Q1GROUP LLC | Q1Medicare.com - a non-government resource for the Medicare community
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

Select your search style and criteria below or use this example to get started

Search by:
State & Plan   ZIP & Plan   PlanID   FormularyID

Search Criteria
PDP     MAPD
Scroll down to see formulary results.

Peoples Health Choices Value (HMO) (H1961-018-0)
Tier 1 (299)
Tier 2 (687)
Tier 3 (880)
Tier 4 (995)
Tier 5 (792)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
Yes No Show either
Cick on the first letter of your drug name to browse the formulary:

A B C D E F G H I J K L 
M N O P Q R S T U V W X Y Z 0-9 
2020 Medicare Part D Plan Formulary Information
Peoples Health Choices Value (HMO) (H1961-018-0)
Benefit Details           
The Peoples Health Choices Value (HMO) (H1961-018-0)
Formulary Drugs Starting with the Letter C

in Acadia Parish, LA: CMS MA Region 16 which includes: LA
Plan Monthly Premium: $0.00 Deductible: $300
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   3* Tier 3 $45.00$135.00None
CABLIVI 11 MG KIT   5 Tier 5 27%27%P Q:30
/30Days
CABOMETYX 20 MG TABLET   5 Tier 5 27%27%P Q:30
/30Days
CABOMETYX 40 MG TABLET   5 Tier 5 27%27%P Q:60
/30Days
CABOMETYX 60 MG TABLET   5 Tier 5 27%27%P Q:30
/30Days
CALCIPOTRIENE 0.005% CREAM (g) [Dovonex]   4 Tier 4 $100.00$300.00None
CALCIPOTRIENE 0.005% OINTMENT [Dovonex]   4 Tier 4 $100.00$300.00None
CALCIPOTRIENE 0.005% SOLUTION [Dovonex Scalp]   3* Tier 3 $45.00$135.00None
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY   3* Tier 3 $45.00$135.00Q:4
/28Days
CALCITRIOL 0.25 MCG CAPSULE [Rocaltrol]   2* Tier 2 $10.00$0.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CALCITRIOL 0.5 MCG CAPSULE [Rocaltrol]   2* Tier 2 $10.00$0.00P
CALCITRIOL 1 MCG/ML SOLUTION ORAL   2* Tier 2 $10.00$0.00P
CALCITRIOL 3 MCG/G OINTMENT   4 Tier 4 $100.00$300.00None
CALCIUM ACETATE 667 MG GELCAPSULE [PhosLo]   3* Tier 3 $45.00$135.00None
CALCIUM ACETATE 667 MG TABLET [PhosLo]   3* Tier 3 $45.00$135.00None
CALQUENCE 100 MG CAPSULE   5 Tier 5 27%27%P Q:60
/30Days
CAMILA 0.35 MG TABLET [Sharobel 28-Day]   3* Tier 3 $45.00$135.00None
CAMRESE LO TABLET   4 Tier 4 $100.00$300.00None
CANASA 1,000 MG SUPPOSITORY   5 Tier 5 27%27%None
CANDESARTAN CILEXETIL 16 MG TABLET [Atacand]   1* Tier 1 $0.00$0.00Q:30
/30Days
CANDESARTAN CILEXETIL 32 MG TABLET [Atacand]   1* Tier 1 $0.00$0.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CANDESARTAN CILEXETIL 4 MG TABLET [Atacand]   1* Tier 1 $0.00$0.00Q:30
/30Days
CANDESARTAN CILEXETIL 8 MG TABLET [Atacand]   1* Tier 1 $0.00$0.00Q:90
/30Days
CANDESARTAN-HCTZ 16-12.5 MG TABLET [Atacand HCT]   1* Tier 1 $0.00$0.00Q:30
/30Days
CANDESARTAN-HCTZ 32-12.5 MG TABLET [Atacand HCT]   1* Tier 1 $0.00$0.00Q:30
/30Days
CANDESARTAN-HCTZ 32-25 MG TABLET [Atacand HCT]   1* Tier 1 $0.00$0.00Q:30
/30Days
CAPLYTA 42 MG CAPSULE   5 Tier 5 27%27%S Q:30
/30Days
CAPRELSA 100 MG TABLET   5 Tier 5 27%27%P
CAPRELSA 300 MG TABLET   5 Tier 5 27%27%P
CAPTOPRIL 100MG TABLET   1* Tier 1 $0.00$0.00Q:120
/30Days
CAPTOPRIL 12.5MG TABLET   1* Tier 1 $0.00$0.00Q:90
/30Days
CAPTOPRIL 25 MG TABLET   1* Tier 1 $0.00$0.00Q:90
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CAPTOPRIL 50MG TABLET   1* Tier 1 $0.00$0.00Q:270
/30Days
Captopril and Hydrochlorothiazide 25; 15mg 100 TABLET BOTTLE   1* Tier 1 $0.00$0.00Q:90
/30Days
Captopril and Hydrochlorothiazide 25; 25mg 100 TABLET BOTTLE   1* Tier 1 $0.00$0.00Q:60
/30Days
Captopril and Hydrochlorothiazide 50; 15mg 100 TABLET BOTTLE   1* Tier 1 $0.00$0.00Q:90
/30Days
Captopril and Hydrochlorothiazide 50; 25mg 100 TABLET BOTTLE   1* Tier 1 $0.00$0.00Q:60
/30Days
CARAC CREAM   5 Tier 5 27%27%P
CARAFATE SUS 1GM/10ML   4 Tier 4 $100.00$300.00None
CARBAGLU 200 MG DISPER TABLET   5 Tier 5 27%27%None
CARBAMAZEPINE 100 MG TABLET CHEW   3* Tier 3 $45.00$135.00None
CARBAMAZEPINE 100 MG/5 ML SUSP   3* Tier 3 $45.00$135.00None
CARBAMAZEPINE 200 MG TABLET [Tegretol]   3* Tier 3 $45.00$135.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARBAMAZEPINE ER 100 MG CAPSULE CPMP 12HR [Carbatrol]   3* Tier 3 $45.00$135.00None
CARBAMAZEPINE ER 100 MG TABLET   3* Tier 3 $45.00$135.00None
CARBAMAZEPINE ER 200 MG CAPSULE CPMP 12HR [Carbatrol]   3* Tier 3 $45.00$135.00None
CARBAMAZEPINE ER 300 MG CAPSULE CPMP 12HR [Carbatrol]   3* Tier 3 $45.00$135.00None
CARBAMAZEPINE XR 200 MG TABLET   3* Tier 3 $45.00$135.00None
CARBAMAZEPINE XR 400 MG TABLET   3* Tier 3 $45.00$135.00None
CARBIDOPA 25 MG TABLET [Lodosyn]   4 Tier 4 $100.00$300.00None
CARBIDOPA AND LEVEDOPA ORALLY DISINTEGRATING TABLETS 10;100MG;MG 100 BOT   2* Tier 2 $10.00$0.00None
CARBIDOPA AND LEVODOPA ODT 25;100MG;MG 100 BOT   2* Tier 2 $10.00$0.00None
CARBIDOPA AND LEVODOPA ODT 25;250MG;MG 100 BOT   2* Tier 2 $10.00$0.00None
CARBIDOPA-LEVO ER 25-100 TABLET [SINEMET CR]   1* Tier 1 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARBIDOPA-LEVO ER 50-200 TABLET [SINEMET CR]   1* Tier 1 $0.00$0.00None
CARBIDOPA-LEVODOPA 10-100 TABLET [SINEMET]   1* Tier 1 $0.00$0.00None
CARBIDOPA-LEVODOPA 100 MG-ENTA TABLET [Stalevo]   4 Tier 4 $100.00$300.00None
CARBIDOPA-LEVODOPA 125 MG-ENTA TABLET [Stalevo]   4 Tier 4 $100.00$300.00None
CARBIDOPA-LEVODOPA 150 MG-ENTA TABLET [Stalevo]   4 Tier 4 $100.00$300.00None
CARBIDOPA-LEVODOPA 200 MG-ENTA TABLET [Stalevo]   4 Tier 4 $100.00$300.00None
CARBIDOPA-LEVODOPA 25-100 TABLET   1* Tier 1 $0.00$0.00None
CARBIDOPA-LEVODOPA 25-250 TABLET   1* Tier 1 $0.00$0.00None
CARBIDOPA-LEVODOPA 75 MG-ENTA TABLET [Stalevo]   4 Tier 4 $100.00$300.00None
CARBIDOPA-LEVODOPA-ENTACAPONE 50 MG [Stalevo]   4 Tier 4 $100.00$300.00None
CARTEOLOL HCL 1% EYE DROPS   2* Tier 2 $10.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARTIA XT 120MG CAPSULE SA   2* Tier 2 $10.00$0.00None
CARTIA XT 180MG CAPSULE SA   2* Tier 2 $10.00$0.00None
CARTIA XT 240MG CAPSULE SA   2* Tier 2 $10.00$0.00None
CARTIA XT 300 MG CAPSULE   2* Tier 2 $10.00$0.00None
CARVEDILOL 12.5 MG TABLET   1* Tier 1 $0.00$0.00None
CARVEDILOL 25 MG TABLET [Coreg]   1* Tier 1 $0.00$0.00None
CARVEDILOL 3.125 MG TABLET [Coreg]   1* Tier 1 $0.00$0.00None
CARVEDILOL 6.25 MG TABLET [Coreg]   1* Tier 1 $0.00$0.00None
CAYSTON KIT 75 MG/VIAL   5 Tier 5 27%27%P
CAZIANT 28 DAY TABLET   4 Tier 4 $100.00$300.00None
CEFACLOR 250 MG CAPSULES   2* Tier 2 $10.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFACLOR 500 MG CAPSULES   2* Tier 2 $10.00$0.00None
CEFADROXIL 250 MG/5 ML ORAL SUSPENSION [Duricef]   2* Tier 2 $10.00$0.00None
CEFADROXIL 500 MG CAPSULE   2* Tier 2 $10.00$0.00None
CEFADROXIL 500 MG/5 ML SUSPENSION   2* Tier 2 $10.00$0.00None
CEFAZOLIN 1 GM VIAL 25/Box   4 Tier 4 $100.00$300.00None
Cefazolin 10g/1 10 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 PACKAGE   4 Tier 4 $100.00$300.00None
CEFAZOLIN 500 MG VIAL   4 Tier 4 $100.00$300.00None
CEFDINIR 125 MG/5 ML SUSPENSION   3* Tier 3 $45.00$135.00None
CEFDINIR 250 MG/5 ML ORAL SUSPENSION [Omnicef]   3* Tier 3 $45.00$135.00None
CEFDINIR 300 MG CAPSULE   3* Tier 3 $45.00$135.00None
CEFEPIME HCL 1 GM VIAL [Maxipime]   4 Tier 4 $100.00$300.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFEPIME HCL 2 GRAM VIAL [Maxipime]   4 Tier 4 $100.00$300.00None
CEFIXIME 100 MG/5 ML SUSPENSION [Suprax]   4 Tier 4 $100.00$300.00None
CEFIXIME 200 MG/5 ML SUSPENSION [Suprax]   4 Tier 4 $100.00$300.00None
CEFIXIME 400 MG CAPSULE [Suprax]   3* Tier 3 $45.00$135.00None
CEFOTETAN 1GM VIAL 1EA x 10   4 Tier 4 $100.00$300.00None
CEFOTETAN 2GM VIAL 1EA x 10   4 Tier 4 $100.00$300.00None
CEFOXITIN 1 GM VIAL [Mefoxin]   4 Tier 4 $100.00$300.00None
CEFOXITIN 10 GM VIAL   4 Tier 4 $100.00$300.00None
CEFOXITIN 2 GM VIAL [Mefoxin]   4 Tier 4 $100.00$300.00None
CEFPODOXIME 100 MG TABLET [Vantin]   4 Tier 4 $100.00$300.00None
CEFPODOXIME 100 MG/5 ML ORAL SUSPENSION [Vantin]   4 Tier 4 $100.00$300.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFPODOXIME 200 MG TABLET   4 Tier 4 $100.00$300.00None
CEFPODOXIME 50 MG/5 ML SUSPENSION   4 Tier 4 $100.00$300.00None
CEFPROZIL 125 MG/5 ML SUSPENSION   3* Tier 3 $45.00$135.00None
CEFPROZIL 250 MG TABLET   3* Tier 3 $45.00$135.00None
CEFPROZIL 250 MG/5 ML SUSPENSION   3* Tier 3 $45.00$135.00None
CEFPROZIL 500 MG TABLET   3* Tier 3 $45.00$135.00None
CEFTAZIDIME 1 GM VIAL [Tazidime]   4 Tier 4 $100.00$300.00None
CEFTAZIDIME FOR INJECTION 2GM/VIAL 10 X 2 CRTN   4 Tier 4 $100.00$300.00None
CEFTAZIDIME FOR INJECTION 6GM/VIAL 6 X 6 CRTN   4 Tier 4 $100.00$300.00None
CEFTRIAXONE 1 GM VIAL   4 Tier 4 $100.00$300.00None
CEFTRIAXONE 10 GM VIAL [Rocephin]   4 Tier 4 $100.00$300.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFTRIAXONE 2 GM VIAL [Rocephin]   4 Tier 4 $100.00$300.00None
CEFTRIAXONE 250 MG VIAL   4 Tier 4 $100.00$300.00None
CEFTRIAXONE 500 MG VIAL   4 Tier 4 $100.00$300.00None
CEFUROXIME 1.5 GM/VIAL FOR INJECTION   4 Tier 4 $100.00$300.00None
CEFUROXIME 750 MG FOR INJECTION   4 Tier 4 $100.00$300.00None
CEFUROXIME AXETIL 250 MG TABLET   2* Tier 2 $10.00$0.00None
CEFUROXIME AXETIL 500 MG TABLET [Ceftin]   2* Tier 2 $10.00$0.00None
CEFUROXIME SOD 7.5 GM VIAL [Zinacef]   4 Tier 4 $100.00$300.00None
CELECOXIB 100 MG CAPSULE [Celebrex]   3* Tier 3 $45.00$135.00Q:60
/30Days
CELECOXIB 200 MG CAPSULE [Celebrex]   3* Tier 3 $45.00$135.00Q:60
/30Days
CELECOXIB 400 MG CAPSULE [Celebrex]   3* Tier 3 $45.00$135.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CELECOXIB 50 MG CAPSULE [Celebrex]   3* Tier 3 $45.00$135.00Q:60
/30Days
CELONTIN 300 MG KAPSEAL   4 Tier 4 $100.00$300.00None
CEPHALEXIN 125 MG/5 ML SUSPENSION   2* Tier 2 $10.00$0.00None
CEPHALEXIN 250 MG CAPSULE   2* Tier 2 $10.00$0.00None
CEPHALEXIN 250 MG/5 ML SUSPENSION   2* Tier 2 $10.00$0.00None
CEPHALEXIN 500 MG CAPSULE   2* Tier 2 $10.00$0.00None
CEPHALEXIN 750 MG CAPSULE   2* Tier 2 $10.00$0.00None
CETIRIZINE HCL 1 MG/ML SYRUP SOLUTION [Zyrtec Pre-Filled Spoons]   2* Tier 2 $10.00$0.00None
CHANTIX 0.5 MG TABLET   3* Tier 3 $45.00$135.00None
CHANTIX 1 MG CONT MONTH BOX   3* Tier 3 $45.00$135.00None
CHANTIX 1 MG TABLET   3* Tier 3 $45.00$135.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CHANTIX STARTING MONTH BOX   3* Tier 3 $45.00$135.00None
CHEMET 100 MG CAPSULE   5 Tier 5 27%27%None
CHENODAL 250 MG TABLET   5 Tier 5 27%27%None
CHLORDIAZEPOXIDE 10 MG CAPSULE   2* Tier 2 $10.00$0.00None
CHLORDIAZEPOXIDE 25 MG CAPSULE   2* Tier 2 $10.00$0.00None
CHLORDIAZEPOXIDE 5 MG CAPSULE   2* Tier 2 $10.00$0.00None
CHLORHEXIDINE GLUCONATE 0.12% RINSE   2* Tier 2 $10.00$0.00None
CHLOROQUINE PH 250 MG TABLET   2* Tier 2 $10.00$0.00None
CHLOROQUINE PH 500 MG TABLET   2* Tier 2 $10.00$0.00None
CHLORPROMAZINE 10 MG TABLET   4 Tier 4 $100.00$300.00None
CHLORPROMAZINE 100 MG TABLET   4 Tier 4 $100.00$300.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CHLORPROMAZINE 200 MG TABLET   4 Tier 4 $100.00$300.00None
CHLORPROMAZINE 25 MG TABLET   4 Tier 4 $100.00$300.00None
CHLORPROMAZINE 50 MG TABLET   4 Tier 4 $100.00$300.00None
CHLORTHALIDONE 25 MG TABLET   2* Tier 2 $10.00$0.00None
CHLORTHALIDONE 50 MG TABLET   2* Tier 2 $10.00$0.00None
CHLORZOXAZONE 500 MG TABLET   3* Tier 3 $45.00$135.00None
CHOLBAM 250 MG CAPSULE   5 Tier 5 27%27%P
CHOLBAM 50 MG CAPSULE   5 Tier 5 27%27%P
CHOLESTYRAMINE LIGHT POWDER   4 Tier 4 $100.00$300.00None
CHOLESTYRAMINE PACKET   4 Tier 4 $100.00$300.00None
CICLOPIROX 0.77% CREAM (g) [Loprox]   3* Tier 3 $45.00$135.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CICLOPIROX 0.77% GEL   3* Tier 3 $45.00$135.00None
CICLOPIROX 0.77% TOPICAL SUSPENSION   3* Tier 3 $45.00$135.00None
CICLOPIROX 1% SHAMPOO   3* Tier 3 $45.00$135.00None
CICLOPIROX 8% SOLUTION [Penlac]   3* Tier 3 $45.00$135.00None
Cilastatin 250 MG / Imipenem 250 MG Injection   4 Tier 4 $100.00$300.00None
Cilastatin 500 MG / Imipenem 500 MG Injection   4 Tier 4 $100.00$300.00None
CILOSTAZOL 100 MG TABLET   2* Tier 2 $10.00$0.00None
CILOSTAZOL 50 MG TABLET   2* Tier 2 $10.00$0.00None
CILOXAN 0.3% OINTMENT   4 Tier 4 $100.00$300.00None
CIMDUO 300-300 MG TABLET   5 Tier 5 27%27%Q:30
/30Days
Cimetidine 200mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC   2* Tier 2 $10.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Cimetidine 300 MG Oral Tablet   2* Tier 2 $10.00$0.00None
CIMETIDINE 400 MG TABLET [Tagamet]   2* Tier 2 $10.00$0.00None
Cimetidine 800mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC   2* Tier 2 $10.00$0.00None
Cimetidine Hydrochloride Oral Solution 300mg/5mL 237 mL in 1 BOTTLE   2* Tier 2 $10.00$0.00None
Cimzia 2 KIT per CARTON / 1 KIT in 1 KIT   5 Tier 5 27%27%P
CIMZIA 200 MG/ML SYRINGE KIT   5 Tier 5 27%27%P
CINACALCET HCL 30 MG TABLET [Sensipar]   4 Tier 4 $100.00$300.00P Q:60
/30Days
CINACALCET HCL 60 MG TABLET [Sensipar]   5 Tier 5 27%27%P Q:60
/30Days
CINACALCET HCL 90 MG TABLET [Sensipar]   5 Tier 5 27%27%P Q:120
/30Days
Cinryze 500[iU]/5mL 1 VIAL per CARTON / 5 mL in 1 VIAL   5 Tier 5 27%27%P
CIPRO HC OTIC SUSPENSION   4 Tier 4 $100.00$300.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CIPRODEX OTIC SUSPENSION   3* Tier 3 $45.00$135.00None
CIPROFLOXACIN 0.3% EYE DROPS [Ciloxan]   2* Tier 2 $10.00$0.00None
CIPROFLOXACIN HCL 100 MG TABLET [Cipro]   3* Tier 3 $45.00$135.00None
CIPROFLOXACIN HCL 250 MG TABLET [Cipro]   2* Tier 2 $10.00$0.00None
CIPROFLOXACIN HCL 500 MG TABLET [Cipro]   2* Tier 2 $10.00$0.00None
CIPROFLOXACIN HCL 750 MG TABLET [Cipro]   2* Tier 2 $10.00$0.00None
CIPROFLOXACIN-D5W 200 MG/100 ML PIGGYBACK [Cipro]   4 Tier 4 $100.00$300.00None
CITALOPRAM HBR 10 MG TABLET [Celexa]   1* Tier 1 $0.00$0.00None
CITALOPRAM HBR 10 MG/5 ML SOLUTION [Celexa]   3* Tier 3 $45.00$135.00None
CITALOPRAM HBR 20 MG TABLET [Celexa]   1* Tier 1 $0.00$0.00None
CITALOPRAM HBR 40 MG TABLET   1* Tier 1 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLARAVIS 10 MG CAPSULE   4 Tier 4 $100.00$300.00P
CLARAVIS 20 MG CAPSULE   4 Tier 4 $100.00$300.00P
Claravis 30mg 3 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK   4 Tier 4 $100.00$300.00P
CLARAVIS 40 MG CAPSULE   4 Tier 4 $100.00$300.00P
CLARITHROMYCIN 125 MG/5ML FOR ORAL SUSPENSION   4 Tier 4 $100.00$300.00None
CLARITHROMYCIN 250 MG TABLET   3* Tier 3 $45.00$135.00None
CLARITHROMYCIN 250 MG/5MLFOR ORAL SUSPENSION   4 Tier 4 $100.00$300.00None
CLARITHROMYCIN 500 MG TABLET [Biaxin]   3* Tier 3 $45.00$135.00None
CLARITHROMYCIN ER 500 MG TABLET 24H [Biaxin XL]   3* Tier 3 $45.00$135.00None
CLENPIQ SOLUTION   3* Tier 3 $45.00$135.00None
CLIMARA PRO DIS WEEKLY 4.40MG/1.39MG   4 Tier 4 $100.00$300.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLINDAMYCIN 150mg/ml vl 25x6ml   4 Tier 4 $100.00$300.00None
CLINDAMYCIN 2% VAGINAL CREAM w/APPL [Clindesse]   3* Tier 3 $45.00$135.00None
CLINDAMYCIN HCL 150 MG CAPSULE [Cleocin]   2* Tier 2 $10.00$0.00None
CLINDAMYCIN HCL 300 MG CAPSULE   2* Tier 2 $10.00$0.00None
CLINDAMYCIN HCL 75 MG 200 CAPSULE BOTTLE   2* Tier 2 $10.00$0.00None
CLINDAMYCIN PEDIATR 75 MG/5 ML SOLN RECON [Cleocin Pediatric]   2* Tier 2 $10.00$0.00None
CLINDAMYCIN PH 1% SOLUTION   3* Tier 3 $45.00$135.00None
CLINDAMYCIN PH 300 MG/2 ML VIAL [Cleocin]   4 Tier 4 $100.00$300.00None
CLINDAMYCIN PH 600 MG/4 ML VIAL [Cleocin]   4 Tier 4 $100.00$300.00None
CLINDAMYCIN PHOSP 1% LOTION [ClindaMax]   3* Tier 3 $45.00$135.00None
Clindamycin Phosphate and Benzoyl Peroxide 1 KIT   4 Tier 4 $100.00$300.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE   3* Tier 3 $45.00$135.00None
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX   3* Tier 3 $45.00$135.00None
Clindamycin-d5w 300 mg/50 ml   4 Tier 4 $100.00$300.00None
Clindamycin-d5w 600 mg/50 ml   4 Tier 4 $100.00$300.00None
Clindamycin-d5w 900 mg/50 ml   4 Tier 4 $100.00$300.00None
CLOBAZAM 10 MG TABLET [ONFI]   4 Tier 4 $100.00$300.00P Q:60
/30Days
CLOBAZAM 2.5 MG/ML ORAL SUSPENSION [ONFI]   5 Tier 5 27%27%P Q:480
/30Days
CLOBAZAM 20 MG TABLET [ONFI]   5 Tier 5 27%27%P Q:60
/30Days
CLOBETASOL 0.05% CREAM (g) [Temovate]   4 Tier 4 $100.00$300.00None
CLOBETASOL 0.05% OINTMENT [Temovate E]   4 Tier 4 $100.00$300.00None
CLOBETASOL 0.05% SOLUTION [Temovate]   3* Tier 3 $45.00$135.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLOBETASOL EMOLLIENT 0.05% CREAM (g) [Temovate E]   4 Tier 4 $100.00$300.00None
Clobetasol Propionate 0.5 MG/ML Medicated Shampoo   4 Tier 4 $100.00$300.00None
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE   4 Tier 4 $100.00$300.00None
CLOMIPRAMINE 25 MG CAPSULE   4 Tier 4 $100.00$300.00None
CLOMIPRAMINE 50 MG CAPSULE   4 Tier 4 $100.00$300.00None
CLOMIPRAMINE 75 MG CAPSULE   4 Tier 4 $100.00$300.00None
CLONAZEPAM 0.125 MG DIS TABLET RAPDIS [Klonopin]   4 Tier 4 $100.00$300.00Q:120
/30Days
CLONAZEPAM 0.25 MG ODT TABLET RAPDIS [Klonopin]   4 Tier 4 $100.00$300.00Q:120
/30Days
CLONAZEPAM 0.5 MG DIS TABLET RAPDIS [Klonopin]   4 Tier 4 $100.00$300.00Q:120
/30Days
CLONAZEPAM 0.5 MG TABLET [Klonopin]   2* Tier 2 $10.00$0.00Q:120
/30Days
CLONAZEPAM 1 MG DIS TABLET RAPDIS [Klonopin]   4 Tier 4 $100.00$300.00Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLONAZEPAM 1 MG TABLET [Klonopin]   2* Tier 2 $10.00$0.00Q:120
/30Days
CLONAZEPAM 2 MG ODT TABLET RAPDIS [Klonopin]   4 Tier 4 $100.00$300.00Q:300
/30Days
CLONAZEPAM 2 MG TABLET [Klonopin]   2* Tier 2 $10.00$0.00Q:300
/30Days
Clonidine 0.1mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH   4 Tier 4 $100.00$300.00None
Clonidine 0.2mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH   4 Tier 4 $100.00$300.00None
Clonidine 0.3mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH   4 Tier 4 $100.00$300.00None
CLONIDINE HCL 0.1 MG TABLET   1* Tier 1 $0.00$0.00None
CLONIDINE HCL 0.2 MG TABLET   1* Tier 1 $0.00$0.00None
CLONIDINE HCL 0.3 MG TABLET   1* Tier 1 $0.00$0.00None
CLONIDINE HCL ER 0.1 MG TABLET   4 Tier 4 $100.00$300.00P
CLOPIDOGREL 75 MG TABLET [Plavix]   2* Tier 2 $10.00$0.00Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLORAZEPATE 15 MG TABLET   3* Tier 3 $45.00$135.00Q:180
/30Days
CLORAZEPATE 3.75 MG TABLET   3* Tier 3 $45.00$135.00Q:720
/30Days
CLORAZEPATE 7.5 MG TABLET   3* Tier 3 $45.00$135.00Q:360
/30Days
CLOTRIMAZOLE 1% CREAM (g) [Mycelex]   2* Tier 2 $10.00$0.00None
CLOTRIMAZOLE 1% SOLUTION   2* Tier 2 $10.00$0.00None
CLOTRIMAZOLE 10 MG TROCHE   2* Tier 2 $10.00$0.00None
CLOTRIMAZOLE-BETAMETHASONE LOT   4 Tier 4 $100.00$300.00None
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE 0.64; 10mg/g; mg/g 45 g in 1 TUBE   3* Tier 3 $45.00$135.00None
CLOVIQUE 250 MG CAPSULE [Syprine]   5 Tier 5 27%27%P Q:240
/30Days
CLOZAPINE 100 MG TABLET [Clozaril]   3* Tier 3 $45.00$135.00None
CLOZAPINE 200 MG TABLET   3* Tier 3 $45.00$135.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLOZAPINE 25 MG TABLET [Clozaril]   3* Tier 3 $45.00$135.00None
CLOZAPINE 50 MG TABLET   3* Tier 3 $45.00$135.00None
CLOZAPINE ODT 100 MG TABLET RAPDIS [Fazaclo]   4 Tier 4 $100.00$300.00Q:270
/30Days
CLOZAPINE ODT 12.5 MG TABLET RAPDIS [Fazaclo]   4 Tier 4 $100.00$300.00Q:60
/30Days
CLOZAPINE ODT 150 MG TABLET RAPDIS [Fazaclo]   4 Tier 4 $100.00$300.00Q:180
/30Days
CLOZAPINE ODT 200 MG TABLET RAPDIS [Fazaclo]   4 Tier 4 $100.00$300.00Q:120
/30Days
CLOZAPINE ODT 25 MG TABLET RAPDIS [Fazaclo]   4 Tier 4 $100.00$300.00Q:90
/30Days
COARTEM 20MG-120MG   4 Tier 4 $100.00$300.00None
CODEINE SULFATE 15 MG TABLET   3* Tier 3 $45.00$135.00Q:180
/30Days
CODEINE SULFATE 30 MG TABLET   3* Tier 3 $45.00$135.00Q:180
/30Days
CODEINE SULFATE 60 MG TABLET   3* Tier 3 $45.00$135.00Q:180
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COLCHICINE 0.6 MG CAPSULE [Mitigare]   3* Tier 3 $45.00$135.00Q:120
/30Days
COLCHICINE 0.6 MG TABLET [Colcrys]   3* Tier 3 $45.00$135.00Q:120
/30Days
COLCRYS 0.6 MG TABLET   3* Tier 3 $45.00$135.00Q:120
/30Days
COLESEVELAM 625 MG TABLET [WelChol]   3* Tier 3 $45.00$135.00None
COLESEVELAM HCL 3.75 G PACKET POWDER PACK [WelChol]   3* Tier 3 $45.00$135.00None
COLESTIPOL HCL GRANULES PACKET [Colestid]   4 Tier 4 $100.00$300.00None
COLESTIPOL MICRONIZED 1 GM TABLET [Colestid]   3* Tier 3 $45.00$135.00None
COLISTIMETHATE 150 MG VIAL [Coly-Mycin M]   5 Tier 5 27%27%None
COMBIGAN 0.2%-0.5% DROPS   3* Tier 3 $45.00$135.00None
COMBIVENT RESPIMAT INHAL SPRAY   3* Tier 3 $45.00$135.00Q:4
/20Days
COMETRIQ 100 MG DAILY-DOSE PACK   5 Tier 5 27%27%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COMETRIQ 140 MG DAILY-DOSE PACK   5 Tier 5 27%27%P
COMETRIQ 60 MG DAILY-DOSE PACK   5 Tier 5 27%27%P
COMPLERA 200; 27.5; 300mg/1; mg/1; mg/1   5 Tier 5 27%27%Q:30
/30Days
COMPRO 25MG SUPPOSITORY   4 Tier 4 $100.00$300.00None
CONSTULOSE 10 GM/15 ML SOLN   2* Tier 2 $10.00$0.00None
COPIKTRA 15 MG CAPSULE   5 Tier 5 27%27%P Q:60
/30Days
COPIKTRA 25 MG CAPSULE   5 Tier 5 27%27%P Q:60
/30Days
CORDRAN 4 MCG/SQ CM LARGE MED. TAPE   4 Tier 4 $100.00$300.00None
CORLANOR 5 MG TABLET   4 Tier 4 $100.00$300.00P Q:60
/30Days
CORLANOR 5 MG/5 ML ORAL SOLUTION   4 Tier 4 $100.00$300.00P Q:450
/30Days
CORLANOR 7.5 MG TABLET   4 Tier 4 $100.00$300.00P Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Cortisone 25 MG TABLET   4 Tier 4 $100.00$300.00None
CORTISPORIN CRE 0.5%   4 Tier 4 $100.00$300.00None
CORTISPORIN OINTMENT   4 Tier 4 $100.00$300.00None
COSENTYX 300 MG DOSE-2 PENS   5 Tier 5 27%27%P
COSENTYX 300 MG DOSE-2 SYRINGE   5 Tier 5 27%27%P
COSOPT PF EYE DROPS   4 Tier 4 $100.00$300.00None
COTELLIC 20 MG TABLET   5 Tier 5 27%27%P Q:90
/30Days
Creon 256.11mg/1 1 BOTTLE per CARTON / 70 CAPSULE, DELAYED RELEASE in 1 BOTTLE   3* Tier 3 $45.00$135.00None
CREON DELAYED RELEASE CAPSULES 12000MG 100 BOTTLE   3* Tier 3 $45.00$135.00None
CREON DELAYED RELEASE CAPSULES 24000MG 100 BOTTLE   3* Tier 3 $45.00$135.00None
CREON DELAYED RELEASE CAPSULES 6000MG 100 BOTTLE   3* Tier 3 $45.00$135.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CREON DR 36,000 UNITS CAPSULE   3* Tier 3 $45.00$135.00None
CRINONE 4% GEL/PF APP   4 Tier 4 $100.00$300.00P
CRINONE 8% GEL/PF APP   4 Tier 4 $100.00$300.00P
CRIXIVAN 200MG CAPSULE   3* Tier 3 $45.00$135.00Q:270
/30Days
CRIXIVAN 400mg, 180 CAPSULE BOTTLE   3* Tier 3 $45.00$135.00Q:180
/30Days
CROMOLYN 100 MG/5 ML ORAL CONC [Gastrocrom]   3* Tier 3 $45.00$135.00None
CROMOLYN 20 MG/2 ML NEB SOLN AMPUL-NEB [Intal]   3* Tier 3 $45.00$135.00P
CROMOLYN SODIUM 4% 40MG 10ML BOTTLE   2* Tier 2 $10.00$0.00None
CUVPOSA 1 MG/5 ML SOLUTION   4 Tier 4 $100.00$300.00P
CYCLAFEM 1-35-28 TABLET [Pirmella]   4 Tier 4 $100.00$300.00None
CYCLAFEM 7-7-7-28 TABLET   4 Tier 4 $100.00$300.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CYCLOBENZAPRINE 10 MG TABLET [Flexeril]   2* Tier 2 $10.00$0.00None
CYCLOBENZAPRINE 5 MG TABLET   2* Tier 2 $10.00$0.00None
CYCLOBENZAPRINE 7.5 MG TABLET   4 Tier 4 $100.00$300.00None
CYCLOPHOSPHAMIDE 25 MG CAPSULE   4 Tier 4 $100.00$300.00P
CYCLOPHOSPHAMIDE 50 MG CAPSULE   4 Tier 4 $100.00$300.00P
CYCLOSET 0.8MG TABLETS   4 Tier 4 $100.00$300.00P Q:180
/30Days
CYCLOSPORINE 100MG CAPSULE   3* Tier 3 $45.00$135.00P
CYCLOSPORINE 25MG CAPSULE   3* Tier 3 $45.00$135.00P
CYCLOSPORINE MODIFIED 100 MG   3* Tier 3 $45.00$135.00P
CYCLOSPORINE MODIFIED 25 MG   3* Tier 3 $45.00$135.00P
CYCLOSPORINE MODIFIED 50 MG   3* Tier 3 $45.00$135.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOTTLE   3* Tier 3 $45.00$135.00P
CYPROHEPTADINE 4 MG TABLET   4 Tier 4 $100.00$300.00None
CYPROHEPTADINE HYDROCHLORIDE SOLUTION USP SYRUP 2MG 473 ML BOTGL   4 Tier 4 $100.00$300.00None
CYRED 28 DAY TABLET [Solia]   4 Tier 4 $100.00$300.00None
CYSTADANE 1 GRAM/1.7 ML POWDER   5 Tier 5 27%27%None
CYSTAGON 150MG CAPSULE   4 Tier 4 $100.00$300.00None
CYSTAGON 50MG CAPSULE   4 Tier 4 $100.00$300.00None
CYSTARAN 0.44% EYE DROPS   5 Tier 5 27%27%None

Chart Legend:

Below are a few notes to help you understand the above 2020 Medicare Part D Peoples Health Choices Value (HMO) 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 September 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.