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2015 Medicare Part D and Medicare Advantage Plan Formulary Browser

This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.
Select your search style and criteria below or use this example to get started

Search by:
State & Plan   ZIP & Plan   PlanID   FormularyID

Search Criteria
PDP     MAPD
Scroll down to see formulary results.

First Health Part D Premier Plus (PDP) (S5768-174-0)
Tier 1 (149)
Tier 2 (1174)
Tier 3 (390)
Tier 4 (1357)
Tier 5 (383)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
Yes No Show either
  *required
 
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 
2015 Medicare Part D Plan Formulary Information
First Health Part D Premier Plus (PDP) (S5768-174-0)
Benefit Details           
The First Health Part D Premier Plus (PDP) (S5768-174-0)
Formulary Drugs Starting with the Letter P

in CMS PDP Region 17 which includes: IL
Plan Monthly Premium: $101.40 Deductible: $0 Qualifies for LIS: No
Drugs Starting with Letter P

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
PACERONE 100MG TABLET   2 Non-Preferred Generic $3.00$9.00None
PACERONE 200MG TABLET   2 Non-Preferred Generic $3.00$9.00None
PACERONE 400MG TABLET   2 Non-Preferred Generic $3.00$9.00None
PACLITAXEL INJECTION SOLUTION 6MG 50ML VIALMD   4 Non-Preferred Brand 50%50%None
PAMIDRONATE 60MG/10ML VIAL   4 Non-Preferred Brand 50%50%None
PAMIDRONATE DISODIUM INJECTION 3MG 10ML VIALSD   4 Non-Preferred Brand 50%50%None
PAMIDRONATE DISODIUM INJECTION 9MG 10ML VIALSD   4 Non-Preferred Brand 50%50%None
PANRETIN 0.1% GEL 60GM TUBE   5 Specialty Tier 33%N/ANone
Pantoprazole 40mg/1 90 TABLET, DELAYED RELEASE in 1 BOTTLE   2 Non-Preferred Generic $3.00$9.00Q:60
/30Days
PANTOPRAZOLE SODIUM 20MG TABLET DELAYED RELEASE   2 Non-Preferred Generic $3.00$9.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PARICALCITOL 1 MCG CAPSULE [Zemplar]   2 Non-Preferred Generic $3.00$9.00None
PARICALCITOL 2 MCG CAPSULE [Zemplar]   2 Non-Preferred Generic $3.00$9.00None
PARICALCITOL 2 MCG/ML VIAL [Zemplar]   2 Non-Preferred Generic $3.00$9.00None
PARICALCITOL 4 MCG CAPSULE [Zemplar]   2 Non-Preferred Generic $3.00$9.00None
PARICALCITOL 5 MCG/ML VIAL [Zemplar]   2 Non-Preferred Generic $3.00$9.00None
PAROMOMYCIN 250MG CAPSULE   2 Non-Preferred Generic $3.00$9.00None
Paroxetine 40mg/1 500 FILM COATED TABLETS in BOTTLE   2 Non-Preferred Generic $3.00$9.00None
PAROXETINE FILM COATED 20MG TABLET (100 CT)   2 Non-Preferred Generic $3.00$9.00None
PAROXETINE HCL TABLET 24 12.5MG   4 Non-Preferred Brand 50%50%Q:90
/30Days
PAROXETINE HCL TABLET 24 25MG   4 Non-Preferred Brand 50%50%Q:90
/30Days
Paroxetine Hydrochloride 37.5mg/1 30 BOTTLE in 1 BOTTLE / 30 TABLET, FILM COATED, EXTENDED RELEASE   4 Non-Preferred Brand 50%50%Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PAROXETINE HYDROCHLORIDE TABLETS 10 MG   2 Non-Preferred Generic $3.00$9.00None
PAROXETINE TABLETS 30MG 90 BOT   2 Non-Preferred Generic $3.00$9.00None
PASER GRANULES 4GM PACKET   4 Non-Preferred Brand 50%50%None
PATADAY 0.2% DROPS   4 Non-Preferred Brand 50%50%None
PATANASE 665ug/1 240 SPRAY, METERED in 1 BOTTLE   4 Non-Preferred Brand 50%50%Q:31
/30Days
PATANOL 0.1% EYE DROPS   4 Non-Preferred Brand 50%50%None
PAXIL ORAL SUSPENSION 10 MG/5ML   4 Non-Preferred Brand 50%50%None
PAZEO 0.7% EYE DROPS   4 Non-Preferred Brand 50%50%None
PCE 333 MG TABLET   4 Non-Preferred Brand 50%50%None
PCE 500 MG TABLET   4 Non-Preferred Brand 50%50%None
PEDVAXHIB VACCINE VIAL   4 Non-Preferred Brand 50%50%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PEG-3350 and Electrolytes 236; 2.97; 6.74; 5.86; 22.74g/2L; g/2L; g/2L; g/2L; g/2L 4 L in 1 JUG   2 Non-Preferred Generic $3.00$9.00None
PEGANONE 250 MG TABLET   4 Non-Preferred Brand 50%50%None
PEGINTRON 1 KIT per CARTON   5 Specialty Tier 33%N/AP
PEGINTRON 120 MCG KIT   5 Specialty Tier 33%N/AP
PegIntron 120ug/0.5mL 1 CARTRIDGE per CARTON / 0.5 mL in 1 CARTRIDGE   5 Specialty Tier 33%N/AP
PEGINTRON 150 MCG KIT   5 Specialty Tier 33%N/AP
PegIntron 150ug/0.5mL 1 CARTRIDGE per CARTON / 0.5 mL in 1 CARTRIDGE   5 Specialty Tier 33%N/AP
PegIntron 50ug/0.5mL 1 CARTRIDGE per CARTON / 0.5 mL in 1 CARTRIDGE   5 Specialty Tier 33%N/AP
PEGINTRON 80 MCG KIT   5 Specialty Tier 33%N/AP
PegIntron 80ug/0.5mL 1 CARTRIDGE per CARTON / 0.5 mL in 1 CARTRIDGE   5 Specialty Tier 33%N/AP
PENICILLIN G POTASSIUM FOR INJECTION 5000000UNIT/VIAL   4 Non-Preferred Brand 50%50%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PENICILLIN G PROCAINE 1200000UNT 2ML CTG   4 Non-Preferred Brand 50%50%None
Penicillin G Sodium 5000000[iU]/1 10 VIAL per CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL   4 Non-Preferred Brand 50%50%None
Penicillin V Potassium 125mg/5mL 200 mL in 1 BOTTLE   2 Non-Preferred Generic $3.00$9.00None
Penicillin V Potassium 250mg/1 1000 TABLET BOTTLE   2 Non-Preferred Generic $3.00$9.00None
PENICILLIN V POTASSIUM 250MG/5ML LIQUID   2 Non-Preferred Generic $3.00$9.00None
PENICILLIN V POTASSIUM 500MG TABLET   2 Non-Preferred Generic $3.00$9.00None
PENTAM 300 INJ 300MG   4 Non-Preferred Brand 50%50%None
PENTASA 250MG CAPSULE SA   4 Non-Preferred Brand 50%50%None
PENTASA 500MG CAPSULE   4 Non-Preferred Brand 50%50%None
PENTOXIFYLLINE 400MG TABLET SA   2 Non-Preferred Generic $3.00$9.00None
PERFOROMIST 20MCG/2ML VIAL NEBULIZER   4 Non-Preferred Brand 50%50%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 BOTTLE   2 Non-Preferred Generic $3.00$9.00None
Perindopril Erbumine 4mg/1 100 TABLET BOTTLE   2 Non-Preferred Generic $3.00$9.00None
Perindopril Erbumine 8mg/1 100 TABLET BOTTLE   2 Non-Preferred Generic $3.00$9.00None
PERIOGARD 0.12% ORAL RINSE   2 Non-Preferred Generic $3.00$9.00None
PERJETA 420 MG/14 ML VIAL   5 Specialty Tier 33%N/AP
Permethrin 50mg/g 1 TUBE per CARTON / 60 g in 1 TUBE   2 Non-Preferred Generic $3.00$9.00None
Perphenazine 16mg/1 100 FILM COATED TABLETS in BOTTLE   4 Non-Preferred Brand 50%50%None
PERPHENAZINE TABLETS 4MG 100 BOXUD   4 Non-Preferred Brand 50%50%None
PERPHENAZINE TABLETS 8MG 100 BOT   4 Non-Preferred Brand 50%50%None
PERPHENAZINE TABLETS USP 2MG 100 BOT   4 Non-Preferred Brand 50%50%None
Phenadoz 12.5 mg Suppository   4 Non-Preferred Brand 50%50%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Phenelzine Sulfate 15mg/1 60 TABLET BOTTLE   3 Preferred Brand $45.00$135.00None
Phenergan 12.5 mg suppository   4 Non-Preferred Brand 50%50%P
Phenergan 25 mg suppository   4 Non-Preferred Brand 50%50%P
Phenergan 50 mg suppository   4 Non-Preferred Brand 50%50%P
Phenobarbital 100mg/1   4 Non-Preferred Brand 50%50%P Q:120
/30Days
Phenobarbital 15mg/1   4 Non-Preferred Brand 50%50%P Q:120
/30Days
PHENOBARBITAL 16.2 MG TABLET   4 Non-Preferred Brand 50%50%P Q:120
/30Days
PHENOBARBITAL 20 MG/5 ML ELIX   4 Non-Preferred Brand 50%50%P Q:1500
/30Days
Phenobarbital 30mg/1   4 Non-Preferred Brand 50%50%P Q:120
/30Days
PHENOBARBITAL 32.4 MG TABLET   4 Non-Preferred Brand 50%50%P Q:120
/30Days
Phenobarbital 60mg/1   4 Non-Preferred Brand 50%50%P Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PHENOBARBITAL 64.8 MG TABLET   4 Non-Preferred Brand 50%50%P Q:120
/30Days
PHENOBARBITAL 97.2 MG TABLET   4 Non-Preferred Brand 50%50%P Q:120
/30Days
phenytoin 50 mg tablet chew   2 Non-Preferred Generic $3.00$9.00None
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT   2 Non-Preferred Generic $3.00$9.00None
PHENYTOIN SOD EXT 200 MG CAP   2 Non-Preferred Generic $3.00$9.00None
PHENYTOIN SODIUM 100MG /2ML INJECTION   4 Non-Preferred Brand 50%50%None
PHENYTOIN SODIUM EXTENDED CAPSULES 100MG (100 CT)   2 Non-Preferred Generic $3.00$9.00None
PHOSPHOLINE IODIDE 0.125% 6.25MG   4 Non-Preferred Brand 50%50%None
PICATO 0.015% GEL   3 Preferred Brand $45.00$135.00Q:3
/30Days
PICATO 0.05% GEL   3 Preferred Brand $45.00$135.00Q:2
/30Days
PILOCARPINE 1% EYE DROPS   2 Non-Preferred Generic $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PILOCARPINE 2% EYE DROPS   2 Non-Preferred Generic $3.00$9.00None
PILOCARPINE 4% EYE DROPS   2 Non-Preferred Generic $3.00$9.00None
PILOCARPINE HCL 5MG TABLET (100 CT)   2 Non-Preferred Generic $3.00$9.00None
Pilocarpine Hydrochloride 7.5mg/1 100 FILM COATED TABLETS in BOTTLE   2 Non-Preferred Generic $3.00$9.00None
PIMTREA 28 DAY TABLET   4 Non-Preferred Brand 50%50%None
PINDOLOL 10MG TABLET   2 Non-Preferred Generic $3.00$9.00None
PINDOLOL 5MG TABLET   2 Non-Preferred Generic $3.00$9.00None
pioglitaz-glimepir 30-2 mg tab   2 Non-Preferred Generic $3.00$9.00Q:30
/30Days
pioglitaz-glimepir 30-4 mg tab   2 Non-Preferred Generic $3.00$9.00Q:30
/30Days
pioglitazone hcl 15 mg tablet [Actos]   2 Non-Preferred Generic $3.00$9.00Q:30
/30Days
pioglitazone hcl 30 mg tablet [Actos]   2 Non-Preferred Generic $3.00$9.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
pioglitazone hcl 45 mg tablet [Actos]   2 Non-Preferred Generic $3.00$9.00Q:30
/30Days
PIOGLITAZONE-METFORMIN 15-500   2 Non-Preferred Generic $3.00$9.00Q:90
/30Days
PIOGLITAZONE-METFORMIN 15-850   2 Non-Preferred Generic $3.00$9.00Q:90
/30Days
PIPERACILLIN 200 MG/ML / TAZOBACTAM 25 MG/ML INJECTABLE SOLUTION   4 Non-Preferred Brand 50%50%None
Piperacillin and Tazobactam 4; 0.5g/1; g/1 10 VIAL, SINGLE-USE per CARTON / 1 INJECTION, POWDER, L   4 Non-Preferred Brand 50%50%None
Pirmella 1-35-28 tablet   4 Non-Preferred Brand 50%50%None
PIROXICAM 10 MG CAPSULE   2 Non-Preferred Generic $3.00$9.00None
Piroxicam 20mg/1 500 CAPSULE BOTTLE   2 Non-Preferred Generic $3.00$9.00None
PODOFILOX 0.5% TOPICAL TUBEX   4 Non-Preferred Brand 50%50%None
POLYETH GLYC NF POWDER FOR ORAL SOLUTION 17GM (527 CT)   2 Non-Preferred Generic $3.00$9.00None
POLYMYXIN B SUL-TRIMETHOPRIM 10K U-0.1%   2 Non-Preferred Generic $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
POMALYST 1 MG CAPSULE   5 Specialty Tier 33%N/AP Q:21
/28Days
POMALYST 2 MG CAPSULE   5 Specialty Tier 33%N/AP Q:21
/28Days
POMALYST 3 MG CAPSULE   5 Specialty Tier 33%N/AP Q:21
/28Days
POMALYST 4 MG CAPSULE   5 Specialty Tier 33%N/AP Q:21
/28Days
PORTIA 0.15-0.03 TABLET   4 Non-Preferred Brand 50%50%None
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.9% 1000ML   2 Non-Preferred Generic $3.00$9.00None
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.45% 1000ML BAG   2 Non-Preferred Generic $3.00$9.00None
POTASSIUM CHLORIDE 20MEQ IN D5W/NACL 0.225%   2 Non-Preferred Generic $3.00$9.00None
POTASSIUM CHLORIDE 40MEQ/NS 1000ML IV SOLUTION   2 Non-Preferred Generic $3.00$9.00None
POTASSIUM CHLORIDE 750MG EXTENDED RELEASE TABLETS   2 Non-Preferred Generic $3.00$9.00None
POTASSIUM CHLORIDE ER CAPSULES 10MEQ   2 Non-Preferred Generic $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
POTASSIUM CHLORIDE ER CPCR 8MEQ   2 Non-Preferred Generic $3.00$9.00None
POTASSIUM CHLORIDE IN 5% DEXTROSE AND 0.2% NACL SOLUTION FOR INJECTION USP 0.15% 250ML X 24 CASE   2 Non-Preferred Generic $3.00$9.00None
POTASSIUM CHLORIDE IN 5% DEXTROSE AND NACL SOLUTION FOR INJECTION 0.075% 1000ML PLASTIC BAGS X 12 CA   2 Non-Preferred Generic $3.00$9.00None
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION   2 Non-Preferred Generic $3.00$9.00None
Potassium Chloride in Dextrose 5; 150g/100mL; mg/100mL 1000 mL in 1 BAG   2 Non-Preferred Generic $3.00$9.00None
Potassium Chloride in Dextrose and Sodium Chloride 5; 0.15; 0.33g/100mL; g/100mL; g/100mL 12 CONTAI   2 Non-Preferred Generic $3.00$9.00None
Potassium Chloride in Dextrose and Sodium Chloride 5; 0.15; 0.45g/100mL; g/100mL; g/100mL 12 CONTAI   2 Non-Preferred Generic $3.00$9.00None
Potassium Chloride in Dextrose and Sodium Chloride 5; 300; 900g/100mL; mg/100mL; mg/100mL 1000 mL i   2 Non-Preferred Generic $3.00$9.00None
Potassium Chloride in Lactated Ringers and Dextrose 20; 5; 179; 600; 310mg/100mL; g/100mL; mg/100mL   2 Non-Preferred Generic $3.00$9.00None
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION   2 Non-Preferred Generic $3.00$9.00None
POTASSIUM CHLORIDE INJECTION 10MEQ/100ML   2 Non-Preferred Generic $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
POTASSIUM CHLORIDE INJECTION 20 MEQ/100ML   2 Non-Preferred Generic $3.00$9.00None
POTASSIUM CHLORIDE INJECTION 40 MEQ/100ML   2 Non-Preferred Generic $3.00$9.00None
POTASSIUM CITRATE ER 10 MEQ TB   4 Non-Preferred Brand 50%50%None
POTASSIUM CITRATE ER 15 MEQ TABLET   4 Non-Preferred Brand 50%50%None
POTASSIUM CITRATE ER 5 MEQ TAB   4 Non-Preferred Brand 50%50%None
POTASSIUM CITRATE ER 8 MEQ TABLET   2 Non-Preferred Generic $3.00$9.00None
Potassium Cl 10% (20 MEQ/15 ML)   2 Non-Preferred Generic $3.00$9.00None
Potassium cl 2 meq/ml vial   2 Non-Preferred Generic $3.00$9.00None
Potassium Cl 20% (40 MEQ/15 ML)   2 Non-Preferred Generic $3.00$9.00None
POTASSIUM CL ER 20 MEQ TABLET   2 Non-Preferred Generic $3.00$9.00None
POTIGA 200 MG TABLET   4 Non-Preferred Brand 50%50%P Q:90
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
POTIGA 300 MG TABLET   4 Non-Preferred Brand 50%50%P Q:90
/30Days
POTIGA 400 MG TABLET   4 Non-Preferred Brand 50%50%P Q:90
/30Days
POTIGA 50 MG TABLET   4 Non-Preferred Brand 50%50%P Q:270
/30Days
PRADAXA 150mg/1 1 BOTTLE per CARTON / 60 CAPSULE BOTTLE   3 Preferred Brand $45.00$135.00Q:60
/30Days
PRADAXA 75mg/1 1 BOTTLE per CARTON / 60 CAPSULE BOTTLE   3 Preferred Brand $45.00$135.00Q:60
/30Days
Pramipexole Dihydrochloride 0.125mg/1 500 TABLET BOTTLE, PLASTIC   2 Non-Preferred Generic $3.00$9.00None
Pramipexole Dihydrochloride 0.25mg/1 500 TABLET BOTTLE, PLASTIC   2 Non-Preferred Generic $3.00$9.00None
Pramipexole Dihydrochloride 0.5mg/1 500 TABLET BOTTLE, PLASTIC   2 Non-Preferred Generic $3.00$9.00None
PRAMIPEXOLE DIHYDROCHLORIDE 0.75MG TABLETS   2 Non-Preferred Generic $3.00$9.00None
Pramipexole Dihydrochloride 1.5mg/1 500 TABLET BOTTLE, PLASTIC   2 Non-Preferred Generic $3.00$9.00None
Pramipexole Dihydrochloride 1mg/1 500 TABLET BOTTLE, PLASTIC   2 Non-Preferred Generic $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PRAVASTATIN SODIUM 20MG TABLET 500 BOT   1 Preferred Generic $0.00$0.00None
PRAVASTATIN SODIUM 40MG TABLET (500 CT)   1 Preferred Generic $0.00$0.00None
Pravastatin Sodium 80mg/1 1000 TABLET BOTTLE   1 Preferred Generic $0.00$0.00None
PRAVASTATIN SODIUM TABLETS 10MG 90 BOT   1 Preferred Generic $0.00$0.00None
PRAZOSIN 5MG CAPSULE   2 Non-Preferred Generic $3.00$9.00None
PRAZOSIN HCL 1MG CAPSULE   2 Non-Preferred Generic $3.00$9.00None
PRAZOSIN HCL 2MG CAPSULE   2 Non-Preferred Generic $3.00$9.00None
PRED G OPHTHALMIC SUSPENSION 1;0.3%;% 5 ML BOTDR   4 Non-Preferred Brand 50%50%None
PRED MILD 0.12% EYE DROPS   4 Non-Preferred Brand 50%50%None
PRED-G S.O.P. EYE OINTMENT   4 Non-Preferred Brand 50%50%None
PREDNICARBATE 0.1% OINTMENT   2 Non-Preferred Generic $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PREDNICARBATE 1 MG/ML TOPICAL CREAM   2 Non-Preferred Generic $3.00$9.00None
PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION 1.0% STERILE 10ML BOTDR   2 Non-Preferred Generic $3.00$9.00None
PREDNISOLONE SOD 1% EYE DROP   2 Non-Preferred Generic $3.00$9.00None
PREDNISOLONE SOD PH 25 MG/5 ML   2 Non-Preferred Generic $3.00$9.00None
PREDNISOLONE SODIUM PHOSPHATE 15MG/5ML SOLUTION ORAL   2 Non-Preferred Generic $3.00$9.00None
PREDNISOLONE SODIUM PHOSPHATE 5MG /5ML ORAL SOLUTION   2 Non-Preferred Generic $3.00$9.00None
PREDNISONE 10MG TABLET (100 CT)   2 Non-Preferred Generic $3.00$9.00None
PREDNISONE 1MG TABLET   2 Non-Preferred Generic $3.00$9.00None
PREDNISONE 2.5MG TABLET   2 Non-Preferred Generic $3.00$9.00None
PREDNISONE 20MG TABLET (1000 CT)   2 Non-Preferred Generic $3.00$9.00None
PREDNISONE 5 MG TABLET   2 Non-Preferred Generic $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PREDNISONE 50MG TABLET   2 Non-Preferred Generic $3.00$9.00None
PREDNISONE 5MG/5ML SOLUTION   2 Non-Preferred Generic $3.00$9.00None
PREDNISONE 5MG/ML SOLUTION   4 Non-Preferred Brand 50%50%None
Premarin 0.625mg/g   3 Preferred Brand $45.00$135.00None
PREMASOL 10% IV SOLUTION   4 Non-Preferred Brand 50%50%P
PREMASOL 6% IV SOLUTION   4 Non-Preferred Brand 50%50%P
PREPOPIK POWDER PACKET   4 Non-Preferred Brand 50%50%None
PREVALITE POW 4GM   2 Non-Preferred Generic $3.00$9.00None
Previfem 6 BLISTER PACK per BLISTER PACK / 1 KIT per BLISTER PACK   4 Non-Preferred Brand 50%50%None
PREZCOBIX 800 MG-150 MG TABLET   5 Specialty Tier 33%N/AQ:30
/30Days
PREZISTA 100 MG/ML SUSPENSION   5 Specialty Tier 33%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PREZISTA 150MG TABLETS   5 Specialty Tier 33%N/ANone
PREZISTA 800 MG TABLET   5 Specialty Tier 33%N/ANone
PREZISTA TABLET 600MG   5 Specialty Tier 33%N/ANone
PREZISTA TABLET 75MG   4 Non-Preferred Brand 50%50%None
PRIFTIN 150MG TABLET   4 Non-Preferred Brand 50%50%None
PRIMAQUINE 26.3MG TABLET   3 Preferred Brand $45.00$135.00None
Primidone 250mg/1 100 TABLET BOTTLE   2 Non-Preferred Generic $3.00$9.00None
Primidone 50mg/1 500 TABLET BOTTLE   2 Non-Preferred Generic $3.00$9.00None
PRISTIQ 100MG TABLET SR 24HR   4 Non-Preferred Brand 50%50%S Q:30
/30Days
PRISTIQ ER 25 MG TABLET   4 Non-Preferred Brand 50%50%S Q:30
/30Days
Pristiq Extended-Release 50mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC   4 Non-Preferred Brand 50%50%S Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PROAIR HFA 90 MCG INHALER   3 Preferred Brand $45.00$135.00Q:17
/30Days
PROAIR RESPICLICK INHAL POWDER   3 Preferred Brand $45.00$135.00Q:2
/30Days
PROBENECID 500MG TABLET   2 Non-Preferred Generic $3.00$9.00None
PROBENECID/COLCHICINE 0.5MG/500MG TABLET   2 Non-Preferred Generic $3.00$9.00None
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   4 Non-Preferred Brand 50%50%P
Prochlorperazine 10 mg/2 ml vl   2 Non-Preferred Generic $3.00$9.00None
PROCHLORPERAZINE MALEATE 10MG TABLET (100 CT)   2 Non-Preferred Generic $3.00$9.00None
Prochlorperazine Maleate 5mg/1 100 FILM COATED TABLETS in BOTTLE   2 Non-Preferred Generic $3.00$9.00None
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX   4 Non-Preferred Brand 50%50%None
PROCRIT 10000U/ML VIAL   3 Preferred Brand $45.00$135.00P Q:12
/28Days
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL   3 Preferred Brand $45.00$135.00P Q:12
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PROCRIT 3,000 UNITS/ML VIAL   3 Preferred Brand $45.00$135.00P Q:12
/28Days
PROCRIT 4,000 UNITS/ML VIAL   3 Preferred Brand $45.00$135.00P Q:12
/28Days
PROCRIT 40000U/ML VIAL PR   5 Specialty Tier 33%N/AP Q:8
/28Days
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY   3 Preferred Brand $45.00$135.00P Q:12
/28Days
PROCTOSOL-HC 2.5% CREAM   2 Non-Preferred Generic $3.00$9.00None
proctozone-hc 2.5% cream   2 Non-Preferred Generic $3.00$9.00None
PROGESTERONE 100 MG CAPSULE   4 Non-Preferred Brand 50%50%None
PROGESTERONE 200 MG CAPSULE   4 Non-Preferred Brand 50%50%None
Proglycem 50mg/mL 1 BOTTLE, DROPPER in 1 BOX / 30 mL in 1 BOTTLE, DROPPER   4 Non-Preferred Brand 50%50%None
PROGRAF 5MG/ML AMPULE   4 Non-Preferred Brand 50%50%P
PROLASTIN-C   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PROLENSA 0.07% EYE DROPS   4 Non-Preferred Brand 50%50%None
PROLEUKIN 22 MILLION UNIT VIAL   5 Specialty Tier 33%N/ANone
PROLIA 60MG/ML INJECTION   4 Non-Preferred Brand 50%50%P Q:1
/180Days
PROMACTA 12.5 MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
PROMACTA 25 MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
PROMACTA 50 MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
PROMACTA 75 MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
PROMETHAZINE 50 MG SUPPOSITORY   4 Non-Preferred Brand 50%50%P
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 12.5MG 12 BOX   4 Non-Preferred Brand 50%50%P
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 25MG 12 BOX   4 Non-Preferred Brand 50%50%P
PROMETHEGAN 25MG SUPP   4 Non-Preferred Brand 50%50%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PROMETHEGAN 50MG SUPPOS   4 Non-Preferred Brand 50%50%P
Propafenone HCl 150mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC   4 Non-Preferred Brand 50%50%None
PROPAFENONE HCL 225MG TABLET   4 Non-Preferred Brand 50%50%None
PROPAFENONE HCL 300MG TABLET (100 CT)   4 Non-Preferred Brand 50%50%None
Propafenone Hydrochloride 225mg/1 60 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC   4 Non-Preferred Brand 50%50%None
PROPAFENONE HYDROCHLORIDE 325MG CAPSULES EXTENDED RELEASE   4 Non-Preferred Brand 50%50%None
PROPAFENONE HYDROCHLORIDE 425MG CAPSULES EXTENDED RELEASE   4 Non-Preferred Brand 50%50%None
Propantheline Bromide 15mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC   2 Non-Preferred Generic $3.00$9.00P
PROPARACAINE 0.5% EYE DROPS   2 Non-Preferred Generic $3.00$9.00None
Propranolol 1mg/mL 1 mL in 1 VIAL   2 Non-Preferred Generic $3.00$9.00None
PROPRANOLOL 20MG/5ML TUBEX   2 Non-Preferred Generic $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PROPRANOLOL 40MG/5ML TUBEX   2 Non-Preferred Generic $3.00$9.00None
PROPRANOLOL 60MG TABLET   2 Non-Preferred Generic $3.00$9.00None
PROPRANOLOL 80 MG TABLET   2 Non-Preferred Generic $3.00$9.00None
PROPRANOLOL ER 120 MG CAPSULE   2 Non-Preferred Generic $3.00$9.00None
PROPRANOLOL ER 160 MG CAPSULE   2 Non-Preferred Generic $3.00$9.00None
PROPRANOLOL HCL 20MG TABLET (1000 CT)   2 Non-Preferred Generic $3.00$9.00None
PROPRANOLOL HCL TABLET USP 10MG (1000 CT)   2 Non-Preferred Generic $3.00$9.00None
PROPRANOLOL HCL TABLET USP 40MG (1000 CT)   2 Non-Preferred Generic $3.00$9.00None
Propranolol Hydrochloride 60mg/1 1000 CAPSULE, EXTENDED RELEASE in 1 BOTTLE   2 Non-Preferred Generic $3.00$9.00None
Propranolol Hydrochloride 80mg/1 500 CAPSULE, EXTENDED RELEASE in 1 BOTTLE   2 Non-Preferred Generic $3.00$9.00None
PROPRANOLOL/HCTZ 40/25 TABLET   2 Non-Preferred Generic $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PROPRANOLOL/HCTZ 80/25 TABLET   2 Non-Preferred Generic $3.00$9.00None
PROPYLTHIOURACIL 50MG TABLET   2 Non-Preferred Generic $3.00$9.00None
PROQUAD 0.5 VIAL   4 Non-Preferred Brand 50%50%None
PROSOL 20% INJECTION   4 Non-Preferred Brand 50%50%P
PROTRIPTYLINE HYDROCHLORIDE 10MG TABLETS   4 Non-Preferred Brand 50%50%None
PROTRIPTYLINE HYDROCHLORIDE TABLETS 5MG   4 Non-Preferred Brand 50%50%None
PULMICORT FLEXHALER 180MCG AEROSOL POWDER BREATH ACTIVATED   4 Non-Preferred Brand 50%50%Q:2
/30Days
PULMICORT FLEXHALER 90MCG AEROSOL POWDER BREATH ACTIVATED   4 Non-Preferred Brand 50%50%Q:2
/30Days
PULMOZYME 1MG/ML AMPUL   5 Specialty Tier 33%N/AP
PURIXAN 20 MG/ML ORAL SUSP   5 Specialty Tier 33%N/AP
PYRAZINAMIDE 500 MG TABLET   4 Non-Preferred Brand 50%50%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Pyridostigmine br 60 mg tablet   3 Preferred Brand $45.00$135.00None

Chart Legend:

Below are a few notes to help you understand the above 2015 Medicare Part D First Health Part D Premier 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 $2960) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2016 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 2015 )

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
  • Q1Medicare®, Q1Rx®, and Q1Group® are registered Service Marks of Q1Group LLC and may not be used in any advertising, publicity, or for commercial purposes without the express authorization of Q1Group.
  • 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 PDPCompare.com and MACompare.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.
    Statement required by Medicare:
    "We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options."
  • 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.