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Blue MedicareRx Value (PDP) (S6506-001-0)
Tier 1 (287)
Tier 2 (473)
Tier 3 (903)
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M N O P Q R S T U V W X Y Z 0-9 
2019 Medicare Part D Plan Formulary Information
Blue MedicareRx Value (PDP) (S6506-001-0)
Benefit Details           
The Blue MedicareRx Value (PDP) (S6506-001-0)
Formulary Drugs Starting with the Letter C
in CMS PDP Region 28 which includes: AZ
Plan Monthly Premium: $32.90 Deductible: $415 Qualifies for LIS: Yes
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 33%33%None
CABOMETYX 20 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
CABOMETYX 40 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
CABOMETYX 60 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
CALCIPOTRIENE 0.005% CREAM   4 Non-Preferred Drug 33%33%P Q:120
/30Days
CALCIPOTRIENE 0.005% SOLUTION   4 Non-Preferred Drug 33%33%P Q:120
/30Days
Calcipotriene 50ug/g 60 g per CARTON   4 Non-Preferred Drug 33%33%P Q:120
/30Days
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY   3 Preferred Brand 16%16%P
CALCITRIOL 0.25 MCG CAPSULE [Rocaltrol]   3 Preferred Brand 16%16%P
CALCITRIOL 0.5 MCG CAPSULE [Rocaltrol]   3 Preferred Brand 16%16%P
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 33%33%P
CALCIUM ACETATE 667 MG TABLET [PhosLo]   3 Preferred Brand 16%16%Q:360
/30Days
CALCIUM ACETATE CAPSULE 667 MG   4 Non-Preferred Drug 33%33%Q:360
/30Days
CALQUENCE 100 MG CAPSULE   5 Specialty Tier 25%N/AP
CAMILA 0.35 MG TABLET   2 Generic $6.00$18.00None
CAPRELSA 100 MG TABLET   5 Specialty Tier 25%N/AP
CAPRELSA 300 MG TABLET   5 Specialty Tier 25%N/AP
CARBAGLU 200 MG DISPER TABLET   5 Specialty Tier 25%N/AP
CARBAMAZEPINE 100 MG TAB CHEW   3 Preferred Brand 16%16%None
CARBAMAZEPINE 100 MG/5 ML SUSP   4 Non-Preferred Drug 33%33%None
CARBAMAZEPINE 200 MG TABLET   3 Preferred Brand 16%16%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CARBAMAZEPINE ER 100 MG CAP CPMP 12HR [Carbatrol]   4 Non-Preferred Drug 33%33%None
CARBAMAZEPINE ER 100 MG TABLET   4 Non-Preferred Drug 33%33%None
CARBAMAZEPINE ER 200 MG CAP CPMP 12HR [Carbatrol]   4 Non-Preferred Drug 33%33%None
CARBAMAZEPINE ER 300 MG CAP CPMP 12HR [Carbatrol]   4 Non-Preferred Drug 33%33%None
CARBAMAZEPINE XR 200 MG TABLET   4 Non-Preferred Drug 33%33%None
CARBAMAZEPINE XR 400 MG TABLET   4 Non-Preferred Drug 33%33%None
CARBIDOPA AND LEVEDOPA ORALLY DISINTEGRATING TABLETS 10;100MG;MG 100 BOT   4 Non-Preferred Drug 33%33%None
CARBIDOPA AND LEVODOPA ODT 25;100MG;MG 100 BOT   4 Non-Preferred Drug 33%33%None
CARBIDOPA AND LEVODOPA ODT 25;250MG;MG 100 BOT   4 Non-Preferred Drug 33%33%None
CARBIDOPA-LEVO ER 25-100 TAB   3 Preferred Brand 16%16%None
CARBIDOPA-LEVO ER 50-200 TAB   3 Preferred Brand 16%16%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CARBIDOPA-LEVODOPA 10-100 TAB   2 Generic $6.00$18.00None
CARBIDOPA-LEVODOPA 25-100 TAB   2 Generic $6.00$18.00None
CARBIDOPA-LEVODOPA 25-250 TAB   2 Generic $6.00$18.00None
CARBIDOPA-LEVODOPA-ENTA 150 MG   4 Non-Preferred Drug 33%33%None
CARBIDOPA-LEVODOPA-ENTA 75 MG   4 Non-Preferred Drug 33%33%None
CARBIDOPA-LEVODOPA-ENTACAPONE 100 MG [Stalevo]   4 Non-Preferred Drug 33%33%None
CARBIDOPA-LEVODOPA-ENTACAPONE 125 MG [Stalevo]   4 Non-Preferred Drug 33%33%None
CARBIDOPA-LEVODOPA-ENTACAPONE 200 MG [Stalevo]   4 Non-Preferred Drug 33%33%None
CARBIDOPA-LEVODOPA-ENTACAPONE 50 MG [Stalevo]   4 Non-Preferred Drug 33%33%None
CARTEOLOL HCL 1% EYE DROPS   2 Generic $6.00$18.00None
CARTIA XT 120MG CAPSULE SA   3 Preferred Brand 16%16%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CARTIA XT 180MG CAPSULE SA   3 Preferred Brand 16%16%None
CARTIA XT 240MG CAPSULE SA   3 Preferred Brand 16%16%None
CARTIA XT 300 MG CAPSULE   3 Preferred Brand 16%16%None
CARVEDILOL 12.5 MG TABLET   1 Preferred Generic $3.00$9.00None
CARVEDILOL 25 MG TABLET   1 Preferred Generic $3.00$9.00None
CARVEDILOL 3.125 MG TABLET   1 Preferred Generic $3.00$9.00None
CARVEDILOL 6.25 MG TABLET   1 Preferred Generic $3.00$9.00None
CASPOFUNGIN ACETATE 50 MG VIAL   5 Specialty Tier 25%N/ANone
CASPOFUNGIN ACETATE 70 MG VIAL   5 Specialty Tier 25%N/ANone
CAYSTON KIT 75 MG/VIAL   5 Specialty Tier 25%N/AP
CAZIANT 28 DAY TABLET   3 Preferred Brand 16%16%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CEFACLOR 250 MG CAPSULES   3 Preferred Brand 16%16%None
CEFACLOR 500 MG CAPSULES   3 Preferred Brand 16%16%None
CEFADROXIL 1 GM TABLET   4 Non-Preferred Drug 33%33%None
CEFADROXIL 250 MG/5 ML SUSP   3 Preferred Brand 16%16%None
CEFADROXIL 500 MG CAPSULE   2 Generic $6.00$18.00None
CEFADROXIL 500 MG/5 ML SUSP   3 Preferred Brand 16%16%None
CEFAZOLIN 1 GM VIAL 25/Box   3 Preferred Brand 16%16%None
Cefazolin 10g/1 10 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 PACKAGE   3 Preferred Brand 16%16%None
CEFAZOLIN 500 MG VIAL   3 Preferred Brand 16%16%None
CEFDINIR 125 MG/5 ML SUSP   4 Non-Preferred Drug 33%33%None
CEFDINIR 250 MG/5 ML SUSP   4 Non-Preferred Drug 33%33%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CEFDINIR 300 MG CAPSULE   3 Preferred Brand 16%16%None
CEFEPIME HCL 1 GM VIAL [Maxipime]   4 Non-Preferred Drug 33%33%None
CEFEPIME HCL 2 GRAM VIAL [Maxipime]   4 Non-Preferred Drug 33%33%None
CEFIXIME 100 MG/5 ML SUSP [Suprax]   4 Non-Preferred Drug 33%33%None
CEFIXIME 200 MG/5 ML SUSP [Suprax]   4 Non-Preferred Drug 33%33%None
CEFOXITIN 1 GM VIAL   4 Non-Preferred Drug 33%33%None
CEFOXITIN 10 GM VIAL   4 Non-Preferred Drug 33%33%None
CEFOXITIN 2 GM VIAL   4 Non-Preferred Drug 33%33%None
CEFPODOXIME 100 MG TABLET   3 Preferred Brand 16%16%None
CEFPODOXIME 100 MG/5 ML SUSP   4 Non-Preferred Drug 33%33%None
CEFPODOXIME 200 MG TABLET   3 Preferred Brand 16%16%None
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 33%33%None
CEFTAZIDIME 1 GM VIAL   3 Preferred Brand 16%16%None
CEFTAZIDIME FOR INJECTION 2GM/VIAL 10 X 2 CRTN   3 Preferred Brand 16%16%None
CEFTAZIDIME FOR INJECTION 6GM/VIAL 6 X 6 CRTN   3 Preferred Brand 16%16%None
CEFTRIAXONE 1 GM VIAL   3 Preferred Brand 16%16%None
CEFTRIAXONE 10 GM VIAL   3 Preferred Brand 16%16%None
CEFTRIAXONE 2 GM VIAL   3 Preferred Brand 16%16%None
CEFTRIAXONE 250 MG VIAL   3 Preferred Brand 16%16%None
CEFTRIAXONE 500 MG VIAL   3 Preferred Brand 16%16%None
CEFUROXIME 1.5 GM/VIAL FOR INJECTION   4 Non-Preferred Drug 33%33%None
CEFUROXIME 750 MG FOR INJECTION   4 Non-Preferred Drug 33%33%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Cefuroxime 95 MG/ML Injectable Solution   4 Non-Preferred Drug 33%33%None
CEFUROXIME AXETIL 250 MG TAB   3 Preferred Brand 16%16%None
CEFUROXIME AXETIL 500 MG TAB   3 Preferred Brand 16%16%None
CELECOXIB 100 MG CAPSULE [Celebrex]   3 Preferred Brand 16%16%Q:120
/30Days
CELECOXIB 200 MG CAPSULE [Celebrex]   3 Preferred Brand 16%16%Q:60
/30Days
CELECOXIB 400 MG CAPSULE [Celebrex]   3 Preferred Brand 16%16%Q:30
/30Days
CELECOXIB 50 MG CAPSULE [Celebrex]   3 Preferred Brand 16%16%Q:240
/30Days
CELONTIN 300 MG KAPSEAL   4 Non-Preferred Drug 33%33%None
CEPHALEXIN 125 MG/5 ML SUSP   3 Preferred Brand 16%16%None
CEPHALEXIN 250 MG CAPSULE   1 Preferred Generic $3.00$9.00None
CEPHALEXIN 250 MG/5 ML SUSP   3 Preferred Brand 16%16%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CEPHALEXIN 500 MG CAPSULE   1 Preferred Generic $3.00$9.00None
CERDELGA 84 MG CAPSULE   5 Specialty Tier 25%N/AP
CETIRIZINE HCL 1 MG/ML SOLN   2 Generic $6.00$18.00None
CHANTIX 0.5 MG TABLET   4 Non-Preferred Drug 33%33%P
CHANTIX 1 MG CONT MONTH BOX   4 Non-Preferred Drug 33%33%P
CHANTIX 1 MG TABLET   4 Non-Preferred Drug 33%33%P
CHANTIX STARTING MONTH BOX   4 Non-Preferred Drug 33%33%P
CHEMET 100 MG CAPSULE   4 Non-Preferred Drug 33%33%None
CHLORHEXIDINE GLUCONATE 0.12% RINSE   1 Preferred Generic $3.00$9.00None
CHLOROQUINE PH 250 MG TABLET   4 Non-Preferred Drug 33%33%None
CHLOROQUINE PH 500 MG TABLET   4 Non-Preferred Drug 33%33%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CHLOROTHIAZIDE 250 MG TABLET   3 Preferred Brand 16%16%None
Chlorothiazide 500mg 100 TABLET BOTTLE   3 Preferred Brand 16%16%None
CHLORPROMAZINE 10 MG TABLET   4 Non-Preferred Drug 33%33%None
CHLORPROMAZINE 100 MG TABLET   4 Non-Preferred Drug 33%33%None
CHLORPROMAZINE 200 MG TABLET   4 Non-Preferred Drug 33%33%None
CHLORPROMAZINE 25 MG TABLET   4 Non-Preferred Drug 33%33%None
CHLORPROMAZINE 50 MG TABLET   4 Non-Preferred Drug 33%33%None
CHLORTHALIDONE 25 MG TABLET (100 CT)   3 Preferred Brand 16%16%None
CHLORTHALIDONE 50 MG TABLET   3 Preferred Brand 16%16%None
CHOLESTYRAMINE LIGHT POWDER   4 Non-Preferred Drug 33%33%None
CHOLESTYRAMINE PACKET   4 Non-Preferred Drug 33%33%None
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 16%16%None
Cilastatin 500 MG / Imipenem 500 MG Injection   3 Preferred Brand 16%16%None
CILOSTAZOL 100 MG TABLET   2 Generic $6.00$18.00None
CILOSTAZOL 50 MG TABLET   2 Generic $6.00$18.00None
CILOXAN 0.3% OINTMENT   3 Preferred Brand 16%16%None
CIMDUO 300-300 MG TABLET   5 Specialty Tier 25%N/ANone
CINACALCET HCL 30 MG TABLET [Sensipar]   5 Specialty Tier 25%N/AP Q:120
/30Days
CINACALCET HCL 60 MG TABLET [Sensipar]   5 Specialty Tier 25%N/AP Q:60
/30Days
CINACALCET HCL 90 MG TABLET [Sensipar]   5 Specialty Tier 25%N/AP Q:120
/30Days
CIPRODEX OTIC SUSPENSION   3 Preferred Brand 16%16%None
CIPROFLOXACIN 0.3% EYE DROP [Ciloxan]   2 Generic $6.00$18.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CIPROFLOXACIN 250 MG TABLET (100 CT) [Cipro]   1 Preferred Generic $3.00$9.00None
CIPROFLOXACIN HCL 100 MG Tablet [Cipro]   4 Non-Preferred Drug 33%33%None
CIPROFLOXACIN HCL 500 MG Tablet [Cipro]   1 Preferred Generic $3.00$9.00None
CIPROFLOXACIN HCL 750 MG Tablet [Cipro]   1 Preferred Generic $3.00$9.00None
CIPROFLOXACIN-D5W 200 MG/100 ML PIGGYBACK [Cipro]   3 Preferred Brand 16%16%None
CITALOPRAM HBR 10 MG TABLET   1 Preferred Generic $3.00$9.00None
CITALOPRAM HBR 10 MG/5 ML SOLN   3 Preferred Brand 16%16%None
CITALOPRAM HBR 20 MG TABLET   1 Preferred Generic $3.00$9.00None
CITALOPRAM HBR 40 MG TABLET   1 Preferred Generic $3.00$9.00None
CLARAVIS 10 MG CAPSULE   4 Non-Preferred Drug 33%33%P
CLARAVIS 20 MG CAPSULE   4 Non-Preferred Drug 33%33%P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Claravis 30mg 3 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK   4 Non-Preferred Drug 33%33%P
CLARAVIS 40 MG CAPSULE   4 Non-Preferred Drug 33%33%P
CLARITHROMYCIN 125 MG/5ML FOR ORAL SUSPENSION   4 Non-Preferred Drug 33%33%None
CLARITHROMYCIN 250 MG TABLET   3 Preferred Brand 16%16%None
CLARITHROMYCIN 250 MG/5MLFOR ORAL SUSPENSION   4 Non-Preferred Drug 33%33%None
CLARITHROMYCIN 500 MG TABLET   3 Preferred Brand 16%16%None
CLARITHROMYCIN ER 500 MG TAB   3 Preferred Brand 16%16%None
Clindamycin 150 MG/ML 2ml   3 Preferred Brand 16%16%None
CLINDAMYCIN 150mg/ml vl 25x6ml   3 Preferred Brand 16%16%None
CLINDAMYCIN 75 MG/5 ML SOLN   4 Non-Preferred Drug 33%33%None
CLINDAMYCIN HCL 150 MG CAPSULE   2 Generic $6.00$18.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CLINDAMYCIN HCL 300 MG CAPSULE   2 Generic $6.00$18.00None
CLINDAMYCIN HCL 75 MG 200 CAPSULE BOTTLE   2 Generic $6.00$18.00None
CLINDAMYCIN PH 1% SOLUTION   3 Preferred Brand 16%16%None
CLINDAMYCIN PH 600 MG/4 ML VL   3 Preferred Brand 16%16%None
CLINDAMYCIN PHOSP 1% LOTION   4 Non-Preferred Drug 33%33%None
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE   4 Non-Preferred Drug 33%33%None
CLINDAMYCIN PHOSPHATE VAGINAL CREAM   3 Preferred Brand 16%16%None
Clindamycin-d5w 300 mg/50 ml   4 Non-Preferred Drug 33%33%None
Clindamycin-d5w 600 mg/50 ml   4 Non-Preferred Drug 33%33%None
Clindamycin-d5w 900 mg/50 ml   4 Non-Preferred Drug 33%33%None
CLINIMIX 4.25%-25% SOLUTION IV SOLN   4 Non-Preferred Drug 33%33%P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CLINIMIX 5/20 SOLUTION   4 Non-Preferred Drug 33%33%P
CLINIMIX 5/25 SULFITE FREE INJECTIONS 1035MG-420MEQ 1000ML BAG   4 Non-Preferred Drug 33%33%P
CLINIMIX 5%-15% SOLUTION   4 Non-Preferred Drug 33%33%P
CLOBAZAM 10 MG TABLET [ONFI]   3 Preferred Brand 16%16%P
CLOBAZAM 2.5 MG/ML Oral Suspension [ONFI]   3 Preferred Brand 16%16%P
CLOBAZAM 20 MG TABLET [ONFI]   3 Preferred Brand 16%16%P
CLOMIPRAMINE 25 MG CAPSULE   4 Non-Preferred Drug 33%33%P
CLOMIPRAMINE 50 MG CAPSULE   4 Non-Preferred Drug 33%33%P
CLOMIPRAMINE 75 MG CAPSULE   4 Non-Preferred Drug 33%33%P
CLONAZEPAM 0.125 MG DIS TAB RAPDIS [Klonopin]   3 Preferred Brand 16%16%Q:90
/30Days
CLONAZEPAM 0.25 MG ODT TAB RAPDIS [Klonopin]   3 Preferred Brand 16%16%Q:90
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CLONAZEPAM 0.5 MG DIS TABLET RAPDIS [Klonopin]   3 Preferred Brand 16%16%Q:90
/30Days
CLONAZEPAM 0.5 MG TABLET [Klonopin]   2 Generic $6.00$18.00Q:90
/30Days
CLONAZEPAM 1 MG DIS TABLET RAPDIS [Klonopin]   3 Preferred Brand 16%16%Q:90
/30Days
CLONAZEPAM 1 MG TABLET [Klonopin]   2 Generic $6.00$18.00Q:90
/30Days
CLONAZEPAM 2 MG ODT TAB RAPDIS [Klonopin]   3 Preferred Brand 16%16%Q:300
/30Days
CLONAZEPAM 2 MG TABLET [Klonopin]   2 Generic $6.00$18.00Q:300
/30Days
Clonidine 0.1mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH   4 Non-Preferred Drug 33%33%None
Clonidine 0.2mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH   4 Non-Preferred Drug 33%33%None
Clonidine 0.3mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH   4 Non-Preferred Drug 33%33%None
CLONIDINE HCL 0.1 MG TABLET   1 Preferred Generic $3.00$9.00None
CLONIDINE HCL 0.2 MG TABLET   1 Preferred Generic $3.00$9.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CLONIDINE HCL 0.3 MG TABLET   1 Preferred Generic $3.00$9.00None
CLOPIDOGREL 75 MG TABLET [Plavix]   1 Preferred Generic $3.00$9.00None
CLORAZEPATE 15 MG TABLET   4 Non-Preferred Drug 33%33%P Q:180
/30Days
CLORAZEPATE 3.75 MG TABLET   4 Non-Preferred Drug 33%33%P Q:180
/30Days
CLORAZEPATE 7.5 MG TABLET   4 Non-Preferred Drug 33%33%P Q:180
/30Days
CLOTRIMAZOLE 1% CREAM   3 Preferred Brand 16%16%None
CLOTRIMAZOLE 10 MG TROCHE   4 Non-Preferred Drug 33%33%None
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE 0.64; 10mg/g; mg/g 45 g in 1 TUBE   3 Preferred Brand 16%16%None
CLOZAPINE 100 MG TABLET [Clozaril]   4 Non-Preferred Drug 33%33%Q:270
/30Days
CLOZAPINE 200 MG TABLET   4 Non-Preferred Drug 33%33%Q:135
/30Days
CLOZAPINE 25 MG TABLET [Clozaril]   3 Preferred Brand 16%16%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CLOZAPINE 50 MG TABLET   3 Preferred Brand 16%16%None
CLOZAPINE ODT 100 MG TABLET RAPDIS [Fazaclo]   4 Non-Preferred Drug 33%33%P Q:270
/30Days
CLOZAPINE ODT 12.5 MG TABLET RAPDIS [Fazaclo]   4 Non-Preferred Drug 33%33%P
CLOZAPINE ODT 150 MG TABLET RAPDIS [Fazaclo]   4 Non-Preferred Drug 33%33%P Q:180
/30Days
CLOZAPINE ODT 200 MG TABLET RAPDIS [Fazaclo]   5 Specialty Tier 25%N/AP Q:135
/30Days
CLOZAPINE ODT 25 MG TABLET RAPDIS [Fazaclo]   4 Non-Preferred Drug 33%33%P
COARTEM 20MG-120MG   4 Non-Preferred Drug 33%33%None
COLCRYS 0.6 MG TABLET   3 Preferred Brand 16%16%Q:120
/30Days
COLESEVELAM 625 MG TABLET [WelChol]   3 Preferred Brand 16%16%None
COLESEVELAM HCL 3.75 G PACKET POWD PACK [WelChol]   3 Preferred Brand 16%16%None
COLESTIPOL HCL 1G TABLET   3 Preferred Brand 16%16%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
COLESTIPOL HCL GRANULES PACKET   4 Non-Preferred Drug 33%33%None
COLISTIMETHATE 150 MG VIAL [Coly-Mycin M]   4 Non-Preferred Drug 33%33%None
COLOCORT 100MG ENEMA   4 Non-Preferred Drug 33%33%None
COMBIGAN 0.2%-0.5% DROPS   3 Preferred Brand 16%16%None
COMBIVENT RESPIMAT INHAL SPRAY   4 Non-Preferred Drug 33%33%Q:8
/30Days
COMETRIQ 100 MG DAILY-DOSE PK   5 Specialty Tier 25%N/AP
COMETRIQ 140 MG DAILY-DOSE PK   5 Specialty Tier 25%N/AP
COMETRIQ 60 MG DAILY-DOSE PACK   5 Specialty Tier 25%N/AP
COMPLERA 200; 27.5; 300mg/1; mg/1; mg/1   5 Specialty Tier 25%N/ANone
COMPRO 25MG SUPPOSITORY   4 Non-Preferred Drug 33%33%None
CONSTULOSE 10 GM/15 ML SOLN   2 Generic $6.00$18.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
COPIKTRA 15 MG CAPSULE   5 Specialty Tier 25%N/AP
COPIKTRA 25 MG CAPSULE   5 Specialty Tier 25%N/AP
CORLANOR 5 MG TABLET   4 Non-Preferred Drug 33%33%None
CORLANOR 7.5 MG TABLET   4 Non-Preferred Drug 33%33%None
Cortisone 25 MG Tablet   4 Non-Preferred Drug 33%33%None
COTELLIC 20 MG TABLET   5 Specialty Tier 25%N/AP
COUMADIN 1 MG TABLET   3 Preferred Brand 16%16%None
COUMADIN 10MG TABLET   3 Preferred Brand 16%16%None
COUMADIN 2.5 MG TABLET   3 Preferred Brand 16%16%None
COUMADIN 2MG TABLET   3 Preferred Brand 16%16%None
COUMADIN 3mg/1 1 BOTTLE per CARTON / 100 TABLET BOTTLE   3 Preferred Brand 16%16%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
COUMADIN 4mg/1 1 BOTTLE in 1 CARTON / 100 TABLET BOTTLE   3 Preferred Brand 16%16%None
COUMADIN 5MG TABLET   3 Preferred Brand 16%16%None
COUMADIN 6MG TABLET   3 Preferred Brand 16%16%None
COUMADIN 7.5MG TABLET   3 Preferred Brand 16%16%None
Creon 256.11mg/1 1 BOTTLE per CARTON / 70 CAPSULE, DELAYED RELEASE in 1 BOTTLE   3 Preferred Brand 16%16%None
CREON DELAYED RELEASE CAPSULES 12000MG 100 BOT   3 Preferred Brand 16%16%None
CREON DELAYED RELEASE CAPSULES 24000MG 100 BOT   3 Preferred Brand 16%16%None
CREON DELAYED RELEASE CAPSULES 6000MG 100 BOT   3 Preferred Brand 16%16%None
CREON DR 36,000 UNITS CAPSULE   3 Preferred Brand 16%16%None
CRIXIVAN 200MG CAPSULE   4 Non-Preferred Drug 33%33%None
CRIXIVAN 400mg, 180 CAPSULE BOTTLE   4 Non-Preferred Drug 33%33%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CROMOLYN 20 MG/2 ML NEB SOLN   3 Preferred Brand 16%16%P
CROMOLYN SODIUM 100 MG/5 ML   5 Specialty Tier 25%N/ANone
CROMOLYN SODIUM 4% 40MG 10ML BOT   1 Preferred Generic $3.00$9.00None
Cyclafem 1/35 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK   2 Generic $6.00$18.00None
CYCLOBENZAPRINE 10 MG TABLET   3 Preferred Brand 16%16%P
CYCLOBENZAPRINE 5 MG TABLET   3 Preferred Brand 16%16%P
CYCLOPHOSPHAMIDE 25 MG CAPSULE   4 Non-Preferred Drug 33%33%P
CYCLOPHOSPHAMIDE 50 MG CAPSULE   4 Non-Preferred Drug 33%33%P
CYCLOSPORINE 100MG CAPSULE   4 Non-Preferred Drug 33%33%P
CYCLOSPORINE 25MG CAPSULE   4 Non-Preferred Drug 33%33%P
CYCLOSPORINE MODIFIED 100 MG   4 Non-Preferred Drug 33%33%P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CYCLOSPORINE MODIFIED 25 MG   4 Non-Preferred Drug 33%33%P
CYCLOSPORINE MODIFIED 50 MG   4 Non-Preferred Drug 33%33%P
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT   4 Non-Preferred Drug 33%33%P
CYPROHEPTADINE 4 MG TABLET   3 Preferred Brand 16%16%P
CYPROHEPTADINE HYDROCHLORIDE SOLUTION USP SYRUP 2MG 473 ML BOTGL   3 Preferred Brand 16%16%P
CYRED EQ 28 DAY TABLET [Solia]   2 Generic $6.00$18.00None
CYSTADANE 1 GRAM/1.7 ML POWDER   5 Specialty Tier 25%N/ANone
CYSTAGON 150MG CAPSULE   4 Non-Preferred Drug 33%33%P
CYSTAGON 50MG CAPSULE   4 Non-Preferred Drug 33%33%P
CYSTARAN 0.44% EYE DROPS   5 Specialty Tier 25%N/AP

Chart Legend:

Below are a few notes to help you understand the above 2019 Medicare Part D Blue MedicareRx Value (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 $415 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 $3820) at a "Preferred" network pharmacy. In most cases, the "Preferred" 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 2019 )

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.