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Medica Prime Solution Thrift w/Rx (Cost) (H2450-007-0)
Tier 1 (327)
Tier 2 (452)
Tier 3 (933)
Tier 4 (927)
Tier 5 (633)
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M N O P Q R S T U V W X Y Z 0-9 
2018 Medicare Part D Plan Formulary Information
Medica Prime Solution Thrift w/Rx (Cost) (H2450-007-0)
Benefit Details           
The Medica Prime Solution Thrift w/Rx (Cost) (H2450-007-0)
Formulary Drugs Starting with the Letter C
in Wright County, MN: CMS MA Region 19 which includes: MN
Plan Monthly Premium: $77.40 Deductible: $260
Drugs Starting with Letter C

Drug Name		 Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order
CABERGOLINE 0.5 MG TABLET   4 Non-Preferred Drug 50%N/ANone
CABOMETYX 20 MG TABLET   5 Specialty Tier 27%N/AP Q:30
/30Days
CABOMETYX 40 MG TABLET   5 Specialty Tier 27%N/AP Q:30
/30Days
CABOMETYX 60 MG TABLET   5 Specialty Tier 27%N/AP Q:30
/30Days
CALCIPOTRIENE 0.005% CREAM   4 Non-Preferred Drug 50%N/ANone
CALCIPOTRIENE 0.005% SOLUTION   4 Non-Preferred Drug 50%N/ANone
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY   3 Preferred Brand $28.00N/AP
CALCITRIOL 0.25 MCG CAPSULE [Rocaltrol]   3 Preferred Brand $28.00N/AP
CALCITRIOL 0.5 MCG CAPSULE [Rocaltrol]   3 Preferred Brand $28.00N/AP
Calcitriol 1 MCG per 1 ML Injection   4 Non-Preferred Drug 50%N/AP
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CALCITRIOL 1MCG/ML SOLUTION ORAL   4 Non-Preferred Drug 50%N/AP
CALCIUM ACETATE 667 MG TABLET   3 Preferred Brand $28.00N/AQ:360
/30Days
CALCIUM ACETATE CAPSULE 667 MG   3 Preferred Brand $28.00N/AQ:360
/30Days
Calcium Chloride 0.002 MEQ/ML / Potassium Chloride 0.004 MEQ/ML / Sodium Chloride 0.147 MEQ/ML Injec   2 Generic $6.00N/ANone
CALQUENCE 100 MG CAPSULE   5 Specialty Tier 27%N/AP
CAMILA 0.35 MG TABLET   2 Generic $6.00N/ANone
CANASA 1,000 MG SUPPOSITORY   4 Non-Preferred Drug 50%N/ANone
CANCIDAS IV 50MG VIAL   5 Specialty Tier 27%N/ANone
CANCIDAS IV 70MG VIAL   5 Specialty Tier 27%N/ANone
CAPASTAT SULFATE 1g/1 1 INJECTION, POWDER, FOR SOLUTION per CARTON   4 Non-Preferred Drug 50%N/ANone
CAPRELSA 100 MG TABLET   5 Specialty Tier 27%N/AP
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CAPRELSA 300 MG TABLET   5 Specialty Tier 27%N/AP
CAPTOPRIL 100MG TABLET   1 Preferred Generic $2.00N/ANone
CAPTOPRIL 12.5MG TABLET   1 Preferred Generic $2.00N/ANone
CAPTOPRIL 25 MG TABLET   1 Preferred Generic $2.00N/ANone
CAPTOPRIL 50MG TABLET   1 Preferred Generic $2.00N/ANone
Captopril and Hydrochlorothiazide 25; 15mg 100 TABLET BOTTLE   1 Preferred Generic $2.00N/ANone
Captopril and Hydrochlorothiazide 25; 25mg 100 TABLET BOTTLE   1 Preferred Generic $2.00N/ANone
Captopril and Hydrochlorothiazide 50; 15mg 100 TABLET BOTTLE   1 Preferred Generic $2.00N/ANone
Captopril and Hydrochlorothiazide 50; 25mg 100 TABLET BOTTLE   1 Preferred Generic $2.00N/ANone
CARBAGLU 200 MG DISPER TABLET   5 Specialty Tier 27%N/AP
CARBAMAZEPINE 100 MG TAB CHEW   3 Preferred Brand $28.00N/ANone
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CARBAMAZEPINE 100 MG/5 ML SUSP   4 Non-Preferred Drug 50%N/ANone
CARBAMAZEPINE 200 MG TABLET   3 Preferred Brand $28.00N/ANone
CARBAMAZEPINE ER 100 MG CAP CPMP 12HR [Carbatrol]   4 Non-Preferred Drug 50%N/ANone
CARBAMAZEPINE ER 100 MG TABLET   4 Non-Preferred Drug 50%N/ANone
CARBAMAZEPINE ER 200 MG CAP CPMP 12HR [Carbatrol]   4 Non-Preferred Drug 50%N/ANone
CARBAMAZEPINE ER 300 MG CAP CPMP 12HR [Carbatrol]   4 Non-Preferred Drug 50%N/ANone
CARBAMAZEPINE XR 200 MG TABLET   4 Non-Preferred Drug 50%N/ANone
CARBAMAZEPINE XR 400 MG TABLET   4 Non-Preferred Drug 50%N/ANone
CARBIDOPA AND LEVEDOPA ORALLY DISINTEGRATING TABLETS 10;100MG;MG 100 BOT   4 Non-Preferred Drug 50%N/ANone
CARBIDOPA AND LEVODOPA ODT 25;100MG;MG 100 BOT   4 Non-Preferred Drug 50%N/ANone
CARBIDOPA AND LEVODOPA ODT 25;250MG;MG 100 BOT   4 Non-Preferred Drug 50%N/ANone
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CARBIDOPA-LEVO ER 25-100 TAB   3 Preferred Brand $28.00N/ANone
CARBIDOPA-LEVO ER 50-200 TAB   3 Preferred Brand $28.00N/ANone
CARBIDOPA-LEVODOPA 10-100 TAB   2 Generic $6.00N/ANone
CARBIDOPA-LEVODOPA 25-100 TAB   2 Generic $6.00N/ANone
CARBIDOPA-LEVODOPA 25-250 TAB   2 Generic $6.00N/ANone
CARBIDOPA-LEVODOPA-ENTA 150 MG   4 Non-Preferred Drug 50%N/ANone
CARBIDOPA-LEVODOPA-ENTA 75 MG   4 Non-Preferred Drug 50%N/ANone
CARBIDOPA-LEVODOPA-ENTACAPONE 100 MG [Stalevo]   4 Non-Preferred Drug 50%N/ANone
CARBIDOPA-LEVODOPA-ENTACAPONE 125 MG [Stalevo]   4 Non-Preferred Drug 50%N/ANone
CARBIDOPA-LEVODOPA-ENTACAPONE 200 MG [Stalevo]   4 Non-Preferred Drug 50%N/ANone
CARBIDOPA-LEVODOPA-ENTACAPONE 50 MG [Stalevo]   4 Non-Preferred Drug 50%N/ANone
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Carboplatin 10 MG/ML Injectable Solution   3 Preferred Brand $28.00N/AP
CARIMUNE NF 6GM VIAL   5 Specialty Tier 27%N/AP
CARTEOLOL HCL 1% EYE DROPS   2 Generic $6.00N/ANone
CARTIA XT 120MG CAPSULE SA   3 Preferred Brand $28.00N/ANone
CARTIA XT 180MG CAPSULE SA   3 Preferred Brand $28.00N/ANone
CARTIA XT 240MG CAPSULE SA   3 Preferred Brand $28.00N/ANone
CARTIA XT 300 MG CAPSULE   3 Preferred Brand $28.00N/ANone
CARVEDILOL 12.5 MG TABLET   1 Preferred Generic $2.00N/ANone
CARVEDILOL 25 MG TABLET   1 Preferred Generic $2.00N/ANone
CARVEDILOL 3.125 MG TABLET   1 Preferred Generic $2.00N/ANone
CARVEDILOL 6.25 MG TABLET   1 Preferred Generic $2.00N/ANone
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CASPOFUNGIN ACETATE 50 MG VIAL   5 Specialty Tier 27%N/ANone
CASPOFUNGIN ACETATE 70 MG VIAL   5 Specialty Tier 27%N/ANone
CAYSTON KIT 75 MG/VIAL   5 Specialty Tier 27%N/AP
CAZIANT 28 DAY TABLET   3 Preferred Brand $28.00N/ANone
CEFACLOR 125 MG/5 ML SUSP Oral Suspension [Ceclor]   4 Non-Preferred Drug 50%N/ANone
CEFACLOR 250 MG CAPSULES   3 Preferred Brand $28.00N/ANone
CEFACLOR 250 MG/5 ML SUSPEN Oral Suspension [Ceclor]   4 Non-Preferred Drug 50%N/ANone
CEFACLOR 375 MG/5 ML SUSPEN Oral Suspension [Ceclor]   4 Non-Preferred Drug 50%N/ANone
CEFACLOR 500 MG CAPSULES   3 Preferred Brand $28.00N/ANone
CEFACLOR ER 500MG TABLET SR 12HR   4 Non-Preferred Drug 50%N/ANone
CEFADROXIL 1 GM TABLET   3 Preferred Brand $28.00N/ANone
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CEFADROXIL 250 MG/5 ML SUSP   3 Preferred Brand $28.00N/ANone
CEFADROXIL 500 MG CAPSULE   2 Generic $6.00N/ANone
CEFADROXIL 500 MG/5 ML SUSP   3 Preferred Brand $28.00N/ANone
CEFAZOLIN 1 GM VIAL 25/Box   3 Preferred Brand $28.00N/ANone
Cefazolin 10g/1 10 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 PACKAGE   3 Preferred Brand $28.00N/ANone
CEFAZOLIN 500 MG VIAL   3 Preferred Brand $28.00N/ANone
CEFDINIR 125 MG/5 ML SUSP   4 Non-Preferred Drug 50%N/ANone
CEFDINIR 250 MG/5 ML SUSP   4 Non-Preferred Drug 50%N/ANone
CEFDINIR 300 MG CAPSULE   3 Preferred Brand $28.00N/ANone
CEFEPIME HCL 1 GM VIAL   4 Non-Preferred Drug 50%N/ANone
CEFEPIME HCL 2 GRAM VIAL   4 Non-Preferred Drug 50%N/ANone
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CEFIXIME 100 MG/5 ML SUSP [Suprax]   4 Non-Preferred Drug 50%N/ANone
CEFIXIME 200 MG/5 ML SUSP [Suprax]   4 Non-Preferred Drug 50%N/ANone
Cefotaxime 500 MG Injection   4 Non-Preferred Drug 50%N/ANone
Cefotaxime sodium 1 gm vial   4 Non-Preferred Drug 50%N/ANone
Cefotaxime sodium 2 gm vial   4 Non-Preferred Drug 50%N/ANone
CEFOXITIN 1 GM VIAL   4 Non-Preferred Drug 50%N/ANone
CEFOXITIN 10 GM VIAL   4 Non-Preferred Drug 50%N/ANone
CEFOXITIN 2 GM VIAL   4 Non-Preferred Drug 50%N/ANone
CEFPODOXIME 100 MG TABLET   4 Non-Preferred Drug 50%N/ANone
CEFPODOXIME 100 MG/5 ML SUSP   4 Non-Preferred Drug 50%N/ANone
CEFPODOXIME 200 MG TABLET   4 Non-Preferred Drug 50%N/ANone
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CEFPODOXIME 50 MG/5 ML SUSP   4 Non-Preferred Drug 50%N/ANone
CEFPROZIL 125 MG/5 ML SUSP   3 Preferred Brand $28.00N/ANone
CEFPROZIL 250 MG TABLET   3 Preferred Brand $28.00N/ANone
CEFPROZIL 250 MG/5 ML SUSP   3 Preferred Brand $28.00N/ANone
CEFPROZIL 500 MG TABLET   3 Preferred Brand $28.00N/ANone
CEFTAZIDIME 1 GM VIAL   4 Non-Preferred Drug 50%N/ANone
CEFTAZIDIME FOR INJECTION 2GM/VIAL 10 X 2 CRTN   4 Non-Preferred Drug 50%N/ANone
CEFTAZIDIME FOR INJECTION 6GM/VIAL 6 X 6 CRTN   4 Non-Preferred Drug 50%N/ANone
CEFTRIAXONE 1 GM VIAL   3 Preferred Brand $28.00N/ANone
CEFTRIAXONE 10 GM VIAL   3 Preferred Brand $28.00N/ANone
CEFTRIAXONE 2 GM VIAL   3 Preferred Brand $28.00N/ANone
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CEFTRIAXONE 250 MG VIAL   3 Preferred Brand $28.00N/ANone
CEFTRIAXONE 500 MG VIAL   3 Preferred Brand $28.00N/ANone
CEFUROXIME 1.5 GM/VIAL FOR INJECTION   4 Non-Preferred Drug 50%N/ANone
CEFUROXIME 750 MG FOR INJECTION   4 Non-Preferred Drug 50%N/ANone
Cefuroxime 95 MG/ML Injectable Solution   4 Non-Preferred Drug 50%N/ANone
CEFUROXIME AXETIL 250 MG TAB   3 Preferred Brand $28.00N/ANone
CEFUROXIME AXETIL 500 MG TAB   3 Preferred Brand $28.00N/ANone
CELECOXIB 100 MG CAPSULE [Celebrex]   4 Non-Preferred Drug 50%N/AQ:120
/30Days
CELECOXIB 200 MG CAPSULE [Celebrex]   4 Non-Preferred Drug 50%N/AQ:60
/30Days
CELECOXIB 400 MG CAPSULE [Celebrex]   4 Non-Preferred Drug 50%N/AQ:30
/30Days
CELECOXIB 50 MG CAPSULE [Celebrex]   4 Non-Preferred Drug 50%N/AQ:240
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CELONTIN 300 MG KAPSEAL   4 Non-Preferred Drug 50%N/ANone
CEPHALEXIN 125 MG/5 ML SUSP   3 Preferred Brand $28.00N/ANone
CEPHALEXIN 250 MG CAPSULE   1 Preferred Generic $2.00N/ANone
CEPHALEXIN 250 MG/5 ML SUSP   3 Preferred Brand $28.00N/ANone
CEPHALEXIN 500 MG CAPSULE   1 Preferred Generic $2.00N/ANone
CERDELGA 84 MG CAPSULE   5 Specialty Tier 27%N/AP
CEREZYME 400 UNITS VIAL   5 Specialty Tier 27%N/AP
CETIRIZINE HCL 1 MG/ML SOLN   2 Generic $6.00N/ANone
CEVIMELINE HCL 30 MG CAPSULE [Evoxac]   4 Non-Preferred Drug 50%N/ANone
CHANTIX 0.5 MG TABLET   4 Non-Preferred Drug 50%N/AP
CHANTIX 1 MG CONT MONTH BOX   4 Non-Preferred Drug 50%N/AP
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CHANTIX 1 MG TABLET   4 Non-Preferred Drug 50%N/AP
CHANTIX STARTING MONTH BOX   4 Non-Preferred Drug 50%N/AP
CHEMET 100 MG CAPSULE   4 Non-Preferred Drug 50%N/ANone
CHLORHEXIDINE GLUCONATE 0.12% RINSE   1 Preferred Generic $2.00N/ANone
CHLOROQUINE PH 250 MG TABLET   3 Preferred Brand $28.00N/ANone
CHLOROQUINE PH 500 MG TABLET   3 Preferred Brand $28.00N/ANone
CHLOROTHIAZIDE 250 MG TABLET   3 Preferred Brand $28.00N/ANone
Chlorothiazide 500mg 100 TABLET BOTTLE   3 Preferred Brand $28.00N/ANone
CHLORPROMAZINE 10 MG TABLET   4 Non-Preferred Drug 50%N/ANone
CHLORPROMAZINE 100 MG TABLET   4 Non-Preferred Drug 50%N/ANone
CHLORPROMAZINE 200 MG TABLET   4 Non-Preferred Drug 50%N/ANone
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CHLORPROMAZINE 25 MG TABLET   4 Non-Preferred Drug 50%N/ANone
CHLORPROMAZINE 25 MG/ML AMP   4 Non-Preferred Drug 50%N/ANone
CHLORPROMAZINE 50 MG TABLET   4 Non-Preferred Drug 50%N/ANone
CHLORTHALIDONE 25 MG TABLET (100 CT)   3 Preferred Brand $28.00N/ANone
CHLORTHALIDONE 50 MG TABLET   3 Preferred Brand $28.00N/ANone
CHOLESTYRAMINE LIGHT POWDER   4 Non-Preferred Drug 50%N/ANone
CHOLESTYRAMINE PACKET   4 Non-Preferred Drug 50%N/ANone
CICLOPIROX 0.77% CREAM   3 Preferred Brand $28.00N/ANone
CICLOPIROX 0.77% GEL   4 Non-Preferred Drug 50%N/ANone
CICLOPIROX 0.77% TOPICAL SUSP   3 Preferred Brand $28.00N/ANone
CICLOPIROX 1% SHAMPOO   4 Non-Preferred Drug 50%N/ANone
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Cilastatin 250 MG / Imipenem 250 MG Injection   3 Preferred Brand $28.00N/ANone
Cilastatin 500 MG / Imipenem 500 MG Injection   3 Preferred Brand $28.00N/ANone
CILOSTAZOL 100 MG TABLET   2 Generic $6.00N/ANone
CILOSTAZOL 50 MG TABLET   2 Generic $6.00N/ANone
CILOXAN 0.3% OINTMENT   3 Preferred Brand $28.00N/ANone
Cinryze 500[iU]/5mL 1 VIAL per CARTON / 5 mL in 1 VIAL   5 Specialty Tier 27%N/AP Q:20
/30Days
CIPRODEX OTIC SUSPENSION   3 Preferred Brand $28.00N/ANone
CIPROFLOXACIN 0.3% EYE DROP [Ciloxan]   2 Generic $6.00N/ANone
CIPROFLOXACIN 250 MG TABLET (100 CT) [Cipro]   1 Preferred Generic $2.00N/ANone
CIPROFLOXACIN 250 MG/5 ML SUSP MC REC [Cipro]   4 Non-Preferred Drug 50%N/ANone
CIPROFLOXACIN 500 MG/5 ML SUSP MC REC [Cipro]   4 Non-Preferred Drug 50%N/ANone
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CIPROFLOXACIN HCL 100 MG Tablet [Cipro]   4 Non-Preferred Drug 50%N/ANone
CIPROFLOXACIN HCL 500 MG Tablet [Cipro]   1 Preferred Generic $2.00N/ANone
CIPROFLOXACIN HCL 750 MG Tablet [Cipro]   1 Preferred Generic $2.00N/ANone
CIPROFLOXACIN-D5W 200 MG/100 ML PIGGYBACK [Cipro]   3 Preferred Brand $28.00N/ANone
CISPLATIN 50MG/50ML MDV   3 Preferred Brand $28.00N/AP
CITALOPRAM HBR 10 MG TABLET   1 Preferred Generic $2.00N/AQ:45
/30Days
CITALOPRAM HBR 10 MG/5 ML SOLN   3 Preferred Brand $28.00N/ANone
CITALOPRAM HBR 20 MG TABLET   1 Preferred Generic $2.00N/AQ:45
/30Days
CITALOPRAM HBR 40 MG TABLET   1 Preferred Generic $2.00N/AQ:30
/30Days
Cladribine 1 MG/ML in 10 ML Injection   5 Specialty Tier 27%N/AP
CLARAVIS 10 MG CAPSULE   4 Non-Preferred Drug 50%N/AP
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CLARAVIS 20 MG CAPSULE   4 Non-Preferred Drug 50%N/AP
Claravis 30mg 3 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK   4 Non-Preferred Drug 50%N/AP
CLARAVIS 40 MG CAPSULE   4 Non-Preferred Drug 50%N/AP
CLARITHROMYCIN 125 MG/5ML FOR ORAL SUSPENSION   4 Non-Preferred Drug 50%N/ANone
CLARITHROMYCIN 250 MG TABLET   3 Preferred Brand $28.00N/ANone
CLARITHROMYCIN 250 MG/5MLFOR ORAL SUSPENSION   4 Non-Preferred Drug 50%N/ANone
CLARITHROMYCIN 500 MG TABLET   3 Preferred Brand $28.00N/ANone
CLARITHROMYCIN ER 500 MG TAB   3 Preferred Brand $28.00N/ANone
CLINDACIN PAC KIT   3 Preferred Brand $28.00N/ANone
Clindamycin 150 MG/ML 2ml   3 Preferred Brand $28.00N/ANone
CLINDAMYCIN 150mg/ml vl 25x6ml   3 Preferred Brand $28.00N/ANone
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CLINDAMYCIN 75 MG/5 ML SOLN   4 Non-Preferred Drug 50%N/ANone
CLINDAMYCIN HCL 150 MG CAPSULE   1 Preferred Generic $2.00N/ANone
CLINDAMYCIN HCL 300 MG CAPSULE   1 Preferred Generic $2.00N/ANone
CLINDAMYCIN HCL 75 MG 200 CAPSULE BOTTLE   1 Preferred Generic $2.00N/ANone
CLINDAMYCIN PH 1% SOLUTION   3 Preferred Brand $28.00N/ANone
CLINDAMYCIN PH 600 MG/4 ML VL   3 Preferred Brand $28.00N/ANone
CLINDAMYCIN PHOSP 1% LOTION   4 Non-Preferred Drug 50%N/ANone
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE   3 Preferred Brand $28.00N/ANone
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX   3 Preferred Brand $28.00N/ANone
CLINDAMYCIN PHOSPHATE VAGINAL CREAM   3 Preferred Brand $28.00N/ANone
Clindamycin-d5w 300 mg/50 ml   4 Non-Preferred Drug 50%N/ANone
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Clindamycin-d5w 600 mg/50 ml   4 Non-Preferred Drug 50%N/ANone
Clindamycin-d5w 900 mg/50 ml   4 Non-Preferred Drug 50%N/ANone
CLINIMIX 2.75%/5% INJECTION 1000ML BAG   4 Non-Preferred Drug 50%N/AP
CLINIMIX 4.25%-25% SOLUTION   4 Non-Preferred Drug 50%N/AP
CLINIMIX 5/20 SOLUTION   4 Non-Preferred Drug 50%N/AP
CLINIMIX 5/25 SULFITE FREE INJECTIONS 1035MG-420MEQ 1000ML BAG   4 Non-Preferred Drug 50%N/AP
CLINIMIX 5%-15% SOLUTION   4 Non-Preferred Drug 50%N/AP
CLOMIPRAMINE 25 MG CAPSULE   4 Non-Preferred Drug 50%N/AP
CLOMIPRAMINE 50 MG CAPSULE   4 Non-Preferred Drug 50%N/AP
CLOMIPRAMINE 75 MG CAPSULE   4 Non-Preferred Drug 50%N/AP
CLONAZEPAM 0.125 MG DIS TAB RAPDIS [Klonopin]   3 Preferred Brand $28.00N/AQ:960
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CLONAZEPAM 0.25 MG ODT TAB RAPDIS [Klonopin]   3 Preferred Brand $28.00N/AQ:480
/30Days
CLONAZEPAM 0.5 MG DIS TABLET RAPDIS [Klonopin]   3 Preferred Brand $28.00N/AQ:240
/30Days
CLONAZEPAM 0.5 MG TABLET [Klonopin]   1 Preferred Generic $2.00N/AQ:240
/30Days
CLONAZEPAM 1 MG DIS TABLET RAPDIS [Klonopin]   3 Preferred Brand $28.00N/AQ:120
/30Days
CLONAZEPAM 1 MG TABLET [Klonopin]   1 Preferred Generic $2.00N/AQ:120
/30Days
CLONAZEPAM 2 MG ODT TAB RAPDIS [Klonopin]   3 Preferred Brand $28.00N/AQ:300
/30Days
CLONAZEPAM 2 MG TABLET [Klonopin]   1 Preferred Generic $2.00N/AQ:300
/30Days
Clonidine 0.1mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH   4 Non-Preferred Drug 50%N/ANone
Clonidine 0.2mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH   4 Non-Preferred Drug 50%N/ANone
Clonidine 0.3mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH   4 Non-Preferred Drug 50%N/ANone
CLONIDINE HCL 0.1 MG TABLET   1 Preferred Generic $2.00N/ANone
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CLONIDINE HCL 0.2 MG TABLET   1 Preferred Generic $2.00N/ANone
CLONIDINE HCL 0.3 MG TABLET   1 Preferred Generic $2.00N/ANone
CLOPIDOGREL 75 MG TABLET [Plavix]   1 Preferred Generic $2.00N/ANone
CLORAZEPATE 15 MG TABLET   3 Preferred Brand $28.00N/AP Q:180
/30Days
CLORAZEPATE 3.75 MG TABLET   3 Preferred Brand $28.00N/AP Q:120
/30Days
CLORAZEPATE 7.5 MG TABLET   3 Preferred Brand $28.00N/AP Q:120
/30Days
CLOTRIMAZOLE 1% CREAM   3 Preferred Brand $28.00N/ANone
CLOTRIMAZOLE 1% SOLUTION   3 Preferred Brand $28.00N/ANone
CLOTRIMAZOLE 10 MG TROCHE   4 Non-Preferred Drug 50%N/ANone
CLOZAPINE 100 MG TABLET [Clozaril]   4 Non-Preferred Drug 50%N/AQ:270
/30Days
CLOZAPINE 200 MG TABLET   4 Non-Preferred Drug 50%N/AQ:135
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CLOZAPINE 25 MG TABLET [Clozaril]   3 Preferred Brand $28.00N/ANone
CLOZAPINE 50 MG TABLET   3 Preferred Brand $28.00N/ANone
CLOZAPINE ODT 100 MG TABLET RAPDIS [Fazaclo]   4 Non-Preferred Drug 50%N/AP Q:270
/30Days
CLOZAPINE ODT 12.5 MG TABLET RAPDIS [Fazaclo]   4 Non-Preferred Drug 50%N/AP
CLOZAPINE ODT 150 MG TABLET RAPDIS [Fazaclo]   4 Non-Preferred Drug 50%N/AP Q:180
/30Days
CLOZAPINE ODT 200 MG TABLET RAPDIS [Fazaclo]   5 Specialty Tier 27%N/AP Q:135
/30Days
CLOZAPINE ODT 25 MG TABLET RAPDIS [Fazaclo]   4 Non-Preferred Drug 50%N/AP
COARTEM 20MG-120MG   4 Non-Preferred Drug 50%N/ANone
COLCRYS 0.6 MG TABLET   3 Preferred Brand $28.00N/AQ:120
/30Days
COLESTIPOL HCL 1G TABLET   3 Preferred Brand $28.00N/ANone
COLESTIPOL HCL GRANULES PACKET   4 Non-Preferred Drug 50%N/ANone
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
COLISTIMETHATE 150 MG VIAL   4 Non-Preferred Drug 50%N/ANone
COLOCORT 100MG ENEMA   4 Non-Preferred Drug 50%N/ANone
COMBIGAN 0.2%-0.5% DROPS   3 Preferred Brand $28.00N/ANone
COMBIVENT RESPIMAT INHAL SPRAY   4 Non-Preferred Drug 50%N/AQ:8
/30Days
COMETRIQ 100 MG DAILY-DOSE PK   5 Specialty Tier 27%N/AP
COMETRIQ 140 MG DAILY-DOSE PK   5 Specialty Tier 27%N/AP
COMETRIQ 60 MG DAILY-DOSE PACK   5 Specialty Tier 27%N/AP
COMPLERA 200; 27.5; 300mg/1; mg/1; mg/1   5 Specialty Tier 27%N/ANone
COMPRO 25MG SUPPOSITORY   4 Non-Preferred Drug 50%N/ANone
CONSTULOSE 10 GM/15 ML SOLN   2 Generic $6.00N/ANone
COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN   5 Specialty Tier 27%N/AP Q:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
COPAXONE 40 MG/ML SYRINGE   5 Specialty Tier 27%N/AP Q:12
/28Days
CORLANOR 5 MG TABLET   4 Non-Preferred Drug 50%N/ANone
CORLANOR 7.5 MG TABLET   4 Non-Preferred Drug 50%N/ANone
Cortisone 25 MG Tablet   4 Non-Preferred Drug 50%N/ANone
COTELLIC 20 MG TABLET   5 Specialty Tier 27%N/AP
COUMADIN 1 MG TABLET   4 Non-Preferred Drug 50%N/ANone
COUMADIN 10MG TABLET   4 Non-Preferred Drug 50%N/ANone
COUMADIN 2.5 MG TABLET   4 Non-Preferred Drug 50%N/ANone
COUMADIN 2MG TABLET   4 Non-Preferred Drug 50%N/ANone
COUMADIN 3mg/1 1 BOTTLE per CARTON / 100 TABLET BOTTLE   4 Non-Preferred Drug 50%N/ANone
COUMADIN 4mg/1 1 BOTTLE in 1 CARTON / 100 TABLET BOTTLE   4 Non-Preferred Drug 50%N/ANone
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
COUMADIN 5MG TABLET   4 Non-Preferred Drug 50%N/ANone
COUMADIN 6MG TABLET   4 Non-Preferred Drug 50%N/ANone
COUMADIN 7.5MG TABLET   4 Non-Preferred Drug 50%N/ANone
Creon 256.11mg/1 1 BOTTLE per CARTON / 70 CAPSULE, DELAYED RELEASE in 1 BOTTLE   3 Preferred Brand $28.00N/ANone
CREON DELAYED RELEASE CAPSULES 12000MG 100 BOT   3 Preferred Brand $28.00N/ANone
CREON DELAYED RELEASE CAPSULES 24000MG 100 BOT   3 Preferred Brand $28.00N/ANone
CREON DELAYED RELEASE CAPSULES 6000MG 100 BOT   3 Preferred Brand $28.00N/ANone
CREON DR 36,000 UNITS CAPSULE   3 Preferred Brand $28.00N/ANone
CRIXIVAN 200MG CAPSULE   4 Non-Preferred Drug 50%N/ANone
CRIXIVAN 400mg, 180 CAPSULE BOTTLE   4 Non-Preferred Drug 50%N/ANone
CROMOLYN 20 MG/2 ML NEB SOLN   3 Preferred Brand $28.00N/AP
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CROMOLYN SODIUM 100 MG/5 ML   5 Specialty Tier 27%N/ANone
CROMOLYN SODIUM 4% 40MG 10ML BOT   1 Preferred Generic $2.00N/ANone
Cyclafem 1/35 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK   2 Generic $6.00N/ANone
CYCLAFEM 7-7-7-28 TABLET   2 Generic $6.00N/ANone
CYCLOBENZAPRINE 10 MG TABLET   4 Non-Preferred Drug 50%N/AP
CYCLOBENZAPRINE 5 MG TABLET   4 Non-Preferred Drug 50%N/AP
CYCLOPHOSPHAMIDE 25 MG CAPSULE   4 Non-Preferred Drug 50%N/AP
CYCLOPHOSPHAMIDE 50 MG CAPSULE   4 Non-Preferred Drug 50%N/AP
CYCLOSPORINE 100MG CAPSULE   4 Non-Preferred Drug 50%N/AP
CYCLOSPORINE 25MG CAPSULE   4 Non-Preferred Drug 50%N/AP
Cyclosporine 50 mg/ml vial   4 Non-Preferred Drug 50%N/AP
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CYCLOSPORINE MODIFIED 100 MG   4 Non-Preferred Drug 50%N/AP
CYCLOSPORINE MODIFIED 25 MG   4 Non-Preferred Drug 50%N/AP
CYCLOSPORINE MODIFIED 50 MG   4 Non-Preferred Drug 50%N/AP
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT   4 Non-Preferred Drug 50%N/AP
CYPROHEPTADINE 4 MG TABLET   4 Non-Preferred Drug 50%N/AP
CYPROHEPTADINE HYDROCHLORIDE SOLUTION USP SYRUP 2MG 473 ML BOTGL   4 Non-Preferred Drug 50%N/AP
CYSTADANE 1 GRAM/1.7 ML POWDER   5 Specialty Tier 27%N/ANone
CYSTAGON 150MG CAPSULE   4 Non-Preferred Drug 50%N/AP
CYSTAGON 50MG CAPSULE   4 Non-Preferred Drug 50%N/AP
CYSTARAN 0.44% EYE DROPS   5 Specialty Tier 27%N/AP
CYTARABINE 20MG/ML VIAL   3 Preferred Brand $28.00N/AP

Chart Legend:

Below are a few notes to help you understand the above 2018 Medicare Part D Medica Prime Solution Thrift w/Rx (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). 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.




(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.