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2014 Medicare Part D or Medicare Advantage Plan Formulary Browser

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Selected Plan:MedicareRx Rewards Standard (PDP) (S5960-131-0)
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    Browse Formulary by clicking on the First Letter of Drug Name:
    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 
: :Example: AARP MedicareRx Preferred (PDP) Formulary in Florida
 
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2014 Medicare Part D Plan Formulary Information
MedicareRx Rewards Standard (PDP) (S5960-131-0)          
The MedicareRx Rewards Standard (PDP) (S5960-131-0) 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: $59.30 Deductible: $310 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
ABACAVIR 300 MG TABLET   3 Preferred Brand $24.00$72.00None
Abacavir Sulfate-Lamivudine-Zidovudine tablets   6 Specialty Tier 25%N/ANone
ABELCENT INJECTION SUSPENSION 5MG/ML   6 Specialty Tier 25%N/AP
ABILIFY 10MG TABLET   4 Non-Preferred Brand $76.00$228.00Q:90/30Days
ABILIFY 15MG TABLET   4 Non-Preferred Brand $76.00$228.00Q:60/30Days
ABILIFY 1MG/ML SOLUTION   4 Non-Preferred Brand $76.00$228.00Q:900/30Days
ABILIFY 20MG TABLET   6 Specialty Tier 25%N/AQ:60/30Days
ABILIFY 2MG TABLET   4 Non-Preferred Brand $76.00$228.00Q:450/30Days
ABILIFY 30MG TABLET   6 Specialty Tier 25%N/AQ:30/30Days
ABILIFY 5MG TABLET (OTSUKA)   4 Non-Preferred Brand $76.00$228.00Q:180/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ABILIFY DISCMELT 10MG TABLET   6 Specialty Tier 25%N/AQ:90/30Days
ABILIFY DISCMELT 15MG TABLET   6 Specialty Tier 25%N/AQ:60/30Days
ABILIFY INJ 9.75MG   5 Injectable Drugs $95.00$285.00None
ABILIFY MAINTENA ER 300 MG VL   6 Specialty Tier 25%N/ANone
ABRAXANE 100MG VIAL   6 Specialty Tier 25%N/AP
Acarbose 100mg/1 1000 TABLET BOTTLE, PLASTIC   2 Non-Preferred Generic $2.00$4.00Q:90/30Days
ACARBOSE 25 MG TABLETS   2 Non-Preferred Generic $2.00$4.00Q:360/30Days
Acarbose 50mg/1 100 TABLET BOTTLE   2 Non-Preferred Generic $2.00$4.00Q:180/30Days
ACEBUTOLOL 200MG CAPSULE   2 Non-Preferred Generic $2.00$4.00None
ACEBUTOLOL 400MG CAPSULE   2 Non-Preferred Generic $2.00$4.00None
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE   3 Preferred Brand $24.00$72.00None
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 $2.00$4.00Q:390/30Days
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD   2 Non-Preferred Generic $2.00$4.00Q:4500/30Days
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT)   2 Non-Preferred Generic $2.00$4.00Q:390/30Days
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT)   2 Non-Preferred Generic $2.00$4.00Q:390/30Days
ACETASOL HC SOLUTION 10ML 10 ML BOT   3 Preferred Brand $24.00$72.00None
ACETAZOLAMIDE 125MG TABLET   2 Non-Preferred Generic $2.00$4.00None
ACETAZOLAMIDE 250MG TABLET (100 CT)   2 Non-Preferred Generic $2.00$4.00None
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT   2 Non-Preferred Generic $2.00$4.00None
ACETIC ACID 2% SOLUTION NON-ORAL   1 Preferred Generic $1.00$2.00None
ACETYLCYSTEINE 10% VIAL   2 Non-Preferred Generic $2.00$4.00P
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN   2 Non-Preferred Generic $2.00$4.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACITRETIN 10 MG CAPSULE   6 Specialty Tier 25%N/ANone
ACITRETIN 17.5 MG CAPSULE   6 Specialty Tier 25%N/ANone
ACITRETIN 25 MG CAPSULE   6 Specialty Tier 25%N/ANone
ACTEMRA INJECTION 200MG/10ML   6 Specialty Tier 25%N/AP
ACTHIB VACCINE VIAL 10-24UNT/5ML   3 Preferred Brand $24.00$72.00None
ACTIMMUNE SOLUTION FOR INJECTION 100MCG   6 Specialty Tier 25%N/AP
ACYCLOVIR 200 MG CAPSULE   2 Non-Preferred Generic $2.00$4.00None
Acyclovir 200mg/5mL 473 mL in 1 BOTTLE   2 Non-Preferred Generic $2.00$4.00None
acyclovir 400mg/1   2 Non-Preferred Generic $2.00$4.00None
ACYCLOVIR 800 MG TABLET   2 Non-Preferred Generic $2.00$4.00None
ACYCLOVIR SODIUM 500MG VIAL   5 Injectable Drugs $95.00$285.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADACEL VIAL 2UNT/5UNT   3 Preferred Brand $24.00$72.00None
ADAGEN 250U/ML VIAL   6 Specialty Tier 25%N/ANone
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA]   6 Specialty Tier 25%N/AP Q:2/28Days
ADAPALENE 0.1% GEL   2 Non-Preferred Generic $2.00$4.00None
ADEFOVIR DIPIVOXIL 10 MG TAB   6 Specialty Tier 25%N/ANone
ADVAIR DISKUS MIS 100/50   3 Preferred Brand $24.00$72.00Q:60/30Days
ADVAIR DISKUS MIS 250/50   3 Preferred Brand $24.00$72.00Q:60/30Days
ADVAIR DISKUS MIS 500/50   3 Preferred Brand $24.00$72.00Q:60/30Days
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER   3 Preferred Brand $24.00$72.00Q:12/30Days
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL   3 Preferred Brand $24.00$72.00Q:12/30Days
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL   3 Preferred Brand $24.00$72.00Q:12/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AFEDITAB CR 30MG TABLET SA   2 Non-Preferred Generic $2.00$4.00None
AFEDITAB CR 60MG TABLET SA   2 Non-Preferred Generic $2.00$4.00None
Afinitor 7.5mg/1 28 BLISTER PACK in 1 CARTON / 1 TABLET in 1 BLISTER PACK   6 Specialty Tier 25%N/AP
AFINITOR DISPERZ 2 MG TABLET   6 Specialty Tier 25%N/AP
AFINITOR DISPERZ 3 MG TABLET   6 Specialty Tier 25%N/AP
AFINITOR DISPERZ 5 MG TABLET   6 Specialty Tier 25%N/AP
AFINITOR TABLETS 10 MG   6 Specialty Tier 25%N/AP
AFINITOR TABLETS 2.5 MG   6 Specialty Tier 25%N/AP
AFINITOR TABLETS 5 MG   6 Specialty Tier 25%N/AP
AGGRENOX 25-200MG CAPSULE   3 Preferred Brand $24.00$72.00Q:60/30Days
AK-CON 0.1% EYE DROPS   1 Preferred Generic $1.00$2.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALBENZA 200 MG TABLET   3 Preferred Brand $24.00$72.00None
ALBUTEROL SULFATE 0.75mg/3mL 30 POUCH in 1 CARTON / 1 VIAL, SINGLE-DOSE in 1 POUCH / 3 mL in 1 VIAL   2 Non-Preferred Generic $2.00$4.00P Q:360/30Days
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER   2 Non-Preferred Generic $2.00$4.00P Q:360/30Days
ALBUTEROL SULFATE 4MG TABLET SR 12HR   2 Non-Preferred Generic $2.00$4.00None
ALBUTEROL SULFATE 8MG TABLET SR 12HR   2 Non-Preferred Generic $2.00$4.00None
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   2 Non-Preferred Generic $2.00$4.00P Q:60/30Days
ALBUTEROL SULFATE SOLUTION FOR INHALATION   2 Non-Preferred Generic $2.00$4.00P Q:360/30Days
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT   2 Non-Preferred Generic $2.00$4.00None
ALBUTEROL SULFATE TABLET 2MG (500 CT)   2 Non-Preferred Generic $2.00$4.00None
ALBUTEROL TABLET 4MG (500 CT)   2 Non-Preferred Generic $2.00$4.00None
ALCLOMETASONE DIPROPIONATE 0.05% CREAM   2 Non-Preferred Generic $2.00$4.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Alclometasone Dipropionate 0.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE   2 Non-Preferred Generic $2.00$4.00None
ALDURAZYME 2.9MG/5ML VIAL   6 Specialty Tier 25%N/AP
ALENDRONATE SODIUM 10MG TABLET   2 Non-Preferred Generic $2.00$4.00Q:30/30Days
ALENDRONATE SODIUM 40MG TABLET   2 Non-Preferred Generic $2.00$4.00Q:30/30Days
ALENDRONATE SODIUM 5MG TABLET   2 Non-Preferred Generic $2.00$4.00Q:30/30Days
ALENDRONATE SODIUM 70mg/1   2 Non-Preferred Generic $2.00$4.00Q:4/28Days
ALENDRONATE SODIUM TABLET 35MG 20 CRTN   2 Non-Preferred Generic $2.00$4.00Q:4/28Days
ALIMTA 500MG VIAL   6 Specialty Tier 25%N/AP
ALINIA 100MG/5ML SUSPENSION   4 Non-Preferred Brand $76.00$228.00None
ALINIA 500 MG TABLET   4 Non-Preferred Brand $76.00$228.00None
ALLOPURINOL 100 MG TABLETS   1 Preferred Generic $1.00$2.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Allopurinol 300mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET in 1 BLISTER PACK   1 Preferred Generic $1.00$2.00None
ALOPRIM SOLUTION FOR INJECTION 500MG/VIAL 30 ML VIALGL   5 Injectable Drugs $95.00$285.00None
AMANTADINE 100MG CAPSULE   2 Non-Preferred Generic $2.00$4.00None
AMANTADINE 100MG TABLET   2 Non-Preferred Generic $2.00$4.00None
AMCINONIDE 0.1% CREAM   3 Preferred Brand $24.00$72.00None
AMCINONIDE 0.1% LOTION   3 Preferred Brand $24.00$72.00None
AMCINONIDE 0.1% OINTMENT 60GM TUBE   3 Preferred Brand $24.00$72.00None
AMIFOSTINE 50mg/mL 3 VIAL, SINGLE-USE in 1 CARTON / 10 mL in 1 VIAL, SINGLE-USE   6 Specialty Tier 25%N/AP
AMIKACIN Sulfate 1g/4mL 10 VIAL, SINGLE-DOSE in 1 CARTON / 4 mL in 1 VIAL, SINGLE-DOSE   5 Injectable Drugs $95.00$285.00None
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET   1 Preferred Generic $1.00$2.00None
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT   2 Non-Preferred Generic $2.00$4.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN HBC INJECTION SULFITE FREE 7%   5 Injectable Drugs $95.00$285.00None
AMINOSYN PF INJECTION   5 Injectable Drugs $95.00$285.00None
AMINOSYN-PF 7% IV SOLUTION   5 Injectable Drugs $95.00$285.00None
AMIODARONE HCL 400MG TABLET   2 Non-Preferred Generic $2.00$4.00None
Amiodarone Hydrochloride 200mg/1 60 TABLET BOTTLE   2 Non-Preferred Generic $2.00$4.00None
AMITRIP/PERPHEN 10-2 TABLET   3 Preferred Brand $24.00$72.00None
AMITRIP/PERPHEN 10-4 TABLET   3 Preferred Brand $24.00$72.00None
AMITRIP/PERPHEN 25-2 TABLET   3 Preferred Brand $24.00$72.00None
AMITRIP/PERPHEN 25-4 TABLET   3 Preferred Brand $24.00$72.00None
AMITRIP/PERPHEN 50-4 TABLET   3 Preferred Brand $24.00$72.00None
AMITRIPTYLINE HCL 100MG TABLET   3 Preferred Brand $24.00$72.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITRIPTYLINE HCL 10MG TABLET   3 Preferred Brand $24.00$72.00P
AMITRIPTYLINE HCL 150 MG TAB   3 Preferred Brand $24.00$72.00P
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)   3 Preferred Brand $24.00$72.00P
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)   3 Preferred Brand $24.00$72.00P
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT   3 Preferred Brand $24.00$72.00P
AMLODIPINE BESYLATE 10MG TABLET (90 CT)   1 Preferred Generic $1.00$2.00Q:30/30Days
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)   1 Preferred Generic $1.00$2.00Q:30/30Days
AMLODIPINE BESYLATE 5MG TABLET (90 CT)   1 Preferred Generic $1.00$2.00Q:45/30Days
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE 10MG/40MG CAPSULES   1 Preferred Generic $1.00$2.00None
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE 5MG/40MG CAPSULES   1 Preferred Generic $1.00$2.00None
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE   1 Preferred Generic $1.00$2.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE   1 Preferred Generic $1.00$2.00None
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE   1 Preferred Generic $1.00$2.00None
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE   1 Preferred Generic $1.00$2.00None
Amnesteem 10mg/1 3 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK   3 Preferred Brand $24.00$72.00None
Amnesteem 20mg/1 3 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK   4 Non-Preferred Brand $76.00$228.00None
Amnesteem 40mg/1 3 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK   4 Non-Preferred Brand $76.00$228.00None
amox tr-k clv 200-28.5/5 susp   3 Preferred Brand $24.00$72.00None
AMOX TR-K CLV 500-125 MG TAB   3 Preferred Brand $24.00$72.00None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE   3 Preferred Brand $24.00$72.00None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET   3 Preferred Brand $24.00$72.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE   3 Preferred Brand $24.00$72.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   3 Preferred Brand $24.00$72.00None
AMOXAPINE 100MG TABLET   2 Non-Preferred Generic $2.00$4.00None
AMOXAPINE 150MG TABLET   2 Non-Preferred Generic $2.00$4.00None
AMOXAPINE 25MG TABLET   2 Non-Preferred Generic $2.00$4.00None
AMOXAPINE 50MG TABLET   2 Non-Preferred Generic $2.00$4.00None
AMOXICILLIN 125MG TABLET CHEW   1 Preferred Generic $1.00$2.00None
AMOXICILLIN 250MG CAPSULE   1 Preferred Generic $1.00$2.00None
Amoxicillin 250mg/1 500 TABLET, CHEWABLE in 1 BOTTLE   1 Preferred Generic $1.00$2.00None
AMOXICILLIN 50 MG/ML / CLAVULANATE 12.5 MG/ML ORAL SUSPENSION   3 Preferred Brand $24.00$72.00None
AMOXICILLIN 500MG TABLET (100 CT)   1 Preferred Generic $1.00$2.00None
Amoxicillin 500mg/1 500 CAPSULE in 1 BOTTLE, PLASTIC   1 Preferred Generic $1.00$2.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN 875MG TABLET   1 Preferred Generic $1.00$2.00None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT   3 Preferred Brand $24.00$72.00None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS EXTENDED RELEASE 1000;62.5MG;MG   3 Preferred Brand $24.00$72.00None
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT   3 Preferred Brand $24.00$72.00None
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT   1 Preferred Generic $1.00$2.00None
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL   1 Preferred Generic $1.00$2.00None
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   1 Preferred Generic $1.00$2.00None
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL   1 Preferred Generic $1.00$2.00None
AMPHETAMINE SALT COMBO 12.5MG TABLET   3 Preferred Brand $24.00$72.00Q:90/30Days
AMPHETAMINE SALT COMBO 15MG TABLET   3 Preferred Brand $24.00$72.00Q:90/30Days
AMPHETAMINE SALT COMBO 30MG TABLET   3 Preferred Brand $24.00$72.00Q:60/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPHETAMINE SALT COMBO 7.5MG TABLET   3 Preferred Brand $24.00$72.00Q:90/30Days
AMPHETAMINE SALTS 20MG TABLET   3 Preferred Brand $24.00$72.00Q:90/30Days
AMPHETAMINE SALTS 5 MG TAB   3 Preferred Brand $24.00$72.00Q:90/30Days
amphotericin b 50mg/10mL 10 mL in 1 VIAL   5 Injectable Drugs $95.00$285.00P
Ampicillin 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS   5 Injectable Drugs $95.00$285.00None
AMPICILLIN CAPSULES 250MG 100 BOT   1 Preferred Generic $1.00$2.00None
AMPICILLIN CAPSULES 500MG 100 BOT   1 Preferred Generic $1.00$2.00None
AMPICILLIN FOR INJECTION POWDER   5 Injectable Drugs $95.00$285.00None
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT   1 Preferred Generic $1.00$2.00None
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT   1 Preferred Generic $1.00$2.00None
AMPICILLIN POWDER FOR INJECTION 1 GM/ML   5 Injectable Drugs $95.00$285.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE in 1 BOTTLE   3 Preferred Brand $24.00$72.00None
Anagrelide Hydrochloride 1mg/1 100 CAPSULE in 1 BOTTLE   3 Preferred Brand $24.00$72.00None
Anastrozole 1mg/1 90 FILM COATED TABLETS in BOTTLE, PLASTIC   3 Preferred Brand $24.00$72.00None
ANDROGEL 1%(50MG) GEL PACKET   3 Preferred Brand $24.00$72.00P Q:300/30Days
Androgel 16.2mg/g 1 BOTTLE, PUMP in 1 CARTON / 88 g in 1 BOTTLE, PUMP   3 Preferred Brand $24.00$72.00P Q:150/30Days
APOKYN 30 MG/3 ML CARTRIDGE   6 Specialty Tier 25%N/AP
Apraclonidine Ophthalmic 5mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 10 mL in 1 BOTTLE, DROPPER   2 Non-Preferred Generic $2.00$4.00None
APRI 0.15-0.03 TABLET   3 Preferred Brand $24.00$72.00None
APTIVUS 250MG CAPSULE   6 Specialty Tier 25%N/ANone
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT   6 Specialty Tier 25%N/ANone
ARANELLE 7-9-5 TABLET   3 Preferred Brand $24.00$72.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP 100ug/0.5mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE in 1 BLISTER PACK / 0.5 mL in 1 SYRINGE   6 Specialty Tier 25%N/AP
ARANESP 100ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE   6 Specialty Tier 25%N/AP
ARANESP 200MCG/0.4ML SYRINGE   6 Specialty Tier 25%N/AP
ARANESP 200MCG/ML VIAL   6 Specialty Tier 25%N/AP
ARANESP 25ug/0.42mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE in 1 BLISTER PACK / 0.42 mL in 1 SYRING   5 Injectable Drugs $95.00$285.00P
ARANESP 25ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE   5 Injectable Drugs $95.00$285.00P
ARANESP 300MCG/ML VIAL   6 Specialty Tier 25%N/AP
ARANESP 500MCG/1ML SYRINGE   6 Specialty Tier 25%N/AP
ARANESP 60MCG/ML VIAL   5 Injectable Drugs $95.00$285.00P
ARANESP 60ug/0.3mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE in 1 BLISTER PACK / 0.3 mL in 1 SYRINGE   5 Injectable Drugs $95.00$285.00P
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR   6 Specialty Tier 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR   6 Specialty Tier 25%N/AP
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR   5 Injectable Drugs $95.00$285.00P
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD   5 Injectable Drugs $95.00$285.00P
ARCALYST INJECTION 220MG/VIAL   6 Specialty Tier 25%N/AP
ARRANON 250MG VIAL   5 Injectable Drugs $95.00$285.00P
ARZERRA 20mg/mL 3 VIAL in 1 CARTON / 5 mL in 1 VIAL   6 Specialty Tier 25%N/AP
ASTAGRAF XL 0.5 MG CAPSULE   4 Non-Preferred Brand $76.00$228.00P
ASTAGRAF XL 1 MG CAPSULE   4 Non-Preferred Brand $76.00$228.00P
ASTAGRAF XL 5 MG CAPSULE   4 Non-Preferred Brand $76.00$228.00P
ATENOLOL 100mg 100 TABLET BOTTLE   2 Non-Preferred Generic $2.00$4.00None
Atenolol 25mg 100 TABLET BOTTLE   2 Non-Preferred Generic $2.00$4.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATENOLOL TABLET USP 50MG (100 CT)   2 Non-Preferred Generic $2.00$4.00None
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT)   2 Non-Preferred Generic $2.00$4.00None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   2 Non-Preferred Generic $2.00$4.00None
ATORVASTATIN 10 MG TABLET   1 Preferred Generic $1.00$2.00Q:30/30Days
ATORVASTATIN 20 MG TABLET   1 Preferred Generic $1.00$2.00Q:30/30Days
ATORVASTATIN 40 MG TABLET   1 Preferred Generic $1.00$2.00Q:30/30Days
ATORVASTATIN 80 MG TABLET   1 Preferred Generic $1.00$2.00Q:30/30Days
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC   6 Specialty Tier 25%N/ANone
ATROVENT HFA AER 17MCG   4 Non-Preferred Brand $76.00$228.00Q:26/30Days
AUGMENTED BETAMETHASONE DIPROPIONATE OINTMENT   2 Non-Preferred Generic $2.00$4.00None
AVASTIN 100MG/4ML VIAL   6 Specialty Tier 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVIANE 0.1-0.02 TABLET   3 Preferred Brand $24.00$72.00None
AVODART 0.5MG SOFTGEL   3 Preferred Brand $24.00$72.00None
AVONEX ADMIN PACK 30MCG SYR   6 Specialty Tier 25%N/AP
AVONEX ADMIN PACK 30MCG VL   6 Specialty Tier 25%N/AP
Azacitidine 100 mg vial   6 Specialty Tier 25%N/AP
AZATHIOPRINE 50MG TABLET   2 Non-Preferred Generic $2.00$4.00P
AZELASTINE 137 MCG NASAL SPRAY   2 Non-Preferred Generic $2.00$4.00Q:30/25Days
AZELASTINE HYDROCHLORIDE OPHTHALMIC SOLUTION   2 Non-Preferred Generic $2.00$4.00None
AZILECT 0.5MG TABLET   3 Preferred Brand $24.00$72.00None
AZILECT 1MG TABLET   3 Preferred Brand $24.00$72.00None
Azithromycin 100mg/5mL 15 mL in 1 BOTTLE   2 Non-Preferred Generic $2.00$4.00Q:15/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Azithromycin 200mg/5mL 22.5 mL in 1 BOTTLE   2 Non-Preferred Generic $2.00$4.00Q:46/1Days
AZITHROMYCIN 250 MG TABLET   2 Non-Preferred Generic $2.00$4.00Q:6/1Days
Azithromycin 500mg/1 10 VIAL, SINGLE-USE in 1 TRAY / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION   5 Injectable Drugs $95.00$285.00None
Azithromycin 500mg/1 30 FILM COATED TABLETS in BOTTLE   2 Non-Preferred Generic $2.00$4.00Q:3/1Days
Azithromycin 600mg/1 30 FILM COATED TABLETS in BOTTLE   2 Non-Preferred Generic $2.00$4.00Q:8/1Days



What does all this mean? Here are a few notes to help you understand the above 2014 Medicare Part D MedicareRx Rewards Standard (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 June 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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