Q1Medicare.com
Powered by Q1Group LLC
Education and Decision Support Tools for the Medicare Community
  • ☰ MENU
  • Home
  • Contact
  • MAPD
  • PDP
  • 2018
  • 2017
  • FAQs
  • Latest Medicare News

2018 Medicare Part D or Medicare Advantage Plan Formulary Browser

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

First Health Part D Value Plus (PDP) (S5768-128-0)
Tier 1 (257)
Tier 2 (506)
Tier 3 (1013)
Tier 4 (2826)
Tier 5 (655)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
Yes No Show either
  *required
 
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 
2018 Medicare Part D Plan Formulary Information
First Health Part D Value Plus (PDP) (S5768-128-0)
Benefits & Contact Info           
The First Health Part D Value Plus (PDP) (S5768-128-0)
Formulary Drugs Starting with the Letter A

in CMS PDP Region 5 which includes: DC DE MD
Plan Monthly Premium: $56.30 Deductible: $0 Qualifies for LIS: No
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 300 MG TABLET   3 Preferred Brand $47.00$141.00None
Abacavir Sulfate-Lamivudine-Zidovudine tablets [Trizivir]   5 Specialty Tier 33%N/ANone
ABACAVIR-LAMIVUDINE 600-300 MG   5 Specialty Tier 33%N/ANone
ABELCET INJECTION SUSPENSION 5MG/ML   5 Specialty Tier 33%N/AP
ABILIFY MAINTENA ER 300 MG SYR   5 Specialty Tier 33%N/AQ:1
/28Days
ABILIFY MAINTENA ER 300 MG VL   5 Specialty Tier 33%N/AQ:1
/28Days
ABILIFY MAINTENA ER 400 MG SYR   5 Specialty Tier 33%N/AQ:1
/28Days
ABRAXANE 100MG VIAL   5 Specialty Tier 33%N/AP
Acamprosate Calcium DR 333 MG tablets [Campral]   4 Non-Preferred Drug 50%50%None
ACARBOSE 100 MG TABLET   2 Generic $2.00$6.00Q:90
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACARBOSE 25 MG TABLET   2 Generic $2.00$6.00Q:90
/30Days
ACARBOSE 50 MG TABLET   2 Generic $2.00$6.00Q:90
/30Days
ACCOLATE 10 MG TABLET   4 Non-Preferred Drug 50%50%Q:60
/30Days
ACCOLATE 20 MG TABLET   4 Non-Preferred Drug 50%50%Q:60
/30Days
ACCUPRIL 10MG TABLET   4 Non-Preferred Drug 50%50%None
ACCUPRIL 20MG TABLET   4 Non-Preferred Drug 50%50%None
ACCUPRIL 40MG TABLET   4 Non-Preferred Drug 50%50%None
ACCUPRIL 5MG TABLET   4 Non-Preferred Drug 50%50%None
ACCURETIC 10-12.5MG TABLET   4 Non-Preferred Drug 50%50%None
ACCURETIC 20-12.5MG TABLET   4 Non-Preferred Drug 50%50%None
ACCURETIC 20-25MG TABLET   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACEBUTOLOL 200 MG CAPSULE   2 Generic $2.00$6.00None
ACEBUTOLOL 400 MG CAPSULE   2 Generic $2.00$6.00None
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE   3 Preferred Brand $47.00$141.00None
ACETAMINOP-CODEINE 120-12 MG/5   2 Generic $2.00$6.00Q:4500
/30Days
Acetaminophen 325 MG / Hydrocodone Bitartrate 5 MG Oral Tablet [Lorcet]   4 Non-Preferred Drug 50%50%Q:180
/30Days
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT)   2 Generic $2.00$6.00Q:180
/30Days
ACETAMINOPHEN-COD #3 TABLET   2 Generic $2.00$6.00Q:180
/30Days
ACETAMINOPHEN-COD #4 TABLET   2 Generic $2.00$6.00Q:180
/30Days
ACETASOL HC SOLUTION 10ML 10 ML BOT   4 Non-Preferred Drug 50%50%None
ACETAZOLAMIDE 125MG TABLET   3 Preferred Brand $47.00$141.00None
ACETAZOLAMIDE 250MG TABLET (100 CT)   3 Preferred Brand $47.00$141.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETAZOLAMIDE ER 500 MG CAP   4 Non-Preferred Drug 50%50%None
ACETIC ACID 2% EAR SOLUTION   3 Preferred Brand $47.00$141.00None
ACETYLCYSTEINE 10% VIAL   3 Preferred Brand $47.00$141.00P
Acetylcysteine 200 MG/ML Inhalant Solution   3 Preferred Brand $47.00$141.00P
ACIPHEX 20MG TABLET EC   4 Non-Preferred Drug 50%50%S
ACITRETIN 10 MG CAPSULE [Soriatane]   3 Preferred Brand $47.00$141.00P
ACITRETIN 17.5 MG CAPSULE [Soriatane]   3 Preferred Brand $47.00$141.00P
ACITRETIN 25 MG CAPSULE [Soriatane]   3 Preferred Brand $47.00$141.00P
ACTHIB VACCINE WITH DILUENT   3 Preferred Brand $47.00$141.00None
ACTIGALL 300MG CAPSULE   4 Non-Preferred Drug 50%50%None
ACTIMMUNE 100 MCG/0.5 ML VIAL   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACTIVELLA 0.5-0.1 MG TABLET   4 Non-Preferred Drug 50%50%P
ACTIVELLA 1 MG-0.5 MG TABLET   4 Non-Preferred Drug 50%50%P
Actonel 150mg 36 DOSE PACK CASE / 1 TRAY DOSE PACK / 1 FILM COATED TABLETS in TRAY   4 Non-Preferred Drug 50%50%S Q:1
/28Days
Actonel 30mg 12 BOTTLE CASE / 30 FILM COATED TABLETS in BOTTLE   4 Non-Preferred Drug 50%50%S Q:30
/30Days
Actonel 35mg 36 DOSE PACK CASE / 1 TRAY DOSE PACK / 4 FILM COATED TABLETS in TRAY   4 Non-Preferred Drug 50%50%S Q:12
/84Days
Actonel 5mg 12 BOTTLE CASE / 30 FILM COATED TABLETS in BOTTLE   4 Non-Preferred Drug 50%50%S Q:30
/30Days
ACTOPLUS MET 15MG/500MG TABLET   4 Non-Preferred Drug 50%50%Q:90
/30Days
ACTOPLUS MET 15MG/850MG TABLET   4 Non-Preferred Drug 50%50%Q:90
/30Days
ACTOS 15 MG TABLET   4 Non-Preferred Drug 50%50%Q:30
/30Days
ACTOS 30 MG TABLET   4 Non-Preferred Drug 50%50%Q:30
/30Days
ACTOS 45 MG TABLET   4 Non-Preferred Drug 50%50%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACULAR 0.5% EYE DROPS   4 Non-Preferred Drug 50%50%S
ACULAR LS 0.4% OPHTH SOL   4 Non-Preferred Drug 50%50%S
ACUVAIL 0.45% OPHTH SOLUTION #30X0.4 EA   4 Non-Preferred Drug 50%50%None
ACYCLOVIR 200 MG CAPSULE   2 Generic $2.00$6.00None
ACYCLOVIR 200 MG/5 ML SUSP   3 Preferred Brand $47.00$141.00None
ACYCLOVIR 400 MG TABLET   2 Generic $2.00$6.00None
Acyclovir 5% Ointment   4 Non-Preferred Drug 50%50%None
ACYCLOVIR 800 MG TABLET   2 Generic $2.00$6.00None
Acyclovir sodium 500 mg vial   4 Non-Preferred Drug 50%50%P
ACZONE 50mg/g 1 TUBE per CARTON / 60 g in 1 TUBE   4 Non-Preferred Drug 50%50%None
ADACEL VIAL 2UNT/5UNT   3 Preferred Brand $47.00$141.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADAGEN 250U/ML VIAL   5 Specialty Tier 33%N/AP
ADALAT CC 30 MG TABLET   4 Non-Preferred Drug 50%50%None
Adalat CC 60mg 1000 FILM COATED TABLETS in BOTTLE   4 Non-Preferred Drug 50%50%None
ADALAT CC 90 MG TABLET   4 Non-Preferred Drug 50%50%None
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA]   5 Specialty Tier 33%N/AP Q:2
/28Days
ADAPALENE 0.1% CREAM   4 Non-Preferred Drug 50%50%P
ADAPALENE 0.1% GEL   4 Non-Preferred Drug 50%50%P
Adapalene 0.3% gel   4 Non-Preferred Drug 50%50%P
ADCIRCA TABLETS 20MG 60 BOTTLE   5 Specialty Tier 33%N/AP
ADDERALL 20 MG TABLET   4 Non-Preferred Drug 50%50%P Q:90
/30Days
ADDERALL 5 MG TABLET   4 Non-Preferred Drug 50%50%P Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADDERALL 7.5 MG TABLET   4 Non-Preferred Drug 50%50%P Q:60
/30Days
ADDERALL XR 10MG CAPSULE SA   4 Non-Preferred Drug 50%50%P Q:30
/30Days
ADDERALL XR 15MG CAPSULE SA   4 Non-Preferred Drug 50%50%P Q:30
/30Days
ADDERALL XR 20MG CAPSULE SA   4 Non-Preferred Drug 50%50%P Q:30
/30Days
ADDERALL XR 25MG CAPSULE SA   4 Non-Preferred Drug 50%50%P Q:30
/30Days
ADDERALL XR 30MG CAPSULE SA   4 Non-Preferred Drug 50%50%P Q:30
/30Days
ADDERALL XR 5MG CAPSULE SA   4 Non-Preferred Drug 50%50%P Q:30
/30Days
ADEFOVIR DIPIVOXIL 10 MG TAB [Hepsera]   4 Non-Preferred Drug 50%50%Q:30
/30Days
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
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
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
Adrenalin 1 mg/ml vial   4 Non-Preferred Drug 50%50%Q:2
/30Days
ADRUCIL 50mg/mL 10 VIAL in 1 TRAY / 10 mL in 1 VIAL   3 Preferred Brand $47.00$141.00P
ADVAIR DISKUS MIS 100/50   3 Preferred Brand $47.00$141.00Q:60
/30Days
ADVAIR DISKUS MIS 250/50   3 Preferred Brand $47.00$141.00Q:60
/30Days
ADVAIR DISKUS MIS 500/50   3 Preferred Brand $47.00$141.00Q:60
/30Days
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER   3 Preferred Brand $47.00$141.00Q:12
/30Days
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL   3 Preferred Brand $47.00$141.00Q:12
/30Days
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL   3 Preferred Brand $47.00$141.00Q:12
/30Days
AEROSPAN 80 MCG INHALER   4 Non-Preferred Drug 50%50%Q:18
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AFEDITAB CR 30MG TABLET SA   4 Non-Preferred Drug 50%50%None
AFEDITAB CR 60MG TABLET SA   4 Non-Preferred Drug 50%50%None
Afinitor 7.5mg/1 28 BLISTER PACK per CARTON / 1 TABLET per BLISTER PACK   5 Specialty Tier 33%N/AP
AFINITOR DISPERZ 2 MG TABLET   5 Specialty Tier 33%N/AP
AFINITOR DISPERZ 3 MG TABLET   5 Specialty Tier 33%N/AP
AFINITOR DISPERZ 5 MG TABLET   5 Specialty Tier 33%N/AP
AFINITOR TABLETS 10 MG   5 Specialty Tier 33%N/AP
AFINITOR TABLETS 2.5 MG   5 Specialty Tier 33%N/AP
AFINITOR TABLETS 5 MG   5 Specialty Tier 33%N/AP
AGGRENOX 25-200MG CAPSULE   4 Non-Preferred Drug 50%50%S Q:60
/30Days
Ala-cort 2.5% cream   1 Preferred Generic $1.00$3.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALA-SCALP HP 2% LOTION   4 Non-Preferred Drug 50%50%None
ALBENZA 200 MG TABLET   5 Specialty Tier 33%N/ANone
ALBUTEROL SUL 2.5 MG/3 ML SOLN   2 Generic $2.00$6.00P
ALBUTEROL SULFATE 0.75mg/3mL 30 POUCH per CARTON / 1 VIAL, SINGLE-DOSE in 1 POUCH / 3 mL in 1 VIAL   2 Generic $2.00$6.00P
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER   2 Generic $2.00$6.00P
ALBUTEROL SULFATE 2 MG TAB   3 Preferred Brand $47.00$141.00None
ALBUTEROL SULFATE 4 MG TAB   3 Preferred Brand $47.00$141.00None
ALBUTEROL SULFATE 4MG TABLET SR 12HR   4 Non-Preferred Drug 50%50%None
ALBUTEROL SULFATE 8MG TABLET SR 12HR   4 Non-Preferred Drug 50%50%None
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   2 Generic $2.00$6.00P
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT   2 Generic $2.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALCLOMETASONE DIPR 0.05% OINT   4 Non-Preferred Drug 50%50%None
ALCLOMETASONE DIPRO 0.05% CRM   4 Non-Preferred Drug 50%50%None
ALDACTONE 100MG TABLET   4 Non-Preferred Drug 50%50%None
ALDACTONE 25MG TABLET   4 Non-Preferred Drug 50%50%None
ALDACTONE 50MG TABLET   4 Non-Preferred Drug 50%50%None
ALDARA 5% CREAM   4 Non-Preferred Drug 50%50%None
ALDURAZYME 2.9MG/5ML VIAL   5 Specialty Tier 33%N/AP
ALECENSA 150 MG CAPSULE   5 Specialty Tier 33%N/AP
ALENDRONATE SODIUM 10 MG TAB   1 Preferred Generic $1.00$3.00Q:30
/30Days
ALENDRONATE SODIUM 35 MG TABLET   1 Preferred Generic $1.00$3.00Q:4
/28Days
ALENDRONATE SODIUM 40 MG TABLET   1 Preferred Generic $1.00$3.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALENDRONATE SODIUM 70 MG TAB   1 Preferred Generic $1.00$3.00Q:4
/28Days
ALENDRONATE SODIUM 70 mg/75 ml   1 Preferred Generic $1.00$3.00None
Alendronic acid 5 MG Oral Tablet   1 Preferred Generic $1.00$3.00Q:30
/30Days
ALFUZOSIN HCL ER 10 MG TABLET   4 Non-Preferred Drug 50%50%Q:30
/30Days
ALIMTA 500MG VIAL   5 Specialty Tier 33%N/AP
ALINIA 100 MG/5 ML SUSPENSION   4 Non-Preferred Drug 50%50%None
ALINIA 500 MG TABLET   4 Non-Preferred Drug 50%50%None
Aliskiren 150 MG / Hydrochlorothiazide 12.5 MG Oral Tablet [Tekturna HCT]   4 Non-Preferred Drug 50%50%Q:30
/30Days
Aliskiren 150 MG / Hydrochlorothiazide 25 MG Oral Tablet [Tekturna HCT]   4 Non-Preferred Drug 50%50%Q:30
/30Days
Aliskiren 300 MG / Hydrochlorothiazide 12.5 MG Oral Tablet [Tekturna HCT]   4 Non-Preferred Drug 50%50%Q:30
/30Days
ALKERAN 50 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
ALLOPURINOL 100 MG TABLET   1 Preferred Generic $1.00$3.00None
ALLOPURINOL 300 MG TABLET   1 Preferred Generic $1.00$3.00None
Almotriptan 12.5 MG Oral Tablet [Axert]   4 Non-Preferred Drug 50%50%Q:8
/30Days
ALMOTRIPTAN MALATE 6.25 MG TAB [Axert]   4 Non-Preferred Drug 50%50%Q:8
/30Days
ALOCRIL 2% EYE DROPS   4 Non-Preferred Drug 50%50%None
ALOMIDE 0.1% EYE DROPS   4 Non-Preferred Drug 50%50%None
ALORA 0.025 MG PATCH   4 Non-Preferred Drug 50%50%P Q:8
/28Days
ALORA 0.05 MG PATCH   4 Non-Preferred Drug 50%50%P Q:8
/28Days
ALORA 0.075 MG PATCH   4 Non-Preferred Drug 50%50%P Q:8
/28Days
ALORA 0.1 MG PATCH   4 Non-Preferred Drug 50%50%P Q:8
/28Days
ALOSETRON HCL 0.5 MG TABLET [Lotronex]   5 Specialty Tier 33%N/AQ:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALOSETRON HCL 1 MG TABLET [Lotronex]   5 Specialty Tier 33%N/AQ:60
/30Days
ALPHAGAN P 0.1% DROPS   3 Preferred Brand $47.00$141.00None
ALPHAGAN P 0.15% EYE DROPS   4 Non-Preferred Drug 50%50%None
ALPRAZOLAM 0.25 MG TABLET   2 Generic $2.00$6.00Q:120
/30Days
ALPRAZOLAM 0.5 MG TABLET   2 Generic $2.00$6.00Q:120
/30Days
ALPRAZOLAM 1 MG TABLET   2 Generic $2.00$6.00Q:150
/30Days
Alprazolam 1mg/mL 1 BOTTLE in 1 CONTAINER / 30 mL in 1 BOTTLE   4 Non-Preferred Drug 50%50%Q:300
/30Days
ALPRAZOLAM 2 MG TABLET   2 Generic $2.00$6.00Q:150
/30Days
ALPRAZOLAM ER 0.5 MG TABLET   4 Non-Preferred Drug 50%50%Q:30
/30Days
ALPRAZOLAM ER 1 MG TABLET   4 Non-Preferred Drug 50%50%Q:30
/30Days
ALPRAZOLAM ER 2 MG TABLET   4 Non-Preferred Drug 50%50%Q:90
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALPRAZOLAM ER 3 MG TABLET   4 Non-Preferred Drug 50%50%Q:60
/30Days
ALPRAZOLAM ODT 0.25 MG TAB   4 Non-Preferred Drug 50%50%Q:120
/30Days
ALPRAZOLAM ODT 0.5 MG TAB   4 Non-Preferred Drug 50%50%None
ALPRAZOLAM ODT 1 MG TAB   4 Non-Preferred Drug 50%50%None
ALPRAZOLAM ODT 2 MG TAB   4 Non-Preferred Drug 50%50%Q:150
/30Days
ALREX 0.2% EYE DROPS   3 Preferred Brand $47.00$141.00None
ALTACE 1.25MG CAPSULE   4 Non-Preferred Drug 50%50%None
ALTACE 10MG CAPSULE (100 CT)   4 Non-Preferred Drug 50%50%None
ALTACE 2.5 MG CAPSULE   4 Non-Preferred Drug 50%50%None
ALTACE 5MG CAPSULE   4 Non-Preferred Drug 50%50%None
ALTOPREV 20 MG TABLET   4 Non-Preferred Drug 50%50%S Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALUNBRIG 30 MG TABLET   5 Specialty Tier 33%N/AP
ALYACEN 1-35-28 TABLET   3 Preferred Brand $47.00$141.00None
Amabelz 0.5 MG/0.1 MG 28 TABLET/BLISTER PACK 3 PER CARTON   3 Preferred Brand $47.00$141.00P
Amabelz 1 MG/0.5 MG 28 TABLET/BLISTER PACK 3 PER CARTON   3 Preferred Brand $47.00$141.00P
AMANTADINE 100 MG TABLET   3 Preferred Brand $47.00$141.00None
AMANTADINE 100MG CAPSULE   4 Non-Preferred Drug 50%50%None
AMANTADINE 50 MG/5 ML SOLUTION   4 Non-Preferred Drug 50%50%None
AMARYL 1MG TABLET   4 Non-Preferred Drug 50%50%None
AMARYL 2MG TABLET   4 Non-Preferred Drug 50%50%None
AMARYL 4MG TABLET   4 Non-Preferred Drug 50%50%None
AMBISOME 50MG VIAL   4 Non-Preferred Drug 50%50%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMERGE 1MG TABLET   4 Non-Preferred Drug 50%50%S Q:9
/30Days
AMERGE 2.5MG TABLET   4 Non-Preferred Drug 50%50%S Q:9
/30Days
Amethia 0.15-0.03-0.01 mg tab   3 Preferred Brand $47.00$141.00None
Amethia lo tablet   3 Preferred Brand $47.00$141.00None
AMIKACIN SULF 500 MG/2 ML VIAL   4 Non-Preferred Drug 50%50%None
AMILORIDE HCL 5 MG TABLET   3 Preferred Brand $47.00$141.00None
AMILORIDE HCL-HCTZ 5-50 MG TAB   2 Generic $2.00$6.00None
Amino Acids 15% Solution   4 Non-Preferred Drug 50%50%P
Amino acids 4.25% in dextrose 10% Injectable Solution [Clinimix 4.25/10]   4 Non-Preferred Drug 50%50%P
Amino acids 4.25% in dextrose 20% Injectable Solution [Clinimix 4.25/20]   4 Non-Preferred Drug 50%50%P
Amino acids 4.25% in dextrose 5% Injectable Solution [Clinimix 4.25/5]   4 Non-Preferred Drug 50%50%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Aminophylline 25 MG/ML 10 ML Injection   4 Non-Preferred Drug 50%50%None
AMINOSYN 7%-ELECTROLYTE SOL   4 Non-Preferred Drug 50%50%P
AMINOSYN HBC INJECTION SULFITE FREE 7%   4 Non-Preferred Drug 50%50%P
AMINOSYN II 10% SOL 6X2000 ML   4 Non-Preferred Drug 50%50%P
AMINOSYN II 7% IV SOLUTION   4 Non-Preferred Drug 50%50%P
AMINOSYN II 8.5% ELECTROLYT   4 Non-Preferred Drug 50%50%P
AMINOSYN II 8.5% ELECTROLYT   4 Non-Preferred Drug 50%50%P
AMINOSYN PF INJECTION   4 Non-Preferred Drug 50%50%P
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5%   4 Non-Preferred Drug 50%50%P
AMINOSYN-PF 7% IV SOLUTION   4 Non-Preferred Drug 50%50%P
AMINOSYN-RF 5.2% IV SOLUTION   4 Non-Preferred Drug 50%50%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Amiodarone hcl 100 mg tablet   2 Generic $2.00$6.00None
AMIODARONE HCL 200 MG TABLET   2 Generic $2.00$6.00None
AMIODARONE HCL 400 MG TABLET   2 Generic $2.00$6.00None
Amiodarone hydrochloride 50 MG/ML in 3 ML Injection   4 Non-Preferred Drug 50%50%None
AMITIZA 8MCG CAPSULE   3 Preferred Brand $47.00$141.00Q:60
/30Days
AMITIZA CAPSULES 24MCG 60 CAP BOT   3 Preferred Brand $47.00$141.00Q:60
/30Days
AMITRIP/CDP 25-10 TABLET   4 Non-Preferred Drug 50%50%P
AMITRIP/PERPHEN 10-4 TABLET   4 Non-Preferred Drug 50%50%P
AMITRIP/PERPHEN 50-4 TABLET   4 Non-Preferred Drug 50%50%P
AMITRIPTYLINE HCL 10 MG TAB   2 Generic $2.00$6.00P
AMITRIPTYLINE HCL 100 MG TAB   2 Generic $2.00$6.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITRIPTYLINE HCL 150 MG TAB   2 Generic $2.00$6.00P
AMITRIPTYLINE HCL 25 MG TAB   2 Generic $2.00$6.00P
AMITRIPTYLINE HCL 50 MG TAB   2 Generic $2.00$6.00P
AMITRIPTYLINE HCL 75 MG TAB   2 Generic $2.00$6.00P
AMLOD-VALSA-HCTZ 10-160-12.5MG   2 Generic $2.00$6.00Q:30
/30Days
AMLOD-VALSA-HCTZ 10-160-25 MG   2 Generic $2.00$6.00Q:30
/30Days
AMLOD-VALSA-HCTZ 10-320-25 MG   2 Generic $2.00$6.00Q:30
/30Days
AMLOD-VALSA-HCTZ 5-160-12.5 MG   2 Generic $2.00$6.00Q:30
/30Days
AMLOD-VALSA-HCTZ 5-160-25 MG   2 Generic $2.00$6.00Q:30
/30Days
AMLODIPINE BESYLATE 10 MG TAB   1 Preferred Generic $1.00$3.00None
AMLODIPINE BESYLATE 2.5 MG TAB   1 Preferred Generic $1.00$3.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE BESYLATE 5 MG TAB   1 Preferred Generic $1.00$3.00None
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE   2 Generic $2.00$6.00Q:30
/30Days
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE   2 Generic $2.00$6.00Q:30
/30Days
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE   2 Generic $2.00$6.00Q:30
/30Days
AMLODIPINE-ATORVAST 10-20 MG [Caduet]   3 Preferred Brand $47.00$141.00None
AMLODIPINE-ATORVAST 10-40 MG [Caduet]   3 Preferred Brand $47.00$141.00None
Amlodipine-Atorvastatin 10-10 mg [Caduet]   3 Preferred Brand $47.00$141.00None
Amlodipine-Atorvastatin 10-80 mg [Caduet]   3 Preferred Brand $47.00$141.00None
Amlodipine-Atorvastatin 2.5-10 mg [Caduet]   3 Preferred Brand $47.00$141.00None
Amlodipine-Atorvastatin 2.5-20 mg [Caduet]   3 Preferred Brand $47.00$141.00None
Amlodipine-Atorvastatin 2.5-40 mg [Caduet]   3 Preferred Brand $47.00$141.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Amlodipine-Atorvastatin 5-10 mg [Caduet]   3 Preferred Brand $47.00$141.00None
Amlodipine-Atorvastatin 5-20 mg [Caduet]   3 Preferred Brand $47.00$141.00None
Amlodipine-Atorvastatin 5-40 mg [Caduet]   3 Preferred Brand $47.00$141.00None
Amlodipine-Atorvastatin 5-80 mg [Caduet]   3 Preferred Brand $47.00$141.00None
AMLODIPINE-BENAZEPRIL 10-40 MG   2 Generic $2.00$6.00Q:30
/30Days
AMLODIPINE-BENAZEPRIL 2.5-10   2 Generic $2.00$6.00Q:30
/30Days
AMLODIPINE-BENAZEPRIL 5-40 MG   2 Generic $2.00$6.00Q:30
/30Days
AMLODIPINE-OLMESARTAN 10-20 MG [Azor]   4 Non-Preferred Drug 50%50%Q:30
/30Days
AMLODIPINE-OLMESARTAN 10-40 MG [Azor]   4 Non-Preferred Drug 50%50%Q:30
/30Days
AMLODIPINE-OLMESARTAN 5-20 MG [Azor]   4 Non-Preferred Drug 50%50%Q:30
/30Days
AMLODIPINE-OLMESARTAN 5-40 MG [Azor]   4 Non-Preferred Drug 50%50%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE-VALSARTAN 10-160 MG   2 Generic $2.00$6.00Q:30
/30Days
AMLODIPINE-VALSARTAN 10-320 MG   2 Generic $2.00$6.00Q:30
/30Days
AMLODIPINE-VALSARTAN 5-160 MG   2 Generic $2.00$6.00Q:30
/30Days
AMLODIPINE-VALSARTAN 5-320 MG   2 Generic $2.00$6.00Q:30
/30Days
AMMONIUM LACTATE 12% CREAM   3 Preferred Brand $47.00$141.00None
AMMONIUM LACTATE 12% LOTION   3 Preferred Brand $47.00$141.00None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE   2 Generic $2.00$6.00None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET   2 Generic $2.00$6.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE   2 Generic $2.00$6.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   2 Generic $2.00$6.00None
AMOX-CLAV 200-28.5 MG/5 ML SUS   2 Generic $2.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOX-CLAV 250-62.5 MG/5 ML SUS   2 Generic $2.00$6.00None
AMOX-CLAV 500-125 MG TABLET   2 Generic $2.00$6.00None
AMOX-CLAV 600-42.9 MG/5 ML SUS   2 Generic $2.00$6.00None
AMOX-CLAV 875-125 MG TABLET   2 Generic $2.00$6.00None
AMOXAPINE 100MG TABLET   3 Preferred Brand $47.00$141.00None
AMOXAPINE 150MG TABLET   3 Preferred Brand $47.00$141.00None
AMOXAPINE 25MG TABLET   3 Preferred Brand $47.00$141.00None
AMOXAPINE 50MG TABLET   3 Preferred Brand $47.00$141.00None
AMOXICILLIN 125 MG/5 ML SUSP   1 Preferred Generic $1.00$3.00None
AMOXICILLIN 125MG TABLET CHEW   1 Preferred Generic $1.00$3.00None
AMOXICILLIN 200 MG/5 ML SUSP   1 Preferred Generic $1.00$3.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN 250 MG CAPSULE   1 Preferred Generic $1.00$3.00None
AMOXICILLIN 250 MG TAB CHEW   1 Preferred Generic $1.00$3.00None
AMOXICILLIN 250 MG/5 ML SUSP   1 Preferred Generic $1.00$3.00None
AMOXICILLIN 400 MG/5 ML SUSP   1 Preferred Generic $1.00$3.00None
AMOXICILLIN 500 MG CAPSULE   1 Preferred Generic $1.00$3.00None
AMOXICILLIN 500 MG TABLET   1 Preferred Generic $1.00$3.00None
AMOXICILLIN 875 MG TABLET   1 Preferred Generic $1.00$3.00None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS EXTENDED RELEASE 1000;62.5MG;MG   4 Non-Preferred Drug 50%50%None
AMPHETAMINE SALT COMBO 12.5MG TABLET   3 Preferred Brand $47.00$141.00P Q:60
/30Days
AMPHETAMINE SALT COMBO 15MG TABLET   3 Preferred Brand $47.00$141.00P Q:60
/30Days
AMPHETAMINE SALT COMBO 7.5MG TABLET   3 Preferred Brand $47.00$141.00P Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
amphotericin b 50mg/10mL 10 mL in 1 VIAL   4 Non-Preferred Drug 50%50%P
Ampicillin 1000 MG / Sulbactam 500 MG Injection   4 Non-Preferred Drug 50%50%None
Ampicillin 1000 MG Injection   4 Non-Preferred Drug 50%50%None
Ampicillin 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS   4 Non-Preferred Drug 50%50%None
Ampicillin 2000 MG / Sulbactam 1000 MG Injection   4 Non-Preferred Drug 50%50%None
AMPICILLIN 250 MG CAPSULE   1 Preferred Generic $1.00$3.00None
AMPICILLIN 500 MG CAPSULE   1 Preferred Generic $1.00$3.00None
AMPICILLIN FOR INJECTION POWDER   4 Non-Preferred Drug 50%50%None
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT   2 Generic $2.00$6.00None
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT   2 Generic $2.00$6.00None
AMPICILLIN-SULBACTAM 15 GM VIAL   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPYRA ER 10 MG TABLET   5 Specialty Tier 33%N/AP
ANADROL-50 TABLET   5 Specialty Tier 33%N/AP
ANAFRANIL 25 MG 30 CAPSULE BOTTLE   4 Non-Preferred Drug 50%50%P
ANAFRANIL 50 MG 30 CAPSULE BOTTLE   4 Non-Preferred Drug 50%50%P
ANAFRANIL 75 MG 30 CAPSULE BOTTLE   4 Non-Preferred Drug 50%50%P
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE   3 Preferred Brand $47.00$141.00None
Anagrelide Hydrochloride 1mg/1 100 CAPSULE BOTTLE   3 Preferred Brand $47.00$141.00None
ANAPROX DS 550MG TABLET   4 Non-Preferred Drug 50%50%None
ANASTROZOLE 1 MG TABLET   2 Generic $2.00$6.00None
ANDRODERM 2 MG/24HR PATCH   4 Non-Preferred Drug 50%50%P Q:30
/30Days
ANDRODERM 4 MG/24HR PATCH   4 Non-Preferred Drug 50%50%P 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 PCKT   4 Non-Preferred Drug 50%50%P
ANDROGEL 1.62% (2.5G) GEL PCKT   4 Non-Preferred Drug 50%50%P
ANDROGEL 1% (50MG) GEL PACKET   4 Non-Preferred Drug 50%50%P Q:300
/30Days
Androgel 10mg/g 30 PACKET in 1 CARTON / 2.5 g in 1 PACKET   4 Non-Preferred Drug 50%50%P Q:300
/30Days
Androgel 16.2mg/g 1 BOTTLE, PUMP per CARTON / 88 g in 1 BOTTLE, PUMP   4 Non-Preferred Drug 50%50%P
Angeliq 0.25/0.5 28 Day Pack   4 Non-Preferred Drug 50%50%P
ANGELIQ 1-0.5MG TABLET   4 Non-Preferred Drug 50%50%P
ANORO ELLIPTA 62.5-25 MCG INH   3 Preferred Brand $47.00$141.00Q:60
/30Days
ANTABUSE 250MG TABLET   4 Non-Preferred Drug 50%50%None
ANTABUSE 500MG TABLET   4 Non-Preferred Drug 50%50%None
ANTARA 30 MG CAPSULE   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANTARA 90 MG CAPSULE   4 Non-Preferred Drug 50%50%None
ANUSOL-HC 2.5% CREAM   4 Non-Preferred Drug 50%50%None
APEXICON E 0.05% CREAM   4 Non-Preferred Drug 50%50%None
APOKYN 30 MG/3 ML CARTRIDGE   5 Specialty Tier 33%N/AP
Apraclonidine 5 MG/ML Ophthalmic Solution   3 Preferred Brand $47.00$141.00None
APREPITANT 125 MG CAPSULE [Emend]   4 Non-Preferred Drug 50%50%P
APREPITANT 125-80-80 MG PACK [Emend]   4 Non-Preferred Drug 50%50%P
APREPITANT 40 MG CAPSULE [Emend]   4 Non-Preferred Drug 50%50%P
APREPITANT 80 MG CAPSULE [Emend]   4 Non-Preferred Drug 50%50%P
APRI 0.15-0.03 TABLET   3 Preferred Brand $47.00$141.00None
APRISO CP24   3 Preferred Brand $47.00$141.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
APTENSIO XR 10 MG CAPSULE   4 Non-Preferred Drug 50%50%P Q:30
/30Days
APTENSIO XR 15 MG CAPSULE   4 Non-Preferred Drug 50%50%P Q:30
/30Days
APTENSIO XR 20 MG CAPSULE   4 Non-Preferred Drug 50%50%P Q:30
/30Days
APTENSIO XR 30 MG CAPSULE   4 Non-Preferred Drug 50%50%P Q:30
/30Days
APTENSIO XR 40 MG CAPSULE   4 Non-Preferred Drug 50%50%P Q:30
/30Days
APTENSIO XR 50 MG CAPSULE   4 Non-Preferred Drug 50%50%P Q:30
/30Days
APTENSIO XR 60 MG CAPSULE   4 Non-Preferred Drug 50%50%P Q:30
/30Days
APTIOM 200 MG TABLET   4 Non-Preferred Drug 50%50%Q:180
/30Days
APTIOM 400 MG TABLET   5 Specialty Tier 33%N/AQ:90
/30Days
APTIOM 600 MG TABLET   5 Specialty Tier 33%N/AQ:60
/30Days
APTIOM 800 MG TABLET   5 Specialty Tier 33%N/AQ:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
APTIVUS 250MG CAPSULE   5 Specialty Tier 33%N/ANone
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT   5 Specialty Tier 33%N/ANone
ARALAST NP 500 MG VIAL   5 Specialty Tier 33%N/AP
ARANELLE 7-9-5 TABLET   3 Preferred Brand $47.00$141.00None
ARANESP 10 MCG/0.4 ML SYRINGE   4 Non-Preferred Drug 50%50%P Q:3
/28Days
ARANESP 100ug/0.5mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.5 mL in 1 SYRINGE   4 Non-Preferred Drug 50%50%P Q:2
/28Days
ARANESP 100ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE   4 Non-Preferred Drug 50%50%P Q:4
/28Days
ARANESP 200MCG/0.4ML SYRINGE   5 Specialty Tier 33%N/AP Q:2
/28Days
ARANESP 200MCG/ML VIAL   5 Specialty Tier 33%N/AP Q:4
/28Days
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%50%P Q:2
/28Days
ARANESP 25ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE   4 Non-Preferred Drug 50%50%P Q:4
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP 300MCG/ML VIAL   5 Specialty Tier 33%N/AP Q:4
/28Days
ARANESP 500MCG/1ML SYRINGE   5 Specialty Tier 33%N/AP Q:1
/21Days
ARANESP 60MCG/ML VIAL   4 Non-Preferred Drug 50%50%P Q:4
/28Days
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%50%P Q:1
/28Days
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR   5 Specialty Tier 33%N/AP Q:1
/28Days
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR   5 Specialty Tier 33%N/AP Q:2
/28Days
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR   4 Non-Preferred Drug 50%50%P Q:2
/28Days
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD   4 Non-Preferred Drug 50%50%P Q:4
/28Days
ARCALYST INJECTION 220MG/VIAL   5 Specialty Tier 33%N/AP
ARICEPT 10MG TABLET   4 Non-Preferred Drug 50%50%S Q:60
/30Days
ARICEPT 23 MG TABLETS   4 Non-Preferred Drug 50%50%S Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARICEPT 5MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
ARIMIDEX 1MG TABLET   4 Non-Preferred Drug 50%50%None
ARIPIPRAZOLE 10 MG TABLET [Abilify]   4 Non-Preferred Drug 50%50%Q:30
/30Days
ARIPIPRAZOLE 15 MG TABLET [Abilify]   4 Non-Preferred Drug 50%50%Q:30
/30Days
ARIPIPRAZOLE 2 MG TABLET [Abilify]   4 Non-Preferred Drug 50%50%Q:30
/30Days
ARIPIPRAZOLE 20 MG TABLET [Abilify]   4 Non-Preferred Drug 50%50%Q:30
/30Days
ARIPIPRAZOLE 30 MG TABLET [Abilify]   4 Non-Preferred Drug 50%50%Q:30
/30Days
ARIPIPRAZOLE 5 MG TABLET [Abilify]   4 Non-Preferred Drug 50%50%Q:30
/30Days
ARIPIPRAZOLE ODT 10 MG TABLET [Abilify]   5 Specialty Tier 33%N/AQ:60
/30Days
ARIPIPRAZOLE ODT 15 MG TABLET [Abilify]   5 Specialty Tier 33%N/AQ:60
/30Days
ARISTADA ER 1064 MG/3.9 ML SYR   5 Specialty Tier 33%N/AQ:4
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARISTADA ER 441 MG/1.6 ML SYRN   5 Specialty Tier 33%N/AQ:2
/28Days
ARISTADA ER 662 MG/2.4 ML SYRN   5 Specialty Tier 33%N/AQ:2
/28Days
ARISTADA ER 882 MG/3.2 ML SYRN   5 Specialty Tier 33%N/AQ:3
/28Days
Armodafinil 150 MG TABLET [NUVIGIL]   4 Non-Preferred Drug 50%50%P Q:30
/30Days
Armodafinil 200 MG Oral Tablet [NUVIGIL]   4 Non-Preferred Drug 50%50%P Q:30
/30Days
Armodafinil 250 MG TABLET [NUVIGIL]   4 Non-Preferred Drug 50%50%P Q:30
/30Days
Armodafinil 50 MG TABLET [NUVIGIL]   4 Non-Preferred Drug 50%50%P Q:30
/30Days
ARNUITY ELLIPTA 100 MCG INH   3 Preferred Brand $47.00$141.00Q:30
/30Days
ARNUITY ELLIPTA 200 MCG INH   3 Preferred Brand $47.00$141.00Q:30
/30Days
AROMASIN 25MG TABLET   4 Non-Preferred Drug 50%50%None
ARRANON 250 MG VIAL   5 Specialty Tier 33%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARTHROTEC 50 50MG TABLET -200MCG (60 CT)   4 Non-Preferred Drug 50%50%None
ARTHROTEC 75 TABLET EC   4 Non-Preferred Drug 50%50%None
ASACOL HD DR 800 MG TABLET   4 Non-Preferred Drug 50%50%None
ASCOMP WITH CODEINE CAPSULE   4 Non-Preferred Drug 50%50%P Q:180
/30Days
ASHLYNA 0.15-0.03-0.01 MG TAB   3 Preferred Brand $47.00$141.00None
Aspirin-Diphenhydramine ER 25-200 MG   4 Non-Preferred Drug 50%50%Q:60
/30Days
ASPIRIN/BUTALBITAL/CAFFEINE/CODEINE   4 Non-Preferred Drug 50%50%P Q:180
/30Days
ASTAGRAF XL 0.5 MG CAPSULE   4 Non-Preferred Drug 50%50%P
ASTAGRAF XL 1 MG CAPSULE   4 Non-Preferred Drug 50%50%P
ASTAGRAF XL 5 MG CAPSULE   4 Non-Preferred Drug 50%50%P
ASTEPRO 0.15% NASAL SPRAY 30 ML   4 Non-Preferred Drug 50%50%Q:30
/25Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATACAND 16MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
ATACAND 32 MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
ATACAND 4MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
ATACAND 8MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
ATACAND HCT 16/12.5MG TABLET   4 Non-Preferred Drug 50%50%S Q:60
/30Days
ATACAND HCT 32/12.5MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
ATACAND HCT TABLETS 32;25MG;MG 90 TABLET BOTTLE   4 Non-Preferred Drug 50%50%S Q:30
/30Days
Atelvia 35mg/1 36 DOSE PACK CASE / 4 TABLET, DELAYED RELEASE in 1 DOSE PACK   4 Non-Preferred Drug 50%50%S Q:4
/28Days
ATENOLOL 100 MG TABLET   1 Preferred Generic $1.00$3.00None
ATENOLOL 25 MG TABLET   1 Preferred Generic $1.00$3.00None
ATENOLOL 50 MG TABLET   1 Preferred Generic $1.00$3.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATENOLOL-CHLORTHALIDONE 100-25   2 Generic $2.00$6.00None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   2 Generic $2.00$6.00None
ATGAM 50MG/ML AMPUL   5 Specialty Tier 33%N/AP
Atomoxetine 10 MG Oral Capsule [Strattera]   4 Non-Preferred Drug 50%50%Q:120
/30Days
Atomoxetine 100 MG Oral Capsule [Strattera]   4 Non-Preferred Drug 50%50%Q:30
/30Days
Atomoxetine 18 MG Oral Capsule [Strattera]   4 Non-Preferred Drug 50%50%Q:120
/30Days
Atomoxetine 25 MG Oral Capsule [Strattera]   4 Non-Preferred Drug 50%50%Q:120
/30Days
Atomoxetine 40 MG Oral Capsule [Strattera]   4 Non-Preferred Drug 50%50%Q:60
/30Days
Atomoxetine 60 MG Oral Capsule [Strattera]   4 Non-Preferred Drug 50%50%Q:30
/30Days
Atomoxetine 80 MG Oral Capsule [Strattera]   4 Non-Preferred Drug 50%50%Q:30
/30Days
ATORVASTATIN 10 MG TABLET [Lipitor]   1 Preferred Generic $1.00$3.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATORVASTATIN 20 MG TABLET [Lipitor]   1 Preferred Generic $1.00$3.00Q:30
/30Days
ATORVASTATIN 40 MG TABLET [Lipitor]   1 Preferred Generic $1.00$3.00Q:30
/30Days
ATORVASTATIN 80 MG TABLET [Lipitor]   1 Preferred Generic $1.00$3.00Q:30
/30Days
ATOVAQUONE 750 MG/5 ML SUSP [Mepron]   4 Non-Preferred Drug 50%50%P
Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone]   4 Non-Preferred Drug 50%50%None
Atovaquone-Proguanil 62.5-25 [Malarone]   4 Non-Preferred Drug 50%50%None
ATRALIN 0.05% GEL   4 Non-Preferred Drug 50%50%P
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC   5 Specialty Tier 33%N/ANone
ATROPINE 0.05MG/ML SYRINGE   4 Non-Preferred Drug 50%50%None
ATROPINE 1% EYE DROPS   4 Non-Preferred Drug 50%50%None
ATROVENT HFA AER 17MCG   4 Non-Preferred Drug 50%50%Q:26
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AUBRA-28 TABLET   3 Preferred Brand $47.00$141.00None
AUGMENTIN 125-31.25 MG/5 ML   4 Non-Preferred Drug 50%50%None
AURYXIA 210 MG TABLET   5 Specialty Tier 33%N/ANone
AVALIDE 150-12.5 MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
AVALIDE 300-12.5 MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
AVANDIA 2 MG TABLET   4 Non-Preferred Drug 50%50%Q:60
/30Days
AVANDIA 4 MG TABLET   4 Non-Preferred Drug 50%50%Q:60
/30Days
AVAPRO 150 MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
AVAPRO 300 MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
AVAPRO 75 MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
AVASTIN 100MG/4ML VIAL   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVASTIN 400 MG/16 ML VIAL   5 Specialty Tier 33%N/AP
AVELOX 400 MG TABLET   4 Non-Preferred Drug 50%50%None
AVELOX IV 400 MG/250 ML   4 Non-Preferred Drug 50%50%None
AVIANE 0.1-0.02 TABLET   3 Preferred Brand $47.00$141.00None
AVITA 0.025% CREAM   4 Non-Preferred Drug 50%50%P
AVITA 0.025% GEL   4 Non-Preferred Drug 50%50%P
AVODART 0.5 MG SOFTGEL   4 Non-Preferred Drug 50%50%Q:30
/30Days
AXERT 12.5 MG TABLET   4 Non-Preferred Drug 50%50%S Q:8
/30Days
AXERT 6.25 MG TABLET   4 Non-Preferred Drug 50%50%S Q:8
/30Days
AXIRON 30mg/1.5mL 1 BOTTLE, WITH APPLICATOR per CARTON / 90 mL in 1 BOTTLE, WITH APPLICATOR   3 Preferred Brand $47.00$141.00P Q:440
/30Days
Aygestin 5mg/1 50 TABLET BOTTLE   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Azacitidine 100 mg vial [Vidaza]   5 Specialty Tier 33%N/AP
AZACTAM INJECTION 1GM/50ML   4 Non-Preferred Drug 50%50%None
AZACTAM INJECTION 2GM/50ML   4 Non-Preferred Drug 50%50%None
AZASAN 100MG TABLET   4 Non-Preferred Drug 50%50%P
AZASAN 75MG TABLET   4 Non-Preferred Drug 50%50%P
AZASITE 1% EYE DROPS   4 Non-Preferred Drug 50%50%None
AZATHIOPRINE 50 MG TABLET   3 Preferred Brand $47.00$141.00P
AZATHIOPRINE SODIUM 100 MG VIAL   4 Non-Preferred Drug 50%50%P
AZELASTINE 0.15% NASAL SPRAY   3 Preferred Brand $47.00$141.00Q:30
/25Days
AZELASTINE 137 MCG NASAL SPRAY   3 Preferred Brand $47.00$141.00Q:30
/25Days
AZELASTINE HCL 0.05% DROPS   3 Preferred Brand $47.00$141.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZILECT 0.5MG TABLET   3 Preferred Brand $47.00$141.00None
AZILECT 1MG TABLET   3 Preferred Brand $47.00$141.00None
AZITHROMYCIN 1 GM PWD PACKET   3 Preferred Brand $47.00$141.00None
AZITHROMYCIN 100 MG/5 ML SUSP   2 Generic $2.00$6.00None
AZITHROMYCIN 200 MG/5 ML SUSP   2 Generic $2.00$6.00None
AZITHROMYCIN 250 MG TABLET   2 Generic $2.00$6.00None
Azithromycin 500 mg tablet   2 Generic $2.00$6.00None
Azithromycin 500mg/1 30 FILM COATED TABLETS in BOTTLE   2 Generic $2.00$6.00None
AZITHROMYCIN 600 MG TABLET   2 Generic $2.00$6.00None
AZITHROMYCIN I.V. 500 MG VIAL   4 Non-Preferred Drug 50%50%None
AZOPT 1% EYE DROPS   3 Preferred Brand $47.00$141.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZOR 10-20 MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
AZOR 10MG-40MG TABLET (30 CT)   4 Non-Preferred Drug 50%50%S Q:30
/30Days
AZOR 5-40 MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
AZOR 5MG-20MG TABLET (30 CT)   4 Non-Preferred Drug 50%50%S Q:30
/30Days
AZTREONAM FOR INJECTION   4 Non-Preferred Drug 50%50%None
AZULFIDINE 500 MG TABLET   4 Non-Preferred Drug 50%50%None
AZULFIDINE ENTAB 500 MG   4 Non-Preferred Drug 50%50%None


Chart Legend:

What does all this mean? Below are a few notes to help you understand the above 2018 Medicare Part D First Health Part D Value Plus (PDP) Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region).

  • 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 the standard $405 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 wit 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 four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
    • Drug Description - This is the Medicare Part D plan’s description of this particular drug tier.
  • Cost Sharing - Copay / Coinsurance - These figures apply to the initial coverage phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on which tier the drug is in. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
    • Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $3750) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2017 Humana Walmart-Preferred Rx Plan the cost-sharing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
    • 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 2017 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Part D plan provider.





Click the G+ button if you have found this page useful:  

Medicare Supplements
fill the gaps in your
Original Medicare
1. Select Your State:
» Medicare Supplement FAQs

Advertisement





.

Advertisement



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.