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2014 Medicare Part D or Medicare Advantage Plan Formulary Browser

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Selected Plan:EnvisionRxPlus Silver (PDP) (S7694-025-0)
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    Browse Formulary by clicking on the First Letter of Drug Name:
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: :Example: AARP MedicareRx Preferred (PDP) Formulary in Florida
 
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2014 Medicare Part D Plan Formulary Information
EnvisionRxPlus Silver (PDP) (S7694-025-0)          
The EnvisionRxPlus Silver (PDP) (S7694-025-0) Formulary for Drugs Starting with the Letter A
in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY
Plan Monthly Premium: $33.40 Deductible: $310 Qualifies for LIS: Yes
Drugs Start 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   2 Non-Preferred Generic 25%N/AQ:60/30Days
Abacavir Sulfate-Lamivudine-Zidovudine tablets   5 Specialty Tier 25%N/AQ:60/30Days
ABILIFY 10MG TABLET   3 Preferred Brand $45.00N/ANone
ABILIFY 15MG TABLET   3 Preferred Brand $45.00N/ANone
ABILIFY 1MG/ML SOLUTION   3 Preferred Brand $45.00N/ANone
ABILIFY 20MG TABLET   3 Preferred Brand $45.00N/ANone
ABILIFY 2MG TABLET   3 Preferred Brand $45.00N/ANone
ABILIFY 30MG TABLET   3 Preferred Brand $45.00N/ANone
ABILIFY 5MG TABLET (OTSUKA)   3 Preferred Brand $45.00N/ANone
ABILIFY DISCMELT 10MG TABLET   3 Preferred Brand $45.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ABILIFY DISCMELT 15MG TABLET   3 Preferred Brand $45.00N/ANone
ABILIFY INJ 9.75MG   3 Preferred Brand $45.00N/ANone
ABILIFY MAINTENA ER 300 MG VL   5 Specialty Tier 25%N/ANone
ABRAXANE 100MG VIAL   4 Non-Preferred Brand 45%N/AP
Acamprosate Calcium DR 333 MG tablets   2 Non-Preferred Generic 25%N/ANone
Acarbose 100mg/1 1000 TABLET BOTTLE, PLASTIC   1 Preferred Generic $10.00$30.00None
ACARBOSE 25 MG TABLETS   1 Preferred Generic $10.00$30.00None
Acarbose 50mg/1 100 TABLET BOTTLE   1 Preferred Generic $10.00$30.00None
ACEBUTOLOL 200MG CAPSULE   2 Non-Preferred Generic 25%N/ANone
ACEBUTOLOL 400MG CAPSULE   2 Non-Preferred Generic 25%N/ANone
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE   4 Non-Preferred Brand 45%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Acetaminophen and Codeine Phosphate 300; 60mg/1; mg/1 500 TABLET BOTTLE   2 Non-Preferred Generic 25%N/AQ:400/30Days
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD   2 Non-Preferred Generic 25%N/AQ:5000/30Days
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT)   2 Non-Preferred Generic 25%N/AQ:400/30Days
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT)   2 Non-Preferred Generic 25%N/AQ:400/30Days
ACETAZOLAMIDE 125MG TABLET   2 Non-Preferred Generic 25%N/ANone
ACETAZOLAMIDE 250MG TABLET (100 CT)   2 Non-Preferred Generic 25%N/ANone
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT   2 Non-Preferred Generic 25%N/ANone
ACETIC ACID 2% SOLUTION NON-ORAL   2 Non-Preferred Generic 25%N/ANone
ACETYLCYSTEINE 10% VIAL   2 Non-Preferred Generic 25%N/AP
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN   2 Non-Preferred Generic 25%N/AP
ACITRETIN 10 MG CAPSULE   5 Specialty Tier 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACITRETIN 17.5 MG CAPSULE   5 Specialty Tier 25%N/ANone
ACITRETIN 25 MG CAPSULE   5 Specialty Tier 25%N/ANone
ACTHIB VACCINE VIAL 10-24UNT/5ML   4 Non-Preferred Brand 45%N/ANone
ACTIMMUNE SOLUTION FOR INJECTION 100MCG   5 Specialty Tier 25%N/ANone
ACYCLOVIR 200 MG CAPSULE   1 Preferred Generic $10.00$30.00None
Acyclovir 200mg/5mL 473 mL in 1 BOTTLE   2 Non-Preferred Generic 25%N/ANone
Acyclovir 400mg/1   2 Non-Preferred Generic 25%N/ANone
ACYCLOVIR 800 MG TABLET   2 Non-Preferred Generic 25%N/ANone
ACYCLOVIR SODIUM 500MG VIAL   1 Preferred Generic $10.00$30.00None
ADACEL VIAL 2UNT/5UNT   4 Non-Preferred Brand 45%N/ANone
ADAGEN 250U/ML VIAL   5 Specialty Tier 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA]   5 Specialty Tier 25%N/ANone
ADEFOVIR DIPIVOXIL 10 MG TAB   5 Specialty Tier 25%N/ANone
ADVAIR DISKUS MIS 100/50   3 Preferred Brand $45.00N/AQ:60/30Days
ADVAIR DISKUS MIS 250/50   3 Preferred Brand $45.00N/AQ:60/30Days
ADVAIR DISKUS MIS 500/50   3 Preferred Brand $45.00N/AQ:60/30Days
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER   3 Preferred Brand $45.00N/AQ:12/30Days
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL   3 Preferred Brand $45.00N/AQ:12/30Days
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL   3 Preferred Brand $45.00N/AQ:12/30Days
AFEDITAB CR 30MG TABLET SA   2 Non-Preferred Generic 25%N/ANone
AFEDITAB CR 60MG TABLET SA   2 Non-Preferred Generic 25%N/ANone
Afinitor 7.5mg/1 28 BLISTER PACK per CARTON / 1 TABLET per BLISTER PACK   5 Specialty Tier 25%N/AQ:30/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AFINITOR DISPERZ 2 MG TABLET   5 Specialty Tier 25%N/AQ:30/30Days
AFINITOR DISPERZ 3 MG TABLET   5 Specialty Tier 25%N/AQ:30/30Days
AFINITOR DISPERZ 5 MG TABLET   5 Specialty Tier 25%N/AQ:60/30Days
AFINITOR TABLETS 10 MG   5 Specialty Tier 25%N/AQ:30/30Days
AFINITOR TABLETS 2.5 MG   5 Specialty Tier 25%N/AQ:30/30Days
AFINITOR TABLETS 5 MG   5 Specialty Tier 25%N/AQ:30/30Days
AGGRENOX 25-200MG CAPSULE   4 Non-Preferred Brand 45%N/ANone
AK-CON 0.1% EYE DROPS   1 Preferred Generic $10.00$30.00None
ALA-CORT 1% CREAM   2 Non-Preferred Generic 25%N/ANone
ALBENZA 200 MG TABLET   4 Non-Preferred Brand 45%N/ANone
ALBUTEROL SULFATE 0.75mg/3mL 30 POUCH per CARTON / 1 VIAL, SINGLE-DOSE in 1 POUCH / 3 mL in 1 VIAL   2 Non-Preferred Generic 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER   2 Non-Preferred Generic 25%N/AP
ALBUTEROL SULFATE 4MG TABLET SR 12HR   2 Non-Preferred Generic 25%N/ANone
ALBUTEROL SULFATE 8MG TABLET SR 12HR   2 Non-Preferred Generic 25%N/ANone
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   2 Non-Preferred Generic 25%N/ANone
ALBUTEROL SULFATE SOLUTION FOR INHALATION   2 Non-Preferred Generic 25%N/AP
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT   2 Non-Preferred Generic 25%N/ANone
ALBUTEROL SULFATE TABLET 2MG (500 CT)   2 Non-Preferred Generic 25%N/ANone
ALBUTEROL TABLET 4MG (500 CT)   2 Non-Preferred Generic 25%N/ANone
ALDURAZYME 2.9MG/5ML VIAL   5 Specialty Tier 25%N/ANone
ALENDRONATE SODIUM 10MG TABLET   2 Non-Preferred Generic 25%N/ANone
Alendronate Sodium 35mg, 4 BLISTER PACK in 1 BOX / 1 TABLET per BLISTER PACK   2 Non-Preferred Generic 25%N/AQ:4/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALENDRONATE SODIUM 40MG TABLET   2 Non-Preferred Generic 25%N/ANone
ALENDRONATE SODIUM 5MG TABLET   2 Non-Preferred Generic 25%N/ANone
Alendronate Sodium 70mg/1   2 Non-Preferred Generic 25%N/AQ:4/28Days
ALIMTA 500MG VIAL   5 Specialty Tier 25%N/ANone
ALINIA 100MG/5ML SUSPENSION   4 Non-Preferred Brand 45%N/AQ:150/30Days
ALINIA 500 MG TABLET   4 Non-Preferred Brand 45%N/AQ:40/30Days
ALKERAN 1 KIT per CARTON   4 Non-Preferred Brand 45%N/AP
ALLOPURINOL 100 MG TABLETS   1 Preferred Generic $10.00$30.00None
Allopurinol 300mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET per BLISTER PACK   1 Preferred Generic $10.00$30.00None
ALPHAGAN P 0.1% DROPS   3 Preferred Brand $45.00N/ANone
ALPHAGAN P 0.15% EYE DROPS   3 Preferred Brand $45.00N/ANone
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 $10.00$30.00None
Alprazolam 0.25mg/1 10 BLISTER PACK per CARTON / 10 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PAC   1 Preferred Generic $10.00$30.00Q:720/30Days
ALPRAZOLAM 0.5 MG TABLET   1 Preferred Generic $10.00$30.00None
Alprazolam 0.5mg/1 10 BLISTER PACK per CARTON / 10 TABLET, ORALLY DISINTEGRATING per BLISTER PACK   1 Preferred Generic $10.00$30.00Q:180/30Days
Alprazolam 0.5mg/1 60 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC   1 Preferred Generic $10.00$30.00Q:120/30Days
ALPRAZOLAM 1 MG TABLET   1 Preferred Generic $10.00$30.00None
Alprazolam 1mg/1 10 BLISTER PACK per CARTON / 10 TABLET, ORALLY DISINTEGRATING per BLISTER PACK   1 Preferred Generic $10.00$30.00Q:360/30Days
Alprazolam 1mg/mL 1 BOTTLE in 1 CONTAINER / 30 mL in 1 BOTTLE   2 Non-Preferred Generic 25%N/ANone
ALPRAZOLAM 2 MG TABLET   1 Preferred Generic $10.00$30.00None
Alprazolam XR 1mg/1   1 Preferred Generic $10.00$30.00Q:120/30Days
Alprazolam XR 3mg/1   1 Preferred Generic $10.00$30.00Q:120/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMANTADINE 100MG CAPSULE   2 Non-Preferred Generic 25%N/ANone
AMANTADINE 100MG TABLET   2 Non-Preferred Generic 25%N/ANone
Amantadine Hydrochloride 50mg/5mL 473 mL in 1 BOTTLE   2 Non-Preferred Generic 25%N/ANone
AMBISOME 50MG VIAL   4 Non-Preferred Brand 45%N/ANone
AMCINONIDE 0.1% CREAM   2 Non-Preferred Generic 25%N/ANone
AMCINONIDE 0.1% LOTION   2 Non-Preferred Generic 25%N/ANone
AMCINONIDE 0.1% OINTMENT 60GM TUBE   1 Preferred Generic $10.00$30.00None
AMIFOSTINE 50mg/mL 3 VIAL, SINGLE-USE per CARTON / 10 mL in 1 VIAL, SINGLE-USE   5 Specialty Tier 25%N/ANone
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET   1 Preferred Generic $10.00$30.00None
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT   1 Preferred Generic $10.00$30.00None
Aminophylline 25mg/mL 5 TRAY per CARTON / 5 AMPULE in 1 TRAY / 10 mL in 1 AMPULE   1 Preferred Generic $10.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN HBC INJECTION SULFITE FREE 7%   4 Non-Preferred Brand 45%N/AP
AMINOSYN II 10% IV SOLUTION   4 Non-Preferred Brand 45%N/AP
AMINOSYN II 7% IV SOLUTION   4 Non-Preferred Brand 45%N/AP
AMINOSYN II 8.5% ELECTROLYT   2 Non-Preferred Generic 25%N/AP
AMINOSYN II 8.5% IV SOLUTION   4 Non-Preferred Brand 45%N/AP
AMINOSYN M 3.5% IV SOLUTION   4 Non-Preferred Brand 45%N/AP
AMINOSYN PF INJECTION   4 Non-Preferred Brand 45%N/AP
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5%   1 Preferred Generic $10.00$30.00P
AMINOSYN-PF 7% IV SOLUTION   4 Non-Preferred Brand 45%N/AP
AMIODARONE HCL 400MG TABLET   2 Non-Preferred Generic 25%N/ANone
AMIODARONE HCL 50 MG INJECTION   1 Preferred Generic $10.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Amiodarone Hydrochloride 200mg/1 60 TABLET BOTTLE   2 Non-Preferred Generic 25%N/ANone
AMITIZA 8MCG CAPSULE   3 Preferred Brand $45.00N/ANone
AMITIZA CAPSULES 24MCG 60 CAP BOT   3 Preferred Brand $45.00N/ANone
AMITRIP/CDP 25-10 TABLET   1 Preferred Generic $10.00$30.00P
AMITRIP/PERPHEN 10-2 TABLET   2 Non-Preferred Generic 25%N/AP
AMITRIP/PERPHEN 10-4 TABLET   1 Preferred Generic $10.00$30.00P
AMITRIP/PERPHEN 25-2 TABLET   2 Non-Preferred Generic 25%N/AP
AMITRIP/PERPHEN 25-4 TABLET   1 Preferred Generic $10.00$30.00P
AMITRIP/PERPHEN 50-4 TABLET   1 Preferred Generic $10.00$30.00P
AMITRIPTYLINE HCL 100MG TABLET   1 Preferred Generic $10.00$30.00P
AMITRIPTYLINE HCL 10MG TABLET   1 Preferred Generic $10.00$30.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITRIPTYLINE HCL 150 MG TAB   2 Non-Preferred Generic 25%N/AP
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)   1 Preferred Generic $10.00$30.00P
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)   1 Preferred Generic $10.00$30.00P
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT   1 Preferred Generic $10.00$30.00P
AMLODIPINE BESYLATE 10MG TABLET (90 CT)   2 Non-Preferred Generic 25%N/AQ:30/30Days
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)   2 Non-Preferred Generic 25%N/ANone
AMLODIPINE BESYLATE 5MG TABLET (90 CT)   2 Non-Preferred Generic 25%N/ANone
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE 10MG/40MG CAPSULES   1 Preferred Generic $10.00$30.00None
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE 5MG/40MG CAPSULES   1 Preferred Generic $10.00$30.00None
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE   1 Preferred Generic $10.00$30.00None
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE   1 Preferred Generic $10.00$30.00None
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 $10.00$30.00None
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE   1 Preferred Generic $10.00$30.00None
Amlodipine-Atorvastatin 10-10 mg [Caduet]   2 Non-Preferred Generic 25%N/ANone
Amlodipine-Atorvastatin 10-80 mg [Caduet]   2 Non-Preferred Generic 25%N/ANone
Amlodipine-Atorvastatin 2.5-10 mg [Caduet]   2 Non-Preferred Generic 25%N/ANone
Amlodipine-Atorvastatin 2.5-20 mg [Caduet]   2 Non-Preferred Generic 25%N/ANone
Amlodipine-Atorvastatin 2.5-40 mg [Caduet]   2 Non-Preferred Generic 25%N/ANone
Amlodipine-Atorvastatin 5-10 mg [Caduet]   2 Non-Preferred Generic 25%N/ANone
Amlodipine-Atorvastatin 5-20 mg [Caduet]   2 Non-Preferred Generic 25%N/ANone
Amlodipine-Atorvastatin 5-40 mg [Caduet]   2 Non-Preferred Generic 25%N/ANone
Amlodipine-Atorvastatin 5-80 mg [Caduet]   2 Non-Preferred Generic 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMMONIUM LACTATE 12% LOTION   2 Non-Preferred Generic 25%N/ANone
amox tr-k clv 200-28.5/5 susp   1 Preferred Generic $10.00$30.00None
AMOX TR-K CLV 500-125 MG TAB   2 Non-Preferred Generic 25%N/ANone
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE   1 Preferred Generic $10.00$30.00None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET   2 Non-Preferred Generic 25%N/ANone
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE   1 Preferred Generic $10.00$30.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   2 Non-Preferred Generic 25%N/ANone
AMOXAPINE 100MG TABLET   2 Non-Preferred Generic 25%N/ANone
AMOXAPINE 150MG TABLET   1 Preferred Generic $10.00$30.00None
AMOXAPINE 25MG TABLET   1 Preferred Generic $10.00$30.00None
AMOXAPINE 50MG TABLET   1 Preferred Generic $10.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN 125MG TABLET CHEW   2 Non-Preferred Generic 25%N/ANone
AMOXICILLIN 250MG CAPSULE   2 Non-Preferred Generic 25%N/ANone
Amoxicillin 250mg/1 500 TABLET, CHEWABLE in 1 BOTTLE   2 Non-Preferred Generic 25%N/ANone
AMOXICILLIN 500MG TABLET (100 CT)   2 Non-Preferred Generic 25%N/ANone
Amoxicillin 500mg/1 500 CAPSULE BOTTLE, PLASTIC   2 Non-Preferred Generic 25%N/ANone
AMOXICILLIN 875MG TABLET   2 Non-Preferred Generic 25%N/ANone
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT   2 Non-Preferred Generic 25%N/ANone
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT   2 Non-Preferred Generic 25%N/ANone
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT   2 Non-Preferred Generic 25%N/ANone
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL   1 Preferred Generic $10.00$30.00None
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   2 Non-Preferred Generic 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL   2 Non-Preferred Generic 25%N/ANone
AMPHETAMINE SALT COMBO 12.5MG TABLET   1 Preferred Generic $10.00$30.00None
AMPHETAMINE SALT COMBO 15MG TABLET   2 Non-Preferred Generic 25%N/ANone
AMPHETAMINE SALT COMBO 30MG TABLET   2 Non-Preferred Generic 25%N/ANone
AMPHETAMINE SALT COMBO 7.5MG TABLET   2 Non-Preferred Generic 25%N/ANone
AMPHETAMINE SALTS 20MG TABLET   2 Non-Preferred Generic 25%N/ANone
AMPHETAMINE SALTS 5 MG TAB   2 Non-Preferred Generic 25%N/ANone
amphotericin b 50mg/10mL 10 mL in 1 VIAL   2 Non-Preferred Generic 25%N/ANone
Ampicillin 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS   2 Non-Preferred Generic 25%N/ANone
AMPICILLIN CAPSULES 250MG 100 BOT   2 Non-Preferred Generic 25%N/ANone
AMPICILLIN CAPSULES 500MG 100 BOT   2 Non-Preferred Generic 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPICILLIN FOR INJECTION POWDER   2 Non-Preferred Generic 25%N/ANone
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT   1 Preferred Generic $10.00$30.00None
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT   1 Preferred Generic $10.00$30.00None
AMPICILLIN POWDER FOR INJECTION 1 GM/ML   2 Non-Preferred Generic 25%N/ANone
ampicillin-sulbactam 15 gm vl   2 Non-Preferred Generic 25%N/ANone
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE   2 Non-Preferred Generic 25%N/ANone
Anastrozole 1mg/1 90 FILM COATED TABLETS in BOTTLE, PLASTIC   2 Non-Preferred Generic 25%N/AQ:30/30Days
ANDRODERM 2 MG/24HR PATCH   3 Preferred Brand $45.00N/ANone
ANDRODERM 4 MG/24HR PATCH   3 Preferred Brand $45.00N/ANone
ANDROGEL 1%(50MG) GEL PACKET   3 Preferred Brand $45.00N/ANone
Androgel 16.2mg/g 1 BOTTLE, PUMP per CARTON / 88 g in 1 BOTTLE, PUMP   3 Preferred Brand $45.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
APIDRA 100 UNITS/ML VIAL   3 Preferred Brand $45.00N/ANone
APIDRA SOLOSTAR 100 UNITS/ML   3 Preferred Brand $45.00N/ANone
Aplenzin 174mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE   4 Non-Preferred Brand 45%N/ANone
APLENZIN TABLETS EXTENDED RELEASE 348 MG   4 Non-Preferred Brand 45%N/ANone
APOKYN 30 MG/3 ML CARTRIDGE   5 Specialty Tier 25%N/AP
Apraclonidine Ophthalmic 5mg/mL 1 BOTTLE, DROPPER per CARTON / 10 mL in 1 BOTTLE, DROPPER   2 Non-Preferred Generic 25%N/ANone
APRISO CP24   3 Preferred Brand $45.00N/ANone
APTIOM 200 MG TABLET   4 Non-Preferred Brand 45%N/ANone
APTIOM 400 MG TABLET   4 Non-Preferred Brand 45%N/ANone
APTIOM 600 MG TABLET   4 Non-Preferred Brand 45%N/ANone
APTIOM 800 MG TABLET   4 Non-Preferred Brand 45%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
APTIVUS 250MG CAPSULE   5 Specialty Tier 25%N/AQ:120/30Days
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT   5 Specialty Tier 25%N/AQ:285/28Days
ARCALYST INJECTION 220MG/VIAL   5 Specialty Tier 25%N/ANone
ARRANON 250MG VIAL   4 Non-Preferred Brand 45%N/AP
ARZERRA 20mg/mL 3 VIAL per CARTON / 5 mL in 1 VIAL   5 Specialty Tier 25%N/AP Q:400/28Days
ASACOL HD 800mg/1 12 BOTTLE CASE / 180 TABLET, DELAYED RELEASE in 1 BOTTLE   3 Preferred Brand $45.00N/ANone
Ascomp with Codeine 325; 50; 40; 30mg/1; mg/1; mg/1; mg/1 500 CAPSULE BOTTLE, PLASTIC   2 Non-Preferred Generic 25%N/AP
ASTAGRAF XL 0.5 MG CAPSULE   4 Non-Preferred Brand 45%N/AP
ASTAGRAF XL 1 MG CAPSULE   4 Non-Preferred Brand 45%N/AP
ASTAGRAF XL 5 MG CAPSULE   5 Specialty Tier 25%N/AP
ASTEPRO 0.15% NASAL SPRAY 30 ML   3 Preferred Brand $45.00N/ANone
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   3 Preferred Brand $45.00N/AS Q:4/28Days
ATENOLOL 100mg 100 TABLET BOTTLE   2 Non-Preferred Generic 25%N/ANone
Atenolol 25mg 100 TABLET BOTTLE   2 Non-Preferred Generic 25%N/ANone
ATENOLOL TABLET USP 50MG (100 CT)   2 Non-Preferred Generic 25%N/ANone
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT)   1 Preferred Generic $10.00$30.00None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   1 Preferred Generic $10.00$30.00None
ATGAM 50MG/ML AMPUL   4 Non-Preferred Brand 45%N/AP
ATORVASTATIN 10 MG TABLET   1 Preferred Generic $10.00$30.00Q:30/30Days
ATORVASTATIN 20 MG TABLET   1 Preferred Generic $10.00$30.00Q:30/30Days
ATORVASTATIN 40 MG TABLET   1 Preferred Generic $10.00$30.00Q:30/30Days
ATORVASTATIN 80 MG TABLET   1 Preferred Generic $10.00$30.00Q:30/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATOVAQUONE 750 MG/5 ML SUSP [Mepron]   5 Specialty Tier 25%N/ANone
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC   5 Specialty Tier 25%N/AQ:30/30Days
ATROPINE 0.05MG/ML SYRINGE   1 Preferred Generic $10.00$30.00None
ATROPINE 0.1MG/ML SYRINGE   1 Preferred Generic $10.00$30.00None
ATROVENT HFA AER 17MCG   3 Preferred Brand $45.00N/AQ:30/30Days
AVASTIN 100MG/4ML VIAL   5 Specialty Tier 25%N/ANone
AVODART 0.5MG SOFTGEL   3 Preferred Brand $45.00N/ANone
AVONEX ADMIN PACK 30MCG SYR   5 Specialty Tier 25%N/ANone
AVONEX ADMIN PACK 30MCG VL   5 Specialty Tier 25%N/ANone
Azacitidine 100 mg vial   5 Specialty Tier 25%N/ANone
AZASAN 100MG TABLET   4 Non-Preferred Brand 45%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZASAN 75MG TABLET   4 Non-Preferred Brand 45%N/AP
AZATHIOPRINE 50MG TABLET   2 Non-Preferred Generic 25%N/AP
AZELASTINE 137 MCG NASAL SPRAY   2 Non-Preferred Generic 25%N/ANone
AZELASTINE HYDROCHLORIDE OPHTHALMIC SOLUTION   2 Non-Preferred Generic 25%N/ANone
AZILECT 0.5MG TABLET   3 Preferred Brand $45.00N/ANone
AZILECT 1MG TABLET   3 Preferred Brand $45.00N/ANone
Azithromycin 100mg/5mL 15 mL in 1 BOTTLE   1 Preferred Generic $10.00$30.00None
Azithromycin 200mg/5mL 22.5 mL in 1 BOTTLE   2 Non-Preferred Generic 25%N/ANone
AZITHROMYCIN 250 MG TABLET   2 Non-Preferred Generic 25%N/ANone
Azithromycin 500mg/1 10 VIAL, SINGLE-USE in 1 TRAY / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION   2 Non-Preferred Generic 25%N/ANone
Azithromycin 500mg/1 30 FILM COATED TABLETS in BOTTLE   2 Non-Preferred Generic 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Azithromycin 600mg/1 30 FILM COATED TABLETS in BOTTLE   2 Non-Preferred Generic 25%N/ANone
AZOR 10MG-20MG TABLET   6 Select Care Drugs $10.00$30.00None
AZOR 10MG-40MG TABLET (30 CT)   6 Select Care Drugs $10.00$30.00None
AZOR 5MG-20MG TABLET (30 CT)   6 Select Care Drugs $10.00$30.00None
AZOR 5MG-40MG TABLET   6 Select Care Drugs $10.00$30.00None
AZTREONAM FOR INJECTION   2 Non-Preferred Generic 25%N/ANone



What does all this mean? Here are a few notes to help you understand the above 2014 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 the standard $310 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 $2850) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2014 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 August 2014 )

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.



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