P
CELONTIN 300MG KAPSEAL	4	Non-Preferred Brand	30%	30%	None
Cephalexin 125mg/5mL 200 mL in 1 BOTTLE	2	Non-Preferred Generic	1%	1%	None
CEPHALEXIN 250MG CAPSULE	1	Preferred Generic	1%	1%	None
CEPHALEXIN 250MG TABLET	1	Preferred Generic	1%	1%	None
CEPHALEXIN 250MG/5ML ORAL SUSP	1	Preferred Generic	1%	1%	None
CEPHALEXIN 500MG TABLET	1	Preferred Generic	1%	1%	None
CEPHALEXIN CAPSULES 500MG (500 CT)	1	Preferred Generic	1%	1%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CEREZYME INJ 200UNIT	5	Specialty Tier	29%	N/A	None
CERUBIDINE 20MG VIAL	4	Non-Preferred Brand	30%	30%	P
CETIRIZINE HCL 5MG/5ML	1	Preferred Generic	1%	1%	None
CHANTIX 0.5MG TABLET	4	Non-Preferred Brand	30%	30%	Q:11 /30Days
CHANTIX 1 KIT in 1 CARTON	4	Non-Preferred Brand	30%	30%	Q:53 /30Days
CHANTIX 1MG TABLET	4	Non-Preferred Brand	30%	30%	Q:180 /90Days
CHLORDIAZEPOXIDE AND AMITRIPTYLINE HCL TABLET 12.5-5MG (500 CT)	1	Preferred Generic	1%	1%	P
CHLORDIAZEPOXIDE HCL 10mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE in 1 BLISTER	1	Preferred Generic	1%	1%	Q:120 /30Days
CHLORDIAZEPOXIDE HCL 25mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE in 1 BLISTER	1	Preferred Generic	1%	1%	Q:120 /30Days
CHLORDIAZEPOXIDE HCL 5mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE in 1 BLISTER	1	Preferred Generic	1%	1%	Q:120 /30Days
CHLORHEXIDINE GLUCONATE 0.12% MOUTHWASH	1	Preferred Generic	1%	1%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CHLOROQUINE PH 500MG TABLET	1	Preferred Generic	1%	1%	None
CHLOROQUINE PHOSPHATE 250MG TABLET (50 CT)	1	Preferred Generic	1%	1%	None
CHLOROTHIAZIDE 250MG TABLET	2	Non-Preferred Generic	1%	1%	None
CHLOROTHIAZIDE 500MG TABLET	2	Non-Preferred Generic	1%	1%	None
CHLORPROMAZINE 10MG TABLET	2	Non-Preferred Generic	1%	1%	P
CHLORPROMAZINE 25MG TABLET	2	Non-Preferred Generic	1%	1%	None
CHLORPROMAZINE 25MG/ML AMP	1	Preferred Generic	1%	1%	P
CHLORPROMAZINE 50 MG TABLET	2	Non-Preferred Generic	1%	1%	None
CHLORPROMAZINE HCL 200MG TABLET	2	Non-Preferred Generic	1%	1%	None
Chlorpromazine Hydrochloride 100mg SUGAR COATED 1000 TABLET BOTTLE	2	Non-Preferred Generic	1%	1%	None
CHLORTHALIDONE 25MG TABLET (100 CT)	1	Preferred Generic	1%	1%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CHLORTHALIDONE 50MG TABLET (1000 CT)	1	Preferred Generic	1%	1%	None
CHOLESTYRAMINE LIGHT POWDER FOR ORAL SUSPENSION	2	Non-Preferred Generic	1%	1%	None
CHORIONIC GONAD 10000U VIAL	2	Non-Preferred Generic	1%	1%	None
Cialis 2.5mg/1 2 BLISTER PACK in 1 CARTON / 15 FILM COATED TABLETS in BLISTER PACK	4	Non-Preferred Brand	30%	30%	P Q:30 /30Days
Cialis 5mg/1 30 FILM COATED TABLETS in BOTTLE	4	Non-Preferred Brand	30%	30%	P Q:30 /30Days
Ciclopirox 7.7mg/mL 60 mL in 1 BOTTLE	2	Non-Preferred Generic	1%	1%	None
CICLOPIROX 8% TOPICAL SOLUTION NAIL LACQUER 6.6ML BOT	2	Non-Preferred Generic	1%	1%	None
CICLOPIROX GEL	2	Non-Preferred Generic	1%	1%	None
Ciclopirox Olamine 7.7mg/g 1 TUBE in 1 TUBE / 15 g in 1 TUBE	2	Non-Preferred Generic	1%	1%	None
Cilostazol 50mg/1 60 TABLET BOTTLE	2	Non-Preferred Generic	1%	1%	None
CILOSTAZOL TABLET 100MG (60 CT)	2	Non-Preferred Generic	1%	1%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CIPRODEX OTIC SUSPENSION	3	Preferred Brand	1%	1%	None
CIPROFLOXACIN 0.3% EYE DROP	2	Non-Preferred Generic	1%	1%	None
CIPROFLOXACIN 250MG TABLET (100 CT)	1	Preferred Generic	1%	1%	None
Ciprofloxacin 400mg/40mL 1 VIAL in 1 CARTON / 40 mL in 1 VIAL	1	Preferred Generic	1%	1%	None
CIPROFLOXACIN 500MG TABLET	1	Preferred Generic	1%	1%	None
Ciprofloxacin and Dextrose 2mg/mL 24 BAG in 1 CASE / 100 mL in 1 BAG	1	Preferred Generic	1%	1%	None
Ciprofloxacin ER 212.6; 287.5mg/1; mg/1 50 TABLET, FILM COATED, in 1 BOTTLE, PLASTIC	2	Non-Preferred Generic	1%	1%	None
Ciprofloxacin ER 425.2; 574.9mg/1; mg/1 50 TABLET, FILM COATED, in 1 BOTTLE, PLASTIC	2	Non-Preferred Generic	1%	1%	None
CIPROFLOXACIN HCL 100MG TABLET	1	Preferred Generic	1%	1%	None
CIPROFLOXACIN TABLETS 750MG 100 BOT	2	Non-Preferred Generic	1%	1%	None
Cisplatin 100mg/100mL 1 VIAL in 1 CARTON / 100 mL in 1 VIAL	2	Non-Preferred Generic	1%	1%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CITALOPRAM HBR 20 MG TABLET	1	Preferred Generic	1%	1%	None
CITALOPRAM HBR ORAL SOLUTION 10MG 240ML BOTPL	2	Non-Preferred Generic	1%	1%	None
CITALOPRAM HYDROBROMIDE TABLETS 40MG 30 BOT	1	Preferred Generic	1%	1%	None
CITOLOPRAM HBR 10MG TABLET (100 CT)	2	Non-Preferred Generic	1%	1%	None
CLADRIBINE 1MG/ML VIAL	2	Non-Preferred Generic	1%	1%	P
CLARAVIS 10MG CAPSULE	2	Non-Preferred Generic	1%	1%	None
CLARAVIS 20MG CAPSULE	2	Non-Preferred Generic	1%	1%	None
Claravis 30mg/1 3 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK	2	Non-Preferred Generic	1%	1%	None
CLARAVIS 40MG CAPSULE	2	Non-Preferred Generic	1%	1%	None
Clarinex 0.5mg/mL 473 mL in 1 BOTTLE	4	Non-Preferred Brand	30%	30%	None
CLARINEX-D 12 HOUR TABLET	4	Non-Preferred Brand	30%	30%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CLARINEX-D 24 HOUR 5; 240mg/1; mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC	4	Non-Preferred Brand	30%	30%	None
CLARITHROMYCIN 250MG TABLET	2	Non-Preferred Generic	1%	1%	None
CLARITHROMYCIN 500MG TABLET	2	Non-Preferred Generic	1%	1%	None
Clemastine Fumarate 0.5mg/5mL 120 mL in 1 BOTTLE	1	Preferred Generic	1%	1%	None
Clindacin PAC 10mg/1 1 JAR in 1 KIT / 69 SWAB in 1 JAR	2	Non-Preferred Generic	1%	1%	None
CLINDAMYCIN 150MG/ML ADDVAN	1	Preferred Generic	1%	1%	None
CLINDAMYCIN HCL 150MG CAPSULE	2	Non-Preferred Generic	1%	1%	None
Clindamycin Hydrochloride 75mg/1 200 CAPSULE in 1 BOTTLE	2	Non-Preferred Generic	1%	1%	None
CLINDAMYCIN HYDROCHLORIDE CAPSULES	2	Non-Preferred Generic	1%	1%	None
CLINDAMYCIN PHOSP 1% LOTION	2	Non-Preferred Generic	1%	1%	None
clindamycin phosphate 10mg/mL 1 BOTTLE in 1 CARTON / 60 mL in 1 BOTTLE	2	Non-Preferred Generic	1%	1%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Clindamycin Phosphate and Benzoyl Peroxide 1 KIT	2	Non-Preferred Generic	1%	1%	None
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE	2	Non-Preferred Generic	1%	1%	None
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX	2	Non-Preferred Generic	1%	1%	None
clindamycin-d5w 300 mg/50 ml	1	Preferred Generic	1%	1%	None
clindamycin-d5w 600 mg/50 ml	1	Preferred Generic	1%	1%	None
clindamycin-d5w 900 mg/50 ml	1	Preferred Generic	1%	1%	None
CLINIMIX 2.75%/5% INJECTION 1000ML BAG	4	Non-Preferred Brand	30%	30%	P
CLINIMIX 4.25/10 SOLUTION	4	Non-Preferred Brand	30%	30%	P
CLINIMIX 4.25/20 SOLUTION	4	Non-Preferred Brand	30%	30%	P
CLINIMIX 4.25/25 SOLUTION	4	Non-Preferred Brand	30%	30%	P
CLINIMIX 4.25/5 SOLUTION	4	Non-Preferred Brand	30%	30%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CLINIMIX 5/15 SOLUTION	4	Non-Preferred Brand	30%	30%	P
CLINIMIX 5/20 SOLUTION	4	Non-Preferred Brand	30%	30%	P
CLINIMIX 5/25 SULFITE FREE INJECTIONS 1035MG-420MEQ 1000ML BAG	4	Non-Preferred Brand	30%	30%	P
CLINIMIX E 2.75/10 SOLUTION	4	Non-Preferred Brand	30%	30%	P
CLINIMIX E 2.75/5 SOLUTION	4	Non-Preferred Brand	30%	30%	P
CLINIMIX E 4.25/25 SOLUTION	4	Non-Preferred Brand	30%	30%	P
CLINIMIX E 4.25/5 SOLUTION	4	Non-Preferred Brand	30%	30%	P
CLINIMIX E 5/20 SOLUTION	4	Non-Preferred Brand	30%	30%	P
CLINIMIX E 5/25 SOLUTION	4	Non-Preferred Brand	30%	30%	P
CLINIMIX E 5%/15% INJECTION 2000ML BAG	4	Non-Preferred Brand	30%	30%	P
CLOBETASOL 0.05% OINTMENT	2	Non-Preferred Generic	1%	1%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CLOBETASOL E 0.05% CREAM	2	Non-Preferred Generic	1%	1%	None
Clobetasol Propionate 0.4625mg/mL 1 BOTTLE in 1 CARTON / 50 mL in 1 BOTTLE	2	Non-Preferred Generic	1%	1%	None
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE	2	Non-Preferred Generic	1%	1%	None
CLOLAR 1MG/ML VIAL	4	Non-Preferred Brand	30%	30%	P
CLOMIPRAMINE HCL 25MG CAPSULE	2	Non-Preferred Generic	1%	1%	None
CLOMIPRAMINE HCL 50MG CAPSULE	2	Non-Preferred Generic	1%	1%	None
CLOMIPRAMINE HCL 75MG CAPSULE	2	Non-Preferred Generic	1%	1%	None
Clonazepam 0.125mg/1 10 BLISTER PACK in 1 CARTON / 6 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PAC	1	Preferred Generic	1%	1%	P
Clonazepam 0.25mg/1 10 BLISTER PACK in 1 CARTON / 6 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PACK	1	Preferred Generic	1%	1%	P
Clonazepam 0.5mg/1 10 BLISTER PACK in 1 CARTON / 6 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PACK	1	Preferred Generic	1%	1%	P
Clonazepam 0.5mg/1 100 TABLET BOTTLE	1	Preferred Generic	1%	1%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Clonazepam 1mg/1 10 BLISTER PACK in 1 CARTON / 6 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PACK	1	Preferred Generic	1%	1%	P
Clonazepam 1mg/1 90 TABLET BOTTLE, PLASTIC	1	Preferred Generic	1%	1%	P
Clonazepam 2mg/1 10 BLISTER PACK in 1 CARTON / 6 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PACK	1	Preferred Generic	1%	1%	P
Clonazepam 2mg/1 100 TABLET BOTTLE	1	Preferred Generic	1%	1%	P
CLONIDINE HCL 0.2MG TABLET (500 CT)	1	Preferred Generic	1%	1%	None
CLONIDINE HCL TABLET 0.1MG (500 CT)	1	Preferred Generic	1%	1%	None
CLONIDINE HCL TABLET 0.3MG (100 CT)	2	Non-Preferred Generic	1%	1%	None
CLOPIDOGREL 300 MG tablet	2	Non-Preferred Generic	1%	1%	None
CLOPIDOGREL TAB 75MG	2	Non-Preferred Generic	1%	1%	None
CLORAZEPATE 15 MG TABLET	1	Preferred Generic	1%	1%	Q:120 /30Days
Clorazepate Dipotassium 3.75mg/1 500 TABLET BOTTLE, PLASTIC	1	Preferred Generic	1%	1%	Q:90 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Clorazepate Dipotassium 7.5mg/1 500 TABLET BOTTLE, PLASTIC	1	Preferred Generic	1%	1%	Q:90 /30Days
CLOTRIMAZOLE 1% CREAM	1	Preferred Generic	1%	1%	None
CLOTRIMAZOLE 10MG TROCHE	2	Non-Preferred Generic	1%	1%	None
CLOTRIMAZOLE SOLUTION TOPICAL 1% 30ML BOTPL	1	Preferred Generic	1%	1%	None
CLOTRIMAZOLE-BETAMETHASONE 1-0.05% LOTION	2	Non-Preferred Generic	1%	1%	None
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE 0.64; 10mg/g; mg/g 45 g in 1 TUBE	2	Non-Preferred Generic	1%	1%	None
Clozapine 100mg/1 100 TABLET BOTTLE	2	Non-Preferred Generic	1%	1%	None
CLOZAPINE 200MG TABLET (500 CT)	2	Non-Preferred Generic	1%	1%	None
CLOZAPINE 25MG TABLET (100 CT)	2	Non-Preferred Generic	1%	1%	None
CLOZAPINE 50MG TABLET (500 CT)	2	Non-Preferred Generic	1%	1%	None
CO-GESIC 5/500 TABLET	2	Non-Preferred Generic	1%	1%	Q:240 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
COLCRYS 0.6 MG TABLET	3	Preferred Brand	1%	1%	None
COLESTIPOL HCL 1G TABLET	2	Non-Preferred Generic	1%	1%	None
COLESTIPOL HYDROCHLORIDE 5g/1 100 SUSPENSION in 1 BOTTLE	1	Preferred Generic	1%	1%	None
colistimethate 150mg/2mL 1 VIAL in 1 CARTON / 2 mL in 1 VIAL	2	Non-Preferred Generic	1%	1%	None
COLLAGENASE SANTYL OINTMENT 250UNT 30GM TUBE	3	Preferred Brand	1%	1%	None
COMBIGAN 0.2%-0.5% DROPS	3	Preferred Brand	1%	1%	None
COMBIVENT INHALER	4	Non-Preferred Brand	30%	30%	None
COMBIVENT RESPIMAT INHAL SPRAY	4	Non-Preferred Brand	30%	30%	None
COMBIVIR 150; 300mg/1; mg/1 120 FILM COATED TABLETS in DOSE PACK	5	Specialty Tier	29%	N/A	None
COMETRIQ 100 MG DAILY-DOSE PK	5	Specialty Tier	29%	N/A	None
COMETRIQ 140 MG DAILY-DOSE PK	5	Specialty Tier	29%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
COMETRIQ 60 MG DAILY-DOSE PACK	5	Specialty Tier	29%	N/A	None
COMPLERA 200; 27.5; 300mg/1; mg/1; mg/1	5	Specialty Tier	29%	N/A	None
COMPRO 25MG SUPPOSITORY	2	Non-Preferred Generic	1%	1%	None
COMTAN 200MG TABLET	3	Preferred Brand	1%	1%	None
COMVAX VACCINE VIAL	4	Non-Preferred Brand	30%	30%	None
CONDYLOX GEL 0.5% 3.5 GM CRTN	4	Non-Preferred Brand	30%	30%	None
CONSTULOSE 10 GM/15 ML SOLN	1	Preferred Generic	1%	1%	None
COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN	5	Specialty Tier	29%	N/A	None
COSMEGEN 0.5MG VIAL	4	Non-Preferred Brand	30%	30%	P
CRESTOR 10MG TABLET	3	Preferred Brand	1%	1%	None
CRESTOR 20MG TABLET	3	Preferred Brand	1%	1%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CRESTOR 40mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC	3	Preferred Brand	1%	1%	None
CRESTOR 5MG TABLET	3	Preferred Brand	1%	1%	None
CRIXIVAN 200MG CAPSULE	3	Preferred Brand	1%	1%	None
CRIXIVAN 400mg/1 90 CAPSULE in 1 BOTTLE	3	Preferred Brand	1%	1%	None
CROMOLYN NEBULIZER SOLUTION	1	Preferred Generic	1%	1%	P
CROMOLYN SODIUM 4% 40MG 10ML BOT	2	Non-Preferred Generic	1%	1%	None
CYCLOBENZAPRINE HCL 10MG TABLET (1000 CT)	1	Preferred Generic	1%	1%	P
Cyclobenzaprine Hydrochloride 5mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC	1	Preferred Generic	1%	1%	P
CYCLOPHOSPHAMIDE 25MG TABLET	2	Non-Preferred Generic	1%	1%	P
CYCLOPHOSPHAMIDE 50MG TABLET	2	Non-Preferred Generic	1%	1%	P
CYCLOSPORINE 100MG CAPSULE	2	Non-Preferred Generic	1%	1%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Cyclosporine 100mg/1 30 BLISTER PACK in 1 CARTON / 1 CAPSULE, LIQUID FILLED in 1 BLISTER PACK	2	Non-Preferred Generic	1%	1%	P
CYCLOSPORINE 25MG CAPSULE	2	Non-Preferred Generic	1%	1%	P
Cyclosporine 25mg/1 30 BLISTER PACK in 1 CARTON / 1 CAPSULE, LIQUID FILLED in 1 BLISTER PACK	2	Non-Preferred Generic	1%	1%	P
Cyclosporine 50mg/1 30 BLISTER PACK in 1 CARTON / 1 CAPSULE, LIQUID FILLED in 1 BLISTER PACK	2	Non-Preferred Generic	1%	1%	P
Cyclosporine 50mg/mL 10 VIAL in 1 BOX / 5 mL in 1 VIAL	2	Non-Preferred Generic	1%	1%	P
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT	2	Non-Preferred Generic	1%	1%	P
CYMBALTA 20MG CAPSULE	4	Non-Preferred Brand	30%	30%	None
Cymbalta 60mg/1 1000 CAPSULE, DELAYED RELEASE in 1 BOTTLE	4	Non-Preferred Brand	30%	30%	None
CYMBALTA CAPSULES DELAYED RELEASE 30MG (30 CT)	4	Non-Preferred Brand	30%	30%	None
CYSTADANE POWDER FOR ORAL SOLUTION 180GM	3	Preferred Brand	1%	1%	None
CYSTAGON 150MG CAPSULE	4	Non-Preferred Brand	30%	30%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CYSTAGON 50MG CAPSULE	4	Non-Preferred Brand	30%	30%	None
CYTARABINE 20MG/ML VIAL	2	Non-Preferred Generic	1%	1%	P
CYTARABINE 500MG VIAL	2	Non-Preferred Generic	1%	1%	P
CYTARABINE SOLUTION INJECTION 100MG 20ML VIALSD	2	Non-Preferred Generic	1%	1%	P

Chart Legend:

Below are a few notes to help you understand the above 2013 Medicare Part D EnvisionRxPlus Gold (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 $325 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 $2970) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2013 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 October 2013 )

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.