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Anthem MediBlue Rx Plus (PDP) (S5596-010-0)
Tier 1 (245)
Tier 2 (722)
Tier 3 (750)
Tier 4 (943)
Tier 5 (494)
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2020 Medicare Part D Plan Formulary Information
Anthem MediBlue Rx Plus (PDP) (S5596-010-0)
Benefits & Contact Info           
The Anthem MediBlue Rx Plus (PDP) (S5596-010-0)
Formulary Drugs Starting with the Letter P

in CMS PDP Region 10 which includes: GA
Plan Monthly Premium: $68.50 Deductible: $0 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 100MG TABLET   4 Non-Preferred Drug 42%42%None
PACERONE 200 MG TABLET   2 Generic $3.00$9.00None
PACERONE 400MG TABLET   3 Preferred Brand $40.00$120.00None
PALIPERIDONE ER 1.5 MG TABLET [INVEGA]   4 Non-Preferred Drug 42%42%Q:240
/30Days
PALIPERIDONE ER 3 MG TABLET [INVEGA]   4 Non-Preferred Drug 42%42%Q:120
/30Days
PALIPERIDONE ER 6 MG TABLET [INVEGA]   4 Non-Preferred Drug 42%42%Q:60
/30Days
PALIPERIDONE ER 9 MG TABLET [INVEGA]   4 Non-Preferred Drug 42%42%Q:30
/30Days
PANRETIN 0.1% GEL 60GM TUBE   5 Specialty Tier 33%N/ANone
PANTOPRAZOLE SOD DR 20 MG TAB   2 Generic $3.00$9.00None
PANTOPRAZOLE SOD DR 40 MG TAB   2 Generic $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PARICALCITOL 1 MCG CAPSULE [Zemplar]   3 Preferred Brand $40.00$120.00P
PARICALCITOL 2 MCG CAPSULE [Zemplar]   4 Non-Preferred Drug 42%42%P
PARICALCITOL 4 MCG CAPSULE [Zemplar]   4 Non-Preferred Drug 42%42%P
PAROMOMYCIN 250 MG CAPSULE   4 Non-Preferred Drug 42%42%None
PAROXETINE HCL 10 MG TABLET   1 Preferred Generic $1.00$3.00Q:180
/30Days
PAROXETINE HCL 20 MG TABLET   1 Preferred Generic $1.00$3.00Q:90
/30Days
PAROXETINE HCL 30 MG TABLET   2 Generic $3.00$9.00Q:60
/30Days
PAROXETINE HCL 40 MG TABLET   2 Generic $3.00$9.00Q:45
/30Days
PASER GRANULES 4GM PACKET   4 Non-Preferred Drug 42%42%None
PAXIL ORAL SUSPENSION 10 MG/5ML   4 Non-Preferred Drug 42%42%Q:900
/30Days
PAZEO 0.7% EYE DROPS   3 Preferred Brand $40.00$120.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PEDVAXHIB VACCINE VIAL   3 Preferred Brand $40.00$120.00None
PEG 3350-ELECTROLYTE SOLUTION RECON [TriLyte]   2 Generic $3.00$9.00None
PEG-3350 AND ELECTROLYTES SOLN SOLN RECON   2 Generic $3.00$9.00None
PEGANONE 250 MG TABLET   4 Non-Preferred Drug 42%42%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 33%N/ANone
PEGASYS INJECTION   5 Specialty Tier 33%N/ANone
PEGASYS PROCLICK 180 MCG/0.5   5 Specialty Tier 33%N/ANone
PENICILLAMINE 250 MG TABLET [Depen]   5 Specialty Tier 33%N/ANone
PENICILLIN G PROCAINE 1200000UNT 2ML CTG   4 Non-Preferred Drug 42%42%None
PENICILLIN GK 20 MILLION UNIT   4 Non-Preferred Drug 42%42%None
PENICILLIN V POTASSIUM 250MG/5ML LIQUID   2 Generic $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PENICILLIN VK 125 MG/5 ML SOLN   2 Generic $3.00$9.00None
PENICILLIN VK 250 MG TABLET   2 Generic $3.00$9.00None
PENICILLIN VK 500 MG TABLET [Veetids]   2 Generic $3.00$9.00None
PENTAM 300 INJ 300MG   4 Non-Preferred Drug 42%42%None
PENTAMIDINE 300 MG INHAL POWDER VIAL-NEB [NebuPent]   3 Preferred Brand $40.00$120.00P
PENTAMIDINE 300 MG VIAL [Pentam]   4 Non-Preferred Drug 42%42%None
PENTASA 250MG CAPSULE SA   4 Non-Preferred Drug 42%42%None
PENTASA 500MG CAPSULE   4 Non-Preferred Drug 42%42%None
PENTOXIFYLLINE 400MG TABLET SA   2 Generic $3.00$9.00None
PERFOROMIST 20MCG/2ML VIAL NEBULIZER   5 Specialty Tier 33%N/AP Q:120
/30Days
PERINDOPRIL ERBUMINE 2 MG TAB   2 Generic $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PERINDOPRIL ERBUMINE 4 MG TAB   2 Generic $3.00$9.00None
PERINDOPRIL ERBUMINE 8 MG TAB   2 Generic $3.00$9.00None
Permethrin 50mg/g 1 TUBE per CARTON / 60 g in 1 TUBE   3 Preferred Brand $40.00$120.00None
PERPHENAZINE 16 MG TABLET [Trilafon]   3 Preferred Brand $40.00$120.00None
PERPHENAZINE 2 MG TABLET [Trilafon]   3 Preferred Brand $40.00$120.00None
PERPHENAZINE 4 MG TABLET [Trilafon]   3 Preferred Brand $40.00$120.00None
PERPHENAZINE 8 MG TABLET [Trilafon]   3 Preferred Brand $40.00$120.00None
Phenelzine Sulfate 15mg/1 60 TABLET BOTTLE   3 Preferred Brand $40.00$120.00None
Phenobarbital 100mg/1   4 Non-Preferred Drug 42%42%P Q:120
/30Days
PHENOBARBITAL 15 MG TABLET   4 Non-Preferred Drug 42%42%P Q:800
/30Days
PHENOBARBITAL 16.2 MG TABLET   4 Non-Preferred Drug 42%42%P Q:741
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PHENOBARBITAL 20 MG/5 ML ELIX   3 Preferred Brand $40.00$120.00P Q:3000
/30Days
PHENOBARBITAL 30 MG TABLET   4 Non-Preferred Drug 42%42%P Q:400
/30Days
PHENOBARBITAL 32.4 MG TABLET   4 Non-Preferred Drug 42%42%P Q:370
/30Days
Phenobarbital 60mg/1   4 Non-Preferred Drug 42%42%P Q:200
/30Days
PHENOBARBITAL 64.8 MG TABLET   4 Non-Preferred Drug 42%42%P Q:185
/30Days
PHENOBARBITAL 97.2 MG TABLET   4 Non-Preferred Drug 42%42%P Q:123
/30Days
PHENYTEK 200 MG CAPSULE   4 Non-Preferred Drug 42%42%None
PHENYTEK 300 MG CAPSULE   4 Non-Preferred Drug 42%42%None
PHENYTOIN 125 MG/5 ML ORAL SUSPENSION [Dilantin]   3 Preferred Brand $40.00$120.00None
PHENYTOIN 50 MG CHEWABLE TABLET [Dilantin]   2 Generic $3.00$9.00None
PHENYTOIN SOD EXT 100 MG CAP   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PHENYTOIN SOD EXT 200 MG CAP   4 Non-Preferred Drug 42%42%None
PHENYTOIN SOD EXT 300 MG CAPSULE [Phenytek]   4 Non-Preferred Drug 42%42%None
PHOSPHOLINE IODIDE 0.125% 6.25MG   4 Non-Preferred Drug 42%42%None
PICATO 0.015% GEL   4 Non-Preferred Drug 42%42%None
PICATO 0.05% GEL   4 Non-Preferred Drug 42%42%None
PIFELTRO 100 MG TABLET   5 Specialty Tier 33%N/AQ:30
/30Days
PILOCARPINE 1% EYE DROPS [Pilocar]   4 Non-Preferred Drug 42%42%None
PILOCARPINE 2% EYE DROPS [Pilocar]   4 Non-Preferred Drug 42%42%None
PILOCARPINE 4% EYE DROPS [Pilocar]   4 Non-Preferred Drug 42%42%None
PILOCARPINE HCL 5 MG TABLET [Salagen]   4 Non-Preferred Drug 42%42%None
PILOCARPINE HCL 7.5 MG TABLET [Salagen]   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PIMECROLIMUS 1% CREAM (g) [Elidel]   4 Non-Preferred Drug 42%42%P Q:100
/90Days
PIMOZIDE 1 MG TABLET [Orap]   3 Preferred Brand $40.00$120.00None
PIMOZIDE 2 MG TABLET [Orap]   3 Preferred Brand $40.00$120.00None
PIMTREA 28 DAY TABLET   3 Preferred Brand $40.00$120.00None
PINDOLOL 10 MG TABLET   4 Non-Preferred Drug 42%42%None
PINDOLOL 5 MG TABLET [Visken]   4 Non-Preferred Drug 42%42%None
PIOGLITAZONE HCL 15 MG TABLET [Actos]   2 Generic $3.00$9.00Q:90
/30Days
PIOGLITAZONE HCL 30 MG TABLET [Actos]   2 Generic $3.00$9.00Q:45
/30Days
PIOGLITAZONE HCL 45 MG TABLET [Actos]   2 Generic $3.00$9.00Q:30
/30Days
PIPERACIL-TAZOBACT 2.25 GM VIAL [Zosyn]   4 Non-Preferred Drug 42%42%None
PIPERACIL-TAZOBACT 3.375 GM VIAL [Zosyn]   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PIPERACIL-TAZOBACT 4.5 GM VIAL   4 Non-Preferred Drug 42%42%None
PIPERACIL-TAZOBACT 40.5 GRAM VIAL [Zosyn]   4 Non-Preferred Drug 42%42%None
PIQRAY 200 MG DAILY DOSE TABLET   5 Specialty Tier 33%N/AP Q:28
/28Days
PIQRAY 250 MG DAILY DOSE TABLET   5 Specialty Tier 33%N/AP Q:56
/28Days
PIQRAY 300 MG DAILY DOSE TABLET   5 Specialty Tier 33%N/AP Q:56
/28Days
PIRMELLA 1-35 28 TABLET   3 Preferred Brand $40.00$120.00None
PIROXICAM 10 MG CAPSULE   2 Generic $3.00$9.00None
PIROXICAM 20 MG CAPSULE   2 Generic $3.00$9.00None
PLASMA-LYTE 148 IV SOLUTION   4 Non-Preferred Drug 42%42%None
PLASMA-LYTE A PH 7.4 SOLUTION 37;368; MG/100ML;   4 Non-Preferred Drug 42%42%None
PODOFILOX 0.5% TOPICAL TUBEX   3 Preferred Brand $40.00$120.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
POLYMYXIN B-TMP EYE DROPS   1 Preferred Generic $1.00$3.00None
POMALYST 1 MG CAPSULE   5 Specialty Tier 33%N/AP Q:120
/30Days
POMALYST 2 MG CAPSULE   5 Specialty Tier 33%N/AP Q:60
/30Days
POMALYST 3 MG CAPSULE   5 Specialty Tier 33%N/AP Q:30
/30Days
POMALYST 4 MG CAPSULE   5 Specialty Tier 33%N/AP Q:30
/30Days
PORTIA 0.15-0.03 TABLET   3 Preferred Brand $40.00$120.00None
POT CHL/SWFI P-B 40 MEQ 24X100 ML   4 Non-Preferred Drug 42%42%None
Potassium Chloride 2 MEQ/ML Injectable Solution   4 Non-Preferred Drug 42%42%None
Potassium Chloride 8 MEQ Extended Release Oral Tablet   2 Generic $3.00$9.00None
Potassium Chloride in Dextrose 5; 150g/100mL; mg/100mL 1000 mL in 1 BAG   4 Non-Preferred Drug 42%42%None
Potassium Chloride in Dextrose and Sodium Chloride 5; 300; 900g/100mL; mg/100mL; mg/100mL 1000 mL i   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION   4 Non-Preferred Drug 42%42%None
POTASSIUM CITRATE ER 10 MEQ TB   3 Preferred Brand $40.00$120.00None
POTASSIUM CITRATE ER 15 MEQ TABLET   3 Preferred Brand $40.00$120.00None
POTASSIUM CITRATE ER 5 MEQ TAB   3 Preferred Brand $40.00$120.00None
POTASSIUM CL 10 MEQ/100 ML SOL PIGGYBACK   4 Non-Preferred Drug 42%42%None
POTASSIUM CL 10% (20 MEQ/15ML) Liquid [Kay Ciel]   4 Non-Preferred Drug 42%42%None
POTASSIUM CL 20 MEQ/100 ML SOL PIGGYBACK   4 Non-Preferred Drug 42%42%None
POTASSIUM CL 20% (40 MEQ/15ML) Liquid [Kaon-CL]   4 Non-Preferred Drug 42%42%None
POTASSIUM CL 40 MEQ/20 ML CONC VIAL [PROAMP]   4 Non-Preferred Drug 42%42%None
POTASSIUM CL ER 10 MEQ CAPSULE   2 Generic $3.00$9.00None
POTASSIUM CL ER 10 MEQ TABLET   2 Generic $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
POTASSIUM CL ER 10 MEQ TABLET [Klotrix]   2 Generic $3.00$9.00None
POTASSIUM CL ER 20 MEQ TABLET   2 Generic $3.00$9.00None
Potassium cl er 20 meq tablet   2 Generic $3.00$9.00None
POTASSIUM CL ER 8 MEQ CAPSULE ER [Micro-K Extencaps]   2 Generic $3.00$9.00None
PRADAXA 110 MG CAPSULE   4 Non-Preferred Drug 42%42%Q:60
/30Days
PRADAXA 150 MG CAPSULE   4 Non-Preferred Drug 42%42%Q:60
/30Days
PRADAXA 75 MG CAPSULE   4 Non-Preferred Drug 42%42%Q:60
/30Days
PRALUENT 150 MG/ML PEN INJCTR   4 Non-Preferred Drug 42%42%P Q:2
/28Days
PRALUENT 75 MG/ML PEN INJCTR   4 Non-Preferred Drug 42%42%P Q:2
/28Days
PRAMIPEXOLE 0.125 MG TABLET   2 Generic $3.00$9.00None
PRAMIPEXOLE 0.25 MG TABLET   2 Generic $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PRAMIPEXOLE 0.5 MG TABLET   2 Generic $3.00$9.00None
PRAMIPEXOLE 0.75 MG TABLET   2 Generic $3.00$9.00None
PRAMIPEXOLE 1 MG TABLET   2 Generic $3.00$9.00None
PRAMIPEXOLE 1.5 MG TABLET [Mirapex]   2 Generic $3.00$9.00None
PRASUGREL 10 MG TABLET [Effient]   3 Preferred Brand $40.00$120.00Q:30
/30Days
PRASUGREL 5 MG TABLET [Effient]   3 Preferred Brand $40.00$120.00Q:30
/30Days
PRAVASTATIN SODIUM 10 MG TABLET [Pravachol]   1 Preferred Generic $1.00$3.00None
PRAVASTATIN SODIUM 20 MG TAB   1 Preferred Generic $1.00$3.00None
PRAVASTATIN SODIUM 40 MG TABLET [Pravachol]   1 Preferred Generic $1.00$3.00None
PRAVASTATIN SODIUM 80 MG TABLET [Pravachol]   1 Preferred Generic $1.00$3.00None
PRAZOSIN 1 MG CAPSULE   2 Generic $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PRAZOSIN 2 MG CAPSULE   2 Generic $3.00$9.00None
PRAZOSIN 5MG CAPSULE   2 Generic $3.00$9.00None
Prednicarbate 0.1% cream   2 Generic $3.00$9.00None
PREDNICARBATE 0.1% OINTMENT [Dermatop]   2 Generic $3.00$9.00None
PREDNISOLONE 15 MG/5 ML SOLN   2 Generic $3.00$9.00None
PREDNISOLONE AC 1% EYE DROP   2 Generic $3.00$9.00None
PREDNISOLONE SOD 1% EYE DROP   3 Preferred Brand $40.00$120.00None
PREDNISOLONE SOD PH 25 MG/5 ML   2 Generic $3.00$9.00None
PREDNISOLONE SODIUM PHOSPHATE 5MG /5ML ORAL SOLUTION   3 Preferred Brand $40.00$120.00None
PREDNISONE 1 MG TABLET   2 Generic $3.00$9.00None
PREDNISONE 10 MG TABLET [Sterapred DS]   1 Preferred Generic $1.00$3.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PREDNISONE 10 MG TABLET DOSE PACK   2 Generic $3.00$9.00None
PREDNISONE 10 MG TABLET DOSE PACK   1 Preferred Generic $1.00$3.00None
PREDNISONE 2.5 MG TABLET   1 Preferred Generic $1.00$3.00None
PREDNISONE 20 MG TABLET [Predone]   1 Preferred Generic $1.00$3.00None
PREDNISONE 5 MG TABLET   2 Generic $3.00$9.00None
PREDNISONE 5 MG TABLET   1 Preferred Generic $1.00$3.00None
PREDNISONE 5 MG TABLET [Sterapred]   1 Preferred Generic $1.00$3.00None
PREDNISONE 5 MG/5 ML SOLUTION   2 Generic $3.00$9.00None
PREDNISONE 50MG TABLET   1 Preferred Generic $1.00$3.00None
PREDNISONE 5MG/ML SOLUTION   3 Preferred Brand $40.00$120.00None
PREGABALIN 100 MG CAPSULE [Lyrica]   2 Generic $3.00$9.00Q:180
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PREGABALIN 150 MG CAPSULE [Lyrica]   2 Generic $3.00$9.00Q:120
/30Days
PREGABALIN 20 MG/ML SOLUTION [Lyrica]   2 Generic $3.00$9.00Q:900
/30Days
PREGABALIN 200 MG CAPSULE [Lyrica]   2 Generic $3.00$9.00Q:90
/30Days
PREGABALIN 225 MG CAPSULE [Lyrica]   2 Generic $3.00$9.00Q:60
/30Days
PREGABALIN 25 MG CAPSULE [Lyrica]   2 Generic $3.00$9.00Q:720
/30Days
PREGABALIN 300 MG CAPSULE [Lyrica]   2 Generic $3.00$9.00Q:60
/30Days
PREGABALIN 50 MG CAPSULE [Lyrica]   2 Generic $3.00$9.00Q:360
/30Days
PREGABALIN 75 MG CAPSULE [Lyrica]   2 Generic $3.00$9.00Q:240
/30Days
PREMARIN 0.3 MG TABLET   3 Preferred Brand $40.00$120.00P
PREMARIN 0.45MG TABLET   3 Preferred Brand $40.00$120.00P
PREMARIN 0.625 MG TABLET   3 Preferred Brand $40.00$120.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Premarin 0.625mg/g   3 Preferred Brand $40.00$120.00None
PREMARIN 0.9MG TABLET   3 Preferred Brand $40.00$120.00P
PREMARIN 1.25 MG TABLET   3 Preferred Brand $40.00$120.00P
PREMASOL 10% IV SOLUTION   4 Non-Preferred Drug 42%42%P
PREMPRO 0.3 MG-1.5 MG TABLET #28 EA   4 Non-Preferred Drug 42%42%P
PREMPRO 0.45-1.5 MG TABLET 28 EA   4 Non-Preferred Drug 42%42%P
PREMPRO 0.625-5 MG TABLET   4 Non-Preferred Drug 42%42%P
Prempro 0.625; 2.5mg/1; mg/1 1 BLISTER PACK per CARTON / 28 TABLET, SUGAR COATED per BLISTER PACK   4 Non-Preferred Drug 42%42%P
PREVALITE PACKET   4 Non-Preferred Drug 42%42%None
PREVIFEM TABLET [VyLibra]   3 Preferred Brand $40.00$120.00None
PREZCOBIX 800 MG-150 MG TABLET   5 Specialty Tier 33%N/AQ:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PREZISTA 100 MG/ML SUSPENSION   5 Specialty Tier 33%N/AQ:400
/30Days
PREZISTA 150MG TABLETS   4 Non-Preferred Drug 42%42%Q:180
/30Days
PREZISTA 800 MG TABLET   5 Specialty Tier 33%N/AQ:60
/30Days
PREZISTA TABLET 600MG   5 Specialty Tier 33%N/AQ:60
/30Days
PREZISTA TABLET 75MG   4 Non-Preferred Drug 42%42%Q:300
/30Days
PRIFTIN 150 MG TABLET   4 Non-Preferred Drug 42%42%None
Primaquine Phosphate 26.3 MG Oral Tablet   3 Preferred Brand $40.00$120.00None
PRIMIDONE 250 MG TABLET [Mysoline]   4 Non-Preferred Drug 42%42%None
PRIMIDONE 50 MG TABLET [Mysoline]   4 Non-Preferred Drug 42%42%None
PROAIR HFA 90 MCG INHALER   3 Preferred Brand $40.00$120.00None
PROAIR RESPICLICK INHAL POWDER   3 Preferred Brand $40.00$120.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PROBENECID 500 MG TABLET   2 Generic $3.00$9.00None
PROBENECID-COLCHICINE TABLET   2 Generic $3.00$9.00None
ProcalAmine 0.21; 0.29; 0.026; 0.014; 3; 0.42; 0.085; 0.21; 0.27; 0.22; 0.054; 0.16; 0.17; 0.041; 0   4 Non-Preferred Drug 42%42%P
PROCHLORPERAZINE 10 MG TAB   2 Generic $3.00$9.00None
PROCHLORPERAZINE 5 MG TABLET   2 Generic $3.00$9.00None
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX   4 Non-Preferred Drug 42%42%None
PROCRIT 10000U/ML VIAL   4 Non-Preferred Drug 42%42%P
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL   4 Non-Preferred Drug 42%42%P
PROCRIT 3,000 UNITS/ML VIAL   4 Non-Preferred Drug 42%42%P
PROCRIT 4,000 UNITS/ML VIAL   4 Non-Preferred Drug 42%42%P
PROCRIT 40000U/ML VIAL PR   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY   5 Specialty Tier 33%N/AP
PROCTO-MED HC 2.5% CREAM   2 Generic $3.00$9.00None
procto-pak 1% cream   2 Generic $3.00$9.00None
PROCTOSOL-HC 2.5% CREAM   2 Generic $3.00$9.00None
PROCTOZONE-HC 2.5% CREAM   2 Generic $3.00$9.00None
PROGESTERONE 100 MG CAPSULE   2 Generic $3.00$9.00None
PROGESTERONE 200 MG CAPSULE [Prometrium]   2 Generic $3.00$9.00None
PROGLYCEM 50 MG/ML ORAL SUSP   4 Non-Preferred Drug 42%42%None
PROGRAF 0.2 MG GRANULE PACKET   4 Non-Preferred Drug 42%42%P
PROGRAF 1 MG GRANULE PACKET   4 Non-Preferred Drug 42%42%P
PROLASTIN C 1,000 MG VIAL   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PROLIA 60MG/ML INJECTION   4 Non-Preferred Drug 42%42%P Q:2
/365Days
PROMACTA 12.5 MG SUSPEN PACKET POWDER PACK   5 Specialty Tier 33%N/AP Q:360
/30Days
PROMACTA 12.5 MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
PROMACTA 25 MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
PROMACTA 50 MG TABLET   5 Specialty Tier 33%N/AP Q:90
/30Days
PROMACTA 75 MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
PROMETHAZINE 12.5 MG TABLET   4 Non-Preferred Drug 42%42%P
PROMETHAZINE 25 MG TABLET   4 Non-Preferred Drug 42%42%P
PROMETHAZINE 50 MG TABLET   4 Non-Preferred Drug 42%42%P
PROPAFENONE HCL 150 MG TABLET [Rythmol]   3 Preferred Brand $40.00$120.00None
PROPAFENONE HCL 225MG TABLET   3 Preferred Brand $40.00$120.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PROPAFENONE HCL 300 MG TAB   3 Preferred Brand $40.00$120.00None
Propantheline Bromide 15mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC   2 Generic $3.00$9.00P
PROPRANOLOL 10 MG TABLET   2 Generic $3.00$9.00None
PROPRANOLOL 20 MG TABLET   2 Generic $3.00$9.00None
PROPRANOLOL 20MG/5ML TUBEX   2 Generic $3.00$9.00None
PROPRANOLOL 40 MG TABLET   2 Generic $3.00$9.00None
PROPRANOLOL 40MG/5ML TUBEX   4 Non-Preferred Drug 42%42%None
PROPRANOLOL 60 MG TABLET   2 Generic $3.00$9.00None
PROPRANOLOL 80 MG TABLET [Inderal]   2 Generic $3.00$9.00None
PROPRANOLOL ER 120 MG CAPSULE   4 Non-Preferred Drug 42%42%None
PROPRANOLOL ER 160 MG CAPSULE   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PROPRANOLOL ER 60 MG CAPSULE   4 Non-Preferred Drug 42%42%None
PROPRANOLOL ER 80 MG CAPSULE   4 Non-Preferred Drug 42%42%None
PROPRANOLOL/HCTZ 40/25 TABLET   2 Generic $3.00$9.00None
PROPRANOLOL/HCTZ 80/25 TABLET   2 Generic $3.00$9.00None
PROPYLTHIOURACIL 50MG TABLET   2 Generic $3.00$9.00None
PROQUAD VIAL   3 Preferred Brand $40.00$120.00None
PROSOL 20% INJECTION   4 Non-Preferred Drug 42%42%P
PROTRIPTYLINE HCL 10 MG TABLET [Vivactil]   4 Non-Preferred Drug 42%42%P
PROTRIPTYLINE HCL 5 MG TABLET [Vivactil]   4 Non-Preferred Drug 42%42%P
PULMOZYME 1MG/ML AMPUL   5 Specialty Tier 33%N/AP
PURIXAN 20 MG/ML ORAL SUSP   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PYRAZINAMIDE 500 MG TABLET   4 Non-Preferred Drug 42%42%None
PYRIDOSTIGMINE 60 MG/5 ML SOLN SYRUP [Mestinon]   5 Specialty Tier 33%N/ANone
PYRIDOSTIGMINE BR 30 MG TABLET   3 Preferred Brand $40.00$120.00None
PYRIDOSTIGMINE BR 60 MG TABLET   3 Preferred Brand $40.00$120.00None
PYRIDOSTIGMINE BR ER 180 MG TAB   4 Non-Preferred Drug 42%42%None

Chart Legend:

Below are a few notes to help you understand the above 2020 Medicare Part D Anthem MediBlue Rx Plus (PDP) Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug or Medicare Advantage 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 $435 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.
    • Tier Number* - Some Part D drug plans exclude one or more drug tiers from the plan’s 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 - This is what you will pay for formulary drugs in 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 initial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $4020) 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 June 2020 )

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 Medicare plan provider.








Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.