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BlueRx Enhanced (PDP) (S1030-010-0)
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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
BlueRx Enhanced (PDP) (S1030-010-0)
Benefit Details           
The BlueRx Enhanced (PDP) (S1030-010-0)
Formulary Drugs Starting with the Letter P

in CMS PDP Region 12 which includes: AL TN
Plan Monthly Premium: $71.50 Deductible: $350 Qualifies for LIS: No
Drugs Starting with Letter P

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
PACERONE 200 MG TABLET   2 Generic $4.00$8.00None
PACERONE 400MG TABLET   2 Generic $4.00$8.00None
PALIPERIDONE ER 1.5 MG TABLET [INVEGA]   4 Non-Preferred Drug 45%45%P Q:30
/30Days
PALIPERIDONE ER 3 MG TABLET [INVEGA]   4 Non-Preferred Drug 45%45%P Q:30
/30Days
PALIPERIDONE ER 6 MG TABLET [INVEGA]   4 Non-Preferred Drug 45%45%P Q:60
/30Days
PALIPERIDONE ER 9 MG TABLET [INVEGA]   5 Specialty Tier 25%25%P Q:30
/30Days
PALYNZIQ 10 MG/0.5 ML SYRINGE   5 Specialty Tier 25%25%P
PALYNZIQ 2.5 MG/0.5 ML SYRINGE   5 Specialty Tier 25%25%P
PALYNZIQ 20 MG/ML SYRINGE   5 Specialty Tier 25%25%P
PANRETIN 0.1% GEL 60GM TUBE   5 Specialty Tier 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PANTOPRAZOLE SOD DR 20 MG TAB   1 Preferred Generic $1.00$2.00Q:30
/30Days
PANTOPRAZOLE SOD DR 40 MG TAB   1 Preferred Generic $1.00$2.00Q:60
/30Days
PARICALCITOL 1 MCG CAPSULE [Zemplar]   2 Generic $4.00$8.00None
PARICALCITOL 2 MCG CAPSULE [Zemplar]   3 Preferred Brand $40.00$80.00None
PARICALCITOL 4 MCG CAPSULE [Zemplar]   3 Preferred Brand $40.00$80.00None
PAROMOMYCIN 250 MG CAPSULE   4 Non-Preferred Drug 45%45%None
PAROXETINE HCL 10 MG TABLET   4 Non-Preferred Drug 45%45%P Q:45
/30Days
PAROXETINE HCL 20 MG TABLET   4 Non-Preferred Drug 45%45%P Q:30
/30Days
PAROXETINE HCL 30 MG TABLET   4 Non-Preferred Drug 45%45%P Q:60
/30Days
PAROXETINE HCL 40 MG TABLET   4 Non-Preferred Drug 45%45%P Q:45
/30Days
PASER GRANULES 4GM PACKET   4 Non-Preferred Drug 45%45%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PAXIL ORAL SUSPENSION 10 MG/5ML   4 Non-Preferred Drug 45%45%P Q:900
/30Days
PAZEO 0.7% EYE DROPS   3 Preferred Brand $40.00$80.00None
PEDVAXHIB VACCINE VIAL   3 Preferred Brand $40.00$80.00None
PEG 3350 ELECTROLYTE SOLN SOLN RECON [GaviLyte-C]   2 Generic $4.00$8.00None
PEG 3350-ELECTROLYTE SOLUTION SOLN RECON   3 Preferred Brand $40.00$80.00None
PEG-3350 AND ELECTROLYTES SOLN SOLN RECON   3 Preferred Brand $40.00$80.00None
PEGANONE 250 MG TABLET   4 Non-Preferred Drug 45%45%None
Pegasys 180ug/0.5mL 1 PACKET in 1 BOX / 4 SYRINGE, GLASS in 1 PACKET / 0.5 mL in 1 SYRINGE, GLASS   5 Specialty Tier 25%25%P
PEGASYS INJECTION   5 Specialty Tier 25%25%P
PEGASYS PROCLICK 180 MCG/0.5   5 Specialty Tier 25%25%P
PENICILLIN G POTASSIUM 2MMUNITS/50ML ISO-OSM   3 Preferred Brand $40.00$80.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PENICILLIN G POTASSIUM 3MMUNITS/50ML ISO-OSM   4 Non-Preferred Drug 45%45%None
Penicillin G Sodium 5000000[iU]/1 10 VIAL per CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL   4 Non-Preferred Drug 45%45%None
PENICILLIN GK 20 MILLION UNIT   2 Generic $4.00$8.00None
PENICILLIN V POTASSIUM 250MG/5ML LIQUID   2 Generic $4.00$8.00None
PENICILLIN V POTASSIUM 500MG TABLET   1 Preferred Generic $1.00$2.00None
PENICILLIN VK 125 MG/5 ML SOLN   2 Generic $4.00$8.00None
PENICILLIN VK 250 MG TABLET   1 Preferred Generic $1.00$2.00None
PENTAM 300 INJ 300MG   4 Non-Preferred Drug 45%45%None
PENTASA 250MG CAPSULE SA   4 Non-Preferred Drug 45%45%None
PENTASA 500MG CAPSULE   4 Non-Preferred Drug 45%45%None
PENTOXIFYLLINE 400MG TABLET SA   2 Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PERINDOPRIL ERBUMINE 2 MG TAB   2 Generic $4.00$8.00None
PERINDOPRIL ERBUMINE 4 MG TAB   2 Generic $4.00$8.00None
PERINDOPRIL ERBUMINE 8 MG TAB   2 Generic $4.00$8.00None
Permethrin 50mg/g 1 TUBE per CARTON / 60 g in 1 TUBE   4 Non-Preferred Drug 45%45%None
Perphenazine 16mg/1 100 FILM COATED TABLETS in BOTTLE   2 Generic $4.00$8.00P
PERPHENAZINE 4 MG TABLET   2 Generic $4.00$8.00P
PERPHENAZINE 8 MG TABLET   2 Generic $4.00$8.00P
PERPHENAZINE TABLETS USP 2MG 100 BOT   2 Generic $4.00$8.00P
PERSERIS ER 120 MG SYRINGE KIT SUSER SYKT   5 Specialty Tier 25%25%P Q:1
/30Days
PERSERIS ER 90 MG SYRINGE KIT SUSER SYKT   5 Specialty Tier 25%25%P Q:1
/30Days
PHENADOZ 12.5 MG SUPPOSITORY   4 Non-Preferred Drug 45%45%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Phenelzine Sulfate 15mg/1 60 TABLET BOTTLE   2 Generic $4.00$8.00None
Phenobarbital 100mg/1   4 Non-Preferred Drug 45%45%None
Phenobarbital 15mg/1   4 Non-Preferred Drug 45%45%None
PHENOBARBITAL 16.2 MG TABLET   4 Non-Preferred Drug 45%45%None
PHENOBARBITAL 20 MG/5 ML ELIX   4 Non-Preferred Drug 45%45%None
Phenobarbital 30mg/1   4 Non-Preferred Drug 45%45%None
PHENOBARBITAL 32.4 MG TABLET   4 Non-Preferred Drug 45%45%None
Phenobarbital 60mg/1   4 Non-Preferred Drug 45%45%None
PHENOBARBITAL 64.8 MG TABLET   4 Non-Preferred Drug 45%45%None
PHENOBARBITAL 97.2 MG TABLET   4 Non-Preferred Drug 45%45%None
PHENOXYBENZAMINE HCL 10 MG Capsule [Dibenzyline]   5 Specialty Tier 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Phenytoin 50 MG Chewable Tablet   2 Generic $4.00$8.00None
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT   2 Generic $4.00$8.00None
PHENYTOIN SOD EXT 100 MG CAP   2 Generic $4.00$8.00None
PHENYTOIN SOD EXT 200 MG CAP   2 Generic $4.00$8.00None
PHENYTOIN SOD EXT 300 MG CAP   2 Generic $4.00$8.00None
Phoslyra 667mg/5mL 1 BOTTLE per CARTON / 473 mL in 1 BOTTLE   3 Preferred Brand $40.00$80.00None
PHOSPHOLINE IODIDE 0.125% 6.25MG   4 Non-Preferred Drug 45%45%None
PHRENILIN FORTE 50-300-40 MG   4 Non-Preferred Drug 45%45%Q:180
/30Days
PICATO 0.015% GEL   3 Preferred Brand $40.00$80.00Q:3
/30Days
PICATO 0.05% GEL   3 Preferred Brand $40.00$80.00Q:2
/30Days
PIFELTRO 100 MG TABLET   5 Specialty Tier 25%25%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PILOCARPINE 1% EYE DROPS [Pilocar]   2 Generic $4.00$8.00None
PILOCARPINE 2% EYE DROPS [Pilocar]   2 Generic $4.00$8.00None
PILOCARPINE 4% EYE DROPS [Pilocar]   2 Generic $4.00$8.00None
PILOCARPINE HCL 5 MG TABLET [Salagen]   2 Generic $4.00$8.00None
PILOCARPINE HCL 7.5 MG TABLET [Salagen]   2 Generic $4.00$8.00None
PIMECROLIMUS 1% CREAM (g) [Elidel]   4 Non-Preferred Drug 45%45%P
PIMOZIDE 1 MG TABLET [Orap]   2 Generic $4.00$8.00None
PIMOZIDE 2 MG TABLET [Orap]   2 Generic $4.00$8.00None
PIMTREA 28 DAY TABLET   2 Generic $4.00$8.00None
PINDOLOL 10 MG TABLET   2 Generic $4.00$8.00None
PINDOLOL 5 MG TABLET   2 Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PIOGLITAZONE HCL 15 MG TABLET [Actos]   1 Preferred Generic $1.00$2.00Q:90
/30Days
PIOGLITAZONE HCL 30 MG TABLET [Actos]   1 Preferred Generic $1.00$2.00Q:30
/30Days
PIOGLITAZONE HCL 45 MG TABLET [Actos]   1 Preferred Generic $1.00$2.00Q:30
/30Days
PIOGLITAZONE-GLIMEPIRIDE 30-2 TABLET [Duetact]   3 Preferred Brand $40.00$80.00Q:30
/30Days
PIOGLITAZONE-GLIMEPIRIDE 30-4 Tablet [Duetact]   3 Preferred Brand $40.00$80.00Q:30
/30Days
PIOGLITAZONE-METFORMIN 15-500   2 Generic $4.00$8.00Q:90
/30Days
PIOGLITAZONE-METFORMIN 15-850   2 Generic $4.00$8.00Q:90
/30Days
PIPERACIL-TAZOBACT 2.25 GM VIAL   2 Generic $4.00$8.00None
PIPERACIL-TAZOBACT 3.375 GM VIAL   4 Non-Preferred Drug 45%45%None
PIPERACIL-TAZOBACT 4.5 GM VIAL   4 Non-Preferred Drug 45%45%None
Pirmella 1-35-28 tablet   2 Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PIROXICAM 10 MG CAPSULE   2 Generic $4.00$8.00Q:60
/30Days
PIROXICAM 20 MG CAPSULE   2 Generic $4.00$8.00Q:30
/30Days
PLEGRIDY 125 MCG/0.5 ML PEN   5 Specialty Tier 25%25%P Q:1
/28Days
PLEGRIDY 125 MCG/0.5 ML SYRING   5 Specialty Tier 25%25%P Q:1
/28Days
PLEGRIDY PEN INJ STARTER PACK   5 Specialty Tier 25%25%P Q:1
/28Days
PLEGRIDY SYRINGE STARTER PACK   5 Specialty Tier 25%25%P Q:1
/28Days
PODOFILOX 0.5% TOPICAL TUBEX   2 Generic $4.00$8.00None
POLYMYXIN B-TMP EYE DROPS   1 Preferred Generic $1.00$2.00None
POMALYST 1 MG CAPSULE   5 Specialty Tier 25%25%P Q:21
/28Days
POMALYST 2 MG CAPSULE   5 Specialty Tier 25%25%P Q:21
/28Days
POMALYST 3 MG CAPSULE   5 Specialty Tier 25%25%P Q:21
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
POMALYST 4 MG CAPSULE   5 Specialty Tier 25%25%P Q:21
/28Days
PORTIA 0.15-0.03 TABLET   2 Generic $4.00$8.00None
Potassium Chloride 2 MEQ/ML Injectable Solution   2 Generic $4.00$8.00None
Potassium Chloride 8 MEQ Extended Release Oral Tablet   3 Preferred Brand $40.00$80.00None
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION   2 Generic $4.00$8.00None
Potassium Chloride in Dextrose 5; 150g/100mL; mg/100mL 1000 mL in 1 BAG   2 Generic $4.00$8.00None
Potassium Chloride in Lactated Ringers and Dextrose 20; 5; 179; 600; 310mg/100mL; g/100mL; mg/100mL   3 Preferred Brand $40.00$80.00None
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION   3 Preferred Brand $40.00$80.00None
POTASSIUM CITRATE ER 10 MEQ TB   2 Generic $4.00$8.00None
POTASSIUM CITRATE ER 15 MEQ TABLET   2 Generic $4.00$8.00None
POTASSIUM CITRATE ER 5 MEQ TAB   2 Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
POTASSIUM CL 10% (20 MEQ/15ML) Liquid [Kay Ciel]   3 Preferred Brand $40.00$80.00None
POTASSIUM CL 2 MEQ/ML VIAL [PROAMP]   2 Generic $4.00$8.00None
POTASSIUM CL ER 10 MEQ CAPSULE   2 Generic $4.00$8.00None
POTASSIUM CL ER 10 MEQ TABLET   2 Generic $4.00$8.00None
POTASSIUM CL ER 10 MEQ TABLET   2 Generic $4.00$8.00None
POTASSIUM CL ER 20 MEQ TABLET   2 Generic $4.00$8.00None
Potassium cl er 20 meq tablet   4 Non-Preferred Drug 45%45%None
POTASSIUM CL ER 8 MEQ CAPSULE   2 Generic $4.00$8.00None
PRADAXA 110 MG CAPSULE   4 Non-Preferred Drug 45%45%Q:71
/90Days
PRADAXA 150 MG CAPSULE   4 Non-Preferred Drug 45%45%Q:60
/30Days
PRADAXA 75 MG CAPSULE   4 Non-Preferred Drug 45%45%Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PRAMIPEXOLE 0.125 MG TABLET   1 Preferred Generic $1.00$2.00None
PRAMIPEXOLE 0.25 MG TABLET   1 Preferred Generic $1.00$2.00None
PRAMIPEXOLE 0.5 MG TABLET   1 Preferred Generic $1.00$2.00None
PRAMIPEXOLE 0.75 MG TABLET   1 Preferred Generic $1.00$2.00None
PRAMIPEXOLE 1 MG TABLET   1 Preferred Generic $1.00$2.00None
PRAMIPEXOLE 1.5 MG TABLET   1 Preferred Generic $1.00$2.00None
PRASUGREL 10 MG TABLET   3 Preferred Brand $40.00$80.00None
PRASUGREL 5 MG TABLET   3 Preferred Brand $40.00$80.00None
PRAVASTATIN SODIUM 10 MG TAB   2 Generic $4.00$8.00Q:45
/30Days
PRAVASTATIN SODIUM 20 MG TAB   2 Generic $4.00$8.00Q:45
/30Days
PRAVASTATIN SODIUM 40 MG TAB   2 Generic $4.00$8.00Q:45
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PRAVASTATIN SODIUM 80 MG TAB   2 Generic $4.00$8.00Q:30
/30Days
PRAZIQUANTEL 600 MG TABLET [Biltricide]   4 Non-Preferred Drug 45%45%None
PRAZOSIN 1 MG CAPSULE   2 Generic $4.00$8.00None
PRAZOSIN 2 MG CAPSULE   2 Generic $4.00$8.00None
PRAZOSIN 5MG CAPSULE   2 Generic $4.00$8.00None
Prednicarbate 0.1% cream   2 Generic $4.00$8.00None
PREDNICARBATE 0.1% OINTMENT   2 Generic $4.00$8.00None
PREDNISOLONE 15 MG/5 ML SOLN   2 Generic $4.00$8.00None
PREDNISOLONE AC 1% EYE DROP   2 Generic $4.00$8.00None
PREDNISOLONE SODIUM PHOSPHATE 5MG /5ML ORAL SOLUTION   3 Preferred Brand $40.00$80.00None
PREDNISONE 1 MG TABLET   1 Preferred Generic $1.00$2.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PREDNISONE 10 MG TAB DOSE PACK   2 Generic $4.00$8.00None
PREDNISONE 10 MG TAB DOSE PACK   2 Generic $4.00$8.00None
PREDNISONE 10 MG TABLET [Sterapred DS]   2 Generic $4.00$8.00None
PREDNISONE 2.5 MG TABLET   1 Preferred Generic $1.00$2.00None
Prednisone 20 MG Oral Tablet   1 Preferred Generic $1.00$2.00None
PREDNISONE 5 MG TABLET   2 Generic $4.00$8.00None
PREDNISONE 5 MG TABLET   2 Generic $4.00$8.00None
PREDNISONE 5 MG TABLET   2 Generic $4.00$8.00None
PREDNISONE 5 MG/5 ML SOLUTION   3 Preferred Brand $40.00$80.00None
PREDNISONE 50MG TABLET   3 Preferred Brand $40.00$80.00None
PREMARIN 0.3 MG TABLET   4 Non-Preferred Drug 45%45%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PREMARIN 0.45MG TABLET   4 Non-Preferred Drug 45%45%None
PREMARIN 0.625 MG TABLET   4 Non-Preferred Drug 45%45%None
Premarin 0.625mg/g   3 Preferred Brand $40.00$80.00None
PREMARIN 0.9MG TABLET   4 Non-Preferred Drug 45%45%None
PREMARIN 1.25 MG TABLET   4 Non-Preferred Drug 45%45%None
PREMASOL 6% IV SOLUTION   2 Generic $4.00$8.00P
PREMPHASE 0.625-5 MG TABLET   4 Non-Preferred Drug 45%45%None
PREMPRO 0.3 MG-1.5 MG TABLET #28 EA   4 Non-Preferred Drug 45%45%None
PREMPRO 0.45-1.5 MG TABLET 28 EA   4 Non-Preferred Drug 45%45%None
PREMPRO 0.625-5 MG TABLET   4 Non-Preferred Drug 45%45%None
Prempro 0.625; 2.5mg/1; mg/1 1 BLISTER PACK per CARTON / 28 TABLET, SUGAR COATED per BLISTER PACK   4 Non-Preferred Drug 45%45%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PREVALITE PACKET   2 Generic $4.00$8.00None
PREVIFEM TABLET [VyLibra]   2 Generic $4.00$8.00None
PREVYMIS 240 MG   5 Specialty Tier 25%25%None
PREVYMIS 480 MG   5 Specialty Tier 25%25%None
PREZCOBIX 800 MG-150 MG TABLET   5 Specialty Tier 25%25%Q:30
/30Days
PREZISTA 100 MG/ML SUSPENSION   5 Specialty Tier 25%25%Q:400
/30Days
PREZISTA 150MG TABLETS   4 Non-Preferred Drug 45%45%Q:180
/30Days
PREZISTA 800 MG TABLET   5 Specialty Tier 25%25%Q:30
/30Days
PREZISTA TABLET 600MG   5 Specialty Tier 25%25%Q:60
/30Days
PREZISTA TABLET 75MG   4 Non-Preferred Drug 45%45%Q:300
/30Days
PRIFTIN 150 MG TABLET   4 Non-Preferred Drug 45%45%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Primaquine Phosphate 26.3 MG Oral Tablet   3 Preferred Brand $40.00$80.00None
PRIMIDONE 250 MG TABLET [Mysoline]   2 Generic $4.00$8.00None
PRIMIDONE 50 MG TABLET [Mysoline]   2 Generic $4.00$8.00None
PROAIR HFA 90 MCG INHALER   3 Preferred Brand $40.00$80.00Q:36
/30Days
PROAIR RESPICLICK INHAL POWDER   3 Preferred Brand $40.00$80.00Q:2
/30Days
PROBENECID 500 MG TABLET   2 Generic $4.00$8.00None
PROBENECID/COLCHICINE 0.5MG/500MG TABLET   2 Generic $4.00$8.00None
PROCHLORPERAZINE 10 MG TAB   2 Generic $4.00$8.00None
PROCHLORPERAZINE 5 MG TABLET   2 Generic $4.00$8.00None
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX   4 Non-Preferred Drug 45%45%None
PROCRIT 10000U/ML VIAL   4 Non-Preferred Drug 45%45%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL   4 Non-Preferred Drug 45%45%P
PROCRIT 3,000 UNITS/ML VIAL   4 Non-Preferred Drug 45%45%P
PROCRIT 4,000 UNITS/ML VIAL   4 Non-Preferred Drug 45%45%P
PROCRIT 40000U/ML VIAL PR   5 Specialty Tier 25%25%P
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY   5 Specialty Tier 25%25%P
PROCTO-MED HC 2.5% CREAM   2 Generic $4.00$8.00None
procto-pak 1% cream   1 Preferred Generic $1.00$2.00None
PROCTOSOL-HC 2.5% CREAM   2 Generic $4.00$8.00None
PROCTOZONE-HC 2.5% CREAM   2 Generic $4.00$8.00None
PROGESTERONE 100 MG CAPSULE   2 Generic $4.00$8.00None
PROGESTERONE 200 MG CAPSULE [Prometrium]   2 Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PROGLYCEM 50 MG/ML ORAL SUSP   4 Non-Preferred Drug 45%45%None
PROGRAF 0.2 MG GRANULE PACKET   4 Non-Preferred Drug 45%45%P
PROGRAF 1 MG GRANULE PACKET   4 Non-Preferred Drug 45%45%P
PROLASTIN C 1,000 MG VIAL   5 Specialty Tier 25%25%P
PROLENSA 0.07% EYE DROPS   4 Non-Preferred Drug 45%45%None
PROLIA 60MG/ML INJECTION   4 Non-Preferred Drug 45%45%P
PROMACTA 12.5 MG SUSPEN PACKET POWDER PACK   5 Specialty Tier 25%25%P
PROMACTA 12.5 MG TABLET   5 Specialty Tier 25%25%P
PROMACTA 25 MG TABLET   5 Specialty Tier 25%25%P
PROMACTA 50 MG TABLET   5 Specialty Tier 25%25%P
PROMACTA 75 MG TABLET   5 Specialty Tier 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PROMETHAZINE 12.5 MG TABLET   4 Non-Preferred Drug 45%45%P
PROMETHAZINE 25 MG TABLET   4 Non-Preferred Drug 45%45%P
PROMETHAZINE 50 MG TABLET   4 Non-Preferred Drug 45%45%P
PROMETHAZINE 6.25 MG/5 ML SYRUP [Prometh Plain]   4 Non-Preferred Drug 45%45%P
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 12.5MG 12 BOX   4 Non-Preferred Drug 45%45%P
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 25MG 12 BOX   4 Non-Preferred Drug 45%45%P
PROMETHEGAN 25MG SUPP   4 Non-Preferred Drug 45%45%P
PROPAFENONE HCL 150 MG TABLET   2 Generic $4.00$8.00None
PROPAFENONE HCL 225MG TABLET   2 Generic $4.00$8.00None
PROPAFENONE HCL 300 MG TAB   2 Generic $4.00$8.00None
PROPAFENONE HCL ER 225 MG CAP   3 Preferred Brand $40.00$80.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PROPAFENONE HYDROCHLORIDE 325MG CAPSULES EXTENDED RELEASE   4 Non-Preferred Drug 45%45%None
PROPAFENONE HYDROCHLORIDE 425MG CAPSULES EXTENDED RELEASE   4 Non-Preferred Drug 45%45%None
PROPRANOLOL 10 MG TABLET   2 Generic $4.00$8.00None
PROPRANOLOL 20 MG TABLET   2 Generic $4.00$8.00None
PROPRANOLOL 40 MG TABLET   2 Generic $4.00$8.00None
PROPRANOLOL 60 MG TABLET   2 Generic $4.00$8.00None
PROPRANOLOL 80 MG TABLET   2 Generic $4.00$8.00None
PROPRANOLOL ER 120 MG CAPSULE   2 Generic $4.00$8.00None
PROPRANOLOL ER 160 MG CAPSULE   2 Generic $4.00$8.00None
PROPRANOLOL ER 60 MG CAPSULE   2 Generic $4.00$8.00None
PROPRANOLOL ER 80 MG CAPSULE   2 Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PROPYLTHIOURACIL 50MG TABLET   2 Generic $4.00$8.00None
PROQUAD VIAL   3 Preferred Brand $40.00$80.00None
PROTRIPTYLINE HCL 10 MG TABLET   4 Non-Preferred Drug 45%45%P
PROTRIPTYLINE HCL 5 MG TABLET   4 Non-Preferred Drug 45%45%P
PULMOZYME 1MG/ML AMPUL   5 Specialty Tier 25%25%P
PURIXAN 20 MG/ML ORAL SUSP   5 Specialty Tier 25%25%None
PYLERA CAPSULE   5 Specialty Tier 25%25%None
PYRAZINAMIDE 500 MG TABLET   3 Preferred Brand $40.00$80.00None
PYRIDOSTIGMINE 60 MG/5 ML SOLN SYRUP [Mestinon]   5 Specialty Tier 25%25%None
PYRIDOSTIGMINE BR 60 MG TABLET   2 Generic $4.00$8.00None
PYRIDOSTIGMINE BR ER 180 MG TAB   4 Non-Preferred Drug 45%45%None

Chart Legend:

Below are a few notes to help you understand the above 2019 Medicare Part D BlueRx Enhanced (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.