Q1Medicare.com 2014 Medicare Part D or Medicare Advantage Plan Formulary Browser

2014 Medicare Part D Plan Formulary Information
Medica HealthCare Plans MedicareMax (HMO-POS) (H5420-001-0) Benefit Details
The Medica HealthCare Plans MedicareMax (HMO-POS) (H5420-001-0) Formulary Drugs Starting with the Letter P in MIAMI-DADE County, FL: CMS MA Region 9 which includes: FL Plan Monthly Premium: $0.00 Deductible: $0
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	Non-Preferred Brand	$25.00	N/A	None
PACERONE 200MG TABLET	1	Preferred Generic	$0.00	N/A	None
PACLITAXEL INJECTION SOLUTION 6MG 50ML VIALMD	2	Preferred Brand	$5.00	N/A	None
PAMIDRONATE 60MG/10ML VIAL	3	Non-Preferred Brand	$25.00	N/A	None
PAMIDRONATE DISODIUM INJECTION 3MG 10ML VIALSD	2	Preferred Brand	$5.00	N/A	None
PAMIDRONATE DISODIUM INJECTION 9MG 10ML VIALSD	2	Preferred Brand	$5.00	N/A	None
Pandel 1mg/g 45 g in 1 TUBE	3	Non-Preferred Brand	$25.00	N/A	None
PANRETIN 0.1% GEL 60GM TUBE	4	Specialty Tier	33%	N/A	P
Pantoprazole 40mg/1 90 TABLET, DELAYED RELEASE in 1 BOTTLE	1	Preferred Generic	$0.00	N/A	None
PANTOPRAZOLE SODIUM 20MG TABLET DELAYED RELEASE	1	Preferred Generic	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
pantoprazole sodium 40 mg vial	3	Non-Preferred Brand	$25.00	N/A	None
PARICALCITOL 1 MCG CAPSULE [Zemplar]	3	Non-Preferred Brand	$25.00	N/A	P
PARICALCITOL 2 MCG CAPSULE [Zemplar]	3	Non-Preferred Brand	$25.00	N/A	P
PARICALCITOL 4 MCG CAPSULE [Zemplar]	3	Non-Preferred Brand	$25.00	N/A	P
PAROMOMYCIN 250MG CAPSULE	1	Preferred Generic	$0.00	N/A	None
Paroxetine 40mg/1 500 FILM COATED TABLETS in BOTTLE	1	Preferred Generic	$0.00	N/A	None
PAROXETINE FILM COATED 20MG TABLET (100 CT)	1	Preferred Generic	$0.00	N/A	None
PAROXETINE HCL TABLET 24 12.5MG	1	Preferred Generic	$0.00	N/A	None
PAROXETINE HCL TABLET 24 25MG	1	Preferred Generic	$0.00	N/A	None
Paroxetine Hydrochloride 37.5mg/1 30 BOTTLE in 1 BOTTLE / 30 TABLET, FILM COATED, EXTENDED RELEASE	1	Preferred Generic	$0.00	N/A	None
PAROXETINE HYDROCHLORIDE TABLETS 10 MG	1	Preferred Generic	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PAROXETINE TABLETS 30MG 90 BOT	1	Preferred Generic	$0.00	N/A	None
PASER GRANULES 4GM PACKET	3	Non-Preferred Brand	$25.00	N/A	None
PATADAY 0.2% DROPS	2	Preferred Brand	$5.00	N/A	None
PATANASE 665ug/1 240 SPRAY, METERED in 1 BOTTLE	2	Preferred Brand	$5.00	N/A	None
PATANOL 0.1% EYE DROPS	2	Preferred Brand	$5.00	N/A	None
PAXIL ORAL SUSPENSION 10 MG/5ML	3	Non-Preferred Brand	$25.00	N/A	None
PCE 333 MG TABLET	3	Non-Preferred Brand	$25.00	N/A	None
PCE 500 MG TABLET	3	Non-Preferred Brand	$25.00	N/A	None
PEDI-DRI TOPICAL POWDER	1	Preferred Generic	$0.00	N/A	None
PEDVAXHIB VACCINE VIAL	2	Preferred Brand	$5.00	N/A	None
PEGANONE 250 MG TABLET	3	Non-Preferred Brand	$25.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Pegasys 180ug/0.5mL 1 PACKET in 1 BOX / 4 SYRINGE, GLASS in 1 PACKET / 0.5 mL in 1 SYRINGE, GLASS	4	Specialty Tier	33%	N/A	P
PEGASYS INJECTION	4	Specialty Tier	33%	N/A	P
PEGASYS PROCLICK 135 MCG/0.5	4	Specialty Tier	33%	N/A	P
PEGINTRON 1 KIT per CARTON	4	Specialty Tier	33%	N/A	P
PEGINTRON 120 MCG KIT per CARTON	4	Specialty Tier	33%	N/A	P
PegIntron 120ug/0.5mL 1 CARTRIDGE per CARTON / 0.5 mL in 1 CARTRIDGE	4	Specialty Tier	33%	N/A	P
PEGINTRON 150 MCG KIT per CARTON	4	Specialty Tier	33%	N/A	P
PegIntron 150ug/0.5mL 1 CARTRIDGE per CARTON / 0.5 mL in 1 CARTRIDGE	4	Specialty Tier	33%	N/A	P
PegIntron 50ug/0.5mL 1 CARTRIDGE per CARTON / 0.5 mL in 1 CARTRIDGE	4	Specialty Tier	33%	N/A	P
PEGINTRON 80 MCG KIT per CARTON	4	Specialty Tier	33%	N/A	P
PegIntron 80ug/0.5mL 1 CARTRIDGE per CARTON / 0.5 mL in 1 CARTRIDGE	4	Specialty Tier	33%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PENICILLIN G POTASSIUM 2MMUNITS/50ML ISO-OSM	2	Preferred Brand	$5.00	N/A	None
PENICILLIN G POTASSIUM 3MMUNITS/50ML ISO-OSM	2	Preferred Brand	$5.00	N/A	None
PENICILLIN G POTASSIUM FOR INJECTION 5000000UNIT/VIAL	3	Non-Preferred Brand	$25.00	N/A	None
PENICILLIN G PROCAINE 1200000UNT 2ML CTG	3	Non-Preferred Brand	$25.00	N/A	None
Penicillin G Sodium 5000000[iU]/1 10 VIAL per CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL	3	Non-Preferred Brand	$25.00	N/A	None
Penicillin V Potassium 125mg/5mL 200 mL in 1 BOTTLE	1	Preferred Generic	$0.00	N/A	None
Penicillin V Potassium 250mg/1 1000 TABLET BOTTLE	1	Preferred Generic	$0.00	N/A	None
PENICILLIN V POTASSIUM 250MG/5ML LIQUID	1	Preferred Generic	$0.00	N/A	None
PENICILLIN V POTASSIUM 500MG TABLET	1	Preferred Generic	$0.00	N/A	None
PENTAM 300 INJ 300MG	3	Non-Preferred Brand	$25.00	N/A	None
PENTASA 250MG CAPSULE SA	3	Non-Preferred Brand	$25.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PENTASA 500MG CAPSULE	3	Non-Preferred Brand	$25.00	N/A	None
PENTOXIFYLLINE 400MG TABLET SA	1	Preferred Generic	$0.00	N/A	None
PERFOROMIST 20MCG/2ML VIAL NEBULIZER	3	Non-Preferred Brand	$25.00	N/A	P
Perindopril Erbumine 2mg/1 100 TABLET BOTTLE	1	Preferred Generic	$0.00	N/A	None
Perindopril Erbumine 4mg/1 100 TABLET BOTTLE	1	Preferred Generic	$0.00	N/A	None
Perindopril Erbumine 8mg/1 100 TABLET BOTTLE	1	Preferred Generic	$0.00	N/A	None
PERIOGARD 0.12% ORAL RINSE	1	Preferred Generic	$0.00	N/A	None
PERJETA 420 MG/14 ML VIAL	4	Specialty Tier	33%	N/A	P
Permethrin 50mg/g 1 TUBE per CARTON / 60 g in 1 TUBE	1	Preferred Generic	$0.00	N/A	None
Perphenazine 16mg/1 100 FILM COATED TABLETS in BOTTLE	1	Preferred Generic	$0.00	N/A	None
PERPHENAZINE TABLETS 4MG 100 BOXUD	1	Preferred Generic	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PERPHENAZINE TABLETS 8MG 100 BOT	1	Preferred Generic	$0.00	N/A	None
PERPHENAZINE TABLETS USP 2MG 100 BOT	1	Preferred Generic	$0.00	N/A	None
PEXEVA 10MG TABLET	3	Non-Preferred Brand	$25.00	N/A	None
PEXEVA 20MG TABLET	3	Non-Preferred Brand	$25.00	N/A	None
PEXEVA 30MG TABLET	3	Non-Preferred Brand	$25.00	N/A	None
PEXEVA 40MG TABLET	3	Non-Preferred Brand	$25.00	N/A	None
Phenadoz 12.5 mg Suppository	2	Preferred Brand	$5.00	N/A	P
PHENADOZ 25 MG SUPPOSITORY	2	Preferred Brand	$5.00	N/A	P
Phenelzine Sulfate 15mg/1 60 TABLET BOTTLE	1	Preferred Generic	$0.00	N/A	None
Phenobarbital 100mg/1	1	Preferred Generic	$0.00	N/A	P
Phenobarbital 15mg/1	1	Preferred Generic	$0.00	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PHENOBARBITAL 16.2 MG TABLET	1	Preferred Generic	$0.00	N/A	P
PHENOBARBITAL 20 MG/5 ML ELIX	1	Preferred Generic	$0.00	N/A	P
Phenobarbital 30mg/1	1	Preferred Generic	$0.00	N/A	P
PHENOBARBITAL 32.4 MG TABLET	1	Preferred Generic	$0.00	N/A	P
Phenobarbital 60mg/1	1	Preferred Generic	$0.00	N/A	P
PHENOBARBITAL 64.8 MG TABLET	1	Preferred Generic	$0.00	N/A	P
PHENOBARBITAL 97.2 MG TABLET	1	Preferred Generic	$0.00	N/A	P
PHENYTEK 200 MG CAPSULE	1	Preferred Generic	$0.00	N/A	None
PHENYTEK 300 MG CAPSULE	1	Preferred Generic	$0.00	N/A	None
phenytoin 50 mg tablet chew	2	Preferred Brand	$5.00	N/A	None
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT	1	Preferred Generic	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PHENYTOIN SOD EXT 200 MG CAP	1	Preferred Generic	$0.00	N/A	None
PHENYTOIN SODIUM 100MG /2ML INJECTION	1	Preferred Generic	$0.00	N/A	None
PHENYTOIN SODIUM EXTENDED CAPSULES 100MG (100 CT)	1	Preferred Generic	$0.00	N/A	None
PHOSLO 667MG CAPSULE	2	Preferred Brand	$5.00	N/A	None
Phoslyra 667mg/5mL 1 BOTTLE per CARTON / 473 mL in 1 BOTTLE	2	Preferred Brand	$5.00	N/A	None
PHOSPHOLINE IODIDE 0.125% 6.25MG	2	Preferred Brand	$5.00	N/A	None
PHYSIOLYTE SOLUTION FOR IRRIGATION	3	Non-Preferred Brand	$25.00	N/A	None
PHYSIOSOL IRRIGATION SOL	3	Non-Preferred Brand	$25.00	N/A	None
PICATO 0.015% GEL	3	Non-Preferred Brand	$25.00	N/A	None
PICATO 0.05% GEL	3	Non-Preferred Brand	$25.00	N/A	None
PILOCARPINE 1% EYE DROPS	1	Preferred Generic	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PILOCARPINE 2% EYE DROPS	1	Preferred Generic	$0.00	N/A	None
PILOCARPINE 4% EYE DROPS	1	Preferred Generic	$0.00	N/A	None
PILOCARPINE HCL 5MG TABLET (100 CT)	1	Preferred Generic	$0.00	N/A	None
Pilocarpine Hydrochloride 7.5mg/1 100 FILM COATED TABLETS in BOTTLE	1	Preferred Generic	$0.00	N/A	None
PIMTREA 28 DAY TABLET	1	Preferred Generic	$0.00	N/A	None
PINDOLOL 10MG TABLET	1	Preferred Generic	$0.00	N/A	None
PINDOLOL 5MG TABLET	1	Preferred Generic	$0.00	N/A	None
pioglitaz-glimepir 30-2 mg tab	1	Preferred Generic	$0.00	N/A	None
pioglitaz-glimepir 30-4 mg tab	1	Preferred Generic	$0.00	N/A	None
pioglitazone hcl 15 mg tablet [Actos]	1	Preferred Generic	$0.00	N/A	None
pioglitazone hcl 30 mg tablet [Actos]	1	Preferred Generic	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
pioglitazone hcl 45 mg tablet [Actos]	1	Preferred Generic	$0.00	N/A	None
PIOGLITAZONE-METFORMIN 15-500	1	Preferred Generic	$0.00	N/A	None
PIOGLITAZONE-METFORMIN 15-850	1	Preferred Generic	$0.00	N/A	None
PIPERACILLIN 200 MG/ML / TAZOBACTAM 25 MG/ML INJECTABLE SOLUTION	2	Preferred Brand	$5.00	N/A	None
Piperacillin and Tazobactam 4; 0.5g/1; g/1 10 VIAL, SINGLE-USE per CARTON / 1 INJECTION, POWDER, L	2	Preferred Brand	$5.00	N/A	None
Pirmella 1-35-28 tablet	1	Preferred Generic	$0.00	N/A	None
PIROXICAM 10 MG CAPSULE	1	Preferred Generic	$0.00	N/A	None
Piroxicam 20mg/1 500 CAPSULE BOTTLE	1	Preferred Generic	$0.00	N/A	None
PLASMA-LYTE 148 IV SOLUTION	3	Non-Preferred Brand	$25.00	N/A	None
PLASMA-LYTE 56/DEXTROSE 5%	3	Non-Preferred Brand	$25.00	N/A	None
PLASMA-LYTE A PH 7.4 SOLUTION 37;368; MG/100ML;	3	Non-Preferred Brand	$25.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PODOFILOX 0.5% TOPICAL TUBEX	1	Preferred Generic	$0.00	N/A	None
POLYETH GLYC NF POWDER FOR ORAL SOLUTION 17GM (527 CT)	1	Preferred Generic	$0.00	N/A	None
POLYMYXIN B SUL-TRIMETHOPRIM 10K U-0.1%	1	Preferred Generic	$0.00	N/A	None
POMALYST 1 MG CAPSULE	4	Specialty Tier	33%	N/A	P
POMALYST 2 MG CAPSULE	4	Specialty Tier	33%	N/A	P
POMALYST 3 MG CAPSULE	4	Specialty Tier	33%	N/A	P
POMALYST 4 MG CAPSULE	4	Specialty Tier	33%	N/A	P
PORTIA 0.15-0.03 TABLET	1	Preferred Generic	$0.00	N/A	None
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.45%	2	Preferred Brand	$5.00	N/A	None
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.9% 1000ML	2	Preferred Brand	$5.00	N/A	None
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.45% 1000ML BAG	2	Preferred Brand	$5.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
POTASSIUM CHLORIDE 149mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 5 mL in 1 VIAL, SINGLE-DOSE	2	Preferred Brand	$5.00	N/A	None
POTASSIUM CHLORIDE 20MEQ IN D5W/NACL 0.225%	2	Preferred Brand	$5.00	N/A	None
POTASSIUM CHLORIDE 40MEQ/NS 1000ML IV SOLUTION	2	Preferred Brand	$5.00	N/A	None
POTASSIUM CHLORIDE 750MG EXTENDED RELEASE TABLETS	1	Preferred Generic	$0.00	N/A	None
POTASSIUM CHLORIDE ER CAPSULES 10MEQ	1	Preferred Generic	$0.00	N/A	None
POTASSIUM CHLORIDE ER CPCR 8MEQ	1	Preferred Generic	$0.00	N/A	None
POTASSIUM CHLORIDE IN 5% DEXTROSE AND 0.2% NACL SOLUTION FOR INJECTION USP 0.15% 250ML X 24 CASE	2	Preferred Brand	$5.00	N/A	None
POTASSIUM CHLORIDE IN 5% DEXTROSE AND NACL SOLUTION FOR INJECTION 0.075% 1000ML PLASTIC BAGS X 12 CA	2	Preferred Brand	$5.00	N/A	None
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION	2	Preferred Brand	$5.00	N/A	None
POTASSIUM CHLORIDE IN DEXTROSE 5; 0.3g/100mL; g/100mL 12 CONTAINER in 1 CASE / 1000 mL in 1 CONTAIN	2	Preferred Brand	$5.00	N/A	None
Potassium Chloride in Dextrose 5; 150g/100mL; mg/100mL 1000 mL in 1 BAG	2	Preferred Brand	$5.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Potassium Chloride in Dextrose and Sodium Chloride 5; 0.15; 0.33g/100mL; g/100mL; g/100mL 12 CONTAI	2	Preferred Brand	$5.00	N/A	None
Potassium Chloride in Dextrose and Sodium Chloride 5; 300; 900g/100mL; mg/100mL; mg/100mL 1000 mL i	2	Preferred Brand	$5.00	N/A	None
Potassium Chloride in Lactated Ringers and Dextrose 20; 5; 179; 600; 310mg/100mL; g/100mL; mg/100mL	2	Preferred Brand	$5.00	N/A	None
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION	2	Preferred Brand	$5.00	N/A	None
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION 0.15%-0.9% 12 X 1000ML BAG	2	Preferred Brand	$5.00	N/A	None
POTASSIUM CHLORIDE INJECTION 10MEQ/100ML	2	Preferred Brand	$5.00	N/A	None
POTASSIUM CHLORIDE INJECTION 20 MEQ/100ML	2	Preferred Brand	$5.00	N/A	None
POTASSIUM CHLORIDE INJECTION 30 UNT/100ML CONCENTRATED	2	Preferred Brand	$5.00	N/A	None
POTASSIUM CHLORIDE INJECTION 40 MEQ/100ML	2	Preferred Brand	$5.00	N/A	None
POTASSIUM CITRATE ER 10 MEQ TB	2	Preferred Brand	$5.00	N/A	None
POTASSIUM CITRATE ER 5 MEQ TAB	2	Preferred Brand	$5.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
POTIGA 200 MG TABLET	3	Non-Preferred Brand	$25.00	N/A	None
POTIGA 300 MG TABLET	3	Non-Preferred Brand	$25.00	N/A	None
POTIGA 400 MG TABLET	3	Non-Preferred Brand	$25.00	N/A	None
POTIGA 50 MG TABLET	3	Non-Preferred Brand	$25.00	N/A	None
PRADAXA 150mg/1 1 BOTTLE per CARTON / 60 CAPSULE BOTTLE	2	Preferred Brand	$5.00	N/A	P Q:60 /30Days
PRADAXA 75mg/1 1 BOTTLE per CARTON / 60 CAPSULE BOTTLE	2	Preferred Brand	$5.00	N/A	P Q:60 /30Days
Pramipexole Dihydrochloride 0.125mg/1 500 TABLET BOTTLE, PLASTIC	1	Preferred Generic	$0.00	N/A	None
Pramipexole Dihydrochloride 0.25mg/1 500 TABLET BOTTLE, PLASTIC	1	Preferred Generic	$0.00	N/A	None
Pramipexole Dihydrochloride 0.5mg/1 500 TABLET BOTTLE, PLASTIC	1	Preferred Generic	$0.00	N/A	None
PRAMIPEXOLE DIHYDROCHLORIDE 0.75MG TABLETS	1	Preferred Generic	$0.00	N/A	None
Pramipexole Dihydrochloride 1.5mg/1 500 TABLET BOTTLE, PLASTIC	1	Preferred Generic	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Pramipexole Dihydrochloride 1mg/1 500 TABLET BOTTLE, PLASTIC	1	Preferred Generic	$0.00	N/A	None
PRANDIMET 1MG/500MG TABLET	3	Non-Preferred Brand	$25.00	N/A	None
PRANDIMET 2MG/500MG TABLET	3	Non-Preferred Brand	$25.00	N/A	None
Prandin 0.5mg/1 100 TABLET BOTTLE, PLASTIC	3	Non-Preferred Brand	$25.00	N/A	None
Prandin 1mg/1 100 TABLET BOTTLE, PLASTIC	3	Non-Preferred Brand	$25.00	N/A	None
Prandin 2mg/1 100 TABLET BOTTLE, PLASTIC	3	Non-Preferred Brand	$25.00	N/A	None
PRAVASTATIN SODIUM 20MG TABLET 500 BOT	1	Preferred Generic	$0.00	N/A	None
PRAVASTATIN SODIUM 40MG TABLET (500 CT)	1	Preferred Generic	$0.00	N/A	None
Pravastatin Sodium 80mg/1 1000 TABLET BOTTLE	1	Preferred Generic	$0.00	N/A	None
PRAVASTATIN SODIUM TABLETS 10MG 90 BOT	1	Preferred Generic	$0.00	N/A	None
PRAZOSIN 5MG CAPSULE	1	Preferred Generic	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PRAZOSIN HCL 1MG CAPSULE	1	Preferred Generic	$0.00	N/A	None
PRAZOSIN HCL 2MG CAPSULE	1	Preferred Generic	$0.00	N/A	None
PRED G OPHTHALMIC SUSPENSION 1;0.3%;% 5 ML BOTDR	3	Non-Preferred Brand	$25.00	N/A	None
PRED-G S.O.P. EYE OINTMENT	3	Non-Preferred Brand	$25.00	N/A	None
PREDNICARBATE 0.1% OINTMENT	1	Preferred Generic	$0.00	N/A	None
PREDNICARBATE 1 MG/ML TOPICAL CREAM	1	Preferred Generic	$0.00	N/A	None
PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION 1.0% STERILE 10ML BOTDR	1	Preferred Generic	$0.00	N/A	None
PREDNISOLONE SOD 1% EYE DROP	1	Preferred Generic	$0.00	N/A	None
PREDNISOLONE SOD PH 25 MG/5 ML	1	Preferred Generic	$0.00	N/A	None
PREDNISOLONE SODIUM PHOSPHATE 15MG/5ML SOLUTION ORAL	1	Preferred Generic	$0.00	N/A	None
PREDNISOLONE SODIUM PHOSPHATE 5MG /5ML ORAL SOLUTION	1	Preferred Generic	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PREDNISONE 10MG TABLET (100 CT)	1	Preferred Generic	$0.00	N/A	None
PREDNISONE 1MG TABLET	1	Preferred Generic	$0.00	N/A	None
PREDNISONE 2.5MG TABLET	1	Preferred Generic	$0.00	N/A	None
PREDNISONE 20MG TABLET (1000 CT)	1	Preferred Generic	$0.00	N/A	None
PREDNISONE 5 MG TABLET	1	Preferred Generic	$0.00	N/A	None
PREDNISONE 50MG TABLET	1	Preferred Generic	$0.00	N/A	None
PREDNISONE 5MG/5ML SOLUTION	1	Preferred Generic	$0.00	N/A	None
PREDNISONE 5MG/ML SOLUTION	1	Preferred Generic	$0.00	N/A	None
PREGNYL INJ 10000UNT	2	Preferred Brand	$5.00	N/A	P
Premarin 0.625mg/g	2	Preferred Brand	$5.00	N/A	None
PREMASOL 10% IV SOLUTION	3	Non-Preferred Brand	$25.00	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PREMASOL 6% IV SOLUTION	2	Preferred Brand	$5.00	N/A	P
PREVALITE POW 4GM	1	Preferred Generic	$0.00	N/A	None
Previfem 6 BLISTER PACK per BLISTER PACK / 1 KIT per BLISTER PACK	1	Preferred Generic	$0.00	N/A	None
PREZISTA 100 MG/ML SUSPENSION	4	Specialty Tier	33%	N/A	None
PREZISTA 150MG TABLETS	3	Non-Preferred Brand	$25.00	N/A	None
PREZISTA 800 MG TABLET	4	Specialty Tier	33%	N/A	None
PREZISTA TABLET 600MG	4	Specialty Tier	33%	N/A	None
PREZISTA TABLET 75MG	3	Non-Preferred Brand	$25.00	N/A	None
PRIFTIN 150MG TABLET	3	Non-Preferred Brand	$25.00	N/A	None
PRIMAQUINE 26.3MG TABLET	2	Preferred Brand	$5.00	N/A	None
Primidone 250mg/1 100 TABLET BOTTLE	1	Preferred Generic	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Primidone 50mg/1 500 TABLET BOTTLE	1	Preferred Generic	$0.00	N/A	None
PRIMSOL 50MG/5ML ORAL SOLUTION	3	Non-Preferred Brand	$25.00	N/A	None
PRISTIQ 100MG TABLET SR 24HR	3	Non-Preferred Brand	$25.00	N/A	P Q:120 /30Days
Pristiq Extended-Release 50mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC	3	Non-Preferred Brand	$25.00	N/A	P Q:30 /30Days
PRIVIGEN 10% VIAL	4	Specialty Tier	33%	N/A	P
PROAIR HFA 90 MCG INHALER	2	Preferred Brand	$5.00	N/A	None
PROBENECID 500MG TABLET	1	Preferred Generic	$0.00	N/A	None
PROBENECID/COLCHICINE 0.5MG/500MG TABLET	1	Preferred Generic	$0.00	N/A	None
PROCAINAMIDE 100MG/ML VIAL	1	Preferred Generic	$0.00	N/A	None
PROCAINAMIDE 500MG/ML VIAL	1	Preferred Generic	$0.00	N/A	None
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	3	Non-Preferred Brand	$25.00	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PROCHLORPERAZINE EDISYLATE INJECTION 10MG 10 X 2ML VIALS CRTN	1	Preferred Generic	$0.00	N/A	None
PROCHLORPERAZINE MALEATE 10MG TABLET (100 CT)	1	Preferred Generic	$0.00	N/A	None
PROCHLORPERAZINE MALEATE 5MG TABLET (100 CT)	1	Preferred Generic	$0.00	N/A	None
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX	1	Preferred Generic	$0.00	N/A	None
PROCRIT 10000U/ML VIAL	3	Non-Preferred Brand	$25.00	N/A	P
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL	3	Non-Preferred Brand	$25.00	N/A	P
PROCRIT 3,000 UNITS/ML VIAL	3	Non-Preferred Brand	$25.00	N/A	P
PROCRIT 4,000 UNITS/ML VIAL	3	Non-Preferred Brand	$25.00	N/A	P
PROCRIT 40000U/ML VIAL PR	4	Specialty Tier	33%	N/A	P
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY	4	Specialty Tier	33%	N/A	P
procto-pak 1% cream	1	Preferred Generic	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Proctocream HC 25mg/g	1	Preferred Generic	$0.00	N/A	None
proctozone-hc 2.5% cream	1	Preferred Generic	$0.00	N/A	None
PROGESTERONE 100 MG CAPSULE	1	Preferred Generic	$0.00	N/A	None
PROGESTERONE 200 MG CAPSULE	1	Preferred Generic	$0.00	N/A	None
Proglycem 50mg/mL 1 BOTTLE, DROPPER in 1 BOX / 30 mL in 1 BOTTLE, DROPPER	3	Non-Preferred Brand	$25.00	N/A	None
PROGRAF 5MG/ML AMPULE	3	Non-Preferred Brand	$25.00	N/A	P
PROLASTIN-C 1 KIT per CARTON	4	Specialty Tier	33%	N/A	P
PROLENSA 0.07% EYE DROPS	3	Non-Preferred Brand	$25.00	N/A	None
PROLEUKIN 22 MILLION UNIT VIAL	4	Specialty Tier	33%	N/A	P
PROLIA 60MG/ML INJECTION	3	Non-Preferred Brand	$25.00	N/A	P
PROMACTA 12.5 MG TABLET	4	Specialty Tier	33%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PROMACTA 25 MG TABLET	4	Specialty Tier	33%	N/A	P
PROMACTA 50 MG TABLET	4	Specialty Tier	33%	N/A	P
PROMACTA 75 MG TABLET	4	Specialty Tier	33%	N/A	P
PROMETHAZINE 12.5 MG TABLET	2	Preferred Brand	$5.00	N/A	P
PROMETHAZINE 50MG/ML VIAL	2	Preferred Brand	$5.00	N/A	None
PROMETHAZINE HCL 25MG TABLET (1000 CT)	2	Preferred Brand	$5.00	N/A	P
PROMETHAZINE HCL 50MG TABLET (100 CT)	2	Preferred Brand	$5.00	N/A	P
PROMETHAZINE HCL INJECTION 25MG 10 X 1ML VIAL	2	Preferred Brand	$5.00	N/A	None
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 12.5MG 12 BOX	2	Preferred Brand	$5.00	N/A	P
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 25MG 12 BOX	2	Preferred Brand	$5.00	N/A	P
PROMETHEGAN 25MG SUPP	2	Preferred Brand	$5.00	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PROMETHEGAN 50MG SUPPOS	2	Preferred Brand	$5.00	N/A	P
Propafenone HCl 150mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC	1	Preferred Generic	$0.00	N/A	None
PROPAFENONE HCL 225MG TABLET	1	Preferred Generic	$0.00	N/A	None
PROPAFENONE HCL 300MG TABLET (100 CT)	1	Preferred Generic	$0.00	N/A	None
Propafenone Hydrochloride 225mg/1 60 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC	2	Preferred Brand	$5.00	N/A	None
PROPAFENONE HYDROCHLORIDE 325MG CAPSULES EXTENDED RELEASE	2	Preferred Brand	$5.00	N/A	None
PROPAFENONE HYDROCHLORIDE 425MG CAPSULES EXTENDED RELEASE	2	Preferred Brand	$5.00	N/A	None
Propantheline Bromide 15mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC	1	Preferred Generic	$0.00	N/A	None
PROPARACAINE 0.5% EYE DROPS	1	Preferred Generic	$0.00	N/A	None
Propranolol 1mg/mL 1 mL in 1 VIAL	1	Preferred Generic	$0.00	N/A	None
PROPRANOLOL 20MG/5ML TUBEX	1	Preferred Generic	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PROPRANOLOL 40MG/5ML TUBEX	1	Preferred Generic	$0.00	N/A	None
PROPRANOLOL 60MG TABLET	1	Preferred Generic	$0.00	N/A	None
PROPRANOLOL 80 MG TABLET	1	Preferred Generic	$0.00	N/A	None
PROPRANOLOL HCL 20MG TABLET (1000 CT)	1	Preferred Generic	$0.00	N/A	None
PROPRANOLOL HCL TABLET USP 10MG (1000 CT)	1	Preferred Generic	$0.00	N/A	None
PROPRANOLOL HCL TABLET USP 40MG (1000 CT)	1	Preferred Generic	$0.00	N/A	None
Propranolol Hydrochloride 120mg EXTENDED RELEASE 100 CAPSULE BOTTLE	1	Preferred Generic	$0.00	N/A	None
Propranolol Hydrochloride 160mg EXTENDED RELEASE 100 CAPSULE BOTTLE	1	Preferred Generic	$0.00	N/A	None
Propranolol Hydrochloride 60mg/1 1000 CAPSULE, EXTENDED RELEASE in 1 BOTTLE	1	Preferred Generic	$0.00	N/A	None
Propranolol Hydrochloride 80mg EXTENDED RELEASE 100 CAPSULE BOTTLE	1	Preferred Generic	$0.00	N/A	None
PROPRANOLOL/HCTZ 40/25 TABLET	1	Preferred Generic	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PROPRANOLOL/HCTZ 80/25 TABLET	1	Preferred Generic	$0.00	N/A	None
PROPYLTHIOURACIL 50MG TABLET	1	Preferred Generic	$0.00	N/A	None
PROQUAD 0.5 VIAL	2	Preferred Brand	$5.00	N/A	None
PROSOL 20% INJECTION	3	Non-Preferred Brand	$25.00	N/A	P
PROTOPIC 0.03% OINTMENT 100GM TUBE	3	Non-Preferred Brand	$25.00	N/A	S
PROTOPIC 0.1% OINTMENT 60GM TUBE	3	Non-Preferred Brand	$25.00	N/A	S
PROTRIPTYLINE HYDROCHLORIDE 10MG TABLETS	1	Preferred Generic	$0.00	N/A	None
PROTRIPTYLINE HYDROCHLORIDE TABLETS 5MG	1	Preferred Generic	$0.00	N/A	None
PRUDOXIN 50mg/g 45 g in 1 TUBE	2	Preferred Brand	$5.00	N/A	None
PULMICORT 1MG/2ML AMPUL FOR NEBULIZATION	3	Non-Preferred Brand	$25.00	N/A	P
PULMICORT FLEXHALER 180MCG AEROSOL POWDER BREATH ACTIVATED	2	Preferred Brand	$5.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PULMICORT FLEXHALER 90MCG AEROSOL POWDER BREATH ACTIVATED	2	Preferred Brand	$5.00	N/A	None
PULMOZYME 1MG/ML AMPUL	4	Specialty Tier	33%	N/A	P
PYRAZINAMIDE 500 MG TABLET	2	Preferred Brand	$5.00	N/A	None
pyridostigmine br 60 mg tablet	1	Preferred Generic	$0.00	N/A	None

Chart Legend:

Below are a few notes to help you understand the above 2014 Medicare Part D Medica HealthCare Plans MedicareMax (HMO-POS) 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 $310 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 $2850) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2014 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 2014 )

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.