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Selected Plan:Aetna Medicare Rx Essentials (PDP) (S5810-059)
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2010 Medicare Part D Plan Formulary Information
Aetna Medicare Rx Essentials (PDP) (S5810-059)    Enrollment in Aetna Medicare Rx Essentials (PDP) not available
The Aetna Medicare Rx Essentials (PDP) (S5810-059) Formulary for Drugs Starting with the Letter A
in CMS Region 25 which includes: IA MN MT NE ND SD WY
Plan Monthly Premium: $28.30 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 $3.00 N/A None
A-HYDROCORT 100MG VIAL 1 Tier 1 Preferred Generic $3.00 N/A None
A-METHAPRED 40MG UNIVIAL 1 Tier 1 Preferred Generic $3.00 N/A None
ABILIFY 10MG TABLET 4 Tier 4 - Non-Preferred Brand $70.00 N/A S Q:1/1Days
ABILIFY 15MG TABLET 4 Tier 4 - Non-Preferred Brand $70.00 N/A S Q:1/1Days
ABILIFY 1MG/ML SOLUTION 4 Tier 4 - Non-Preferred Brand $70.00 N/A S Q:30/1Days
ABILIFY 20MG TABLET 4 Tier 4 - Non-Preferred Brand $70.00 N/A S Q:1/1Days
ABILIFY 2MG TABLET 4 Tier 4 - Non-Preferred Brand $70.00 N/A S Q:1/1Days
ABILIFY 30MG TABLET 4 Tier 4 - Non-Preferred Brand $70.00 N/A S Q:1/1Days
ABILIFY 5MG TABLET (OTSUKA) 4 Tier 4 - Non-Preferred Brand $70.00 N/A S Q:1/1Days
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
ABILIFY DISCMELT 10MG TABLET 4 Tier 4 - Non-Preferred Brand $70.00 N/A S Q:2/1Days
ABILIFY DISCMELT 15MG TABLET 4 Tier 4 - Non-Preferred Brand $70.00 N/A S Q:2/1Days
ABILIFY INJ 9.75MG 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
ABRAXANE 100MG VIAL 5 Tier 5 Specialty 25% N/A None
ACARBOSE 100MG TABLET S 2 Tier 2 - Non-Preferred Generic $28.00 N/A None
ACARBOSE 25MG TABLET S 2 Tier 2 - Non-Preferred Generic $28.00 N/A None
ACARBOSE 50MG TABLET S 2 Tier 2 - Non-Preferred Generic $28.00 N/A None
ACCOLATE 10MG TABLET 4 Tier 4 - Non-Preferred Brand $70.00 N/A Q:2/1Days
ACCOLATE 20MG TABLET 4 Tier 4 - Non-Preferred Brand $70.00 N/A Q:2/1Days
ACEBUTOLOL 200MG CAPSULE 1 Tier 1 Preferred Generic $3.00 N/A S
ACEBUTOLOL 400MG CAPSULE 1 Tier 1 Preferred Generic $3.00 N/A S
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
ACEON 2MG TABLET 4 Tier 4 - Non-Preferred Brand $70.00 N/A Q:2/1Days
ACEON 4MG TABLET 4 Tier 4 - Non-Preferred Brand $70.00 N/A Q:2/1Days
ACEON 8MG TABLET 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD 1 Tier 1 Preferred Generic $3.00 N/A Q:167/1Days
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT) 1 Tier 1 Preferred Generic $3.00 N/A Q:13/1Days
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT) 1 Tier 1 Preferred Generic $3.00 N/A Q:13/1Days
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT) 1 Tier 1 Preferred Generic $3.00 N/A Q:13/1Days
ACETASOL HC OTIC SOLUTION 1 Tier 1 Preferred Generic $3.00 N/A None
ACETASOL HC SOLUTION 10ML 10 ML BOT 1 Tier 1 Preferred Generic $3.00 N/A None
ACETAZOLAMIDE 125MG TABLET 1 Tier 1 Preferred Generic $3.00 N/A None
ACETAZOLAMIDE 250MG TABLET (100 CT) 1 Tier 1 Preferred Generic $3.00 N/A None
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT 1 Tier 1 Preferred Generic $3.00 N/A None
ACETAZOLAMIDE SOD 500MG VL 2 Tier 2 - Non-Preferred Generic $28.00 N/A None
ACETIC ACID 2% SOLUTION NON-ORAL 1 Tier 1 Preferred Generic $3.00 N/A None
ACETIC ACID IN AQUEOUS ALUMINUM ACETATE OTIC SOLUTION 2% 60 ML BOT 1 Tier 1 Preferred Generic $3.00 N/A None
ACETYLCYSTEINE 10% VIAL 1 Tier 1 Preferred Generic $3.00 N/A P
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN 1 Tier 1 Preferred Generic $3.00 N/A P
ACTHIB VACCINE VIAL 10-24UNT/5ML 3 Tier 3 - Preferred Brand $30.00 N/A None
ACTICIN 5% CREAM 1 Tier 1 Preferred Generic $3.00 N/A None
ACTIMMUNE SOLUTION FOR INJECTION 100MCG 5 Tier 5 Specialty 25% N/A P
ACTIVELLA 0.5-0.1MG TABLET 28 DLPK 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
ACTONEL 150MG TABLET 3 Tier 3 - Preferred Brand $30.00 N/A Q:1/28Days
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
ACTONEL 30MG TABLET 3 Tier 3 - Preferred Brand $30.00 N/A None
ACTONEL 35MG TABLET 3 Tier 3 - Preferred Brand $30.00 N/A Q:4/28Days
ACTONEL 5MG TABLET 3 Tier 3 - Preferred Brand $30.00 N/A None
ACTONEL 75MG TABLET 3 Tier 3 - Preferred Brand $30.00 N/A Q:2/28Days
ACTONEL WITH CALCIUM TABLET 3 Tier 3 - Preferred Brand $30.00 N/A Q:1/1Days
ACTOPLUS MET 15MG/500MG TABLET 3 Tier 3 - Preferred Brand $30.00 N/A None
ACTOPLUS MET 15MG/850MG TABLET 3 Tier 3 - Preferred Brand $30.00 N/A None
ACTOS 15MG TABLET 3 Tier 3 - Preferred Brand $30.00 N/A None
ACTOS 30MG TABLET (500 CT) 3 Tier 3 - Preferred Brand $30.00 N/A None
ACTOS 45MG TABLET 3 Tier 3 - Preferred Brand $30.00 N/A None
ACULAR 0.5% EYE DROPS 4 Tier 4 - Non-Preferred Brand $70.00 N/A S
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
ACULAR LS 0.4% OPHTH SOL 4 Tier 4 - Non-Preferred Brand $70.00 N/A S
ACYCLOVIR 200MG CAPSULE (1000 CT) 1 Tier 1 Preferred Generic $3.00 N/A None
ACYCLOVIR 200MG/5ML SUSP 2 Tier 2 - Non-Preferred Generic $28.00 N/A None
ACYCLOVIR 400MG TABLET (100 CT) 1 Tier 1 Preferred Generic $3.00 N/A None
ACYCLOVIR SODIUM 500MG VIAL 2 Tier 2 - Non-Preferred Generic $28.00 N/A None
ACYCLOVIR TABLET USP 800MG (100 CT) 1 Tier 1 Preferred Generic $3.00 N/A None
ADACEL VIAL 2UNT/5UNT 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
ADAGEN 250U/ML VIAL 5 Tier 5 Specialty 25% N/A None
ADCIRCA TABLETS 20MG 60 BOT 5 Tier 5 Specialty 25% N/A P
ADVAIR DISKU MIS 100/50 3 Tier 3 - Preferred Brand $30.00 N/A None
ADVAIR DISKU MIS 250/50 3 Tier 3 - Preferred Brand $30.00 N/A None
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
ADVAIR DISKU MIS 500/50 3 Tier 3 - Preferred Brand $30.00 N/A None
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL 3 Tier 3 - Preferred Brand $30.00 N/A None
ADVAIR HFA INHALER 230;21MCG;MCG 3 Tier 3 - Preferred Brand $30.00 N/A None
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL 3 Tier 3 - Preferred Brand $30.00 N/A None
ADVICOR ER 20-750MG TABLET (90 CT) 4 Tier 4 - Non-Preferred Brand $70.00 N/A Q:2/1Days
ADVICOR EXTENDED RELEASE TABLETS 20;1000MG;MG 90 BOTPL 4 Tier 4 - Non-Preferred Brand $70.00 N/A Q:2/1Days
ADVICOR EXTENDED RELEASE TABLETS 20;500MG;MG 90 BOTPL 4 Tier 4 - Non-Preferred Brand $70.00 N/A Q:2/1Days
ADVICOR EXTENDED RELEASE TABLETS 40;1000MG;MG 90 BOTPL 4 Tier 4 - Non-Preferred Brand $70.00 N/A Q:2/1Days
AEROBID-M AEROSOL W/ADAPTER 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
AFEDITAB CR 30MG TABLET SA 1 Tier 1 Preferred Generic $3.00 N/A Q:1/1Days
AFEDITAB CR 60MG TABLET SA 1 Tier 1 Preferred Generic $3.00 N/A Q:2/1Days
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
AGGRENOX 25-200MG CAPSULE 3 Tier 3 - Preferred Brand $30.00 N/A None
AK-CON 0.1% EYE DROPS 1 Tier 1 Preferred Generic $3.00 N/A None
AK-POLY-BAC EYE OINTMENT 500UNT/1000UNT 1 Tier 1 Preferred Generic $3.00 N/A None
AKNE-MYCIN 2% OINTMENT 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
AKTOB 0.3% EYE DROPS 1 Tier 1 Preferred Generic $3.00 N/A None
ALA-CORT 1% CREAM 1 Tier 1 Preferred Generic $3.00 N/A None
ALA-CORT 1% LOTION 1 Tier 1 Preferred Generic $3.00 N/A None
ALA-SCALP HP 2% LOTION 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
ALAMAST 0.1% DROPS 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
ALBENZA 200MG TABLET 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
ALBUTEROL SULFATE 0.63MG/3ML VIAL NEBULIZER 1 Tier 1 Preferred Generic $3.00 N/A P
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER 1 Tier 1 Preferred Generic $3.00 N/A P
ALBUTEROL SULFATE 2.5MG/3ML VIAL NEBULIZER 1 Tier 1 Preferred Generic $3.00 N/A P
ALBUTEROL SULFATE 4MG TABLET SR 12HR 2 Tier 2 - Non-Preferred Generic $28.00 N/A None
ALBUTEROL SULFATE 8MG TABLET SR 12HR 2 Tier 2 - Non-Preferred Generic $28.00 N/A None
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR 1 Tier 1 Preferred Generic $3.00 N/A P
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT 1 Tier 1 Preferred Generic $3.00 N/A None
ALBUTEROL SULFATE TABLET 2MG (500 CT) 1 Tier 1 Preferred Generic $3.00 N/A None
ALBUTEROL TABLET 4MG (500 CT) 1 Tier 1 Preferred Generic $3.00 N/A None
ALCLOMETASONE DIPROPIONATE 0.05% CREAM 1 Tier 1 Preferred Generic $3.00 N/A None
ALCLOMETASONE DIPROPIONATE 0.05% OINTMENT 1 Tier 1 Preferred Generic $3.00 N/A None
ALCOHOL 5%/DEXTROSE 5% 1 Tier 1 Preferred Generic $3.00 N/A None
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
ALDARA IMIQUIMOD CREAM 5% 24 PKT X 250 MG CRTN 3 Tier 3 - Preferred Brand $30.00 N/A None
ALDURAZYME 2.9MG/5ML VIAL 5 Tier 5 Specialty 25% N/A None
ALENDRONATE SODIUM 10MG TABLET 1 Tier 1 Preferred Generic $3.00 N/A None
ALENDRONATE SODIUM 40MG TABLET 1 Tier 1 Preferred Generic $3.00 N/A None
ALENDRONATE SODIUM 5MG TABLET 1 Tier 1 Preferred Generic $3.00 N/A None
ALENDRONATE SODIUM 70MG TABLET 4 BLPK 1 Tier 1 Preferred Generic $3.00 N/A Q:4/28Days
ALENDRONATE SODIUM TABLET 35MG 20 CRTN 1 Tier 1 Preferred Generic $3.00 N/A Q:4/28Days
ALIMTA 500MG VIAL 5 Tier 5 Specialty 25% N/A None
ALINIA 100MG/5ML SUSPENSION 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
ALINIA 500MG TABLET 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
ALKERAN FOR INJECTION 50MG/VIAL 1 VIALSU 5 Tier 5 Specialty 25% N/A P
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
ALLOPURINOL SODIUM 500MG VIAL 5 Tier 5 Specialty 25% N/A None
ALLOPURINOL TABLET 300MG (1000 CT) 1 Tier 1 Preferred Generic $3.00 N/A None
ALLOPURINOL TABLET USP 100MG (1000 CT) 1 Tier 1 Preferred Generic $3.00 N/A None
ALOCRIL 2% EYE DROPS 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
ALOMIDE 0.1% EYE DROPS 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
ALORA 0.025MG PATCH 4 Tier 4 - Non-Preferred Brand $70.00 N/A Q:8/28Days
ALORA 0.05MG PATCH 4 Tier 4 - Non-Preferred Brand $70.00 N/A Q:8/28Days
ALORA 0.075MG PATCH 4 Tier 4 - Non-Preferred Brand $70.00 N/A Q:8/28Days
ALORA 0.1MG PATCH 4 Tier 4 - Non-Preferred Brand $70.00 N/A Q:8/28Days
ALPHAGAN P 0.1% DROPS 3 Tier 3 - Preferred Brand $30.00 N/A None
ALPHAGAN P 0.15% EYE DROPS 3 Tier 3 - Preferred Brand $30.00 N/A None
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
ALREX 0.2% EYE DROPS 4 Tier 4 - Non-Preferred Brand $70.00 N/A S
ALTABAX 1% OINTMENT 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
ALTOPREV 20MG TABLET SR 24HR 4 Tier 4 - Non-Preferred Brand $70.00 N/A S Q:1/1Days
ALTOPREV 40MG TABLET SR 24HR 4 Tier 4 - Non-Preferred Brand $70.00 N/A S Q:1/1Days
ALTOPREV 60MG TABLET SR 24HR 4 Tier 4 - Non-Preferred Brand $70.00 N/A S Q:1/1Days
ALVESCO 160MCG/ACT AERS 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
ALVESCO 80MCG/ACT AERS 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
AMANTADINE 100MG CAPSULE 1 Tier 1 Preferred Generic $3.00 N/A None
AMANTADINE 100MG TABLET 1 Tier 1 Preferred Generic $3.00 N/A None
AMCINONIDE 0.1% CREAM 1 Tier 1 Preferred Generic $3.00 N/A None
AMCINONIDE 0.1% LOTION 1 Tier 1 Preferred Generic $3.00 N/A None
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
AMCINONIDE 0.1% OINTMENT 60GM TUBE 1 Tier 1 Preferred Generic $3.00 N/A None
AMERGE 1MG TABLET 3 Tier 3 - Preferred Brand $30.00 N/A Q:9/30Days
AMERGE 2.5MG TABLET 3 Tier 3 - Preferred Brand $30.00 N/A Q:9/30Days
AMEVIVE ADMISTRATION PACK FOR INTRAMUSCULAR ADMINISTRATION KIT 15MG 1 X 4 PKGCOM 5 Tier 5 Specialty 25% N/A None
AMIFOSTINE FOR INJECTION 500MG/VIAL 5 Tier 5 Specialty 25% N/A None
AMIKACIN 250MG/ML VIAL 2 Tier 2 - Non-Preferred Generic $28.00 N/A None
AMIKACIN 50MG/ML VIAL 1 Tier 1 Preferred Generic $3.00 N/A None
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET 1 Tier 1 Preferred Generic $3.00 N/A None
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT 1 Tier 1 Preferred Generic $3.00 N/A None
AMINOPHYLLINE 100MG TABLET 1 Tier 1 Preferred Generic $3.00 N/A None
AMINOPHYLLINE 200MG TABLET (1000 CT) 1 Tier 1 Preferred Generic $3.00 N/A None
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
AMINOPHYLLINE INJECTION 250MG 10ML X 25 VIALSD 1 Tier 1 Preferred Generic $3.00 N/A None
AMINOSYN 10% IV SOLUTION 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
AMINOSYN 3.5% IV SOLUTION 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
AMINOSYN 5% IV SOLUTION 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
AMINOSYN 7% IV SOLUTION 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
AMINOSYN 7%-ELECTROLYTE SOL 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
AMINOSYN 8.5% IV SOLUTION 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
AMINOSYN II 10% IV SOLUTION 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
AMINOSYN II 15% IV SOLUTION 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
AMINOSYN II 3.5% IN D25W IV 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
AMINOSYN II 3.5% M/D5W IV 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
AMINOSYN II 3.5% W/ELEC DEX 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
AMINOSYN II 4.25% IN D10W 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
AMINOSYN II 4.25% IN D20W 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
AMINOSYN II 4.25% W/ELEC DW 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
AMINOSYN II 4.25%-D25W IV 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
AMINOSYN II 5% IN D25W IV 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
AMINOSYN II 7% IV SOLUTION 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
AMINOSYN II 8.5% ELECTROLYT 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
AMINOSYN II 8.5% IV SOLUTION 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
AMINOSYN M 3.5% IV SOLUTION 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
AMINOSYN PF INJECTION 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
AMINOSYN-HBC 7% IV SOLUTION 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
AMINOSYN-HF 8% IV SOLUTION 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
AMINOSYN-PF 7% IV SOLUTION 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
AMIODARONE HCL 200MG TABLET (60 CT) 1 Tier 1 Preferred Generic $3.00 N/A None
AMIODARONE HCL 400MG TABLET 1 Tier 1 Preferred Generic $3.00 N/A None
AMIODARONE HCL INJECTION 1 Tier 1 Preferred Generic $3.00 N/A None
AMITIZA 8MCG CAPSULE 4 Tier 4 - Non-Preferred Brand $70.00 N/A P S Q:60/30Days
AMITIZA CAPSULES 24MCG 60 CAP BOT 4 Tier 4 - Non-Preferred Brand $70.00 N/A S Q:60/30Days
AMITRIP/CDP 25-10 TABLET 1 Tier 1 Preferred Generic $3.00 N/A None
AMITRIP/PERPHEN 10-2 TABLET 1 Tier 1 Preferred Generic $3.00 N/A None
AMITRIP/PERPHEN 10-4 TABLET 1 Tier 1 Preferred Generic $3.00 N/A None
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
AMITRIP/PERPHEN 25-2 TABLET 1 Tier 1 Preferred Generic $3.00 N/A None
AMITRIP/PERPHEN 25-4 TABLET 1 Tier 1 Preferred Generic $3.00 N/A None
AMITRIP/PERPHEN 50-4 TABLET 1 Tier 1 Preferred Generic $3.00 N/A None
AMITRIPTYLINE HCL 100MG TABLET 1 Tier 1 Preferred Generic $3.00 N/A None
AMITRIPTYLINE HCL 10MG TABLET 1 Tier 1 Preferred Generic $3.00 N/A None
AMITRIPTYLINE HCL 150MG TABLET (100 CT) 1 Tier 1 Preferred Generic $3.00 N/A None
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT) 1 Tier 1 Preferred Generic $3.00 N/A None
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT) 1 Tier 1 Preferred Generic $3.00 N/A None
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT 1 Tier 1 Preferred Generic $3.00 N/A None
AMLODIPINE BESYLATE 10MG TABLET (90 CT) 1 Tier 1 Preferred Generic $3.00 N/A S
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT) 1 Tier 1 Preferred Generic $3.00 N/A S Q:1/1Days
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
AMLODIPINE BESYLATE 5MG TABLET (90 CT) 1 Tier 1 Preferred Generic $3.00 N/A S Q:1/1Days
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE 2 Tier 2 - Non-Preferred Generic $28.00 N/A None
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE 2 Tier 2 - Non-Preferred Generic $28.00 N/A None
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE 2 Tier 2 - Non-Preferred Generic $28.00 N/A None
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE 2 Tier 2 - Non-Preferred Generic $28.00 N/A None
AMMONIUM CHLORIDE 5 MEQ/ML 1 Tier 1 Preferred Generic $3.00 N/A None
AMMONIUM LACTATE 12% CREAM 1 Tier 1 Preferred Generic $3.00 N/A None
AMMONIUM LACTATE 12% LOTION 1 Tier 1 Preferred Generic $3.00 N/A None
AMNESTEEM 10MG CAPSULE 2 Tier 2 - Non-Preferred Generic $28.00 N/A P
AMNESTEEM 20MG CAPSULE 2 Tier 2 - Non-Preferred Generic $28.00 N/A P
AMNESTEEM 40MG CAPSULE 2 Tier 2 - Non-Preferred Generic $28.00 N/A P
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
AMOCLAN 200-28.5/5 SUSPENSION RECONSTITUTED ORAL 1 Tier 1 Preferred Generic $3.00 N/A None
AMOCLAN 400-57MG/5 SUSPENSION RECONSTITUTED ORAL 1 Tier 1 Preferred Generic $3.00 N/A None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL 1 Tier 1 Preferred Generic $3.00 N/A None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE 1 Tier 1 Preferred Generic $3.00 N/A None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET 1 Tier 1 Preferred Generic $3.00 N/A None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE 1 Tier 1 Preferred Generic $3.00 N/A None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL 1 Tier 1 Preferred Generic $3.00 N/A None
AMOX TR-POTASSIUM CLAVULANATE 500-125MG TABLET 1 Tier 1 Preferred Generic $3.00 N/A None
AMOXAPINE 100MG TABLET 1 Tier 1 Preferred Generic $3.00 N/A None
AMOXAPINE 150MG TABLET 1 Tier 1 Preferred Generic $3.00 N/A None
AMOXAPINE 25MG TABLET 1 Tier 1 Preferred Generic $3.00 N/A None
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
AMOXAPINE 50MG TABLET 1 Tier 1 Preferred Generic $3.00 N/A None
AMOXICILLIN 125MG TABLET CHEW 1 Tier 1 Preferred Generic $3.00 N/A None
AMOXICILLIN 200MG TABLET CHEW 1 Tier 1 Preferred Generic $3.00 N/A None
AMOXICILLIN 250MG CAPSULE 1 Tier 1 Preferred Generic $3.00 N/A None
AMOXICILLIN 400MG TABLET CHEW 1 Tier 1 Preferred Generic $3.00 N/A None
AMOXICILLIN 500MG CAPSULE 1 Tier 1 Preferred Generic $3.00 N/A None
AMOXICILLIN 500MG TABLET (100 CT) 1 Tier 1 Preferred Generic $3.00 N/A None
AMOXICILLIN 875MG TABLET 1 Tier 1 Preferred Generic $3.00 N/A None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT 1 Tier 1 Preferred Generic $3.00 N/A None
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT 1 Tier 1 Preferred Generic $3.00 N/A None
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT 1 Tier 1 Preferred Generic $3.00 N/A None
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL 1 Tier 1 Preferred Generic $3.00 N/A None
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT 1 Tier 1 Preferred Generic $3.00 N/A None
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL 1 Tier 1 Preferred Generic $3.00 N/A None
AMOXICILLIN TABLET USP CHEWABLE 250MG (250 CT) 1 Tier 1 Preferred Generic $3.00 N/A None
AMOXIL 250MG/5ML SUSPENSION 1 Tier 1 Preferred Generic $3.00 N/A None
AMOXIL CAPSULES 500MG 1 Tier 1 Preferred Generic $3.00 N/A None
AMPHET ASP/ AMPHET/ D-AMPHET 5MG TABLET 1 Tier 1 Preferred Generic $3.00 N/A P Q:2/1Days
AMPHETAMINE SALT COMBO 12.5MG TABLET 1 Tier 1 Preferred Generic $3.00 N/A P Q:2/1Days
AMPHETAMINE SALT COMBO 15MG TABLET 1 Tier 1 Preferred Generic $3.00 N/A P Q:2/1Days
AMPHETAMINE SALT COMBO 30MG TABLET 1 Tier 1 Preferred Generic $3.00 N/A P Q:2/1Days
AMPHETAMINE SALT COMBO 7.5MG TABLET 1 Tier 1 Preferred Generic $3.00 N/A P Q:2/1Days
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
AMPHETAMINE SALTS 20MG TABLET 1 Tier 1 Preferred Generic $3.00 N/A P Q:3/1Days
AMPHOTERICIN B FOR INJECTION 50 MG 2 Tier 2 - Non-Preferred Generic $28.00 N/A None
AMPICILLIN AND SULBACTAM FOR INJECTION 10-5 1 VIAL 2 Tier 2 - Non-Preferred Generic $28.00 N/A None
AMPICILLIN AND SULBACTAM FOR INJECTION 2-1 10 VIAL 2 Tier 2 - Non-Preferred Generic $28.00 N/A None
AMPICILLIN CAPSULES 250MG 100 BOT 1 Tier 1 Preferred Generic $3.00 N/A None
AMPICILLIN CAPSULES 500MG 100 BOT 1 Tier 1 Preferred Generic $3.00 N/A None
AMPICILLIN FOR INJECTION POWDER 2 Tier 2 - Non-Preferred Generic $28.00 N/A None
AMPICILLIN FOR INJECTION USP 125MG/ML 1 VIAL 2 Tier 2 - Non-Preferred Generic $28.00 N/A None
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT 1 Tier 1 Preferred Generic $3.00 N/A None
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT 1 Tier 1 Preferred Generic $3.00 N/A None
AMPICILLIN POWDER FOR INJECTION 1 GM/ML 2 Tier 2 - Non-Preferred Generic $28.00 N/A None
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
ANADROL-50 50MG TABLET (100 CT) 5 Tier 5 Specialty 25% N/A P
ANAGRELIDE HCL 0.5MG CAPSULE 2 Tier 2 - Non-Preferred Generic $28.00 N/A None
ANAGRELIDE HCL 1MG CAPSULE 2 Tier 2 - Non-Preferred Generic $28.00 N/A None
ANCOBON 250MG CAPSULE 5 Tier 5 Specialty 25% N/A None
ANCOBON 500MG CAPSULE 5 Tier 5 Specialty 25% N/A None
ANDRODERM 2.5MG/24HR PATCH 3 Tier 3 - Preferred Brand $30.00 N/A None
ANDRODERM 5MG/24HR PATCH 3 Tier 3 - Preferred Brand $30.00 N/A None
ANDROGEL 1%(50MG) GEL PACKET 3 Tier 3 - Preferred Brand $30.00 N/A None
ANDROID 10MG CAPSULE 4 Tier 4 - Non-Preferred Brand $70.00 N/A P
ANESTACON 15ML 1 Tier 1 Preferred Generic $3.00 N/A None
ANTABUSE 250MG TABLET 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
ANTABUSE 500MG TABLET 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
ANTARA 130MG CAPSULE 4 Tier 4 - Non-Preferred Brand $70.00 N/A S
ANTARA 43MG CAPSULE 4 Tier 4 - Non-Preferred Brand $70.00 N/A S
ANTIVERT 12.5MG TABLET 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
ANTIVERT 25MG TABLET 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
ANTIVERT 50MG TABLET 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
ANZEMET 100MG TABLET 4 Tier 4 - Non-Preferred Brand $70.00 N/A P S Q:5/30Days
ANZEMET 50MG TABLET 4 Tier 4 - Non-Preferred Brand $70.00 N/A P S Q:5/30Days
APAP-CAFFEINE-DIHYDROCODE TAB 30 EA 2 Tier 2 - Non-Preferred Generic $28.00 N/A Q:5/1Days
APHTHASOL 5% PASTE 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
APIDRA 100UNITS/ML VIAL 3 Tier 3 - Preferred Brand $30.00 N/A None
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
APOKYN FOR INJECTION 30MG 5 CTG 5 Tier 5 Specialty 25% N/A P
APRI 0.15-0.03 TABLET 1 Tier 1 Preferred Generic $3.00 N/A None
APTIVUS 250MG CAPSULE 5 Tier 5 Specialty 25% N/A None
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT 5 Tier 5 Specialty 25% N/A None
ARALAST 500MG VIAL 5 Tier 5 Specialty 25% N/A None
ARANELLE 7-9-5 TABLET 1 Tier 1 Preferred Generic $3.00 N/A None
ARANESP 100MCG/ML VIAL 5 Tier 5 Specialty 25% N/A P
ARANESP 200MCG/0.4ML SYRINGE 5 Tier 5 Specialty 25% N/A P
ARANESP 200MCG/ML VIAL 5 Tier 5 Specialty 25% N/A P
ARANESP 25MCG/ML VIAL 3 Tier 3 - Preferred Brand $30.00 N/A P
ARANESP 300MCG/ML VIAL 5 Tier 5 Specialty 25% N/A P
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
ARANESP 500MCG/1ML SYRINGE 5 Tier 5 Specialty 25% N/A P
ARANESP 60MCG/ML VIAL 5 Tier 5 Specialty 25% N/A P
ARANESP PREFILLED SYRINGE SINGLE USE 100MCG/0.5ML 1 SYR 5 Tier 5 Specialty 25% N/A P
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR 5 Tier 5 Specialty 25% N/A P
ARANESP PREFILLED SYRINGE SINGLE USE 25MCG/0.42ML SYR 3 Tier 3 - Preferred Brand $30.00 N/A P
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR 5 Tier 5 Specialty 25% N/A P
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR 3 Tier 3 - Preferred Brand $30.00 N/A P
ARANESP PREFILLED SYRINGE SINGLE USE 60MCG/0.3ML 60MCG/ 0.3ML SYR 5 Tier 5 Specialty 25% N/A P
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD 3 Tier 3 - Preferred Brand $30.00 N/A P
ARCALYST INJECTION 220MG/VIAL 5 Tier 5 Specialty 25% N/A None
ARICEPT 10MG TABLET 3 Tier 3 - Preferred Brand $30.00 N/A None
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
ARICEPT 5MG TABLET 3 Tier 3 - Preferred Brand $30.00 N/A None
ARICEPT ODT 10MG TABLET 3 Tier 3 - Preferred Brand $30.00 N/A None
ARICEPT ODT 5MG TABLET 3 Tier 3 - Preferred Brand $30.00 N/A None
ARIMIDEX 1MG TABLET 3 Tier 3 - Preferred Brand $30.00 N/A None
ARIXTRA 10MG SYRINGE 5 Tier 5 Specialty 25% N/A None
ARIXTRA 2.5MG SYRINGE 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
ARIXTRA 5MG SYRINGE 5 Tier 5 Specialty 25% N/A None
ARIXTRA 7.5MG SYRINGE 5 Tier 5 Specialty 25% N/A None
AROMASIN 25MG TABLET 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
ARRANON 250MG VIAL 5 Tier 5 Specialty 25% N/A None
ARTHROTEC 50 50MG TABLET -200MCG (60 CT) 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
ARTHROTEC 75 TABLET EC 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
ASACOL 400MG TABLET EC 4 Tier 4 - Non-Preferred Brand $70.00 N/A S Q:12/1Days
ASACOL HD DELAYED RELEASE TABLETS 800MG 180 BOT 4 Tier 4 - Non-Preferred Brand $70.00 N/A S Q:6/1Days
ASCOMP W/CODEINE 30-50-325 CAPSULE 2 Tier 2 - Non-Preferred Generic $28.00 N/A Q:6/1Days
ASMANEX 220MCG(14) AEROSOL POWDER BREATH ACTIVATED 3 Tier 3 - Preferred Brand $30.00 N/A None
ASMANEX TWISTHALER 220MCG #120 3 Tier 3 - Preferred Brand $30.00 N/A None
ASMANEX TWISTHALER 220MCG #30 3 Tier 3 - Preferred Brand $30.00 N/A None
ASMANEX TWISTHALER 220MCG #60 3 Tier 3 - Preferred Brand $30.00 N/A None
ASTELIN 137MCG AEROSOL SPRAY W/PUMP 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
ASTEPRO NASAL SPRAY 137 MCG/SPRY 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
ASTRAMORPH-PF 0.5MG/ML VIAL 1 Tier 1 Preferred Generic $3.00 N/A P
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
ASTRAMORPH-PF 1MG/ML VIAL 1 Tier 1 Preferred Generic $3.00 N/A P
ATACAND 16MG TABLET 4 Tier 4 - Non-Preferred Brand $70.00 N/A S Q:2/1Days
ATACAND 32MG TABLET 4 Tier 4 - Non-Preferred Brand $70.00 N/A S
ATACAND 4MG TABLET 4 Tier 4 - Non-Preferred Brand $70.00 N/A S Q:2/1Days
ATACAND 8MG TABLET 4 Tier 4 - Non-Preferred Brand $70.00 N/A S Q:2/1Days
ATACAND HCT 16/12.5MG TABLET 4 Tier 4 - Non-Preferred Brand $70.00 N/A S Q:2/1Days
ATACAND HCT 32/12.5MG TABLET 4 Tier 4 - Non-Preferred Brand $70.00 N/A S
ATACAND HCT TABLETS 32;25MG;MG 90 TABLETS BOT 4 Tier 4 - Non-Preferred Brand $70.00 N/A S
ATAMET 1 Tier 1 Preferred Generic $3.00 N/A None
ATENOLOL 25MG TABLET (100 CT) 1 Tier 1 Preferred Generic $3.00 N/A None
ATENOLOL TABLET USP 50MG (100 CT) 1 Tier 1 Preferred Generic $3.00 N/A None
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
ATENOLOL TABLETS USP 100MG 1 BLPK 1 Tier 1 Preferred Generic $3.00 N/A None
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT) 1 Tier 1 Preferred Generic $3.00 N/A None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT) 1 Tier 1 Preferred Generic $3.00 N/A None
ATGAM 50MG/ML AMPUL 5 Tier 5 Specialty 25% N/A P
ATRIPLA TABLET 600MG/200MG 5 Tier 5 Specialty 25% N/A None
ATROPINE 0.05MG/ML SYRINGE 1 Tier 1 Preferred Generic $3.00 N/A P
ATROPINE 0.1MG/ML SYRINGE 1 Tier 1 Preferred Generic $3.00 N/A P
ATROVENT HFA AER 17MCG 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
ATTENUVAX VACCINE W/DILUENT 1 DOSE/0.5ML 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
AUGMENTIN XR 1000-62.5 TABLET 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
AVANDAMET 2MG/1000MG TABLET 3 Tier 3 - Preferred Brand $30.00 N/A None
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
AVANDAMET 2MG/500MG TABLET 3 Tier 3 - Preferred Brand $30.00 N/A None
AVANDAMET 4MG/500MG TABLET 3 Tier 3 - Preferred Brand $30.00 N/A None
AVANDAMET TABLET 4-1000MG 3 Tier 3 - Preferred Brand $30.00 N/A None
AVANDARYL 4MG/1MG TABLET 3 Tier 3 - Preferred Brand $30.00 N/A None
AVANDARYL 4MG/2MG TABLET 3 Tier 3 - Preferred Brand $30.00 N/A None
AVANDARYL 4MG/4MG TABLET 3 Tier 3 - Preferred Brand $30.00 N/A None
AVANDARYL 8MG-2MG TABLET 3 Tier 3 - Preferred Brand $30.00 N/A None
AVANDARYL 8MG-4MG TABLET 3 Tier 3 - Preferred Brand $30.00 N/A None
AVANDIA 2MG TABLET 3 Tier 3 - Preferred Brand $30.00 N/A None
AVANDIA 4MG TABLET (90 CT) 3 Tier 3 - Preferred Brand $30.00 N/A None
AVANDIA 8MG TABLET (90 CT) 3 Tier 3 - Preferred Brand $30.00 N/A None
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
AVASTIN 100MG/4ML VIAL 5 Tier 5 Specialty 25% N/A None
AVELOX 400MG TABLET 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
AVELOX ABC PACK 400MG TABLET 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
AVELOX IV 400MG/250ML 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
AVIANE 0.1-0.02 TABLET 1 Tier 1 Preferred Generic $3.00 N/A None
AVITA 0.025% CREAM 1 Tier 1 Preferred Generic $3.00 N/A None
AVODART 0.5MG SOFTGEL 3 Tier 3 - Preferred Brand $30.00 N/A P
AVONEX ADMIN PACK 30MCG SYR 5 Tier 5 Specialty 25% N/A P
AVONEX ADMIN PACK 30MCG VL 5 Tier 5 Specialty 25% N/A P
AXID 15MG/ML ORAL SOLUTION 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
AZACTAM 2GM VIAL 3 Tier 3 - Preferred Brand $30.00 N/A None
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
AZACTAM INJECTION 1GM 50ML BAG 3 Tier 3 - Preferred Brand $30.00 N/A None
AZACTAM/ISO-OSMOT 2GM/50ML 3 Tier 3 - Preferred Brand $30.00 N/A None
AZASAN 100MG TABLET 4 Tier 4 - Non-Preferred Brand $70.00 N/A P
AZASAN 75MG TABLET 4 Tier 4 - Non-Preferred Brand $70.00 N/A P
AZASITE 1% DROPS 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
AZATHIOPRINE 50MG TABLET 1 Tier 1 Preferred Generic $3.00 N/A P
AZATHIOPRINE SOD 100MG VIAL 5 Tier 5 Specialty 25% N/A P
AZELEX 20% CREAM 30GM TUBE 4 Tier 4 - Non-Preferred Brand $70.00 N/A None
AZILECT 0.5MG TABLET 3 Tier 3 - Preferred Brand $30.00 N/A None
AZILECT 1MG TABLET 3 Tier 3 - Preferred Brand $30.00 N/A None
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL 1 Tier 1 Preferred Generic $3.00 N/A None
Drug Name Tier
Nbr.		 Tier
Description		 Ntwk.
Pharm		 Mail
Order		 Drug
Usage
Mgmt
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL 1 Tier 1 Preferred Generic $3.00 N/A None
AZITHROMYCIN 250MG TABLET (30 CT) 1 Tier 1 Preferred Generic $3.00 N/A None
AZITHROMYCIN 500MG TABLET (30 CT) 1 Tier 1 Preferred Generic $3.00 N/A None
AZITHROMYCIN FOR INJECTION 500MG 10 VIALSD 2 Tier 2 - Non-Preferred Generic $28.00 N/A None
AZITHROMYCIN TABLET 600MG (30 CT) 1 Tier 1 Preferred Generic $3.00 N/A None
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT 4 Tier 4 - Non-Preferred Brand $70.00 N/A S



What does all this mean? Here are a few notes to help you understand the above 2010 Medicare Part D Aetna Medicare Rx Essentials (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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