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Selected Plan:HealthSpring Prescription Drug Plan-Reg 25 (PDP) (S5932-024-0)
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2013 Medicare Part D Plan Formulary Information
HealthSpring Prescription Drug Plan-Reg 25 (PDP) (S5932-024-0)          
The HealthSpring Prescription Drug Plan-Reg 25 (PDP) (S5932-024-0) 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: $40.60 Deductible: $325 Qualifies for LIS: No
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
A-HYDROCORT 100MG VIAL   1 Forumlary Drugs 25% 25% None
ABACAVIR 300 MG TABLET   1 Forumlary Drugs 25% 25% None
ABELCENT INJECTION SUSPENSION 5MG/ML   1 Forumlary Drugs 25% 25% P
ABILIFY 10MG TABLET   1 Forumlary Drugs 25% 25% Q:30/30Days
ABILIFY 15MG TABLET   1 Forumlary Drugs 25% 25% Q:30/30Days
ABILIFY 1MG/ML SOLUTION   1 Forumlary Drugs 25% 25% Q:900/30Days
ABILIFY 20MG TABLET   1 Forumlary Drugs 25% 25% Q:30/30Days
ABILIFY 2MG TABLET   1 Forumlary Drugs 25% 25% Q:30/30Days
ABILIFY 30MG TABLET   1 Forumlary Drugs 25% 25% Q:30/30Days
ABILIFY 5MG TABLET (OTSUKA)   1 Forumlary Drugs 25% 25% Q:30/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ABILIFY DISCMELT 10MG TABLET   1 Forumlary Drugs 25% 25% Q:60/30Days
ABILIFY DISCMELT 15MG TABLET   1 Forumlary Drugs 25% 25% Q:60/30Days
ABILIFY INJ 9.75MG   1 Forumlary Drugs 25% 25% None
ABRAXANE 100MG VIAL   1 Forumlary Drugs 25% 25% P
Acarbose 100mg/1 1000 TABLET BOTTLE, PLASTIC   1 Forumlary Drugs 25% 25% Q:90/30Days
Acarbose 50mg/1 100 TABLET BOTTLE   1 Forumlary Drugs 25% 25% Q:90/30Days
ACARBOSE TABLETS   1 Forumlary Drugs 25% 25% Q:90/30Days
ACEBUTOLOL 200MG CAPSULE   1 Forumlary Drugs 25% 25% None
ACEBUTOLOL 400MG CAPSULE   1 Forumlary Drugs 25% 25% None
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE   1 Forumlary Drugs 25% 25% None
Acetaminophen and Codeine Phosphate 300; 60mg/1; mg/1 500 TABLET BOTTLE   1 Forumlary Drugs 25% 25% Q:240/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD   1 Forumlary Drugs 25% 25% Q:5000/30Days
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT)   1 Forumlary Drugs 25% 25% Q:360/30Days
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT)   1 Forumlary Drugs 25% 25% Q:360/30Days
ACETASOL HC SOLUTION 10ML 10 ML BOT   1 Forumlary Drugs 25% 25% None
ACETAZOLAMIDE 125MG TABLET   1 Forumlary Drugs 25% 25% None
ACETAZOLAMIDE 250MG TABLET (100 CT)   1 Forumlary Drugs 25% 25% None
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT   1 Forumlary Drugs 25% 25% None
ACETAZOLAMIDE SOD 500MG VL   1 Forumlary Drugs 25% 25% None
ACETIC ACID 2% SOLUTION NON-ORAL   1 Forumlary Drugs 25% 25% None
ACETYLCYSTEINE 10% VIAL   1 Forumlary Drugs 25% 25% P
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN   1 Forumlary Drugs 25% 25% P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ACTHIB VACCINE VIAL 10-24UNT/5ML   1 Forumlary Drugs 25% 25% None
ACTIMMUNE SOLUTION FOR INJECTION 100MCG   1 Forumlary Drugs 25% 25% P
Actonel 150mg/1 36 DOSE PACK in 1 CASE / 1 TRAY in 1 DOSE PACK / 1 TABLET, FILM COATED in 1 TRAY   1 Forumlary Drugs 25% 25% Q:1/28Days
Actonel 30mg/1 12 BOTTLE in 1 CASE / 30 TABLET, FILM COATED in 1 BOTTLE   1 Forumlary Drugs 25% 25% Q:30/30Days
Actonel 35mg/1 36 DOSE PACK in 1 CASE / 1 TRAY in 1 DOSE PACK / 4 TABLET, FILM COATED in 1 TRAY   1 Forumlary Drugs 25% 25% Q:4/28Days
Actonel 5mg/1 12 BOTTLE in 1 CASE / 30 TABLET, FILM COATED in 1 BOTTLE   1 Forumlary Drugs 25% 25% Q:30/30Days
ACTOPLUS MET 15MG/500MG TABLET   1 Forumlary Drugs 25% 25% Q:90/30Days
ACTOPLUS MET 15MG/850MG TABLET   1 Forumlary Drugs 25% 25% Q:90/30Days
ACTOS 15MG TABLET   1 Forumlary Drugs 25% 25% Q:30/30Days
Actos 30mg/90 Tablet Bottle   1 Forumlary Drugs 25% 25% Q:30/30Days
ACTOS 45MG TABLET   1 Forumlary Drugs 25% 25% Q:30/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ACYCLOVIR 200 MG CAPSULE   1 Forumlary Drugs 25% 25% None
Acyclovir 200mg/5mL 473 mL in 1 BOTTLE   1 Forumlary Drugs 25% 25% None
acyclovir 400mg/1   1 Forumlary Drugs 25% 25% None
ACYCLOVIR 800 MG TABLET   1 Forumlary Drugs 25% 25% None
ACYCLOVIR SODIUM 500MG VIAL   1 Forumlary Drugs 25% 25% None
ADACEL VIAL 2UNT/5UNT   1 Forumlary Drugs 25% 25% None
ADAGEN 250U/ML VIAL   1 Forumlary Drugs 25% 25% P
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA]   1 Forumlary Drugs 25% 25% P Q:2/28Days
ADVAIR DISKUS MIS 100/50   1 Forumlary Drugs 25% 25% Q:60/30Days
ADVAIR DISKUS MIS 250/50   1 Forumlary Drugs 25% 25% Q:60/30Days
ADVAIR DISKUS MIS 500/50   1 Forumlary Drugs 25% 25% Q:60/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER   1 Forumlary Drugs 25% 25% Q:24/30Days
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL   1 Forumlary Drugs 25% 25% Q:24/30Days
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL   1 Forumlary Drugs 25% 25% Q:24/30Days
AFEDITAB CR 30MG TABLET SA   1 Forumlary Drugs 25% 25% None
AFEDITAB CR 60MG TABLET SA   1 Forumlary Drugs 25% 25% None
Afinitor 7.5mg/1 28 BLISTER PACK in 1 CARTON / 1 TABLET in 1 BLISTER PACK   1 Forumlary Drugs 25% 25% P Q:30/30Days
AFINITOR TABLETS 10 MG   1 Forumlary Drugs 25% 25% P Q:30/30Days
AFINITOR TABLETS 2.5 MG   1 Forumlary Drugs 25% 25% P Q:30/30Days
AFINITOR TABLETS 5 MG   1 Forumlary Drugs 25% 25% P Q:30/30Days
AGGRENOX 25-200MG CAPSULE   1 Forumlary Drugs 25% 25% Q:60/30Days
AK-CON 0.1% EYE DROPS   1 Forumlary Drugs 25% 25% None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ALA-CORT 1% CREAM   1 Forumlary Drugs 25% 25% None
ALA-SCALP HP 2% LOTION   1 Forumlary Drugs 25% 25% None
ALBENZA 200 MG TABLET   1 Forumlary Drugs 25% 25% None
ALBUTEROL SULFATE 0.75mg/3mL 30 POUCH in 1 CARTON / 1 VIAL, SINGLE-DOSE in 1 POUCH / 3 mL in 1 VIAL   1 Forumlary Drugs 25% 25% P Q:375/30Days
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER   1 Forumlary Drugs 25% 25% P Q:375/30Days
ALBUTEROL SULFATE 4MG TABLET SR 12HR   1 Forumlary Drugs 25% 25% None
ALBUTEROL SULFATE 8MG TABLET SR 12HR   1 Forumlary Drugs 25% 25% None
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   1 Forumlary Drugs 25% 25% P Q:360/30Days
ALBUTEROL SULFATE SOLUTION FOR INHALATION   1 Forumlary Drugs 25% 25% P Q:375/30Days
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT   1 Forumlary Drugs 25% 25% None
ALBUTEROL SULFATE TABLET 2MG (500 CT)   1 Forumlary Drugs 25% 25% None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ALBUTEROL TABLET 4MG (500 CT)   1 Forumlary Drugs 25% 25% None
ALCLOMETASONE DIPROPIONATE 0.05% CREAM   1 Forumlary Drugs 25% 25% None
Alclometasone Dipropionate 0.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE   1 Forumlary Drugs 25% 25% None
ALDURAZYME 2.9MG/5ML VIAL   1 Forumlary Drugs 25% 25% P
ALENDRONATE SODIUM 10MG TABLET   1 Forumlary Drugs 25% 25% Q:30/30Days
ALENDRONATE SODIUM 40MG TABLET   1 Forumlary Drugs 25% 25% Q:30/30Days
ALENDRONATE SODIUM 5MG TABLET   1 Forumlary Drugs 25% 25% Q:30/30Days
ALENDRONATE SODIUM 70mg/1   1 Forumlary Drugs 25% 25% Q:4/28Days
ALENDRONATE SODIUM TABLET 35MG 20 CRTN   1 Forumlary Drugs 25% 25% Q:4/28Days
ALIMTA 500MG VIAL   1 Forumlary Drugs 25% 25% P
ALINIA 100MG/5ML SUSPENSION   1 Forumlary Drugs 25% 25% None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ALINIA 500MG TABLET   1 Forumlary Drugs 25% 25% None
Allopurinol 300mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET in 1 BLISTER PACK   1 Forumlary Drugs 25% 25% None
ALLOPURINOL SODIUM 500MG VIAL   1 Forumlary Drugs 25% 25% None
ALLOPURINOL TABLETS   1 Forumlary Drugs 25% 25% None
ALOCRIL 2% EYE DROPS   1 Forumlary Drugs 25% 25% None
ALOXI 0.25MG/5ML   1 Forumlary Drugs 25% 25% P
ALPRAZOLAM 0.25 MG TABLET   1 Forumlary Drugs 25% 25% Q:90/30Days
Alprazolam 0.25mg/1 10 BLISTER PACK in 1 CARTON / 10 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PAC   1 Forumlary Drugs 25% 25% Q:90/30Days
ALPRAZOLAM 0.5 MG TABLET   1 Forumlary Drugs 25% 25% Q:90/30Days
Alprazolam 0.5mg/1 10 BLISTER PACK in 1 CARTON / 10 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PACK   1 Forumlary Drugs 25% 25% Q:90/30Days
ALPRAZOLAM 1 MG TABLET   1 Forumlary Drugs 25% 25% Q:300/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Alprazolam 1mg/1 10 BLISTER PACK in 1 CARTON / 10 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PACK   1 Forumlary Drugs 25% 25% Q:300/30Days
ALPRAZOLAM 2 MG TABLET   1 Forumlary Drugs 25% 25% Q:150/30Days
Alprazolam 2mg/1 10 BLISTER PACK in 1 CARTON / 10 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PACK   1 Forumlary Drugs 25% 25% Q:150/30Days
AMANTADINE 100MG CAPSULE   1 Forumlary Drugs 25% 25% None
AMANTADINE 100MG TABLET   1 Forumlary Drugs 25% 25% None
Amantadine Hydrochloride 50mg/5mL 473 mL in 1 BOTTLE   1 Forumlary Drugs 25% 25% None
AMBISOME 50MG VIAL   1 Forumlary Drugs 25% 25% P
AMCINONIDE 0.1% CREAM   1 Forumlary Drugs 25% 25% None
AMCINONIDE 0.1% LOTION   1 Forumlary Drugs 25% 25% None
AMCINONIDE 0.1% OINTMENT 60GM TUBE   1 Forumlary Drugs 25% 25% None
AMIFOSTINE 50mg/mL 3 VIAL, SINGLE-USE in 1 CARTON / 10 mL in 1 VIAL, SINGLE-USE   1 Forumlary Drugs 25% 25% P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
AMIKACIN 50MG/ML VIAL   1 Forumlary Drugs 25% 25% None
AMIKACIN Sulfate 1g/4mL 10 VIAL, SINGLE-DOSE in 1 CARTON / 4 mL in 1 VIAL, SINGLE-DOSE   1 Forumlary Drugs 25% 25% None
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET   1 Forumlary Drugs 25% 25% None
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT   1 Forumlary Drugs 25% 25% None
Aminophylline 25mg/mL 5 TRAY in 1 CARTON / 5 AMPULE in 1 TRAY / 10 mL in 1 AMPULE   1 Forumlary Drugs 25% 25% None
AMINOSYN HBC INJECTION SULFITE FREE 7%   1 Forumlary Drugs 25% 25% P
AMINOSYN II 10% IV SOLUTION   1 Forumlary Drugs 25% 25% P
AMINOSYN II 7% IV SOLUTION   1 Forumlary Drugs 25% 25% P
AMINOSYN II 8.5% ELECTROLYT   1 Forumlary Drugs 25% 25% P
AMINOSYN II 8.5% IV SOLUTION   1 Forumlary Drugs 25% 25% P
Aminosyn II Sulfite-Free 1490; 1527; 1050; 1107; 750; 450; 990; 1500; 1575; 258; 405; 447; 1083; 79   1 Forumlary Drugs 25% 25% P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
AMINOSYN M 3.5% IV SOLUTION   1 Forumlary Drugs 25% 25% P
AMINOSYN PF INJECTION   1 Forumlary Drugs 25% 25% P
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5%   1 Forumlary Drugs 25% 25% P
AMINOSYN-PF 7% IV SOLUTION   1 Forumlary Drugs 25% 25% P
AMIODARONE HCL 400MG TABLET   1 Forumlary Drugs 25% 25% None
AMIODARONE HCL INJECTION   1 Forumlary Drugs 25% 25% None
Amiodarone Hydrochloride 200mg/1 60 TABLET BOTTLE   1 Forumlary Drugs 25% 25% None
AMITIZA 8MCG CAPSULE   1 Forumlary Drugs 25% 25% Q:60/30Days
AMITIZA CAPSULES 24MCG 60 CAP BOT   1 Forumlary Drugs 25% 25% Q:60/30Days
AMITRIP/PERPHEN 10-2 TABLET   1 Forumlary Drugs 25% 25% None
AMITRIP/PERPHEN 10-4 TABLET   1 Forumlary Drugs 25% 25% None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
AMITRIP/PERPHEN 25-2 TABLET   1 Forumlary Drugs 25% 25% None
AMITRIP/PERPHEN 25-4 TABLET   1 Forumlary Drugs 25% 25% None
AMITRIP/PERPHEN 50-4 TABLET   1 Forumlary Drugs 25% 25% None
AMITRIPTYLINE HCL 100MG TABLET   1 Forumlary Drugs 25% 25% None
AMITRIPTYLINE HCL 10MG TABLET   1 Forumlary Drugs 25% 25% None
AMITRIPTYLINE HCL 150 MG TAB   1 Forumlary Drugs 25% 25% None
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)   1 Forumlary Drugs 25% 25% None
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)   1 Forumlary Drugs 25% 25% None
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT   1 Forumlary Drugs 25% 25% None
AMLODIPINE BESYLATE 10MG TABLET (90 CT)   1 Forumlary Drugs 25% 25% None
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)   1 Forumlary Drugs 25% 25% None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
AMLODIPINE BESYLATE 5MG TABLET (90 CT)   1 Forumlary Drugs 25% 25% None
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE CAPSULES   1 Forumlary Drugs 25% 25% None
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE CAPSULES   1 Forumlary Drugs 25% 25% None
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE   1 Forumlary Drugs 25% 25% None
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE   1 Forumlary Drugs 25% 25% None
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE   1 Forumlary Drugs 25% 25% None
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE   1 Forumlary Drugs 25% 25% None
AMMONIUM LACTATE 12% CREAM   1 Forumlary Drugs 25% 25% None
AMMONIUM LACTATE 12% LOTION   1 Forumlary Drugs 25% 25% None
Amnesteem 10mg/1 3 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK   1 Forumlary Drugs 25% 25% None
Amnesteem 20mg/1 3 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK   1 Forumlary Drugs 25% 25% None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Amnesteem 40mg/1 3 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK   1 Forumlary Drugs 25% 25% None
amox tr-k clv 200-28.5/5 susp   1 Forumlary Drugs 25% 25% None
AMOX TR-K CLV 500-125 MG TAB   1 Forumlary Drugs 25% 25% None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE   1 Forumlary Drugs 25% 25% None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET   1 Forumlary Drugs 25% 25% None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE   1 Forumlary Drugs 25% 25% None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   1 Forumlary Drugs 25% 25% None
AMOXAPINE 100MG TABLET   1 Forumlary Drugs 25% 25% None
AMOXAPINE 150MG TABLET   1 Forumlary Drugs 25% 25% None
AMOXAPINE 25MG TABLET   1 Forumlary Drugs 25% 25% None
AMOXAPINE 50MG TABLET   1 Forumlary Drugs 25% 25% None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
AMOXICILLIN 125MG TABLET CHEW   1 Forumlary Drugs 25% 25% None
AMOXICILLIN 250MG CAPSULE   1 Forumlary Drugs 25% 25% None
Amoxicillin 250mg/1 500 TABLET, CHEWABLE in 1 BOTTLE   1 Forumlary Drugs 25% 25% None
AMOXICILLIN 50 MG/ML / CLAVULANATE 12.5 MG/ML ORAL SUSPENSION   1 Forumlary Drugs 25% 25% None
AMOXICILLIN 500MG TABLET (100 CT)   1 Forumlary Drugs 25% 25% None
Amoxicillin 500mg/1 500 CAPSULE in 1 BOTTLE, PLASTIC   1 Forumlary Drugs 25% 25% None
AMOXICILLIN 875MG TABLET   1 Forumlary Drugs 25% 25% None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT   1 Forumlary Drugs 25% 25% None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS EXTENDED RELEASE 1000;62.5MG;MG   1 Forumlary Drugs 25% 25% None
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT   1 Forumlary Drugs 25% 25% None
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT   1 Forumlary Drugs 25% 25% None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL   1 Forumlary Drugs 25% 25% None
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   1 Forumlary Drugs 25% 25% None
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL   1 Forumlary Drugs 25% 25% None
AMPHETAMINE SALT COMBO 12.5MG TABLET   1 Forumlary Drugs 25% 25% Q:90/30Days
AMPHETAMINE SALT COMBO 15MG TABLET   1 Forumlary Drugs 25% 25% Q:90/30Days
AMPHETAMINE SALT COMBO 30MG TABLET   1 Forumlary Drugs 25% 25% Q:90/30Days
AMPHETAMINE SALT COMBO 7.5MG TABLET   1 Forumlary Drugs 25% 25% Q:90/30Days
AMPHETAMINE SALTS 20MG TABLET   1 Forumlary Drugs 25% 25% Q:90/30Days
AMPHETAMINE SALTS 5 MG TAB   1 Forumlary Drugs 25% 25% Q:90/30Days
AMPHOTEC FOR INJECTION 50MG/VIAL   1 Forumlary Drugs 25% 25% P
amphotericin b 50mg/10mL 10 mL in 1 VIAL   1 Forumlary Drugs 25% 25% P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Ampicillin 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS   1 Forumlary Drugs 25% 25% None
AMPICILLIN CAPSULES 250MG 100 BOT   1 Forumlary Drugs 25% 25% None
AMPICILLIN CAPSULES 500MG 100 BOT   1 Forumlary Drugs 25% 25% None
AMPICILLIN FOR INJECTION POWDER   1 Forumlary Drugs 25% 25% None
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT   1 Forumlary Drugs 25% 25% None
AMPICILLIN POWDER FOR INJECTION 1 GM/ML   1 Forumlary Drugs 25% 25% None
ampicillin-sulbactam 15 gm vl   1 Forumlary Drugs 25% 25% None
ampicillin-sulbactam 3 gm vial   1 Forumlary Drugs 25% 25% None
AMPYRA ER 10 MG TABLET   1 Forumlary Drugs 25% 25% P Q:60/30Days
Amturnide 150; 5; 12.5mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   1 Forumlary Drugs 25% 25% S
Amturnide 300; 10; 12.5mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   1 Forumlary Drugs 25% 25% S
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Amturnide 300; 10; 25mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   1 Forumlary Drugs 25% 25% S
Amturnide 300; 5; 12.5mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   1 Forumlary Drugs 25% 25% S
Amturnide 300; 5; 25mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   1 Forumlary Drugs 25% 25% S
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE in 1 BOTTLE   1 Forumlary Drugs 25% 25% None
Anagrelide Hydrochloride 1mg/1 100 CAPSULE in 1 BOTTLE   1 Forumlary Drugs 25% 25% None
ANASTROZOLE TABLETS   1 Forumlary Drugs 25% 25% Q:30/30Days
ANDROGEL 1%(50MG) GEL PACKET   1 Forumlary Drugs 25% 25% P
Androgel 16.2mg/g 1 BOTTLE, PUMP in 1 CARTON / 88 g in 1 BOTTLE, PUMP   1 Forumlary Drugs 25% 25% P
APAP-CAFFEINE-DIHYDROCODE TAB 30 EA   1 Forumlary Drugs 25% 25% Q:150/30Days
APOKYN 30 MG/3 ML CARTRIDGE   1 Forumlary Drugs 25% 25% P Q:60/30Days
Apraclonidine Ophthalmic 5mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 10 mL in 1 BOTTLE, DROPPER   1 Forumlary Drugs 25% 25% None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
APRI 0.15-0.03 TABLET   1 Forumlary Drugs 25% 25% None
APRISO CP24   1 Forumlary Drugs 25% 25% None
APTIVUS 250MG CAPSULE   1 Forumlary Drugs 25% 25% None
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT   1 Forumlary Drugs 25% 25% Q:300/30Days
ARANELLE 7-9-5 TABLET   1 Forumlary Drugs 25% 25% None
ARANESP 100ug/0.5mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE in 1 BLISTER PACK / 0.5 mL in 1 SYRINGE   1 Forumlary Drugs 25% 25% P
ARANESP 100ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE   1 Forumlary Drugs 25% 25% P
ARANESP 200MCG/0.4ML SYRINGE   1 Forumlary Drugs 25% 25% P
ARANESP 200MCG/ML VIAL   1 Forumlary Drugs 25% 25% P
ARANESP 25ug/0.42mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE in 1 BLISTER PACK / 0.42 mL in 1 SYRING   1 Forumlary Drugs 25% 25% P
ARANESP 25ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE   1 Forumlary Drugs 25% 25% P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ARANESP 300MCG/ML VIAL   1 Forumlary Drugs 25% 25% P
ARANESP 500MCG/1ML SYRINGE   1 Forumlary Drugs 25% 25% P
ARANESP 60MCG/ML VIAL   1 Forumlary Drugs 25% 25% P
ARANESP 60ug/0.3mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE in 1 BLISTER PACK / 0.3 mL in 1 SYRINGE   1 Forumlary Drugs 25% 25% P
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR   1 Forumlary Drugs 25% 25% P
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR   1 Forumlary Drugs 25% 25% P
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR   1 Forumlary Drugs 25% 25% P
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD   1 Forumlary Drugs 25% 25% P
ARCALYST INJECTION 220MG/VIAL   1 Forumlary Drugs 25% 25% P
ARZERRA 20mg/mL 3 VIAL in 1 CARTON / 5 mL in 1 VIAL   1 Forumlary Drugs 25% 25% P
ASACOL 400mg/1 12 BOTTLE in 1 CASE / 180 TABLET, DELAYED RELEASE in 1 BOTTLE   1 Forumlary Drugs 25% 25% None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Ascomp with Codeine 325; 50; 40; 30mg/1; mg/1; mg/1; mg/1 500 CAPSULE in 1 BOTTLE, PLASTIC   1 Forumlary Drugs 25% 25% Q:360/30Days
ASTRAMORPH PF INJECTION 0.5MG/ML   1 Forumlary Drugs 25% 25% None
ASTRAMORPH PF INJECTION 1MG/ML   1 Forumlary Drugs 25% 25% None
Atelvia 35mg/1 36 DOSE PACK in 1 CASE / 4 TABLET, DELAYED RELEASE in 1 DOSE PACK   1 Forumlary Drugs 25% 25% Q:4/28Days
ATENOLOL 100mg 100 TABLET BOTTLE   1 Forumlary Drugs 25% 25% None
Atenolol 25mg 100 TABLET BOTTLE   1 Forumlary Drugs 25% 25% None
ATENOLOL TABLET USP 50MG (100 CT)   1 Forumlary Drugs 25% 25% None
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT)   1 Forumlary Drugs 25% 25% None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   1 Forumlary Drugs 25% 25% None
ATGAM 50MG/ML AMPUL   1 Forumlary Drugs 25% 25% P
ATORVASTATIN 10 MG TABLET   1 Forumlary Drugs 25% 25% Q:30/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ATORVASTATIN 20 MG TABLET   1 Forumlary Drugs 25% 25% Q:30/30Days
ATORVASTATIN 40 MG TABLET   1 Forumlary Drugs 25% 25% Q:30/30Days
ATORVASTATIN 80 MG TABLET   1 Forumlary Drugs 25% 25% Q:30/30Days
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE, PLASTIC   1 Forumlary Drugs 25% 25% None
ATROPINE 0.05MG/ML SYRINGE   1 Forumlary Drugs 25% 25% None
ATROPINE 0.1MG/ML SYRINGE   1 Forumlary Drugs 25% 25% None
ATROVENT HFA AER 17MCG   1 Forumlary Drugs 25% 25% Q:26/30Days
AUGMENTED BETAMETHASONE DIPROPIONATE OINTMENT   1 Forumlary Drugs 25% 25% None
AVASTIN 100MG/4ML VIAL   1 Forumlary Drugs 25% 25% P
AVELOX 400MG TABLET   1 Forumlary Drugs 25% 25% None
AVELOX ABC PACK 400MG TABLET   1 Forumlary Drugs 25% 25% None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
AVELOX IV 400MG/250ML   1 Forumlary Drugs 25% 25% None
AVIANE 0.1-0.02 TABLET   1 Forumlary Drugs 25% 25% None
AVITA 0.025% CREAM   1 Forumlary Drugs 25% 25% P
Avita 0.25mg/g 45 g in 1 TUBE   1 Forumlary Drugs 25% 25% P
AVODART 0.5MG SOFTGEL   1 Forumlary Drugs 25% 25% None
AVONEX ADMIN PACK 30MCG SYR   1 Forumlary Drugs 25% 25% P Q:4/28Days
AVONEX ADMIN PACK 30MCG VL   1 Forumlary Drugs 25% 25% P Q:4/28Days
AZACTAM INJECTION 1GM/50ML   1 Forumlary Drugs 25% 25% None
AZACTAM INJECTION 2GM/50ML   1 Forumlary Drugs 25% 25% None
AZASAN 100MG TABLET   1 Forumlary Drugs 25% 25% P
AZASAN 75MG TABLET   1 Forumlary Drugs 25% 25% P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
AZASITE 1% DROPS   1 Forumlary Drugs 25% 25% None
AZATHIOPRINE 50MG TABLET   1 Forumlary Drugs 25% 25% None
AZELASTINE 137 MCG NASAL SPRAY   1 Forumlary Drugs 25% 25% Q:60/30Days
AZELASTINE HYDROCHLORIDE OPHTHALMIC SOLUTION   1 Forumlary Drugs 25% 25% None
AZILECT 0.5MG TABLET   1 Forumlary Drugs 25% 25% None
AZILECT 1MG TABLET   1 Forumlary Drugs 25% 25% None
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Forumlary Drugs 25% 25% Q:150/30Days
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Forumlary Drugs 25% 25% Q:75/30Days
AZITHROMYCIN 250 MG TABLET   1 Forumlary Drugs 25% 25% Q:12/28Days
Azithromycin 500mg/1 10 VIAL, SINGLE-USE in 1 TRAY / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION   1 Forumlary Drugs 25% 25% None
Azithromycin 500mg/1 30 TABLET, FILM COATED in 1 BOTTLE   1 Forumlary Drugs 25% 25% Q:12/28Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Azithromycin 600mg/1 30 TABLET, FILM COATED in 1 BOTTLE   1 Forumlary Drugs 25% 25% Q:12/28Days
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT   1 Forumlary Drugs 25% 25% None
AZTREONAM FOR INJECTION   1 Forumlary Drugs 25% 25% None



What does all this mean? Here are a few notes to help you understand the above 2013 Medicare Part D HealthSpring Prescription Drug Plan-Reg 25 (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 $325 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 $2970) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2013 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 April 2013 )

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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