2015 Blue Cross MedicareRx Basic (PDP) Drug Coverage Details



Below is the Formulary, or drug list, for Blue Cross MedicareRx Basic (PDP) from Hcsc Insurance Services Company This formulary is a list of prescription medications that are covered under Hcsc Insurance Services Company's 2015 Part-D Plan. The Blue Cross MedicareRx Basic (PDP) plan has a $320 drug deductible. This deductible is the amount of expenses that must be paid out of pocket before the Initial Coverage period begins. However some drugs do not require that the deductible is met before you receive coverage. You can see if the deductible is required below in the "Does the Deductible Apply" column. The Initial Coverage Limit (ICL) for this plan is $2960. The Initial Coverage Period is the period after the Deductible has been met but before the Coverage Gap phase. Once you and your plan provider have spent $2960 on covered drugs. (combined amount plus your deductible) You will enter the coverage gap. (AKA "donut hole") Once you reach the coverage gap you will be required to pay 45% of the plan's cost for covered brand-name prescription drugs unless your plan offers additional coverage. You can see if this plan offers coverage in the "donut hole" be clicking the "Coverage Gap" link on the left above the chart. In 2015 if you have spent $4700 in expenditures you enter the Catastrophic Phase. During the Catastrophic Period you will begin to receive significant coverage. Blue Cross MedicareRx Basic (PDP) will begin paying approximately 95% of your covered medication expenses. You can see if this plan covers your drugs in the Catastrophic Phase by clicking the "Catastrophic" link on the left above the chart.





Plan Name:
Blue Cross MedicareRx Basic (PDP)
Plan ID:
S5715-013
Provider: Hcsc Insurance Services Company
Plan Year:2015
Premium:$18.30
Deductible:$320
Initial Coverage Limit:$2960
Coverage Area:New Mexico






Current Table info:


Coverage level : Initial Coverage
Days Supply : 30 Days
Drugs Starting With Letter: C



Change Table Options:


Drugs Starting Letter:
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 

Coverage Level:
Pre-deductible,Initial Coverage
Coverage Gap, Catastrophic

Drug Days Pricing:
30 Day Supply, 60 Day Supply, 90 Day Supply

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(Click the Drug Name to Compare every Plans Price)

Drug Name Drug Strength Units in Package Tier Level Amount Limit Days Limit Prior Authorization Y/N Step Therapy Y/N Does the Deduct Apply Cost Prefered Max Cost Pref Cost Non Pref Max Cost Non Pref Cost Amt Mail Max Cost Mail
Cabergoline .5mg 1 Bottle In 1 Carton > 8 Tablet In 1 Bottle
2
N N N N Y $4None$10NoneNANone
Calcipotriene .05mg/mL 60 Ml In 1 Bottle, Plastic
2
N N N N Y $4None$10NoneNANone
Calcipotriene .05mg/g 1 Tube In 1 Carton > 120 G In 1 Tube
4
N N N N Y $90None$95NoneNANone
Calcitonin Salmon 200[iU] 1 Bottle, Glass In 1 Carton > 30 Spray, Metered In 1 Bottle, Glass
2
N N N N Y $4None$10NoneNANone
Calcitriol .25ug 100 Capsule In 1 Bottle, Plastic
2
N N N N Y $4None$10NoneNANone
Calcitriol 1ug/mL 1 Bottle, With Applicator In 1 Carton > 15 Ml In 1 Bottle, With Applicator
2
N N N N Y $4None$10NoneNANone
Calcitriol .5ug 100 Capsule, Liquid Filled In 1 Bottle
2
N N N N Y $4None$10NoneNANone
Calcitriol 1ug/mL 25 Ampule In 1 Carton > 1 Ml In 1 Ampule
2
N N N N Y $4None$10NoneNANone
Calcium Acetate 667mg 200 Capsule In 1 Bottle
2
N N N N Y $4None$10NoneNANone
Camila .35mg 6 Blister Pack In 1 Carton > 28 Tablet In 1 Blister Pack
2
N N N N Y $4None$10NoneNANone
Canasa 1000mg 30 Suppository In 1 Box
5
N N N N Y 25%None25%NoneNANone
Cancidas 5mg/mL 1 Vial, Single-use In 1 Carton > 10.8 Ml In 1 Vial, Single-use
5
N N N N Y 25%None25%NoneNANone
Cancidas 7mg/mL 1 Vial, Single-use In 1 Carton > 10.8 Ml In 1 Vial, Single-use
5
N N N N Y 25%None25%NoneNANone
Capastat Sulfate 1g 1 Injection, Powder, For Solution In 1 Carton
4
N N N N Y $90None$95NoneNANone
Caprelsa 100mg 30 Tablet In 1 Bottle, Plastic
5
60 30 Y N Y 25%None25%NoneNANone
Caprelsa 300mg 30 Tablet In 1 Bottle, Plastic
5
30 30 Y N Y 25%None25%NoneNANone
Captopril 12.5mg 100 Tablet In 1 Bottle, Plastic
1
N N N N Y $0None$5NoneNANone
Captopril 25mg 100 Tablet In 1 Bottle, Plastic
1
N N N N Y $0None$5NoneNANone
Captopril 50mg 100 Tablet In 1 Bottle, Plastic
2
N N N N Y $4None$10NoneNANone
Captopril 100mg 100 Tablet In 1 Bottle, Plastic
2
N N N N Y $4None$10NoneNANone
Carbamazepine 200mg 1000 Tablet In 1 Bottle
1
N N N N Y $0None$5NoneNANone
Carbamazepine 100mg 100 Tablet, Chewable In 1 Bottle
1
N N N N Y $0None$5NoneNANone
Carbamazepine 300mg 120 Capsule, Extended Release In 1 Bottle
2
N N N N Y $4None$10NoneNANone
Carbamazepine 100mg 120 Capsule, Extended Release In 1 Bottle
2
N N N N Y $4None$10NoneNANone
Carbamazepine 200mg 120 Capsule, Extended Release In 1 Bottle
2
N N N N Y $4None$10NoneNANone
Carbamazepine 200mg 100 Tablet, Extended Release In 1 Bottle
2
N N N N Y $4None$10NoneNANone
Carbamazepine 400mg 100 Tablet, Extended Release In 1 Bottle
2
N N N N Y $4None$10NoneNANone
Carbamazepine 100mg/5mL 450 Ml In 1 Bottle, Plastic
2
N N N N Y $4None$10NoneNANone
Carbidopa 25mg 100 Tablet In 1 Bottle
2
N N N N Y $4None$10NoneNANone
Carbidopa And Levodopa 10; 100mg/1; mg 100 Tablet In 1 Bottle
2
N N N N Y $4None$10NoneNANone
Carbidopa And Levodopa 25; 100mg/1; mg 100 Tablet In 1 Bottle
2
N N N N Y $4None$10NoneNANone
Carbidopa And Levodopa 25; 250mg/1; mg 100 Tablet In 1 Bottle
2
N N N N Y $4None$10NoneNANone
Carbidopa And Levodopa 10; 100mg/1; mg 100 Tablet, Orally Disintegrating In 1 Bottle, Plastic
2
N N N N Y $4None$10NoneNANone
Carbidopa And Levodopa 25; 100mg/1; mg 100 Tablet, Orally Disintegrating In 1 Bottle, Plastic
2
N N N N Y $4None$10NoneNANone
Carbidopa And Levodopa 25; 250mg/1; mg 100 Tablet, Orally Disintegrating In 1 Bottle, Plastic
2
N N N N Y $4None$10NoneNANone
Carbidopa And Levodopa 50; 200mg/1; mg 100 Blister Pack In 1 Box, Unit-dose
2
N N N N Y $4None$10NoneNANone
Carbidopa And Levodopa 25; 100mg/1; mg 100 Blister Pack In 1 Box, Unit-dose
2
N N N N Y $4None$10NoneNANone
Carboplatin 10mg/mL 1 Vial In 1 Box > 15 Ml In 1 Vial
2
N N N N Y $4None$10NoneNANone
Carteolol Hydrochloride 10mg/mL 15 Ml In 1 Bottle, Plastic
2
N N N N Y $4None$10NoneNANone
Cartia 120mg 90 Capsule, Extended Release In 1 Bottle
2
N N N N Y $4None$10NoneNANone
Cartia 180mg 90 Capsule, Extended Release In 1 Bottle
2
N N N N Y $4None$10NoneNANone
Cartia 240mg 90 Capsule, Extended Release In 1 Bottle
2
N N N N Y $4None$10NoneNANone
Cartia 300mg 500 Capsule, Extended Release In 1 Bottle
2
N N N N Y $4None$10NoneNANone
Carvedilol 3.125mg 100 Tablet, Film Coated In 1 Bottle, Plastic
1
N N N N Y $0None$5NoneNANone
Carvedilol 6.25mg 100 Tablet, Film Coated In 1 Bottle, Plastic
1
N N N N Y $0None$5NoneNANone
Carvedilol 12.5mg 100 Tablet, Film Coated In 1 Bottle, Plastic
1
N N N N Y $0None$5NoneNANone
Carvedilol 25mg 100 Tablet, Film Coated In 1 Bottle, Plastic
1
N N N N Y $0None$5NoneNANone
Cefaclor 250mg 100 Capsule In 1 Bottle
2
N N N N Y $4None$10NoneNANone
Cefaclor 500mg 100 Capsule In 1 Bottle
2
N N N N Y $4None$10NoneNANone
Cefazolin 500mg 10 Vial In 1 Carton
2
N N N N Y $4None$10NoneNANone
Cefazolin 1g 25 Vial In 1 Carton > 1 Injection, Powder, For Solution In 1 Vial
2
N N N N Y $4None$10NoneNANone
Cefdinir 250mg/5mL 100 Ml In 1 Bottle
4
N N N N Y $90None$95NoneNANone
Cefdinir 300mg 60 Capsule In 1 Bottle
2
N N N N Y $4None$10NoneNANone
Cefdinir 125mg/5mL 100 Ml In 1 Bottle
4
N N N N Y $90None$95NoneNANone
Cefepime 2g 10 Vial In 1 Box > 1 Injection, Powder, For Solution In 1 Vial
4
N N N N Y $90None$95NoneNANone
Cefepime 1g 1 Vial In 1 Box > 1 Injection, Powder, For Solution In 1 Vial
4
N N N N Y $90None$95NoneNANone
Cefotaxime 1g 25 Vial In 1 Package
4
N N N N Y $90None$95NoneNANone
Cefotaxime 2g 25 Vial In 1 Package
4
N N N N Y $90None$95NoneNANone
Cefoxitin 1g 10 Vial In 1 Carton > 1 Powder In 1 Vial
4
N N N N Y $90None$95NoneNANone
Cefoxitin 2g 10 Vial In 1 Carton > 1 Powder In 1 Vial
4
N N N N Y $90None$95NoneNANone
Cefprozil 250mg 100 Tablet, Film Coated In 1 Bottle
2
N N N N Y $4None$10NoneNANone
Cefprozil 500mg 100 Tablet, Film Coated In 1 Bottle
2
N N N N Y $4None$10NoneNANone
Ceftazidime 1g 25 Vial In 1 Carton > 1 Injection, Powder, For Solution In 1 Vial
4
N N N N Y $90None$95NoneNANone
Ceftazidime 2g 10 Vial In 1 Carton > 1 Injection, Powder, For Solution In 1 Vial
4
N N N N Y $90None$95NoneNANone
Ceftazidime 6g/30mL 6 Bottle In 1 Carton > 30 Ml In 1 Bottle
4
N N N N Y $90None$95NoneNANone
Ceftriaxone 250mg 10 Carton In 1 Carton > 1 Injection, Powder, For Solution In 1 Carton
2
N N N N Y $4None$10NoneNANone
Ceftriaxone 500mg 10 Vial In 1 Carton > 1 Injection, Powder, For Solution In 1 Vial
2
N N N N Y $4None$10NoneNANone
Ceftriaxone Sodium 1g 10 Vial, Single-use In 1 Carton > 1 Injection, Powder, For Solution In 1 Vial, Single-use
4
N N N N Y $90None$95NoneNANone
Ceftriaxone Sodium 10g/100mL 1 Vial, Pharmacy Bulk Package In 1 Carton > 100 Ml In 1 Vial, Pharmacy Bulk Package
4
N N N N Y $90None$95NoneNANone
Ceftriaxone Sodium 2g 10 Vial, Single-use In 1 Carton > 1 Injection, Powder, For Solution In 1 Vial, Single-use
4
N N N N Y $90None$95NoneNANone
Cefuroxime 1.5g 25 Injection In 1 Carton
2
N N N N Y $4None$10NoneNANone
Cefuroxime 750mg 25 Injection In 1 Carton
2
N N N N Y $4None$10NoneNANone
Cefuroxime 7.5g/80mL 10 Vial In 1 Carton > 80 Ml In 1 Vial
2
N N N N Y $4None$10NoneNANone
Cefuroxime Axetil 500mg 20 Tablet, Film Coated In 1 Bottle
2
N N N N Y $4None$10NoneNANone
Cefuroxime Axetil 250mg 20 Tablet In 1 Bottle
2
N N N N Y $4None$10NoneNANone
Cellcept 200mg/mL 1 Bottle, Plastic In 1 Carton > 225 Ml In 1 Bottle, Plastic
5
N N Y N Y 25%None25%NoneNANone
Cellcept 500mg/20mL 4 Vial In 1 Carton > 20 Ml In 1 Vial
4
N N Y N Y $90None$95NoneNANone
Celontin 300mg 100 Capsule In 1 Bottle
4
N N N N Y $90None$95NoneNANone
Cephalexin 125mg/5mL 200 Ml In 1 Bottle
2
N N N N Y $4None$10NoneNANone
Cephalexin 250mg/5mL 200 Ml In 1 Bottle
2
N N N N Y $4None$10NoneNANone
Cephalexin 500mg 500 Capsule In 1 Bottle, Plastic
2
N N N N Y $4None$10NoneNANone
Cephalexin 250mg 500 Capsule In 1 Bottle
1
N N N N Y $0None$5NoneNANone
Cerezyme 40U/mL 10 Ml In 1 Vial, Glass
5
N N N N Y 25%None25%NoneNANone
Cervarix 20; 20ug/.5mL; ug/.5mL 10 Syringe In 1 Carton
4
N N N N Y $90None$95NoneNANone
Chantix .5mg 56 Tablet, Film Coated In 1 Bottle
4
336 365 N N Y $90None$95NoneNANone
Chantix 1mg 56 Tablet, Film Coated In 1 Bottle
4
336 365 N N Y $90None$95NoneNANone
Chantix 1 Kit In 1 Carton * 11 Tablet, Film Coated In 1 Blister Pack * 42 Tablet, Film Coated In 1 Blister Pack
4
336 365 N N Y $90None$95NoneNANone
Chemet 100mg 100 Capsule In 1 Bottle
4
N N N N Y $90None$95NoneNANone
Chenodal 250mg 100 Tablet, Film Coated In 1 Bottle, Plastic
5
N N N N Y 25%None25%NoneNANone
Chloramphenicol Sodium Succinate 1g/10mL 10 Vial In 1 Tray > 10 Ml In 1 Vial
4
N N N N Y $90None$95NoneNANone
Chlorhexidine Gluconate 1.2mg/mL 473 Ml In 1 Bottle, Plastic
1
N N N N Y $0None$5NoneNANone
Chloroquine 500mg 25 Tablet, Coated In 1 Bottle, Plastic
2
N N N N Y $4None$10NoneNANone
Chloroquine Phosphate 250mg 50 Tablet In 1 Bottle
2
N N N N Y $4None$10NoneNANone
Chlorpromazine Hydrochloride 25mg/mL 25 Ampule In 1 Carton
4
N N N N Y $90None$95NoneNANone
Chlorpromazine Hydrochloride 50mg 100 Tablet, Sugar Coated In 1 Bottle
2
N N N N Y $4None$10NoneNANone
Chlorpromazine Hydrochloride 10mg 100 Tablet, Sugar Coated In 1 Bottle
2
N N N N Y $4None$10NoneNANone
Chlorpromazine Hydrochloride 25mg 1000 Tablet, Sugar Coated In 1 Bottle
2
N N N N Y $4None$10NoneNANone
Chlorpromazine Hydrochloride 100mg 1000 Tablet, Sugar Coated In 1 Bottle
2
N N N N Y $4None$10NoneNANone
Chlorpromazine Hydrochloride 200mg 1000 Tablet, Sugar Coated In 1 Bottle
2
N N N N Y $4None$10NoneNANone
Chlorthalidone 25mg 100 Tablet In 1 Bottle, Plastic
4
N N N N Y $90None$95NoneNANone
Cholestyramine Light 4g/5.7g 60 Pouch In 1 Carton > 5.7 G In 1 Pouch
2
N N N N Y $4None$10NoneNANone
Chorionic Gonadotropin 1 Kit In 1 Carton * 10 Ml In 1 Vial, Multi-dose * 10 Ml In 1 Vial, Multi-dose
4
N N N N Y $90None$95NoneNANone
Ciclopirox 80mg/mL 6.6 Ml In 1 Bottle, With Applicator
2
N N N N Y $4None$10NoneNANone
Cilostazol 50mg 60 Tablet In 1 Bottle
2
N N N N Y $4None$10NoneNANone
Cilostazol 100mg 60 Tablet In 1 Bottle
2
N N N N Y $4None$10NoneNANone
Cinryze 500[iU]/5mL 1 Vial, Single-use In 1 Carton > 5 Ml In 1 Vial, Single-use
5
100 30 Y N Y 25%None25%NoneNANone
Ciprofloxacin 500mg 100 Tablet, Film Coated In 1 Bottle
2
N N N N Y $4None$10NoneNANone
Ciprofloxacin 250mg 100 Tablet, Film Coated In 1 Bottle
2
N N N N Y $4None$10NoneNANone
Ciprofloxacin 750mg 100 Tablet, Film Coated In 1 Bottle
2
N N N N Y $4None$10NoneNANone
Ciprofloxacin 400mg/40mL 1 Vial In 1 Carton > 40 Ml In 1 Vial
2
N N N N Y $4None$10NoneNANone
Ciprofloxacin 3mg/mL 1 Bottle, Dropper In 1 Carton > 5 Ml In 1 Bottle, Dropper
2
N N N N Y $4None$10NoneNANone
Ciprofloxacin 100mg 6 Tablet, Film Coated In 1 Package
2
N N N N Y $4None$10NoneNANone
Ciprofloxacin And Dextrose 2mg/mL 24 Bag In 1 Case > 100 Ml In 1 Bag
2
N N N N Y $4None$10NoneNANone
Cisplatin 100mg/100mL 1 Vial, Multi-dose In 1 Carton > 100 Ml In 1 Vial, Multi-dose
2
N N N N Y $4None$10NoneNANone
Citalopram 10mg 100 Tablet In 1 Bottle
1
30 30 N N Y $0None$5NoneNANone
Citalopram Hydrobromide 40mg 30 Tablet In 1 Bottle
1
30 30 N N Y $0None$5NoneNANone
Citalopram Hydrobromide 20mg 1000 Tablet In 1 Bottle
1
30 30 N N Y $0None$5NoneNANone
Citalopram Hydrobromide 10mg/5mL 240 Ml In 1 Bottle
2
600 30 N N Y $4None$10NoneNANone
Cladribine 1mg/mL 10 Ml In 1 Vial
5
N N Y N Y 25%None25%NoneNANone
Claravis 10mg 10 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack
4
N N N N Y $90None$95NoneNANone
Claravis 20mg 10 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack
4
N N N N Y $90None$95NoneNANone
Claravis 30mg 3 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack
4
N N N N Y $90None$95NoneNANone
Claravis 40mg 10 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack
4
N N N N Y $90None$95NoneNANone
Clarithromycin 250mg 60 Tablet, Coated In 1 Bottle, Plastic
2
N N N N Y $4None$10NoneNANone
Clarithromycin 500mg 60 Tablet, Coated In 1 Bottle, Plastic
2
N N N N Y $4None$10NoneNANone
Clarithromycin 125mg/5mL 100 Ml In 1 Bottle
2
N N N N Y $4None$10NoneNANone
Clarithromycin 250mg/5mL 100 Ml In 1 Bottle
4
N N N N Y $90None$95NoneNANone
Clemastine Fumarate 2.68mg 100 Tablet In 1 Bottle
4
N N Y N Y $90None$95NoneNANone
Clindamycin 150mg/mL 25 Vial, Patent Delivery System In 1 Tray > 4 Ml In 1 Vial, Patent Delivery System
2
N N N N Y $4None$10NoneNANone
Clindamycin Hydrochloride 75mg 200 Capsule In 1 Bottle
2
N N N N Y $4None$10NoneNANone
Clindamycin Hydrochloride 300mg 100 Capsule In 1 Bottle
2
N N N N Y $4None$10NoneNANone
Clindamycin Hydrochloride 150mg 100 Capsule In 1 Bottle, Plastic
2
N N N N Y $4None$10NoneNANone
Clindamycin Phosphate 20mg/g 40 G In 1 Tube, With Applicator
2
N N N N Y $4None$10NoneNANone
Clinisol 2.17; 1.47; 434; 749; 1.04; 894; 749; 1.04; 1.18; g/100mL; g/100mL; mg/100mL; mg/100mL; g/100mL; mg 500 Ml In 1 Bag
4
N N Y N Y $90None$95NoneNANone
Clobetasol Propionate .05mg/g 1 Tube In 1 Carton > 60 G In 1 Tube
2
N N N N Y $4None$10NoneNANone
Clobetasol Propionate .4625mg/mL 1 Bottle In 1 Carton > 50 Ml In 1 Bottle
2
N N N N Y $4None$10NoneNANone
Clobetasol Propionate .5mg/g 1 Tube In 1 Carton > 30 G In 1 Tube
2
N N N N Y $4None$10NoneNANone
Clobetasol Propionate .5mg/g 1 Tube In 1 Carton > 30 G In 1 Tube
2
N N N N Y $4None$10NoneNANone
Clolar 1mg/mL 1 Vial, Single-use In 1 Carton > 20 Ml In 1 Vial, Single-use
5
N N N N Y 25%None25%NoneNANone
Clomipramine Hydrochloride 25mg 90 Capsule In 1 Bottle
4
N N Y N Y $90None$95NoneNANone
Clomipramine Hydrochloride 50mg 90 Capsule In 1 Bottle
4
N N Y N Y $90None$95NoneNANone
Clomipramine Hydrochloride 75mg 90 Capsule In 1 Bottle
4
N N Y N Y $90None$95NoneNANone
Clonazepam .5mg 100 Tablet In 1 Bottle
2
90 30 Y N Y $4None$10NoneNANone
Clonazepam 2mg 100 Tablet In 1 Bottle
2
300 30 Y N Y $4None$10NoneNANone
Clonazepam .125mg 10 Blister Pack In 1 Carton > 6 Tablet, Orally Disintegrating In 1 Blister Pack
4
90 30 Y N Y $90None$95NoneNANone
Clonazepam .25mg 10 Blister Pack In 1 Carton > 6 Tablet, Orally Disintegrating In 1 Blister Pack
4
90 30 Y N Y $90None$95NoneNANone
Clonazepam .5mg 10 Blister Pack In 1 Carton > 6 Tablet, Orally Disintegrating In 1 Blister Pack
4
90 30 Y N Y $90None$95NoneNANone
Clonazepam 1mg 10 Blister Pack In 1 Carton > 6 Tablet, Orally Disintegrating In 1 Blister Pack
4
90 30 Y N Y $90None$95NoneNANone
Clonazepam 2mg 10 Blister Pack In 1 Carton > 6 Tablet, Orally Disintegrating In 1 Blister Pack
4
300 30 Y N Y $90None$95NoneNANone
Clonazepam 1mg 90 Tablet In 1 Bottle, Plastic
2
90 30 Y N Y $4None$10NoneNANone
Clonidine Hydrochloride .2mg 500 Tablet In 1 Bottle
1
N N N N Y $0None$5NoneNANone
Clonidine Hydrochloride .1mg 500 Tablet In 1 Bottle, Plastic
1
N N N N Y $0None$5NoneNANone
Clonidine Hydrochloride .1mg 60 Tablet, Extended Release In 1 Bottle
2
120 30 N N Y $4None$10NoneNANone
Clonidine Hydrochloride .3mg 100 Tablet In 1 Bottle, Plastic
1
N N N N Y $0None$5NoneNANone
Clopidogrel Bisulfate 75mg 90 Tablet, Film Coated In 1 Bottle, Plastic
1
N N N N Y $0None$5NoneNANone
Clorazepate Dipotassium 3.75mg 500 Tablet In 1 Bottle, Plastic
2
90 30 Y N Y $4None$10NoneNANone
Clorazepate Dipotassium 7.5mg 500 Tablet In 1 Bottle, Plastic
2
90 30 Y N Y $4None$10NoneNANone
Clorazepate Dipotassium 15mg 100 Tablet In 1 Bottle
2
180 30 Y N Y $4None$10NoneNANone
Clotrimazole 10mg 140 Lozenge In 1 Bottle, Plastic
2
N N N N Y $4None$10NoneNANone
Clozapine 25mg 100 Tablet In 1 Bottle
2
90 30 N N Y $4None$10NoneNANone
Clozapine 50mg 500 Tablet In 1 Bottle
2
90 30 N N Y $4None$10NoneNANone
Clozapine 200mg 500 Tablet In 1 Bottle
2
120 30 N N Y $4None$10NoneNANone
Clozapine 100mg 100 Tablet In 1 Bottle
2
270 30 N N Y $4None$10NoneNANone
Coartem 20; 120mg/1; mg 24 Tablet In 1 Bottle
4
N N N N Y $90None$95NoneNANone
Colcrys .6mg 100 Tablet, Film Coated In 1 Bottle, Plastic
3
N N N N Y $40None$45NoneNANone
Colestipol Hydrochloride 1g 120 Tablet, Film Coated In 1 Bottle, Plastic
2
N N N N Y $4None$10NoneNANone
Colestipol Hydrochloride 5g 100 Suspension In 1 Bottle
2
N N N N Y $4None$10NoneNANone
Collagenase Santyl 250[arb'U]/g 1 Tube In 1 Carton > 30 G In 1 Tube
3
N N N N Y $40None$45NoneNANone
Colocort 100mg/60mL 7 Bottle, Dispensing In 1 Box > 60 Ml In 1 Bottle, Dispensing
2
N N N N Y $4None$10NoneNANone
Cometriq 4 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
5
112 28 Y N Y 25%None25%NoneNANone
Cometriq 4 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
5
56 28 Y N Y 25%None25%NoneNANone
Cometriq 20mg 4 Blister Pack In 1 Carton > 21 Capsule In 1 Blister Pack
5
84 28 Y N Y 25%None25%NoneNANone
Complera 200; 25; 300mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle
5
30 30 N N Y 25%None25%NoneNANone
Compro 25mg 12 Packet In 1 Carton > 1 Suppository In 1 Packet
4
N N N N Y $90None$95NoneNANone
Comvax 7.5; 5ug/.5mL; ug/.5mL 10 Vial, Single-dose In 1 Carton
4
N N N N Y $90None$95NoneNANone
Constulose 10g/15mL 946 Ml In 1 Bottle
2
N N N N Y $4None$10NoneNANone
Copaxone 20mg/mL 30 Blister Pack In 1 Carton > 1 Syringe, Glass In 1 Blister Pack > 1 Ml In 1 Syringe, Glass
5
30 30 Y N Y 25%None25%NoneNANone
Copaxone 40mg/mL 12 Blister Pack In 1 Carton > 1 Syringe, Glass In 1 Blister Pack > 1 Ml In 1 Syringe, Glass
5
12 28 Y N Y 25%None25%NoneNANone
Cortisone Acetate 25mg 100 Tablet In 1 Bottle, Plastic
4
N N N N Y $90None$95NoneNANone
Cosmegen .5mg/mL 12 Vial, Single-dose In 1 Carton > 1 Ml In 1 Vial, Single-dose
5
N N N N Y 25%None25%NoneNANone
Creon 15000; 3000; 9500[USP'U]/1; [USP'U]/1; [USP'U] 1 Bottle In 1 Carton > 70 Capsule, Delayed Release In 1 Bottle
3
N N N N Y $40None$45NoneNANone
Creon 30000; 6000; 19000[USP'U]/1; [USP'U]/1; [USP'U] 1 Bottle In 1 Carton > 100 Capsule, Delayed Release Pellets In 1 Bottle
3
N N N N Y $40None$45NoneNANone
Creon 60000; 12000; 38000[USP'U]/1; [USP'U]/1; [USP'U] 100 Capsule, Delayed Release Pellets In 1 Bottle
3
N N N N Y $40None$45NoneNANone
Creon 120000; 24000; 76000[USP'U]/1; [USP'U]/1; [USP'U] 100 Capsule, Delayed Release Pellets In 1 Bottle
3
N N N N Y $40None$45NoneNANone
Creon 180000; 36000; 114000[USP'U]/1; [USP'U]/1; [USP'U] 250 Capsule, Delayed Release Pellets In 1 Bottle
3
N N N N Y $40None$45NoneNANone
Crestor 10mg 90 Tablet, Film Coated In 1 Bottle, Plastic
3
45 30 N N Y $40None$45NoneNANone
Crestor 20mg 90 Tablet, Film Coated In 1 Bottle, Plastic
3
45 30 N N Y $40None$45NoneNANone
Crestor 40mg 30 Tablet, Film Coated In 1 Bottle, Plastic
3
30 30 N N Y $40None$45NoneNANone
Crestor 5mg 90 Tablet, Film Coated In 1 Bottle, Plastic
3
45 30 N N Y $40None$45NoneNANone
Crixivan 200mg 360 Capsule In 1 Bottle
3
270 30 N N Y $40None$45NoneNANone
Crixivan 400mg 180 Capsule In 1 Bottle
3
180 30 N N Y $40None$45NoneNANone
Cromolyn Sodium 20mg/2mL 120 Vial, Single-dose In 1 Carton
2
N N Y N Y $4None$10NoneNANone
Cromolyn Sodium 40mg/mL 10 Ml In 1 Bottle, Plastic
1
N N N N Y $0None$5NoneNANone
Cryselle 6 Pouch In 1 Carton > 1 Blister Pack In 1 Pouch > 1 Kit In 1 Blister Pack
2
N N N N Y $4None$10NoneNANone
Cyclafem 1/35 6 Blister Pack In 1 Carton
2
N N N N Y $4None$10NoneNANone
Cyclafem 7/7/7 6 Blister Pack In 1 Carton
2
N N N N Y $4None$10NoneNANone
Cyclobenzaprine Hydrochloride 5mg 100 Tablet, Film Coated In 1 Bottle, Plastic
4
N N N Y Y $90None$95NoneNANone
Cyclobenzaprine Hydrochloride 10mg 1000 Tablet In 1 Bottle
4
N N N Y Y $90None$95NoneNANone
Cyclophosphamide 25mg 100 Capsule In 1 Bottle
4
N N Y N Y $90None$95NoneNANone
Cyclophosphamide 50mg 100 Capsule In 1 Bottle
4
N N Y N Y $90None$95NoneNANone
Cyclophosphamide 25mg 100 Tablet In 1 Bottle, Plastic
4
N N Y N Y $90None$95NoneNANone
Cyclophosphamide 50mg 100 Tablet In 1 Bottle, Plastic
4
N N Y N Y $90None$95NoneNANone
Cycloset .8mg 200 Tablet In 1 Bottle
4
180 30 N N Y $90None$95NoneNANone
Cyclosporine 25mg 30 Blister Pack In 1 Carton
2
N N Y N Y $4None$10NoneNANone
Cyclosporine 50mg 30 Blister Pack In 1 Carton
4
N N Y N Y $90None$95NoneNANone
Cyclosporine 100mg 30 Blister Pack In 1 Carton
2
N N Y N Y $4None$10NoneNANone
Cyclosporine 100mg/mL 1 Bottle In 1 Package > 50 Ml In 1 Bottle
2
N N Y N Y $4None$10NoneNANone
Cyclosporine 50mg/mL 10 Ampule In 1 Carton > 5 Ml In 1 Ampule
2
N N Y N Y $4None$10NoneNANone
Cyclosporine 25mg 30 Capsule, Liquid Filled In 1 Bottle
2
N N Y N Y $4None$10NoneNANone
Cyclosporine 100mg 30 Capsule, Liquid Filled In 1 Bottle
4
N N Y N Y $90None$95NoneNANone
Cystadane 6g 180 Powder, For Solution In 1 Bottle
5
N N N N Y 25%None25%NoneNANone
Cystagon 50mg 500 Capsule In 1 Bottle, Plastic
4
N N N N Y $90None$95NoneNANone
Cystagon 150mg 500 Capsule In 1 Bottle, Plastic
4
N N N N Y $90None$95NoneNANone
Cytarabine 20mg/mL 1 Vial, Multi-dose In 1 Carton > 25 Ml In 1 Vial, Multi-dose
2
N N Y N Y $4None$10NoneNANone
Cytarabine 100mg/mL 1 Vial, Single-dose In 1 Carton > 20 Ml In 1 Vial, Single-dose
2
N N Y N Y $4None$10NoneNANone



Medicare Help's

Additional Notes:



Coverage Levels for S5715-013

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1.Pre-Deductable: Before you reach the plans deductible of $320. Some plans offer select Pre-deductible drug Coverage
2.Initial Coverage: (ICL) After you reach the plans deductible but before the Initial Coverage limit of $2960
3.Coverage Gap: (AKA Donut Hole) After you reach the plans ICL but before the Catastrophic of $4700 in 2015.
4.Catastrophic: Anything over $4700 you will receive a significant increase in coverage.

Definitions:

Premium: A monthly flat fee that varies by plan.
Deductible: The amount you must pay each year for your prescriptions before your plan begins to pay its share of your covered drugs. The max in 2015 is $320. Some plans have a $0 Deductible.
Tier Level: Medicare drug plans place drugs into different "tiers" on their formularies. Drugs in each tier have a different cost. A drug in a lower tier will generally cost you less.
Quantity Limit Amount/Days: Certain drugs have a Quantity Limit. That means the plan will only cover the drug up to a designated quantity or amount. If your prescribing doctor feels it is necessary to exceed the set limit, he or she must get prior approval before the higher quantity will be covered.
Prior Authorization: Certain Drugs require you or your doctor to get prior authorization in order to be covered. Usually just an additional form. If you dont get approval, the plan may not cover the drug.
Does the Deduct Apply: Some drugs do not require that the deductible is met before you receive coverage.
Step Therapy: Means you must first try one drug to treat your medical condition before the plan will cover another drug for the same condition. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.
Cost Prefered: Your Cost for the Drug at the Providers In Network Prefered Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Non Pref: Your Cost for the Prescription Drug at a Non-Prefered Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Mail: Your Cost for Prescription Drugs through a Mail Order Pharmacy. As a Percent of the total drug cost or a flat rate.


What if a drug I need is not listed?

Please check the formulary for different brand and generic names. If you still cannot locate your drugs, your plan may not offer coverage. Talk to your doctor first about changing your prescription to a drug on your plans formulary. If this is not an option, you can request an exception to have the plan review its coverage decision based on your individual circumstances.

Source:CMS Formulary Data Oct. 2014
Source:NDC Directory by FDA.gov

**We make every attempt to keep our information accurate. But please check with the plan providers to verify all information.

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