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First Health Part D Value Plus (PDP) (S5768-131-0)
Tier 1 (256)
Tier 2 (514)
Tier 3 (1063)
Tier 4 (2825)
Tier 5 (720)
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Cick on the first letter of your drug name to browse the formulary:

A B C D E F G H I J K L 
M N O P Q R S T U V W X Y Z 0-9 
2018 Medicare Part D Plan Formulary Information
First Health Part D Value Plus (PDP) (S5768-131-0)
Benefit Details           
The First Health Part D Value Plus (PDP) (S5768-131-0)
Formulary Drugs Starting with the Letter A

in CMS PDP Region 8 which includes: NC
Plan Monthly Premium: $56.20 Deductible: $0 Qualifies for LIS: No
Drugs Starting with Letter A

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
ABACAVIR 20 MG/ML SOLUTION   3 Preferred Brand $47.00$141.00None
ABACAVIR 300 MG TABLET   3 Preferred Brand $47.00$141.00None
Abacavir Sulfate-Lamivudine-Zidovudine tablets [Trizivir]   5 Specialty Tier 33%N/ANone
ABACAVIR-LAMIVUDINE 600-300 MG   5 Specialty Tier 33%N/ANone
ABELCET INJECTION SUSPENSION 5MG/ML   5 Specialty Tier 33%N/AP
ABILIFY MAINTENA ER 300 MG SYR   5 Specialty Tier 33%N/AQ:1
/28Days
ABILIFY MAINTENA ER 300 MG VL   5 Specialty Tier 33%N/AQ:1
/28Days
ABILIFY MAINTENA ER 400 MG SUSER VIAL   5 Specialty Tier 33%N/AQ:1
/28Days
ABILIFY MAINTENA ER 400 MG SYR   5 Specialty Tier 33%N/AQ:1
/28Days
ABRAXANE 100MG VIAL   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Acamprosate Calcium DR 333 MG tablets [Campral]   4 Non-Preferred Drug 50%50%None
ACARBOSE 100 MG TABLET   2 Generic $2.00$6.00Q:90
/30Days
ACARBOSE 25 MG TABLET   2 Generic $2.00$6.00Q:90
/30Days
ACARBOSE 50 MG TABLET   2 Generic $2.00$6.00Q:90
/30Days
ACCOLATE 10 MG TABLET   4 Non-Preferred Drug 50%50%Q:60
/30Days
ACCOLATE 20 MG TABLET   4 Non-Preferred Drug 50%50%Q:60
/30Days
ACCUPRIL 10MG TABLET   4 Non-Preferred Drug 50%50%None
ACCUPRIL 20MG TABLET   4 Non-Preferred Drug 50%50%None
ACCUPRIL 40MG TABLET   4 Non-Preferred Drug 50%50%None
ACCUPRIL 5MG TABLET   4 Non-Preferred Drug 50%50%None
ACCURETIC 10-12.5MG TABLET   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACCURETIC 20-12.5MG TABLET   4 Non-Preferred Drug 50%50%None
ACCURETIC 20-25MG TABLET   4 Non-Preferred Drug 50%50%None
ACEBUTOLOL 200 MG CAPSULE   2 Generic $2.00$6.00None
ACEBUTOLOL 400 MG CAPSULE   2 Generic $2.00$6.00None
ACETAMINOP-CODEINE 120-12 MG/5   2 Generic $2.00$6.00Q:4500
/30Days
Acetaminophen 325 MG / Hydrocodone Bitartrate 5 MG Oral Tablet [Lorcet]   4 Non-Preferred Drug 50%50%Q:180
/30Days
ACETAMINOPHEN-COD #2 TABLET   2 Generic $2.00$6.00Q:180
/30Days
ACETAMINOPHEN-COD #3 TABLET   2 Generic $2.00$6.00Q:180
/30Days
ACETAMINOPHEN-COD #4 TABLET   2 Generic $2.00$6.00Q:180
/30Days
ACETAZOLAMIDE 125MG TABLET   3 Preferred Brand $47.00$141.00None
ACETAZOLAMIDE 250MG TABLET (100 CT)   3 Preferred Brand $47.00$141.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETAZOLAMIDE ER 500 MG CAP   4 Non-Preferred Drug 50%50%None
ACETIC ACID 2% EAR SOLUTION   3 Preferred Brand $47.00$141.00None
ACETYLCYSTEINE 10% VIAL   3 Preferred Brand $47.00$141.00P
Acetylcysteine 200 MG/ML Inhalant Solution   3 Preferred Brand $47.00$141.00P
ACIPHEX 20MG TABLET EC   4 Non-Preferred Drug 50%50%S
ACITRETIN 10 MG CAPSULE [Soriatane]   3 Preferred Brand $47.00$141.00P
ACITRETIN 17.5 MG CAPSULE [Soriatane]   3 Preferred Brand $47.00$141.00P
ACITRETIN 25 MG CAPSULE [Soriatane]   3 Preferred Brand $47.00$141.00P
ACTHIB VACCINE WITH DILUENT   3 Preferred Brand $47.00$141.00None
ACTIGALL 300MG CAPSULE   4 Non-Preferred Drug 50%50%None
ACTIMMUNE 100 MCG/0.5 ML VIAL   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACTIVELLA 0.5-0.1 MG TABLET   4 Non-Preferred Drug 50%50%P
ACTIVELLA 1 MG-0.5 MG TABLET   4 Non-Preferred Drug 50%50%P
ACTONEL 150 MG TABLET   4 Non-Preferred Drug 50%50%S Q:1
/28Days
ACTONEL 30 MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
ACTONEL 35 MG TABLET   4 Non-Preferred Drug 50%50%S Q:12
/84Days
ACTONEL 5 MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
ACTOPLUS MET 15MG/500MG TABLET   4 Non-Preferred Drug 50%50%Q:90
/30Days
ACTOPLUS MET 15MG/850MG TABLET   4 Non-Preferred Drug 50%50%Q:90
/30Days
ACTOS 15 MG TABLET   4 Non-Preferred Drug 50%50%Q:30
/30Days
ACTOS 30 MG TABLET   4 Non-Preferred Drug 50%50%Q:30
/30Days
ACTOS 45 MG TABLET   4 Non-Preferred Drug 50%50%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACULAR 0.5% EYE DROPS   4 Non-Preferred Drug 50%50%S
ACULAR LS 0.4% OPHTH SOL   4 Non-Preferred Drug 50%50%S
ACUVAIL 0.45% OPHTH SOLUTION #30X0.4 EA   4 Non-Preferred Drug 50%50%None
ACYCLOVIR 200 MG CAPSULE   2 Generic $2.00$6.00None
ACYCLOVIR 200 MG/5 ML SUSP   3 Preferred Brand $47.00$141.00None
ACYCLOVIR 400 MG TABLET   2 Generic $2.00$6.00None
Acyclovir 5% Ointment   4 Non-Preferred Drug 50%50%None
ACYCLOVIR 800 MG TABLET   2 Generic $2.00$6.00None
Acyclovir sodium 500 mg vial   4 Non-Preferred Drug 50%50%P
ACZONE 5% GEL   4 Non-Preferred Drug 50%50%None
ADACEL TDAP SYRINGE   3 Preferred Brand $47.00$141.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADACEL VIAL 2UNT/5UNT   3 Preferred Brand $47.00$141.00None
ADAGEN 250U/ML VIAL   5 Specialty Tier 33%N/AP
ADALAT CC 30 MG TABLET   4 Non-Preferred Drug 50%50%None
ADALAT CC 60 MG TABLET   4 Non-Preferred Drug 50%50%None
ADALAT CC 90 MG TABLET   4 Non-Preferred Drug 50%50%None
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA]   5 Specialty Tier 33%N/AP Q:2
/28Days
ADAPALENE 0.1% CREAM   4 Non-Preferred Drug 50%50%P
ADAPALENE 0.1% GEL   4 Non-Preferred Drug 50%50%P
Adapalene 0.3% gel   4 Non-Preferred Drug 50%50%P
ADCIRCA TABLETS 20MG 60 BOTTLE   5 Specialty Tier 33%N/AP
ADDERALL 20 MG TABLET   4 Non-Preferred Drug 50%50%P Q:90
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADDERALL 5 MG TABLET   4 Non-Preferred Drug 50%50%P Q:60
/30Days
ADDERALL 7.5 MG TABLET   4 Non-Preferred Drug 50%50%P Q:60
/30Days
ADDERALL XR 10MG CAPSULE SA   4 Non-Preferred Drug 50%50%P Q:30
/30Days
ADDERALL XR 15MG CAPSULE SA   4 Non-Preferred Drug 50%50%P Q:30
/30Days
ADDERALL XR 20MG CAPSULE SA   4 Non-Preferred Drug 50%50%P Q:30
/30Days
ADDERALL XR 25MG CAPSULE SA   4 Non-Preferred Drug 50%50%P Q:30
/30Days
ADDERALL XR 30MG CAPSULE SA   4 Non-Preferred Drug 50%50%P Q:30
/30Days
ADDERALL XR 5MG CAPSULE SA   4 Non-Preferred Drug 50%50%P Q:30
/30Days
ADEFOVIR DIPIVOXIL 10 MG TAB [Hepsera]   4 Non-Preferred Drug 50%50%Q:30
/30Days
ADEMPAS 0.5 MG TABLET   5 Specialty Tier 33%N/AP Q:90
/30Days
ADEMPAS 1 MG TABLET   5 Specialty Tier 33%N/AP Q:90
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADEMPAS 1.5 MG TABLET   5 Specialty Tier 33%N/AP Q:90
/30Days
ADEMPAS 2 MG TABLET   5 Specialty Tier 33%N/AP Q:90
/30Days
ADEMPAS 2.5 MG TABLET   5 Specialty Tier 33%N/AP Q:90
/30Days
Adrenalin 1 mg/ml vial   4 Non-Preferred Drug 50%50%Q:2
/30Days
ADRUCIL 50mg/mL 10 VIAL in 1 TRAY / 10 mL in 1 VIAL   3 Preferred Brand $47.00$141.00P
ADVAIR DISKUS MIS 100/50   3 Preferred Brand $47.00$141.00Q:60
/30Days
ADVAIR DISKUS MIS 250/50   3 Preferred Brand $47.00$141.00Q:60
/30Days
ADVAIR DISKUS MIS 500/50   3 Preferred Brand $47.00$141.00Q:60
/30Days
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER   3 Preferred Brand $47.00$141.00Q:12
/30Days
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL   3 Preferred Brand $47.00$141.00Q:12
/30Days
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL   3 Preferred Brand $47.00$141.00Q:12
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AFEDITAB CR 30MG TABLET SA   4 Non-Preferred Drug 50%50%None
AFEDITAB CR 60MG TABLET SA   4 Non-Preferred Drug 50%50%None
Afinitor 7.5mg/1 28 BLISTER PACK per CARTON / 1 TABLET per BLISTER PACK   5 Specialty Tier 33%N/AP
AFINITOR DISPERZ 2 MG TABLET   5 Specialty Tier 33%N/AP
AFINITOR DISPERZ 3 MG TABLET   5 Specialty Tier 33%N/AP
AFINITOR DISPERZ 5 MG TABLET   5 Specialty Tier 33%N/AP
AFINITOR TABLETS 10 MG   5 Specialty Tier 33%N/AP
AFINITOR TABLETS 2.5 MG   5 Specialty Tier 33%N/AP
AFINITOR TABLETS 5 MG   5 Specialty Tier 33%N/AP
AGGRENOX 25-200MG CAPSULE   4 Non-Preferred Drug 50%50%S Q:60
/30Days
Ala-cort 2.5% cream   1 Preferred Generic $1.00$3.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALA-SCALP HP 2% LOTION   4 Non-Preferred Drug 50%50%None
ALBENZA 200 MG TABLET   5 Specialty Tier 33%N/ANone
ALBUTEROL SUL 2.5 MG/3 ML SOLN   2 Generic $2.00$6.00P
ALBUTEROL SULFATE 0.75mg/3mL 30 POUCH per CARTON / 1 VIAL, SINGLE-DOSE in 1 POUCH / 3 mL in 1 VIAL   2 Generic $2.00$6.00P
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER   2 Generic $2.00$6.00P
ALBUTEROL SULFATE 2 MG TAB   3 Preferred Brand $47.00$141.00None
ALBUTEROL SULFATE 4 MG TAB   3 Preferred Brand $47.00$141.00None
ALBUTEROL SULFATE 4MG TABLET SR 12HR   4 Non-Preferred Drug 50%50%None
ALBUTEROL SULFATE 8MG TABLET SR 12HR   4 Non-Preferred Drug 50%50%None
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   2 Generic $2.00$6.00P
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT   2 Generic $2.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALCLOMETASONE DIPR 0.05% OINT   4 Non-Preferred Drug 50%50%None
ALCLOMETASONE DIPRO 0.05% CRM   4 Non-Preferred Drug 50%50%None
ALDACTONE 100MG TABLET   4 Non-Preferred Drug 50%50%None
ALDACTONE 25MG TABLET   4 Non-Preferred Drug 50%50%None
ALDACTONE 50MG TABLET   4 Non-Preferred Drug 50%50%None
ALDARA 5% CREAM   4 Non-Preferred Drug 50%50%None
ALDURAZYME 2.9MG/5ML VIAL   5 Specialty Tier 33%N/AP
ALECENSA 150 MG CAPSULE   5 Specialty Tier 33%N/AP
ALENDRONATE SODIUM 10 MG TAB   1 Preferred Generic $1.00$3.00Q:30
/30Days
ALENDRONATE SODIUM 35 MG TAB   1 Preferred Generic $1.00$3.00Q:4
/28Days
ALENDRONATE SODIUM 40 MG TABLET   1 Preferred Generic $1.00$3.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALENDRONATE SODIUM 5 MG TABLET   1 Preferred Generic $1.00$3.00Q:30
/30Days
ALENDRONATE SODIUM 70 MG TAB   1 Preferred Generic $1.00$3.00Q:4
/28Days
ALENDRONATE SODIUM 70 MG/75 ML   1 Preferred Generic $1.00$3.00None
ALFUZOSIN HCL ER 10 MG TABLET   4 Non-Preferred Drug 50%50%Q:30
/30Days
ALIMTA 100 MG VIAL   5 Specialty Tier 33%N/AP
ALIMTA 500 MG VIAL   5 Specialty Tier 33%N/AP
ALINIA 100 MG/5 ML SUSPENSION   4 Non-Preferred Drug 50%50%None
ALINIA 500 MG TABLET   4 Non-Preferred Drug 50%50%None
ALIQOPA 60 MG VIAL   5 Specialty Tier 33%N/AP Q:3
/28Days
Aliskiren 150 MG / Hydrochlorothiazide 12.5 MG Oral Tablet [Tekturna HCT]   4 Non-Preferred Drug 50%50%Q:30
/30Days
Aliskiren 150 MG / Hydrochlorothiazide 25 MG Oral Tablet [Tekturna HCT]   4 Non-Preferred Drug 50%50%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Aliskiren 300 MG / Hydrochlorothiazide 12.5 MG Oral Tablet [Tekturna HCT]   4 Non-Preferred Drug 50%50%Q:30
/30Days
ALKERAN 50 MG VIAL   5 Specialty Tier 33%N/AP
ALLOPURINOL 100 MG TABLET   1 Preferred Generic $1.00$3.00None
ALLOPURINOL 300 MG TABLET   1 Preferred Generic $1.00$3.00None
ALMOTRIPTAN MALATE 12.5 MG TAB [Axert]   4 Non-Preferred Drug 50%50%Q:8
/30Days
ALMOTRIPTAN MALATE 6.25 MG TAB [Axert]   4 Non-Preferred Drug 50%50%Q:8
/30Days
ALOCRIL 2% EYE DROPS   4 Non-Preferred Drug 50%50%None
ALOMIDE 0.1% EYE DROPS   4 Non-Preferred Drug 50%50%None
ALORA 0.025 MG PATCH   4 Non-Preferred Drug 50%50%P Q:8
/28Days
ALORA 0.05 MG PATCH   4 Non-Preferred Drug 50%50%P Q:8
/28Days
ALORA 0.075 MG PATCH   4 Non-Preferred Drug 50%50%P Q:8
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALORA 0.1 MG PATCH   4 Non-Preferred Drug 50%50%P Q:8
/28Days
ALOSETRON HCL 0.5 MG TABLET [Lotronex]   5 Specialty Tier 33%N/AQ:60
/30Days
ALOSETRON HCL 1 MG TABLET [Lotronex]   5 Specialty Tier 33%N/AQ:60
/30Days
ALPHAGAN P 0.1% DROPS   3 Preferred Brand $47.00$141.00None
ALPHAGAN P 0.15% EYE DROPS   4 Non-Preferred Drug 50%50%None
ALPRAZOLAM 0.25 MG TABLET   2 Generic $2.00$6.00Q:120
/30Days
ALPRAZOLAM 0.5 MG TABLET   2 Generic $2.00$6.00Q:120
/30Days
ALPRAZOLAM 1 MG TABLET   2 Generic $2.00$6.00Q:150
/30Days
Alprazolam 1mg/1 10 BLISTER PACK per CARTON / 10 TABLET, ORALLY DISINTEGRATING per BLISTER PACK   4 Non-Preferred Drug 50%50%None
Alprazolam 1mg/mL 1 BOTTLE in 1 CONTAINER / 30 mL in 1 BOTTLE   4 Non-Preferred Drug 50%50%Q:300
/30Days
ALPRAZOLAM 2 MG TABLET   2 Generic $2.00$6.00Q:150
/30Days
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   4 Non-Preferred Drug 50%50%Q:150
/30Days
ALPRAZOLAM ER 0.5 MG TABLET   4 Non-Preferred Drug 50%50%Q:30
/30Days
ALPRAZOLAM ER 1 MG TABLET   4 Non-Preferred Drug 50%50%Q:30
/30Days
ALPRAZOLAM ER 2 MG TABLET   4 Non-Preferred Drug 50%50%Q:90
/30Days
ALPRAZOLAM ER 3 MG TABLET   4 Non-Preferred Drug 50%50%Q:60
/30Days
ALPRAZOLAM ODT 0.25 MG TABLET   4 Non-Preferred Drug 50%50%Q:120
/30Days
ALPRAZOLAM ODT 0.5 MG TABLET   4 Non-Preferred Drug 50%50%None
ALREX 0.2% EYE DROPS   3 Preferred Brand $47.00$141.00None
ALTACE 1.25MG CAPSULE   4 Non-Preferred Drug 50%50%None
ALTACE 10MG CAPSULE (100 CT)   4 Non-Preferred Drug 50%50%None
ALTACE 2.5 MG CAPSULE   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALTACE 5MG CAPSULE   4 Non-Preferred Drug 50%50%None
ALTAVERA-28 TABLET   3 Preferred Brand $47.00$141.00None
ALTOPREV 20 MG TABLET   4 Non-Preferred Drug 50%50%S Q:60
/30Days
ALUNBRIG 180 MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
ALUNBRIG 30 MG TABLET   5 Specialty Tier 33%N/AP
ALUNBRIG 90 MG TABLET   5 Specialty Tier 33%N/AP Q:60
/30Days
ALUNBRIG 90 MG-180 MG TABLET PACK   5 Specialty Tier 33%N/AP Q:60
/365Days
ALYACEN 1-35-28 TABLET   3 Preferred Brand $47.00$141.00None
Amabelz 0.5 MG/0.1 MG 28 TABLET/BLISTER PACK 3 PER CARTON   3 Preferred Brand $47.00$141.00P
Amabelz 1 MG/0.5 MG 28 TABLET/BLISTER PACK 3 PER CARTON   3 Preferred Brand $47.00$141.00P
AMANTADINE 100 MG CAPSULE   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMANTADINE 100 MG TABLET   3 Preferred Brand $47.00$141.00None
AMANTADINE 50 MG/5 ML SOLUTION   4 Non-Preferred Drug 50%50%None
AMARYL 1MG TABLET   4 Non-Preferred Drug 50%50%None
AMARYL 2MG TABLET   4 Non-Preferred Drug 50%50%None
AMARYL 4MG TABLET   4 Non-Preferred Drug 50%50%None
AMBISOME 50MG VIAL   4 Non-Preferred Drug 50%50%P
AMERGE 1MG TABLET   4 Non-Preferred Drug 50%50%S Q:9
/30Days
AMERGE 2.5MG TABLET   4 Non-Preferred Drug 50%50%S Q:9
/30Days
AMETHIA 0.15-0.03-0.01 MG TABLET   3 Preferred Brand $47.00$141.00None
AMETHIA LO TABLET   3 Preferred Brand $47.00$141.00None
AMIKACIN SULF 500 MG/2 ML VIAL   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMILORIDE HCL 5 MG TABLET   3 Preferred Brand $47.00$141.00None
AMILORIDE HCL-HCTZ 5-50 MG TABLET   2 Generic $2.00$6.00None
Amino Acids 15% Solution   4 Non-Preferred Drug 50%50%P
Amino acids 4.25% in dextrose 10% Injectable Solution [Clinimix 4.25/10]   4 Non-Preferred Drug 50%50%P
Amino acids 4.25% in dextrose 20% Injectable Solution [Clinimix 4.25/20]   4 Non-Preferred Drug 50%50%P
Amino acids 4.25% in dextrose 5% Injectable Solution [Clinimix 4.25/5]   4 Non-Preferred Drug 50%50%P
Aminophylline 25 MG/ML 10 ML Injection   4 Non-Preferred Drug 50%50%None
AMINOSYN 7%-ELECTROLYTE SOL   4 Non-Preferred Drug 50%50%P
AMINOSYN HBC INJECTION SULFITE FREE 7%   4 Non-Preferred Drug 50%50%P
AMINOSYN II 10% SOL 6X2000 ML   4 Non-Preferred Drug 50%50%P
AMINOSYN II 8.5% ELECTROLYT   4 Non-Preferred Drug 50%50%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN II 8.5% ELECTROLYT   4 Non-Preferred Drug 50%50%P
AMINOSYN PF INJECTION   4 Non-Preferred Drug 50%50%P
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5%   4 Non-Preferred Drug 50%50%P
AMINOSYN-PF 7% IV SOLUTION   4 Non-Preferred Drug 50%50%P
AMINOSYN-RF 5.2% IV SOLUTION   4 Non-Preferred Drug 50%50%P
AMIODARONE HCL 100 MG TABLET   2 Generic $2.00$6.00None
AMIODARONE HCL 200 MG TABLET   2 Generic $2.00$6.00None
AMIODARONE HCL 400 MG TABLET   2 Generic $2.00$6.00None
AMIODARONE HCL 50 MG/ML in 3 ML Injection   4 Non-Preferred Drug 50%50%None
AMITIZA 8MCG CAPSULE   3 Preferred Brand $47.00$141.00Q:60
/30Days
AMITIZA CAPSULES 24MCG 60 CAP BOT   3 Preferred Brand $47.00$141.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITRIP/CDP 25-10 TABLET   4 Non-Preferred Drug 50%50%P
AMITRIP/PERPHEN 10-4 TABLET   4 Non-Preferred Drug 50%50%P
AMITRIP/PERPHEN 50-4 TABLET   4 Non-Preferred Drug 50%50%P
AMITRIPTYLINE HCL 10 MG TAB   2 Generic $2.00$6.00P
AMITRIPTYLINE HCL 100 MG TAB   2 Generic $2.00$6.00P
AMITRIPTYLINE HCL 150 MG TAB   2 Generic $2.00$6.00P
AMITRIPTYLINE HCL 25 MG TAB   2 Generic $2.00$6.00P
AMITRIPTYLINE HCL 50 MG TAB   2 Generic $2.00$6.00P
AMITRIPTYLINE HCL 75 MG TAB   2 Generic $2.00$6.00P
AMLOD-VALSA-HCTZ 10-160-12.5MG [Exforge HCT]   2 Generic $2.00$6.00Q:30
/30Days
AMLOD-VALSA-HCTZ 10-160-25 MG [Exforge HCT]   2 Generic $2.00$6.00Q:30
/30Days
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 Generic $2.00$6.00Q:30
/30Days
AMLOD-VALSA-HCTZ 5-160-12.5 MG [Exforge HCT]   2 Generic $2.00$6.00Q:30
/30Days
AMLOD-VALSA-HCTZ 5-160-25 MG [Exforge HCT]   2 Generic $2.00$6.00Q:30
/30Days
AMLODIPINE BESYLATE 10 MG TAB   1 Preferred Generic $1.00$3.00None
AMLODIPINE BESYLATE 2.5 MG TAB   1 Preferred Generic $1.00$3.00None
AMLODIPINE BESYLATE 5 MG TAB   1 Preferred Generic $1.00$3.00None
AMLODIPINE-ATORVAST 10-20 MG [Caduet]   3 Preferred Brand $47.00$141.00None
AMLODIPINE-ATORVAST 10-40 MG [Caduet]   3 Preferred Brand $47.00$141.00None
Amlodipine-Atorvastatin 10-10 mg [Caduet]   3 Preferred Brand $47.00$141.00None
Amlodipine-Atorvastatin 10-80 mg [Caduet]   3 Preferred Brand $47.00$141.00None
Amlodipine-Atorvastatin 2.5-10 mg [Caduet]   3 Preferred Brand $47.00$141.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Amlodipine-Atorvastatin 2.5-20 mg [Caduet]   3 Preferred Brand $47.00$141.00None
Amlodipine-Atorvastatin 2.5-40 mg [Caduet]   3 Preferred Brand $47.00$141.00None
Amlodipine-Atorvastatin 5-10 mg [Caduet]   3 Preferred Brand $47.00$141.00None
Amlodipine-Atorvastatin 5-20 mg [Caduet]   3 Preferred Brand $47.00$141.00None
Amlodipine-Atorvastatin 5-40 mg [Caduet]   3 Preferred Brand $47.00$141.00None
Amlodipine-Atorvastatin 5-80 mg [Caduet]   3 Preferred Brand $47.00$141.00None
AMLODIPINE-BENAZEPRIL 10-20 MG Capsule [Lotrel]   2 Generic $2.00$6.00Q:30
/30Days
AMLODIPINE-BENAZEPRIL 10-40 MG Capsule [Lotrel]   2 Generic $2.00$6.00Q:30
/30Days
AMLODIPINE-BENAZEPRIL 2.5-10 Capsule [Lotrel]   2 Generic $2.00$6.00Q:30
/30Days
AMLODIPINE-BENAZEPRIL 5-10 MG Capsule [Lotrel]   2 Generic $2.00$6.00Q:30
/30Days
AMLODIPINE-BENAZEPRIL 5-20 MG Capsule [Lotrel]   2 Generic $2.00$6.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE-BENAZEPRIL 5-40 MG Capsule [Lotrel]   2 Generic $2.00$6.00Q:30
/30Days
AMLODIPINE-OLMESARTAN 10-20 MG [Azor]   4 Non-Preferred Drug 50%50%Q:30
/30Days
AMLODIPINE-OLMESARTAN 10-40 MG [Azor]   4 Non-Preferred Drug 50%50%Q:30
/30Days
AMLODIPINE-OLMESARTAN 5-20 MG [Azor]   4 Non-Preferred Drug 50%50%Q:30
/30Days
AMLODIPINE-OLMESARTAN 5-40 MG [Azor]   4 Non-Preferred Drug 50%50%Q:30
/30Days
AMLODIPINE-VALSARTAN 10-160 MG   2 Generic $2.00$6.00Q:30
/30Days
AMLODIPINE-VALSARTAN 10-320 MG   2 Generic $2.00$6.00Q:30
/30Days
AMLODIPINE-VALSARTAN 5-160 MG   2 Generic $2.00$6.00Q:30
/30Days
AMLODIPINE-VALSARTAN 5-320 MG   2 Generic $2.00$6.00Q:30
/30Days
AMMONIUM LACTATE 12% CREAM   3 Preferred Brand $47.00$141.00None
AMMONIUM LACTATE 12% LOTION   3 Preferred Brand $47.00$141.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMNESTEEM 10 MG CAPSULE   4 Non-Preferred Drug 50%50%None
AMNESTEEM 20 MG CAPSULE   4 Non-Preferred Drug 50%50%None
AMNESTEEM 40 MG CAPSULE   4 Non-Preferred Drug 50%50%None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE [Augmentin]   2 Generic $2.00$6.00None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET [Augmentin]   2 Generic $2.00$6.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE [Augmentin]   2 Generic $2.00$6.00None
AMOX-CLAV 200-28.5 MG/5 ML SUS   2 Generic $2.00$6.00None
AMOX-CLAV 250-62.5 MG/5 ML SUS   2 Generic $2.00$6.00None
AMOX-CLAV 400-57 MG/5 ML SUSP   2 Generic $2.00$6.00None
AMOX-CLAV 500-125 MG TABLET [Augmentin]   2 Generic $2.00$6.00None
AMOX-CLAV 600-42.9 MG/5 ML SUS   2 Generic $2.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOX-CLAV 875-125 MG TABLET [Augmentin]   2 Generic $2.00$6.00None
AMOX-CLAV ER 1,000-62.5 MG TABLET [Augmentin]   4 Non-Preferred Drug 50%50%None
AMOXAPINE 100MG TABLET   3 Preferred Brand $47.00$141.00None
AMOXAPINE 150MG TABLET   3 Preferred Brand $47.00$141.00None
AMOXAPINE 25MG TABLET   3 Preferred Brand $47.00$141.00None
AMOXAPINE 50MG TABLET   3 Preferred Brand $47.00$141.00None
AMOXICILLIN 125 MG/5 ML SUSP   1 Preferred Generic $1.00$3.00None
AMOXICILLIN 125MG TABLET CHEW   1 Preferred Generic $1.00$3.00None
AMOXICILLIN 200 MG/5 ML SUSP   1 Preferred Generic $1.00$3.00None
AMOXICILLIN 250 MG CAPSULE   1 Preferred Generic $1.00$3.00None
AMOXICILLIN 250 MG TAB CHEW   1 Preferred Generic $1.00$3.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN 250 MG/5 ML SUSP   1 Preferred Generic $1.00$3.00None
AMOXICILLIN 400 MG/5 ML SUSP   1 Preferred Generic $1.00$3.00None
AMOXICILLIN 500 MG CAPSULE   1 Preferred Generic $1.00$3.00None
AMOXICILLIN 500 MG TABLET   1 Preferred Generic $1.00$3.00None
AMOXICILLIN 875 MG TABLET   1 Preferred Generic $1.00$3.00None
AMPHETAMINE SALT COMBO 12.5MG TABLET   3 Preferred Brand $47.00$141.00P Q:60
/30Days
AMPHETAMINE SALT COMBO 15MG TABLET   3 Preferred Brand $47.00$141.00P Q:60
/30Days
AMPHETAMINE SALT COMBO 7.5MG TABLET   3 Preferred Brand $47.00$141.00P Q:60
/30Days
AMPHETAMINE SALTS 5 MG TAB   3 Preferred Brand $47.00$141.00P Q:60
/30Days
amphotericin b 50mg/10mL 10 mL in 1 VIAL   4 Non-Preferred Drug 50%50%P
AMPICILLIN 10 GM VIAL   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Ampicillin 1000 MG / Sulbactam 500 MG Injection   4 Non-Preferred Drug 50%50%None
Ampicillin 1000 MG Injection   4 Non-Preferred Drug 50%50%None
Ampicillin 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS   4 Non-Preferred Drug 50%50%None
Ampicillin 2000 MG / Sulbactam 1000 MG Injection   4 Non-Preferred Drug 50%50%None
AMPICILLIN CAPSULES 500MG 100 BOT   1 Preferred Generic $1.00$3.00None
AMPICILLIN-SULBACTAM 15 GM VL   4 Non-Preferred Drug 50%50%None
AMPYRA ER 10 MG TABLET   5 Specialty Tier 33%N/AP
ANADROL-50 TABLET   5 Specialty Tier 33%N/AP
ANAFRANIL 25 MG 30 CAPSULE BOTTLE   4 Non-Preferred Drug 50%50%P
ANAFRANIL 50 MG 30 CAPSULE BOTTLE   4 Non-Preferred Drug 50%50%P
ANAFRANIL 75 MG 30 CAPSULE BOTTLE   4 Non-Preferred Drug 50%50%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE   3 Preferred Brand $47.00$141.00None
Anagrelide Hydrochloride 1mg/1 100 CAPSULE BOTTLE   3 Preferred Brand $47.00$141.00None
ANASTROZOLE 1 MG TABLET   2 Generic $2.00$6.00None
ANDRODERM 2 MG/24HR PATCH   4 Non-Preferred Drug 50%50%P Q:30
/30Days
ANDRODERM 4 MG/24HR PATCH   4 Non-Preferred Drug 50%50%P Q:30
/30Days
ANDROGEL 1.62% (1.25G) GEL PCKT   4 Non-Preferred Drug 50%50%P
ANDROGEL 1.62% (2.5G) GEL PCKT   4 Non-Preferred Drug 50%50%P
ANDROGEL 1% (50MG) GEL PACKET   4 Non-Preferred Drug 50%50%P Q:300
/30Days
Androgel 10mg/g 30 PACKET in 1 CARTON / 2.5 g in 1 PACKET   4 Non-Preferred Drug 50%50%P Q:300
/30Days
Androgel 16.2mg/g 1 BOTTLE, PUMP per CARTON / 88 g in 1 BOTTLE, PUMP   4 Non-Preferred Drug 50%50%P
Angeliq 0.25/0.5 28 Day Pack   4 Non-Preferred Drug 50%50%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANGELIQ 1-0.5MG TABLET   4 Non-Preferred Drug 50%50%P
ANORO ELLIPTA 62.5-25 MCG INH   3 Preferred Brand $47.00$141.00Q:60
/30Days
ANTABUSE 250MG TABLET   4 Non-Preferred Drug 50%50%None
ANTABUSE 500MG TABLET   4 Non-Preferred Drug 50%50%None
ANTARA 30 MG CAPSULE   4 Non-Preferred Drug 50%50%None
ANTARA 90 MG CAPSULE   4 Non-Preferred Drug 50%50%None
Antineoplastic Agent Etoposide 20 mg / mL Intravenous Injection Multiple Dose Vial 5 mL   3 Preferred Brand $47.00$141.00None
ANUSOL-HC 2.5% CREAM   4 Non-Preferred Drug 50%50%None
APEXICON E 0.05% CREAM   4 Non-Preferred Drug 50%50%None
APOKYN 30 MG/3 ML CARTRIDGE   5 Specialty Tier 33%N/AP
Apraclonidine 5 MG/ML Ophthalmic Solution   3 Preferred Brand $47.00$141.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
APREPITANT 125 MG CAPSULE [Emend]   4 Non-Preferred Drug 50%50%P
APREPITANT 125-80-80 MG PACK [Emend]   4 Non-Preferred Drug 50%50%P
APREPITANT 40 MG CAPSULE [Emend]   4 Non-Preferred Drug 50%50%P
APREPITANT 80 MG CAPSULE [Emend]   4 Non-Preferred Drug 50%50%P
APRI 0.15-0.03 TABLET   3 Preferred Brand $47.00$141.00None
APRISO CP24   3 Preferred Brand $47.00$141.00None
APTENSIO XR 10 MG CAPSULE   4 Non-Preferred Drug 50%50%P Q:30
/30Days
APTENSIO XR 15 MG CAPSULE   4 Non-Preferred Drug 50%50%P Q:30
/30Days
APTENSIO XR 20 MG CAPSULE   4 Non-Preferred Drug 50%50%P Q:30
/30Days
APTENSIO XR 30 MG CAPSULE   4 Non-Preferred Drug 50%50%P Q:30
/30Days
APTENSIO XR 40 MG CAPSULE   4 Non-Preferred Drug 50%50%P Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
APTENSIO XR 50 MG CAPSULE   4 Non-Preferred Drug 50%50%P Q:30
/30Days
APTENSIO XR 60 MG CAPSULE   4 Non-Preferred Drug 50%50%P Q:30
/30Days
APTIOM 200 MG TABLET   4 Non-Preferred Drug 50%50%Q:180
/30Days
APTIOM 400 MG TABLET   5 Specialty Tier 33%N/AQ:90
/30Days
APTIOM 600 MG TABLET   5 Specialty Tier 33%N/AQ:60
/30Days
APTIOM 800 MG TABLET   5 Specialty Tier 33%N/AQ:60
/30Days
APTIVUS 250MG CAPSULE   5 Specialty Tier 33%N/ANone
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT   5 Specialty Tier 33%N/ANone
ARALAST NP 1,000 MG VIAL   5 Specialty Tier 33%N/AP
ARANELLE 7-9-5 TABLET   3 Preferred Brand $47.00$141.00None
ARANESP 10 MCG/0.4 ML SYRINGE   4 Non-Preferred Drug 50%50%P Q:3
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP 100ug/0.5mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.5 mL in 1 SYRINGE   4 Non-Preferred Drug 50%50%P Q:2
/28Days
ARANESP 100ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE   4 Non-Preferred Drug 50%50%P Q:4
/28Days
ARANESP 200MCG/0.4ML SYRINGE   5 Specialty Tier 33%N/AP Q:2
/28Days
ARANESP 200MCG/ML VIAL   5 Specialty Tier 33%N/AP Q:4
/28Days
ARANESP 25ug/0.42mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.42 mL in 1 SYRING   4 Non-Preferred Drug 50%50%P Q:2
/28Days
ARANESP 25ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE   4 Non-Preferred Drug 50%50%P Q:4
/28Days
ARANESP 300MCG/ML VIAL   5 Specialty Tier 33%N/AP Q:4
/28Days
ARANESP 500MCG/1ML SYRINGE   5 Specialty Tier 33%N/AP Q:1
/21Days
ARANESP 60MCG/ML VIAL   4 Non-Preferred Drug 50%50%P Q:4
/28Days
ARANESP 60ug/0.3mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.3 mL in 1 SYRINGE   4 Non-Preferred Drug 50%50%P Q:1
/28Days
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR   5 Specialty Tier 33%N/AP Q:1
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR   5 Specialty Tier 33%N/AP Q:2
/28Days
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR   4 Non-Preferred Drug 50%50%P Q:2
/28Days
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD   4 Non-Preferred Drug 50%50%P Q:4
/28Days
ARCALYST INJECTION 220MG/VIAL   5 Specialty Tier 33%N/AP
ARICEPT 10MG TABLET   4 Non-Preferred Drug 50%50%S Q:60
/30Days
ARICEPT 23 MG TABLETS   4 Non-Preferred Drug 50%50%S Q:30
/30Days
ARICEPT 5MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
ARIMIDEX 1MG TABLET   4 Non-Preferred Drug 50%50%None
ARIPIPRAZOLE 1 MG/ML SOLUTION [Abilify]   4 Non-Preferred Drug 50%50%Q:900
/30Days
ARIPIPRAZOLE 10 MG TABLET [Abilify]   4 Non-Preferred Drug 50%50%Q:30
/30Days
ARIPIPRAZOLE 15 MG TABLET [Abilify]   4 Non-Preferred Drug 50%50%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARIPIPRAZOLE 2 MG TABLET [Abilify]   4 Non-Preferred Drug 50%50%Q:30
/30Days
ARIPIPRAZOLE 20 MG TABLET [Abilify]   4 Non-Preferred Drug 50%50%Q:30
/30Days
ARIPIPRAZOLE 30 MG TABLET [Abilify]   4 Non-Preferred Drug 50%50%Q:30
/30Days
ARIPIPRAZOLE 5 MG TABLET [Abilify]   4 Non-Preferred Drug 50%50%Q:30
/30Days
ARIPIPRAZOLE ODT 10 MG TABLET [Abilify]   5 Specialty Tier 33%N/AQ:60
/30Days
ARIPIPRAZOLE ODT 15 MG TABLET [Abilify]   5 Specialty Tier 33%N/AQ:60
/30Days
ARISTADA ER 1064 MG/3.9 ML SYR   5 Specialty Tier 33%N/AQ:4
/28Days
ARISTADA ER 441 MG/1.6 ML SYRN   5 Specialty Tier 33%N/AQ:2
/28Days
ARISTADA ER 662 MG/2.4 ML SYRN   5 Specialty Tier 33%N/AQ:2
/28Days
ARISTADA ER 882 MG/3.2 ML SYRN   5 Specialty Tier 33%N/AQ:3
/28Days
Armodafinil 150 MG TABLET [NUVIGIL]   4 Non-Preferred Drug 50%50%P Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Armodafinil 200 MG Oral Tablet [NUVIGIL]   4 Non-Preferred Drug 50%50%P Q:30
/30Days
Armodafinil 250 MG TABLET [NUVIGIL]   4 Non-Preferred Drug 50%50%P Q:30
/30Days
Armodafinil 50 MG TABLET [NUVIGIL]   4 Non-Preferred Drug 50%50%P Q:30
/30Days
ARNUITY ELLIPTA 100 MCG INH   3 Preferred Brand $47.00$141.00Q:30
/30Days
ARNUITY ELLIPTA 200 MCG INH   3 Preferred Brand $47.00$141.00Q:30
/30Days
ARNUITY ELLIPTA 50 MCG INH BLST W/DEV   3 Preferred Brand $47.00$141.00Q:30
/30Days
AROMASIN 25MG TABLET   4 Non-Preferred Drug 50%50%None
ARRANON 250 MG VIAL   5 Specialty Tier 33%N/ANone
ARTHROTEC 50 50MG TABLET -200MCG (60 CT)   4 Non-Preferred Drug 50%50%None
ARTHROTEC 75 TABLET EC   4 Non-Preferred Drug 50%50%None
ASACOL HD DR 800 MG TABLET   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ASCOMP WITH CODEINE CAPSULE   4 Non-Preferred Drug 50%50%P Q:180
/30Days
ASHLYNA 0.15-0.03-0.01 MG TAB   3 Preferred Brand $47.00$141.00None
Aspirin-Diphenhydramine ER 25-200 MG   4 Non-Preferred Drug 50%50%Q:60
/30Days
ASPIRIN/BUTALBITAL/CAFFEINE/CODEINE   4 Non-Preferred Drug 50%50%P Q:180
/30Days
ASTAGRAF XL 0.5 MG CAPSULE   4 Non-Preferred Drug 50%50%P
ASTAGRAF XL 1 MG CAPSULE   4 Non-Preferred Drug 50%50%P
ASTAGRAF XL 5 MG CAPSULE   4 Non-Preferred Drug 50%50%P
ASTEPRO 0.15% NASAL SPRAY 30 ML   4 Non-Preferred Drug 50%50%Q:30
/25Days
ATACAND 16MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
ATACAND 32 MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
ATACAND 4MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATACAND 8MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
ATACAND HCT 16/12.5MG TABLET   4 Non-Preferred Drug 50%50%S Q:60
/30Days
ATACAND HCT 32/12.5MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
ATACAND HCT TABLETS 32;25MG;MG 90 TABLET BOTTLE   4 Non-Preferred Drug 50%50%S Q:30
/30Days
ATAZANAVIR SULFATE 150 MG CAP [Reyataz]   5 Specialty Tier 33%N/ANone
ATAZANAVIR SULFATE 200 MG CAP [Reyataz]   5 Specialty Tier 33%N/ANone
ATAZANAVIR SULFATE 300 MG CAP [Reyataz]   5 Specialty Tier 33%N/ANone
Atelvia 35mg/1 36 DOSE PACK CASE / 4 TABLET, DELAYED RELEASE in 1 DOSE PACK   4 Non-Preferred Drug 50%50%S Q:4
/28Days
ATENOLOL 100 MG TABLET   1 Preferred Generic $1.00$3.00None
ATENOLOL 25 MG TABLET   1 Preferred Generic $1.00$3.00None
ATENOLOL 50 MG TABLET   1 Preferred Generic $1.00$3.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATENOLOL-CHLORTHALIDONE 100-25   2 Generic $2.00$6.00None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   2 Generic $2.00$6.00None
ATGAM 50MG/ML AMPUL   5 Specialty Tier 33%N/AP
ATIVAN 1 MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
ATOMOXETINE HCL 10 MG CAPSULE [Strattera]   4 Non-Preferred Drug 50%50%Q:120
/30Days
ATOMOXETINE HCL 100 MG CAPSULE [Strattera]   4 Non-Preferred Drug 50%50%Q:30
/30Days
ATOMOXETINE HCL 18 MG CAPSULE [Strattera]   4 Non-Preferred Drug 50%50%Q:120
/30Days
ATOMOXETINE HCL 25 MG CAPSULE [Strattera]   4 Non-Preferred Drug 50%50%Q:120
/30Days
ATOMOXETINE HCL 40 MG CAPSULE [Strattera]   4 Non-Preferred Drug 50%50%Q:60
/30Days
ATOMOXETINE HCL 60 MG CAPSULE [Strattera]   4 Non-Preferred Drug 50%50%Q:30
/30Days
ATOMOXETINE HCL 80 MG CAPSULE [Strattera]   4 Non-Preferred Drug 50%50%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATORVASTATIN 10 MG TABLET [Lipitor]   1 Preferred Generic $1.00$3.00Q:30
/30Days
ATORVASTATIN 20 MG TABLET [Lipitor]   1 Preferred Generic $1.00$3.00Q:30
/30Days
ATORVASTATIN 40 MG TABLET [Lipitor]   1 Preferred Generic $1.00$3.00Q:30
/30Days
ATORVASTATIN 80 MG TABLET [Lipitor]   1 Preferred Generic $1.00$3.00Q:30
/30Days
ATOVAQUONE 750 MG/5 ML SUSP [Mepron]   4 Non-Preferred Drug 50%50%P
Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone]   4 Non-Preferred Drug 50%50%None
ATOVAQUONE-PROGUANIL 62.5-25 [Malarone]   4 Non-Preferred Drug 50%50%None
ATRALIN 0.05% GEL   4 Non-Preferred Drug 50%50%P
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC   5 Specialty Tier 33%N/ANone
ATROPINE 0.05MG/ML SYRINGE   4 Non-Preferred Drug 50%50%None
ATROPINE 1% EYE DROPS   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATROVENT HFA AER 17MCG   4 Non-Preferred Drug 50%50%Q:26
/30Days
AUBRA-28 TABLET   3 Preferred Brand $47.00$141.00None
AUGMENTIN 125-31.25 MG/5 ML   4 Non-Preferred Drug 50%50%None
AURYXIA 210 MG TABLET   5 Specialty Tier 33%N/ANone
AVALIDE 150-12.5 MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
AVALIDE 300-12.5 MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
AVANDIA 2 MG TABLET   4 Non-Preferred Drug 50%50%Q:60
/30Days
AVANDIA 4 MG TABLET   4 Non-Preferred Drug 50%50%Q:60
/30Days
AVAPRO 150 MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
AVAPRO 300 MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
AVAPRO 75 MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVASTIN 100MG/4ML VIAL   5 Specialty Tier 33%N/AP
AVASTIN 400 MG/16 ML VIAL   5 Specialty Tier 33%N/AP
AVELOX 400 MG TABLET   4 Non-Preferred Drug 50%50%None
AVELOX IV 400 MG/250 ML   4 Non-Preferred Drug 50%50%None
AVIANE 0.1-0.02 TABLET   3 Preferred Brand $47.00$141.00None
AVITA 0.025% CREAM   4 Non-Preferred Drug 50%50%P
Avita 0.25mg/g 45 g in 1 TUBE   4 Non-Preferred Drug 50%50%P
AVODART 0.5 MG SOFTGEL   4 Non-Preferred Drug 50%50%Q:30
/30Days
AXERT 12.5 MG TABLET   4 Non-Preferred Drug 50%50%S Q:8
/30Days
Aygestin 5mg/1 50 TABLET BOTTLE   4 Non-Preferred Drug 50%50%None
Azacitidine 100 mg vial [Vidaza]   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZASAN 100MG TABLET   4 Non-Preferred Drug 50%50%P
AZASAN 75MG TABLET   4 Non-Preferred Drug 50%50%P
AZASITE 1% EYE DROPS   4 Non-Preferred Drug 50%50%None
AZATHIOPRINE 50 MG TABLET   3 Preferred Brand $47.00$141.00P
AZATHIOPRINE SODIUM 100 MG VIAL   4 Non-Preferred Drug 50%50%P
AZELASTINE 0.15% NASAL SPRAY   3 Preferred Brand $47.00$141.00Q:30
/25Days
AZELASTINE 137 MCG NASAL SPRAY   3 Preferred Brand $47.00$141.00Q:30
/25Days
AZELASTINE HCL 0.05% DROPS   3 Preferred Brand $47.00$141.00None
AZILECT 0.5MG TABLET   3 Preferred Brand $47.00$141.00None
AZILECT 1MG TABLET   3 Preferred Brand $47.00$141.00None
AZITHROMYCIN 1 GM PWD PACKET   3 Preferred Brand $47.00$141.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZITHROMYCIN 100 MG/5 ML SUSP   2 Generic $2.00$6.00None
AZITHROMYCIN 200 MG/5 ML SUSP   2 Generic $2.00$6.00None
AZITHROMYCIN 250 MG TABLET   2 Generic $2.00$6.00None
AZITHROMYCIN 500 MG TABLET   2 Generic $2.00$6.00None
Azithromycin 500mg/1 30 FILM COATED TABLETS in BOTTLE   2 Generic $2.00$6.00None
AZITHROMYCIN 600 MG TABLET   2 Generic $2.00$6.00None
AZITHROMYCIN I.V. 500 MG VIAL   4 Non-Preferred Drug 50%50%None
AZOPT 1% EYE DROPS   3 Preferred Brand $47.00$141.00None
AZOR 10-20 MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
AZOR 10MG-40MG TABLET (30 CT)   4 Non-Preferred Drug 50%50%S Q:30
/30Days
AZOR 5-40 MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZOR 5MG-20MG TABLET (30 CT)   4 Non-Preferred Drug 50%50%S Q:30
/30Days
Aztreonam 1000 MG Injection [Azactam]   4 Non-Preferred Drug 50%50%None
Aztreonam 2000 MG Injection [Azactam]   4 Non-Preferred Drug 50%50%None
AZTREONAM FOR INJECTION   4 Non-Preferred Drug 50%50%None
AZULFIDINE 500 MG TABLET   4 Non-Preferred Drug 50%50%None
AZULFIDINE ENTAB 500 MG   4 Non-Preferred Drug 50%50%None

Chart Legend:

Below are a few notes to help you understand the above 2018 Medicare Part D First Health Part D Value Plus (PDP) Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region). 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.