2017 Medicare Part D and Medicare Advantage Plan Formulary Browser

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Kaiser Permanente Medicare Plus Basic w/D (AB) (Cost) (H2150-033-0)

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2017 Medicare Part D Plan Formulary Information
Kaiser Permanente Medicare Plus Basic w/D (AB) (Cost) (H2150-033-0) Benefit Details
The Kaiser Permanente Medicare Plus Basic w/D (AB) (Cost) (H2150-033-0) Formulary Drugs Starting with the Letter A in District of Columbia County, DC: CMS MA Region 5 which includes: DC Plan Monthly Premium: $26.00 Deductible: $400
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	Tier 2	25%	N/A	None
Abacavir Sulfate-Lamivudine-Zidovudine tablets [Trizivir]	2	Tier 2	25%	N/A	None
ABACAVIR-LAMIVUDINE 600-300 MG [Epzicom]	2	Tier 2	25%	N/A	None
ABELCENT INJECTION SUSPENSION 5MG/ML	4	Tier 4	25%	N/A	None
ABILIFY 10MG TABLET	4	Tier 4	25%	N/A	None
ABILIFY 15MG TABLET	4	Tier 4	25%	N/A	None
ABILIFY 20MG TABLET	4	Tier 4	25%	N/A	None
ABILIFY 2MG TABLET	4	Tier 4	25%	N/A	None
ABILIFY 30MG TABLET	4	Tier 4	25%	N/A	None
ABILIFY 5MG TABLET (OTSUKA)	4	Tier 4	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ABILIFY MAINTENA ER 300 MG SYR	4	Tier 4	25%	N/A	None
ABILIFY MAINTENA ER 300 MG VL	4	Tier 4	25%	N/A	None
ABILIFY MAINTENA ER 400 MG SYR	4	Tier 4	25%	N/A	None
ABRAXANE 100MG VIAL	3	Tier 3	25%	N/A	None
ABSORICA 10 MG CAPSULE	4	Tier 4	25%	N/A	None
ABSORICA 20 MG CAPSULE	4	Tier 4	25%	N/A	None
ABSORICA 25 MG CAPSULE	4	Tier 4	25%	N/A	None
ABSORICA 30 MG CAPSULE	4	Tier 4	25%	N/A	None
ABSORICA 35 MG CAPSULE	4	Tier 4	25%	N/A	None
ABSORICA 40 MG CAPSULE	4	Tier 4	25%	N/A	None
ABSTRAL 100 MCG TAB SUBLINGUAL	4	Tier 4	25%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ABSTRAL 200 MCG TAB SUBLINGUAL	4	Tier 4	25%	N/A	P
ABSTRAL 300 MCG TAB SUBLINGUAL	4	Tier 4	25%	N/A	P
ABSTRAL 400 MCG TAB SUBLINGUAL	4	Tier 4	25%	N/A	P
ABSTRAL 600 MCG TAB SUBLINGUAL	4	Tier 4	25%	N/A	P
ABSTRAL 800 MCG TAB SUBLINGUAL	4	Tier 4	25%	N/A	P
Acamprosate Calcium DR 333 MG tablets [Campral]	2	Tier 2	25%	N/A	None
ACANYA 25; 10mg/g; mg/g 1 BOTTLE, PUMP per CARTON / 50 g in 1 BOTTLE, PUMP	4	Tier 4	25%	N/A	None
ACARBOSE 100 MG TABLET	2	Tier 2	25%	N/A	None
ACARBOSE 25 MG TABLET	2	Tier 2	25%	N/A	None
Acarbose 50mg/1 100 TABLET BOTTLE	2	Tier 2	25%	N/A	None
ACCOLATE 10 MG TABLET	4	Tier 4	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ACCOLATE 20 MG TABLET	4	Tier 4	25%	N/A	None
ACCUPRIL 10MG TABLET	4	Tier 4	25%	N/A	None
ACCUPRIL 20MG TABLET	4	Tier 4	25%	N/A	None
ACCUPRIL 40MG TABLET	4	Tier 4	25%	N/A	None
ACCUPRIL 5MG TABLET	4	Tier 4	25%	N/A	None
ACCURETIC 10-12.5MG TABLET	4	Tier 4	25%	N/A	None
ACCURETIC 20-12.5MG TABLET	4	Tier 4	25%	N/A	None
ACCURETIC 20-25MG TABLET	4	Tier 4	25%	N/A	None
ACEBUTOLOL 200MG CAPSULE	2	Tier 2	25%	N/A	None
ACEBUTOLOL 400MG CAPSULE	2	Tier 2	25%	N/A	None
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE	6	Tier 6	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ACETAMINOP-CODEINE 120-12 MG/5	2	Tier 2	25%	N/A	None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT)	2	Tier 2	25%	N/A	None
ACETAMINOPHEN-COD #3 TABLET	2	Tier 2	25%	N/A	None
ACETAMINOPHEN-COD #4 TABLET	2	Tier 2	25%	N/A	None
ACETASOL HC SOLUTION 10ML 10 ML BOT	2	Tier 2	25%	N/A	None
ACETAZOLAMIDE 125MG TABLET	2	Tier 2	25%	N/A	None
ACETAZOLAMIDE 250MG TABLET (100 CT)	2	Tier 2	25%	N/A	None
Acetazolamide 500mg/5mL 1 VIAL in 1 CARTON / 5 mL in 1 VIAL	2	Tier 2	25%	N/A	None
ACETAZOLAMIDE ER CAPSULES 500MG 100 BOT	2	Tier 2	25%	N/A	None
ACETIC ACID 2% EAR SOLUTION	2	Tier 2	25%	N/A	None
ACETYLCYSTEINE 10% VIAL	2	Tier 2	25%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ACETYLCYSTEINE 20% VIAL	2	Tier 2	25%	N/A	P
ACIPHEX 20MG TABLET EC	4	Tier 4	25%	N/A	None
ACIPHEX SPRINKLE DR 10 MG CAP	4	Tier 4	25%	N/A	None
ACIPHEX SPRINKLE DR 5 MG CAP	4	Tier 4	25%	N/A	None
ACITRETIN 10 MG CAPSULE [Soriatane]	2	Tier 2	25%	N/A	None
ACITRETIN 17.5 MG CAPSULE [Soriatane]	2	Tier 2	25%	N/A	None
ACITRETIN 25 MG CAPSULE [Soriatane]	2	Tier 2	25%	N/A	None
ACTEMRA 162 MG/0.9 ML SYRINGE	5	Tier 5	25%	N/A	None
ACTEMRA 400 MG/20 ML VIAL	4	Tier 4	25%	N/A	None
ACTEMRA 80 MG/4 ML VIAL	4	Tier 4	25%	N/A	None
ACTEMRA INJECTION 200MG/10ML	4	Tier 4	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ACTHIB VACCINE WITH DILUENT	6	Tier 6	25%	N/A	None
ACTIGALL 300MG CAPSULE	4	Tier 4	25%	N/A	None
ACTIMMUNE 100 MCG/0.5 ML VIAL	5	Tier 5	25%	N/A	None
ACTIQ 1200MCG LOZENGE	4	Tier 4	25%	N/A	P
ACTIQ 1600MCG LOZENGE	4	Tier 4	25%	N/A	P
ACTIQ 200MCG LOZENGE	4	Tier 4	25%	N/A	P
ACTIQ 400MCG LOZENGE	4	Tier 4	25%	N/A	P
ACTIQ 600MCG LOZENGE	4	Tier 4	25%	N/A	P
ACTIQ 800MCG LOZENGE	4	Tier 4	25%	N/A	P
ACTIVELLA 0.5-0.1 MG TABLET	4	Tier 4	25%	N/A	None
ACTIVELLA 1 MG-0.5 MG TABLET	4	Tier 4	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Actonel 150mg 36 DOSE PACK CASE / 1 TRAY DOSE PACK / 1 FILM COATED TABLETS in TRAY	4	Tier 4	25%	N/A	None
Actonel 30mg 12 BOTTLE CASE / 30 FILM COATED TABLETS in BOTTLE	4	Tier 4	25%	N/A	None
Actonel 35mg 36 DOSE PACK CASE / 1 TRAY DOSE PACK / 4 FILM COATED TABLETS in TRAY	4	Tier 4	25%	N/A	None
Actonel 5mg 12 BOTTLE CASE / 30 FILM COATED TABLETS in BOTTLE	4	Tier 4	25%	N/A	None
ACTOPLUS MET 15MG/500MG TABLET	4	Tier 4	25%	N/A	None
ACTOPLUS MET 15MG/850MG TABLET	4	Tier 4	25%	N/A	None
ACTOPLUS MET XR TABLETS ER 15;1000 MG;MG	4	Tier 4	25%	N/A	None
ACTOPLUS MET XR TABLETS ER 30;1000 MG;MG	4	Tier 4	25%	N/A	None
ACTOS 15 MG TABLET	4	Tier 4	25%	N/A	None
ACTOS 30 MG TABLET	4	Tier 4	25%	N/A	None
ACTOS 45 MG TABLET	4	Tier 4	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ACULAR 0.5% EYE DROPS	4	Tier 4	25%	N/A	None
ACULAR LS 0.4% OPHTH SOL	4	Tier 4	25%	N/A	None
ACUVAIL 0.45% OPHTH SOLUTION #30X0.4 EA	4	Tier 4	25%	N/A	None
Acyclovir 200mg 100 CAPSULE BOTTLE	2	Tier 2	25%	N/A	None
Acyclovir 200mg/5mL 473 mL BOTTLE	2	Tier 2	25%	N/A	None
Acyclovir 400mg/1	2	Tier 2	25%	N/A	None
Acyclovir 5% Ointment	2	Tier 2	25%	N/A	None
ACYCLOVIR 800 MG TABLET	2	Tier 2	25%	N/A	None
Acyclovir sodium 500 mg vial	2	Tier 2	25%	N/A	None
ACZONE 50mg/g 1 TUBE per CARTON / 60 g in 1 TUBE	4	Tier 4	25%	N/A	None
ADACEL VIAL 2UNT/5UNT	6	Tier 6	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ADAGEN 250U/ML VIAL	3	Tier 3	25%	N/A	None
ADALAT CC 30 MG TABLET	4	Tier 4	25%	N/A	None
Adalat CC 60mg 1000 FILM COATED TABLETS in BOTTLE	4	Tier 4	25%	N/A	None
ADALAT CC 90 MG TABLET	4	Tier 4	25%	N/A	None
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA]	5	Tier 5	25%	N/A	None
ADAPALENE 0.1% CREAM	2	Tier 2	25%	N/A	None
ADAPALENE 0.1% GEL	2	Tier 2	25%	N/A	None
Adapalene 0.3% gel	2	Tier 2	25%	N/A	None
ADCIRCA TABLETS 20MG 60 BOTTLE	5	Tier 5	25%	N/A	P
ADDERALL 20 MG TABLET	2	Tier 2	25%	N/A	None
ADDERALL 5 MG TABLET	2	Tier 2	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ADDERALL 7.5 MG TABLET	2	Tier 2	25%	N/A	None
ADDERALL XR 10MG CAPSULE SA	3	Tier 3	25%	N/A	None
ADDERALL XR 15MG CAPSULE SA	3	Tier 3	25%	N/A	None
ADDERALL XR 20MG CAPSULE SA	3	Tier 3	25%	N/A	None
ADDERALL XR 25MG CAPSULE SA	3	Tier 3	25%	N/A	None
ADDERALL XR 30MG CAPSULE SA	3	Tier 3	25%	N/A	None
ADDERALL XR 5MG CAPSULE SA	3	Tier 3	25%	N/A	None
ADEFOVIR DIPIVOXIL 10 MG TAB [Hepsera]	2	Tier 2	25%	N/A	None
ADEMPAS 0.5 MG TABLET	5	Tier 5	25%	N/A	None
ADEMPAS 1 MG TABLET	5	Tier 5	25%	N/A	None
ADEMPAS 1.5 MG TABLET	5	Tier 5	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ADEMPAS 2 MG TABLET	5	Tier 5	25%	N/A	None
ADEMPAS 2.5 MG TABLET	5	Tier 5	25%	N/A	None
ADLYXIN 10-20 MCG STARTER PACK	4	Tier 4	25%	N/A	None
ADLYXIN 20 MCG MAINTENANCE PK	4	Tier 4	25%	N/A	None
Adrenalin 1 mg/ml vial	4	Tier 4	25%	N/A	None
Adriamycin 20 mg/10 ml vial	2	Tier 2	25%	N/A	None
ADRUCIL 50mg/mL 10 VIAL in 1 TRAY / 10 mL in 1 VIAL	2	Tier 2	25%	N/A	None
ADVAIR DISKUS MIS 100/50	3	Tier 3	25%	N/A	None
ADVAIR DISKUS MIS 250/50	3	Tier 3	25%	N/A	None
ADVAIR DISKUS MIS 500/50	3	Tier 3	25%	N/A	None
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER	4	Tier 4	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL	4	Tier 4	25%	N/A	None
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL	4	Tier 4	25%	N/A	None
ADZENYS XR-ODT 12.5 MG TABLET	4	Tier 4	25%	N/A	None
ADZENYS XR-ODT 15.7 MG TABLET	4	Tier 4	25%	N/A	None
ADZENYS XR-ODT 18.8 MG TABLET	4	Tier 4	25%	N/A	None
ADZENYS XR-ODT 3.1 MG TABLET	4	Tier 4	25%	N/A	None
ADZENYS XR-ODT 6.3 MG TABLET	4	Tier 4	25%	N/A	None
ADZENYS XR-ODT 9.4 MG TABLET	4	Tier 4	25%	N/A	None
AEROSPAN 80 MCG INHALER	4	Tier 4	25%	N/A	None
AFEDITAB CR 30MG TABLET SA	2	Tier 2	25%	N/A	None
AFEDITAB CR 60MG TABLET SA	2	Tier 2	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Afinitor 7.5mg/1 28 BLISTER PACK per CARTON / 1 TABLET per BLISTER PACK	5	Tier 5	25%	N/A	None
AFINITOR DISPERZ 2 MG TABLET	5	Tier 5	25%	N/A	None
AFINITOR DISPERZ 3 MG TABLET	5	Tier 5	25%	N/A	None
AFINITOR DISPERZ 5 MG TABLET	5	Tier 5	25%	N/A	None
AFINITOR TABLETS 10 MG	5	Tier 5	25%	N/A	None
AFINITOR TABLETS 2.5 MG	5	Tier 5	25%	N/A	None
AFINITOR TABLETS 5 MG	5	Tier 5	25%	N/A	None
AFREZZA 30-4 UNIT + 60-8 UNIT	4	Tier 4	25%	N/A	None
AFREZZA 4 UNIT/8 UNIT/12 UNIT	4	Tier 4	25%	N/A	None
AFREZZA 4 UNITS CARTRIDGE INH	4	Tier 4	25%	N/A	None
AFREZZA 60-4 UNIT + 30-8 UNIT	4	Tier 4	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AFREZZA 60-8 UNIT + 30-12 UNIT	4	Tier 4	25%	N/A	None
AFREZZA 90-4 UNIT / 90-8 UNIT	4	Tier 4	25%	N/A	None
AGGRENOX 25-200MG CAPSULE	4	Tier 4	25%	N/A	None
AGRYLIN 0.5MG CAPSULE	4	Tier 4	25%	N/A	None
AIRDUO RESPICLICK 113-14 MCG	4	Tier 4	25%	N/A	None
AIRDUO RESPICLICK 232-14 MCG	4	Tier 4	25%	N/A	None
AIRDUO RESPICLICK 55-14 MCG	4	Tier 4	25%	N/A	None
AKYNZEO 300-0.5 MG CAPSULE	3	Tier 3	25%	N/A	P
ALA-CORT 1% CREAM	2	Tier 2	25%	N/A	None
Ala-cort 2.5% cream	2	Tier 2	25%	N/A	None
ALA-SCALP HP 2% LOTION	2	Tier 2	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ALBENZA 200 MG TABLET	3	Tier 3	25%	N/A	None
ALBUTEROL SULFATE 0.75mg/3mL 30 POUCH per CARTON / 1 VIAL, SINGLE-DOSE in 1 POUCH / 3 mL in 1 VIAL	2	Tier 2	25%	N/A	P
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER	2	Tier 2	25%	N/A	P
ALBUTEROL SULFATE 4MG TABLET SR 12HR	2	Tier 2	25%	N/A	None
ALBUTEROL SULFATE 8MG TABLET SR 12HR	2	Tier 2	25%	N/A	None
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR	1	Tier 1	25%	N/A	P
ALBUTEROL SULFATE SOLUTION FOR INHALATION	1	Tier 1	25%	N/A	P
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT	2	Tier 2	25%	N/A	None
ALBUTEROL SULFATE TABLET 2MG (500 CT)	2	Tier 2	25%	N/A	None
ALBUTEROL TABLET 4MG (500 CT)	2	Tier 2	25%	N/A	None
ALCLOMETASONE DIPROPIONATE 0.05% CREAM	2	Tier 2	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Alclometasone Dipropionate 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE	2	Tier 2	25%	N/A	None
ALDACTAZIDE 25/25 TABLET	4	Tier 4	25%	N/A	None
ALDACTAZIDE 50/50 TABLET	4	Tier 4	25%	N/A	None
ALDACTONE 100MG TABLET	4	Tier 4	25%	N/A	None
ALDACTONE 25MG TABLET	4	Tier 4	25%	N/A	None
ALDACTONE 50MG TABLET	4	Tier 4	25%	N/A	None
ALDARA 5% CREAM	4	Tier 4	25%	N/A	None
ALDURAZYME 2.9MG/5ML VIAL	3	Tier 3	25%	N/A	None
ALECENSA 150 MG CAPSULE	5	Tier 5	25%	N/A	None
ALENDRONATE SODIUM 10 MG TABLET	1	Tier 1	25%	N/A	None
ALENDRONATE SODIUM 35 MG TABLET	2	Tier 2	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ALENDRONATE SODIUM 40 MG TABLET	2	Tier 2	25%	N/A	None
ALENDRONATE SODIUM 5 MG TABLET	2	Tier 2	25%	N/A	None
ALENDRONATE SODIUM 70 MG TAB	1	Tier 1	25%	N/A	None
ALENDRONATE SODIUM 70 mg/75 ml	2	Tier 2	25%	N/A	None
ALFUZOSIN HYDROCHLORIDE 10mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE	2	Tier 2	25%	N/A	None
ALIMTA 500MG VIAL	3	Tier 3	25%	N/A	None
ALINIA 100 MG/5 ML SUSPENSION	3	Tier 3	25%	N/A	None
ALINIA 500 MG TABLET	3	Tier 3	25%	N/A	None
Aliskiren 150 MG / Hydrochlorothiazide 12.5 MG Oral Tablet [Tekturna HCT]	4	Tier 4	25%	N/A	None
Aliskiren 150 MG / Hydrochlorothiazide 25 MG Oral Tablet [Tekturna HCT]	4	Tier 4	25%	N/A	None
Aliskiren 300 MG / Hydrochlorothiazide 12.5 MG Oral Tablet [Tekturna HCT]	4	Tier 4	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ALKERAN 50 MG VIAL	4	Tier 4	25%	N/A	None
ALLOPURINOL 100 MG TABLETS	2	Tier 2	25%	N/A	None
Allopurinol 300mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET per BLISTER PACK	2	Tier 2	25%	N/A	None
Allopurinol sodium 500 mg vial	2	Tier 2	25%	N/A	None
ALLZITAL 25-325 MG TABLET	2	Tier 2	25%	N/A	None
ALMOTRIPTAN MALATE 12.5 MG TAB [Axert]	2	Tier 2	25%	N/A	None
ALMOTRIPTAN MALATE 6.25 MG TAB [Axert]	2	Tier 2	25%	N/A	None
ALOCRIL 2% EYE DROPS	4	Tier 4	25%	N/A	None
ALOGLIPTIN 12.5 MG TABLET [Nesina]	2	Tier 2	25%	N/A	None
ALOGLIPTIN 25 MG TABLET [Nesina]	2	Tier 2	25%	N/A	None
ALOGLIPTIN 6.25 MG TABLET [Nesina]	2	Tier 2	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ALOGLIPTIN-METFORMIN 12.5-1000 [Kazano]	4	Tier 4	25%	N/A	None
ALOGLIPTIN-METFORMIN 12.5-500 [Kazano]	4	Tier 4	25%	N/A	None
ALOGLIPTIN-PIOGLIT 12.5-15 MG [Oseni]	2	Tier 2	25%	N/A	None
ALOGLIPTIN-PIOGLIT 12.5-30 MG [Oseni]	2	Tier 2	25%	N/A	None
ALOGLIPTIN-PIOGLIT 12.5-45 MG [Oseni]	2	Tier 2	25%	N/A	None
ALOGLIPTIN-PIOGLIT 25-15 MG TABLET [Oseni]	2	Tier 2	25%	N/A	None
ALOGLIPTIN-PIOGLIT 25-30 MG TABLET [Oseni]	2	Tier 2	25%	N/A	None
ALOGLIPTIN-PIOGLIT 25-45 MG TABLET [Oseni]	2	Tier 2	25%	N/A	None
ALOMIDE 0.1% EYE DROPS	4	Tier 4	25%	N/A	None
ALOPRIM SOLUTION FOR INJECTION 500MG/VIAL 30 ML VIALGL	4	Tier 4	25%	N/A	None
ALORA 0.025 MG PATCH	4	Tier 4	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ALORA 0.05 MG PATCH	4	Tier 4	25%	N/A	None
ALORA 0.075 MG PATCH	4	Tier 4	25%	N/A	None
ALORA 0.1 MG PATCH	4	Tier 4	25%	N/A	None
ALOSETRON HCL 0.5 MG TABLET [Lotronex]	2	Tier 2	25%	N/A	None
ALOSETRON HCL 1 MG TABLET [Lotronex]	2	Tier 2	25%	N/A	None
ALOXI 0.25 MG/5 ML	4	Tier 4	25%	N/A	None
ALPHAGAN P 0.1% DROPS	4	Tier 4	25%	N/A	None
ALPHAGAN P 0.15% EYE DROPS	4	Tier 4	25%	N/A	None
ALPRAZOLAM 0.25 MG TABLET	2	Tier 2	25%	N/A	None
Alprazolam 0.25mg/1 10 BLISTER PACK per CARTON / 10 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PAC	2	Tier 2	25%	N/A	None
ALPRAZOLAM 0.5 MG TABLET	2	Tier 2	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Alprazolam 0.5mg/1 10 BLISTER PACK per CARTON / 10 TABLET, ORALLY DISINTEGRATING per BLISTER PACK	2	Tier 2	25%	N/A	None
ALPRAZOLAM 1 MG TABLET	2	Tier 2	25%	N/A	None
Alprazolam 1mg/1 10 BLISTER PACK per CARTON / 10 TABLET, ORALLY DISINTEGRATING per BLISTER PACK	2	Tier 2	25%	N/A	None
Alprazolam 1mg/mL 1 BOTTLE in 1 CONTAINER / 30 mL in 1 BOTTLE	2	Tier 2	25%	N/A	None
ALPRAZOLAM 2 MG TABLET	2	Tier 2	25%	N/A	None
Alprazolam 2mg/1 10 BLISTER PACK per CARTON / 10 TABLET, ORALLY DISINTEGRATING per BLISTER PACK	2	Tier 2	25%	N/A	None
ALPRAZOLAM ER 0.5 MG TABLET	2	Tier 2	25%	N/A	None
ALPRAZOLAM ER 1 MG TABLET	2	Tier 2	25%	N/A	None
ALPRAZOLAM ER 2 MG TABLET	2	Tier 2	25%	N/A	None
ALPRAZOLAM ER 3 MG TABLET	2	Tier 2	25%	N/A	None
ALREX 0.2% EYE DROPS	4	Tier 4	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ALTACE 1.25MG CAPSULE	4	Tier 4	25%	N/A	None
ALTACE 10MG CAPSULE (100 CT)	4	Tier 4	25%	N/A	None
ALTACE 2.5 MG CAPSULE	4	Tier 4	25%	N/A	None
ALTACE 5MG CAPSULE	4	Tier 4	25%	N/A	None
ALTOPREV 20 MG TABLET	4	Tier 4	25%	N/A	None
ALTOPREV 40MG TABLET SR 24HR	4	Tier 4	25%	N/A	None
ALTOPREV 60 MG TABLET	4	Tier 4	25%	N/A	None
ALUNBRIG 30 MG TABLET	5	Tier 5	25%	N/A	None
ALVESCO 160MCG/ACT AERS	4	Tier 4	25%	N/A	None
ALVESCO 80MCG/ACT AERS	4	Tier 4	25%	N/A	None
Alyacen 1-35-28 tablet	2	Tier 2	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Amabelz 0.5 mg-0.1 mg tablet	2	Tier 2	25%	N/A	None
Amabelz 1 mg-0.5 mg tablet	2	Tier 2	25%	N/A	None
AMANTADINE 100MG CAPSULE	2	Tier 2	25%	N/A	None
AMANTADINE 100MG TABLET	2	Tier 2	25%	N/A	None
Amantadine Hydrochloride 50mg/5mL 473 mL in 1 BOTTLE	2	Tier 2	25%	N/A	None
AMARYL 1MG TABLET	4	Tier 4	25%	N/A	None
AMARYL 2MG TABLET	4	Tier 4	25%	N/A	None
AMARYL 4MG TABLET	4	Tier 4	25%	N/A	None
AMBIEN 10 MG TABLET	4	Tier 4	25%	N/A	None
AMBIEN CR 12.5MG TABLET	4	Tier 4	25%	N/A	None
AMBIEN CR 6.25MG TABLET	4	Tier 4	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMBIEN TABLETS 5MG 100 BOTTLE	4	Tier 4	25%	N/A	None
AMBISOME 50MG VIAL	5	Tier 5	25%	N/A	None
AMCINONIDE 0.1% CREAM	2	Tier 2	25%	N/A	None
AMCINONIDE 0.1% LOTION	2	Tier 2	25%	N/A	None
AMCINONIDE 0.1% OINTMENT 60GM TUBE	2	Tier 2	25%	N/A	None
AMERGE 1MG TABLET	4	Tier 4	25%	N/A	None
AMERGE 2.5MG TABLET	4	Tier 4	25%	N/A	None
Amethia 0.15-0.03-0.01 mg tab	2	Tier 2	25%	N/A	None
Amethia lo tablet	2	Tier 2	25%	N/A	None
AMIKACIN SULFATE 500 MG/2 ML VIAL	2	Tier 2	25%	N/A	None
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET	1	Tier 1	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT	2	Tier 2	25%	N/A	None
Amino Acids 15% Solution	2	Tier 2	25%	N/A	None
Aminophylline 25mg/mL 5 TRAY per CARTON / 5 AMPULE in 1 TRAY / 10 mL in 1 AMPULE	2	Tier 2	25%	N/A	None
AMINOSYN 7%-ELECTROLYTE SOL	4	Tier 4	25%	N/A	None
AMINOSYN HBC INJECTION SULFITE FREE 7%	4	Tier 4	25%	N/A	None
AMINOSYN II 10% IV SOLUTION	4	Tier 4	25%	N/A	None
AMINOSYN II 15% IV SOLUTION	4	Tier 4	25%	N/A	None
AMINOSYN II 8.5% ELECTROLYT	2	Tier 2	25%	N/A	None
AMINOSYN II 8.5% ELECTROLYT	4	Tier 4	25%	N/A	None
AMINOSYN PF INJECTION	4	Tier 4	25%	N/A	None
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5%	2	Tier 2	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMINOSYN-PF 7% IV SOLUTION	4	Tier 4	25%	N/A	None
AMINOSYN-RF 5.2% IV SOLUTION	4	Tier 4	25%	N/A	None
Amiodarone 150 mg/3 ml ampule	2	Tier 2	25%	N/A	None
Amiodarone hcl 100 mg tablet	2	Tier 2	25%	N/A	None
AMIODARONE HCL 200 MG TABLET	2	Tier 2	25%	N/A	None
AMIODARONE HCL 400MG TABLET	2	Tier 2	25%	N/A	None
AMITIZA 8MCG CAPSULE	4	Tier 4	25%	N/A	None
AMITIZA CAPSULES 24MCG 60 CAP BOT	4	Tier 4	25%	N/A	None
AMITRIP/CDP 25-10 TABLET	2	Tier 2	25%	N/A	None
AMITRIP/PERPHEN 10-2 TABLET	2	Tier 2	25%	N/A	None
AMITRIP/PERPHEN 10-4 TABLET	2	Tier 2	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMITRIP/PERPHEN 25-2 TABLET	2	Tier 2	25%	N/A	None
AMITRIP/PERPHEN 25-4 TABLET	2	Tier 2	25%	N/A	None
AMITRIP/PERPHEN 50-4 TABLET	2	Tier 2	25%	N/A	None
AMITRIPTYLINE HCL 100MG TABLET	2	Tier 2	25%	N/A	None
AMITRIPTYLINE HCL 10MG TABLET	2	Tier 2	25%	N/A	None
AMITRIPTYLINE HCL 150 MG TAB	2	Tier 2	25%	N/A	None
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)	2	Tier 2	25%	N/A	None
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)	2	Tier 2	25%	N/A	None
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT	2	Tier 2	25%	N/A	None
AMLOD-VALSA-HCTZ 10-160-12.5 MG [EXFORGE HCT]	2	Tier 2	25%	N/A	None
AMLOD-VALSA-HCTZ 10-160-25 MG [EXFORGE HCT]	2	Tier 2	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMLOD-VALSA-HCTZ 10-320-25 MG [EXFORGE HCT]	2	Tier 2	25%	N/A	None
AMLOD-VALSA-HCTZ 5-160-12.5 MG [EXFORGE HCT]	2	Tier 2	25%	N/A	None
AMLOD-VALSA-HCTZ 5-160-25 MG [EXFORGE HCT]	2	Tier 2	25%	N/A	None
AMLODIPINE BESYLATE 10MG TABLET (90 CT)	1	Tier 1	25%	N/A	None
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)	1	Tier 1	25%	N/A	None
AMLODIPINE BESYLATE 5MG TABLET (90 CT)	1	Tier 1	25%	N/A	None
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE	2	Tier 2	25%	N/A	None
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE	2	Tier 2	25%	N/A	None
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE	2	Tier 2	25%	N/A	None
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE	2	Tier 2	25%	N/A	None
Amlodipine-Atorvastatin 10-10 mg [Caduet]	2	Tier 2	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Amlodipine-Atorvastatin 10-20 mg [Caduet]	2	Tier 2	25%	N/A	None
Amlodipine-Atorvastatin 10-40 mg [Caduet]	2	Tier 2	25%	N/A	None
Amlodipine-Atorvastatin 10-80 mg [Caduet]	2	Tier 2	25%	N/A	None
Amlodipine-Atorvastatin 2.5-10 mg [Caduet]	2	Tier 2	25%	N/A	None
Amlodipine-Atorvastatin 2.5-20 mg [Caduet]	2	Tier 2	25%	N/A	None
Amlodipine-Atorvastatin 2.5-40 mg [Caduet]	2	Tier 2	25%	N/A	None
Amlodipine-Atorvastatin 5-10 mg [Caduet]	2	Tier 2	25%	N/A	None
Amlodipine-Atorvastatin 5-20 mg [Caduet]	2	Tier 2	25%	N/A	None
Amlodipine-Atorvastatin 5-40 mg [Caduet]	2	Tier 2	25%	N/A	None
Amlodipine-Atorvastatin 5-80 mg [Caduet]	2	Tier 2	25%	N/A	None
AMLODIPINE-BENAZEPRIL 10-40 MG	2	Tier 2	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMLODIPINE-BENAZEPRIL 5-40 MG	2	Tier 2	25%	N/A	None
AMLODIPINE-OLMESARTAN 5-40 MG [Azor]	2	Tier 2	25%	N/A	None
Amlodipine-Olmesartan medoxomil 10 MG / 20 MG Oral Tablet [Azor]	2	Tier 2	25%	N/A	None
Amlodipine-Olmesartan medoxomil 10 MG / 40 MG Oral Tablet [Azor]	2	Tier 2	25%	N/A	None
Amlodipine-Olmesartan medoxomil 5 MG / 20 MG Oral Tablet [Azor]	2	Tier 2	25%	N/A	None
AMLODIPINE-VALSARTAN 10-160 MG	2	Tier 2	25%	N/A	None
AMLODIPINE-VALSARTAN 10-320 MG	2	Tier 2	25%	N/A	None
AMLODIPINE-VALSARTAN 5-160 MG	2	Tier 2	25%	N/A	None
AMLODIPINE-VALSARTAN 5-320 MG	2	Tier 2	25%	N/A	None
AMMONIUM LACTATE 12% CREAM	2	Tier 2	25%	N/A	None
AMMONIUM LACTATE 12% LOTION	2	Tier 2	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMOX TR-K CLV 500-125 MG TAB	2	Tier 2	25%	N/A	None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE	2	Tier 2	25%	N/A	None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET	2	Tier 2	25%	N/A	None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE	2	Tier 2	25%	N/A	None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL	2	Tier 2	25%	N/A	None
AMOX-CLAV 200-28.5 MG/5 ML SUS	2	Tier 2	25%	N/A	None
AMOXAPINE 100MG TABLET	2	Tier 2	25%	N/A	None
AMOXAPINE 150MG TABLET	2	Tier 2	25%	N/A	None
AMOXAPINE 25MG TABLET	2	Tier 2	25%	N/A	None
AMOXAPINE 50MG TABLET	2	Tier 2	25%	N/A	None
AMOXICILLIN 125MG TABLET CHEW	2	Tier 2	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMOXICILLIN 250MG 500 CHEWABLE TABLET in BOTTLE	2	Tier 2	25%	N/A	None
AMOXICILLIN 250MG CAPSULE	2	Tier 2	25%	N/A	None
AMOXICILLIN 50 MG/ML / CLAVULANATE 12.5 MG/ML ORAL SUSPENSION	2	Tier 2	25%	N/A	None
AMOXICILLIN 500MG 500 CAPSULE BOTTLE	2	Tier 2	25%	N/A	None
AMOXICILLIN 500MG TABLET (100 CT)	2	Tier 2	25%	N/A	None
AMOXICILLIN 875MG TABLET	2	Tier 2	25%	N/A	None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT	2	Tier 2	25%	N/A	None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS EXTENDED RELEASE 1000;62.5MG;MG	2	Tier 2	25%	N/A	None
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT	2	Tier 2	25%	N/A	None
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT	2	Tier 2	25%	N/A	None
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL	2	Tier 2	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT	2	Tier 2	25%	N/A	None
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL	2	Tier 2	25%	N/A	None
AMPHETAMINE SALT COMBO 12.5MG TABLET	2	Tier 2	25%	N/A	None
AMPHETAMINE SALT COMBO 15MG TABLET	2	Tier 2	25%	N/A	None
AMPHETAMINE SALT COMBO 7.5MG TABLET	2	Tier 2	25%	N/A	None
AMPHETAMINE SALTS 5 MG TAB	2	Tier 2	25%	N/A	None
amphotericin b 50mg/10mL 10 mL in 1 VIAL	2	Tier 2	25%	N/A	None
Ampicillin 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS	2	Tier 2	25%	N/A	None
AMPICILLIN CAPSULES 250MG 100 BOT	2	Tier 2	25%	N/A	None
AMPICILLIN CAPSULES 500MG 100 BOT	2	Tier 2	25%	N/A	None
AMPICILLIN FOR INJECTION POWDER	2	Tier 2	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT	2	Tier 2	25%	N/A	None
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT	2	Tier 2	25%	N/A	None
AMPICILLIN POWDER FOR INJECTION 1 GM/ML	2	Tier 2	25%	N/A	None
ampicillin-sulbactam 1.5 gm vl	2	Tier 2	25%	N/A	None
AMPICILLIN-SULBACTAM 15 GM VIAL	2	Tier 2	25%	N/A	None
AMPICILLIN-SULBACTAM 3 GM VIAL	2	Tier 2	25%	N/A	None
AMPYRA ER 10 MG TABLET	5	Tier 5	25%	N/A	None
AMRIX 30 MG	4	Tier 4	25%	N/A	P
AMRIX CAPSULES EXTENDED RELEASE 15MG 60 CAPSULES BOT	4	Tier 4	25%	N/A	P
ANADROL-50 TABLET	4	Tier 4	25%	N/A	None
ANAFRANIL 25 MG 30 CAPSULE BOTTLE	4	Tier 4	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ANAFRANIL 50 MG 30 CAPSULE BOTTLE	4	Tier 4	25%	N/A	None
ANAFRANIL 75 MG 30 CAPSULE BOTTLE	4	Tier 4	25%	N/A	None
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE	2	Tier 2	25%	N/A	None
Anagrelide Hydrochloride 1mg/1 100 CAPSULE BOTTLE	2	Tier 2	25%	N/A	None
ANAPROX DS 550MG TABLET	4	Tier 4	25%	N/A	None
Anastrozole 1mg/1 90 FILM COATED TABLETS in BOTTLE, PLASTIC	2	Tier 2	25%	N/A	None
ANCOBON 250MG CAPSULE	5	Tier 5	25%	N/A	None
ANCOBON 500MG CAPSULE	5	Tier 5	25%	N/A	None
ANDRODERM 2 MG/24HR PATCH	3	Tier 3	25%	N/A	None
ANDRODERM 4 MG/24HR PATCH	3	Tier 3	25%	N/A	None
ANDROGEL 1.62% (1.25G) GEL PCKT	4	Tier 4	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ANDROGEL 1.62% (2.5G) GEL PCKT	4	Tier 4	25%	N/A	None
ANDROGEL 1% (50MG) GEL PACKET	4	Tier 4	25%	N/A	None
Androgel 10mg/g 30 PACKET in 1 CARTON / 2.5 g in 1 PACKET	4	Tier 4	25%	N/A	None
Androgel 16.2mg/g 1 BOTTLE, PUMP per CARTON / 88 g in 1 BOTTLE, PUMP	4	Tier 4	25%	N/A	None
ANDROID 10 MG CAPSULE	4	Tier 4	25%	N/A	None
ANGELIQ 0.25 MG-0.5 MG TABLET	4	Tier 4	25%	N/A	None
ANGELIQ 1-0.5MG TABLET	4	Tier 4	25%	N/A	None
ANORO ELLIPTA 62.5-25 MCG INH	4	Tier 4	25%	N/A	None
ANTABUSE 250MG TABLET	2	Tier 2	25%	N/A	None
ANTABUSE 500MG TABLET	2	Tier 2	25%	N/A	None
ANTARA 30 MG CAPSULE	4	Tier 4	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ANTARA 90 MG CAPSULE	4	Tier 4	25%	N/A	None
ANUSOL-HC 2.5% CREAM	2	Tier 2	25%	N/A	None
ANZEMET 100 MG TABLET	4	Tier 4	25%	N/A	P
ANZEMET 50 MG TABLET	4	Tier 4	25%	N/A	P
Apexicon E 0.05% Cream	2	Tier 2	25%	N/A	None
APIDRA 100 UNITS/ML VIAL	4	Tier 4	25%	N/A	P
APIDRA SOLOSTAR 100 UNITS/ML	4	Tier 4	25%	N/A	None
APLENZIN ER 174 MG TABLET	4	Tier 4	25%	N/A	None
APLENZIN ER 348 MG TABLET	4	Tier 4	25%	N/A	None
APLENZIN ER 522 MG TABLET	4	Tier 4	25%	N/A	None
APOKYN 30 MG/3 ML CARTRIDGE	5	Tier 5	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Apraclonidine Ophthalmic 5mg/mL 1 BOTTLE, DROPPER per CARTON / 10 mL in 1 BOTTLE, DROPPER	2	Tier 2	25%	N/A	None
APREPITANT 125 MG CAPSULE [Emend]	2	Tier 2	25%	N/A	P
APREPITANT 125-80-80 MG PACK [Emend]	2	Tier 2	25%	N/A	P
APREPITANT 40 MG CAPSULE [Emend]	2	Tier 2	25%	N/A	P
APREPITANT 80 MG CAPSULE [Emend]	2	Tier 2	25%	N/A	P
APRI 0.15-0.03 TABLET	2	Tier 2	25%	N/A	None
APRISO CP24	4	Tier 4	25%	N/A	None
APTENSIO XR 10 MG CAPSULE	3	Tier 3	25%	N/A	None
APTENSIO XR 15 MG CAPSULE	3	Tier 3	25%	N/A	None
APTENSIO XR 20 MG CAPSULE	3	Tier 3	25%	N/A	None
APTENSIO XR 30 MG CAPSULE	3	Tier 3	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
APTENSIO XR 40 MG CAPSULE	3	Tier 3	25%	N/A	None
APTENSIO XR 50 MG CAPSULE	3	Tier 3	25%	N/A	None
APTENSIO XR 60 MG CAPSULE	3	Tier 3	25%	N/A	None
APTIOM 200 MG TABLET	4	Tier 4	25%	N/A	None
APTIOM 400 MG TABLET	4	Tier 4	25%	N/A	None
APTIOM 600 MG TABLET	4	Tier 4	25%	N/A	None
APTIOM 800 MG TABLET	4	Tier 4	25%	N/A	None
APTIVUS 250MG CAPSULE	3	Tier 3	25%	N/A	None
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT	3	Tier 3	25%	N/A	None
ARALAST NP 500 MG VIAL	5	Tier 5	25%	N/A	None
ARANELLE 7-9-5 TABLET	2	Tier 2	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ARANESP 10 MCG/0.4 ML SYRINGE	4	Tier 4	25%	N/A	P
ARANESP 100ug/0.5mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.5 mL in 1 SYRINGE	4	Tier 4	25%	N/A	P
ARANESP 100ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE	4	Tier 4	25%	N/A	P
ARANESP 200MCG/0.4ML SYRINGE	4	Tier 4	25%	N/A	P
ARANESP 200MCG/ML VIAL	4	Tier 4	25%	N/A	P
ARANESP 25ug/0.42mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.42 mL in 1 SYRING	4	Tier 4	25%	N/A	P
ARANESP 25ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE	4	Tier 4	25%	N/A	P
ARANESP 300MCG/ML VIAL	4	Tier 4	25%	N/A	P
ARANESP 500MCG/1ML SYRINGE	4	Tier 4	25%	N/A	P
ARANESP 60MCG/ML VIAL	4	Tier 4	25%	N/A	P
ARANESP 60ug/0.3mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.3 mL in 1 SYRINGE	4	Tier 4	25%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR	4	Tier 4	25%	N/A	P
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR	4	Tier 4	25%	N/A	P
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR	4	Tier 4	25%	N/A	P
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD	4	Tier 4	25%	N/A	P
ARAVA 10MG TABLET	4	Tier 4	25%	N/A	None
ARAVA 20MG TABLET	4	Tier 4	25%	N/A	None
ARCALYST INJECTION 220MG/VIAL	5	Tier 5	25%	N/A	None
Arcapta Neohaler 75ug/1 30 BLISTER PACK in 1 BOX / 1 CAPSULE per BLISTER PACK	4	Tier 4	25%	N/A	None
Argatroban 125mg/125mL 2 VIAL, SINGLE-USE per CARTON / 125 mL in 1 VIAL, SINGLE-USE	4	Tier 4	25%	N/A	None
Argatroban 2.5 ML 100 MG/ML Injection	2	Tier 2	25%	N/A	None
ARICEPT 10MG TABLET	4	Tier 4	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ARICEPT 23 MG TABLETS	4	Tier 4	25%	N/A	None
ARICEPT 5MG TABLET	4	Tier 4	25%	N/A	None
ARIMIDEX 1MG TABLET	4	Tier 4	25%	N/A	None
ARIPIPRAZOLE 10 MG TABLET [Abilify]	2	Tier 2	25%	N/A	None
ARIPIPRAZOLE 15 MG TABLET [Abilify]	2	Tier 2	25%	N/A	None
ARIPIPRAZOLE 2 MG TABLET [Abilify]	2	Tier 2	25%	N/A	None
ARIPIPRAZOLE 20 MG TABLET [Abilify]	2	Tier 2	25%	N/A	None
ARIPIPRAZOLE 30 MG TABLET [Abilify]	2	Tier 2	25%	N/A	None
ARIPIPRAZOLE 5 MG TABLET [Abilify]	2	Tier 2	25%	N/A	None
ARIPIPRAZOLE ODT 10 MG TABLET [Abilify]	2	Tier 2	25%	N/A	None
ARIPIPRAZOLE ODT 15 MG TABLET [Abilify]	2	Tier 2	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ARISTADA ER 1064 MG/3.9 ML SYR	5	Tier 5	25%	N/A	None
ARISTADA ER 441 MG/1.6 ML SYRN	5	Tier 5	25%	N/A	None
ARISTADA ER 662 MG/2.4 ML SYRN	5	Tier 5	25%	N/A	None
ARISTADA ER 882 MG/3.2 ML SYRN	5	Tier 5	25%	N/A	None
ARIXTRA 10 MG/0.8 ML SYRINGE	4	Tier 4	25%	N/A	None
ARIXTRA 2.5 MG SYRINGE	4	Tier 4	25%	N/A	None
ARIXTRA 5 MG/0.4 ML SYRINGE	4	Tier 4	25%	N/A	None
ARIXTRA 7.5 MG/0.6 ML SYRINGE	4	Tier 4	25%	N/A	None
Armodafinil 150 MG TABLET [NUVIGIL]	2	Tier 2	25%	N/A	P
Armodafinil 200 MG Oral Tablet [NUVIGIL]	2	Tier 2	25%	N/A	P
Armodafinil 250 MG TABLET [NUVIGIL]	2	Tier 2	25%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Armodafinil 50 MG TABLET [NUVIGIL]	2	Tier 2	25%	N/A	P
ARNUITY ELLIPTA 100 MCG INH	4	Tier 4	25%	N/A	None
ARNUITY ELLIPTA 200 MCG INH	4	Tier 4	25%	N/A	None
AROMASIN 25MG TABLET	4	Tier 4	25%	N/A	None
ARRANON 250 MG VIAL	3	Tier 3	25%	N/A	None
ARTHROTEC 50 50MG TABLET -200MCG (60 CT)	4	Tier 4	25%	N/A	None
ARTHROTEC 75 TABLET EC	4	Tier 4	25%	N/A	None
ASACOL HD DR 800 MG TABLET	4	Tier 4	25%	N/A	None
ASCOMP WITH CODEINE CAPSULE	2	Tier 2	25%	N/A	None
Ashlyna 0.15-0.03-0.01 mg tablet	2	Tier 2	25%	N/A	None
ASMANEX HFA 100 MCG INHALER	3	Tier 3	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ASMANEX HFA 200 MCG INHALER	3	Tier 3	25%	N/A	None
ASMANEX TWISTHALER 110 MCG #30	3	Tier 3	25%	N/A	None
ASMANEX TWISTHALER 220 MCG #30	4	Tier 4	25%	N/A	None
ASMANEX TWISTHALER 220MCG #120	3	Tier 3	25%	N/A	None
ASMANEX TWISTHALER 220MCG #60	3	Tier 3	25%	N/A	None
Aspirin-Diphenhydramine ER 25-200 MG	2	Tier 2	25%	N/A	None
ASPIRIN/BUTALBITAL/CAFFEINE/CODEINE	2	Tier 2	25%	N/A	None
ASTAGRAF XL 0.5 MG CAPSULE	4	Tier 4	25%	N/A	P
ASTAGRAF XL 1 MG CAPSULE	4	Tier 4	25%	N/A	P
ASTAGRAF XL 5 MG CAPSULE	5	Tier 5	25%	N/A	P
ASTEPRO 0.15% NASAL SPRAY 30 ML	4	Tier 4	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ATACAND 16MG TABLET	4	Tier 4	25%	N/A	None
ATACAND 32MG TABLET	4	Tier 4	25%	N/A	None
ATACAND 4MG TABLET	4	Tier 4	25%	N/A	None
ATACAND 8MG TABLET	4	Tier 4	25%	N/A	None
ATACAND HCT 16/12.5MG TABLET	4	Tier 4	25%	N/A	None
ATACAND HCT 32/12.5MG TABLET	4	Tier 4	25%	N/A	None
ATACAND HCT TABLETS 32;25MG;MG 90 TABLET BOTTLE	4	Tier 4	25%	N/A	None
Atelvia 35mg/1 36 DOSE PACK CASE / 4 TABLET, DELAYED RELEASE in 1 DOSE PACK	4	Tier 4	25%	N/A	None
ATENOLOL 100 MG100 TABLET BOTTLE	1	Tier 1	25%	N/A	None
ATENOLOL 25 MG 100 TABLET BOTTLE	1	Tier 1	25%	N/A	None
ATENOLOL TABLET USP 50MG (100 CT)	1	Tier 1	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ATENOLOL-CHLORTHALIDONE 100-25	2	Tier 2	25%	N/A	None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)	2	Tier 2	25%	N/A	None
ATGAM 50MG/ML AMPUL	4	Tier 4	25%	N/A	None
ATIVAN 0.5 MG TABLET	4	Tier 4	25%	N/A	None
ATIVAN 1 MG TABLET	4	Tier 4	25%	N/A	None
ATIVAN 2 MG TABLET	4	Tier 4	25%	N/A	None
Atomoxetine 10 MG Oral Capsule [Strattera]	2	Tier 2	25%	N/A	None
Atomoxetine 100 MG Oral Capsule [Strattera]	2	Tier 2	25%	N/A	None
Atomoxetine 18 MG Oral Capsule [Strattera]	2	Tier 2	25%	N/A	None
Atomoxetine 25 MG Oral Capsule [Strattera]	2	Tier 2	25%	N/A	None
Atomoxetine 40 MG Oral Capsule [Strattera]	2	Tier 2	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Atomoxetine 60 MG Oral Capsule [Strattera]	2	Tier 2	25%	N/A	None
Atomoxetine 80 MG Oral Capsule [Strattera]	2	Tier 2	25%	N/A	None
ATORVASTATIN 10 MG TABLET [Lipitor]	1	Tier 1	25%	N/A	None
ATORVASTATIN 20 MG TABLET [Lipitor]	1	Tier 1	25%	N/A	None
ATORVASTATIN 40 MG TABLET [Lipitor]	1	Tier 1	25%	N/A	None
ATORVASTATIN 80 MG TABLET [Lipitor]	1	Tier 1	25%	N/A	None
ATOVAQUONE 750 MG/5 ML SUSP [Mepron]	2	Tier 2	25%	N/A	None
Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone]	2	Tier 2	25%	N/A	None
Atovaquone-Proguanil 62.5-25 [Malarone]	2	Tier 2	25%	N/A	None
ATRALIN 0.05% GEL	4	Tier 4	25%	N/A	P
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC	3	Tier 3	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ATROPINE 0.05MG/ML SYRINGE	4	Tier 4	25%	N/A	None
Atropine 1% Eye Drops	2	Tier 2	25%	N/A	None
ATROVENT HFA AER 17MCG	3	Tier 3	25%	N/A	None
AUBAGIO 14 MG TABLET	5	Tier 5	25%	N/A	P
AUBAGIO 7 MG TABLET	5	Tier 5	25%	N/A	P
AUBRA-28 TABLET	2	Tier 2	25%	N/A	None
AUGMENTIN 125; 31.25mg/5mL; mg/5mL 100 mL in 1 BOTTLE	3	Tier 3	25%	N/A	None
AURYXIA 210 MG TABLET	4	Tier 4	25%	N/A	None
AUSTEDO 12 MG TABLET	5	Tier 5	25%	N/A	None
AUSTEDO 6 MG TABLET	5	Tier 5	25%	N/A	None
AUSTEDO 9 MG TABLET	5	Tier 5	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AUVI-Q 0.15 MG AUTO-INJECTOR	5	Tier 5	25%	N/A	None
AUVI-Q 0.3 MG AUTO-INJECTOR	5	Tier 5	25%	N/A	None
AVALIDE 150-12.5 MG TABLET	4	Tier 4	25%	N/A	None
AVALIDE 300-12.5 MG TABLET	4	Tier 4	25%	N/A	None
AVANDIA 2 MG TABLET	4	Tier 4	25%	N/A	None
AVANDIA 4 MG TABLET	4	Tier 4	25%	N/A	None
AVAPRO 150 MG TABLET	4	Tier 4	25%	N/A	None
AVAPRO 300 MG TABLET	4	Tier 4	25%	N/A	None
AVAPRO 75 MG TABLET	4	Tier 4	25%	N/A	None
AVASTIN 100MG/4ML VIAL	3	Tier 3	25%	N/A	None
AVASTIN 400 MG/16 ML VIAL	3	Tier 3	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AVC 15% CREAM	3	Tier 3	25%	N/A	None
AVEED 750 MG/3 ML VIAL	4	Tier 4	25%	N/A	None
AVELOX 400 MG TABLET	4	Tier 4	25%	N/A	None
AVELOX IV 400 MG/250 ML	3	Tier 3	25%	N/A	None
AVIANE 0.1-0.02 TABLET	2	Tier 2	25%	N/A	None
AVITA 0.025% CREAM	2	Tier 2	25%	N/A	P
Avita 0.25mg/g 45 g in 1 TUBE	2	Tier 2	25%	N/A	P
AVODART 0.5MG SOFTGEL	4	Tier 4	25%	N/A	None
AVONEX ADMIN PACK 30 MCG VL	5	Tier 5	25%	N/A	None
AVONEX PEN 30 MCG/0.5 ML KIT	5	Tier 5	25%	N/A	None
AVONEX PREFILLED SYR 30 MCG KT	5	Tier 5	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AVYCAZ 2.5 GRAM VIAL	4	Tier 4	25%	N/A	None
AXERT 12.5 MG TABLET	4	Tier 4	25%	N/A	None
AXERT 6.25 MG TABLET	4	Tier 4	25%	N/A	None
AXIRON 30mg/1.5mL 1 BOTTLE, WITH APPLICATOR per CARTON / 90 mL in 1 BOTTLE, WITH APPLICATOR	4	Tier 4	25%	N/A	None
Aygestin 5mg/1 50 TABLET BOTTLE	2	Tier 2	25%	N/A	None
Azacitidine 100 mg vial [Vidaza]	2	Tier 2	25%	N/A	None
AZACTAM INJECTION 1GM/50ML	3	Tier 3	25%	N/A	None
AZACTAM INJECTION 2GM/50ML	3	Tier 3	25%	N/A	None
AZASAN 100MG TABLET	2	Tier 2	25%	N/A	P
AZASAN 75MG TABLET	2	Tier 2	25%	N/A	P
AZASITE 1% EYE DROPS	4	Tier 4	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AZATHIOPRINE 50 MG TABLET	2	Tier 2	25%	N/A	P
AZATHIOPRINE SODIUM 100 MG VIAL	2	Tier 2	25%	N/A	P
AZELASTINE 0.15% NASAL SPRAY	2	Tier 2	25%	N/A	None
AZELASTINE 137 MCG NASAL SPRAY	2	Tier 2	25%	N/A	None
AZELASTINE HYDROCHLORIDE OPHTHALMIC SOLUTION	2	Tier 2	25%	N/A	None
AZELEX 20% CREAM 30GM TUBE	3	Tier 3	25%	N/A	None
AZILECT 0.5MG TABLET	3	Tier 3	25%	N/A	None
AZILECT 1MG TABLET	3	Tier 3	25%	N/A	None
AZITHROMYCIN 1 GM PWD PACKET	3	Tier 3	25%	N/A	None
AZITHROMYCIN 100 MG/5 ML SUSP	2	Tier 2	25%	N/A	None
Azithromycin 200mg/5mL 22.5 mL in 1 BOTTLE	2	Tier 2	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AZITHROMYCIN 250 MG TABLET	2	Tier 2	25%	N/A	None
AZITHROMYCIN 250 MG TABLET	2	Tier 2	25%	N/A	None
Azithromycin 500 mg tablet	2	Tier 2	25%	N/A	None
Azithromycin 500mg/1 10 VIAL, SINGLE-USE in 1 TRAY / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION	2	Tier 2	25%	N/A	None
Azithromycin 500mg/1 30 FILM COATED TABLETS in BOTTLE	2	Tier 2	25%	N/A	None
Azithromycin 600mg/1 30 FILM COATED TABLETS in BOTTLE	2	Tier 2	25%	N/A	None
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT	4	Tier 4	25%	N/A	None
AZOR 10-20 MG TABLET	4	Tier 4	25%	N/A	None
AZOR 10MG-40MG TABLET (30 CT)	4	Tier 4	25%	N/A	None
AZOR 5-40 MG TABLET	4	Tier 4	25%	N/A	None
AZOR 5MG-20MG TABLET (30 CT)	4	Tier 4	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AZTREONAM FOR INJECTION	2	Tier 2	25%	N/A	None
AZULFIDINE 500MG TABLET	4	Tier 4	25%	N/A	None
AZULFIDINE EN TABLET S 500MG TABLET 6 X (300 CT)PL	4	Tier 4	25%	N/A	None

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Chart Legend:

Below are a few notes to help you understand the above 2017 Medicare Part D Kaiser Permanente Medicare Plus Basic w/D (AB) (Cost) 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 $400 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 $3700) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2017 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.

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(Chart Source: Centers for Medicare and Medicaid files: CMS Data September 2017 )

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.