2017 HumanaChoice R5826-012 (Regional PPO) Formulary



Below is the Formulary, or drug list, for HumanaChoice R5826-012 (Regional PPO) from Humana Insurance Company This formulary is a list of prescription medications that are covered under Humana Insurance Company's 2017 Medicare Advantage Plan. The HumanaChoice R5826-012 (Regional PPO) plan has a $200 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 $3700. 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 $3700 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 2017 if you have spent $4700 in expenditures you enter the Catastrophic Phase. During the Catastrophic Period you will begin to receive significant coverage. HumanaChoice R5826-012 (Regional PPO) 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.

See More on HumanaChoice R5826-012 (Regional PPO)





Plan Name:
HumanaChoice R5826-012 (Regional PPO)
Plan ID:
R5826-012
Provider: Humana Insurance Company
Plan Year:2017
Premium:$35.00
Deductible:$200
Initial Coverage Limit:$3700
Coverage Area:Texas




Current Table info:


Coverage Level:
Initial Coverage
Days Supply:
30 Days
Drugs Starting With Letter: A

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:
Drug Days Pricing:60 Day
90 Day











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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 Preferred Max Cost Non Preferred Max Cost Mail Max
A Hydrocort 100mg/2mL 10 Vial, Single-dose In 1 Carton > 2 Ml In 1 Vial, Single-dose
1
N N N $7N$10N$7N
Abacavir Sulfate 300mg 1 Bottle, Plastic In 1 Carton > 60 Tablet, Film Coated In 1 Bottle, Plastic
4
60.00 30 N N Y $99N$100N$99N
Abacavir Sulfate, Lamivudine And Zidovudine 300; 150; 300mg/1; mg/1; mg 1 Bottle In 1 Carton > 60 Tablet In 1 Bottle
5
60.00 30 N N Y 29%N29%N29%N
Abelcet 5; 3.4; 1.5mg/mL; mg/mL; mg/mL 1 Vial In 1 Carton > 20 Ml In 1 Vial
5
Y N Y 29%N29%N29%N
Abilify Maintena 1 Kit In 1 Carton * 1.5 Ml In 1 Vial, Single-use * 5 Ml In 1 Vial, Single-use
5
1.00 28 Y N Y 29%N29%N29%N
Abraxane 100mg/20mL 1 Vial, Single-use In 1 Carton > 20 Ml In 1 Vial, Single-use
5
Y N Y 29%N29%N29%N
Acamprosate Calcium 333mg 180 Tablet, Delayed Release In 1 Bottle
4
N N Y $99N$100N$99N
Acarbose 25mg 100 Tablet In 1 Bottle
3
N N N $47N$47N$47N
Acarbose 50mg 100 Tablet In 1 Bottle
3
N N N $47N$47N$47N
Acarbose 100 Tablet In 1 Bottle
3
N N N $47N$47N$47N
Acebutolol Hydrochloride 200mg 100 Capsule In 1 Bottle
2
N N N $12N$17N$12N
Acebutolol Hydrochloride 400mg 100 Capsule In 1 Bottle
2
N N N $12N$17N$12N
Acetaminophen And Codeine 300; 30mg/1; mg 60 Tablet In 1 Bottle, Plastic
3
360.00 30 N N N $47N$47N$47N
Acetaminophen And Codeine Phosphate 300; 15mg/1; mg 100 Tablet In 1 Bottle
3
390.00 30 N N N $47N$47N$47N
Acetaminophen And Codeine Phosphate 300; 60mg/1; mg 500 Tablet In 1 Bottle
3
180.00 30 N N N $47N$47N$47N
Acetaminophen And Codeine Phosphate 120; 12mg/5mL; mg/5mL 10 Tray In 1 Case > 10 Cup, Unit-dose In 1 Tray > 12.5 Ml In 1 Cup, Unit-dose
3
2700.00 30 N N N $47N$47N$47N
Acetasol Hc 2.41; 1.1g/100mL; g/100mL 1 Bottle In 1 Carton > 10 Ml In 1 Bottle
4
N N Y $99N$100N$99N
Acetazolamide 250mg 100 Tablet In 1 Bottle, Plastic
3
N N N $47N$47N$47N
Acetazolamide 500mg/5mL 1 Vial, Glass In 1 Carton > 5 Ml In 1 Vial, Glass
2
N N N $12N$17N$12N
Acetazolamide 125mg 100 Tablet In 1 Bottle
3
N N N $47N$47N$47N
Acetazolamide 500mg 100 Capsule, Extended Release In 1 Bottle
4
N N Y $99N$100N$99N
Acetic Acid 1 Bottle In 1 Box > 15 Ml In 1 Bottle
2
N N N $12N$17N$12N
Acetylcysteine 3 Vial, Glass In 1 Box > 10 Ml In 1 Vial, Glass
3
Y N N $47N$47N$47N
Acetylcysteine 3 Vial In 1 Carton > 10 Ml In 1 Vial
3
Y N N $47N$47N$47N
Aciphex 20mg 30 Tablet, Delayed Release In 1 Bottle
4
30.00 30 Y N Y $99N$100N$99N
Acitretin 10mg 30 Capsule In 1 Bottle
5
N N Y 29%N29%N29%N
Acitretin 25mg 30 Capsule In 1 Bottle
5
N N Y 29%N29%N29%N
Acitretin 17.5mg 30 Capsule In 1 Bottle
5
N N Y 29%N29%N29%N
Acyclovir 50mg/g 1 Tube In 1 Carton > 15 G In 1 Tube
4
Y N Y $99N$100N$99N
Acyclovir 200mg 100 Capsule In 1 Bottle
2
N N N $12N$17N$12N
Acyclovir 200mg/5mL 473 Ml In 1 Bottle
4
N N Y $99N$100N$99N
Acyclovir 400mg 100 Tablet In 1 Bottle
2
N N N $12N$17N$12N
Acyclovir 800mg 100 Tablet In 1 Bottle
2
N N N $12N$17N$12N
Acyclovir Sodium 500mg/10mL 10 Vial, Single-dose In 1 Carton > 10 Ml In 1 Vial, Single-dose
4
Y N Y $99N$100N$99N
Adacel 5; 5; 3; 2.5; 5; 2ug/.5mL; ug/.5mL; ug/.5mL; ug/.5mL; [Lf]/.5mL; [Lf 10 Vial In 1 Package
4
N N Y $99N$100N$99N
Adagen 250[iU]/mL 4 Vial, Single-use In 1 Box > 1.5 Ml In 1 Vial, Single-use
5
N N Y 29%N29%N29%N
Adalat Cc 30mg 100 Tablet, Film Coated In 1 Bottle, Plastic
4
60.00 30 N N Y $99N$100N$99N
Adalat Cc 60mg 1000 Tablet, Film Coated In 1 Bottle, Plastic
4
60.00 30 N N Y $99N$100N$99N
Adalat Cc 90mg 100 Tablet, Film Coated In 1 Bottle, Plastic
4
60.00 30 N N Y $99N$100N$99N
Adapalene 1mg/g 45 G In 1 Tube
4
N N Y $99N$100N$99N
Adcirca 20mg 60 Tablet In 1 Bottle
5
60.00 30 Y N Y 29%N29%N29%N
Adefovir Dipivoxil 10mg 30 Tablet In 1 Bottle
5
N N Y 29%N29%N29%N
Adempas .5mg 90 Tablet, Film Coated In 1 Bottle
5
90.00 30 Y N Y 29%N29%N29%N
Adempas 1mg 90 Tablet, Film Coated In 1 Bottle
5
90.00 30 Y N Y 29%N29%N29%N
Adempas 1.5mg 90 Tablet, Film Coated In 1 Bottle
5
90.00 30 Y N Y 29%N29%N29%N
Adempas 2mg 90 Tablet, Film Coated In 1 Bottle
5
90.00 30 Y N Y 29%N29%N29%N
Adempas 2.5mg 90 Tablet, Film Coated In 1 Bottle
5
90.00 30 Y N Y 29%N29%N29%N
Advair 100; 50ug/1; ug 1 Inhaler In 1 Carton > 60 Powder In 1 Inhaler
3
60.00 30 N N N $47N$47N$47N
Advair 250; 50ug/1; ug 1 Inhaler In 1 Carton > 60 Powder In 1 Inhaler
3
60.00 30 N N N $47N$47N$47N
Advair 500; 50ug/1; ug 1 Inhaler In 1 Carton > 60 Powder In 1 Inhaler
3
60.00 30 N N N $47N$47N$47N
Advair Hfa 45; 21ug/1; ug 1 Inhaler In 1 Carton > 120 Aerosol, Metered In 1 Inhaler
3
12.00 30 N N N $47N$47N$47N
Advair Hfa 115; 21ug/1; ug 1 Inhaler In 1 Carton > 120 Aerosol, Metered In 1 Inhaler
3
12.00 30 N N N $47N$47N$47N
Advair Hfa 230; 21ug/1; ug 1 Inhaler In 1 Carton > 120 Aerosol, Metered In 1 Inhaler
3
12.00 30 N N N $47N$47N$47N
Afeditab 30mg 100 Tablet, Film Coated, Extended Release In 1 Bottle
3
60.00 30 N N N $47N$47N$47N
Afeditab 60mg 100 Tablet, Film Coated, Extended Release In 1 Bottle
3
60.00 30 N N N $47N$47N$47N
Afinitor 5mg 28 Blister Pack In 1 Carton
5
30.00 30 Y N Y 29%N29%N29%N
Afinitor 10mg 28 Blister Pack In 1 Carton
5
30.00 30 Y N Y 29%N29%N29%N
Afinitor 2.5mg 28 Blister Pack In 1 Carton
5
30.00 30 Y N Y 29%N29%N29%N
Afinitor 7.5mg 28 Blister Pack In 1 Carton
5
30.00 30 Y N Y 29%N29%N29%N
Afinitor 2mg 28 Blister Pack In 1 Carton
5
Y N Y 29%N29%N29%N
Afinitor 3mg 28 Blister Pack In 1 Carton
5
Y N Y 29%N29%N29%N
Afinitor 5mg 28 Blister Pack In 1 Carton
5
Y N Y 29%N29%N29%N
Aggrenox 25; 200mg/1; mg 1 Bottle In 1 Carton > 60 Capsule In 1 Bottle
4
N Y Y $99N$100N$99N
Alacort 10mg/g 85.2 G In 1 Tube
2
N N N $12N$17N$12N
Albenza 200mg 2 Tablet, Film Coated In 1 Bottle
5
N N Y 29%N29%N29%N
Albuterol 2mg 500 Tablet In 1 Bottle, Plastic
4
N N Y $99N$100N$99N
Albuterol Sulfate 4mg 100 Tablet, Film Coated, Extended Release In 1 Bottle, Plastic
4
N N Y $99N$100N$99N
Albuterol Sulfate 8mg 100 Tablet, Film Coated, Extended Release In 1 Bottle, Plastic
4
N N Y $99N$100N$99N
Albuterol Sulfate .75mg/3mL 30 Pouch In 1 Carton > 1 Vial, Single-dose In 1 Pouch > 3 Ml In 1 Vial, Single-dose
2
Y N N $12N$17N$12N
Albuterol Sulfate 2.5mg/3mL 30 Pouch In 1 Carton > 1 Vial, Single-dose In 1 Pouch > 3 Ml In 1 Vial, Single-dose
2
Y N N $12N$17N$12N
Albuterol Sulfate 1.5mg/3mL 30 Pouch In 1 Carton > 1 Vial, Single-dose In 1 Pouch > 3 Ml In 1 Vial, Single-dose
2
Y N N $12N$17N$12N
Albuterol Sulfate 2mg/5mL 473 Ml In 1 Bottle
2
N N N $12N$17N$12N
Albuterol Sulfate 5mg/mL 1 Bottle, Glass In 1 Carton > 20 Ml In 1 Bottle, Glass
2
Y N N $12N$17N$12N
Albuterol Sulfate 4mg 500 Tablet In 1 Bottle
4
N N Y $99N$100N$99N
Alclometasone Dipropionate .5mg/g 45 G In 1 Tube
3
N N N $47N$47N$47N
Alclometasone Dipropionate .5mg/g 1 Tube In 1 Carton > 60 G In 1 Tube
3
N N N $47N$47N$47N
Alendronate Sodium 5mg 30 Tablet In 1 Bottle
1
30.00 30 N N N $7N$10N$7N
Alendronate Sodium 10mg 30 Tablet In 1 Bottle
1
30.00 30 N N N $7N$10N$7N
Alendronate Sodium 40mg 30 Tablet In 1 Bottle
1
30.00 30 N N N $7N$10N$7N
Alendronate Sodium 70mg 4 Blister Pack In 1 Box
1
4.00 28 N N N $7N$10N$7N
Alendronate Sodium 1 Blister Pack In 1 Carton > 4 Tablet In 1 Blister Pack
1
4.00 28 N N N $7N$10N$7N
Alfuzosin Hydrochloride 10mg 100 Tablet, Extended Release In 1 Bottle
2
30.00 30 N N N $12N$17N$12N
Alimta 500mg/20mL 1 Vial In 1 Carton > 20 Ml In 1 Vial
5
Y N Y 29%N29%N29%N
Alinia 500mg 1 Bottle, Plastic In 1 Carton > 30 Tablet In 1 Bottle, Plastic
4
40.00 30 N N Y $99N$100N$99N
Alinia 100mg/5mL 1 Bottle, Glass In 1 Carton > 60 Ml In 1 Bottle, Glass
4
150.00 30 N N Y $99N$100N$99N
Alkeran 1 Kit In 1 Carton
4
Y N Y $99N$100N$99N
Allopurinol 100mg 1000 Tablet In 1 Bottle, Plastic
2
N N N $12N$17N$12N
Allopurinol 300mg 100 Blister Pack In 1 Box, Unit-dose
2
N N N $12N$17N$12N
Aloprim 500mg/25mL 1 Vial, Glass In 1 Carton > 25 Ml In 1 Vial, Glass
4
N N Y $99N$100N$99N
Alora .05mg/d 8 Pouch In 1 Box > 1 Patch In 1 Pouch > 3.5 D In 1 Patch
4
8.00 28 N N Y $99N$100N$99N
Alora .075mg/d 8 Pouch In 1 Box > 1 Patch In 1 Pouch > 3.5 D In 1 Patch
4
8.00 28 N N Y $99N$100N$99N
Alora .1mg/d 8 Pouch In 1 Box > 1 Patch In 1 Pouch > 3.5 D In 1 Patch
4
8.00 28 N N Y $99N$100N$99N
Alora .025mg/d 8 Pouch In 1 Box > 1 Patch In 1 Pouch > 3.5 D In 1 Patch
4
8.00 28 N N Y $99N$100N$99N
Alphagan P 1.5mg/mL 1 Bottle, Dropper In 1 Carton > 15 Ml In 1 Bottle, Dropper
3
N N N $47N$47N$47N
Alphagan P 1mg/mL 1 Bottle, Dropper In 1 Carton > 15 Ml In 1 Bottle, Dropper
3
N N N $47N$47N$47N
Alprazolam .5mg 100 Tablet In 1 Bottle
2
120.00 30 N N N $12N$17N$12N
Alprazolam 1mg 500 Tablet In 1 Bottle
2
120.00 30 N N N $12N$17N$12N
Alprazolam .25mg 500 Tablet In 1 Bottle
2
120.00 30 N N N $12N$17N$12N
Alprazolam 2mg 500 Tablet In 1 Bottle
2
150.00 30 N N N $12N$17N$12N
Altabax 10mg/g 1 Tube In 1 Carton > 30 G In 1 Tube
4
N N Y $99N$100N$99N
Amantadine Hydrochloride 100mg 500 Capsule In 1 Bottle
4
N N Y $99N$100N$99N
Amantadine Hydrochloride 100mg 500 Tablet In 1 Bottle
4
N N Y $99N$100N$99N
Amantadine Hydrochloride 50mg/5mL 473 Ml In 1 Bottle
3
N N N $47N$47N$47N
Ambien 6.25mg 100 Tablet, Coated In 1 Bottle
4
30.00 30 Y N Y $99N$100N$99N
Ambien 12.5mg 100 Tablet, Coated In 1 Bottle
4
30.00 30 Y N Y $99N$100N$99N
Ambisome 50mg/12.5mL 12.5 Ml In 1 Vial, Single-dose
4
Y N Y $99N$100N$99N
Amethia 2 Blister Pack In 1 Carton
4
N N Y $99N$100N$99N
Amethyst 20; 90ug/1; ug 1 Blister Pack In 1 Carton > 28 Tablet In 1 Blister Pack
4
N N Y $99N$100N$99N
Amifostine 50mg/mL 3 Vial, Single-use In 1 Carton > 10 Ml In 1 Vial, Single-use
5
Y N Y 29%N29%N29%N
Amikacin Sulfate 10 Vial In 1 Carton > 2 Ml In 1 Vial
4
N N Y $99N$100N$99N
Amiloride Hydrochloride 5mg 100 Tablet In 1 Bottle
3
N N N $47N$47N$47N
Amiloride Hydrochloride And Hydrochlorothiazide 5; 50mg/1; mg 1000 Tablet In 1 Bottle
2
N N N $12N$17N$12N
Amino Acids 6 Carton In 1 Case > 1 Bottle, Glass In 1 Carton > 1000 Ml In 1 Bottle, Glass
4
Y N Y $99N$100N$99N
Aminophylline 25mg/mL 5 Tray In 1 Carton > 5 Ampule In 1 Tray > 10 Ml In 1 Ampule
2
N N N $12N$17N$12N
Aminosyn 660; 507; 660; 154; 789; 1576; 265; 206; 228; 448;mg/100mL; mg/100mL; mg/100mL; mg/100mL; mg/100mL; 12 Pouch In 1 Case > 1 Bag In 1 Pouch > 500 Ml In 1 Bag
4
Y N Y $99N$100N$99N
Aminosyn 12 Pouch In 1 Case > 1 Bag In 1 Pouch > 500 Ml In 1 Bag
4
Y N Y $99N$100N$99N
Aminosyn 1100; 850; 1100; 260; 620; 810; 624; 102; 340; 380mg/100mL; mg/100mL; mg/100mL; mg/100mL; mg/100mL; 6 Pouch In 1 Case > 1 Bag In 1 Pouch > 1000 Ml In 1 Bag
4
Y N Y $99N$100N$99N
Aminosyn Ii 695; 713; 490; 517; 350; 210; 462; 700; 735; 120; mg/100mL; mg/100mL; mg/100mL; mg/100mL; mg/100mL; 12 Pouch In 1 Case > 1 Bag In 1 Pouch > 500 Ml In 1 Bag
4
Y N Y $99N$100N$99N
Aminosyn Ii 12 Pouch In 1 Case > 1 Bag In 1 Pouch > 500 Ml In 1 Bag
4
Y N Y $99N$100N$99N
Aminosyn Ii 6 Pouch In 1 Case > 1 Bag In 1 Pouch > 2000 Ml In 1 Bag
4
Y N Y $99N$100N$99N
Aminosyn Ii 1490; 1527; 1050; 1107; 750; 450; 990; 1500; 1575;mg/100mL; mg/100mL; mg/100mL; mg/100mL; mg/100mL; 6 Pouch In 1 Case > 1 Bag In 1 Pouch > 2000 Ml In 1 Bag
4
Y N Y $99N$100N$99N
Aminosyn Ii With Electrolytes 844; 865; 595; 627; 425; 255; 561; 850; 893; 102; mg/100mL; mg/100mL; mg/100mL; mg/100mL; mg/100mL; 12 Bag In 1 Case > 500 Ml In 1 Bag
4
Y N Y $99N$100N$99N
Aminosyn Rf 12 Pouch In 1 Case > 1 Bag In 1 Pouch > 500 Ml In 1 Bag
4
Y N Y $99N$100N$99N
Aminosyn-pf 490; 861; 370; 576; 270; 220; 534; 831; 475; 125; mg/100mL; mg/100mL; mg/100mL; mg/100mL; mg/100mL; 12 Bag In 1 Case > 500 Ml In 1 Bag
4
Y N Y $99N$100N$99N
Aminosyn-pf 698; 1227; 527; 820; 385; 312; 760; 1200; 677; 180mg/100mL; mg/100mL; mg/100mL; mg/100mL; mg/100mL; 6 Bag In 1 Case > 1000 Ml In 1 Bag
4
Y N Y $99N$100N$99N
Amiodarone Hydrochloride 200mg 60 Tablet In 1 Bottle
2
N N N $12N$17N$12N
Amiodarone Hydrochloride 50mg/mL 2 Tray In 1 Package > 5 Ampule In 1 Tray > 3 Ml In 1 Ampule
2
N N N $12N$17N$12N
Amiodarone Hydrochloride 400mg 30 Tablet In 1 Bottle
4
N N Y $99N$100N$99N
Amitiza 8ug 60 Capsule, Gelatin Coated In 1 Bottle
3
60.00 30 N N N $47N$47N$47N
Amitiza 24ug 60 Capsule, Gelatin Coated In 1 Bottle
3
60.00 30 N N N $47N$47N$47N
Amitriptyline Hydrochloride 50mg 100 Tablet, Film Coated In 1 Bottle, Plastic
3
N N N $47N$47N$47N
Amitriptyline Hydrochloride 100mg 100 Tablet, Film Coated In 1 Bottle, Plastic
3
N N N $47N$47N$47N
Amitriptyline Hydrochloride 10mg 1000 Tablet, Film Coated In 1 Bottle, Plastic
3
N N N $47N$47N$47N
Amitriptyline Hydrochloride 25mg 100 Tablet, Film Coated In 1 Bottle, Plastic
3
N N N $47N$47N$47N
Amitriptyline Hydrochloride 150mg 100 Tablet, Film Coated In 1 Bottle, Plastic
3
N N N $47N$47N$47N
Amitriptyline Hydrochloride 75mg 100 Tablet, Film Coated In 1 Bottle
3
N N N $47N$47N$47N
Amlodipine And Atorvastatin 10; 20mg/1; mg 30 Tablet, Film Coated In 1 Bottle, Plastic
4
30.00 30 N N Y $99N$100N$99N
Amlodipine And Atorvastatin 10; 40mg/1; mg 30 Tablet, Film Coated In 1 Bottle, Plastic
4
30.00 30 N N Y $99N$100N$99N
Amlodipine And Benazepril Hydrochloride 5; 40mg/1; mg 500 Capsule In 1 Bottle
2
30.00 30 N N N $12N$17N$12N
Amlodipine And Benazepril Hydrochloride 10; 40mg/1; mg 100 Capsule In 1 Bottle
2
30.00 30 N N N $12N$17N$12N
Amlodipine And Valsartan 30 Tablet In 1 Bottle, Plastic
4
30.00 30 N N Y $99N$100N$99N
Amlodipine And Valsartan 30 Tablet In 1 Bottle, Plastic
4
30.00 30 N N Y $99N$100N$99N
Amlodipine And Valsartan 30 Tablet In 1 Bottle, Plastic
4
30.00 30 N N Y $99N$100N$99N
Amlodipine And Valsartan 30 Tablet In 1 Bottle, Plastic
4
30.00 30 N N Y $99N$100N$99N
Amlodipine Besylate 2.5mg 90 Tablet In 1 Bottle
1
N N N $7N$10N$7N
Amlodipine Besylate 5mg 90 Tablet In 1 Bottle
1
N N N $7N$10N$7N
Amlodipine Besylate 10mg 90 Tablet In 1 Bottle
1
N N N $7N$10N$7N
Amlodipine Besylate And Atorvastatin Calcium 10; 80mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
30.00 30 N N Y $99N$100N$99N
Amlodipine Besylate And Atorvastatin Calcium 5; 80mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
30.00 30 N N Y $99N$100N$99N
Amlodipine Besylate And Atorvastatin Calcium 5; 40mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
30.00 30 N N Y $99N$100N$99N
Amlodipine Besylate And Atorvastatin Calcium 2.5; 40mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
30.00 30 N N Y $99N$100N$99N
Amlodipine Besylate And Atorvastatin Calcium 5; 20mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
30.00 30 N N Y $99N$100N$99N
Amlodipine Besylate And Atorvastatin Calcium 2.5; 20mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
30.00 30 N N Y $99N$100N$99N
Amlodipine Besylate And Atorvastatin Calcium 10; 10mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
30.00 30 N N Y $99N$100N$99N
Amlodipine Besylate And Atorvastatin Calcium 5; 10mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
30.00 30 N N Y $99N$100N$99N
Amlodipine Besylate And Atorvastatin Calcium 2.5; 10mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
30.00 30 N N Y $99N$100N$99N
Amlodipine Besylate And Benazepril Hydrochloride 2.5; 10mg/1; mg 100 Capsule In 1 Bottle
2
60.00 30 N N N $12N$17N$12N
Amlodipine Besylate And Benazepril Hydrochloride 5; 10mg/1; mg 100 Capsule In 1 Bottle
2
60.00 30 N N N $12N$17N$12N
Amlodipine Besylate And Benazepril Hydrochloride 5; 20mg/1; mg 100 Capsule In 1 Bottle
2
60.00 30 N N N $12N$17N$12N
Amlodipine Besylate And Benazepril Hydrochloride 10; 20mg/1; mg 100 Capsule In 1 Bottle
2
60.00 30 N N N $12N$17N$12N
Ammonium Chloride 5meq/mL 25 Vial, Single-dose In 1 Tray > 20 Ml In 1 Vial, Single-dose
1
N N N $7N$10N$7N
Ammonium Lactate 12g/100g 400 G In 1 Bottle, Plastic
2
N N N $12N$17N$12N
Ammonium Lactate 2 Tube In 1 Carton > 140 G In 1 Tube
2
N N N $12N$17N$12N
Amoxapine 25mg 100 Tablet In 1 Bottle, Plastic
4
N N Y $99N$100N$99N
Amoxapine 50mg 100 Tablet In 1 Bottle, Plastic
4
N N Y $99N$100N$99N
Amoxapine 100mg 100 Tablet In 1 Bottle, Plastic
4
N N Y $99N$100N$99N
Amoxapine 150mg 30 Tablet In 1 Bottle, Plastic
4
N N Y $99N$100N$99N
Amoxicillin 500mg 100 Tablet, Film Coated In 1 Bottle
1
N N N $7N$10N$7N
Amoxicillin 875mg 100 Tablet, Film Coated In 1 Bottle
1
N N N $7N$10N$7N
Amoxicillin 125mg 100 Tablet, Chewable In 1 Bottle
1
N N N $7N$10N$7N
Amoxicillin 250mg 500 Tablet, Chewable In 1 Bottle
1
N N N $7N$10N$7N
Amoxicillin 500mg 500 Capsule In 1 Bottle, Plastic
1
N N N $7N$10N$7N
Amoxicillin 250mg 12 Bottle In 1 Package
1
N N N $7N$10N$7N
Amoxicillin 125mg/5mL 100 Ml In 1 Bottle
1
N N N $7N$10N$7N
Amoxicillin 250mg/5mL 100 Ml In 1 Bottle
1
N N N $7N$10N$7N
Amoxicillin 200mg/5mL 100 Ml In 1 Bottle
1
N N N $7N$10N$7N
Amoxicillin 400mg/5mL 50 Ml In 1 Bottle
1
N N N $7N$10N$7N
Amoxicillin And Clavulanate Potassium 200; 28.5mg/1; mg 20 Tablet, Chewable In 1 Bottle
2
N N N $12N$17N$12N
Amoxicillin And Clavulanate Potassium 400; 57mg/1; mg 20 Tablet, Chewable In 1 Bottle
2
N N N $12N$17N$12N
Amoxicillin And Clavulanate Potassium 500; 125mg/1; mg 20 Tablet, Film Coated In 1 Bottle
2
N N N $12N$17N$12N
Amoxicillin And Clavulanate Potassium 875; 125mg/1; mg 20 Tablet, Film Coated In 1 Bottle
2
N N N $12N$17N$12N
Amoxicillin And Clavulanate Potassium 400; 57mg/5mL; mg/5mL 100 Ml In 1 Bottle
2
N N N $12N$17N$12N
Amoxicillin And Clavulanate Potassium 600; 42.9mg/5mL; mg/5mL 125 Ml In 1 Bottle
2
N N N $12N$17N$12N
Amoxicillin And Clavulanate Potassium 250; 125mg/1; mg 30 Tablet, Film Coated In 1 Bottle
2
N N N $12N$17N$12N
Amoxicillin And Clavulanate Potassium 562.5; 437.5; 62.5mg/1; mg/1; mg 28 Tablet, Multilayer, Extended Release In 1 Bottle
4
N N Y $99N$100N$99N
Amoxicillin And Clavulanate Potassium 100 Ml In 1 Bottle
2
N N N $12N$17N$12N
Amoxicillin And Clavulanate Potassium 250; 62.5mg/5mL; mg/5mL 150 Ml In 1 Bottle, Plastic
2
N N N $12N$17N$12N
Amphotericin B 50mg/10mL 10 Ml In 1 Vial
4
Y N Y $99N$100N$99N
Ampicillin 250mg 100 Capsule In 1 Bottle
2
N N N $12N$17N$12N
Ampicillin 500mg 100 Capsule In 1 Bottle
2
N N N $12N$17N$12N
Ampicillin 125mg 10 Vial, Glass In 1 Package
4
N N Y $99N$100N$99N
Ampicillin 1g 10 Vial, Glass In 1 Package
4
N N Y $99N$100N$99N
Ampicillin 10g 10 Vial, Pharmacy Bulk Package In 1 Package
4
N N Y $99N$100N$99N
Ampicillin 25mg/mL 100 Ml In 1 Bottle, Plastic
2
N N N $12N$17N$12N
Ampicillin 50mg/mL 100 Ml In 1 Bottle, Plastic
2
N N N $12N$17N$12N
Ampicillin And Sulbactam 100; 50mg/mL; mg/mL 100 Ml In 1 Vial, Pharmacy Bulk Package
4
N N Y $99N$100N$99N
Ampicillin And Sulbactam 2; 1g/3g; g/3g 10 Vial In 1 Carton
4
N N Y $99N$100N$99N
Ampyra 10mg 60 Tablet, Film Coated, Extended Release In 1 Bottle
5
60.00 30 Y N Y 29%N29%N29%N
Anadrol-50 50mg 1 Bottle In 1 Carton > 100 Tablet In 1 Bottle
5
N N Y 29%N29%N29%N
Anagrelide Hydrochloride 1mg 100 Capsule In 1 Bottle
3
N N N $47N$47N$47N
Anagrelide Hydrochloride .5mg 100 Capsule In 1 Bottle
3
N N N $47N$47N$47N
Anastrozole 1mg 90 Tablet, Film Coated In 1 Bottle, Plastic
1
30.00 30 N N N $7N$10N$7N
Androgel 30 Packet In 1 Carton
3
150.00 30 N N N $47N$47N$47N
Androgel 30 Packet In 1 Carton
3
37.50 30 N N N $47N$47N$47N
Androgel 16.2mg/g 1 Bottle, Pump In 1 Carton > 88 G In 1 Bottle, Pump
3
150.00 30 N N N $47N$47N$47N
Anoro Ellipta 62.5; 25ug/1; ug 1 Tray In 1 Carton > 1 Inhaler In 1 Tray > 30 Powder In 1 Inhaler
3
60.00 30 N N N $47N$47N$47N
Anusol 25mg/g 30 G In 1 Tube
4
N N Y $99N$100N$99N
Apokyn 30mg/3mL 5 Cartridge In 1 Carton
5
60.00 28 N N Y 29%N29%N29%N
Apraclonidine Ophthalmic 5mg/mL 1 Bottle, Dropper In 1 Carton > 10 Ml In 1 Bottle, Dropper
4
N N Y $99N$100N$99N
Apri 6 Pouch In 1 Carton > 1 Blister Pack In 1 Pouch > 1 Kit In 1 Blister Pack
4
N N Y $99N$100N$99N
Apriso 375mg 120 Capsule, Extended Release In 1 Bottle
3
120.00 30 N N N $47N$47N$47N
Aptiom 200mg 30 Tablet In 1 Bottle
4
30.00 30 Y N Y $99N$100N$99N
Aptiom 400mg 30 Tablet In 1 Bottle
4
30.00 30 Y N Y $99N$100N$99N
Aptiom 600mg 60 Tablet In 1 Bottle
4
60.00 30 Y N Y $99N$100N$99N
Aptiom 800mg 30 Tablet In 1 Bottle
4
30.00 30 Y N Y $99N$100N$99N
Aptivus 100mg/mL 1 Bottle, Glass In 1 Carton > 95 Ml In 1 Bottle, Glass
5
285.00 28 N N Y 29%N29%N29%N
Aptivus 250mg 1 Bottle, Plastic In 1 Carton > 120 Capsule, Liquid Filled In 1 Bottle, Plastic
5
120.00 30 N N Y 29%N29%N29%N
Aralast 1 Kit In 1 Carton
5
Y N Y 29%N29%N29%N
Aranelle 3 Pouch In 1 Carton > 28 Blister Pack In 1 Pouch > 1 Kit In 1 Blister Pack
4
N N Y $99N$100N$99N
Arcalyst 160mg/2mL 4 Vial, Single-use In 1 Carton > 2 Ml In 1 Vial, Single-use
5
Y N Y 29%N29%N29%N
Argatroban 100mg/mL 1 Vial In 1 Carton > 2.5 Ml In 1 Vial
1
N N N $7N$10N$7N
Arnuity Ellipta 30 Powder In 1 Inhaler
3
30.00 30 N N N $47N$47N$47N
Arnuity Ellipta 30 Powder In 1 Inhaler
3
30.00 30 N N N $47N$47N$47N
Arranon 5mg/mL 6 Vial, Glass In 1 Carton
5
N N Y 29%N29%N29%N
Arthrotec 50; 200mg/1; ug 60 Tablet, Film Coated In 1 Bottle
4
Y N Y $99N$100N$99N
Arthrotec 75; 200mg/1; ug 60 Tablet, Film Coated In 1 Bottle
4
Y N Y $99N$100N$99N
Atelvia 30.1; 4.9mg/1; mg 36 Dose Pack In 1 Case > 4 Tablet, Delayed Release In 1 Dose Pack
4
4.00 28 N N Y $99N$100N$99N
Atenolol 100mg 100 Tablet In 1 Bottle
1
N N N $7N$10N$7N
Atenolol 25mg 100 Tablet In 1 Bottle, Plastic
1
N N N $7N$10N$7N
Atenolol 50mg 100 Tablet In 1 Bottle
1
N N N $7N$10N$7N
Atenolol And Chlorthalidone 100; 25mg/1; mg 100 Tablet In 1 Bottle, Plastic
2
N N N $12N$17N$12N
Atenolol And Chlorthalidone 50; 25mg/1; mg 100 Tablet In 1 Bottle
2
N N N $12N$17N$12N
Atgam 50mg/mL 5 Ampule In 1 Carton
4
Y N Y $99N$100N$99N
Atovaquone 750mg/5mL 210 Ml In 1 Carton
5
N N Y 29%N29%N29%N
Atovaquone And Proguanil Hydrochloride 62.5; 25mg/1; mg 100 Tablet, Film Coated In 1 Bottle, Plastic
4
N N Y $99N$100N$99N
Atovaquone And Proguanil Hydrochloride 250; 100mg/1; mg 2 Blister Pack In 1 Carton > 12 Tablet, Film Coated In 1 Blister Pack
4
N N Y $99N$100N$99N
Atripla 600; 200; 300mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle, Plastic
5
30.00 30 N N Y 29%N29%N29%N
Atropine 1 Bottle, Dropper In 1 Carton > 15 Ml In 1 Bottle, Dropper
2
N N N $12N$17N$12N
Atrovent 17ug 1 Canister In 1 Carton > 200 Aerosol, Metered In 1 Canister
4
25.80 30 N N Y $99N$100N$99N
Avandia 60 Tablet, Film Coated In 1 Bottle
4
60.00 30 N N Y $99N$100N$99N
Avandia 30 Tablet, Film Coated In 1 Bottle
4
60.00 30 N N Y $99N$100N$99N
Avastin 100mg/4mL 1 Vial, Single-use In 1 Carton > 4 Ml In 1 Vial, Single-use
5
Y N Y 29%N29%N29%N
Avastin 1 Vial, Single-use In 1 Carton > 16 Ml In 1 Vial, Single-use
5
Y N Y 29%N29%N29%N
Avelox 400mg 30 Tablet, Film Coated In 1 Bottle, Plastic
4
Y N Y $99N$100N$99N
Avelox 400mg 5 Tablet, Film Coated In 1 Box, Unit-dose
4
Y N Y $99N$100N$99N
Avelox 400mg/250mL 250 Ml In 1 Bag
4
N N Y $99N$100N$99N
Aviane 6 Pouch In 1 Carton > 1 Blister Pack In 1 Pouch > 1 Kit In 1 Blister Pack
4
N N Y $99N$100N$99N
Avodart .5mg 90 Capsule, Liquid Filled In 1 Bottle
4
30.00 30 Y N Y $99N$100N$99N
Aygestin 5mg 50 Tablet In 1 Bottle
4
N N Y $99N$100N$99N
Azacitidine 100mg 1 Injection, Powder, Lyophilized, For Solution In 1 Carton
5
Y N Y 29%N29%N29%N
Azasite 1 Bottle, Dropper In 1 Carton > 2.5 Ml In 1 Bottle, Dropper
3
N N N $47N$47N$47N
Azathioprine 100 Tablet In 1 Bottle
1
Y N N $7N$10N$7N
Azelastine Hcl Nasal 205.5ug 1 Bottle In 1 Carton > 200 Spray In 1 Bottle
4
30.00 25 N N Y $99N$100N$99N
Azelastine Hydrochloride .5mg/mL 1 Bottle, Plastic In 1 Box > 6 Ml In 1 Bottle, Plastic
3
N N N $47N$47N$47N
Azelastine Hydrochloride 137ug 1 Bottle, Spray In 1 Carton > 200 Spray, Metered In 1 Bottle, Spray
3
30.00 25 N N N $47N$47N$47N
Azilect .5mg 30 Tablet In 1 Bottle
3
N N N $47N$47N$47N
Azilect 1mg 30 Tablet In 1 Bottle
3
N N N $47N$47N$47N
Azithromycin 200mg/5mL 22.5 Ml In 1 Bottle
3
N N N $47N$47N$47N
Azithromycin 15 Ml In 1 Bottle
3
N N N $47N$47N$47N
Azithromycin 250mg 30 Tablet, Film Coated In 1 Bottle
2
N N N $12N$17N$12N
Azithromycin 500mg 30 Tablet, Film Coated In 1 Bottle
2
N N N $12N$17N$12N
Azithromycin 500mg 10 Vial, Single-use In 1 Tray > 1 Injection, Powder, Lyophilized, For Solution In 1 Vial, Single-use
2
N N N $12N$17N$12N
Azithromycin 600mg 30 Tablet, Film Coated In 1 Bottle
2
N N N $12N$17N$12N
Azithromycin 1g 3 Packet In 1 Box > 1 Powder, For Suspension In 1 Packet
3
N N N $47N$47N$47N
Azithromycin 3 Blister Pack In 1 Carton
2
N N N $12N$17N$12N
Azopt 10mg/mL 15 Ml In 1 Bottle, Plastic
3
N N N $47N$47N$47N
Azor 5; 20mg/1; mg 30 Tablet, Film Coated In 1 Bottle, Plastic
4
30.00 30 Y N Y $99N$100N$99N
Azor 10; 20mg/1; mg 90 Tablet, Film Coated In 1 Bottle, Plastic
4
30.00 30 Y N Y $99N$100N$99N
Azor 5; 40mg/1; mg 90 Tablet, Film Coated In 1 Bottle, Plastic
4
30.00 30 Y N Y $99N$100N$99N
Azor 10; 40mg/1; mg 30 Tablet, Film Coated In 1 Bottle, Plastic
4
30.00 30 Y N Y $99N$100N$99N
Aztreonam 1g 10 Vial In 1 Tray > 1 Injection, Powder, Lyophilized, For Solution In 1 Vial
4
N N Y $99N$100N$99N



Medicare Help's Additional Notes:

Coverage Levels for R5826-012

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1.Pre-Deductable: Before you reach the plans deductible of $200. 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 $3700
3.Coverage Gap: (AKA Donut Hole) After you reach the plans ICL but before the Catastrophic of $4950 in 2017.
4.Catastrophic: Anything over $4950 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 2017 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. 2016
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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