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2021 Medicare Part D and Medicare Advantage Plan Formulary Browser

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BlueMedicare Premier (HMO) (H1035-024-0)
Tier 1 (450)
Tier 2 (1685)
Tier 3 (347)
Tier 4 (1023)
Tier 5 (814)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
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Has Quantity Limits:
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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 
2021 Medicare Part D Plan Formulary Information
BlueMedicare Premier (HMO) (H1035-024-0)
Benefits & Contact Info           
This plan covers some insulin for $35 or less.
Possible forms of insulin are marked with $35 or less below. Call plan to confirm detail.
The BlueMedicare Premier (HMO) (H1035-024-0)
Formulary Drugs Starting with the Letter A

in Miami-Dade County, FL: CMS MA Region 9 which includes: FL
Plan Monthly Premium: $0.00 Deductible: $0
Drugs Starting with Letter A

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
ABACAVIR 20 MG/ML SOLUTION [Ziagen]   2 Generic $0.00$0.00Q:960
/30Days
ABACAVIR 300 MG TABLET [Ziagen]   2 Generic $0.00$0.00Q:60
/30Days
Abacavir Sulfate-Lamivudine-Zidovudine tablets [Trizivir]   5 Specialty Tier 33%N/AQ:60
/30Days
ABACAVIR-LAMIVUDINE 600-300 MG TABLET [Epzicom]   2 Generic $0.00$0.00Q:30
/30Days
ABILIFY 10MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
ABILIFY 15MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
ABILIFY 20MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
ABILIFY 2MG TABLET   5 Specialty Tier 33%N/AP Q:45
/30Days
ABILIFY 30MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
ABILIFY 5 MG TABLET   5 Specialty Tier 33%N/AP Q:45
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ABILIFY MAINTENA ER 300 MG SYRINGE   5 Specialty Tier 33%N/AQ:1
/28Days
ABILIFY MAINTENA ER 300 MG VIAL   5 Specialty Tier 33%N/AQ:1
/28Days
ABILIFY MAINTENA ER 400 MG SUSER VIAL   5 Specialty Tier 33%N/AQ:1
/28Days
ABILIFY MAINTENA ER 400 MG SYRINGE   5 Specialty Tier 33%N/AQ:1
/28Days
ABIRATERONE ACETATE 250 MG TABLET [ZYTIGA]   5 Specialty Tier 33%N/AP Q:120
/30Days
Acamprosate Calcium DR 333 MG tablets [Campral]   2 Generic $0.00$0.00None
ACARBOSE 100 MG TABLET [Precose]   2 Generic $0.00$0.00Q:90
/30Days
ACARBOSE 25 MG TABLET [Precose]   2 Generic $0.00$0.00Q:360
/30Days
ACARBOSE 50 MG TABLET [Precose]   2 Generic $0.00$0.00Q:180
/30Days
ACCOLATE 10 MG TABLET   4 Non-Preferred Drug $50.00$150.00None
ACCOLATE 20 MG TABLET   4 Non-Preferred Drug $50.00$150.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACCUPRIL 10MG TABLET   4 Non-Preferred Drug $50.00$150.00None
ACCUPRIL 20MG TABLET   4 Non-Preferred Drug $50.00$150.00None
ACCUPRIL 40MG TABLET   4 Non-Preferred Drug $50.00$150.00None
ACCUPRIL 5MG TABLET   4 Non-Preferred Drug $50.00$150.00None
ACCURETIC 10-12.5MG TABLET   4 Non-Preferred Drug $50.00$150.00None
ACCURETIC 20-12.5MG TABLET   4 Non-Preferred Drug $50.00$150.00None
ACCURETIC 20-25MG TABLET   4 Non-Preferred Drug $50.00$150.00None
ACEBUTOLOL 200 MG CAPSULE [Sectral]   2 Generic $0.00$0.00None
ACEBUTOLOL 400 MG CAPSULE [Sectral]   2 Generic $0.00$0.00None
ACETAMINOP-CODEINE 120-12 MG/5   1 Preferred Generic $0.00$0.00Q:2700
/30Days
ACETAMINOPHEN-COD #2 TABLET   2 Generic $0.00$0.00Q:360
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETAMINOPHEN-COD #3 TABLET [Tylenol with Codeine No.3]   2 Generic $0.00$0.00Q:360
/30Days
ACETAMINOPHEN-COD #4 TABLET   2 Generic $0.00$0.00Q:180
/30Days
ACETAZOLAMIDE 125MG TABLET   2 Generic $0.00$0.00None
ACETAZOLAMIDE 250 MG TABLET [Diamox]   2 Generic $0.00$0.00None
ACETAZOLAMIDE ER 500 MG CAPSULE   2 Generic $0.00$0.00None
ACETIC ACID 2% EAR SOLUTION [VoSoL]   2 Generic $0.00$0.00None
ACETYLCYSTEINE 10% VIAL   2 Generic $0.00$0.00P
ACETYLCYSTEINE 20% VIAL [Mucosil Acetylcysteine]   2 Generic $0.00$0.00P
ACITRETIN 10 MG CAPSULE [Soriatane]   2 Generic $0.00$0.00None
ACITRETIN 17.5 MG CAPSULE [Soriatane]   2 Generic $0.00$0.00None
ACITRETIN 25 MG CAPSULE [Soriatane]   2 Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACTHIB VACCINE WITH DILUENT   3 Preferred Brand $0.00$0.00None
ACTIGALL 300 MG CAPSULE   5 Specialty Tier 33%N/ANone
ACTIMMUNE 100 MCG/0.5 ML VIAL   5 Specialty Tier 33%N/AP
ACTOS 15 MG TABLET   4 Non-Preferred Drug $50.00$150.00Q:90
/30Days
ACTOS 30 MG TABLET   4 Non-Preferred Drug $50.00$150.00Q:30
/30Days
ACTOS 45 MG TABLET   4 Non-Preferred Drug $50.00$150.00Q:30
/30Days
ACULAR 0.5% EYE DROPS   4 Non-Preferred Drug $50.00$150.00None
ACULAR LS 0.4% OPHTH SOLUTION   4 Non-Preferred Drug $50.00$150.00None
ACYCLOVIR 200 MG CAPSULE [Zovirax]   1 Preferred Generic $0.00$0.00None
ACYCLOVIR 200 MG/5 ML SUSP   2 Generic $0.00$0.00None
ACYCLOVIR 400 MG TABLET   1 Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACYCLOVIR 5% OINTMENT [Zovirax]   2 Generic $0.00$0.00P
ACYCLOVIR 800 MG TABLET   1 Preferred Generic $0.00$0.00None
Acyclovir sodium 500 mg vial   2 Generic $0.00$0.00P
ADACEL TDAP SYRINGE   3 Preferred Brand $0.00$0.00None
ADACEL VIAL 2UNT/5UNT   3 Preferred Brand $0.00$0.00None
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA]   5 Specialty Tier 33%N/AP
ADCIRCA TABLETS 20MG 60 BOTTLE   5 Specialty Tier 33%N/AP Q:60
/30Days
ADDERALL XR 10MG CAPSULE SA   4 Non-Preferred Drug $50.00$150.00Q:30
/30Days
ADDERALL XR 15MG CAPSULE SA   4 Non-Preferred Drug $50.00$150.00Q:30
/30Days
ADDERALL XR 20MG CAPSULE SA   4 Non-Preferred Drug $50.00$150.00Q:30
/30Days
ADDERALL XR 25MG CAPSULE SA   4 Non-Preferred Drug $50.00$150.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADDERALL XR 30MG CAPSULE SA   4 Non-Preferred Drug $50.00$150.00Q:30
/30Days
ADDERALL XR 5MG CAPSULE SA   4 Non-Preferred Drug $50.00$150.00Q:30
/30Days
ADEFOVIR DIPIVOXIL 10 MG TABLET [Hepsera]   5 Specialty Tier 33%N/ANone
ADEMPAS 0.5 MG TABLET   5 Specialty Tier 33%N/AP Q:90
/30Days
ADEMPAS 1 MG TABLET   5 Specialty Tier 33%N/AP Q:90
/30Days
ADEMPAS 1.5 MG TABLET   5 Specialty Tier 33%N/AP Q:90
/30Days
ADEMPAS 2 MG TABLET   5 Specialty Tier 33%N/AP Q:90
/30Days
ADEMPAS 2.5 MG TABLET   5 Specialty Tier 33%N/AP Q:90
/30Days
ADVAIR DISKUS MIS 100/50   3 Preferred Brand $0.00$0.00Q:60
/30Days
ADVAIR DISKUS MIS 250/50   3 Preferred Brand $0.00$0.00Q:60
/30Days
ADVAIR DISKUS MIS 500/50   3 Preferred Brand $0.00$0.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER   3 Preferred Brand $0.00$0.00Q:12
/30Days
ADVAIR HFA INHALER 115;21MCG;MCG 120 ACTN INHL   3 Preferred Brand $0.00$0.00Q:12
/30Days
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL   3 Preferred Brand $0.00$0.00Q:12
/30Days
AFINITOR 10 MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
AFINITOR 2.5 MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
AFINITOR 5 MG TABLET   5 Specialty Tier 33%N/AP Q:60
/30Days
Afinitor 7.5mg/1 28 BLISTER PACK per CARTON / 1 TABLET per BLISTER PACK   5 Specialty Tier 33%N/AP Q:30
/30Days
AFINITOR DISPERZ 2 MG TABLET   5 Specialty Tier 33%N/AP Q:60
/30Days
AFINITOR DISPERZ 3 MG TABLET   5 Specialty Tier 33%N/AP Q:90
/30Days
AFINITOR DISPERZ 5 MG TABLET   5 Specialty Tier 33%N/AP Q:60
/30Days
AGGRENOX 25-200MG CAPSULE   4 Non-Preferred Drug $50.00$150.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AGRYLIN 0.5MG CAPSULE   4 Non-Preferred Drug $50.00$150.00None
AIMOVIG 140 MG/ML AUTOINJECTOR   3 Preferred Brand $0.00$0.00P Q:1
/30Days
AIMOVIG 70 MG/ML AUTOINJECTOR   3 Preferred Brand $0.00$0.00P Q:2
/30Days
ALBENDAZOLE 200 MG TABLET [Albenza]   2 Generic $0.00$0.00None
ALBUTEROL 2.5 MG/0.5 ML SOL VIAL-NEB   2 Generic $0.00$0.00P
ALBUTEROL SUL 0.63 MG/3 ML SOL VIAL-NEB   2 Generic $0.00$0.00P
ALBUTEROL SUL 1.25 MG/3 ML SOL VIAL-NEB   2 Generic $0.00$0.00P
ALBUTEROL SUL 2.5 MG/3 ML SOLUTION VIAL-NEB   2 Generic $0.00$0.00P
ALBUTEROL SULF 2 MG/5 ML SYRUP   2 Generic $0.00$0.00None
ALBUTEROL SULFATE 2 MG TABLET   2 Generic $0.00$0.00None
ALBUTEROL SULFATE 4 MG TABLET   2 Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALBUTEROL SULFATE 4MG TABLET SR 12HR   4 Non-Preferred Drug $50.00$150.00None
ALBUTEROL SULFATE 8MG TABLET SR 12HR   4 Non-Preferred Drug $50.00$150.00None
ALCLOMETASONE DIPR 0.05% OINTMENT [Aclovate]   2 Generic $0.00$0.00Q:120
/30Days
ALCLOMETASONE DIPRO 0.05% CREAM   2 Generic $0.00$0.00Q:120
/30Days
ALDACTAZIDE 25/25 TABLET   4 Non-Preferred Drug $50.00$150.00None
ALDACTONE 100MG TABLET   4 Non-Preferred Drug $50.00$150.00None
ALDACTONE 25MG TABLET   4 Non-Preferred Drug $50.00$150.00None
ALDACTONE 50MG TABLET   4 Non-Preferred Drug $50.00$150.00None
ALDARA 5% CREAM   4 Non-Preferred Drug $50.00$150.00P
ALECENSA 150 MG CAPSULE   5 Specialty Tier 33%N/AP Q:240
/30Days
ALENDRONATE SODIUM 10 MG TABLET [Fosamax]   1 Preferred Generic $0.00$0.00Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALENDRONATE SODIUM 35 MG TABLET [Fosamax]   1 Preferred Generic $0.00$0.00Q:4
/28Days
ALENDRONATE SODIUM 70 MG TABLET [Fosamax]   1 Preferred Generic $0.00$0.00Q:4
/28Days
ALFUZOSIN HCL ER 10 MG TABLET   1 Preferred Generic $0.00$0.00Q:30
/30Days
ALINIA 100 MG/5 ML SUSPENSION   5 Specialty Tier 33%N/AQ:540
/30Days
ALINIA 500 MG TABLET   5 Specialty Tier 33%N/AQ:20
/30Days
Aliskiren 150 MG / Hydrochlorothiazide 12.5 MG Oral Tablet [Tekturna HCT]   3 Preferred Brand $0.00$0.00Q:30
/30Days
Aliskiren 150 MG / Hydrochlorothiazide 25 MG Oral Tablet [Tekturna HCT]   3 Preferred Brand $0.00$0.00Q:30
/30Days
ALISKIREN 150 MG TABLET [Tekturna]   2 Generic $0.00$0.00Q:30
/30Days
Aliskiren 300 MG / Hydrochlorothiazide 12.5 MG Oral Tablet [Tekturna HCT]   3 Preferred Brand $0.00$0.00Q:30
/30Days
ALISKIREN 300 MG TABLET [Tekturna]   2 Generic $0.00$0.00Q:30
/30Days
ALLOPURINOL 100 MG TABLET [Zyloprim]   1 Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALLOPURINOL 300 MG TABLET [Zyloprim]   1 Preferred Generic $0.00$0.00None
ALOSETRON HCL 0.5 MG TABLET [Lotronex]   5 Specialty Tier 33%N/AP Q:60
/30Days
ALOSETRON HCL 1 MG TABLET [Lotronex]   5 Specialty Tier 33%N/AP Q:60
/30Days
ALPHAGAN P 0.1% EYE DROPS   3 Preferred Brand $0.00$0.00None
ALPHAGAN P 0.15% EYE DROPS   3 Preferred Brand $0.00$0.00None
ALPRAZOLAM 0.25 MG TABLET [Xanax]   1 Preferred Generic $0.00$0.00Q:120
/30Days
ALPRAZOLAM 0.5 MG TABLET   1 Preferred Generic $0.00$0.00Q:120
/30Days
ALPRAZOLAM 1 MG TABLET   1 Preferred Generic $0.00$0.00Q:120
/30Days
ALPRAZOLAM 2 MG TABLET   1 Preferred Generic $0.00$0.00Q:150
/30Days
ALTACE 1.25MG CAPSULE   4 Non-Preferred Drug $50.00$150.00None
ALTACE 10MG CAPSULE (100 CT)   4 Non-Preferred Drug $50.00$150.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALTACE 2.5 MG CAPSULE   4 Non-Preferred Drug $50.00$150.00None
ALTACE 5MG CAPSULE   4 Non-Preferred Drug $50.00$150.00None
ALTAVERA-28 TABLET [Portia]   2 Generic $0.00$0.00None
ALUNBRIG 180 MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
ALUNBRIG 30 MG TABLET   5 Specialty Tier 33%N/AP Q:120
/30Days
ALUNBRIG 90 MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
ALUNBRIG 90 MG-180 MG TABLET PACK   5 Specialty Tier 33%N/AP Q:30
/30Days
ALYACEN 1-35-28 TABLET   2 Generic $0.00$0.00None
ALYQ 20 MG TABLET   5 Specialty Tier 33%N/AP Q:60
/30Days
Amabelz 0.5 MG/0.1 MG 28 TABLET/BLISTER PACK 3 PER CARTON   2 Generic $0.00$0.00None
Amabelz 1 MG/0.5 MG 28 TABLET/BLISTER PACK 3 PER CARTON   2 Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMANTADINE 100 MG CAPSULE [Symmetrel]   2 Generic $0.00$0.00None
AMANTADINE 100 MG TABLET   2 Generic $0.00$0.00None
AMANTADINE 50 MG/5 ML SOLUTION   2 Generic $0.00$0.00None
AMARYL 1MG TABLET   4 Non-Preferred Drug $50.00$150.00Q:240
/30Days
AMARYL 2MG TABLET   4 Non-Preferred Drug $50.00$150.00Q:120
/30Days
AMARYL 4MG TABLET   4 Non-Preferred Drug $50.00$150.00Q:60
/30Days
AMBISOME 50MG VIAL   5 Specialty Tier 33%N/AP
AMBRISENTAN 10 MG TABLET [LETAIRIS]   5 Specialty Tier 33%N/AP Q:30
/30Days
AMBRISENTAN 5 MG TABLET [LETAIRIS]   5 Specialty Tier 33%N/AP Q:30
/30Days
AMERGE 1MG TABLET   4 Non-Preferred Drug $50.00$150.00S Q:18
/30Days
AMERGE 2.5MG TABLET   4 Non-Preferred Drug $50.00$150.00S Q:18
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMETHIA 0.15-0.03-0.01 MG TABLET   2 Generic $0.00$0.00None
AMIKACIN SULF 500 MG/2 ML VIAL   2 Generic $0.00$0.00None
AMILORIDE HCL 5 MG TABLET [Midamor]   2 Generic $0.00$0.00None
AMILORIDE HCL-HCTZ 5-50 MG TABLET [Moduretic]   2 Generic $0.00$0.00None
AMINOSYN II 10% SOL 6X2000 ML   4 Non-Preferred Drug $50.00$150.00P
AMIODARONE HCL 200 MG TABLET [Pacerone]   1 Preferred Generic $0.00$0.00None
AMIODARONE HCL 400 MG TABLET [Pacerone]   2 Generic $0.00$0.00None
AMITRIPTYLINE HCL 10 MG TABLET [Elavil]   2 Generic $0.00$0.00None
AMITRIPTYLINE HCL 100 MG TABLET   2 Generic $0.00$0.00None
AMITRIPTYLINE HCL 150 MG TABLET   2 Generic $0.00$0.00None
AMITRIPTYLINE HCL 25 MG TABLET   2 Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITRIPTYLINE HCL 50 MG TABLET   2 Generic $0.00$0.00None
AMITRIPTYLINE HCL 75 MG TABLET   2 Generic $0.00$0.00None
AMLOD-VALSA-HCTZ 10-160-12.5 MG [Exforge HCT]   2 Generic $0.00$0.00Q:30
/30Days
AMLOD-VALSA-HCTZ 10-160-25 MG [Exforge HCT]   2 Generic $0.00$0.00Q:30
/30Days
AMLOD-VALSA-HCTZ 10-320-25 MG [Exforge HCT]   2 Generic $0.00$0.00Q:30
/30Days
AMLOD-VALSA-HCTZ 5-160-12.5 MG [Exforge HCT]   2 Generic $0.00$0.00Q:30
/30Days
AMLOD-VALSA-HCTZ 5-160-25 MG [Exforge HCT]   2 Generic $0.00$0.00Q:30
/30Days
AMLODIPINE BESYLATE 10 MG TABLET [Norvasc]   1 Preferred Generic $0.00$0.00None
AMLODIPINE BESYLATE 2.5 MG TABLET [Norvasc]   1 Preferred Generic $0.00$0.00None
AMLODIPINE BESYLATE 5 MG TABLET [Norvasc]   1 Preferred Generic $0.00$0.00None
AMLODIPINE-ATORVAST 10-20 MG [Caduet]   2 Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE-ATORVAST 10-40 MG [Caduet]   2 Generic $0.00$0.00None
Amlodipine-Atorvastatin 10-10 mg [Caduet]   2 Generic $0.00$0.00None
Amlodipine-Atorvastatin 10-80 mg [Caduet]   2 Generic $0.00$0.00None
Amlodipine-Atorvastatin 2.5-10 mg [Caduet]   2 Generic $0.00$0.00None
Amlodipine-Atorvastatin 2.5-20 mg [Caduet]   2 Generic $0.00$0.00None
Amlodipine-Atorvastatin 2.5-40 mg [Caduet]   2 Generic $0.00$0.00None
Amlodipine-Atorvastatin 5-10 mg [Caduet]   2 Generic $0.00$0.00None
Amlodipine-Atorvastatin 5-20 mg [Caduet]   2 Generic $0.00$0.00None
Amlodipine-Atorvastatin 5-40 mg [Caduet]   2 Generic $0.00$0.00None
Amlodipine-Atorvastatin 5-80 mg [Caduet]   2 Generic $0.00$0.00None
AMLODIPINE-BENAZEPRIL 10-20 MG CAPSULE [Lotrel]   1 Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE-BENAZEPRIL 10-40 MG CAPSULE [Lotrel]   1 Preferred Generic $0.00$0.00None
AMLODIPINE-BENAZEPRIL 2.5-10 CAPSULE [Lotrel]   1 Preferred Generic $0.00$0.00None
AMLODIPINE-BENAZEPRIL 5-10 MG CAPSULE [Lotrel]   1 Preferred Generic $0.00$0.00None
AMLODIPINE-BENAZEPRIL 5-20 MG CAPSULE [Lotrel]   1 Preferred Generic $0.00$0.00None
AMLODIPINE-BENAZEPRIL 5-40 MG CAPSULE [Lotrel]   1 Preferred Generic $0.00$0.00None
AMLODIPINE-OLMESARTAN 10-20 MG TABLET [AZOR]   2 Generic $0.00$0.00Q:30
/30Days
AMLODIPINE-OLMESARTAN 10-40 MG TABLET [AZOR]   2 Generic $0.00$0.00Q:30
/30Days
AMLODIPINE-OLMESARTAN 5-20 MG TABLET [AZOR]   2 Generic $0.00$0.00Q:30
/30Days
AMLODIPINE-OLMESARTAN 5-40 MG TABLET [AZOR]   2 Generic $0.00$0.00Q:30
/30Days
AMLODIPINE-VALSARTAN 10-160 MG TABLET [Exforge]   1 Preferred Generic $0.00$0.00Q:30
/30Days
AMLODIPINE-VALSARTAN 10-320 MG TABLET [Exforge]   1 Preferred Generic $0.00$0.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE-VALSARTAN 5-160 MG TABLET [Exforge]   1 Preferred Generic $0.00$0.00Q:30
/30Days
AMLODIPINE-VALSARTAN 5-320 MG TABLET [Exforge]   1 Preferred Generic $0.00$0.00Q:30
/30Days
AMMONIUM LACTATE 12% CREAM (g) [Lac-Hydrin]   2 Generic $0.00$0.00None
AMMONIUM LACTATE 12% LOTION   2 Generic $0.00$0.00None
AMNESTEEM 10 MG CAPSULE [ZENATANE]   2 Generic $0.00$0.00None
AMNESTEEM 20 MG CAPSULE [ZENATANE]   2 Generic $0.00$0.00None
AMNESTEEM 40 MG CAPSULE [ZENATANE]   2 Generic $0.00$0.00None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE [Augmentin]   3 Preferred Brand $0.00$0.00None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET [Augmentin]   2 Generic $0.00$0.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE [Augmentin]   3 Preferred Brand $0.00$0.00None
AMOX-CLAV 200-28.5 MG/5 ML SUS   2 Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOX-CLAV 400-57 MG/5 ML ORAL SUSPENSION [Augmentin]   2 Generic $0.00$0.00None
AMOX-CLAV 500-125 MG TABLET [Augmentin]   2 Generic $0.00$0.00None
AMOX-CLAV 600-42.9 MG/5 ML SUS   2 Generic $0.00$0.00None
AMOX-CLAV 875-125 MG TABLET [Augmentin]   2 Generic $0.00$0.00None
AMOX-CLAV ER 1,000-62.5 MG TABLET [Augmentin]   4 Non-Preferred Drug $50.00$150.00None
AMOXAPINE 100MG TABLET   4 Non-Preferred Drug $50.00$150.00None
AMOXAPINE 150MG TABLET   4 Non-Preferred Drug $50.00$150.00None
AMOXAPINE 25MG TABLET   4 Non-Preferred Drug $50.00$150.00None
AMOXAPINE 50MG TABLET   4 Non-Preferred Drug $50.00$150.00None
AMOXICILLIN 125 MG/5 ML SUSP   1 Preferred Generic $0.00$0.00None
AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION [Amoxil]   1 Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN 250 MG CAPSULE [Trimox]   1 Preferred Generic $0.00$0.00None
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION [Trimox]   1 Preferred Generic $0.00$0.00None
AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION [Amoxil]   1 Preferred Generic $0.00$0.00None
AMOXICILLIN 500 MG CAPSULE [Trimox]   1 Preferred Generic $0.00$0.00None
AMOXICILLIN 500 MG TABLET   1 Preferred Generic $0.00$0.00None
AMOXICILLIN 875 MG TABLET   1 Preferred Generic $0.00$0.00None
AMPHETAMINE SALT COMBO 12.5MG TABLET   2 Generic $0.00$0.00Q:60
/30Days
AMPHETAMINE SALT COMBO 15MG TABLET   2 Generic $0.00$0.00Q:60
/30Days
AMPHETAMINE SALT COMBO 7.5MG TABLET   2 Generic $0.00$0.00Q:60
/30Days
AMPHETAMINE SALTS 5 MG TABLET   2 Generic $0.00$0.00Q:60
/30Days
amphotericin b 50mg/10mL 10 mL in 1 VIAL   4 Non-Preferred Drug $50.00$150.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPICILLIN 1 GM VIAL   2 Generic $0.00$0.00None
AMPICILLIN 10 GM VIAL   2 Generic $0.00$0.00None
AMPICILLIN CAPSULES 500MG 100 BOTTLE   4 Non-Preferred Drug $50.00$150.00None
AMPICILLIN-SULBACTAM 3 GM VIAL [Unasyn]   2 Generic $0.00$0.00None
AMPYRA ER 10 MG TABLET   5 Specialty Tier 33%N/AP
ANADROL-50 TABLET   5 Specialty Tier 33%N/AP
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE   2 Generic $0.00$0.00None
Anagrelide Hydrochloride 1mg/1 100 CAPSULE BOTTLE   2 Generic $0.00$0.00None
ANASTROZOLE 1 MG TABLET   1 Preferred Generic $0.00$0.00None
ANDRODERM 2 MG/24HR PATCH   3 Preferred Brand $0.00$0.00P Q:30
/30Days
ANDRODERM 4 MG/24HR PATCH   3 Preferred Brand $0.00$0.00P Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANDROGEL 1.62% (1.25G) GEL PACKET   4 Non-Preferred Drug $50.00$150.00P Q:38
/30Days
ANDROGEL 1.62% (2.5G) GEL PACKET   4 Non-Preferred Drug $50.00$150.00P Q:150
/30Days
ANDROGEL 1% (50MG) GEL PACKET   4 Non-Preferred Drug $50.00$150.00P Q:300
/30Days
Androgel 10mg/g 30 PACKET in 1 CARTON / 2.5 g in 1 PACKET   4 Non-Preferred Drug $50.00$150.00P Q:225
/30Days
Androgel 16.2mg/g 1 BOTTLE, PUMP per CARTON / 88 g in 1 BOTTLE, PUMP   4 Non-Preferred Drug $50.00$150.00P Q:150
/30Days
ANORO ELLIPTA 62.5-25 MCG INH   3 Preferred Brand $0.00$0.00Q:60
/30Days
ANTABUSE 250MG TABLET   4 Non-Preferred Drug $50.00$150.00None
ANTABUSE 500MG TABLET   4 Non-Preferred Drug $50.00$150.00None
APOKYN 30 MG/3 ML CARTRIDGE   5 Specialty Tier 33%N/AP Q:60
/30Days
APREPITANT 125 MG CAPSULE [Emend]   2 Generic $0.00$0.00P
APREPITANT 125-80-80 MG PACK [Emend]   2 Generic $0.00$0.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
APREPITANT 40 MG CAPSULE [Emend]   2 Generic $0.00$0.00P
APREPITANT 80 MG CAPSULE [Emend]   2 Generic $0.00$0.00P
APRI 0.15-0.03 TABLET   2 Generic $0.00$0.00None
APRISO CP24   4 Non-Preferred Drug $50.00$150.00Q:120
/30Days
APTIOM 200 MG TABLET   5 Specialty Tier 33%N/ANone
APTIOM 400 MG TABLET   5 Specialty Tier 33%N/ANone
APTIOM 600 MG TABLET   5 Specialty Tier 33%N/ANone
APTIOM 800 MG TABLET   5 Specialty Tier 33%N/ANone
APTIVUS 250MG CAPSULE   5 Specialty Tier 33%N/AQ:120
/30Days
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT   5 Specialty Tier 33%N/AQ:380
/30Days
ARANELLE 7-9-5 TABLET   2 Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP 10 MCG/0.4 ML SYRINGE   4 Non-Preferred Drug $50.00$150.00P
ARANESP 100ug/0.5mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.5 mL in 1 SYRINGE   5 Specialty Tier 33%N/AP
ARANESP 100ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE   5 Specialty Tier 33%N/AP
ARANESP 200MCG/0.4ML SYRINGE   5 Specialty Tier 33%N/AP
ARANESP 200MCG/ML VIAL   5 Specialty Tier 33%N/AP
ARANESP 25ug/0.42mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.42 mL in 1 SYRING   4 Non-Preferred Drug $50.00$150.00P
ARANESP 25ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE   4 Non-Preferred Drug $50.00$150.00P
ARANESP 300MCG/ML VIAL   5 Specialty Tier 33%N/AP
ARANESP 500MCG/1ML SYRINGE   5 Specialty Tier 33%N/AP
ARANESP 60MCG/ML VIAL   5 Specialty Tier 33%N/AP
ARANESP 60ug/0.3mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.3 mL in 1 SYRINGE   4 Non-Preferred Drug $50.00$150.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR   5 Specialty Tier 33%N/AP
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR   5 Specialty Tier 33%N/AP
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR   4 Non-Preferred Drug $50.00$150.00P
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD   4 Non-Preferred Drug $50.00$150.00P
ARCALYST INJECTION 220MG/VIAL   5 Specialty Tier 33%N/AP
ARICEPT 10MG TABLET   4 Non-Preferred Drug $50.00$150.00None
ARICEPT 5MG TABLET   4 Non-Preferred Drug $50.00$150.00None
ARIMIDEX 1 MG TABLET   4 Non-Preferred Drug $50.00$150.00None
ARIPIPRAZOLE 1 MG/ML SOLUTION [Abilify]   2 Generic $0.00$0.00P Q:750
/30Days
ARIPIPRAZOLE 10 MG TABLET [Abilify]   2 Generic $0.00$0.00P Q:30
/30Days
ARIPIPRAZOLE 15 MG TABLET [Abilify]   2 Generic $0.00$0.00P Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARIPIPRAZOLE 2 MG TABLET [Abilify]   2 Generic $0.00$0.00P Q:45
/30Days
ARIPIPRAZOLE 20 MG TABLET [Abilify]   2 Generic $0.00$0.00P Q:30
/30Days
ARIPIPRAZOLE 30 MG TABLET [Abilify]   2 Generic $0.00$0.00P Q:30
/30Days
ARIPIPRAZOLE 5 MG TABLET [Abilify]   2 Generic $0.00$0.00P Q:45
/30Days
ARIPIPRAZOLE ODT 10 MG TABLET RAPDIS [Abilify Discmelt]   5 Specialty Tier 33%N/AP Q:60
/30Days
ARIPIPRAZOLE ODT 15 MG TABLET RAPDIS [Abilify Discmelt]   5 Specialty Tier 33%N/AP Q:60
/30Days
ARISTADA ER 1064 MG/3.9 ML SYRINGE   5 Specialty Tier 33%N/AQ:4
/56Days
ARISTADA ER 441 MG/1.6 ML SYRINGE   5 Specialty Tier 33%N/AQ:2
/28Days
ARISTADA ER 662 MG/2.4 ML SYRINGE   5 Specialty Tier 33%N/AQ:2
/28Days
ARISTADA ER 882 MG/3.2 ML SYRINGE   5 Specialty Tier 33%N/AQ:3
/28Days
ARISTADA INITIO ER 675 MG/2.4 SUSER SYRINGE   5 Specialty Tier 33%N/AQ:2
/42Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARMODAFINIL 150 MG TABLET [Nuvigil]   2 Generic $0.00$0.00P Q:30
/30Days
ARMODAFINIL 200 MG TABLET [Nuvigil]   2 Generic $0.00$0.00P Q:30
/30Days
ARMODAFINIL 250 MG TABLET [Nuvigil]   2 Generic $0.00$0.00P Q:30
/30Days
ARMODAFINIL 50 MG TABLET [Nuvigil]   2 Generic $0.00$0.00P Q:30
/30Days
ARNUITY ELLIPTA 100 MCG INH   3 Preferred Brand $0.00$0.00Q:30
/30Days
ARNUITY ELLIPTA 200 MCG INH   3 Preferred Brand $0.00$0.00Q:30
/30Days
ARNUITY ELLIPTA 50 MCG INH BLST W/DEV   3 Preferred Brand $0.00$0.00Q:30
/30Days
AROMASIN 25MG TABLET   5 Specialty Tier 33%N/ANone
ARTHROTEC 50 50MG TABLET -200MCG (60 CT)   4 Non-Preferred Drug $50.00$150.00Q:120
/30Days
ARTHROTEC 75 TABLET EC   4 Non-Preferred Drug $50.00$150.00Q:90
/30Days
ASACOL HD DR 800 MG TABLET   5 Specialty Tier 33%N/AQ:180
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ASHLYNA 0.15-0.03-0.01 MG TABLET   2 Generic $0.00$0.00None
ASMANEX HFA 100 MCG INHALER   3 Preferred Brand $0.00$0.00Q:13
/30Days
ASMANEX HFA 200 MCG INHALER   3 Preferred Brand $0.00$0.00Q:13
/30Days
ASMANEX HFA 50 MCG INHALER HFA AER AD   3 Preferred Brand $0.00$0.00Q:13
/30Days
ASMANEX TWISTHALER 110 MCG #30   3 Preferred Brand $0.00$0.00Q:1
/30Days
ASMANEX TWISTHALER 220 MCG #30   3 Preferred Brand $0.00$0.00Q:1
/30Days
ASMANEX TWISTHALER 220MCG #120   3 Preferred Brand $0.00$0.00Q:1
/30Days
ASMANEX TWISTHALER 220MCG #60   3 Preferred Brand $0.00$0.00Q:1
/30Days
Aspirin-Diphenhydramine ER 25-200 MG   2 Generic $0.00$0.00None
ASTAGRAF XL 0.5 MG CAPSULE   4 Non-Preferred Drug $50.00$150.00P
ASTAGRAF XL 1 MG CAPSULE   4 Non-Preferred Drug $50.00$150.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ASTAGRAF XL 5 MG CAPSULE   4 Non-Preferred Drug $50.00$150.00P
ATACAND 16 MG TABLET   4 Non-Preferred Drug $50.00$150.00Q:60
/30Days
ATACAND 32 MG TABLET   4 Non-Preferred Drug $50.00$150.00Q:30
/30Days
ATACAND 4 MG TABLET   4 Non-Preferred Drug $50.00$150.00Q:60
/30Days
ATACAND 8 MG TABLET   4 Non-Preferred Drug $50.00$150.00Q:60
/30Days
ATACAND HCT 16-12.5 MG TABLET   4 Non-Preferred Drug $50.00$150.00Q:30
/30Days
ATACAND HCT 32-12.5 MG TABLET   4 Non-Preferred Drug $50.00$150.00Q:30
/30Days
ATACAND HCT 32-25 MG TABLET   4 Non-Preferred Drug $50.00$150.00Q:30
/30Days
ATAZANAVIR SULFATE 150 MG CAPSULE [Reyataz]   2 Generic $0.00$0.00Q:30
/30Days
ATAZANAVIR SULFATE 200 MG CAPSULE [Reyataz]   2 Generic $0.00$0.00Q:60
/30Days
ATAZANAVIR SULFATE 300 MG CAPSULE [Reyataz]   2 Generic $0.00$0.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Atelvia 35mg/1 36 DOSE PACK CASE / 4 TABLET, DELAYED RELEASE in 1 DOSE PACK   4 Non-Preferred Drug $50.00$150.00Q:4
/28Days
ATENOLOL 100 MG TABLET [Tenormin]   1 Preferred Generic $0.00$0.00None
ATENOLOL 25 MG TABLET   1 Preferred Generic $0.00$0.00None
ATENOLOL 50 MG TABLET [Tenormin]   1 Preferred Generic $0.00$0.00None
ATENOLOL-CHLORTHALIDONE 100-25   2 Generic $0.00$0.00None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   2 Generic $0.00$0.00None
ATOMOXETINE HCL 10 MG CAPSULE [Strattera]   2 Generic $0.00$0.00Q:60
/30Days
ATOMOXETINE HCL 100 MG CAPSULE [Strattera]   2 Generic $0.00$0.00Q:30
/30Days
ATOMOXETINE HCL 18 MG CAPSULE [Strattera]   2 Generic $0.00$0.00Q:60
/30Days
ATOMOXETINE HCL 25 MG CAPSULE [Strattera]   2 Generic $0.00$0.00Q:60
/30Days
ATOMOXETINE HCL 40 MG CAPSULE [Strattera]   2 Generic $0.00$0.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATOMOXETINE HCL 60 MG CAPSULE [Strattera]   2 Generic $0.00$0.00Q:30
/30Days
ATOMOXETINE HCL 80 MG CAPSULE [Strattera]   2 Generic $0.00$0.00Q:30
/30Days
ATORVASTATIN 10 MG TABLET [Lipitor]   1 Preferred Generic $0.00$0.00Q:45
/30Days
ATORVASTATIN 20 MG TABLET [Lipitor]   1 Preferred Generic $0.00$0.00Q:45
/30Days
ATORVASTATIN 40 MG TABLET [Lipitor]   1 Preferred Generic $0.00$0.00Q:45
/30Days
ATORVASTATIN 80 MG TABLET [Lipitor]   1 Preferred Generic $0.00$0.00Q:30
/30Days
ATOVAQUONE 750 MG/5 ML SUSP [Mepron]   5 Specialty Tier 33%N/ANone
Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone]   2 Generic $0.00$0.00None
ATOVAQUONE-PROGUANIL 62.5-25 [Malarone]   2 Generic $0.00$0.00None
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC   5 Specialty Tier 33%N/AQ:30
/30Days
ATROVENT HFA AER 17MCG   4 Non-Preferred Drug $50.00$150.00Q:26
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AUBRA EQ-28 TABLET [Vienva]   2 Generic $0.00$0.00None
AURYXIA 210 MG TABLET   5 Specialty Tier 33%N/AP Q:360
/30Days
AVALIDE 150-12.5 MG TABLET   4 Non-Preferred Drug $50.00$150.00Q:30
/30Days
AVALIDE 300-12.5 MG TABLET   4 Non-Preferred Drug $50.00$150.00Q:30
/30Days
AVAPRO 150 MG TABLET   4 Non-Preferred Drug $50.00$150.00Q:30
/30Days
AVAPRO 300 MG TABLET   4 Non-Preferred Drug $50.00$150.00Q:30
/30Days
AVAPRO 75 MG TABLET   4 Non-Preferred Drug $50.00$150.00Q:30
/30Days
AVIANE 0.1-0.02 TABLET   2 Generic $0.00$0.00None
AVITA 0.025% CREAM (g) [Tretin-X]   2 Generic $0.00$0.00P
Avita 0.25mg/g 45 g in 1 TUBE   2 Generic $0.00$0.00P
AVODART 0.5 MG SOFTGEL   4 Non-Preferred Drug $50.00$150.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVONEX PEN 30 MCG/0.5 ML KIT   5 Specialty Tier 33%N/AP Q:1
/28Days
AVONEX PREFILLED SYR 30 MCG KT   5 Specialty Tier 33%N/AP Q:1
/28Days
Aygestin 5mg/1 50 TABLET BOTTLE   4 Non-Preferred Drug $50.00$150.00None
AYVAKIT 100 MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
AYVAKIT 200 MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
AYVAKIT 300 MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
AZASAN 100 MG TABLET   4 Non-Preferred Drug $50.00$150.00P
AZASAN 75 MG TABLET   4 Non-Preferred Drug $50.00$150.00P
AZATHIOPRINE 50 MG TABLET [Imuran]   2 Generic $0.00$0.00P
AZELAIC ACID 15% GEL [Finacea]   2 Generic $0.00$0.00None
AZELASTINE 0.15% NASAL SPRAY   2 Generic $0.00$0.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZELASTINE 137 MCG NASAL SPRAY   2 Generic $0.00$0.00Q:60
/30Days
AZELASTINE HCL 0.05% EYE DROPS [Optivar]   2 Generic $0.00$0.00None
AZELEX 20% CREAM (G)   4 Non-Preferred Drug $50.00$150.00None
AZILECT 0.5MG TABLET   4 Non-Preferred Drug $50.00$150.00None
AZILECT 1MG TABLET   4 Non-Preferred Drug $50.00$150.00None
AZITHROMYCIN 1 GM POWDER PACKET   4 Non-Preferred Drug $50.00$150.00None
AZITHROMYCIN 100 MG/5 ML ORAL SUSPENSION [Zithromax]   2 Generic $0.00$0.00None
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [Zithromax]   2 Generic $0.00$0.00None
AZITHROMYCIN 250 MG TABLET   2 Generic $0.00$0.00None
AZITHROMYCIN 250 MG TABLET [Zithromax Z-Pak]   2 Generic $0.00$0.00None
AZITHROMYCIN 500 MG TABLET   2 Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZITHROMYCIN 500 MG TABLET [Zithromax Tri-Pak]   2 Generic $0.00$0.00None
AZITHROMYCIN 600 MG TABLET [Zithromax Z-Pak]   2 Generic $0.00$0.00None
AZITHROMYCIN I.V. 500 MG VIAL [Zithromax]   2 Generic $0.00$0.00None
AZOPT 1% EYE DROPS   4 Non-Preferred Drug $50.00$150.00None
AZOR 10-20 MG TABLET   4 Non-Preferred Drug $50.00$150.00Q:30
/30Days
AZOR 10MG-40MG TABLET (30 CT)   4 Non-Preferred Drug $50.00$150.00Q:30
/30Days
AZOR 5-40 MG TABLET   4 Non-Preferred Drug $50.00$150.00Q:30
/30Days
AZOR 5MG-20MG TABLET (30 CT)   4 Non-Preferred Drug $50.00$150.00Q:30
/30Days
Aztreonam 1000 MG Injection [Azactam]   4 Non-Preferred Drug $50.00$150.00None
Aztreonam 2000 MG Injection [Azactam]   4 Non-Preferred Drug $50.00$150.00None
AZTREONAM FOR INJECTION   2 Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZULFIDINE 500 MG TABLET   4 Non-Preferred Drug $50.00$150.00None
AZULFIDINE ENTAB 500 MG   4 Non-Preferred Drug $50.00$150.00None

Chart Legend:

Below are a few notes to help you understand the above 2021 Medicare Part D BlueMedicare Premier (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 $445 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 $4130) 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.

      * When the text "$35 or less" appears, this Part D plan may offer this particular insulin as part of the Senior Savings Model.  The Senior Savings Model stipulates that the insulin will cost no more than $35 in the deductible, initial coverage, and coverage gap phases of your Part D plan. Please contact the drug plan for more details.

    • 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 October 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.