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2016 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.

BlueMedicare Rx-Option 2 (PDP) (S5904-002-0)
Tier 1 (431)
Tier 2 (1445)
Tier 3 (284)
Tier 4 (1372)
Tier 5 (616)
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 
2016 Medicare Part D Plan Formulary Information
BlueMedicare Rx-Option 2 (PDP) (S5904-002-0)
Benefit Details           
The BlueMedicare Rx-Option 2 (PDP) (S5904-002-0)
Formulary Drugs Starting with the Letter A

in CMS PDP Region 11 which includes: FL
Plan Monthly Premium: $174.70 Deductible: $0 Qualifies for LIS: No
Drugs Starting with Letter A

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
ABACAVIR 300 MG TABLET   2 Generic $10.00$30.00Q:60
/30Days
Abacavir Sulfate-Lamivudine-Zidovudine tablets [Trizivir]   5 Specialty Tier 33%N/AQ:60
/30Days
ABILIFY 10MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
ABILIFY 15MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
ABILIFY 20MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
ABILIFY 2MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
ABILIFY 30MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
ABILIFY 5MG TABLET (OTSUKA)   5 Specialty Tier 33%N/AP Q:30
/30Days
ABILIFY MAINTENA ER 300 MG SYR   5 Specialty Tier 33%N/AP Q:1
/30Days
ABILIFY MAINTENA ER 300 MG VL   5 Specialty Tier 33%N/AP Q:1
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ABILIFY MAINTENA ER 400 MG SYR   5 Specialty Tier 33%N/AP Q:1
/30Days
ABRAXANE 100MG VIAL   5 Specialty Tier 33%N/ANone
ABSTRAL 100 MCG TAB SUBLINGUAL   5 Specialty Tier 33%N/AP Q:120
/30Days
ABSTRAL 200 MCG TAB SUBLINGUAL   5 Specialty Tier 33%N/AP Q:120
/30Days
ABSTRAL 300 MCG TAB SUBLINGUAL   5 Specialty Tier 33%N/AP Q:120
/30Days
ABSTRAL 400 MCG TAB SUBLINGUAL   5 Specialty Tier 33%N/AP Q:120
/30Days
ABSTRAL 600 MCG TAB SUBLINGUAL   5 Specialty Tier 33%N/AP Q:120
/30Days
ABSTRAL 800 MCG TAB SUBLINGUAL   5 Specialty Tier 33%N/AP Q:120
/30Days
Acamprosate Calcium DR 333 MG tablets [Campral]   2 Generic $10.00$30.00None
ACARBOSE 100 MG TABLET   2 Generic $10.00$30.00Q:90
/30Days
ACARBOSE 25 MG TABLET   2 Generic $10.00$30.00Q:360
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Acarbose 50mg/1 100 TABLET BOTTLE   2 Generic $10.00$30.00Q:180
/30Days
ACCOLATE 10 MG TABLET   4 Non-Preferred Brand $95.00$285.00None
ACCOLATE 20 MG TABLET   4 Non-Preferred Brand $95.00$285.00None
ACCUPRIL 10MG TABLET   4 Non-Preferred Brand $95.00$285.00None
ACCUPRIL 20MG TABLET   4 Non-Preferred Brand $95.00$285.00None
ACCUPRIL 40MG TABLET   4 Non-Preferred Brand $95.00$285.00None
ACCUPRIL 5MG TABLET   4 Non-Preferred Brand $95.00$285.00None
ACCURETIC 10-12.5MG TABLET   4 Non-Preferred Brand $95.00$285.00None
ACCURETIC 20-12.5MG TABLET   4 Non-Preferred Brand $95.00$285.00None
ACCURETIC 20-25MG TABLET   4 Non-Preferred Brand $95.00$285.00None
ACEBUTOLOL 200MG CAPSULE   2 Generic $10.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACEBUTOLOL 400MG CAPSULE   2 Generic $10.00$30.00None
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE   4 Non-Preferred Brand $95.00$285.00None
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD   1 Preferred Generic $3.00$9.00Q:2700
/30Days
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT)   1 Preferred Generic $3.00$9.00Q:360
/30Days
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT)   1 Preferred Generic $3.00$9.00Q:360
/30Days
ACETAMINOPHEN-COD #4 TABLET   1 Preferred Generic $3.00$9.00Q:180
/30Days
ACETASOL HC SOLUTION 10ML 10 ML BOT   2 Generic $10.00$30.00None
ACETAZOLAMIDE 125MG TABLET   4 Non-Preferred Brand $95.00$285.00None
ACETAZOLAMIDE 250MG TABLET (100 CT)   2 Generic $10.00$30.00None
ACETAZOLAMIDE ER CAPSULES 500MG 100 BOT   2 Generic $10.00$30.00None
ACETIC ACID 2% EAR SOLUTION   2 Generic $10.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETYLCYSTEINE 10% VIAL   2 Generic $10.00$30.00P
ACETYLCYSTEINE 20% VIAL   2 Generic $10.00$30.00P
ACITRETIN 10 MG CAPSULE [Soriatane]   5 Specialty Tier 33%N/ANone
ACITRETIN 17.5 MG CAPSULE [Soriatane]   5 Specialty Tier 33%N/ANone
ACITRETIN 25 MG CAPSULE [Soriatane]   5 Specialty Tier 33%N/ANone
ACTHIB VACCINE WITH DILUENT   4 Non-Preferred Brand $95.00$285.00None
ACTIGALL 300MG CAPSULE   4 Non-Preferred Brand $95.00$285.00None
ACTIMMUNE 100 MCG/0.5 ML VIAL   5 Specialty Tier 33%N/ANone
ACTOS 15 MG TABLET   4 Non-Preferred Brand $95.00$285.00Q:90
/30Days
Actos 30mg/90 Tablet Bottle   4 Non-Preferred Brand $95.00$285.00Q:30
/30Days
ACTOS 45MG TABLET   4 Non-Preferred Brand $95.00$285.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACULAR 0.5% EYE DROPS   4 Non-Preferred Brand $95.00$285.00None
ACULAR LS 0.4% OPHTH SOL   4 Non-Preferred Brand $95.00$285.00None
Acyclovir 200mg 100 CAPSULE BOTTLE   1 Preferred Generic $3.00$9.00None
Acyclovir 200mg/5mL 473 mL BOTTLE   2 Generic $10.00$30.00None
Acyclovir 400mg/1   2 Generic $10.00$30.00None
Acyclovir 5% Ointment   2 Generic $10.00$30.00None
ACYCLOVIR 800 MG TABLET   2 Generic $10.00$30.00None
Acyclovir sodium 500 mg vial   2 Generic $10.00$30.00P
ADACEL VIAL 2UNT/5UNT   4 Non-Preferred Brand $95.00$285.00None
ADAGEN 250U/ML VIAL   5 Specialty Tier 33%N/ANone
Adalat CC 30mg 100 FILM COATED TABLETS in BOTTLE   4 Non-Preferred Brand $95.00$285.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Adalat CC 60mg 1000 FILM COATED TABLETS in BOTTLE   4 Non-Preferred Brand $95.00$285.00None
Adalat CC 90mg 100 FILM COATED TABLETS in BOTTLE   4 Non-Preferred Brand $95.00$285.00None
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA]   5 Specialty Tier 33%N/AP
ADCIRCA TABLETS 20MG 60 BOTTLE   5 Specialty Tier 33%N/AP Q:60
/30Days
ADDERALL XR 10MG CAPSULE SA   4 Non-Preferred Brand $95.00$285.00Q:30
/30Days
ADDERALL XR 15MG CAPSULE SA   4 Non-Preferred Brand $95.00$285.00Q:30
/30Days
ADDERALL XR 20MG CAPSULE SA   4 Non-Preferred Brand $95.00$285.00Q:30
/30Days
ADDERALL XR 25MG CAPSULE SA   4 Non-Preferred Brand $95.00$285.00Q:30
/30Days
ADDERALL XR 30MG CAPSULE SA   4 Non-Preferred Brand $95.00$285.00Q:30
/30Days
ADDERALL XR 5MG CAPSULE SA   4 Non-Preferred Brand $95.00$285.00Q:30
/30Days
ADEFOVIR DIPIVOXIL 10 MG TAB [Hepsera]   5 Specialty Tier 33%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADEMPAS 0.5 MG TABLET   5 Specialty Tier 33%N/AP Q:90
/30Days
ADEMPAS 1 MG TABLET   5 Specialty Tier 33%N/AP Q:90
/30Days
ADEMPAS 1.5 MG TABLET   5 Specialty Tier 33%N/AP Q:90
/30Days
ADEMPAS 2 MG TABLET   5 Specialty Tier 33%N/AP Q:90
/30Days
ADEMPAS 2.5 MG TABLET   5 Specialty Tier 33%N/AP Q:90
/30Days
ADRUCIL 50mg/mL 10 VIAL in 1 TRAY / 10 mL in 1 VIAL   2 Generic $10.00$30.00P
ADVAIR DISKUS MIS 100/50   3 Preferred Brand $42.00$126.00Q:60
/30Days
ADVAIR DISKUS MIS 250/50   3 Preferred Brand $42.00$126.00Q:60
/30Days
ADVAIR DISKUS MIS 500/50   3 Preferred Brand $42.00$126.00Q:60
/30Days
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER   3 Preferred Brand $42.00$126.00Q:12
/30Days
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL   3 Preferred Brand $42.00$126.00Q:12
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL   3 Preferred Brand $42.00$126.00Q:12
/30Days
AFEDITAB CR 30MG TABLET SA   2 Generic $10.00$30.00None
AFEDITAB CR 60MG TABLET SA   2 Generic $10.00$30.00None
Afinitor 7.5mg/1 28 BLISTER PACK per CARTON / 1 TABLET per BLISTER PACK   5 Specialty Tier 33%N/AP Q:30
/30Days
AFINITOR DISPERZ 2 MG TABLET   5 Specialty Tier 33%N/AP Q:60
/30Days
AFINITOR DISPERZ 3 MG TABLET   5 Specialty Tier 33%N/AP Q:90
/30Days
AFINITOR DISPERZ 5 MG TABLET   5 Specialty Tier 33%N/AP Q:60
/30Days
AFINITOR TABLETS 10 MG   5 Specialty Tier 33%N/AP Q:30
/30Days
AFINITOR TABLETS 2.5 MG   5 Specialty Tier 33%N/AP Q:30
/30Days
AFINITOR TABLETS 5 MG   5 Specialty Tier 33%N/AP Q:30
/30Days
AGGRENOX 25-200MG CAPSULE   4 Non-Preferred Brand $95.00$285.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AGRYLIN 0.5MG CAPSULE   4 Non-Preferred Brand $95.00$285.00None
AK-CON 0.1% EYE DROPS   4 Non-Preferred Brand $95.00$285.00None
ALA-CORT 1% CREAM   1 Preferred Generic $3.00$9.00None
ALBENZA 200 MG TABLET   4 Non-Preferred Brand $95.00$285.00None
ALBUTEROL SULFATE 0.75mg/3mL 30 POUCH per CARTON / 1 VIAL, SINGLE-DOSE in 1 POUCH / 3 mL in 1 VIAL   2 Generic $10.00$30.00P
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER   2 Generic $10.00$30.00P
ALBUTEROL SULFATE 4MG TABLET SR 12HR   2 Generic $10.00$30.00None
ALBUTEROL SULFATE 8MG TABLET SR 12HR   2 Generic $10.00$30.00None
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   2 Generic $10.00$30.00P
ALBUTEROL SULFATE SOLUTION FOR INHALATION   2 Generic $10.00$30.00P
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT   1 Preferred Generic $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALBUTEROL SULFATE TABLET 2MG (500 CT)   2 Generic $10.00$30.00None
ALBUTEROL TABLET 4MG (500 CT)   2 Generic $10.00$30.00None
ALCLOMETASONE DIPROPIONATE 0.05% CREAM   2 Generic $10.00$30.00None
Alclometasone Dipropionate 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE   2 Generic $10.00$30.00None
ALDACTAZIDE 25/25 TABLET   4 Non-Preferred Brand $95.00$285.00None
ALDACTONE 100MG TABLET   4 Non-Preferred Brand $95.00$285.00None
ALDACTONE 25MG TABLET   4 Non-Preferred Brand $95.00$285.00None
ALDACTONE 50MG TABLET   4 Non-Preferred Brand $95.00$285.00None
ALDARA 5% CREAM   4 Non-Preferred Brand $95.00$285.00P
ALDURAZYME 2.9MG/5ML VIAL   5 Specialty Tier 33%N/ANone
ALECENSA 150 MG CAPSULE   5 Specialty Tier 33%N/AP Q:240
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALENDRONATE SODIUM 10MG TABLET   1 Preferred Generic $3.00$9.00Q:120
/30Days
ALENDRONATE SODIUM 35 MG TABLET   1 Preferred Generic $3.00$9.00Q:4
/28Days
ALENDRONATE SODIUM 5MG TABLET   1 Preferred Generic $3.00$9.00Q:30
/30Days
Alendronate Sodium 70mg/1 4 BLISTER PACK in 1 BOX / 1 TABLET in 1 BLISTER PACK   1 Preferred Generic $3.00$9.00Q:4
/28Days
ALFUZOSIN HYDROCHLORIDE 10mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE   2 Generic $10.00$30.00Q:30
/30Days
ALIMTA 500MG VIAL   5 Specialty Tier 33%N/ANone
ALINIA 100MG/5ML SUSPENSION   4 Non-Preferred Brand $95.00$285.00None
ALINIA 500 MG TABLET   4 Non-Preferred Brand $95.00$285.00None
ALLOPURINOL 100 MG TABLETS   1 Preferred Generic $3.00$9.00None
Allopurinol 300mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET per BLISTER PACK   1 Preferred Generic $3.00$9.00None
ALOPRIM SOLUTION FOR INJECTION 500MG/VIAL 30 ML VIALGL   4 Non-Preferred Brand $95.00$285.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALOSETRON HCL 0.5 MG TABLET [Lotronex]   5 Specialty Tier 33%N/ANone
ALOSETRON HCL 1 MG TABLET [Lotronex]   5 Specialty Tier 33%N/ANone
ALOXI 0.25 MG/5 ML   4 Non-Preferred Brand $95.00$285.00None
ALPHAGAN P 0.1% DROPS   4 Non-Preferred Brand $95.00$285.00None
ALPHAGAN P 0.15% EYE DROPS   4 Non-Preferred Brand $95.00$285.00None
ALTACE 1.25MG CAPSULE   4 Non-Preferred Brand $95.00$285.00None
ALTACE 10MG CAPSULE (100 CT)   4 Non-Preferred Brand $95.00$285.00None
ALTACE 2.5 MG CAPSULE   4 Non-Preferred Brand $95.00$285.00None
ALTACE 5MG CAPSULE   4 Non-Preferred Brand $95.00$285.00None
AMANTADINE 100MG CAPSULE   2 Generic $10.00$30.00None
AMANTADINE 100MG TABLET   4 Non-Preferred Brand $95.00$285.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Amantadine Hydrochloride 50mg/5mL 473 mL in 1 BOTTLE   2 Generic $10.00$30.00None
AMARYL 1MG TABLET   4 Non-Preferred Brand $95.00$285.00Q:240
/30Days
AMARYL 2MG TABLET   4 Non-Preferred Brand $95.00$285.00Q:120
/30Days
AMARYL 4MG TABLET   4 Non-Preferred Brand $95.00$285.00Q:60
/30Days
AMBISOME 50MG VIAL   5 Specialty Tier 33%N/AP
AMERGE 1MG TABLET   4 Non-Preferred Brand $95.00$285.00Q:18
/30Days
AMERGE 2.5MG TABLET   4 Non-Preferred Brand $95.00$285.00Q:18
/30Days
Amethia 2 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK   2 Generic $10.00$30.00None
Amethyst 20; 90ug/1; ug/1 1 BLISTER PACK per CARTON / 28 TABLET per BLISTER PACK   2 Generic $10.00$30.00None
AMIFOSTINE 50mg/mL 3 VIAL, SINGLE-USE per CARTON / 10 mL in 1 VIAL, SINGLE-USE   5 Specialty Tier 33%N/ANone
AMIKACIN SULFATE 500 MG/2 ML VIAL   2 Generic $10.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET   1 Preferred Generic $3.00$9.00None
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT   2 Generic $10.00$30.00None
Amino Acids 15% Solution   2 Generic $10.00$30.00P
AMINOSYN II 15% IV SOLUTION   4 Non-Preferred Brand $95.00$285.00P
AMIODARONE HCL 200MG 60 TABLET BOTTLE   1 Preferred Generic $3.00$9.00None
AMIODARONE HCL 400MG TABLET   1 Preferred Generic $3.00$9.00None
AMITIZA 8MCG CAPSULE   3 Preferred Brand $42.00$126.00P
AMITIZA CAPSULES 24MCG 60 CAP BOT   3 Preferred Brand $42.00$126.00P
AMITRIPTYLINE HCL 100MG TABLET   4 Non-Preferred Brand $95.00$285.00P
AMITRIPTYLINE HCL 10MG TABLET   4 Non-Preferred Brand $95.00$285.00P
AMITRIPTYLINE HCL 150 MG TAB   4 Non-Preferred Brand $95.00$285.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)   4 Non-Preferred Brand $95.00$285.00P
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)   4 Non-Preferred Brand $95.00$285.00P
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT   4 Non-Preferred Brand $95.00$285.00P
AMLOD-VALSA-HCTZ 10-160-12.5 MG [EXFORGE HCT]   2 Generic $10.00$30.00Q:30
/30Days
AMLOD-VALSA-HCTZ 10-160-25 MG [EXFORGE HCT]   2 Generic $10.00$30.00Q:30
/30Days
AMLOD-VALSA-HCTZ 10-320-25 MG [EXFORGE HCT]   2 Generic $10.00$30.00Q:30
/30Days
AMLOD-VALSA-HCTZ 5-160-12.5 MG [EXFORGE HCT]   2 Generic $10.00$30.00Q:30
/30Days
AMLOD-VALSA-HCTZ 5-160-25 MG [EXFORGE HCT]   2 Generic $10.00$30.00Q:30
/30Days
AMLODIPINE BESYLATE 10MG TABLET (90 CT)   1 Preferred Generic $3.00$9.00None
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)   1 Preferred Generic $3.00$9.00None
AMLODIPINE BESYLATE 5MG TABLET (90 CT)   1 Preferred Generic $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE   2 Generic $10.00$30.00None
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE   2 Generic $10.00$30.00None
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE   2 Generic $10.00$30.00None
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE   2 Generic $10.00$30.00None
Amlodipine-Atorvastatin 10-10 mg [Caduet]   2 Generic $10.00$30.00None
Amlodipine-Atorvastatin 10-20 mg [Caduet]   2 Generic $10.00$30.00None
Amlodipine-Atorvastatin 10-40 mg [Caduet]   2 Generic $10.00$30.00None
Amlodipine-Atorvastatin 10-80 mg [Caduet]   2 Generic $10.00$30.00None
Amlodipine-Atorvastatin 2.5-10 mg [Caduet]   2 Generic $10.00$30.00None
Amlodipine-Atorvastatin 2.5-20 mg [Caduet]   2 Generic $10.00$30.00None
Amlodipine-Atorvastatin 2.5-40 mg [Caduet]   2 Generic $10.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Amlodipine-Atorvastatin 5-10 mg [Caduet]   2 Generic $10.00$30.00None
Amlodipine-Atorvastatin 5-20 mg [Caduet]   2 Generic $10.00$30.00None
Amlodipine-Atorvastatin 5-40 mg [Caduet]   2 Generic $10.00$30.00None
Amlodipine-Atorvastatin 5-80 mg [Caduet]   2 Generic $10.00$30.00None
AMLODIPINE-BENAZEPRIL 10-40 MG   2 Generic $10.00$30.00None
AMLODIPINE-BENAZEPRIL 5-40 MG   2 Generic $10.00$30.00None
AMLODIPINE-VALSARTAN 10-160 MG   2 Generic $10.00$30.00Q:30
/30Days
AMLODIPINE-VALSARTAN 10-320 MG   2 Generic $10.00$30.00Q:30
/30Days
AMLODIPINE-VALSARTAN 5-160 MG   2 Generic $10.00$30.00Q:30
/30Days
AMLODIPINE-VALSARTAN 5-320 MG   2 Generic $10.00$30.00Q:30
/30Days
AMMONIUM LACTATE 12% CREAM   2 Generic $10.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMMONIUM LACTATE 12% LOTION   1 Preferred Generic $3.00$9.00None
AMOX TR-K CLV 500-125 MG TAB   2 Generic $10.00$30.00None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE   2 Generic $10.00$30.00None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET   2 Generic $10.00$30.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE   2 Generic $10.00$30.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   2 Generic $10.00$30.00None
AMOX-CLAV 200-28.5 MG/5 ML SUSPENSION   2 Generic $10.00$30.00None
AMOXAPINE 100MG TABLET   4 Non-Preferred Brand $95.00$285.00None
AMOXAPINE 150MG TABLET   4 Non-Preferred Brand $95.00$285.00None
AMOXAPINE 25MG TABLET   4 Non-Preferred Brand $95.00$285.00None
AMOXAPINE 50MG TABLET   4 Non-Preferred Brand $95.00$285.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN 250MG CAPSULE   1 Preferred Generic $3.00$9.00None
AMOXICILLIN 500MG 500 CAPSULE BOTTLE   1 Preferred Generic $3.00$9.00None
AMOXICILLIN 500MG TABLET (100 CT)   1 Preferred Generic $3.00$9.00None
AMOXICILLIN 875MG TABLET   1 Preferred Generic $3.00$9.00None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT   2 Generic $10.00$30.00None
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT   2 Generic $10.00$30.00None
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT   1 Preferred Generic $3.00$9.00None
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL   1 Preferred Generic $3.00$9.00None
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   1 Preferred Generic $3.00$9.00None
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL   1 Preferred Generic $3.00$9.00None
amphotericin b 50mg/10mL 10 mL in 1 VIAL   4 Non-Preferred Brand $95.00$285.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPICILLIN CAPSULES 250MG 100 BOT   1 Preferred Generic $3.00$9.00None
AMPICILLIN CAPSULES 500MG 100 BOT   1 Preferred Generic $3.00$9.00None
AMPICILLIN FOR INJECTION POWDER   2 Generic $10.00$30.00None
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT   4 Non-Preferred Brand $95.00$285.00None
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT   4 Non-Preferred Brand $95.00$285.00None
AMPICILLIN POWDER FOR INJECTION 1 GM/ML   2 Generic $10.00$30.00None
AMPICILLIN-SULBACTAM 3 GM VIAL   2 Generic $10.00$30.00None
AMPYRA ER 10 MG TABLET   5 Specialty Tier 33%N/AP
ANADROL-50 TABLET   5 Specialty Tier 33%N/AP
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE   2 Generic $10.00$30.00None
Anagrelide Hydrochloride 1mg/1 100 CAPSULE BOTTLE   2 Generic $10.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANAPROX DS 550MG TABLET   4 Non-Preferred Brand $95.00$285.00None
Anastrozole 1mg/1 90 FILM COATED TABLETS in BOTTLE, PLASTIC   1 Preferred Generic $3.00$9.00None
ANDRODERM 2 MG/24HR PATCH   3 Preferred Brand $42.00$126.00P Q:30
/30Days
ANDRODERM 4 MG/24HR PATCH   3 Preferred Brand $42.00$126.00P Q:30
/30Days
ANDROGEL 1.62% (1.25G) GEL PCKT   3 Preferred Brand $42.00$126.00P Q:38
/30Days
ANDROGEL 1.62% (2.5G) GEL PCKT   3 Preferred Brand $42.00$126.00P Q:150
/30Days
ANDROGEL 1% (50MG) GEL PACKET   3 Preferred Brand $42.00$126.00P Q:300
/30Days
Androgel 10mg/g 30 PACKET in 1 CARTON / 2.5 g in 1 PACKET   3 Preferred Brand $42.00$126.00P Q:225
/30Days
Androgel 16.2mg/g 1 BOTTLE, PUMP per CARTON / 88 g in 1 BOTTLE, PUMP   3 Preferred Brand $42.00$126.00P Q:150
/30Days
ANDROID 10 MG CAPSULE   4 Non-Preferred Brand $95.00$285.00P
ANDROID 10 MG CAPSULE   4 Non-Preferred Brand $95.00$285.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANORO ELLIPTA 62.5-25 MCG INH   3 Preferred Brand $42.00$126.00Q:60
/30Days
ANTABUSE 250MG TABLET   4 Non-Preferred Brand $95.00$285.00None
ANTABUSE 500MG TABLET   4 Non-Preferred Brand $95.00$285.00None
APOKYN 30 MG/3 ML CARTRIDGE   5 Specialty Tier 33%N/ANone
APRI 0.15-0.03 TABLET   2 Generic $10.00$30.00None
APRISO CP24   4 Non-Preferred Brand $95.00$285.00None
APTIOM 200 MG TABLET   4 Non-Preferred Brand $95.00$285.00None
APTIOM 400 MG TABLET   4 Non-Preferred Brand $95.00$285.00None
APTIOM 600 MG TABLET   4 Non-Preferred Brand $95.00$285.00None
APTIOM 800 MG TABLET   4 Non-Preferred Brand $95.00$285.00None
APTIVUS 250MG CAPSULE   5 Specialty Tier 33%N/AQ:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT   5 Specialty Tier 33%N/AQ:380
/30Days
ARANELLE 7-9-5 TABLET   1 Preferred Generic $3.00$9.00None
ARANESP 10 MCG/0.4 ML SYRINGE   4 Non-Preferred Brand $95.00$285.00P
ARANESP 100ug/0.5mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.5 mL in 1 SYRINGE   5 Specialty Tier 33%N/AP
ARANESP 100ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE   5 Specialty Tier 33%N/AP
ARANESP 200MCG/0.4ML SYRINGE   5 Specialty Tier 33%N/AP
ARANESP 200MCG/ML VIAL   5 Specialty Tier 33%N/AP
ARANESP 25ug/0.42mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.42 mL in 1 SYRING   4 Non-Preferred Brand $95.00$285.00P
ARANESP 25ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE   4 Non-Preferred Brand $95.00$285.00P
ARANESP 300MCG/ML VIAL   5 Specialty Tier 33%N/AP
ARANESP 500MCG/1ML SYRINGE   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP 60MCG/ML VIAL   4 Non-Preferred Brand $95.00$285.00P
ARANESP 60ug/0.3mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.3 mL in 1 SYRINGE   4 Non-Preferred Brand $95.00$285.00P
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR   5 Specialty Tier 33%N/AP
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR   5 Specialty Tier 33%N/AP
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR   4 Non-Preferred Brand $95.00$285.00P
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD   4 Non-Preferred Brand $95.00$285.00P
ARCALYST INJECTION 220MG/VIAL   5 Specialty Tier 33%N/AP
ARICEPT 10MG TABLET   4 Non-Preferred Brand $95.00$285.00None
ARICEPT 5MG TABLET   4 Non-Preferred Brand $95.00$285.00None
ARIMIDEX 1MG TABLET   4 Non-Preferred Brand $95.00$285.00None
ARIPIPRAZOLE 10 MG TABLET [Abilify]   5 Specialty Tier 33%N/AP Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARIPIPRAZOLE 15 MG TABLET [Abilify]   5 Specialty Tier 33%N/AP Q:30
/30Days
ARIPIPRAZOLE 2 MG TABLET [Abilify]   5 Specialty Tier 33%N/AP Q:30
/30Days
ARIPIPRAZOLE 20 MG TABLET [Abilify]   5 Specialty Tier 33%N/AP Q:30
/30Days
ARIPIPRAZOLE 30 MG TABLET [Abilify]   5 Specialty Tier 33%N/AP Q:30
/30Days
ARIPIPRAZOLE 5 MG TABLET [Abilify]   5 Specialty Tier 33%N/AP Q:30
/30Days
ARIPIPRAZOLE ODT 10 MG TABLET [Abilify]   5 Specialty Tier 33%N/AP Q:60
/30Days
ARIPIPRAZOLE ODT 15 MG TABLET [Abilify]   5 Specialty Tier 33%N/AP Q:60
/30Days
Armodafinil 150 MG TABLET [NUVIGIL]   2 Generic $10.00$30.00P Q:30
/30Days
Armodafinil 250 MG TABLET [NUVIGIL]   2 Generic $10.00$30.00P Q:30
/30Days
Armodafinil 50 MG TABLET [NUVIGIL]   2 Generic $10.00$30.00P Q:30
/30Days
ARNUITY ELLIPTA 100 MCG INH   3 Preferred Brand $42.00$126.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARNUITY ELLIPTA 200 MCG INH   3 Preferred Brand $42.00$126.00Q:30
/30Days
AROMASIN 25MG TABLET   4 Non-Preferred Brand $95.00$285.00None
ARRANON 250MG VIAL   5 Specialty Tier 33%N/ANone
ARTHROTEC 50 50MG TABLET -200MCG (60 CT)   4 Non-Preferred Brand $95.00$285.00None
ARTHROTEC 75 TABLET EC   4 Non-Preferred Brand $95.00$285.00None
ASACOL HD 800mg/1 12 BOTTLE CASE / 180 TABLET, DELAYED RELEASE in 1 BOTTLE   3 Preferred Brand $42.00$126.00None
ASCOMP WITH CODEINE CAPSULE   4 Non-Preferred Brand $95.00$285.00P Q:180
/30Days
Ashlyna 0.15-0.03-0.01 mg tablet   2 Generic $10.00$30.00None
ASMANEX HFA 100 MCG INHALER   3 Preferred Brand $42.00$126.00Q:13
/30Days
ASMANEX HFA 200 MCG INHALER   3 Preferred Brand $42.00$126.00Q:13
/30Days
ASMANEX TWISTHALER 110 MCG #30   3 Preferred Brand $42.00$126.00Q:1
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ASMANEX TWISTHALER 220 MCG #30   3 Preferred Brand $42.00$126.00Q:1
/30Days
ASMANEX TWISTHALER 220MCG #120   3 Preferred Brand $42.00$126.00Q:1
/30Days
ASMANEX TWISTHALER 220MCG #60   3 Preferred Brand $42.00$126.00Q:1
/30Days
ASPIRIN/BUTALBITAL/CAFFEINE/CODEINE   4 Non-Preferred Brand $95.00$285.00P Q:180
/30Days
ASTAGRAF XL 0.5 MG CAPSULE   4 Non-Preferred Brand $95.00$285.00P
ASTAGRAF XL 1 MG CAPSULE   4 Non-Preferred Brand $95.00$285.00P
ASTAGRAF XL 5 MG CAPSULE   4 Non-Preferred Brand $95.00$285.00P
ASTEPRO 0.15% NASAL SPRAY 30 ML   4 Non-Preferred Brand $95.00$285.00Q:60
/30Days
ATACAND 16MG TABLET   4 Non-Preferred Brand $95.00$285.00Q:60
/30Days
ATACAND 32MG TABLET   4 Non-Preferred Brand $95.00$285.00Q:30
/30Days
ATACAND 4MG TABLET   4 Non-Preferred Brand $95.00$285.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATACAND 8MG TABLET   4 Non-Preferred Brand $95.00$285.00Q:60
/30Days
ATACAND HCT 16/12.5MG TABLET   4 Non-Preferred Brand $95.00$285.00Q:30
/30Days
ATACAND HCT 32/12.5MG TABLET   4 Non-Preferred Brand $95.00$285.00Q:30
/30Days
ATACAND HCT TABLETS 32;25MG;MG 90 TABLET BOTTLE   4 Non-Preferred Brand $95.00$285.00Q:30
/30Days
Atelvia 35mg/1 36 DOSE PACK CASE / 4 TABLET, DELAYED RELEASE in 1 DOSE PACK   4 Non-Preferred Brand $95.00$285.00Q:4
/28Days
ATENOLOL 100 MG100 TABLET BOTTLE   1 Preferred Generic $3.00$9.00None
ATENOLOL 25 MG 100 TABLET BOTTLE   1 Preferred Generic $3.00$9.00None
ATENOLOL TABLET USP 50MG (100 CT)   1 Preferred Generic $3.00$9.00None
ATENOLOL-CHLORTHALIDONE 100-25   1 Preferred Generic $3.00$9.00None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   1 Preferred Generic $3.00$9.00None
ATGAM 50MG/ML AMPUL   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATORVASTATIN 10 MG TABLET [Lipitor]   1 Preferred Generic $3.00$9.00Q:45
/30Days
ATORVASTATIN 20 MG TABLET [Lipitor]   1 Preferred Generic $3.00$9.00Q:45
/30Days
ATORVASTATIN 40 MG TABLET [Lipitor]   1 Preferred Generic $3.00$9.00Q:45
/30Days
ATORVASTATIN 80 MG TABLET [Lipitor]   1 Preferred Generic $3.00$9.00Q:30
/30Days
ATOVAQUONE 750 MG/5 ML SUSP [Mepron]   5 Specialty Tier 33%N/ANone
Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone]   2 Generic $10.00$30.00None
Atovaquone-Proguanil 62.5-25 [Malarone]   2 Generic $10.00$30.00None
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC   5 Specialty Tier 33%N/AQ:30
/30Days
ATROVENT HFA AER 17MCG   4 Non-Preferred Brand $95.00$285.00Q:26
/30Days
ATROVENT NASAL SPRAY 0.03%   4 Non-Preferred Brand $95.00$285.00Q:60
/30Days
ATROVENT NASAL SPRAY 0.06%   4 Non-Preferred Brand $95.00$285.00Q:45
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AUBRA-28 TABLET   1 Preferred Generic $3.00$9.00None
AVALIDE 150-12.5 MG TABLET   4 Non-Preferred Brand $95.00$285.00Q:30
/30Days
AVALIDE 300-12.5 MG TABLET   4 Non-Preferred Brand $95.00$285.00Q:30
/30Days
AVAPRO 150 MG TABLET   4 Non-Preferred Brand $95.00$285.00Q:30
/30Days
AVAPRO 300 MG TABLET   4 Non-Preferred Brand $95.00$285.00Q:30
/30Days
AVAPRO 75 MG TABLET   4 Non-Preferred Brand $95.00$285.00Q:30
/30Days
AVASTIN 100MG/4ML VIAL   5 Specialty Tier 33%N/ANone
AVASTIN 400 MG/16 ML VIAL   5 Specialty Tier 33%N/ANone
AVELOX 400MG TABLET   4 Non-Preferred Brand $95.00$285.00None
AVELOX ABC PACK 400MG TABLET   4 Non-Preferred Brand $95.00$285.00None
AVELOX IV 400MG/250ML   3 Preferred Brand $42.00$126.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVIANE 0.1-0.02 TABLET   1 Preferred Generic $3.00$9.00None
AVITA 0.025% CREAM   2 Generic $10.00$30.00None
Avita 0.25mg/g 45 g in 1 TUBE   2 Generic $10.00$30.00None
AVODART 0.5MG SOFTGEL   4 Non-Preferred Brand $95.00$285.00Q:30
/30Days
AVONEX ADMIN PACK 30 MCG VL   5 Specialty Tier 33%N/AP Q:4
/28Days
AVONEX PEN 30 MCG/0.5 ML KIT   5 Specialty Tier 33%N/AP Q:1
/28Days
AVONEX PREFILLED SYR 30 MCG KT   5 Specialty Tier 33%N/AP Q:1
/28Days
AXIRON 30mg/1.5mL 1 BOTTLE, WITH APPLICATOR per CARTON / 90 mL in 1 BOTTLE, WITH APPLICATOR   4 Non-Preferred Brand $95.00$285.00P Q:180
/30Days
Aygestin 5mg/1 50 TABLET BOTTLE   4 Non-Preferred Brand $95.00$285.00None
Azacitidine 100 mg vial [Vidaza]   5 Specialty Tier 33%N/ANone
AZACTAM 1g/1 10 VIAL, SINGLE-DOSE in 1 CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, SINGLE   4 Non-Preferred Brand $95.00$285.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZACTAM INJECTION 1GM/50ML   4 Non-Preferred Brand $95.00$285.00None
AZACTAM INJECTION 2GM/50ML   4 Non-Preferred Brand $95.00$285.00None
AZASAN 100MG TABLET   4 Non-Preferred Brand $95.00$285.00P
AZASAN 75MG TABLET   4 Non-Preferred Brand $95.00$285.00P
AZATHIOPRINE 50 MG TABLET   2 Generic $10.00$30.00P
AZATHIOPRINE SODIUM 100 MG VIAL   4 Non-Preferred Brand $95.00$285.00P
AZELASTINE 0.15% NASAL SPRAY   2 Generic $10.00$30.00Q:60
/30Days
AZELASTINE 137 MCG NASAL SPRAY   2 Generic $10.00$30.00Q:60
/30Days
AZELASTINE HYDROCHLORIDE OPHTHALMIC SOLUTION   2 Generic $10.00$30.00None
AZELEX 20% CREAM 30GM TUBE   4 Non-Preferred Brand $95.00$285.00None
AZILECT 0.5MG TABLET   3 Preferred Brand $42.00$126.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZILECT 1MG TABLET   3 Preferred Brand $42.00$126.00None
AZITHROMYCIN 1 GM PWD PACKET   4 Non-Preferred Brand $95.00$285.00None
AZITHROMYCIN 100 MG/5 ML SUSP   2 Generic $10.00$30.00None
Azithromycin 200mg/5mL 22.5 mL in 1 BOTTLE   2 Generic $10.00$30.00None
AZITHROMYCIN 250 MG TABLET   1 Preferred Generic $3.00$9.00None
AZITHROMYCIN 250 MG TABLET   1 Preferred Generic $3.00$9.00None
Azithromycin 500mg/1 10 VIAL, SINGLE-USE in 1 TRAY / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION   2 Generic $10.00$30.00None
Azithromycin 500mg/1 30 FILM COATED TABLETS in BOTTLE   1 Preferred Generic $3.00$9.00None
Azithromycin 600mg/1 30 FILM COATED TABLETS in BOTTLE   1 Preferred Generic $3.00$9.00None
Azithromycin i.v. 500 mg vial   2 Generic $10.00$30.00None
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT   4 Non-Preferred Brand $95.00$285.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZTREONAM FOR INJECTION   2 Generic $10.00$30.00None
AZULFIDINE 500MG TABLET   4 Non-Preferred Brand $95.00$285.00None
AZULFIDINE EN TABLET S 500MG TABLET 6 X (300 CT)PL   4 Non-Preferred Brand $95.00$285.00None

Chart Legend:

Below are a few notes to help you understand the above 2016 Medicare Part D BlueMedicare Rx-Option 2 (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 $360 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 $3310) 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 2016 )

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 PDP-Compare.com and MA-Compare.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.
  • 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.