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Browse 2010 Drug Only (PDP) Plan Formulary

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Selected Plan:AARP MedicareRx Saver (PDP) (S5921-321)
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2010 Medicare Part D Plan Formulary Information
AARP MedicareRx Saver (PDP) (S5921-321)    Enroll in AARP MedicareRx Saver (PDP)
The AARP MedicareRx Saver (PDP) (S5921-321) Formulary for Drugs Starting with the Letter A
in CMS Region 20 which includes: MS
Plan Monthly Premium: $30.20 Deductible: $310
Drugs Start with Letter A

Drug Name		 Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order
A METHAPRED METHLYPREDNISOLONE SODIUM SUCCINATE FOR INJECTION 125 MG 1 Tier 1 Preferred Generic Brand $6.00 N/A None
A-HYDROCORT 100MG VIAL 1 Tier 1 Preferred Generic Brand $6.00 N/A None
A-METHAPRED 40MG UNIVIAL 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ABELCENT INJECTION SUSPENSION 5MG/ML 4 Tier 4 Specialty 25% N/A P
ABILIFY 10MG TABLET 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A S Q:31/31Days
ABILIFY 15MG TABLET 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A S Q:31/31Days
ABILIFY 1MG/ML SOLUTION 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A S Q:775/31Days
ABILIFY 20MG TABLET 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A S Q:31/31Days
ABILIFY 2MG TABLET 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A S Q:31/31Days
ABILIFY 30MG TABLET 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A S Q:31/31Days
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
ABILIFY 5MG TABLET (OTSUKA) 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A S Q:31/31Days
ABILIFY DISCMELT 10MG TABLET 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A S Q:62/31Days
ABILIFY DISCMELT 15MG TABLET 4 Tier 4 Specialty 25% N/A S Q:62/31Days
ABILIFY INJ 9.75MG 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A None
ABRAXANE 100MG VIAL 4 Tier 4 Specialty 25% N/A None
ACARBOSE 100MG TABLET S 1 Tier 1 Preferred Generic Brand $6.00 N/A S
ACARBOSE 25MG TABLET S 1 Tier 1 Preferred Generic Brand $6.00 N/A S
ACARBOSE 50MG TABLET S 1 Tier 1 Preferred Generic Brand $6.00 N/A S
ACCOLATE 10MG TABLET 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A S Q:62/31Days
ACCOLATE 20MG TABLET 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A S Q:62/31Days
ACEBUTOLOL 200MG CAPSULE 1 Tier 1 Preferred Generic Brand $6.00 N/A None
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
ACEBUTOLOL 400MG CAPSULE 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ACETADOTE 200MG/ML VIAL 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A None
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT) 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT) 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT) 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ACETASOL HC OTIC SOLUTION 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ACETASOL HC SOLUTION 10ML 10 ML BOT 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ACETAZOLAMIDE 125MG TABLET 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ACETAZOLAMIDE 250MG TABLET (100 CT) 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT 2 Tier 2 Generic Preferred Brand $25.00 N/A None
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
ACETAZOLAMIDE SOD 500MG VL 2 Tier 2 Generic Preferred Brand $25.00 N/A None
ACETIC ACID 2% SOLUTION NON-ORAL 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ACETIC ACID IN AQUEOUS ALUMINUM ACETATE OTIC SOLUTION 2% 60 ML BOT 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ACETYLCYSTEINE 10% VIAL 1 Tier 1 Preferred Generic Brand $6.00 N/A P
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN 1 Tier 1 Preferred Generic Brand $6.00 N/A P
ACTHIB VACCINE VIAL 10-24UNT/5ML 2 Tier 2 Generic Preferred Brand $25.00 N/A None
ACTICIN 5% CREAM 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ACTIMMUNE SOLUTION FOR INJECTION 100MCG 4 Tier 4 Specialty 25% N/A None
ACTIVELLA 0.5-0.1MG TABLET 28 DLPK 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A None
ACTIVELLA 1-0.5MG TABLET 28 DLPK 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A None
ACTONEL 150MG TABLET 2 Tier 2 Generic Preferred Brand $25.00 N/A Q:1/28Days
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
ACTONEL 30MG TABLET 2 Tier 2 Generic Preferred Brand $25.00 N/A Q:31/31Days
ACTONEL 35MG TABLET 2 Tier 2 Generic Preferred Brand $25.00 N/A Q:4/28Days
ACTONEL 5MG TABLET 2 Tier 2 Generic Preferred Brand $25.00 N/A Q:31/31Days
ACTONEL 75MG TABLET 2 Tier 2 Generic Preferred Brand $25.00 N/A Q:2/28Days
ACTONEL WITH CALCIUM TABLET 2 Tier 2 Generic Preferred Brand $25.00 N/A Q:31/31Days
ACTOPLUS MET 15MG/500MG TABLET 2 Tier 2 Generic Preferred Brand $25.00 N/A S
ACTOPLUS MET 15MG/850MG TABLET 2 Tier 2 Generic Preferred Brand $25.00 N/A S
ACTOS 15MG TABLET 2 Tier 2 Generic Preferred Brand $25.00 N/A S
ACTOS 30MG TABLET (500 CT) 2 Tier 2 Generic Preferred Brand $25.00 N/A S
ACTOS 45MG TABLET 2 Tier 2 Generic Preferred Brand $25.00 N/A S
ACULAR 0.5% EYE DROPS 2 Tier 2 Generic Preferred Brand $25.00 N/A None
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
ACULAR LS 0.4% OPHTH SOL 2 Tier 2 Generic Preferred Brand $25.00 N/A None
ACYCLOVIR 200MG CAPSULE (1000 CT) 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ACYCLOVIR 200MG/5ML SUSP 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ACYCLOVIR 400MG TABLET (100 CT) 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ACYCLOVIR SODIUM 500MG VIAL 2 Tier 2 Generic Preferred Brand $25.00 N/A P
ACYCLOVIR TABLET USP 800MG (100 CT) 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ADACEL VIAL 2UNT/5UNT 2 Tier 2 Generic Preferred Brand $25.00 N/A None
ADAGEN 250U/ML VIAL 4 Tier 4 Specialty 25% N/A None
ADCIRCA TABLETS 20MG 60 BOT 4 Tier 4 Specialty 25% N/A P Q:62/31Days
ADDERALL XR 10MG CAPSULE SA 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A Q:62/31Days
ADDERALL XR 15MG CAPSULE SA 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A Q:62/31Days
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
ADDERALL XR 20MG CAPSULE SA 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A Q:31/31Days
ADDERALL XR 25MG CAPSULE SA 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A Q:31/31Days
ADDERALL XR 30MG CAPSULE SA 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A Q:31/31Days
ADDERALL XR 5MG CAPSULE SA 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A Q:62/31Days
ADVAIR DISKU MIS 100/50 2 Tier 2 Generic Preferred Brand $25.00 N/A Q:60/30Days
ADVAIR DISKU MIS 250/50 2 Tier 2 Generic Preferred Brand $25.00 N/A Q:60/30Days
ADVAIR DISKU MIS 500/50 2 Tier 2 Generic Preferred Brand $25.00 N/A Q:60/30Days
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL 2 Tier 2 Generic Preferred Brand $25.00 N/A Q:12/30Days
ADVAIR HFA INHALER 230;21MCG;MCG 2 Tier 2 Generic Preferred Brand $25.00 N/A Q:12/30Days
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL 2 Tier 2 Generic Preferred Brand $25.00 N/A Q:12/30Days
AEROBID-M AEROSOL W/ADAPTER 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A S Q:21/30Days
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
AFEDITAB CR 30MG TABLET SA 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AFEDITAB CR 60MG TABLET SA 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AGGRENOX 25-200MG CAPSULE 2 Tier 2 Generic Preferred Brand $25.00 N/A Q:62/31Days
AK-CON 0.1% EYE DROPS 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AK-POLY-BAC EYE OINTMENT 500UNT/1000UNT 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AKNE-MYCIN 2% OINTMENT 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A None
AKTOB 0.3% EYE DROPS 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ALA-CORT 1% CREAM 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ALA-CORT 1% LOTION 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ALA-SCALP HP 2% LOTION 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A None
ALAMAST 0.1% DROPS 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A None
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
ALBENZA 200MG TABLET 2 Tier 2 Generic Preferred Brand $25.00 N/A None
ALBUTEROL SULFATE 0.63MG/3ML VIAL NEBULIZER 1 Tier 1 Preferred Generic Brand $6.00 N/A P
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER 1 Tier 1 Preferred Generic Brand $6.00 N/A P
ALBUTEROL SULFATE 2.5MG/3ML VIAL NEBULIZER 1 Tier 1 Preferred Generic Brand $6.00 N/A P
ALBUTEROL SULFATE 4MG TABLET SR 12HR 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ALBUTEROL SULFATE 8MG TABLET SR 12HR 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR 1 Tier 1 Preferred Generic Brand $6.00 N/A P
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ALBUTEROL SULFATE TABLET 2MG (500 CT) 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ALBUTEROL TABLET 4MG (500 CT) 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ALCAINE 0.5% EYE DROPS 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A None
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
ALCLOMETASONE DIPROPIONATE 0.05% CREAM 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ALCLOMETASONE DIPROPIONATE 0.05% OINTMENT 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ALCOHOL 5%/DEXTROSE 5% 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ALDARA IMIQUIMOD CREAM 5% 24 PKT X 250 MG CRTN 2 Tier 2 Generic Preferred Brand $25.00 N/A None
ALDURAZYME 2.9MG/5ML VIAL 4 Tier 4 Specialty 25% N/A None
ALENDRONATE SODIUM 10MG TABLET 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ALENDRONATE SODIUM 40MG TABLET 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ALENDRONATE SODIUM 5MG TABLET 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ALENDRONATE SODIUM 70MG TABLET 4 BLPK 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ALENDRONATE SODIUM TABLET 35MG 20 CRTN 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ALFERON N INJ 5MU/ML 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A None
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
ALIMTA 500MG VIAL 4 Tier 4 Specialty 25% N/A P
ALINIA 100MG/5ML SUSPENSION 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A None
ALINIA 500MG TABLET 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A None
ALKERAN FOR INJECTION 50MG/VIAL 1 VIALSU 4 Tier 4 Specialty 25% N/A None
ALLOPURINOL SODIUM 500MG VIAL 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ALLOPURINOL TABLET 300MG (1000 CT) 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ALLOPURINOL TABLET USP 100MG (1000 CT) 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ALOCRIL 2% EYE DROPS 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A None
ALOMIDE 0.1% EYE DROPS 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A None
ALORA 0.025MG PATCH 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A None
ALORA 0.05MG PATCH 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A None
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
ALORA 0.075MG PATCH 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A None
ALORA 0.1MG PATCH 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A None
ALOXI 0.25MG/5ML 4 Tier 4 Specialty 25% N/A None
ALPHAGAN P 0.1% DROPS 2 Tier 2 Generic Preferred Brand $25.00 N/A None
ALPHAGAN P 0.15% EYE DROPS 2 Tier 2 Generic Preferred Brand $25.00 N/A None
ALREX 0.2% EYE DROPS 2 Tier 2 Generic Preferred Brand $25.00 N/A None
ALTABAX 1% OINTMENT 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A None
ALVESCO 160MCG/ACT AERS 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A S Q:12/30Days
ALVESCO 80MCG/ACT AERS 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A S Q:12/30Days
AMANTADINE 100MG CAPSULE 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMANTADINE 100MG TABLET 1 Tier 1 Preferred Generic Brand $6.00 N/A None
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
AMBISOME 50MG VIAL 4 Tier 4 Specialty 25% N/A P
AMCINONIDE 0.1% CREAM 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMCINONIDE 0.1% LOTION 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMCINONIDE 0.1% OINTMENT 60GM TUBE 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMEVIVE ADMISTRATION PACK FOR INTRAMUSCULAR ADMINISTRATION KIT 15MG 1 X 4 PKGCOM 4 Tier 4 Specialty 25% N/A P
AMIFOSTINE FOR INJECTION 500MG/VIAL 4 Tier 4 Specialty 25% N/A None
AMIKACIN 250MG/ML VIAL 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMIKACIN 50MG/ML VIAL 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMINESS 5.2% IV SOLUTION 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A P
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
AMINOPHYLLINE 100MG TABLET 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMINOPHYLLINE 200MG TABLET (1000 CT) 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMINOPHYLLINE INJECTION 250MG 10ML X 25 VIALSD 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMINOSYN 10% IV SOLUTION 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A P
AMINOSYN 3.5% IV SOLUTION 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A P
AMINOSYN 5% IV SOLUTION 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A P
AMINOSYN 7% IV SOLUTION 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A P
AMINOSYN 7%-ELECTROLYTE SOL 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A P
AMINOSYN 8.5% IV SOLUTION 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A P
AMINOSYN II 10% IV SOLUTION 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A P
AMINOSYN II 3.5% IN D25W IV 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A P
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
AMINOSYN II 3.5% M/D5W IV 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A P
AMINOSYN II 3.5% W/ELEC DEX 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A P
AMINOSYN II 4.25% IN D10W 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A P
AMINOSYN II 4.25% IN D20W 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A P
AMINOSYN II 4.25% W/ELEC DW 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A P
AMINOSYN II 4.25%-D25W IV 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A P
AMINOSYN II 5% IN D25W IV 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A P
AMINOSYN II 7% IV SOLUTION 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A P
AMINOSYN II 8.5% ELECTROLYT 1 Tier 1 Preferred Generic Brand $6.00 N/A P
AMINOSYN II 8.5% IV SOLUTION 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A P
AMINOSYN M 3.5% IV SOLUTION 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A P
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
AMINOSYN PF INJECTION 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A P
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5% 1 Tier 1 Preferred Generic Brand $6.00 N/A P
AMINOSYN-HBC 7% IV SOLUTION 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A P
AMINOSYN-HF 8% IV SOLUTION 2 Tier 2 Generic Preferred Brand $25.00 N/A P
AMINOSYN-PF 7% IV SOLUTION 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A P
AMIODARONE HCL 200MG TABLET (60 CT) 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMIODARONE HCL 400MG TABLET 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMIODARONE HCL INJECTION 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMITIZA 8MCG CAPSULE 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A P Q:62/31Days
AMITIZA CAPSULES 24MCG 60 CAP BOT 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A P Q:62/31Days
AMITRIP/CDP 25-10 TABLET 1 Tier 1 Preferred Generic Brand $6.00 N/A None
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
AMITRIP/PERPHEN 10-2 TABLET 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMITRIP/PERPHEN 10-4 TABLET 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMITRIP/PERPHEN 25-2 TABLET 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMITRIP/PERPHEN 25-4 TABLET 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMITRIP/PERPHEN 50-4 TABLET 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMITRIPTYLINE HCL 100MG TABLET 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMITRIPTYLINE HCL 10MG TABLET 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMITRIPTYLINE HCL 150MG TABLET (100 CT) 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT) 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT) 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT 1 Tier 1 Preferred Generic Brand $6.00 N/A None
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
AMLODIPINE BESYLATE 10MG TABLET (90 CT) 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT) 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMLODIPINE BESYLATE 5MG TABLET (90 CT) 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE 1 Tier 1 Preferred Generic Brand $6.00 N/A Q:31/31Days
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE 1 Tier 1 Preferred Generic Brand $6.00 N/A Q:31/31Days
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE 1 Tier 1 Preferred Generic Brand $6.00 N/A Q:31/31Days
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE 1 Tier 1 Preferred Generic Brand $6.00 N/A Q:31/31Days
AMMONIUM CHLORIDE 5 MEQ/ML 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A None
AMMONIUM LACTATE 12% CREAM 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMMONIUM LACTATE 12% LOTION 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMNESTEEM 10MG CAPSULE 2 Tier 2 Generic Preferred Brand $25.00 N/A None
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
AMNESTEEM 20MG CAPSULE 2 Tier 2 Generic Preferred Brand $25.00 N/A None
AMNESTEEM 40MG CAPSULE 2 Tier 2 Generic Preferred Brand $25.00 N/A None
AMOCLAN 200-28.5/5 SUSPENSION RECONSTITUTED ORAL 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMOCLAN 400-57MG/5 SUSPENSION RECONSTITUTED ORAL 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMOX TR-POTASSIUM CLAVULANATE 500-125MG TABLET 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMOXAPINE 100MG TABLET 1 Tier 1 Preferred Generic Brand $6.00 N/A None
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
AMOXAPINE 150MG TABLET 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMOXAPINE 25MG TABLET 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMOXAPINE 50MG TABLET 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMOXICILLIN 125MG TABLET CHEW 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMOXICILLIN 200MG TABLET CHEW 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMOXICILLIN 250MG CAPSULE 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMOXICILLIN 400MG TABLET CHEW 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMOXICILLIN 500MG CAPSULE 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMOXICILLIN 500MG TABLET (100 CT) 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMOXICILLIN 875MG TABLET 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT 1 Tier 1 Preferred Generic Brand $6.00 N/A None
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMOXICILLIN TABLET USP CHEWABLE 250MG (250 CT) 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMOXIL 250MG/5ML SUSPENSION 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMOXIL 400MG/5ML SUSPENSION 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A None
AMOXIL CAPSULES 500MG 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMPHET ASP/ AMPHET/ D-AMPHET 5MG TABLET 1 Tier 1 Preferred Generic Brand $6.00 N/A Q:372/31Days
AMPHETAMINE SALT COMBO 12.5MG TABLET 1 Tier 1 Preferred Generic Brand $6.00 N/A Q:155/31Days
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
AMPHETAMINE SALT COMBO 15MG TABLET 1 Tier 1 Preferred Generic Brand $6.00 N/A Q:124/31Days
AMPHETAMINE SALT COMBO 30MG TABLET 1 Tier 1 Preferred Generic Brand $6.00 N/A Q:62/31Days
AMPHETAMINE SALT COMBO 7.5MG TABLET 1 Tier 1 Preferred Generic Brand $6.00 N/A Q:248/31Days
AMPHETAMINE SALTS 20MG TABLET 1 Tier 1 Preferred Generic Brand $6.00 N/A Q:93/31Days
AMPHOTEC INJ 50MG 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A P
AMPHOTERICIN B FOR INJECTION 50 MG 2 Tier 2 Generic Preferred Brand $25.00 N/A P
AMPICILLIN AND SULBACTAM FOR INJECTION 10-5 1 VIAL 2 Tier 2 Generic Preferred Brand $25.00 N/A None
AMPICILLIN AND SULBACTAM FOR INJECTION 2-1 10 VIAL 2 Tier 2 Generic Preferred Brand $25.00 N/A None
AMPICILLIN CAPSULES 250MG 100 BOT 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMPICILLIN CAPSULES 500MG 100 BOT 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMPICILLIN FOR INJECTION POWDER 2 Tier 2 Generic Preferred Brand $25.00 N/A None
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
AMPICILLIN FOR INJECTION USP 125MG/ML 1 VIAL 2 Tier 2 Generic Preferred Brand $25.00 N/A None
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AMPICILLIN POWDER FOR INJECTION 1 GM/ML 2 Tier 2 Generic Preferred Brand $25.00 N/A None
ANADROL-50 50MG TABLET (100 CT) 4 Tier 4 Specialty 25% N/A P
ANAGRELIDE HCL 0.5MG CAPSULE 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ANAGRELIDE HCL 1MG CAPSULE 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ANCOBON 250MG CAPSULE 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A None
ANCOBON 500MG CAPSULE 4 Tier 4 Specialty 25% N/A None
ANDRODERM 2.5MG/24HR PATCH 2 Tier 2 Generic Preferred Brand $25.00 N/A P
ANDRODERM 5MG/24HR PATCH 2 Tier 2 Generic Preferred Brand $25.00 N/A P
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
ANDROGEL 1%(50MG) GEL PACKET 2 Tier 2 Generic Preferred Brand $25.00 N/A P
ANESTACON 15ML 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ANTABUSE 250MG TABLET 2 Tier 2 Generic Preferred Brand $25.00 N/A None
ANTABUSE 500MG TABLET 2 Tier 2 Generic Preferred Brand $25.00 N/A None
APAP-CAFFEINE-DIHYDROCODE TAB 30 EA 1 Tier 1 Preferred Generic Brand $6.00 N/A None
APOKYN FOR INJECTION 30MG 5 CTG 4 Tier 4 Specialty 25% N/A P
APRI 0.15-0.03 TABLET 1 Tier 1 Preferred Generic Brand $6.00 N/A None
APTIVUS 250MG CAPSULE 4 Tier 4 Specialty 25% N/A None
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT 4 Tier 4 Specialty 25% N/A None
ARALAST 500MG VIAL 4 Tier 4 Specialty 25% N/A None
ARANELLE 7-9-5 TABLET 1 Tier 1 Preferred Generic Brand $6.00 N/A None
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
ARANESP 100MCG/ML VIAL 4 Tier 4 Specialty 25% N/A P
ARANESP 200MCG/0.4ML SYRINGE 4 Tier 4 Specialty 25% N/A P
ARANESP 200MCG/ML VIAL 4 Tier 4 Specialty 25% N/A P
ARANESP 25MCG/ML VIAL 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A P Q:5/31Days
ARANESP 300MCG/ML VIAL 4 Tier 4 Specialty 25% N/A P
ARANESP 500MCG/1ML SYRINGE 4 Tier 4 Specialty 25% N/A P
ARANESP 60MCG/ML VIAL 4 Tier 4 Specialty 25% N/A P
ARANESP PREFILLED SYRINGE SINGLE USE 100MCG/0.5ML 1 SYR 4 Tier 4 Specialty 25% N/A P
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR 4 Tier 4 Specialty 25% N/A P
ARANESP PREFILLED SYRINGE SINGLE USE 25MCG/0.42ML SYR 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A P Q:2/31Days
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR 4 Tier 4 Specialty 25% N/A P
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A P
ARANESP PREFILLED SYRINGE SINGLE USE 60MCG/0.3ML 60MCG/ 0.3ML SYR 4 Tier 4 Specialty 25% N/A P
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A P
ARCALYST INJECTION 220MG/VIAL 4 Tier 4 Specialty 25% N/A P
ARICEPT 10MG TABLET 2 Tier 2 Generic Preferred Brand $25.00 N/A Q:31/31Days
ARICEPT 5MG TABLET 2 Tier 2 Generic Preferred Brand $25.00 N/A Q:31/31Days
ARICEPT ODT 10MG TABLET 2 Tier 2 Generic Preferred Brand $25.00 N/A Q:31/31Days
ARICEPT ODT 5MG TABLET 2 Tier 2 Generic Preferred Brand $25.00 N/A Q:31/31Days
ARIMIDEX 1MG TABLET 2 Tier 2 Generic Preferred Brand $25.00 N/A None
ARIXTRA 10MG SYRINGE 4 Tier 4 Specialty 25% N/A None
ARIXTRA 2.5MG SYRINGE 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A None
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
ARIXTRA 5MG SYRINGE 4 Tier 4 Specialty 25% N/A None
ARIXTRA 7.5MG SYRINGE 4 Tier 4 Specialty 25% N/A None
AROMASIN 25MG TABLET 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A None
ARRANON 250MG VIAL 4 Tier 4 Specialty 25% N/A None
ARTHROTEC 50 50MG TABLET -200MCG (60 CT) 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A None
ARTHROTEC 75 TABLET EC 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A None
ASACOL 400MG TABLET EC 2 Tier 2 Generic Preferred Brand $25.00 N/A None
ASCOMP W/CODEINE 30-50-325 CAPSULE 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ASMANEX 220MCG(14) AEROSOL POWDER BREATH ACTIVATED 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A S Q:240/30Days
ASMANEX TWISTHALER 220MCG #120 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A S Q:240/30Days
ASMANEX TWISTHALER 220MCG #30 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A S Q:240/30Days
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
ASMANEX TWISTHALER 220MCG #60 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A S Q:240/30Days
ASTELIN 137MCG AEROSOL SPRAY W/PUMP 2 Tier 2 Generic Preferred Brand $25.00 N/A Q:60/31Days
ASTRAMORPH-PF 0.5MG/ML VIAL 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ASTRAMORPH-PF 1MG/ML VIAL 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ATAMET 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ATENOLOL 25MG TABLET (100 CT) 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ATENOLOL TABLET USP 50MG (100 CT) 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ATENOLOL TABLETS USP 100MG 1 BLPK 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT) 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT) 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ATGAM 50MG/ML AMPUL 4 Tier 4 Specialty 25% N/A P
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
ATRIPLA TABLET 600MG/200MG 4 Tier 4 Specialty 25% N/A None
ATROPINE 0.05MG/ML SYRINGE 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ATROPINE 0.1MG/ML SYRINGE 1 Tier 1 Preferred Generic Brand $6.00 N/A None
ATROVENT HFA AER 17MCG 2 Tier 2 Generic Preferred Brand $25.00 N/A None
ATTENUVAX VACCINE W/DILUENT 1 DOSE/0.5ML 2 Tier 2 Generic Preferred Brand $25.00 N/A None
AUGMENTIN 125 SUSPENSION 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A None
AUGMENTIN 250 SUSPENSION 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A None
AUGMENTIN TABLETS COMBO 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A None
AUGMENTIN XR 1000-62.5 TABLET 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A None
AVANDAMET 2MG/1000MG TABLET 2 Tier 2 Generic Preferred Brand $25.00 N/A S
AVANDAMET 2MG/500MG TABLET 2 Tier 2 Generic Preferred Brand $25.00 N/A S
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
AVANDAMET 4MG/500MG TABLET 2 Tier 2 Generic Preferred Brand $25.00 N/A S
AVANDAMET TABLET 4-1000MG 2 Tier 2 Generic Preferred Brand $25.00 N/A S
AVANDARYL 4MG/1MG TABLET 2 Tier 2 Generic Preferred Brand $25.00 N/A S
AVANDARYL 4MG/2MG TABLET 2 Tier 2 Generic Preferred Brand $25.00 N/A S
AVANDARYL 4MG/4MG TABLET 2 Tier 2 Generic Preferred Brand $25.00 N/A S
AVANDARYL 8MG-2MG TABLET 2 Tier 2 Generic Preferred Brand $25.00 N/A S
AVANDARYL 8MG-4MG TABLET 2 Tier 2 Generic Preferred Brand $25.00 N/A S
AVANDIA 2MG TABLET 2 Tier 2 Generic Preferred Brand $25.00 N/A S
AVANDIA 4MG TABLET (90 CT) 2 Tier 2 Generic Preferred Brand $25.00 N/A S
AVANDIA 8MG TABLET (90 CT) 2 Tier 2 Generic Preferred Brand $25.00 N/A S
AVASTIN 100MG/4ML VIAL 4 Tier 4 Specialty 25% N/A P
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
AVELOX 400MG TABLET 2 Tier 2 Generic Preferred Brand $25.00 N/A None
AVELOX ABC PACK 400MG TABLET 2 Tier 2 Generic Preferred Brand $25.00 N/A None
AVELOX IV 400MG/250ML 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A None
AVIANE 0.1-0.02 TABLET 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AVITA 0.025% CREAM 1 Tier 1 Preferred Generic Brand $6.00 N/A P
AVODART 0.5MG SOFTGEL 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A Q:31/31Days
AVONEX ADMIN PACK 30MCG SYR 4 Tier 4 Specialty 25% N/A P
AVONEX ADMIN PACK 30MCG VL 4 Tier 4 Specialty 25% N/A P
AZACTAM 2GM VIAL 2 Tier 2 Generic Preferred Brand $25.00 N/A None
AZACTAM INJECTION 1GM 50ML BAG 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A None
AZACTAM/ISO-OSMOT 2GM/50ML 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A None
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
AZASAN 100MG TABLET 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A None
AZASAN 75MG TABLET 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A None
AZATHIOPRINE 50MG TABLET 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AZATHIOPRINE SOD 100MG VIAL 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AZILECT 0.5MG TABLET 2 Tier 2 Generic Preferred Brand $25.00 N/A None
AZILECT 1MG TABLET 2 Tier 2 Generic Preferred Brand $25.00 N/A None
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AZITHROMYCIN 250MG TABLET (30 CT) 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AZITHROMYCIN 500MG TABLET (30 CT) 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AZITHROMYCIN FOR INJECTION 500MG 10 VIALSD 2 Tier 2 Generic Preferred Brand $25.00 N/A None
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
AZITHROMYCIN TABLET 600MG (30 CT) 1 Tier 1 Preferred Generic Brand $6.00 N/A None
AZMACORT INHALATION AEROSOL .1MG/1IHL 20 GM CSTR 3 Tier 3 Non-Preferred Generic Non-Preferred Brand $71.75 N/A S Q:40/30Days
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT 2 Tier 2 Generic Preferred Brand $25.00 N/A None
AZOR 10MG-20MG TABLET 2 Tier 2 Generic Preferred Brand $25.00 N/A Q:31/31Days
AZOR 10MG-40MG TABLET (30 CT) 2 Tier 2 Generic Preferred Brand $25.00 N/A Q:31/31Days
AZOR 5MG-20MG TABLET (30 CT) 2 Tier 2 Generic Preferred Brand $25.00 N/A Q:31/31Days
AZOR 5MG-40MG TABLET 2 Tier 2 Generic Preferred Brand $25.00 N/A Q:31/31Days



What does all this mean? Here are a few notes to help you understand the above 2010 Medicare Part D AARP MedicareRx Saver (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:
    • Network Preferred Pharmacy - (Ntwk. Pharm) - This is the cost-share amount you would pay during the intial coverage phase (until your total retail prescription drug costs reach $(2830)) at a network pharmacy.
    • Mail Order - This is the cost-share amount you would pay during the initial coverage phase if you purchased your medication through your plan’s 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 (10/31/2009) )

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.






Last updated on: 09/09/2010

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