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2015 Medicare Part D Plan Formulary Information
EnvisionRxPlus Silver (PDP) (S7694-025-0) Benefit Details
The EnvisionRxPlus Silver (PDP) (S7694-025-0) Formulary Drugs Starting with the Letter A in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY Plan Monthly Premium: $32.40 Deductible: $320 Qualifies for LIS: No
Drugs Starting with Letter A Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter A Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ABACAVIR 300 MG TABLET	3	Non-Preferred Brand	31%	31%	Q:60 /30Days
Abacavir Sulfate-Lamivudine-Zidovudine tablets [Trizivir]	3	Non-Preferred Brand	31%	31%	Q:60 /30Days
ABELCENT INJECTION SUSPENSION 5MG/ML	3	Non-Preferred Brand	31%	31%	None
ABILIFY 10MG TABLET	3	Non-Preferred Brand	31%	31%	S
ABILIFY 15MG TABLET	3	Non-Preferred Brand	31%	31%	S
ABILIFY 20MG TABLET	3	Non-Preferred Brand	31%	31%	S
ABILIFY 2MG TABLET	3	Non-Preferred Brand	31%	31%	S
ABILIFY 30MG TABLET	3	Non-Preferred Brand	31%	31%	S
ABILIFY 5MG TABLET (OTSUKA)	3	Non-Preferred Brand	31%	31%	S
ABILIFY MAINTENA ER 300 MG SYR	4	Specialty Tier	25%	N/A	S
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ABILIFY MAINTENA ER 300 MG VL	4	Specialty Tier	25%	N/A	S
ABILIFY MAINTENA ER 400 MG SYR	4	Specialty Tier	25%	N/A	S
ABRAXANE 100MG VIAL	3	Non-Preferred Brand	31%	31%	P
Acamprosate Calcium DR 333 MG tablets [Campral]	3	Non-Preferred Brand	31%	31%	None
ACARBOSE 100 MG TABLET	1	Preferred Generic	$2.00	$6.00	None
ACARBOSE 25 MG TABLET	1	Preferred Generic	$2.00	$6.00	None
Acarbose 50mg/1 100 TABLET BOTTLE	1	Preferred Generic	$2.00	$6.00	None
ACEBUTOLOL 200MG CAPSULE	1	Preferred Generic	$2.00	$6.00	None
ACEBUTOLOL 400MG CAPSULE	1	Preferred Generic	$2.00	$6.00	None
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE	3	Non-Preferred Brand	31%	31%	None
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD	1	Preferred Generic	$2.00	$6.00	Q:5000 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT)	1	Preferred Generic	$2.00	$6.00	Q:400 /30Days
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT)	1	Preferred Generic	$2.00	$6.00	Q:400 /30Days
ACETAMINOPHEN-COD #4 TABLET	1	Preferred Generic	$2.00	$6.00	Q:400 /30Days
ACETAZOLAMIDE 125MG TABLET	3	Non-Preferred Brand	31%	31%	None
ACETAZOLAMIDE 250MG TABLET (100 CT)	3	Non-Preferred Brand	31%	31%	None
ACETAZOLAMIDE ER CAPSULES 500MG 100 BOT	3	Non-Preferred Brand	31%	31%	None
ACETIC ACID 2% SOLUTION NON-ORAL	1	Preferred Generic	$2.00	$6.00	None
ACETYLCYSTEINE 10% VIAL	3	Non-Preferred Brand	31%	31%	P
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN	3	Non-Preferred Brand	31%	31%	P
ACITRETIN 10 MG CAPSULE [Soriatane]	4	Specialty Tier	25%	N/A	None
ACITRETIN 17.5 MG CAPSULE [Soriatane]	4	Specialty Tier	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ACITRETIN 25 MG CAPSULE [Soriatane]	4	Specialty Tier	25%	N/A	None
ACTHIB VACCINE VIAL 10-24UNT/5ML	3	Non-Preferred Brand	31%	31%	None
ACTIMMUNE 100 MCG/0.5 ML VIAL	3	Non-Preferred Brand	31%	31%	P
Acyclovir 200mg 100 CAPSULE BOTTLE	1	Preferred Generic	$2.00	$6.00	None
Acyclovir 200mg/5mL 473 mL BOTTLE	1	Preferred Generic	$2.00	$6.00	None
Acyclovir 400 MG	1	Preferred Generic	$2.00	$6.00	None
ACYCLOVIR 800 MG TABLET	1	Preferred Generic	$2.00	$6.00	None
Acyclovir sodium 500 mg vial	3	Non-Preferred Brand	31%	31%	None
ADACEL VIAL 2UNT/5UNT	3	Non-Preferred Brand	31%	31%	None
ADAGEN 250U/ML VIAL	4	Specialty Tier	25%	N/A	P
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA]	4	Specialty Tier	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ADEFOVIR DIPIVOXIL 10 MG TAB [Hepsera]	3	Non-Preferred Brand	31%	31%	None
ADRUCIL 50mg/mL 10 VIAL in 1 TRAY / 10 mL in 1 VIAL	3	Non-Preferred Brand	31%	31%	P
ADVAIR DISKUS MIS 100/50	2	Preferred Brand	15%	15%	Q:60 /30Days
ADVAIR DISKUS MIS 250/50	2	Preferred Brand	15%	15%	Q:60 /30Days
ADVAIR DISKUS MIS 500/50	2	Preferred Brand	15%	15%	Q:60 /30Days
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER	2	Preferred Brand	15%	15%	Q:12 /30Days
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL	2	Preferred Brand	15%	15%	Q:12 /30Days
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL	2	Preferred Brand	15%	15%	Q:12 /30Days
AFEDITAB CR 30MG TABLET SA	3	Non-Preferred Brand	31%	31%	None
AFEDITAB CR 60MG TABLET SA	3	Non-Preferred Brand	31%	31%	None
Afinitor 7.5mg/1 28 BLISTER PACK per CARTON / 1 TABLET per BLISTER PACK	3	Non-Preferred Brand	31%	31%	P Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AFINITOR DISPERZ 2 MG TABLET	3	Non-Preferred Brand	31%	31%	P Q:30 /30Days
AFINITOR DISPERZ 3 MG TABLET	3	Non-Preferred Brand	31%	31%	P Q:30 /30Days
AFINITOR DISPERZ 5 MG TABLET	3	Non-Preferred Brand	31%	31%	P Q:60 /30Days
AFINITOR TABLETS 10 MG	3	Non-Preferred Brand	31%	31%	P Q:30 /30Days
AFINITOR TABLETS 2.5 MG	3	Non-Preferred Brand	31%	31%	P Q:30 /30Days
AFINITOR TABLETS 5 MG	3	Non-Preferred Brand	31%	31%	P Q:30 /30Days
AGGRENOX 25-200MG CAPSULE	3	Non-Preferred Brand	31%	31%	None
AK-CON 0.1% EYE DROPS	1	Preferred Generic	$2.00	$6.00	None
ALBENZA 200 MG TABLET	3	Non-Preferred Brand	31%	31%	None
ALBUTEROL SULFATE 0.75mg/3mL 30 POUCH per CARTON / 1 VIAL, SINGLE-DOSE in 1 POUCH / 3 mL in 1 VIAL	1	Preferred Generic	$2.00	$6.00	P
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER	1	Preferred Generic	$2.00	$6.00	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ALBUTEROL SULFATE 4MG TABLET SR 12HR	1	Preferred Generic	$2.00	$6.00	None
ALBUTEROL SULFATE 8MG TABLET SR 12HR	1	Preferred Generic	$2.00	$6.00	None
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR	1	Preferred Generic	$2.00	$6.00	P
ALBUTEROL SULFATE SOLUTION FOR INHALATION	1	Preferred Generic	$2.00	$6.00	P
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT	1	Preferred Generic	$2.00	$6.00	None
ALBUTEROL SULFATE TABLET 2MG (500 CT)	1	Preferred Generic	$2.00	$6.00	None
ALBUTEROL TABLET 4MG (500 CT)	1	Preferred Generic	$2.00	$6.00	None
ALDURAZYME 2.9MG/5ML VIAL	4	Specialty Tier	25%	N/A	None
ALENDRONATE SODIUM 10MG TABLET	1	Preferred Generic	$2.00	$6.00	None
Alendronate Sodium 35mg/1 12 TABLET in 1 BOX, UNIT-DOSE	1	Preferred Generic	$2.00	$6.00	Q:4 /28Days
ALENDRONATE SODIUM 40MG TABLET	1	Preferred Generic	$2.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ALENDRONATE SODIUM 5MG TABLET	1	Preferred Generic	$2.00	$6.00	None
Alendronate Sodium 70mg/1 4 BLISTER PACK in 1 BOX / 1 TABLET in 1 BLISTER PACK	1	Preferred Generic	$2.00	$6.00	Q:4 /28Days
ALIMTA 500MG VIAL	3	Non-Preferred Brand	31%	31%	P
ALINIA 100MG/5ML SUSPENSION	3	Non-Preferred Brand	31%	31%	Q:150 /30Days
ALINIA 500 MG TABLET	3	Non-Preferred Brand	31%	31%	Q:40 /30Days
ALLOPURINOL 100 MG TABLETS	1	Preferred Generic	$2.00	$6.00	None
Allopurinol 300mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET per BLISTER PACK	1	Preferred Generic	$2.00	$6.00	None
ALOSETRON HCL 0.5 MG TABLET [Lotronex]	3	Non-Preferred Brand	31%	31%	None
ALOSETRON HCL 1 MG TABLET [Lotronex]	3	Non-Preferred Brand	31%	31%	None
ALPHAGAN P 0.1% DROPS	2	Preferred Brand	15%	15%	None
ALPHAGAN P 0.15% EYE DROPS	2	Preferred Brand	15%	15%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ALPRAZOLAM 0.25 MG TABLET	1	Preferred Generic	$2.00	$6.00	None
Alprazolam 0.25mg/1 10 BLISTER PACK per CARTON / 10 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PAC	1	Preferred Generic	$2.00	$6.00	Q:720 /30Days
ALPRAZOLAM 0.5 MG TABLET	1	Preferred Generic	$2.00	$6.00	None
Alprazolam 0.5mg/1 10 BLISTER PACK per CARTON / 10 TABLET, ORALLY DISINTEGRATING per BLISTER PACK	1	Preferred Generic	$2.00	$6.00	Q:180 /30Days
Alprazolam 0.5mg/1 60 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC	1	Preferred Generic	$2.00	$6.00	Q:120 /30Days
ALPRAZOLAM 1 MG TABLET	1	Preferred Generic	$2.00	$6.00	None
Alprazolam 1mg/1 10 BLISTER PACK per CARTON / 10 TABLET, ORALLY DISINTEGRATING per BLISTER PACK	1	Preferred Generic	$2.00	$6.00	Q:360 /30Days
Alprazolam 1mg/mL 1 BOTTLE in 1 CONTAINER / 30 mL in 1 BOTTLE	1	Preferred Generic	$2.00	$6.00	None
ALPRAZOLAM 2 MG TABLET	1	Preferred Generic	$2.00	$6.00	None
Alprazolam 2mg/1 10 BLISTER PACK per CARTON / 10 TABLET, ORALLY DISINTEGRATING per BLISTER PACK	3	Non-Preferred Brand	31%	31%	None
ALPRAZOLAM ER 1 MG TABLET	1	Preferred Generic	$2.00	$6.00	Q:120 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ALPRAZOLAM ER 2 MG TABLET	3	Non-Preferred Brand	31%	31%	None
ALPRAZOLAM ER 3 MG TABLET	1	Preferred Generic	$2.00	$6.00	Q:120 /30Days
AMANTADINE 100MG CAPSULE	1	Preferred Generic	$2.00	$6.00	None
AMANTADINE 100MG TABLET	1	Preferred Generic	$2.00	$6.00	None
Amantadine Hydrochloride 50mg/5mL 473 mL in 1 BOTTLE	1	Preferred Generic	$2.00	$6.00	None
AMBISOME 50MG VIAL	3	Non-Preferred Brand	31%	31%	P
AMCINONIDE 0.1% CREAM	3	Non-Preferred Brand	31%	31%	None
AMCINONIDE 0.1% LOTION	3	Non-Preferred Brand	31%	31%	None
AMCINONIDE 0.1% OINTMENT 60GM TUBE	3	Non-Preferred Brand	31%	31%	None
AMIFOSTINE 50mg/mL 3 VIAL, SINGLE-USE per CARTON / 10 mL in 1 VIAL, SINGLE-USE	3	Non-Preferred Brand	31%	31%	None
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET	1	Preferred Generic	$2.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT	1	Preferred Generic	$2.00	$6.00	None
Aminophylline 25mg/mL 5 TRAY per CARTON / 5 AMPULE in 1 TRAY / 10 mL in 1 AMPULE	3	Non-Preferred Brand	31%	31%	None
AMINOSYN 7%-ELECTROLYTE SOL	3	Non-Preferred Brand	31%	31%	P
AMINOSYN II 10% IV SOLUTION	3	Non-Preferred Brand	31%	31%	P
AMINOSYN PF INJECTION	3	Non-Preferred Brand	31%	31%	P
AMINOSYN-RF 5.2% IV SOLUTION	3	Non-Preferred Brand	31%	31%	P
AMIODARONE HCL 200MG 60 TABLET BOTTLE	1	Preferred Generic	$2.00	$6.00	None
AMIODARONE HCL 400MG TABLET	1	Preferred Generic	$2.00	$6.00	None
AMIODARONE HCL 50 MG INJECTION	1	Preferred Generic	$2.00	$6.00	None
AMITIZA 8MCG CAPSULE	2	Preferred Brand	15%	15%	None
AMITIZA CAPSULES 24MCG 60 CAP BOT	2	Preferred Brand	15%	15%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMITRIP/CDP 25-10 TABLET	1	Preferred Generic	$2.00	$6.00	P
AMITRIP/PERPHEN 10-2 TABLET	1	Preferred Generic	$2.00	$6.00	P
AMITRIP/PERPHEN 10-4 TABLET	1	Preferred Generic	$2.00	$6.00	P
AMITRIP/PERPHEN 25-2 TABLET	1	Preferred Generic	$2.00	$6.00	P
AMITRIP/PERPHEN 25-4 TABLET	1	Preferred Generic	$2.00	$6.00	P
AMITRIP/PERPHEN 50-4 TABLET	1	Preferred Generic	$2.00	$6.00	P
AMITRIPTYLINE HCL 100MG TABLET	1	Preferred Generic	$2.00	$6.00	P
AMITRIPTYLINE HCL 10MG TABLET	1	Preferred Generic	$2.00	$6.00	P
AMITRIPTYLINE HCL 150 MG TAB	1	Preferred Generic	$2.00	$6.00	P
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)	1	Preferred Generic	$2.00	$6.00	P
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)	1	Preferred Generic	$2.00	$6.00	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT	1	Preferred Generic	$2.00	$6.00	P
AMLOD-VALSA-HCTZ 10-160-12.5 MG [EXFORGE HCT]	1	Preferred Generic	$2.00	$6.00	None
AMLOD-VALSA-HCTZ 10-160-25 MG [EXFORGE HCT]	1	Preferred Generic	$2.00	$6.00	None
AMLOD-VALSA-HCTZ 10-320-25 MG [EXFORGE HCT]	1	Preferred Generic	$2.00	$6.00	None
AMLOD-VALSA-HCTZ 5-160-12.5 MG [EXFORGE HCT]	1	Preferred Generic	$2.00	$6.00	None
AMLOD-VALSA-HCTZ 5-160-25 MG [EXFORGE HCT]	1	Preferred Generic	$2.00	$6.00	None
AMLODIPINE BESYLATE 10MG TABLET (90 CT)	1	Preferred Generic	$2.00	$6.00	Q:30 /30Days
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)	1	Preferred Generic	$2.00	$6.00	None
AMLODIPINE BESYLATE 5MG TABLET (90 CT)	1	Preferred Generic	$2.00	$6.00	None
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE	1	Preferred Generic	$2.00	$6.00	None
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE	1	Preferred Generic	$2.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE	1	Preferred Generic	$2.00	$6.00	None
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE	1	Preferred Generic	$2.00	$6.00	None
AMLODIPINE-BENAZEPRIL 10-40 MG	1	Preferred Generic	$2.00	$6.00	None
AMLODIPINE-BENAZEPRIL 5-40 MG	1	Preferred Generic	$2.00	$6.00	None
AMLODIPINE-VALSARTAN 10-160 MG	1	Preferred Generic	$2.00	$6.00	None
AMLODIPINE-VALSARTAN 10-320 MG	1	Preferred Generic	$2.00	$6.00	None
AMLODIPINE-VALSARTAN 5-160 MG	1	Preferred Generic	$2.00	$6.00	None
AMLODIPINE-VALSARTAN 5-320 MG	1	Preferred Generic	$2.00	$6.00	None
AMMONIUM LACTATE 12% LOTION	3	Non-Preferred Brand	31%	31%	None
amox tr-k clv 200-28.5/5 susp	1	Preferred Generic	$2.00	$6.00	None
AMOX TR-K CLV 500-125 MG TAB	1	Preferred Generic	$2.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE	1	Preferred Generic	$2.00	$6.00	None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET	1	Preferred Generic	$2.00	$6.00	None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE	1	Preferred Generic	$2.00	$6.00	None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL	1	Preferred Generic	$2.00	$6.00	None
AMOXAPINE 100MG TABLET	1	Preferred Generic	$2.00	$6.00	None
AMOXAPINE 150MG TABLET	1	Preferred Generic	$2.00	$6.00	None
AMOXAPINE 25MG TABLET	1	Preferred Generic	$2.00	$6.00	None
AMOXAPINE 50MG TABLET	1	Preferred Generic	$2.00	$6.00	None
AMOXICILLIN 125MG TABLET CHEW	1	Preferred Generic	$2.00	$6.00	None
AMOXICILLIN 250MG 500 CHEWABLE TABLET in BOTTLE	1	Preferred Generic	$2.00	$6.00	None
AMOXICILLIN 250MG CAPSULE	1	Preferred Generic	$2.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMOXICILLIN 500MG 500 CAPSULE BOTTLE	1	Preferred Generic	$2.00	$6.00	None
AMOXICILLIN 500MG TABLET (100 CT)	1	Preferred Generic	$2.00	$6.00	None
AMOXICILLIN 875MG TABLET	1	Preferred Generic	$2.00	$6.00	None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT	1	Preferred Generic	$2.00	$6.00	None
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT	1	Preferred Generic	$2.00	$6.00	None
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT	1	Preferred Generic	$2.00	$6.00	None
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL	1	Preferred Generic	$2.00	$6.00	None
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT	1	Preferred Generic	$2.00	$6.00	None
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL	1	Preferred Generic	$2.00	$6.00	None
AMPHETAMINE SALT COMBO 12.5MG TABLET	3	Non-Preferred Brand	31%	31%	None
AMPHETAMINE SALT COMBO 15MG TABLET	3	Non-Preferred Brand	31%	31%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMPHETAMINE SALT COMBO 30MG TABLET	3	Non-Preferred Brand	31%	31%	None
AMPHETAMINE SALT COMBO 7.5MG TABLET	3	Non-Preferred Brand	31%	31%	None
AMPHETAMINE SALTS 20MG TABLET	3	Non-Preferred Brand	31%	31%	None
AMPHETAMINE SALTS 5 MG TAB	2	Preferred Brand	15%	15%	None
amphotericin b 50mg/10mL 10 mL in 1 VIAL	3	Non-Preferred Brand	31%	31%	P
Ampicillin 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS	1	Preferred Generic	$2.00	$6.00	None
AMPICILLIN CAPSULES 250MG 100 BOT	1	Preferred Generic	$2.00	$6.00	None
AMPICILLIN CAPSULES 500MG 100 BOT	1	Preferred Generic	$2.00	$6.00	None
AMPICILLIN FOR INJECTION POWDER	1	Preferred Generic	$2.00	$6.00	None
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT	1	Preferred Generic	$2.00	$6.00	None
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT	1	Preferred Generic	$2.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMPICILLIN POWDER FOR INJECTION 1 GM/ML	1	Preferred Generic	$2.00	$6.00	None
AMPICILLIN-SULBACTAM 15 GM VIAL	1	Preferred Generic	$2.00	$6.00	None
AMPICILLIN-SULBACTAM FOR INJECTION	1	Preferred Generic	$2.00	$6.00	None
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE	1	Preferred Generic	$2.00	$6.00	None
Anastrozole 1mg/1 90 FILM COATED TABLETS in BOTTLE, PLASTIC	1	Preferred Generic	$2.00	$6.00	Q:30 /30Days
ANDRODERM 2 MG/24HR PATCH	2	Preferred Brand	15%	15%	None
ANDRODERM 4 MG/24HR PATCH	2	Preferred Brand	15%	15%	None
ANDROGEL 1.62% (1.25G) GEL PCKT	2	Preferred Brand	15%	15%	None
ANDROGEL 1.62% (2.5G) GEL PCKT	2	Preferred Brand	15%	15%	None
ANDROGEL 1% (50MG) GEL PACKET	2	Preferred Brand	15%	15%	None
Androgel 10mg/g 2 BOTTLE, PUMP in 1 CARTON / 75 g in 1 BOTTLE, PUMP	2	Preferred Brand	15%	15%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Androgel 10mg/g 30 PACKET in 1 CARTON / 2.5 g in 1 PACKET	2	Preferred Brand	15%	15%	None
Androgel 16.2mg/g 1 BOTTLE, PUMP per CARTON / 88 g in 1 BOTTLE, PUMP	2	Preferred Brand	15%	15%	None
ANORO ELLIPTA 62.5-25 MCG INH	3	Non-Preferred Brand	31%	31%	Q:60 /30Days
APIDRA 100 UNITS/ML VIAL	2	Preferred Brand	15%	15%	None
APIDRA SOLOSTAR 100 UNITS/ML	2	Preferred Brand	15%	15%	None
APLENZIN ER 174 MG TABLET	3	Non-Preferred Brand	31%	31%	S
APLENZIN ER 348 MG TABLET	3	Non-Preferred Brand	31%	31%	S
APOKYN 30 MG/3 ML CARTRIDGE	4	Specialty Tier	25%	N/A	P
Apraclonidine Ophthalmic 5mg/mL 1 BOTTLE, DROPPER per CARTON / 10 mL in 1 BOTTLE, DROPPER	3	Non-Preferred Brand	31%	31%	None
APRISO CP24	2	Preferred Brand	15%	15%	None
APTIOM 200 MG TABLET	3	Non-Preferred Brand	31%	31%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
APTIOM 400 MG TABLET	4	Specialty Tier	25%	N/A	None
APTIOM 600 MG TABLET	4	Specialty Tier	25%	N/A	None
APTIOM 800 MG TABLET	4	Specialty Tier	25%	N/A	None
APTIVUS 250MG CAPSULE	4	Specialty Tier	25%	N/A	Q:120 /30Days
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT	4	Specialty Tier	25%	N/A	Q:285 /28Days
ARCALYST INJECTION 220MG/VIAL	4	Specialty Tier	25%	N/A	None
ARIPIPRAZOLE 10 MG TABLET [Abilify]	3	Non-Preferred Brand	31%	31%	S
ARIPIPRAZOLE 15 MG TABLET [Abilify]	3	Non-Preferred Brand	31%	31%	S
ARIPIPRAZOLE 2 MG TABLET [Abilify]	3	Non-Preferred Brand	31%	31%	S
ARIPIPRAZOLE 20 MG TABLET [Abilify]	3	Non-Preferred Brand	31%	31%	S
ARIPIPRAZOLE 30 MG TABLET [Abilify]	3	Non-Preferred Brand	31%	31%	S
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ARIPIPRAZOLE 5 MG TABLET [Abilify]	3	Non-Preferred Brand	31%	31%	S
ARRANON 250MG VIAL	3	Non-Preferred Brand	31%	31%	P
ARZERRA 20mg/mL 3 VIAL per CARTON / 5 mL in 1 VIAL	2	Preferred Brand	15%	15%	P Q:400 /28Days
ASACOL HD 800mg/1 12 BOTTLE CASE / 180 TABLET, DELAYED RELEASE in 1 BOTTLE	3	Non-Preferred Brand	31%	31%	S
ASCOMP WITH CODEINE CAPSULE	3	Non-Preferred Brand	31%	31%	P
ASTAGRAF XL 0.5 MG CAPSULE	3	Non-Preferred Brand	31%	31%	P S
ASTAGRAF XL 1 MG CAPSULE	3	Non-Preferred Brand	31%	31%	P S
ASTAGRAF XL 5 MG CAPSULE	3	Non-Preferred Brand	31%	31%	P S
ASTEPRO 0.15% NASAL SPRAY 30 ML	2	Preferred Brand	15%	15%	None
Atelvia 35mg/1 36 DOSE PACK CASE / 4 TABLET, DELAYED RELEASE in 1 DOSE PACK	2	Preferred Brand	15%	15%	S Q:4 /28Days
ATENOLOL 100 MG100 TABLET BOTTLE	1	Preferred Generic	$2.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ATENOLOL 25 MG 100 TABLET BOTTLE	1	Preferred Generic	$2.00	$6.00	None
ATENOLOL TABLET USP 50MG (100 CT)	1	Preferred Generic	$2.00	$6.00	None
ATENOLOL-CHLORTHALIDONE 100-25	1	Preferred Generic	$2.00	$6.00	None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)	1	Preferred Generic	$2.00	$6.00	None
ATGAM 50MG/ML AMPUL	3	Non-Preferred Brand	31%	31%	P
ATORVASTATIN 10 MG TABLET [Lipitor]	3	Non-Preferred Brand	31%	31%	S Q:30 /30Days
ATORVASTATIN 20 MG TABLET [Lipitor]	3	Non-Preferred Brand	31%	31%	S Q:30 /30Days
ATORVASTATIN 40 MG TABLET [Lipitor]	3	Non-Preferred Brand	31%	31%	S Q:30 /30Days
ATORVASTATIN 80 MG TABLET [Lipitor]	3	Non-Preferred Brand	31%	31%	S Q:30 /30Days
ATOVAQUONE 750 MG/5 ML SUSP [Mepron]	3	Non-Preferred Brand	31%	31%	None
Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone]	3	Non-Preferred Brand	31%	31%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC	3	Non-Preferred Brand	31%	31%	Q:30 /30Days
ATROPINE 0.05MG/ML SYRINGE	1	Preferred Generic	$2.00	$6.00	None
ATROPINE 0.1MG/ML SYRINGE	1	Preferred Generic	$2.00	$6.00	None
Atropine 1% Eye Drops	3	Non-Preferred Brand	31%	31%	None
ATROVENT HFA AER 17MCG	3	Non-Preferred Brand	31%	31%	Q:30 /30Days
AURYXIA 210 MG TABLET	3	Non-Preferred Brand	31%	31%	None
AVASTIN 100MG/4ML VIAL	2	Preferred Brand	15%	15%	P
AVODART 0.5MG SOFTGEL	2	Preferred Brand	15%	15%	None
AVONEX ADMIN PACK 30MCG SYR	4	Specialty Tier	25%	N/A	None
AVONEX ADMIN PACK 30MCG VL	4	Specialty Tier	25%	N/A	None
AVONEX PEN 30 MCG/0.5 ML KIT	4	Specialty Tier	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Azacitidine 100 mg vial [Vidaza]	3	Non-Preferred Brand	31%	31%	None
AZACTAM 1g/1 10 VIAL, SINGLE-DOSE in 1 CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, SINGLE	3	Non-Preferred Brand	31%	31%	None
AZASAN 100MG TABLET	3	Non-Preferred Brand	31%	31%	P S
AZASAN 75MG TABLET	3	Non-Preferred Brand	31%	31%	P S
AZATHIOPRINE 50MG TABLET	1	Preferred Generic	$2.00	$6.00	P
AZELASTINE 0.15% NASAL SPRAY	3	Non-Preferred Brand	31%	31%	None
AZELASTINE 137 MCG NASAL SPRAY	3	Non-Preferred Brand	31%	31%	None
AZELASTINE HYDROCHLORIDE OPHTHALMIC SOLUTION	3	Non-Preferred Brand	31%	31%	None
AZILECT 0.5MG TABLET	2	Preferred Brand	15%	15%	None
AZILECT 1MG TABLET	2	Preferred Brand	15%	15%	None
AZITHROMYCIN 1 GM PWD PACKET	1	Preferred Generic	$2.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Azithromycin 100mg/5mL 15 mL in 1 BOTTLE	1	Preferred Generic	$2.00	$6.00	None
Azithromycin 200mg/5mL 22.5 mL in 1 BOTTLE	1	Preferred Generic	$2.00	$6.00	None
AZITHROMYCIN 250 MG TABLET	1	Preferred Generic	$2.00	$6.00	None
Azithromycin 500mg/1 10 VIAL, SINGLE-USE in 1 TRAY / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION	3	Non-Preferred Brand	31%	31%	None
Azithromycin 500mg/1 30 FILM COATED TABLETS in BOTTLE	1	Preferred Generic	$2.00	$6.00	None
Azithromycin 600mg/1 30 FILM COATED TABLETS in BOTTLE	1	Preferred Generic	$2.00	$6.00	None
AZOR 10MG-20MG TABLET	2	Preferred Brand	15%	15%	None
AZOR 10MG-40MG TABLET (30 CT)	2	Preferred Brand	15%	15%	None
AZOR 5MG-20MG TABLET (30 CT)	2	Preferred Brand	15%	15%	None
AZOR 5MG-40MG TABLET	2	Preferred Brand	15%	15%	None
AZTREONAM FOR INJECTION	1	Preferred Generic	$2.00	$6.00	None

Chart Legend:

Below are a few notes to help you understand the above 2015 Medicare Part D EnvisionRxPlus Silver (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 standard $320 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 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 the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
- Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $2960) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2016 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 2015 )

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.