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2019 Medicare Part D Plan Formulary Information
Allwell Dual Medicare (HMO SNP) (H5190-004-0) Benefit Details
The Allwell Dual Medicare (HMO SNP) (H5190-004-0) Formulary Drugs Starting with the Letter C in Miami-Dade County, FL: CMS MA Region 9 which includes: FL Plan Monthly Premium: $30.30 Deductible: $415
Drugs Starting with Letter C Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter C Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CABERGOLINE 0.5 MG TABLET	3	Preferred Brand	$47.00	$141.00	None
CABOMETYX 20 MG TABLET	5	Specialty Tier	25%	N/A	P
CABOMETYX 40 MG TABLET	5	Specialty Tier	25%	N/A	P
CABOMETYX 60 MG TABLET	5	Specialty Tier	25%	N/A	P
CALCIPOTRIENE 0.005% CREAM	4	Non-Preferred Drug	$100.00	$300.00	None
CALCIPOTRIENE 0.005% SOLUTION	4	Non-Preferred Drug	$100.00	$300.00	None
Calcipotriene 50ug/g 60 g per CARTON	4	Non-Preferred Drug	$100.00	$300.00	None
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY	3	Preferred Brand	$47.00	$141.00	None
CALCITRIOL 0.25 MCG CAPSULE [Rocaltrol]	2*	Generic	$0.00	$0.00	None
CALCITRIOL 0.5 MCG CAPSULE [Rocaltrol]	2*	Generic	$0.00	$0.00	None
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	$100.00	$300.00	None
CALCIUM ACETATE CAPSULE 667 MG	4	Non-Preferred Drug	$100.00	$300.00	None
CALQUENCE 100 MG CAPSULE	5	Specialty Tier	25%	N/A	P
CAMILA 0.35 MG TABLET	2*	Generic	$0.00	$0.00	None
CAMRESE LO TABLET	3	Preferred Brand	$47.00	$141.00	None
CANDESARTAN CILEXETIL 16 MG TABLET [Atacand]	6*	Select Care Drugs	$0.00	$0.00	None
CANDESARTAN CILEXETIL 32 MG TABLET [Atacand]	6*	Select Care Drugs	$0.00	$0.00	None
CANDESARTAN CILEXETIL 4 MG TABLET [Atacand]	6*	Select Care Drugs	$0.00	$0.00	None
CANDESARTAN CILEXETIL 8 MG TABLET [Atacand]	6*	Select Care Drugs	$0.00	$0.00	None
candesartan-hctz 16-12.5 mg tablet	6*	Select Care Drugs	$0.00	$0.00	None
candesartan-hctz 32-12.5 mg tablet	6*	Select Care Drugs	$0.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CANDESARTAN-HCTZ 32-25 MG TAB	6*	Select Care Drugs	$0.00	$0.00	None
CAPRELSA 100 MG TABLET	5	Specialty Tier	25%	N/A	P
CAPRELSA 300 MG TABLET	5	Specialty Tier	25%	N/A	P
CAPTOPRIL 100MG TABLET	6*	Select Care Drugs	$0.00	$0.00	None
CAPTOPRIL 12.5MG TABLET	6*	Select Care Drugs	$0.00	$0.00	None
CAPTOPRIL 25 MG TABLET	6*	Select Care Drugs	$0.00	$0.00	None
CAPTOPRIL 50MG TABLET	6*	Select Care Drugs	$0.00	$0.00	None
Captopril and Hydrochlorothiazide 25; 15mg 100 TABLET BOTTLE	6*	Select Care Drugs	$0.00	$0.00	None
Captopril and Hydrochlorothiazide 25; 25mg 100 TABLET BOTTLE	6*	Select Care Drugs	$0.00	$0.00	None
Captopril and Hydrochlorothiazide 50; 15mg 100 TABLET BOTTLE	6*	Select Care Drugs	$0.00	$0.00	None
Captopril and Hydrochlorothiazide 50; 25mg 100 TABLET BOTTLE	6*	Select Care Drugs	$0.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CARAC CREAM	5	Specialty Tier	25%	N/A	None
CARBAGLU 200 MG DISPER TABLET	4	Non-Preferred Drug	$100.00	$300.00	None
CARBAMAZEPINE 100 MG TAB CHEW	3	Preferred Brand	$47.00	$141.00	None
CARBAMAZEPINE 100 MG/5 ML SUSP	2*	Generic	$0.00	$0.00	None
CARBAMAZEPINE 200 MG TABLET	2*	Generic	$0.00	$0.00	None
CARBAMAZEPINE ER 100 MG CAP CPMP 12HR [Carbatrol]	3	Preferred Brand	$47.00	$141.00	None
CARBAMAZEPINE ER 100 MG TABLET	2*	Generic	$0.00	$0.00	None
CARBAMAZEPINE ER 200 MG CAP CPMP 12HR [Carbatrol]	3	Preferred Brand	$47.00	$141.00	None
CARBAMAZEPINE ER 300 MG CAP CPMP 12HR [Carbatrol]	3	Preferred Brand	$47.00	$141.00	None
CARBAMAZEPINE XR 200 MG TABLET	2*	Generic	$0.00	$0.00	None
CARBAMAZEPINE XR 400 MG TABLET	2*	Generic	$0.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Carbidopa 25mg Tab 100 [Lodosyn]	4	Non-Preferred Drug	$100.00	$300.00	None
CARBIDOPA AND LEVEDOPA ORALLY DISINTEGRATING TABLETS 10;100MG;MG 100 BOT	2*	Generic	$0.00	$0.00	None
CARBIDOPA AND LEVODOPA ODT 25;100MG;MG 100 BOT	2*	Generic	$0.00	$0.00	None
CARBIDOPA AND LEVODOPA ODT 25;250MG;MG 100 BOT	2*	Generic	$0.00	$0.00	None
CARBIDOPA-LEVO ER 25-100 TAB	3	Preferred Brand	$47.00	$141.00	None
CARBIDOPA-LEVO ER 50-200 TAB	3	Preferred Brand	$47.00	$141.00	None
CARBIDOPA-LEVODOPA 10-100 TAB	2*	Generic	$0.00	$0.00	None
CARBIDOPA-LEVODOPA 25-100 TAB	2*	Generic	$0.00	$0.00	None
CARBIDOPA-LEVODOPA 25-250 TAB	2*	Generic	$0.00	$0.00	None
CARBINOXAMINE 4 MG/5 ML LIQUID	2*	Generic	$0.00	$0.00	P
CARBINOXAMINE MALEATE 4 MG TAB	2*	Generic	$0.00	$0.00	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CARISOPRODOL 350 MG TABLET	2*	Generic	$0.00	$0.00	P
CARTEOLOL HCL 1% EYE DROPS	2*	Generic	$0.00	$0.00	None
CARTIA XT 120MG CAPSULE SA	3	Preferred Brand	$47.00	$141.00	None
CARTIA XT 180MG CAPSULE SA	3	Preferred Brand	$47.00	$141.00	None
CARTIA XT 240MG CAPSULE SA	3	Preferred Brand	$47.00	$141.00	None
CARTIA XT 300 MG CAPSULE	3	Preferred Brand	$47.00	$141.00	None
CARVEDILOL 12.5 MG TABLET	1*	Preferred Generic	$0.00	$0.00	None
CARVEDILOL 25 MG TABLET	1*	Preferred Generic	$0.00	$0.00	None
CARVEDILOL 3.125 MG TABLET	1*	Preferred Generic	$0.00	$0.00	None
CARVEDILOL 6.25 MG TABLET	1*	Preferred Generic	$0.00	$0.00	None
CARVEDILOL ER 10 MG CAPSULE	2*	Generic	$0.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CARVEDILOL ER 20 MG CAPSULE	2*	Generic	$0.00	$0.00	None
CARVEDILOL ER 40 MG CAPSULE	2*	Generic	$0.00	$0.00	None
CARVEDILOL ER 80 MG CAPSULE	2*	Generic	$0.00	$0.00	None
CAYSTON KIT 75 MG/VIAL	5	Specialty Tier	25%	N/A	P
CEFACLOR 250 MG CAPSULES	3	Preferred Brand	$47.00	$141.00	None
CEFACLOR 500 MG CAPSULES	3	Preferred Brand	$47.00	$141.00	None
CEFADROXIL 1 GM TABLET	1*	Preferred Generic	$0.00	$0.00	None
CEFADROXIL 250 MG/5 ML SUSP	1*	Preferred Generic	$0.00	$0.00	None
CEFADROXIL 500 MG CAPSULE	2*	Generic	$0.00	$0.00	None
CEFADROXIL 500 MG/5 ML SUSP	1*	Preferred Generic	$0.00	$0.00	None
CEFAZOLIN 1 GM VIAL 25/Box	4	Non-Preferred Drug	$100.00	$300.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Cefazolin 10g/1 10 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 PACKAGE	4	Non-Preferred Drug	$100.00	$300.00	None
CEFAZOLIN 500 MG VIAL	4	Non-Preferred Drug	$100.00	$300.00	None
CEFDINIR 125 MG/5 ML SUSP	3	Preferred Brand	$47.00	$141.00	None
CEFDINIR 250 MG/5 ML SUSP	3	Preferred Brand	$47.00	$141.00	None
CEFDINIR 300 MG CAPSULE	3	Preferred Brand	$47.00	$141.00	None
CEFEPIME HCL 1 GM VIAL [Maxipime]	4	Non-Preferred Drug	$100.00	$300.00	None
CEFEPIME HCL 2 GRAM VIAL [Maxipime]	4	Non-Preferred Drug	$100.00	$300.00	None
CEFOXITIN 1 GM VIAL	2*	Generic	$0.00	$0.00	None
CEFOXITIN 10 GM VIAL	2*	Generic	$0.00	$0.00	None
CEFOXITIN 2 GM VIAL	2*	Generic	$0.00	$0.00	None
CEFPODOXIME 100 MG TABLET	4	Non-Preferred Drug	$100.00	$300.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CEFPODOXIME 100 MG/5 ML SUSP	2*	Generic	$0.00	$0.00	None
CEFPODOXIME 200 MG TABLET	4	Non-Preferred Drug	$100.00	$300.00	None
CEFPODOXIME 50 MG/5 ML SUSP	2*	Generic	$0.00	$0.00	None
CEFPROZIL 125 MG/5 ML SUSP	1*	Preferred Generic	$0.00	$0.00	None
CEFPROZIL 250 MG TABLET	3	Preferred Brand	$47.00	$141.00	None
CEFPROZIL 250 MG/5 ML SUSP	1*	Preferred Generic	$0.00	$0.00	None
CEFPROZIL 500 MG TABLET	3	Preferred Brand	$47.00	$141.00	None
CEFTAZIDIME 1 GM VIAL	4	Non-Preferred Drug	$100.00	$300.00	None
CEFTAZIDIME FOR INJECTION 2GM/VIAL 10 X 2 CRTN	4	Non-Preferred Drug	$100.00	$300.00	None
CEFTAZIDIME FOR INJECTION 6GM/VIAL 6 X 6 CRTN	4	Non-Preferred Drug	$100.00	$300.00	None
CEFTRIAXONE 1 GM VIAL	3	Preferred Brand	$47.00	$141.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CEFTRIAXONE 10 GM VIAL	3	Preferred Brand	$47.00	$141.00	None
CEFTRIAXONE 2 GM VIAL	3	Preferred Brand	$47.00	$141.00	None
CEFTRIAXONE 250 MG VIAL	3	Preferred Brand	$47.00	$141.00	None
CEFTRIAXONE 500 MG VIAL	3	Preferred Brand	$47.00	$141.00	None
CEFUROXIME 1.5 GM/VIAL FOR INJECTION	1*	Preferred Generic	$0.00	$0.00	None
CEFUROXIME 750 MG FOR INJECTION	4	Non-Preferred Drug	$100.00	$300.00	None
Cefuroxime 95 MG/ML Injectable Solution	1*	Preferred Generic	$0.00	$0.00	None
CEFUROXIME AXETIL 250 MG TAB	3	Preferred Brand	$47.00	$141.00	None
CEFUROXIME AXETIL 500 MG TAB	3	Preferred Brand	$47.00	$141.00	None
CELECOXIB 100 MG CAPSULE [Celebrex]	3	Preferred Brand	$47.00	$141.00	None
CELECOXIB 200 MG CAPSULE [Celebrex]	3	Preferred Brand	$47.00	$141.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CELECOXIB 400 MG CAPSULE [Celebrex]	3	Preferred Brand	$47.00	$141.00	None
CELECOXIB 50 MG CAPSULE [Celebrex]	3	Preferred Brand	$47.00	$141.00	None
CELONTIN 300 MG KAPSEAL	4	Non-Preferred Drug	$100.00	$300.00	None
CEPHALEXIN 125 MG/5 ML SUSP	3	Preferred Brand	$47.00	$141.00	None
CEPHALEXIN 250 MG CAPSULE	1*	Preferred Generic	$0.00	$0.00	None
CEPHALEXIN 250 MG/5 ML SUSP	3	Preferred Brand	$47.00	$141.00	None
CEPHALEXIN 500 MG CAPSULE	1*	Preferred Generic	$0.00	$0.00	None
CEPHALEXIN 750 MG CAPSULE	1*	Preferred Generic	$0.00	$0.00	None
CERDELGA 84 MG CAPSULE	5	Specialty Tier	25%	N/A	P
CESAMET 1 MG CAPSULES	4	Non-Preferred Drug	$100.00	$300.00	P
CETIRIZINE HCL 1 MG/ML SOLN	1*	Preferred Generic	$0.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CETRAXAL 0.2% EAR SOLUTION DROPERETTE	4	Non-Preferred Drug	$100.00	$300.00	None
CEVIMELINE HCL 30 MG CAPSULE [Evoxac]	4	Non-Preferred Drug	$100.00	$300.00	None
CHANTIX 0.5 MG TABLET	4	Non-Preferred Drug	$100.00	$300.00	None
CHANTIX 1 MG CONT MONTH BOX	4	Non-Preferred Drug	$100.00	$300.00	None
CHANTIX 1 MG TABLET	4	Non-Preferred Drug	$100.00	$300.00	None
CHANTIX STARTING MONTH BOX	4	Non-Preferred Drug	$100.00	$300.00	None
CHENODAL 250 MG TABLET	5	Specialty Tier	25%	N/A	None
CHLORDIAZEPO-AMITRIPTYL 5-12.5	2*	Generic	$0.00	$0.00	P
CHLORHEXIDINE GLUCONATE 0.12% RINSE	1*	Preferred Generic	$0.00	$0.00	None
CHLOROQUINE PH 250 MG TABLET	2*	Generic	$0.00	$0.00	None
CHLOROQUINE PH 500 MG TABLET	2*	Generic	$0.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Chlorothiazide 500mg 100 TABLET BOTTLE	3	Preferred Brand	$47.00	$141.00	None
CHLORPROMAZINE 10 MG TABLET	4	Non-Preferred Drug	$100.00	$300.00	None
CHLORPROMAZINE 100 MG TABLET	4	Non-Preferred Drug	$100.00	$300.00	None
CHLORPROMAZINE 200 MG TABLET	4	Non-Preferred Drug	$100.00	$300.00	None
CHLORPROMAZINE 25 MG TABLET	4	Non-Preferred Drug	$100.00	$300.00	None
CHLORPROMAZINE 50 MG TABLET	4	Non-Preferred Drug	$100.00	$300.00	None
CHLORTHALIDONE 25 MG TABLET (100 CT)	2*	Generic	$0.00	$0.00	None
CHLORTHALIDONE 50 MG TABLET	2*	Generic	$0.00	$0.00	None
CHLORZOXAZONE 500 MG TABLET	3	Preferred Brand	$47.00	$141.00	P
CHOLESTYRAMINE LIGHT POWDER	1*	Preferred Generic	$0.00	$0.00	None
CHOLESTYRAMINE PACKET	4	Non-Preferred Drug	$100.00	$300.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CICLOPIROX 0.77% CREAM	4	Non-Preferred Drug	$100.00	$300.00	None
CICLOPIROX 0.77% GEL	4	Non-Preferred Drug	$100.00	$300.00	None
CICLOPIROX 0.77% TOPICAL SUSP	3	Preferred Brand	$47.00	$141.00	None
CICLOPIROX 1% SHAMPOO	4	Non-Preferred Drug	$100.00	$300.00	None
CICLOPIROX 8% SOLUTION	3	Preferred Brand	$47.00	$141.00	None
Cilastatin 250 MG / Imipenem 250 MG Injection	1*	Preferred Generic	$0.00	$0.00	None
Cilastatin 500 MG / Imipenem 500 MG Injection	3	Preferred Brand	$47.00	$141.00	None
CILOSTAZOL 100 MG TABLET	2*	Generic	$0.00	$0.00	None
CILOSTAZOL 50 MG TABLET	2*	Generic	$0.00	$0.00	None
CIMDUO 300-300 MG TABLET	5	Specialty Tier	25%	N/A	None
Cimetidine 200mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC	1*	Preferred Generic	$0.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Cimetidine 300 MG Oral Tablet	3	Preferred Brand	$47.00	$141.00	None
Cimetidine 400mg/1 100 FILM COATED TABLETS in BOTTLE	3	Preferred Brand	$47.00	$141.00	None
Cimetidine 800mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC	3	Preferred Brand	$47.00	$141.00	None
CINACALCET HCL 30 MG TABLET [Sensipar]	3	Preferred Brand	$47.00	$141.00	None
CINACALCET HCL 60 MG TABLET [Sensipar]	5	Specialty Tier	25%	N/A	None
CINACALCET HCL 90 MG TABLET [Sensipar]	5	Specialty Tier	25%	N/A	None
Cinryze 500[iU]/5mL 1 VIAL per CARTON / 5 mL in 1 VIAL	5	Specialty Tier	25%	N/A	P
CIPRODEX OTIC SUSPENSION	3	Preferred Brand	$47.00	$141.00	None
CIPROFLOXACIN 0.2% OTIC SOLN DROPERETTE [Cetraxal]	4	Non-Preferred Drug	$100.00	$300.00	None
CIPROFLOXACIN 0.3% EYE DROP [Ciloxan]	2*	Generic	$0.00	$0.00	None
CIPROFLOXACIN 250 MG TABLET (100 CT) [Cipro]	1*	Preferred Generic	$0.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CIPROFLOXACIN HCL 100 MG Tablet [Cipro]	1*	Preferred Generic	$0.00	$0.00	None
CIPROFLOXACIN HCL 500 MG Tablet [Cipro]	1*	Preferred Generic	$0.00	$0.00	None
CIPROFLOXACIN HCL 750 MG Tablet [Cipro]	1*	Preferred Generic	$0.00	$0.00	None
CIPROFLOXACIN-D5W 200 MG/100 ML PIGGYBACK [Cipro]	3	Preferred Brand	$47.00	$141.00	None
CITALOPRAM HBR 10 MG TABLET	1*	Preferred Generic	$0.00	$0.00	None
CITALOPRAM HBR 10 MG/5 ML SOLN	4	Non-Preferred Drug	$100.00	$300.00	None
CITALOPRAM HBR 20 MG TABLET	1*	Preferred Generic	$0.00	$0.00	None
CITALOPRAM HBR 40 MG TABLET	1*	Preferred Generic	$0.00	$0.00	None
CLARAVIS 10 MG CAPSULE	4	Non-Preferred Drug	$100.00	$300.00	None
CLARAVIS 20 MG CAPSULE	4	Non-Preferred Drug	$100.00	$300.00	None
Claravis 30mg 3 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK	2*	Generic	$0.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CLARAVIS 40 MG CAPSULE	4	Non-Preferred Drug	$100.00	$300.00	None
CLARINEX-D 12 HOUR TABLET	4	Non-Preferred Drug	$100.00	$300.00	None
CLARITHROMYCIN 250 MG TABLET	3	Preferred Brand	$47.00	$141.00	None
CLARITHROMYCIN 250 MG/5MLFOR ORAL SUSPENSION	3	Preferred Brand	$47.00	$141.00	None
CLARITHROMYCIN 500 MG TABLET	3	Preferred Brand	$47.00	$141.00	None
CLARITHROMYCIN ER 500 MG TAB	3	Preferred Brand	$47.00	$141.00	None
Clemastine fum 2.68 mg tab	3	Preferred Brand	$47.00	$141.00	P
CLIND PH-BENZOYL PEROX 1.2-5% [Benzaclin]	4	Non-Preferred Drug	$100.00	$300.00	None
CLINDACIN PAC KIT	3	Preferred Brand	$47.00	$141.00	None
Clindamycin 150 MG/ML 2ml	3	Preferred Brand	$47.00	$141.00	None
CLINDAMYCIN 150mg/ml vl 25x6ml	3	Preferred Brand	$47.00	$141.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CLINDAMYCIN 75 MG/5 ML SOLN	3	Preferred Brand	$47.00	$141.00	None
CLINDAMYCIN HCL 150 MG CAPSULE	1*	Preferred Generic	$0.00	$0.00	None
CLINDAMYCIN HCL 300 MG CAPSULE	1*	Preferred Generic	$0.00	$0.00	None
CLINDAMYCIN HCL 75 MG 200 CAPSULE BOTTLE	1*	Preferred Generic	$0.00	$0.00	None
CLINDAMYCIN PH 1% SOLUTION	3	Preferred Brand	$47.00	$141.00	None
CLINDAMYCIN PH 600 MG/4 ML VL	3	Preferred Brand	$47.00	$141.00	None
CLINDAMYCIN PHOSP 1% LOTION	4	Non-Preferred Drug	$100.00	$300.00	None
CLINDAMYCIN PHOSPHATE 1% FOAM	3	Preferred Brand	$47.00	$141.00	None
Clindamycin Phosphate and Benzoyl Peroxide 1 KIT	4	Non-Preferred Drug	$100.00	$300.00	None
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE	3	Preferred Brand	$47.00	$141.00	None
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX	3	Preferred Brand	$47.00	$141.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CLINDAMYCIN PHOSPHATE VAGINAL CREAM	3	Preferred Brand	$47.00	$141.00	None
Clindamycin-d5w 300 mg/50 ml	2*	Generic	$0.00	$0.00	None
Clindamycin-d5w 600 mg/50 ml	2*	Generic	$0.00	$0.00	None
Clindamycin-d5w 900 mg/50 ml	2*	Generic	$0.00	$0.00	None
CLINISOL 15% SOLUTION	4	Non-Preferred Drug	$100.00	$300.00	P
CLOBAZAM 10 MG TABLET [ONFI]	2*	Generic	$0.00	$0.00	None
CLOBAZAM 2.5 MG/ML Oral Suspension [ONFI]	2*	Generic	$0.00	$0.00	None
CLOBAZAM 20 MG TABLET [ONFI]	5	Specialty Tier	25%	N/A	None
CLOBETASOL 0.05% CREAM (g) [Temovate]	4	Non-Preferred Drug	$100.00	$300.00	None
CLOBETASOL 0.05% OINTMENT	4	Non-Preferred Drug	$100.00	$300.00	None
CLOBETASOL 0.05% SOLUTION	4	Non-Preferred Drug	$100.00	$300.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CLOBETASOL 0.05% TOPICAL LOTN	4	Non-Preferred Drug	$100.00	$300.00	None
CLOBETASOL EMOLLIENT 0.05% CREAM (g) [Temovate E]	4	Non-Preferred Drug	$100.00	$300.00	None
CLOBETASOL EMOLLNT 0.05% FOAM [Olux-E]	4	Non-Preferred Drug	$100.00	$300.00	None
Clobetasol Propionate 0.5 MG/ML Medicated Shampoo	4	Non-Preferred Drug	$100.00	$300.00	None
Clobetasol Propionate 0.5mg/g 1 CAN per CARTON / 100 g in 1 CAN	4	Non-Preferred Drug	$100.00	$300.00	None
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE	4	Non-Preferred Drug	$100.00	$300.00	None
Clodan 0.05% shampoo	4	Non-Preferred Drug	$100.00	$300.00	None
CLOMIPRAMINE 25 MG CAPSULE	4	Non-Preferred Drug	$100.00	$300.00	P
CLOMIPRAMINE 50 MG CAPSULE	4	Non-Preferred Drug	$100.00	$300.00	P
CLOMIPRAMINE 75 MG CAPSULE	4	Non-Preferred Drug	$100.00	$300.00	P
CLONAZEPAM 0.125 MG DIS TAB RAPDIS [Klonopin]	3	Preferred Brand	$47.00	$141.00	None
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	$47.00	$141.00	None
CLONAZEPAM 0.5 MG DIS TABLET RAPDIS [Klonopin]	3	Preferred Brand	$47.00	$141.00	None
CLONAZEPAM 0.5 MG TABLET [Klonopin]	1*	Preferred Generic	$0.00	$0.00	None
CLONAZEPAM 1 MG DIS TABLET RAPDIS [Klonopin]	3	Preferred Brand	$47.00	$141.00	None
CLONAZEPAM 1 MG TABLET [Klonopin]	1*	Preferred Generic	$0.00	$0.00	None
CLONAZEPAM 2 MG ODT TAB RAPDIS [Klonopin]	3	Preferred Brand	$47.00	$141.00	None
CLONAZEPAM 2 MG TABLET [Klonopin]	1*	Preferred Generic	$0.00	$0.00	None
Clonidine 0.1mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH	4	Non-Preferred Drug	$100.00	$300.00	None
Clonidine 0.2mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH	4	Non-Preferred Drug	$100.00	$300.00	None
Clonidine 0.3mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH	4	Non-Preferred Drug	$100.00	$300.00	None
CLONIDINE HCL 0.1 MG TABLET	2*	Generic	$0.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CLONIDINE HCL 0.2 MG TABLET	2*	Generic	$0.00	$0.00	None
CLONIDINE HCL 0.3 MG TABLET	2*	Generic	$0.00	$0.00	None
CLONIDINE HCL ER 0.1 MG TABLET	4	Non-Preferred Drug	$100.00	$300.00	None
CLOPIDOGREL 75 MG TABLET [Plavix]	1*	Preferred Generic	$0.00	$0.00	None
CLORAZEPATE 15 MG TABLET	3	Preferred Brand	$47.00	$141.00	None
CLORAZEPATE 3.75 MG TABLET	3	Preferred Brand	$47.00	$141.00	None
CLORAZEPATE 7.5 MG TABLET	3	Preferred Brand	$47.00	$141.00	None
CLOTRIMAZOLE 1% CREAM	2*	Generic	$0.00	$0.00	None
CLOTRIMAZOLE 1% SOLUTION	3	Preferred Brand	$47.00	$141.00	None
CLOTRIMAZOLE 10 MG TROCHE	3	Preferred Brand	$47.00	$141.00	None
CLOTRIMAZOLE-BETAMETHASONE LOT	4	Non-Preferred Drug	$100.00	$300.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE 0.64; 10mg/g; mg/g 45 g in 1 TUBE	3	Preferred Brand	$47.00	$141.00	None
CLOZAPINE 100 MG TABLET [Clozaril]	3	Preferred Brand	$47.00	$141.00	None
CLOZAPINE 200 MG TABLET	3	Preferred Brand	$47.00	$141.00	None
CLOZAPINE 25 MG TABLET [Clozaril]	3	Preferred Brand	$47.00	$141.00	None
CLOZAPINE 50 MG TABLET	3	Preferred Brand	$47.00	$141.00	None
CLOZAPINE ODT 100 MG TABLET RAPDIS [Fazaclo]	4	Non-Preferred Drug	$100.00	$300.00	None
CLOZAPINE ODT 12.5 MG TABLET RAPDIS [Fazaclo]	2*	Generic	$0.00	$0.00	None
CLOZAPINE ODT 150 MG TABLET RAPDIS [Fazaclo]	4	Non-Preferred Drug	$100.00	$300.00	None
CLOZAPINE ODT 200 MG TABLET RAPDIS [Fazaclo]	5	Specialty Tier	25%	N/A	None
CLOZAPINE ODT 25 MG TABLET RAPDIS [Fazaclo]	4	Non-Preferred Drug	$100.00	$300.00	None
COARTEM 20MG-120MG	3	Preferred Brand	$47.00	$141.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
COLCHICINE 0.6 MG TABLET [Colcrys]	3	Preferred Brand	$47.00	$141.00	None
COLESEVELAM 625 MG TABLET [WelChol]	2*	Generic	$0.00	$0.00	None
COLESEVELAM HCL 3.75 G PACKET POWD PACK [WelChol]	2*	Generic	$0.00	$0.00	None
COLESTIPOL HCL 1G TABLET	3	Preferred Brand	$47.00	$141.00	None
COLESTIPOL HCL GRANULES PACKET	1*	Preferred Generic	$0.00	$0.00	None
COLISTIMETHATE 150 MG VIAL [Coly-Mycin M]	4	Non-Preferred Drug	$100.00	$300.00	None
COLOCORT 100MG ENEMA	4	Non-Preferred Drug	$100.00	$300.00	None
COMBIGAN 0.2%-0.5% DROPS	3	Preferred Brand	$47.00	$141.00	None
COMBIVENT RESPIMAT INHAL SPRAY	4	Non-Preferred Drug	$100.00	$300.00	None
COMETRIQ 100 MG DAILY-DOSE PK	5	Specialty Tier	25%	N/A	P
COMETRIQ 140 MG DAILY-DOSE PK	5	Specialty Tier	25%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
COMETRIQ 60 MG DAILY-DOSE PACK	5	Specialty Tier	25%	N/A	P
COMPLERA 200; 27.5; 300mg/1; mg/1; mg/1	5	Specialty Tier	25%	N/A	None
COMPRO 25MG SUPPOSITORY	4	Non-Preferred Drug	$100.00	$300.00	None
CONSTULOSE 10 GM/15 ML SOLN	3	Preferred Brand	$47.00	$141.00	None
COPAXONE 40 MG/ML SYRINGE	5	Specialty Tier	25%	N/A	P
COPIKTRA 15 MG CAPSULE	5	Specialty Tier	25%	N/A	P
COPIKTRA 25 MG CAPSULE	5	Specialty Tier	25%	N/A	P
CORLANOR 5 MG TABLET	4	Non-Preferred Drug	$100.00	$300.00	None
CORLANOR 7.5 MG TABLET	4	Non-Preferred Drug	$100.00	$300.00	None
Cortisone 25 MG Tablet	1*	Preferred Generic	$0.00	$0.00	None
COTELLIC 20 MG TABLET	5	Specialty Tier	25%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Creon 256.11mg/1 1 BOTTLE per CARTON / 70 CAPSULE, DELAYED RELEASE in 1 BOTTLE	3	Preferred Brand	$47.00	$141.00	None
CREON DELAYED RELEASE CAPSULES 12000MG 100 BOT	3	Preferred Brand	$47.00	$141.00	None
CREON DELAYED RELEASE CAPSULES 24000MG 100 BOT	4	Non-Preferred Drug	$100.00	$300.00	None
CREON DELAYED RELEASE CAPSULES 6000MG 100 BOT	3	Preferred Brand	$47.00	$141.00	None
CREON DR 36,000 UNITS CAPSULE	3	Preferred Brand	$47.00	$141.00	None
CRESEMBA 186 MG CAPSULE	5	Specialty Tier	25%	N/A	None
CRIXIVAN 200MG CAPSULE	4	Non-Preferred Drug	$100.00	$300.00	None
CRIXIVAN 400mg, 180 CAPSULE BOTTLE	4	Non-Preferred Drug	$100.00	$300.00	None
CROMOLYN 20 MG/2 ML NEB SOLN	1*	Preferred Generic	$0.00	$0.00	P
CROMOLYN SODIUM 100 MG/5 ML	4	Non-Preferred Drug	$100.00	$300.00	None
CROMOLYN SODIUM 4% 40MG 10ML BOT	1*	Preferred Generic	$0.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Cyclafem 1/35 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK	2*	Generic	$0.00	$0.00	None
CYCLAFEM 7-7-7-28 TABLET	2*	Generic	$0.00	$0.00	None
CYCLOBENZAPRINE 10 MG TABLET	2*	Generic	$0.00	$0.00	P
CYCLOBENZAPRINE 5 MG TABLET	2*	Generic	$0.00	$0.00	P
CYCLOPHOSPHAMIDE 25 MG CAPSULE	2*	Generic	$0.00	$0.00	P
CYCLOPHOSPHAMIDE 50 MG CAPSULE	2*	Generic	$0.00	$0.00	P
CYCLOSET 0.8MG TABLETS	4	Non-Preferred Drug	$100.00	$300.00	Q:6 /1Days
CYCLOSPORINE 100MG CAPSULE	4	Non-Preferred Drug	$100.00	$300.00	P
CYCLOSPORINE 25MG CAPSULE	4	Non-Preferred Drug	$100.00	$300.00	P
CYCLOSPORINE MODIFIED 100 MG	4	Non-Preferred Drug	$100.00	$300.00	P
CYCLOSPORINE MODIFIED 25 MG	4	Non-Preferred Drug	$100.00	$300.00	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CYCLOSPORINE MODIFIED 50 MG	2*	Generic	$0.00	$0.00	P
CYPROHEPTADINE 4 MG TABLET	3	Preferred Brand	$47.00	$141.00	P
CYPROHEPTADINE HYDROCHLORIDE SOLUTION USP SYRUP 2MG 473 ML BOTGL	3	Preferred Brand	$47.00	$141.00	P
CYRED EQ 28 DAY TABLET [Solia]	2*	Generic	$0.00	$0.00	None
CYSTAGON 150MG CAPSULE	4	Non-Preferred Drug	$100.00	$300.00	None
CYSTAGON 50MG CAPSULE	4	Non-Preferred Drug	$100.00	$300.00	None
CYSTARAN 0.44% EYE DROPS	4	Non-Preferred Drug	$100.00	$300.00	Q:2 /1Days

Chart Legend:

Below are a few notes to help you understand the above 2019 Medicare Part D Allwell Dual Medicare (HMO SNP) Plan Formulary.

Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region). The plan name is followed by the plan type (PDP, HMO, HMO-POS, PPO, PFFS, etc.)
Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.
Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $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.