2018 Medicare Part D and Medicare Advantage Plan Formulary Browser

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Senior Advantage Medicare Medi-Cal Plan North (HMO SNP) (H0524-030-0)

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2018 Medicare Part D Plan Formulary Information
Senior Advantage Medicare Medi-Cal Plan North (HMO SNP) (H0524-030-0) Benefit Details
The Senior Advantage Medicare Medi-Cal Plan North (HMO SNP) (H0524-030-0) Formulary Drugs Starting with the Letter A in Marin County, CA: CMS MA Region 24 which includes: CA Plan Monthly Premium: $32.00 Deductible: $405
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 20 MG/ML SOLUTION	2	Tier 2	$0.00	N/A	None
ABACAVIR 300 MG TABLET	2	Tier 2	$0.00	N/A	None
Abacavir Sulfate-Lamivudine-Zidovudine tablets [Trizivir]	2	Tier 2	$0.00	N/A	None
ABACAVIR-LAMIVUDINE 600-300 MG	2	Tier 2	$0.00	N/A	None
ABELCET INJECTION SUSPENSION 5MG/ML	4	Tier 4	$0.00	N/A	None
ABILIFY 10MG TABLET	4	Tier 4	$0.00	N/A	None
ABILIFY 15MG TABLET	4	Tier 4	$0.00	N/A	None
ABILIFY 20MG TABLET	4	Tier 4	$0.00	N/A	None
ABILIFY 2MG TABLET	4	Tier 4	$0.00	N/A	None
ABILIFY 30MG TABLET	4	Tier 4	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ABILIFY 5 MG TABLET	4	Tier 4	$0.00	N/A	None
ABILIFY MAINTENA ER 300 MG SYR	4	Tier 4	$0.00	N/A	None
ABILIFY MAINTENA ER 300 MG VL	4	Tier 4	$0.00	N/A	None
ABILIFY MAINTENA ER 400 MG SUSER VIAL	4	Tier 4	$0.00	N/A	None
ABILIFY MAINTENA ER 400 MG SYR	4	Tier 4	$0.00	N/A	None
ABRAXANE 100MG VIAL	3	Tier 3	$0.00	N/A	None
ABSORICA 10 MG CAPSULE	4	Tier 4	$0.00	N/A	None
ABSORICA 20 MG CAPSULE	4	Tier 4	$0.00	N/A	None
ABSORICA 25 MG CAPSULE	4	Tier 4	$0.00	N/A	None
ABSORICA 30 MG CAPSULE	4	Tier 4	$0.00	N/A	None
ABSORICA 35 MG CAPSULE	4	Tier 4	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ABSORICA 40 MG CAPSULE	4	Tier 4	$0.00	N/A	None
ABSTRAL 100 MCG TAB SUBLINGUAL	4	Tier 4	$0.00	N/A	P
ABSTRAL 200 MCG TAB SUBLINGUAL	4	Tier 4	$0.00	N/A	P
ABSTRAL 300 MCG TAB SUBLINGUAL	4	Tier 4	$0.00	N/A	P
ABSTRAL 400 MCG TAB SUBLINGUAL	4	Tier 4	$0.00	N/A	P
ABSTRAL 600 MCG TAB SUBLINGUAL	4	Tier 4	$0.00	N/A	P
ABSTRAL 800 MCG TAB SUBLINGUAL	4	Tier 4	$0.00	N/A	P
Acamprosate Calcium DR 333 MG tablets [Campral]	2	Tier 2	$0.00	N/A	None
ACANYA 25; 10mg/g; mg/g 1 BOTTLE, PUMP per CARTON / 50 g in 1 BOTTLE, PUMP	4	Tier 4	$0.00	N/A	None
ACARBOSE 100 MG TABLET	2	Tier 2	$0.00	N/A	None
ACARBOSE 25 MG TABLET	2	Tier 2	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ACARBOSE 50 MG TABLET	2	Tier 2	$0.00	N/A	None
ACCOLATE 10 MG TABLET	4	Tier 4	$0.00	N/A	None
ACCOLATE 20 MG TABLET	4	Tier 4	$0.00	N/A	None
ACCUPRIL 10MG TABLET	4	Tier 4	$0.00	N/A	None
ACCUPRIL 20MG TABLET	4	Tier 4	$0.00	N/A	None
ACCUPRIL 40MG TABLET	4	Tier 4	$0.00	N/A	None
ACCUPRIL 5MG TABLET	4	Tier 4	$0.00	N/A	None
ACCURETIC 10-12.5MG TABLET	4	Tier 4	$0.00	N/A	None
ACCURETIC 20-12.5MG TABLET	4	Tier 4	$0.00	N/A	None
ACCURETIC 20-25MG TABLET	4	Tier 4	$0.00	N/A	None
ACEBUTOLOL 200 MG CAPSULE	2	Tier 2	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ACEBUTOLOL 400 MG CAPSULE	2	Tier 2	$0.00	N/A	None
ACETAMINOP-CODEINE 120-12 MG/5	2	Tier 2	$0.00	N/A	None
Acetaminophen 325 MG / Hydrocodone Bitartrate 5 MG Oral Tablet [Lorcet]	2	Tier 2	$0.00	N/A	None
ACETAMINOPHEN-COD #2 TABLET	2	Tier 2	$0.00	N/A	None
ACETAMINOPHEN-COD #3 TABLET	2	Tier 2	$0.00	N/A	None
ACETAMINOPHEN-COD #4 TABLET	2	Tier 2	$0.00	N/A	None
ACETAZOLAMIDE 125MG TABLET	2	Tier 2	$0.00	N/A	None
ACETAZOLAMIDE 250MG TABLET (100 CT)	2	Tier 2	$0.00	N/A	None
Acetazolamide 500mg/5mL 1 VIAL in 1 CARTON / 5 mL in 1 VIAL	2	Tier 2	$0.00	N/A	None
ACETAZOLAMIDE ER 500 MG CAP	2	Tier 2	$0.00	N/A	None
ACETIC ACID 2% EAR SOLUTION	2	Tier 2	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ACETYLCYSTEINE 10% VIAL	2	Tier 2	$0.00	N/A	P
Acetylcysteine 200 MG/ML Inhalant Solution	2	Tier 2	$0.00	N/A	P
ACIPHEX 20MG TABLET EC	4	Tier 4	$0.00	N/A	None
ACIPHEX SPRINKLE DR 10 MG CAP	4	Tier 4	$0.00	N/A	None
ACIPHEX SPRINKLE DR 5 MG CAP	4	Tier 4	$0.00	N/A	None
ACITRETIN 10 MG CAPSULE [Soriatane]	2	Tier 2	$0.00	N/A	None
ACITRETIN 17.5 MG CAPSULE [Soriatane]	2	Tier 2	$0.00	N/A	None
ACITRETIN 25 MG CAPSULE [Soriatane]	2	Tier 2	$0.00	N/A	None
ACTEMRA 162 MG/0.9 ML SYRINGE	5	Tier 5	$0.00	N/A	None
ACTEMRA 400 MG/20 ML VIAL	4	Tier 4	$0.00	N/A	None
ACTEMRA 80 MG/4 ML VIAL	4	Tier 4	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ACTEMRA INJECTION 200MG/10ML	4	Tier 4	$0.00	N/A	None
ACTHIB VACCINE WITH DILUENT	6	Tier 6	$0.00	N/A	None
ACTIGALL 300MG CAPSULE	4	Tier 4	$0.00	N/A	None
ACTIMMUNE 100 MCG/0.5 ML VIAL	5	Tier 5	$0.00	N/A	None
ACTIQ 1200MCG LOZENGE	5	Tier 5	$0.00	N/A	P
ACTIQ 1600MCG LOZENGE	5	Tier 5	$0.00	N/A	P
ACTIQ 200MCG LOZENGE	4	Tier 4	$0.00	N/A	P
ACTIQ 400MCG LOZENGE	5	Tier 5	$0.00	N/A	P
ACTIQ 600MCG LOZENGE	5	Tier 5	$0.00	N/A	P
ACTIQ 800MCG LOZENGE	5	Tier 5	$0.00	N/A	P
ACTIVELLA 0.5-0.1 MG TABLET	4	Tier 4	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ACTIVELLA 1 MG-0.5 MG TABLET	4	Tier 4	$0.00	N/A	None
ACTONEL 150 MG TABLET	4	Tier 4	$0.00	N/A	None
ACTONEL 30 MG TABLET	4	Tier 4	$0.00	N/A	None
ACTONEL 35 MG TABLET	4	Tier 4	$0.00	N/A	None
ACTONEL 5 MG TABLET	4	Tier 4	$0.00	N/A	None
ACTOPLUS MET 15MG/500MG TABLET	4	Tier 4	$0.00	N/A	None
ACTOPLUS MET 15MG/850MG TABLET	4	Tier 4	$0.00	N/A	None
ACTOPLUS MET XR TABLETS ER 15;1000 MG;MG	4	Tier 4	$0.00	N/A	None
ACTOPLUS MET XR TABLETS ER 30;1000 MG;MG	4	Tier 4	$0.00	N/A	None
ACTOS 15 MG TABLET	4	Tier 4	$0.00	N/A	None
ACTOS 30 MG TABLET	4	Tier 4	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ACTOS 45 MG TABLET	4	Tier 4	$0.00	N/A	None
ACULAR 0.5% EYE DROPS	4	Tier 4	$0.00	N/A	None
ACULAR LS 0.4% OPHTH SOL	4	Tier 4	$0.00	N/A	None
ACUVAIL 0.45% OPHTH SOLUTION #30X0.4 EA	4	Tier 4	$0.00	N/A	None
ACYCLOVIR 200 MG CAPSULE	2	Tier 2	$0.00	N/A	None
ACYCLOVIR 200 MG/5 ML SUSP	2	Tier 2	$0.00	N/A	None
ACYCLOVIR 400 MG TABLET	2	Tier 2	$0.00	N/A	None
Acyclovir 5% Ointment	2	Tier 2	$0.00	N/A	None
ACYCLOVIR 800 MG TABLET	2	Tier 2	$0.00	N/A	None
Acyclovir sodium 500 mg vial	2	Tier 2	$0.00	N/A	None
ACZONE 5% GEL	4	Tier 4	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ADACEL TDAP SYRINGE	6	Tier 6	$0.00	N/A	None
ADACEL VIAL 2UNT/5UNT	6	Tier 6	$0.00	N/A	None
ADAGEN 250U/ML VIAL	3	Tier 3	$0.00	N/A	None
ADALAT CC 30 MG TABLET	4	Tier 4	$0.00	N/A	None
ADALAT CC 60 MG TABLET	4	Tier 4	$0.00	N/A	None
ADALAT CC 90 MG TABLET	4	Tier 4	$0.00	N/A	None
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA]	5	Tier 5	$0.00	N/A	None
ADAPALENE 0.1% CREAM	2	Tier 2	$0.00	N/A	None
ADAPALENE 0.1% GEL	2	Tier 2	$0.00	N/A	None
Adapalene 0.3% gel	2	Tier 2	$0.00	N/A	None
ADAPALENE-BNZYL PEROX 0.1-2.5% [EPIDUO]	2	Tier 2	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ADCIRCA TABLETS 20MG 60 BOTTLE	5	Tier 5	$0.00	N/A	P
ADDERALL 20 MG TABLET	2	Tier 2	$0.00	N/A	None
ADDERALL 5 MG TABLET	2	Tier 2	$0.00	N/A	None
ADDERALL 7.5 MG TABLET	2	Tier 2	$0.00	N/A	None
ADDERALL XR 10MG CAPSULE SA	3	Tier 3	$0.00	N/A	None
ADDERALL XR 15MG CAPSULE SA	3	Tier 3	$0.00	N/A	None
ADDERALL XR 20MG CAPSULE SA	3	Tier 3	$0.00	N/A	None
ADDERALL XR 25MG CAPSULE SA	3	Tier 3	$0.00	N/A	None
ADDERALL XR 30MG CAPSULE SA	3	Tier 3	$0.00	N/A	None
ADDERALL XR 5MG CAPSULE SA	3	Tier 3	$0.00	N/A	None
ADEFOVIR DIPIVOXIL 10 MG TAB [Hepsera]	2	Tier 2	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ADEMPAS 0.5 MG TABLET	5	Tier 5	$0.00	N/A	P
ADEMPAS 1 MG TABLET	5	Tier 5	$0.00	N/A	P
ADEMPAS 1.5 MG TABLET	5	Tier 5	$0.00	N/A	P
ADEMPAS 2 MG TABLET	5	Tier 5	$0.00	N/A	P
ADEMPAS 2.5 MG TABLET	5	Tier 5	$0.00	N/A	P
ADLYXIN 10-20 MCG STARTER PACK	4	Tier 4	$0.00	N/A	None
ADLYXIN 20 MCG MAINTENANCE PK	4	Tier 4	$0.00	N/A	None
ADMELOG 100 UNIT/ML VIAL [Humalog]	4	Tier 4	$0.00	N/A	None
ADMELOG SOLOSTAR 100 UNIT/ML INSULN PEN [Humalog KwikPen]	4	Tier 4	$0.00	N/A	None
Adrenalin 1 mg/ml vial	4	Tier 4	$0.00	N/A	None
Adriamycin 20 mg/10 ml vial	2	Tier 2	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ADRUCIL 50mg/mL 10 VIAL in 1 TRAY / 10 mL in 1 VIAL	2	Tier 2	$0.00	N/A	None
ADVAIR DISKUS MIS 100/50	3	Tier 3	$0.00	N/A	None
ADVAIR DISKUS MIS 250/50	3	Tier 3	$0.00	N/A	None
ADVAIR DISKUS MIS 500/50	3	Tier 3	$0.00	N/A	None
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER	3	Tier 3	$0.00	N/A	None
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL	3	Tier 3	$0.00	N/A	None
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL	3	Tier 3	$0.00	N/A	None
ADZENYS ER 1.25 MG/ML SUSP BP 24H	4	Tier 4	$0.00	N/A	None
ADZENYS XR-ODT 12.5 MG TABLET	4	Tier 4	$0.00	N/A	None
ADZENYS XR-ODT 15.7 MG TABLET	4	Tier 4	$0.00	N/A	None
ADZENYS XR-ODT 18.8 MG TABLET	4	Tier 4	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ADZENYS XR-ODT 3.1 MG TABLET	4	Tier 4	$0.00	N/A	None
ADZENYS XR-ODT 6.3 MG TABLET	4	Tier 4	$0.00	N/A	None
ADZENYS XR-ODT 9.4 MG TABLET	4	Tier 4	$0.00	N/A	None
AFEDITAB CR 30MG TABLET SA	2	Tier 2	$0.00	N/A	None
AFEDITAB CR 60MG TABLET SA	2	Tier 2	$0.00	N/A	None
Afinitor 7.5mg/1 28 BLISTER PACK per CARTON / 1 TABLET per BLISTER PACK	5	Tier 5	$0.00	N/A	None
AFINITOR DISPERZ 2 MG TABLET	5	Tier 5	$0.00	N/A	None
AFINITOR DISPERZ 3 MG TABLET	5	Tier 5	$0.00	N/A	None
AFINITOR DISPERZ 5 MG TABLET	5	Tier 5	$0.00	N/A	None
AFINITOR TABLETS 10 MG	5	Tier 5	$0.00	N/A	None
AFINITOR TABLETS 2.5 MG	5	Tier 5	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AFINITOR TABLETS 5 MG	5	Tier 5	$0.00	N/A	None
AFREZZA 12 UNIT CARTRIDGE CART INHAL	4	Tier 4	$0.00	N/A	None
AFREZZA 30-4 UNIT + 60-8 UNIT	4	Tier 4	$0.00	N/A	None
AFREZZA 4 UNIT/8 UNIT/12 UNIT	4	Tier 4	$0.00	N/A	None
AFREZZA 4 UNITS CARTRIDGE INH	4	Tier 4	$0.00	N/A	None
AFREZZA 60-8 UNIT + 30-12 UNIT	4	Tier 4	$0.00	N/A	None
AFREZZA 8 UNIT CARTRIDGE CART INHAL	4	Tier 4	$0.00	N/A	None
AFREZZA 90-4 UNIT / 90-8 UNIT	4	Tier 4	$0.00	N/A	None
AGGRENOX 25-200MG CAPSULE	3	Tier 3	$0.00	N/A	None
AGRYLIN 0.5MG CAPSULE	4	Tier 4	$0.00	N/A	None
AIMOVIG 140 MG DOSE-2 AUTO INJCT	4	Tier 4	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AIRDUO RESPICLICK 113-14 MCG	4	Tier 4	$0.00	N/A	None
AIRDUO RESPICLICK 232-14 MCG	4	Tier 4	$0.00	N/A	None
AIRDUO RESPICLICK 55-14 MCG	4	Tier 4	$0.00	N/A	None
AKTIPAK 3%-5% GEL POUCH	4	Tier 4	$0.00	N/A	None
Ala-cort 2.5% cream	2	Tier 2	$0.00	N/A	None
ALA-SCALP HP 2% LOTION	2	Tier 2	$0.00	N/A	None
ALBENZA 200 MG TABLET	3	Tier 3	$0.00	N/A	None
ALBUTEROL SUL 2.5 MG/3 ML SOLN	1	Tier 1	$0.00	N/A	P
ALBUTEROL SULFATE 0.75mg/3mL 30 POUCH per CARTON / 1 VIAL, SINGLE-DOSE in 1 POUCH / 3 mL in 1 VIAL	2	Tier 2	$0.00	N/A	P
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER	2	Tier 2	$0.00	N/A	P
ALBUTEROL SULFATE 2 MG TAB	2	Tier 2	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ALBUTEROL SULFATE 4 MG TAB	2	Tier 2	$0.00	N/A	None
ALBUTEROL SULFATE 4MG TABLET SR 12HR	2	Tier 2	$0.00	N/A	None
ALBUTEROL SULFATE 8MG TABLET SR 12HR	2	Tier 2	$0.00	N/A	None
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR	1	Tier 1	$0.00	N/A	P
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT	2	Tier 2	$0.00	N/A	None
ALCLOMETASONE DIPR 0.05% OINT	2	Tier 2	$0.00	N/A	None
ALCLOMETASONE DIPRO 0.05% CRM	2	Tier 2	$0.00	N/A	None
ALDACTAZIDE 25/25 TABLET	4	Tier 4	$0.00	N/A	None
ALDACTAZIDE 50/50 TABLET	4	Tier 4	$0.00	N/A	None
ALDACTONE 100MG TABLET	4	Tier 4	$0.00	N/A	None
ALDACTONE 25MG TABLET	4	Tier 4	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ALDACTONE 50MG TABLET	4	Tier 4	$0.00	N/A	None
ALDARA 5% CREAM	4	Tier 4	$0.00	N/A	None
ALDURAZYME 2.9MG/5ML VIAL	3	Tier 3	$0.00	N/A	None
ALECENSA 150 MG CAPSULE	5	Tier 5	$0.00	N/A	None
ALENDRONATE SODIUM 10 MG TAB	1	Tier 1	$0.00	N/A	None
ALENDRONATE SODIUM 35 MG TAB	2	Tier 2	$0.00	N/A	None
ALENDRONATE SODIUM 40 MG TABLET	2	Tier 2	$0.00	N/A	None
ALENDRONATE SODIUM 5 MG TABLET	2	Tier 2	$0.00	N/A	None
ALENDRONATE SODIUM 70 MG TAB	1	Tier 1	$0.00	N/A	None
ALENDRONATE SODIUM 70 MG/75 ML	2	Tier 2	$0.00	N/A	None
ALFUZOSIN HCL ER 10 MG TABLET	2	Tier 2	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ALIMTA 100 MG VIAL	4	Tier 4	$0.00	N/A	None
ALIMTA 500 MG VIAL	3	Tier 3	$0.00	N/A	None
ALINIA 100 MG/5 ML SUSPENSION	3	Tier 3	$0.00	N/A	None
ALINIA 500 MG TABLET	3	Tier 3	$0.00	N/A	None
ALIQOPA 60 MG VIAL	5	Tier 5	$0.00	N/A	None
Aliskiren 150 MG / Hydrochlorothiazide 12.5 MG Oral Tablet [Tekturna HCT]	4	Tier 4	$0.00	N/A	None
Aliskiren 150 MG / Hydrochlorothiazide 25 MG Oral Tablet [Tekturna HCT]	4	Tier 4	$0.00	N/A	None
Aliskiren 300 MG / Hydrochlorothiazide 12.5 MG Oral Tablet [Tekturna HCT]	4	Tier 4	$0.00	N/A	None
ALKERAN 50 MG VIAL	4	Tier 4	$0.00	N/A	None
ALLOPURINOL 100 MG TABLET	2	Tier 2	$0.00	N/A	None
ALLOPURINOL 300 MG TABLET	2	Tier 2	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Allopurinol sodium 500 mg vial	2	Tier 2	$0.00	N/A	None
ALLZITAL 25-325 MG TABLET	2	Tier 2	$0.00	N/A	None
ALMOTRIPTAN MALATE 12.5 MG TAB [Axert]	2	Tier 2	$0.00	N/A	None
ALMOTRIPTAN MALATE 6.25 MG TAB [Axert]	2	Tier 2	$0.00	N/A	None
ALOCRIL 2% EYE DROPS	4	Tier 4	$0.00	N/A	None
ALOGLIPTIN 12.5 MG TABLET [Nesina]	2	Tier 2	$0.00	N/A	None
ALOGLIPTIN 25 MG TABLET [Nesina]	2	Tier 2	$0.00	N/A	None
ALOGLIPTIN 6.25 MG TABLET [Nesina]	2	Tier 2	$0.00	N/A	None
ALOGLIPTIN-METFORMIN 12.5-1000 [Kazano]	4	Tier 4	$0.00	N/A	None
ALOGLIPTIN-METFORMIN 12.5-500 [Kazano]	4	Tier 4	$0.00	N/A	None
ALOGLIPTIN-PIOGLIT 12.5-15 MG [Oseni]	2	Tier 2	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ALOGLIPTIN-PIOGLIT 12.5-30 MG [Oseni]	2	Tier 2	$0.00	N/A	None
ALOGLIPTIN-PIOGLIT 12.5-45 MG [Oseni]	2	Tier 2	$0.00	N/A	None
ALOGLIPTIN-PIOGLIT 25-15 MG TABLET [Oseni]	2	Tier 2	$0.00	N/A	None
ALOGLIPTIN-PIOGLIT 25-30 MG TABLET [Oseni]	2	Tier 2	$0.00	N/A	None
ALOGLIPTIN-PIOGLIT 25-45 MG TABLET [Oseni]	2	Tier 2	$0.00	N/A	None
ALOMIDE 0.1% EYE DROPS	4	Tier 4	$0.00	N/A	None
ALOPRIM SOLUTION FOR INJECTION 500MG/VIAL 30 ML VIALGL	4	Tier 4	$0.00	N/A	None
ALORA 0.025 MG PATCH	4	Tier 4	$0.00	N/A	None
ALORA 0.05 MG PATCH	4	Tier 4	$0.00	N/A	None
ALORA 0.075 MG PATCH	4	Tier 4	$0.00	N/A	None
ALORA 0.1 MG PATCH	4	Tier 4	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ALOSETRON HCL 0.5 MG TABLET [Lotronex]	2	Tier 2	$0.00	N/A	None
ALOSETRON HCL 1 MG TABLET [Lotronex]	2	Tier 2	$0.00	N/A	None
ALOXI 0.25 MG/5 ML	4	Tier 4	$0.00	N/A	None
ALPHAGAN P 0.1% DROPS	4	Tier 4	$0.00	N/A	None
ALPHAGAN P 0.15% EYE DROPS	4	Tier 4	$0.00	N/A	None
ALPRAZOLAM 0.25 MG TABLET	2	Tier 2	$0.00	N/A	None
ALPRAZOLAM 0.5 MG TABLET	2	Tier 2	$0.00	N/A	None
ALPRAZOLAM 1 MG TABLET	2	Tier 2	$0.00	N/A	None
Alprazolam 1mg/1 10 BLISTER PACK per CARTON / 10 TABLET, ORALLY DISINTEGRATING per BLISTER PACK	2	Tier 2	$0.00	N/A	None
Alprazolam 1mg/mL 1 BOTTLE in 1 CONTAINER / 30 mL in 1 BOTTLE	2	Tier 2	$0.00	N/A	None
ALPRAZOLAM 2 MG TABLET	2	Tier 2	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Alprazolam 2mg/1 10 BLISTER PACK per CARTON / 10 TABLET, ORALLY DISINTEGRATING per BLISTER PACK	2	Tier 2	$0.00	N/A	None
ALPRAZOLAM ER 0.5 MG TABLET	2	Tier 2	$0.00	N/A	None
ALPRAZOLAM ER 1 MG TABLET	2	Tier 2	$0.00	N/A	None
ALPRAZOLAM ER 2 MG TABLET	2	Tier 2	$0.00	N/A	None
ALPRAZOLAM ER 3 MG TABLET	2	Tier 2	$0.00	N/A	None
ALPRAZOLAM ODT 0.25 MG TABLET	2	Tier 2	$0.00	N/A	None
ALPRAZOLAM ODT 0.5 MG TABLET	2	Tier 2	$0.00	N/A	None
ALREX 0.2% EYE DROPS	4	Tier 4	$0.00	N/A	None
ALTACE 1.25MG CAPSULE	4	Tier 4	$0.00	N/A	None
ALTACE 10MG CAPSULE (100 CT)	4	Tier 4	$0.00	N/A	None
ALTACE 2.5 MG CAPSULE	4	Tier 4	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ALTACE 5MG CAPSULE	4	Tier 4	$0.00	N/A	None
ALTAVERA-28 TABLET	2	Tier 2	$0.00	N/A	None
ALTOPREV 20 MG TABLET	4	Tier 4	$0.00	N/A	None
ALTOPREV 60 MG TABLET	4	Tier 4	$0.00	N/A	None
ALUNBRIG 180 MG TABLET	5	Tier 5	$0.00	N/A	None
ALUNBRIG 30 MG TABLET	5	Tier 5	$0.00	N/A	None
ALUNBRIG 90 MG TABLET	5	Tier 5	$0.00	N/A	None
ALUNBRIG 90 MG-180 MG TABLET PACK	5	Tier 5	$0.00	N/A	None
ALVESCO 160MCG/ACT AERS	4	Tier 4	$0.00	N/A	None
ALVESCO 80MCG/ACT AERS	4	Tier 4	$0.00	N/A	None
ALYACEN 1-35-28 TABLET	2	Tier 2	$0.00	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 28 TABLET/BLISTER PACK 3 PER CARTON	2	Tier 2	$0.00	N/A	None
Amabelz 1 MG/0.5 MG 28 TABLET/BLISTER PACK 3 PER CARTON	2	Tier 2	$0.00	N/A	None
AMANTADINE 100 MG CAPSULE	2	Tier 2	$0.00	N/A	None
AMANTADINE 100 MG TABLET	2	Tier 2	$0.00	N/A	None
AMANTADINE 50 MG/5 ML SOLUTION	2	Tier 2	$0.00	N/A	None
AMARYL 1MG TABLET	4	Tier 4	$0.00	N/A	None
AMARYL 2MG TABLET	4	Tier 4	$0.00	N/A	None
AMARYL 4MG TABLET	4	Tier 4	$0.00	N/A	None
AMBIEN 10 MG TABLET	4	Tier 4	$0.00	N/A	None
AMBIEN CR 12.5MG TABLET	4	Tier 4	$0.00	N/A	None
AMBIEN CR 6.25MG TABLET	4	Tier 4	$0.00	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	$0.00	N/A	None
AMBISOME 50MG VIAL	5	Tier 5	$0.00	N/A	None
AMCINONIDE 0.1% CREAM	2	Tier 2	$0.00	N/A	None
AMCINONIDE 0.1% LOTION	2	Tier 2	$0.00	N/A	None
AMCINONIDE 0.1% OINTMENT 60GM TUBE	2	Tier 2	$0.00	N/A	None
AMERGE 1MG TABLET	4	Tier 4	$0.00	N/A	None
AMERGE 2.5MG TABLET	4	Tier 4	$0.00	N/A	None
AMETHIA 0.15-0.03-0.01 MG TABLET	2	Tier 2	$0.00	N/A	None
AMETHIA LO TABLET	2	Tier 2	$0.00	N/A	None
AMIKACIN SULF 500 MG/2 ML VIAL	2	Tier 2	$0.00	N/A	None
AMILORIDE HCL 5 MG TABLET	2	Tier 2	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMILORIDE HCL-HCTZ 5-50 MG TABLET	1	Tier 1	$0.00	N/A	None
Amino Acids 15% Solution	2	Tier 2	$0.00	N/A	None
Amino acids 4.25% in dextrose 10% Injectable Solution [Clinimix 4.25/10]	3	Tier 3	$0.00	N/A	None
Amino acids 4.25% in dextrose 20% Injectable Solution [Clinimix 4.25/20]	3	Tier 3	$0.00	N/A	None
Amino acids 4.25% in dextrose 5% Injectable Solution [Clinimix 4.25/5]	3	Tier 3	$0.00	N/A	None
Amino acids 4.25% with electrolytes in dextrose 10% Injectable Solution [Clinimix E 4.25/10]	3	Tier 3	$0.00	N/A	None
Aminophylline 25 MG/ML 10 ML Injection	2	Tier 2	$0.00	N/A	None
AMINOSYN 7%-ELECTROLYTE SOL	4	Tier 4	$0.00	N/A	None
AMINOSYN HBC INJECTION SULFITE FREE 7%	4	Tier 4	$0.00	N/A	None
AMINOSYN II 10% SOL 6X2000 ML	4	Tier 4	$0.00	N/A	None
AMINOSYN II 15% IV SOLUTION	4	Tier 4	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMINOSYN II 8.5% ELECTROLYT	2	Tier 2	$0.00	N/A	None
AMINOSYN II 8.5% ELECTROLYT	4	Tier 4	$0.00	N/A	None
AMINOSYN PF INJECTION	4	Tier 4	$0.00	N/A	None
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5%	2	Tier 2	$0.00	N/A	None
AMINOSYN-PF 7% IV SOLUTION	4	Tier 4	$0.00	N/A	None
AMINOSYN-RF 5.2% IV SOLUTION	4	Tier 4	$0.00	N/A	None
AMIODARONE HCL 100 MG TABLET	2	Tier 2	$0.00	N/A	None
AMIODARONE HCL 200 MG TABLET	2	Tier 2	$0.00	N/A	None
AMIODARONE HCL 400 MG TABLET	2	Tier 2	$0.00	N/A	None
AMIODARONE HCL 50 MG/ML in 3 ML Injection	2	Tier 2	$0.00	N/A	None
AMITIZA 8MCG CAPSULE	4	Tier 4	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMITIZA CAPSULES 24MCG 60 CAP BOT	4	Tier 4	$0.00	N/A	None
AMITRIP/CDP 25-10 TABLET	2	Tier 2	$0.00	N/A	None
AMITRIP/PERPHEN 10-4 TABLET	2	Tier 2	$0.00	N/A	None
AMITRIP/PERPHEN 50-4 TABLET	2	Tier 2	$0.00	N/A	None
AMITRIPTYLINE HCL 10 MG TAB	2	Tier 2	$0.00	N/A	None
AMITRIPTYLINE HCL 100 MG TAB	2	Tier 2	$0.00	N/A	None
AMITRIPTYLINE HCL 150 MG TAB	2	Tier 2	$0.00	N/A	None
AMITRIPTYLINE HCL 25 MG TAB	2	Tier 2	$0.00	N/A	None
AMITRIPTYLINE HCL 50 MG TAB	2	Tier 2	$0.00	N/A	None
AMITRIPTYLINE HCL 75 MG TAB	2	Tier 2	$0.00	N/A	None
AMLOD-VALSA-HCTZ 10-160-12.5MG [Exforge HCT]	2	Tier 2	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMLOD-VALSA-HCTZ 10-160-25 MG [Exforge HCT]	2	Tier 2	$0.00	N/A	None
AMLOD-VALSA-HCTZ 10-320-25 MG [Exforge HCT]	2	Tier 2	$0.00	N/A	None
AMLOD-VALSA-HCTZ 5-160-12.5 MG [Exforge HCT]	2	Tier 2	$0.00	N/A	None
AMLOD-VALSA-HCTZ 5-160-25 MG [Exforge HCT]	2	Tier 2	$0.00	N/A	None
AMLODIPINE BESYLATE 10 MG TAB	1	Tier 1	$0.00	N/A	None
AMLODIPINE BESYLATE 2.5 MG TAB	1	Tier 1	$0.00	N/A	None
AMLODIPINE BESYLATE 5 MG TAB	1	Tier 1	$0.00	N/A	None
AMLODIPINE-ATORVAST 10-20 MG [Caduet]	2	Tier 2	$0.00	N/A	None
AMLODIPINE-ATORVAST 10-40 MG [Caduet]	2	Tier 2	$0.00	N/A	None
Amlodipine-Atorvastatin 10-10 mg [Caduet]	2	Tier 2	$0.00	N/A	None
Amlodipine-Atorvastatin 10-80 mg [Caduet]	2	Tier 2	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Amlodipine-Atorvastatin 2.5-10 mg [Caduet]	2	Tier 2	$0.00	N/A	None
Amlodipine-Atorvastatin 2.5-20 mg [Caduet]	2	Tier 2	$0.00	N/A	None
Amlodipine-Atorvastatin 2.5-40 mg [Caduet]	2	Tier 2	$0.00	N/A	None
Amlodipine-Atorvastatin 5-10 mg [Caduet]	2	Tier 2	$0.00	N/A	None
Amlodipine-Atorvastatin 5-20 mg [Caduet]	2	Tier 2	$0.00	N/A	None
Amlodipine-Atorvastatin 5-40 mg [Caduet]	2	Tier 2	$0.00	N/A	None
Amlodipine-Atorvastatin 5-80 mg [Caduet]	2	Tier 2	$0.00	N/A	None
AMLODIPINE-BENAZEPRIL 10-20 MG Capsule [Lotrel]	2	Tier 2	$0.00	N/A	None
AMLODIPINE-BENAZEPRIL 10-40 MG Capsule [Lotrel]	2	Tier 2	$0.00	N/A	None
AMLODIPINE-BENAZEPRIL 2.5-10 Capsule [Lotrel]	2	Tier 2	$0.00	N/A	None
AMLODIPINE-BENAZEPRIL 5-10 MG Capsule [Lotrel]	2	Tier 2	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMLODIPINE-BENAZEPRIL 5-20 MG Capsule [Lotrel]	2	Tier 2	$0.00	N/A	None
AMLODIPINE-BENAZEPRIL 5-40 MG Capsule [Lotrel]	2	Tier 2	$0.00	N/A	None
AMLODIPINE-OLMESARTAN 10-20 MG [Azor]	2	Tier 2	$0.00	N/A	None
AMLODIPINE-OLMESARTAN 10-40 MG [Azor]	2	Tier 2	$0.00	N/A	None
AMLODIPINE-OLMESARTAN 5-20 MG [Azor]	2	Tier 2	$0.00	N/A	None
AMLODIPINE-OLMESARTAN 5-40 MG [Azor]	2	Tier 2	$0.00	N/A	None
AMLODIPINE-VALSARTAN 10-160 MG	2	Tier 2	$0.00	N/A	None
AMLODIPINE-VALSARTAN 10-320 MG	2	Tier 2	$0.00	N/A	None
AMLODIPINE-VALSARTAN 5-160 MG	2	Tier 2	$0.00	N/A	None
AMLODIPINE-VALSARTAN 5-320 MG	2	Tier 2	$0.00	N/A	None
AMMONIUM LACTATE 12% CREAM	2	Tier 2	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMMONIUM LACTATE 12% LOTION	2	Tier 2	$0.00	N/A	None
AMNESTEEM 10 MG CAPSULE	2	Tier 2	$0.00	N/A	None
AMNESTEEM 20 MG CAPSULE	2	Tier 2	$0.00	N/A	None
AMNESTEEM 40 MG CAPSULE	2	Tier 2	$0.00	N/A	None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE [Augmentin]	2	Tier 2	$0.00	N/A	None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET [Augmentin]	2	Tier 2	$0.00	N/A	None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE [Augmentin]	2	Tier 2	$0.00	N/A	None
AMOX-CLAV 200-28.5 MG/5 ML SUS	2	Tier 2	$0.00	N/A	None
AMOX-CLAV 250-62.5 MG/5 ML SUS	2	Tier 2	$0.00	N/A	None
AMOX-CLAV 400-57 MG/5 ML SUSP	2	Tier 2	$0.00	N/A	None
AMOX-CLAV 500-125 MG TABLET [Augmentin]	2	Tier 2	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMOX-CLAV 600-42.9 MG/5 ML SUS	2	Tier 2	$0.00	N/A	None
AMOX-CLAV 875-125 MG TABLET [Augmentin]	2	Tier 2	$0.00	N/A	None
AMOX-CLAV ER 1,000-62.5 MG TABLET [Augmentin]	2	Tier 2	$0.00	N/A	None
AMOXAPINE 100MG TABLET	2	Tier 2	$0.00	N/A	None
AMOXAPINE 150MG TABLET	2	Tier 2	$0.00	N/A	None
AMOXAPINE 25MG TABLET	2	Tier 2	$0.00	N/A	None
AMOXAPINE 50MG TABLET	2	Tier 2	$0.00	N/A	None
AMOXICILLIN 125 MG/5 ML SUSP	2	Tier 2	$0.00	N/A	None
AMOXICILLIN 125MG TABLET CHEW	2	Tier 2	$0.00	N/A	None
AMOXICILLIN 200 MG/5 ML SUSP	2	Tier 2	$0.00	N/A	None
AMOXICILLIN 250 MG CAPSULE	2	Tier 2	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMOXICILLIN 250 MG TAB CHEW	2	Tier 2	$0.00	N/A	None
AMOXICILLIN 250 MG/5 ML SUSP	2	Tier 2	$0.00	N/A	None
AMOXICILLIN 400 MG/5 ML SUSP	2	Tier 2	$0.00	N/A	None
AMOXICILLIN 500 MG CAPSULE	2	Tier 2	$0.00	N/A	None
AMOXICILLIN 500 MG TABLET	2	Tier 2	$0.00	N/A	None
AMOXICILLIN 875 MG TABLET	2	Tier 2	$0.00	N/A	None
AMPHETAMINE SALT COMBO 12.5MG TABLET	2	Tier 2	$0.00	N/A	None
AMPHETAMINE SALT COMBO 15MG TABLET	2	Tier 2	$0.00	N/A	None
AMPHETAMINE SALT COMBO 7.5MG TABLET	2	Tier 2	$0.00	N/A	None
AMPHETAMINE SALTS 5 MG TAB	2	Tier 2	$0.00	N/A	None
amphotericin b 50mg/10mL 10 mL in 1 VIAL	2	Tier 2	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMPICILLIN 10 GM VIAL	2	Tier 2	$0.00	N/A	None
Ampicillin 1000 MG / Sulbactam 500 MG Injection	2	Tier 2	$0.00	N/A	None
Ampicillin 1000 MG Injection	2	Tier 2	$0.00	N/A	None
Ampicillin 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS	2	Tier 2	$0.00	N/A	None
Ampicillin 2000 MG / Sulbactam 1000 MG Injection	2	Tier 2	$0.00	N/A	None
AMPICILLIN CAPSULES 500MG 100 BOT	2	Tier 2	$0.00	N/A	None
AMPICILLIN-SULBACTAM 15 GM VL	2	Tier 2	$0.00	N/A	None
AMPYRA ER 10 MG TABLET	5	Tier 5	$0.00	N/A	None
AMRIX 30 MG	4	Tier 4	$0.00	N/A	P
AMRIX CAPSULES EXTENDED RELEASE 15MG 60 CAPSULES BOT	4	Tier 4	$0.00	N/A	P
ANADROL-50 TABLET	4	Tier 4	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ANAFRANIL 25 MG 30 CAPSULE BOTTLE	4	Tier 4	$0.00	N/A	None
ANAFRANIL 50 MG 30 CAPSULE BOTTLE	4	Tier 4	$0.00	N/A	None
ANAFRANIL 75 MG 30 CAPSULE BOTTLE	4	Tier 4	$0.00	N/A	None
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE	2	Tier 2	$0.00	N/A	None
Anagrelide Hydrochloride 1mg/1 100 CAPSULE BOTTLE	2	Tier 2	$0.00	N/A	None
ANASTROZOLE 1 MG TABLET	2	Tier 2	$0.00	N/A	None
ANCOBON 250MG CAPSULE	5	Tier 5	$0.00	N/A	None
ANCOBON 500MG CAPSULE	5	Tier 5	$0.00	N/A	None
ANDRODERM 2 MG/24HR PATCH	3	Tier 3	$0.00	N/A	None
ANDRODERM 4 MG/24HR PATCH	3	Tier 3	$0.00	N/A	None
ANDROGEL 1.62% (1.25G) GEL PCKT	4	Tier 4	$0.00	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	$0.00	N/A	None
ANDROGEL 1% (50MG) GEL PACKET	4	Tier 4	$0.00	N/A	None
Androgel 10mg/g 30 PACKET in 1 CARTON / 2.5 g in 1 PACKET	4	Tier 4	$0.00	N/A	None
Androgel 16.2mg/g 1 BOTTLE, PUMP per CARTON / 88 g in 1 BOTTLE, PUMP	4	Tier 4	$0.00	N/A	None
ANDROID 10 MG CAPSULE	4	Tier 4	$0.00	N/A	None
Angeliq 0.25/0.5 28 Day Pack	4	Tier 4	$0.00	N/A	None
ANGELIQ 1-0.5MG TABLET	4	Tier 4	$0.00	N/A	None
ANORO ELLIPTA 62.5-25 MCG INH	4	Tier 4	$0.00	N/A	None
ANTABUSE 250MG TABLET	2	Tier 2	$0.00	N/A	None
ANTABUSE 500MG TABLET	2	Tier 2	$0.00	N/A	None
ANTARA 30 MG CAPSULE	4	Tier 4	$0.00	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	$0.00	N/A	None
Antineoplastic Agent Etoposide 20 mg / mL Intravenous Injection Multiple Dose Vial 5 mL	2	Tier 2	$0.00	N/A	None
ANUSOL-HC 2.5% CREAM	2	Tier 2	$0.00	N/A	None
ANZEMET 100 MG TABLET	4	Tier 4	$0.00	N/A	P
ANZEMET 50 MG TABLET	4	Tier 4	$0.00	N/A	P
APEXICON E 0.05% CREAM	2	Tier 2	$0.00	N/A	None
APIDRA 100 UNITS/ML VIAL	4	Tier 4	$0.00	N/A	P
APIDRA SOLOSTAR 100 UNITS/ML	4	Tier 4	$0.00	N/A	None
APLENZIN ER 174 MG TABLET	4	Tier 4	$0.00	N/A	None
APLENZIN ER 348 MG TABLET	4	Tier 4	$0.00	N/A	None
APLENZIN ER 522 MG TABLET	4	Tier 4	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
APOKYN 30 MG/3 ML CARTRIDGE	5	Tier 5	$0.00	N/A	None
Apraclonidine 5 MG/ML Ophthalmic Solution	2	Tier 2	$0.00	N/A	None
APREPITANT 125 MG CAPSULE [Emend]	2	Tier 2	$0.00	N/A	P
APREPITANT 125-80-80 MG PACK [Emend]	2	Tier 2	$0.00	N/A	P
APREPITANT 40 MG CAPSULE [Emend]	2	Tier 2	$0.00	N/A	P
APREPITANT 80 MG CAPSULE [Emend]	2	Tier 2	$0.00	N/A	P
APRI 0.15-0.03 TABLET	2	Tier 2	$0.00	N/A	None
APRISO CP24	4	Tier 4	$0.00	N/A	None
APTENSIO XR 10 MG CAPSULE	3	Tier 3	$0.00	N/A	None
APTENSIO XR 15 MG CAPSULE	3	Tier 3	$0.00	N/A	None
APTENSIO XR 20 MG CAPSULE	3	Tier 3	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
APTENSIO XR 30 MG CAPSULE	3	Tier 3	$0.00	N/A	None
APTENSIO XR 40 MG CAPSULE	3	Tier 3	$0.00	N/A	None
APTENSIO XR 50 MG CAPSULE	3	Tier 3	$0.00	N/A	None
APTENSIO XR 60 MG CAPSULE	3	Tier 3	$0.00	N/A	None
APTIOM 200 MG TABLET	4	Tier 4	$0.00	N/A	None
APTIOM 400 MG TABLET	4	Tier 4	$0.00	N/A	None
APTIOM 600 MG TABLET	4	Tier 4	$0.00	N/A	None
APTIOM 800 MG TABLET	4	Tier 4	$0.00	N/A	None
APTIVUS 250MG CAPSULE	3	Tier 3	$0.00	N/A	None
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT	3	Tier 3	$0.00	N/A	None
ARALAST NP 1,000 MG VIAL	5	Tier 5	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ARANELLE 7-9-5 TABLET	2	Tier 2	$0.00	N/A	None
ARANESP 10 MCG/0.4 ML SYRINGE	4	Tier 4	$0.00	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	$0.00	N/A	P
ARANESP 100ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE	4	Tier 4	$0.00	N/A	P
ARANESP 200MCG/0.4ML SYRINGE	4	Tier 4	$0.00	N/A	P
ARANESP 200MCG/ML VIAL	4	Tier 4	$0.00	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	$0.00	N/A	P
ARANESP 25ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE	4	Tier 4	$0.00	N/A	P
ARANESP 300MCG/ML VIAL	4	Tier 4	$0.00	N/A	P
ARANESP 500MCG/1ML SYRINGE	4	Tier 4	$0.00	N/A	P
ARANESP 60MCG/ML VIAL	4	Tier 4	$0.00	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ARANESP 60ug/0.3mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.3 mL in 1 SYRINGE	4	Tier 4	$0.00	N/A	P
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR	4	Tier 4	$0.00	N/A	P
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR	4	Tier 4	$0.00	N/A	P
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR	4	Tier 4	$0.00	N/A	P
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD	4	Tier 4	$0.00	N/A	P
ARAVA 10MG TABLET	4	Tier 4	$0.00	N/A	None
ARAVA 20MG TABLET	4	Tier 4	$0.00	N/A	None
ARCALYST INJECTION 220MG/VIAL	5	Tier 5	$0.00	N/A	None
ARCAPTA NEOHALER 75 MCG CAP	4	Tier 4	$0.00	N/A	None
Argatroban 125mg/125mL 2 VIAL, SINGLE-USE per CARTON / 125 mL in 1 VIAL, SINGLE-USE	4	Tier 4	$0.00	N/A	None
ARGATROBAN 250 MG VL 2.5 ML	2	Tier 2	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ARICEPT 10MG TABLET	4	Tier 4	$0.00	N/A	None
ARICEPT 23 MG TABLETS	4	Tier 4	$0.00	N/A	None
ARICEPT 5MG TABLET	4	Tier 4	$0.00	N/A	None
ARIMIDEX 1MG TABLET	4	Tier 4	$0.00	N/A	None
ARIPIPRAZOLE 1 MG/ML SOLUTION [Abilify]	2	Tier 2	$0.00	N/A	None
ARIPIPRAZOLE 10 MG TABLET [Abilify]	2	Tier 2	$0.00	N/A	None
ARIPIPRAZOLE 15 MG TABLET [Abilify]	2	Tier 2	$0.00	N/A	None
ARIPIPRAZOLE 2 MG TABLET [Abilify]	2	Tier 2	$0.00	N/A	None
ARIPIPRAZOLE 20 MG TABLET [Abilify]	2	Tier 2	$0.00	N/A	None
ARIPIPRAZOLE 30 MG TABLET [Abilify]	2	Tier 2	$0.00	N/A	None
ARIPIPRAZOLE 5 MG TABLET [Abilify]	2	Tier 2	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ARIPIPRAZOLE ODT 10 MG TABLET [Abilify]	2	Tier 2	$0.00	N/A	None
ARIPIPRAZOLE ODT 15 MG TABLET [Abilify]	2	Tier 2	$0.00	N/A	None
ARISTADA ER 1064 MG/3.9 ML SYR	5	Tier 5	$0.00	N/A	None
ARISTADA ER 441 MG/1.6 ML SYRN	5	Tier 5	$0.00	N/A	None
ARISTADA ER 662 MG/2.4 ML SYRN	5	Tier 5	$0.00	N/A	None
ARISTADA ER 882 MG/3.2 ML SYRN	5	Tier 5	$0.00	N/A	None
ARIXTRA 7.5 MG/0.6 ML SYRINGE	5	Tier 5	$0.00	N/A	None
Armodafinil 150 MG TABLET [NUVIGIL]	2	Tier 2	$0.00	N/A	P
Armodafinil 200 MG Oral Tablet [NUVIGIL]	2	Tier 2	$0.00	N/A	P
Armodafinil 250 MG TABLET [NUVIGIL]	2	Tier 2	$0.00	N/A	P
Armodafinil 50 MG TABLET [NUVIGIL]	2	Tier 2	$0.00	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ARMONAIR RESPICLICK 113 MCG	4	Tier 4	$0.00	N/A	None
ARMONAIR RESPICLICK 232 MCG	4	Tier 4	$0.00	N/A	None
ARMONAIR RESPICLICK 55 MCG	4	Tier 4	$0.00	N/A	None
ARNUITY ELLIPTA 100 MCG INH	4	Tier 4	$0.00	N/A	None
ARNUITY ELLIPTA 200 MCG INH	4	Tier 4	$0.00	N/A	None
ARNUITY ELLIPTA 50 MCG INH BLST W/DEV	4	Tier 4	$0.00	N/A	None
AROMASIN 25MG TABLET	4	Tier 4	$0.00	N/A	None
ARRANON 250 MG VIAL	3	Tier 3	$0.00	N/A	None
ARTHROTEC 50 50MG TABLET -200MCG (60 CT)	4	Tier 4	$0.00	N/A	None
ARTHROTEC 75 TABLET EC	4	Tier 4	$0.00	N/A	None
ASACOL HD DR 800 MG TABLET	4	Tier 4	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ASCOMP WITH CODEINE CAPSULE	2	Tier 2	$0.00	N/A	None
ASHLYNA 0.15-0.03-0.01 MG TAB	2	Tier 2	$0.00	N/A	None
ASMANEX HFA 100 MCG INHALER	3	Tier 3	$0.00	N/A	None
ASMANEX HFA 200 MCG INHALER	3	Tier 3	$0.00	N/A	None
ASMANEX TWISTHALER 110 MCG #30	3	Tier 3	$0.00	N/A	None
ASMANEX TWISTHALER 220 MCG #30	4	Tier 4	$0.00	N/A	None
ASMANEX TWISTHALER 220MCG #120	3	Tier 3	$0.00	N/A	None
ASMANEX TWISTHALER 220MCG #60	3	Tier 3	$0.00	N/A	None
Aspirin-Diphenhydramine ER 25-200 MG	2	Tier 2	$0.00	N/A	None
ASPIRIN/BUTALBITAL/CAFFEINE/CODEINE	2	Tier 2	$0.00	N/A	None
ASTAGRAF XL 0.5 MG CAPSULE	4	Tier 4	$0.00	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ASTAGRAF XL 1 MG CAPSULE	4	Tier 4	$0.00	N/A	P
ASTAGRAF XL 5 MG CAPSULE	5	Tier 5	$0.00	N/A	P
ASTEPRO 0.15% NASAL SPRAY 30 ML	4	Tier 4	$0.00	N/A	None
ATACAND 16MG TABLET	4	Tier 4	$0.00	N/A	None
ATACAND 32 MG TABLET	4	Tier 4	$0.00	N/A	None
ATACAND 4MG TABLET	4	Tier 4	$0.00	N/A	None
ATACAND 8MG TABLET	4	Tier 4	$0.00	N/A	None
ATACAND HCT 16/12.5MG TABLET	4	Tier 4	$0.00	N/A	None
ATACAND HCT 32/12.5MG TABLET	4	Tier 4	$0.00	N/A	None
ATACAND HCT TABLETS 32;25MG;MG 90 TABLET BOTTLE	4	Tier 4	$0.00	N/A	None
ATAZANAVIR SULFATE 150 MG CAP [Reyataz]	2	Tier 2	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ATAZANAVIR SULFATE 200 MG CAP [Reyataz]	2	Tier 2	$0.00	N/A	None
ATAZANAVIR SULFATE 300 MG CAP [Reyataz]	2	Tier 2	$0.00	N/A	None
Atelvia 35mg/1 36 DOSE PACK CASE / 4 TABLET, DELAYED RELEASE in 1 DOSE PACK	4	Tier 4	$0.00	N/A	None
ATENOLOL 100 MG TABLET	1	Tier 1	$0.00	N/A	None
ATENOLOL 25 MG TABLET	1	Tier 1	$0.00	N/A	None
ATENOLOL 50 MG TABLET	1	Tier 1	$0.00	N/A	None
ATENOLOL-CHLORTHALIDONE 100-25	2	Tier 2	$0.00	N/A	None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)	2	Tier 2	$0.00	N/A	None
ATGAM 50MG/ML AMPUL	4	Tier 4	$0.00	N/A	None
ATIVAN 0.5 MG TABLET	4	Tier 4	$0.00	N/A	None
ATIVAN 1 MG TABLET	4	Tier 4	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ATIVAN 1 MG TABLET	4	Tier 4	$0.00	N/A	None
ATIVAN 2 MG TABLET	4	Tier 4	$0.00	N/A	None
ATOMOXETINE HCL 10 MG CAPSULE [Strattera]	2	Tier 2	$0.00	N/A	None
ATOMOXETINE HCL 100 MG CAPSULE [Strattera]	2	Tier 2	$0.00	N/A	None
ATOMOXETINE HCL 18 MG CAPSULE [Strattera]	2	Tier 2	$0.00	N/A	None
ATOMOXETINE HCL 25 MG CAPSULE [Strattera]	2	Tier 2	$0.00	N/A	None
ATOMOXETINE HCL 40 MG CAPSULE [Strattera]	2	Tier 2	$0.00	N/A	None
ATOMOXETINE HCL 60 MG CAPSULE [Strattera]	2	Tier 2	$0.00	N/A	None
ATOMOXETINE HCL 80 MG CAPSULE [Strattera]	2	Tier 2	$0.00	N/A	None
ATORVASTATIN 10 MG TABLET [Lipitor]	1	Tier 1	$0.00	N/A	None
ATORVASTATIN 20 MG TABLET [Lipitor]	1	Tier 1	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ATORVASTATIN 40 MG TABLET [Lipitor]	1	Tier 1	$0.00	N/A	None
ATORVASTATIN 80 MG TABLET [Lipitor]	1	Tier 1	$0.00	N/A	None
ATOVAQUONE 750 MG/5 ML SUSP [Mepron]	2	Tier 2	$0.00	N/A	None
Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone]	2	Tier 2	$0.00	N/A	None
ATOVAQUONE-PROGUANIL 62.5-25 [Malarone]	2	Tier 2	$0.00	N/A	None
ATRALIN 0.05% GEL	4	Tier 4	$0.00	N/A	P
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC	3	Tier 3	$0.00	N/A	None
ATROPINE 0.05MG/ML SYRINGE	4	Tier 4	$0.00	N/A	None
ATROPINE 1% EYE DROPS	4	Tier 4	$0.00	N/A	None
ATROVENT HFA AER 17MCG	3	Tier 3	$0.00	N/A	None
AUBAGIO 14 MG TABLET	5	Tier 5	$0.00	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AUBAGIO 7 MG TABLET	5	Tier 5	$0.00	N/A	P
AUBRA-28 TABLET	2	Tier 2	$0.00	N/A	None
AUGMENTIN 125-31.25 MG/5 ML	3	Tier 3	$0.00	N/A	None
AURYXIA 210 MG TABLET	4	Tier 4	$0.00	N/A	None
AUSTEDO 12 MG TABLET	5	Tier 5	$0.00	N/A	None
AUSTEDO 6 MG TABLET	5	Tier 5	$0.00	N/A	None
AUSTEDO 9 MG TABLET	5	Tier 5	$0.00	N/A	None
AUVI-Q 0.1 MG AUTO-INJECTOR	5	Tier 5	$0.00	N/A	None
AUVI-Q 0.15 MG AUTO-INJECTOR	5	Tier 5	$0.00	N/A	None
AUVI-Q 0.3 MG AUTO-INJECTOR	5	Tier 5	$0.00	N/A	None
AVALIDE 150-12.5 MG TABLET	4	Tier 4	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AVALIDE 300-12.5 MG TABLET	4	Tier 4	$0.00	N/A	None
AVANDIA 2 MG TABLET	4	Tier 4	$0.00	N/A	None
AVANDIA 4 MG TABLET	4	Tier 4	$0.00	N/A	None
AVAPRO 150 MG TABLET	4	Tier 4	$0.00	N/A	None
AVAPRO 300 MG TABLET	4	Tier 4	$0.00	N/A	None
AVAPRO 75 MG TABLET	4	Tier 4	$0.00	N/A	None
AVASTIN 100MG/4ML VIAL	3	Tier 3	$0.00	N/A	None
AVASTIN 400 MG/16 ML VIAL	3	Tier 3	$0.00	N/A	None
AVC 15% CREAM	3	Tier 3	$0.00	N/A	None
AVEED 750 MG/3 ML VIAL	4	Tier 4	$0.00	N/A	None
AVELOX 400 MG TABLET	4	Tier 4	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AVELOX IV 400 MG/250 ML	3	Tier 3	$0.00	N/A	None
AVIANE 0.1-0.02 TABLET	2	Tier 2	$0.00	N/A	None
AVITA 0.025% CREAM	2	Tier 2	$0.00	N/A	P
Avita 0.25mg/g 45 g in 1 TUBE	2	Tier 2	$0.00	N/A	P
AVODART 0.5 MG SOFTGEL	4	Tier 4	$0.00	N/A	None
AVONEX ADMIN PACK 30 MCG VL	5	Tier 5	$0.00	N/A	None
AVONEX PEN 30 MCG/0.5 ML KIT	5	Tier 5	$0.00	N/A	None
AVONEX PREFILLED SYR 30 MCG KT	5	Tier 5	$0.00	N/A	None
AVYCAZ 2.5 GRAM VIAL	4	Tier 4	$0.00	N/A	None
AXERT 12.5 MG TABLET	4	Tier 4	$0.00	N/A	None
Aygestin 5mg/1 50 TABLET BOTTLE	2	Tier 2	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Azacitidine 100 mg vial [Vidaza]	2	Tier 2	$0.00	N/A	None
AZASAN 100MG TABLET	2	Tier 2	$0.00	N/A	P
AZASAN 75MG TABLET	2	Tier 2	$0.00	N/A	P
AZASITE 1% EYE DROPS	4	Tier 4	$0.00	N/A	None
AZATHIOPRINE 50 MG TABLET	2	Tier 2	$0.00	N/A	P
AZATHIOPRINE SODIUM 100 MG VIAL	2	Tier 2	$0.00	N/A	None
AZELASTINE 0.15% NASAL SPRAY	2	Tier 2	$0.00	N/A	None
AZELASTINE 137 MCG NASAL SPRAY	2	Tier 2	$0.00	N/A	None
AZELASTINE HCL 0.05% DROPS	2	Tier 2	$0.00	N/A	None
AZELEX 20% CREAM 30GM TUBE	3	Tier 3	$0.00	N/A	None
AZILECT 0.5MG TABLET	4	Tier 4	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AZILECT 1MG TABLET	4	Tier 4	$0.00	N/A	None
AZITHROMYCIN 1 GM PWD PACKET	3	Tier 3	$0.00	N/A	None
AZITHROMYCIN 100 MG/5 ML SUSP	2	Tier 2	$0.00	N/A	None
AZITHROMYCIN 200 MG/5 ML SUSP	2	Tier 2	$0.00	N/A	None
AZITHROMYCIN 250 MG TABLET	2	Tier 2	$0.00	N/A	None
AZITHROMYCIN 250 MG TABLET	2	Tier 2	$0.00	N/A	None
AZITHROMYCIN 500 MG TABLET	2	Tier 2	$0.00	N/A	None
Azithromycin 500mg/1 30 FILM COATED TABLETS in BOTTLE	2	Tier 2	$0.00	N/A	None
AZITHROMYCIN 600 MG TABLET	2	Tier 2	$0.00	N/A	None
AZITHROMYCIN I.V. 500 MG VIAL	2	Tier 2	$0.00	N/A	None
AZOPT 1% EYE DROPS	4	Tier 4	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AZOR 10-20 MG TABLET	4	Tier 4	$0.00	N/A	None
AZOR 10MG-40MG TABLET (30 CT)	4	Tier 4	$0.00	N/A	None
AZOR 5-40 MG TABLET	4	Tier 4	$0.00	N/A	None
AZOR 5MG-20MG TABLET (30 CT)	4	Tier 4	$0.00	N/A	None
Aztreonam 1000 MG Injection [Azactam]	3	Tier 3	$0.00	N/A	None
Aztreonam 2000 MG Injection [Azactam]	3	Tier 3	$0.00	N/A	None
AZTREONAM FOR INJECTION	2	Tier 2	$0.00	N/A	None
AZULFIDINE 500 MG TABLET	4	Tier 4	$0.00	N/A	None
AZULFIDINE ENTAB 500 MG	4	Tier 4	$0.00	N/A	None

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Chart Legend:

Below are a few notes to help you understand the above 2018 Medicare Part D Senior Advantage Medicare Medi-Cal Plan North (HMO SNP) 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). The plan name is followed by the plan type (PDP, HMO, HMO-POS, PPO, PFFS, etc.)
  
  
• 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 $405 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 five (5) tiers 1=Preferred Generics, 2=Generics, 3=Preferred Brands, 4=Non-preferred Brands, 5=Specialty Drugs. *Some Part D plans exclude one or more drug tiers from the deductible. If the drug tier field above is followed by * (example: 2*), then this drug tier is excluded from the plan’s deductible.
  • Tier 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 $3750) at a "Preferred" network pharmacy. In most cases, the "Preferred" network network pharmacy cost-sharing is lower than the standard (non-preferred) network pharmacy cost-sharing.
  • 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 2018 )

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.