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2015 Medicare Part D Plan Formulary Information
Anthem Blue MedicareRx Standard (PDP) (S5596-017-0) Benefit Details
The Anthem Blue MedicareRx Standard (PDP) (S5596-017-0) Formulary Drugs Starting with the Letter C in CMS PDP Region 15 which includes: IN KY Plan Monthly Premium: $37.20 Deductible: $320 Qualifies for LIS: No
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 0.005% CREAM	4	Non-Preferred Brand	33%	33%	Q:120 /30Days
Calcipotriene 50ug/g 60 g per CARTON	4	Non-Preferred Brand	33%	33%	Q:120 /30Days
CALCIPOTRIENE TOPICAL SOLUTION	3	Preferred Brand	$29.00	$87.00	Q:60 /30Days
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY	2	Non-Preferred Generic	$6.00	$12.00	Q:4 /30Days
CALCITRIOL 0.25MCG CAPSULE	2	Non-Preferred Generic	$6.00	$12.00	P
CALCITRIOL 0.5MCG CAPSULE	2	Non-Preferred Generic	$6.00	$12.00	P
Calcitriol 1 mcg/ml ampul	4	Non-Preferred Brand	33%	33%	P
CALCITRIOL 1MCG/ML SOLUTION ORAL	3	Preferred Brand	$29.00	$87.00	P
CALCIUM ACETATE CAPSULE 667 MG	2	Non-Preferred Generic	$6.00	$12.00	None
CAMILA 0.35MG TABLET	2	Non-Preferred Generic	$6.00	$12.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CANASA RECTAL SUPPOSITORIES 1000MG 30 BOX	4	Non-Preferred Brand	33%	33%	None
CANCIDAS IV 50MG VIAL	5	Specialty Tier	25%	N/A	P
CANCIDAS IV 70MG VIAL	5	Specialty Tier	25%	N/A	P
CANDESARTAN CILEXETIL 16 MG TABLET [Atacand]	2	Non-Preferred Generic	$6.00	$12.00	Q:60 /30Days
CANDESARTAN CILEXETIL 32 MG TABLET [Atacand]	2	Non-Preferred Generic	$6.00	$12.00	Q:30 /30Days
CANDESARTAN CILEXETIL 4 MG TABLET [Atacand]	2	Non-Preferred Generic	$6.00	$12.00	Q:60 /30Days
CANDESARTAN CILEXETIL 8 MG TABLET [Atacand]	2	Non-Preferred Generic	$6.00	$12.00	Q:60 /30Days
candesartan-hctz 16-12.5 mg tablet	2	Non-Preferred Generic	$6.00	$12.00	Q:60 /30Days
candesartan-hctz 32-12.5 mg tablet	2	Non-Preferred Generic	$6.00	$12.00	Q:30 /30Days
candesartan-hctz 32-25 mg	2	Non-Preferred Generic	$6.00	$12.00	Q:30 /30Days
CAPASTAT SULFATE 1g/1 1 INJECTION, POWDER, FOR SOLUTION per CARTON	4	Non-Preferred Brand	33%	33%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CAPRELSA 100mg/1 30 TABLET BOTTLE	5	Specialty Tier	25%	N/A	P
CAPRELSA 300mg/1 30 TABLET BOTTLE	5	Specialty Tier	25%	N/A	P
CAPTOPRIL 100MG TABLET	1*	Preferred Generic	$1.00	$2.00	None
CAPTOPRIL 12.5MG TABLET	1*	Preferred Generic	$1.00	$2.00	None
CAPTOPRIL 25MG TABLET	1*	Preferred Generic	$1.00	$2.00	None
CAPTOPRIL 50MG TABLET	1*	Preferred Generic	$1.00	$2.00	None
Captopril and Hydrochlorothiazide 25; 15mg 100 TABLET BOTTLE	1*	Preferred Generic	$1.00	$2.00	None
Captopril and Hydrochlorothiazide 25; 25mg 100 TABLET BOTTLE	1*	Preferred Generic	$1.00	$2.00	None
Captopril and Hydrochlorothiazide 50; 15mg 100 TABLET BOTTLE	1*	Preferred Generic	$1.00	$2.00	None
Captopril and Hydrochlorothiazide 50; 25mg 100 TABLET BOTTLE	1*	Preferred Generic	$1.00	$2.00	None
CARBAMAZEPINE 100 MG/5 ML SUSP	3	Preferred Brand	$29.00	$87.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Carbamazepine 100mg, CHEWABLE 100 TABLET BOTTLE	3	Preferred Brand	$29.00	$87.00	None
Carbamazepine 100mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE	3	Preferred Brand	$29.00	$87.00	None
Carbamazepine 200mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE	3	Preferred Brand	$29.00	$87.00	None
Carbamazepine 300mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE	3	Preferred Brand	$29.00	$87.00	None
CARBAMAZEPINE TABLET USP 200MG (1000 CT)	3	Preferred Brand	$29.00	$87.00	None
CARBAMAZEPINE XR 200 MG TABLET	3	Preferred Brand	$29.00	$87.00	None
CARBAMAZEPINE XR 400 MG TABLET	3	Preferred Brand	$29.00	$87.00	None
CARBIDOPA AND LEVEDOPA ORALLY DISINTEGRATING TABLETS 10;100MG;MG 100 BOT	3	Preferred Brand	$29.00	$87.00	None
Carbidopa and Levodopa 25; 100mg/1; mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, EXTENDED	3	Preferred Brand	$29.00	$87.00	None
Carbidopa and Levodopa 50; 200mg/1; mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, EXTENDED	3	Preferred Brand	$29.00	$87.00	None
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;100MG;MG 100 BOT	3	Preferred Brand	$29.00	$87.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;250MG;MG 100 BOT	3	Preferred Brand	$29.00	$87.00	None
CARBIDOPA/LEVO 10/100 TABLET	3	Preferred Brand	$29.00	$87.00	None
CARBIDOPA/LEVO 25/100 TABLET	3	Preferred Brand	$29.00	$87.00	None
CARBIDOPA/LEVO 25/250 TABLET	3	Preferred Brand	$29.00	$87.00	None
Carboplatin 10mg/mL	4	Non-Preferred Brand	33%	33%	P
CARIMUNE NF 6GM VIAL	5	Specialty Tier	25%	N/A	P
CARTEOLOL HCL OPHTHALMIC SOLUTION USP 1% 15ML BOT	1*	Preferred Generic	$1.00	$2.00	None
CARTIA XT 120MG CAPSULE SA	2	Non-Preferred Generic	$6.00	$12.00	None
CARTIA XT 180MG CAPSULE SA	2	Non-Preferred Generic	$6.00	$12.00	None
CARTIA XT 240MG CAPSULE SA	2	Non-Preferred Generic	$6.00	$12.00	None
CARTIA XT 300MG CAPSULE SR 24 HR	2	Non-Preferred Generic	$6.00	$12.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Carvedilol 12.5mg 100 FILM COATED TABLETS in BOTTLE, PLASTIC	1*	Preferred Generic	$1.00	$2.00	None
Carvedilol 25mg 100 FILM COATED TABLETS in BOTTLE, PLASTIC	1*	Preferred Generic	$1.00	$2.00	None
Carvedilol 3.125mg 100 FILM COATED TABLETS in BOTTLE, PLASTIC	1*	Preferred Generic	$1.00	$2.00	None
Carvedilol 6.25mg 100 FILM COATED TABLETS in BOTTLE, PLASTIC	1*	Preferred Generic	$1.00	$2.00	None
CAYSTON KIT 75 MG/VIAL	5	Specialty Tier	25%	N/A	P
CEFACLOR 125 MG/5 ML SUSP	2	Non-Preferred Generic	$6.00	$12.00	None
CEFACLOR 250 MG CAPSULES	2	Non-Preferred Generic	$6.00	$12.00	None
CEFACLOR 250 MG/5 ML SUSP	2	Non-Preferred Generic	$6.00	$12.00	None
CEFACLOR 375 MG/5 ML SUSPEN	2	Non-Preferred Generic	$6.00	$12.00	None
CEFACLOR 500 MG CAPSULES	3	Preferred Brand	$29.00	$87.00	None
CEFACLOR ER 500MG TABLET SR 12HR	2	Non-Preferred Generic	$6.00	$12.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CEFADROXIL 1G TABLET	3	Preferred Brand	$29.00	$87.00	None
CEFADROXIL 250 MG/5 ML SUSP	2	Non-Preferred Generic	$6.00	$12.00	None
Cefadroxil 500mg/1 100 CAPSULE BOTTLE	2	Non-Preferred Generic	$6.00	$12.00	None
Cefadroxil 500mg/5mL	2	Non-Preferred Generic	$6.00	$12.00	None
CEFAZOLIN 1 GM VIAL	4	Non-Preferred Brand	33%	33%	None
Cefazolin 10g/1 10 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 PACKAGE	4	Non-Preferred Brand	33%	33%	None
CEFAZOLIN 1GM/D5W BAG	4	Non-Preferred Brand	33%	33%	None
CEFAZOLIN 500MG FOR INJECTION	4	Non-Preferred Brand	33%	33%	None
CEFDINIR 250MG/5ML SUSPENSION RECONSTITUTED ORAL	3	Preferred Brand	$29.00	$87.00	None
CEFDINIR CAPSULES 300MG (60 CT)	3	Preferred Brand	$29.00	$87.00	None
CEFDINIR FOR ORAL SUSPENSION 125MG/5ML (100 CT)	3	Preferred Brand	$29.00	$87.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CEFEPIME HCL 2 GRAM VIAL	4	Non-Preferred Brand	33%	33%	None
CEFEPIME INJ 1GM 20ML APX 10x1G VIAL	4	Non-Preferred Brand	33%	33%	None
Cefotaxime sodium 1 gm vial	4	Non-Preferred Brand	33%	33%	None
Cefotaxime sodium 2 gm vial	4	Non-Preferred Brand	33%	33%	None
Cefotaxime sodium 500 mg vial	4	Non-Preferred Brand	33%	33%	None
Cefoxitin 1g/1 10 POWDER per CARTON	4	Non-Preferred Brand	33%	33%	None
Cefoxitin 2g/1 10 POWDER per CARTON	4	Non-Preferred Brand	33%	33%	None
CEFOXITIN FOR INJECTION SOLUTION	4	Non-Preferred Brand	33%	33%	None
CEFPODOXIME 100 MG/5 ML SUSP	4	Non-Preferred Brand	33%	33%	None
CEFPODOXIME 200 MG TABLET	4	Non-Preferred Brand	33%	33%	None
CEFPODOXIME 50 MG/5 ML SUSP	4	Non-Preferred Brand	33%	33%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CEFPODOXIME PROXETIL FILM COATED TABLET 100MG (20 CT)	4	Non-Preferred Brand	33%	33%	None
cefprozil 125 mg/5 ml susp	4	Non-Preferred Brand	33%	33%	None
cefprozil 250 mg/5 ml susp	3	Preferred Brand	$29.00	$87.00	None
Cefprozil 250mg 100 FILM COATED TABLETS in BOTTLE	2	Non-Preferred Generic	$6.00	$12.00	None
CEFPROZIL TABLETS 500MG 100 BOT	3	Preferred Brand	$29.00	$87.00	None
CEFTRIAXONE 10GM VIAL	4	Non-Preferred Brand	33%	33%	None
CEFTRIAXONE 250 MG VIAL	4	Non-Preferred Brand	33%	33%	None
CEFTRIAXONE FOR INJECTION	4	Non-Preferred Brand	33%	33%	None
CEFTRIAXONE FOR INJECTION	4	Non-Preferred Brand	33%	33%	None
Ceftriaxone Sodium 500mg	4	Non-Preferred Brand	33%	33%	None
CEFUROXIME 1.5 GM/VIAL FOR INJECTION	4	Non-Preferred Brand	33%	33%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CEFUROXIME 7.5 GM FOR INJECTION	4	Non-Preferred Brand	33%	33%	None
CEFUROXIME 750 MG FOR INJECTION	4	Non-Preferred Brand	33%	33%	None
Cefuroxime Axetil 250 MG	2	Non-Preferred Generic	$6.00	$12.00	None
Cefuroxime Axetil 500mg	2	Non-Preferred Generic	$6.00	$12.00	None
CELLCEPT 200 MG/ML ORAL SUSP	5	Specialty Tier	25%	N/A	P
CELLCEPT IV INJ 500 MG	4	Non-Preferred Brand	33%	33%	P
CELONTIN 300 MG KAPSEAL	4	Non-Preferred Brand	33%	33%	None
Cephalexin 125mg/5mL 200 mL in 1 BOTTLE	2	Non-Preferred Generic	$6.00	$12.00	None
CEPHALEXIN 250 MG CAPSULE	2	Non-Preferred Generic	$6.00	$12.00	None
CEPHALEXIN 250 MG TABLET	2	Non-Preferred Generic	$6.00	$12.00	None
CEPHALEXIN 250 MG/5ML ORAL SUSP	2	Non-Preferred Generic	$6.00	$12.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CEPHALEXIN 500 MG TABLET	2	Non-Preferred Generic	$6.00	$12.00	None
CEPHALEXIN CAPSULES 500 MG (500 CT)	2	Non-Preferred Generic	$6.00	$12.00	None
CEREZYME 400 UNITS VIAL	5	Specialty Tier	25%	N/A	P
CERVARIX VACCINE SYRINGE	3	Preferred Brand	$29.00	$87.00	None
CHANTIX 0.5 MG TABLET	4	Non-Preferred Brand	33%	33%	P Q:60 /30Days
CHANTIX 1 KIT per CARTON	4	Non-Preferred Brand	33%	33%	P Q:53 /365Days
CHANTIX 1 MG TABLET	4	Non-Preferred Brand	33%	33%	P Q:60 /30Days
Chantix 1.0mg/1 56 FILM COATED TABLETS in BOX	4	Non-Preferred Brand	33%	33%	P Q:56 /28Days
CHLORAMPHEN NA SUCC 1GM VL	4	Non-Preferred Brand	33%	33%	None
CHLORHEXIDINE GLUCONATE 0.12% MOUTHWASH	1*	Preferred Generic	$1.00	$2.00	None
CHLOROQUINE PH 500 MG TABLET	2	Non-Preferred Generic	$6.00	$12.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CHLOROQUINE PHOSPHATE 250 MG TABLET (50 CT)	2	Non-Preferred Generic	$6.00	$12.00	None
CHLOROTHIAZIDE 250 MG TABLET	1*	Preferred Generic	$1.00	$2.00	None
Chlorothiazide 500mg 100 TABLET BOTTLE	1*	Preferred Generic	$1.00	$2.00	None
CHLORPROMAZINE 10 MG TABLET	2	Non-Preferred Generic	$6.00	$12.00	P
CHLORPROMAZINE 25 MG TABLET	2	Non-Preferred Generic	$6.00	$12.00	P
CHLORPROMAZINE 25 MG/ML AMP	4	Non-Preferred Brand	33%	33%	P
CHLORPROMAZINE 50 MG TABLET	2	Non-Preferred Generic	$6.00	$12.00	P
CHLORPROMAZINE HCL 200 MG TABLET	3	Preferred Brand	$29.00	$87.00	P
Chlorpromazine Hydrochloride 100mg SUGAR COATED 1000 TABLET BOTTLE	3	Preferred Brand	$29.00	$87.00	P
CHLORTHALIDONE 25 MG TABLET (100 CT)	1*	Preferred Generic	$1.00	$2.00	None
CHLORTHALIDONE 50 MG TABLET (1000 CT)	2	Non-Preferred Generic	$6.00	$12.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CHOLESTYRAMINE LIGHT POWDER FOR ORAL SUSPENSION	2	Non-Preferred Generic	$6.00	$12.00	None
Cialis 2.5mg/1 2 BLISTER PACK per CARTON / 15 FILM COATED TABLETS in BLISTER PACK	4	Non-Preferred Brand	33%	33%	P Q:30 /30Days
Cialis 5mg/1 30 FILM COATED TABLETS in BOTTLE	4	Non-Preferred Brand	33%	33%	P Q:30 /30Days
CICLOPIROX 1% SHAMPOO	3	Preferred Brand	$29.00	$87.00	None
Ciclopirox 7.7mg/mL 60 mL in 1 BOTTLE	3	Preferred Brand	$29.00	$87.00	None
CICLOPIROX 8% TOPICAL SOLUTION NAIL LACQUER 6.6 ML BOT	3	Preferred Brand	$29.00	$87.00	P
CICLOPIROX GEL	3	Preferred Brand	$29.00	$87.00	None
Ciclopirox Olamine 7.7mg/g 1 TUBE in 1 TUBE / 15 g in 1 TUBE	3	Preferred Brand	$29.00	$87.00	None
cidofovir 375 mg/5 ml vial [Vistide]	5	Specialty Tier	25%	N/A	P
Cilostazol 50mg/1 60 TABLET BOTTLE	2	Non-Preferred Generic	$6.00	$12.00	None
CILOSTAZOL TABLET 100MG (60 CT)	2	Non-Preferred Generic	$6.00	$12.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Cimzia 2 KIT per CARTON / 1 KIT in 1 KIT	5	Specialty Tier	25%	N/A	P Q:6 /28Days
CIMZIA 200 MG/ML SYRINGE KIT	5	Specialty Tier	25%	N/A	P Q:6 /28Days
CIPRODEX OTIC SUSPENSION	4	Non-Preferred Brand	33%	33%	None
CIPROFLOXACIN 0.3% EYE DROP	2	Non-Preferred Generic	$6.00	$12.00	None
CIPROFLOXACIN 250 MG TABLET (100 CT)	2	Non-Preferred Generic	$6.00	$12.00	None
Ciprofloxacin 400mg/40mL 1 VIAL per CARTON / 40 mL in 1 VIAL	4	Non-Preferred Brand	33%	33%	None
Ciprofloxacin and Dextrose 2mg/mL 24 BAG in 1 CASE / 100 mL in 1 BAG	4	Non-Preferred Brand	33%	33%	None
CIPROFLOXACIN HCL 100 MG TABLET	2	Non-Preferred Generic	$6.00	$12.00	None
CIPROFLOXACIN HCL 500 MG TAB	2	Non-Preferred Generic	$6.00	$12.00	None
CIPROFLOXACIN TABLETS 750 MG 100 BOT	2	Non-Preferred Generic	$6.00	$12.00	None
Cisplatin 100mg/100mL 1 VIAL per CARTON / 100 mL in 1 VIAL	4	Non-Preferred Brand	33%	33%	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	$1.00	$2.00	Q:60 /30Days
CITALOPRAM HBR ORAL SOLUTION 10MG 240 ML BOTPL	2	Non-Preferred Generic	$6.00	$12.00	Q:600 /30Days
CITALOPRAM HYDROBROMIDE TABLETS 40 MG 30 BOT	1*	Preferred Generic	$1.00	$2.00	Q:30 /30Days
CITOLOPRAM HBR 10 MG TABLET (100 CT)	1*	Preferred Generic	$1.00	$2.00	Q:120 /30Days
Cladribine 10 mg/10 ml vial	5	Specialty Tier	25%	N/A	P
CLARITHROMYCIN 125 MG/5ML FOR ORAL SUSPENSION	3	Preferred Brand	$29.00	$87.00	None
CLARITHROMYCIN 250 MG TABLET	3	Preferred Brand	$29.00	$87.00	None
CLARITHROMYCIN 250 MG/5MLFOR ORAL SUSPENSION	3	Preferred Brand	$29.00	$87.00	None
CLARITHROMYCIN 500 MG TABLET	3	Preferred Brand	$29.00	$87.00	None
CLARITHROMYCIN ER 500 MG TABLET (60 CT)	3	Preferred Brand	$29.00	$87.00	Q:28 /1Days
CLEMASTINE FUM 2.68 MG TABLET	3	Preferred Brand	$29.00	$87.00	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CLINDAMYCIN 150MG/ML ADDVAN	4	Non-Preferred Brand	33%	33%	None
CLINDAMYCIN HCL 150 MG CAPSULE	2	Non-Preferred Generic	$6.00	$12.00	None
CLINDAMYCIN HCL 300 MG 100 CAPSULE in 1 BOTTLE	2	Non-Preferred Generic	$6.00	$12.00	None
CLINDAMYCIN HCL 75 MG 200 CAPSULE BOTTLE	2	Non-Preferred Generic	$6.00	$12.00	None
CLINDAMYCIN PHOSP 1% LOTION	2	Non-Preferred Generic	$6.00	$12.00	None
clindamycin phosphate 10mg/mL 1 BOTTLE per CARTON / 60 mL in 1 BOTTLE	2	Non-Preferred Generic	$6.00	$12.00	None
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE	2	Non-Preferred Generic	$6.00	$12.00	None
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX	2	Non-Preferred Generic	$6.00	$12.00	None
CLINDAMYCIN PHOSPHATE VAGINAL CREAM	3	Preferred Brand	$29.00	$87.00	None
clindamycin-d5w 300 mg/50 ml	4	Non-Preferred Brand	33%	33%	None
clindamycin-d5w 600 mg/50 ml	4	Non-Preferred Brand	33%	33%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
clindamycin-d5w 900 mg/50 ml	4	Non-Preferred Brand	33%	33%	None
CLOBETASOL 0.05% OINTMENT	2	Non-Preferred Generic	$6.00	$12.00	None
CLOBETASOL 0.05% SHAMPOO	3	Preferred Brand	$29.00	$87.00	None
CLOBETASOL 0.05% TOPICAL LOTION	3	Preferred Brand	$29.00	$87.00	None
CLOBETASOL E 0.05% CREAM	2	Non-Preferred Generic	$6.00	$12.00	None
Clobetasol Propionate 0.4625mg/mL 1 BOTTLE per CARTON / 50 mL in 1 BOTTLE	2	Non-Preferred Generic	$6.00	$12.00	None
Clobetasol Propionate 0.5mg/g 1 CAN per CARTON / 100 g in 1 CAN	3	Preferred Brand	$29.00	$87.00	None
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE	2	Non-Preferred Generic	$6.00	$12.00	None
CLOLAR 20 MG/20 ML VIAL	5	Specialty Tier	25%	N/A	P
CLOMIPRAMINE HCL 25MG CAPSULE	4	Non-Preferred Brand	33%	33%	P
CLOMIPRAMINE HCL 50MG CAPSULE	4	Non-Preferred Brand	33%	33%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CLOMIPRAMINE HCL 75MG CAPSULE	4	Non-Preferred Brand	33%	33%	P
Clonazepam 0.125mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PAC	4	Non-Preferred Brand	33%	33%	P Q:4800 /30Days
Clonazepam 0.25mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING per BLISTER PACK	4	Non-Preferred Brand	33%	33%	P Q:2400 /30Days
Clonazepam 0.5mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING per BLISTER PACK	4	Non-Preferred Brand	33%	33%	P Q:1200 /30Days
Clonazepam 0.5mg/1 100 TABLET BOTTLE	3	Preferred Brand	$29.00	$87.00	P Q:1200 /30Days
Clonazepam 1mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING per BLISTER PACK	4	Non-Preferred Brand	33%	33%	P Q:600 /30Days
Clonazepam 1mg/1 90 TABLET BOTTLE, PLASTIC	3	Preferred Brand	$29.00	$87.00	P Q:600 /30Days
Clonazepam 2mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING per BLISTER PACK	4	Non-Preferred Brand	33%	33%	P Q:300 /30Days
Clonazepam 2mg/1 100 TABLET BOTTLE	3	Preferred Brand	$29.00	$87.00	P Q:300 /30Days
CLONIDINE HCL 0.2MG TABLET (500 CT)	1*	Preferred Generic	$1.00	$2.00	None
CLONIDINE HCL TABLET 0.1MG (500 CT)	1*	Preferred Generic	$1.00	$2.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CLONIDINE HCL TABLET 0.3MG (100 CT)	1*	Preferred Generic	$1.00	$2.00	None
CLOPIDOGREL 300 MG TABLET [Plavix]	3	Preferred Brand	$29.00	$87.00	Q:1 /30Days
CLOPIDOGREL 75 MG TABLET [Plavix]	2	Non-Preferred Generic	$6.00	$12.00	Q:30 /30Days
CLORAZEPATE 15 MG TABLET	2	Non-Preferred Generic	$6.00	$12.00	Q:120 /30Days
Clorazepate Dipotassium 3.75mg/1 500 TABLET BOTTLE, PLASTIC	2	Non-Preferred Generic	$6.00	$12.00	Q:120 /30Days
Clorazepate Dipotassium 7.5mg/1 500 TABLET BOTTLE, PLASTIC	2	Non-Preferred Generic	$6.00	$12.00	Q:120 /30Days
CLOTRIMAZOLE 1% CREAM	2	Non-Preferred Generic	$6.00	$12.00	None
CLOTRIMAZOLE 10MG TROCHE	2	Non-Preferred Generic	$6.00	$12.00	None
CLOTRIMAZOLE SOLUTION TOPICAL 1% 30ML BOTPL	2	Non-Preferred Generic	$6.00	$12.00	None
CLOTRIMAZOLE-BETAMETHASONE 1-0.05% LOTION	3	Preferred Brand	$29.00	$87.00	None
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE 0.64; 10mg/g; mg/g 45 g in 1 TUBE	2	Non-Preferred Generic	$6.00	$12.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Clozapine 100mg/1 100 TABLET BOTTLE	3	Preferred Brand	$29.00	$87.00	Q:270 /30Days
CLOZAPINE 200MG TABLET (500 CT)	3	Preferred Brand	$29.00	$87.00	Q:135 /30Days
CLOZAPINE 25MG TABLET (100 CT)	3	Preferred Brand	$29.00	$87.00	Q:1080 /30Days
CLOZAPINE 50MG TABLET (500 CT)	3	Preferred Brand	$29.00	$87.00	Q:540 /30Days
CLOZAPINE ODT 100 MG TABLET	4	Non-Preferred Brand	33%	33%	Q:270 /30Days
CLOZAPINE ODT 12.5 MG TABLET	4	Non-Preferred Brand	33%	33%	Q:2160 /30Days
CLOZAPINE ODT 150 MG TABLET	4	Non-Preferred Brand	33%	33%	Q:180 /30Days
CLOZAPINE ODT 200 MG TABLET	4	Non-Preferred Brand	33%	33%	Q:135 /30Days
CLOZAPINE ODT 25 MG TABLET	4	Non-Preferred Brand	33%	33%	Q:1080 /30Days
COLCRYS 0.6 MG TABLET	3	Preferred Brand	$29.00	$87.00	None
COLESTIPOL HCL 1G TABLET	2	Non-Preferred Generic	$6.00	$12.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
COLESTIPOL HYDROCHLORIDE 5g/1 100 SUSPENSION in 1 BOTTLE	2	Non-Preferred Generic	$6.00	$12.00	None
colistimethate 150mg/2mL 1 VIAL per CARTON / 2 mL in 1 VIAL	4	Non-Preferred Brand	33%	33%	None
COLLAGENASE SANTYL OINTMENT 250UNT 30GM TUBE	4	Non-Preferred Brand	33%	33%	Q:30 /30Days
COMBIVENT RESPIMAT INHAL SPRAY	4	Non-Preferred Brand	33%	33%	Q:8 /30Days
COMETRIQ 100 MG DAILY-DOSE PK	5	Specialty Tier	25%	N/A	P
COMETRIQ 140 MG DAILY-DOSE PK	5	Specialty Tier	25%	N/A	P
COMETRIQ 60 MG DAILY-DOSE PACK	5	Specialty Tier	25%	N/A	P
COMPLERA 200; 27.5; 300mg/1; mg/1; mg/1	5	Specialty Tier	25%	N/A	None
COMPRO 25MG SUPPOSITORY	3	Preferred Brand	$29.00	$87.00	P
COMVAX VACCINE VIAL	3	Preferred Brand	$29.00	$87.00	None
CONSTULOSE 10 GM/15 ML SOLN	2	Non-Preferred Generic	$6.00	$12.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN	5	Specialty Tier	25%	N/A	P Q:30 /30Days
COPAXONE 40 MG/ML SYRINGE	5	Specialty Tier	25%	N/A	P Q:12 /28Days
COREG CR 10MG CAPSULE MULTIPHASIC RELEASE 24 HR	4	Non-Preferred Brand	33%	33%	S
COREG CR 20MG CAPSULE MULTIPHASIC RELEASE 24 HR	4	Non-Preferred Brand	33%	33%	S
COREG CR 40MG CAPSULE MULTIPHASIC RELEASE 24 HR	4	Non-Preferred Brand	33%	33%	S
COREG CR 80MG CAPSULE MULTIPHASIC RELEASE 24 HR	4	Non-Preferred Brand	33%	33%	S
CORMAX 0.05% SOLUTION	2	Non-Preferred Generic	$6.00	$12.00	None
Cortisone 25 MG Tablet	2	Non-Preferred Generic	$6.00	$12.00	None
COSMEGEN 0.5 MG VIAL	5	Specialty Tier	25%	N/A	P
COUMADIN 1 MG TABLET	4	Non-Preferred Brand	33%	33%	None
COUMADIN 10MG TABLET	4	Non-Preferred Brand	33%	33%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
COUMADIN 2.5MG TABLET	4	Non-Preferred Brand	33%	33%	None
COUMADIN 2MG TABLET	4	Non-Preferred Brand	33%	33%	None
COUMADIN 3mg/1 1 BOTTLE per CARTON / 100 TABLET BOTTLE	4	Non-Preferred Brand	33%	33%	None
COUMADIN 4mg/1 1 BOTTLE in 1 CARTON / 100 TABLET BOTTLE	4	Non-Preferred Brand	33%	33%	None
COUMADIN 5MG TABLET	4	Non-Preferred Brand	33%	33%	None
COUMADIN 6MG TABLET	4	Non-Preferred Brand	33%	33%	None
COUMADIN 7.5MG TABLET	4	Non-Preferred Brand	33%	33%	None
Creon 256.11mg/1 1 BOTTLE per CARTON / 70 CAPSULE, DELAYED RELEASE in 1 BOTTLE	3	Preferred Brand	$29.00	$87.00	None
CREON DELAYED RELEASE CAPSULES 12000MG 100 BOT	3	Preferred Brand	$29.00	$87.00	None
CREON DELAYED RELEASE CAPSULES 24000MG 100 BOT	3	Preferred Brand	$29.00	$87.00	None
CREON DELAYED RELEASE CAPSULES 6000MG 100 BOT	3	Preferred Brand	$29.00	$87.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CREON DR 36,000 UNITS CAPSULE	3	Preferred Brand	$29.00	$87.00	None
CRESTOR 10MG TABLET	3	Preferred Brand	$29.00	$87.00	Q:30 /30Days
CRESTOR 20MG TABLET	3	Preferred Brand	$29.00	$87.00	Q:30 /30Days
CRESTOR 40mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC	3	Preferred Brand	$29.00	$87.00	Q:30 /30Days
CRESTOR 5MG TABLET	3	Preferred Brand	$29.00	$87.00	Q:30 /30Days
CRIXIVAN 200MG CAPSULE	3	Preferred Brand	$29.00	$87.00	None
CRIXIVAN 400mg, 180 CAPSULE BOTTLE	3	Preferred Brand	$29.00	$87.00	None
CROMOLYN NEBULIZER SOLUTION 20MG/2ML	2	Non-Preferred Generic	$6.00	$12.00	P Q:240 /30Days
CROMOLYN SODIUM 100 MG/5 ML	4	Non-Preferred Brand	33%	33%	None
CROMOLYN SODIUM 4% 40MG 10ML BOT	2	Non-Preferred Generic	$6.00	$12.00	None
Cyclafem 1/35 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK	4	Non-Preferred Brand	33%	33%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Cyclafem 7/7/7 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK	4	Non-Preferred Brand	33%	33%	None
Cyclobenzaprine 7.5 mg tablet	4	Non-Preferred Brand	33%	33%	P
CYCLOBENZAPRINE HCL 10MG TABLET (1000 CT)	4	Non-Preferred Brand	33%	33%	P
Cyclobenzaprine Hydrochloride 5mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC	4	Non-Preferred Brand	33%	33%	P
CYCLOPHOSPHAMIDE 25 MG CAPSULE	4	Non-Preferred Brand	33%	33%	P
CYCLOPHOSPHAMIDE 50 MG CAPSULE	4	Non-Preferred Brand	33%	33%	P
CYCLOSET 0.8MG TABLETS	4	Non-Preferred Brand	33%	33%	S Q:180 /30Days
Cyclosporine 100mg 30 BLISTER PACK per CARTON / 1 CAPSULE, LIQUID FILLED per BLISTER PACK	3	Preferred Brand	$29.00	$87.00	P
CYCLOSPORINE 100MG CAPSULE	4	Non-Preferred Brand	33%	33%	P
Cyclosporine 25mg 30 BLISTER PACK per CARTON / 1 CAPSULE, LIQUID FILLED per BLISTER PACK	3	Preferred Brand	$29.00	$87.00	P
CYCLOSPORINE 25MG CAPSULE	3	Preferred Brand	$29.00	$87.00	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Cyclosporine 50 mg/ml vial	4	Non-Preferred Brand	33%	33%	P
Cyclosporine 50mg 30 BLISTER PACK per CARTON / 1 CAPSULE, LIQUID FILLED per BLISTER PACK	3	Preferred Brand	$29.00	$87.00	P
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT	3	Preferred Brand	$29.00	$87.00	P
CYSTADANE POWDER FOR ORAL SOLUTION 180GM	5	Specialty Tier	25%	N/A	None
CYSTAGON 150MG CAPSULE	3	Preferred Brand	$29.00	$87.00	None
CYSTAGON 50MG CAPSULE	3	Preferred Brand	$29.00	$87.00	None
CYTARABINE 20MG/ML VIAL	4	Non-Preferred Brand	33%	33%	P
CYTARABINE SOLUTION INJECTION 100MG 20ML VIALSD	4	Non-Preferred Brand	33%	33%	P

Chart Legend:

Below are a few notes to help you understand the above 2015 Medicare Part D Anthem Blue MedicareRx Standard (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.