Exhibit_A,_Attachment_A.3_-_Medicare_Part_D_Drug_List.xlsx

XLSX spreadsheet 26 KB Posted

Attached to
Medicare Supplement and Part D Pharmacy Insurance
Solicitation number
26-P-67TF
Issued by
Volusia County, Florida

About this file

This is a Medicare Part D Drug List exhibit prepared for Volusia County, Florida's Medicare Supplement and Part D Pharmacy Insurance solicitation. The document provides a formulary classification template requiring the selected contractor to categorize approximately 100 commonly utilized medications across five tier levels: Generic (Tier 1), Brand Preferred (Tier 2), Brand Non-Preferred (Tier 3), Specialty (Tier 4), and Not Covered (Tier 5). The listed medications include a comprehensive range of pharmaceutical products covering multiple therapeutic categories such as diabetes management (Januvia, Lantus, Trulicity), anticoagulation (Eliquis, Xarelto, Brilinta), cardiovascular treatment (Entresto, Multaq), respiratory conditions (Advair, Breo Ellipta, Spiriva), and specialty medications (Humira, Enbrel, Stelara). The contractor must complete the classification column using the specified numeric coding system and integrate this formulary with the pharmacy plan structure, which requires a $0 deductible with tiered copayments of $15 for generic drugs, $35 for preferred brand medications, $55 for non-preferred brand and specialty medications. The proposal response deadline is May 11, 2026, at 3:01 p.m., and the contract term runs five years beginning January 1, 2027, with an optional five-year renewal. The contractor must maintain a minimum pharmacy network including major chains (CVS, Walgreens, Publix, Walmart, and others) and coordinate all operations with the County's existing Third Party Administrator, WEX, to ensure seamless integration with current eligibility, enrollment, and billing systems serving approximately 500+ Medicare-eligible participants.

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Drug List Legal Company Name:

Requested Data Input A list of highly utilized medications is provided below.

The Contractor shall indicate the drug tier classification of these medications under the Plan (generic, brand preferred, brand non-preferred or specialty and Not Covered) in the Classification column.

Use the numbers 1, 2, 3, and 4 as designated below for each drug tier classification.

Generic Tier = 1 Brand Preferred = 2 Brand Non-Preferred = 3 Specialty = 4 and Not Covered = 5

NDCCommon MedicationsClassification
59572050221POMALYST CAP 2MG
57894006103STELARA INJ 90MG/ML
00078060715GILENYA CAP 0.5MG
58468021002AUBAGIO TAB 14MG
00074433902HUMIRA PEN INJ 40MG/0.8
00074379902HUMIRA KIT 40MG/0.8
58406043504ENBREL INJ 50MG/ML
00003089421ELIQUIS TAB 5MG
58468021004AUBAGIO TAB 14MG
61958200201DESCOVY TAB 200/25
00006027782JANUVIA TAB 100MG
62559052101INDERAL LA CAP 80MG
00002879959HUMALOG KWIK INJ 100/ML
00002143480TRULICITY INJ 1.5/0.5
00173088710TRELEGY AER ELLIPTA
00169266015TRESIBA FLEX INJ 100UNIT
00088221905LANTUS SOLOS INJ 100/ML
00051846233ANDROGEL GEL 1.62%
58406002104ENBREL INJ 50MG/ML
69865026501NUCYNTA ER TAB 250MG
00169255013TRESIBA FLEX INJ 200UNIT
50458057990XARELTO TAB 20MG
00006057561JANUMET TAB 50-500MG
00310621030FARXIGA TAB 10MG
64764017530DEXILANT CAP 60MG DR
00169406012VICTOZA INJ 18MG/3ML
69097091402OMEPRA/BICAR CAP 40-1100
00023916330RESTASIS EMU 0.05%
00078077720ENTRESTO TAB 49-51MG
50458014130INVOKANA TAB 300MG
67877049090EZETIMIBE TAB 10MG
00310654004BYDUREON BC INJ 2/0.85ML
45802075401TESTOSTERONE GEL 1.62%
61958100301RANEXA TAB 500MG
00002840001FORTEO SOL 600/2.4
00032301628CREON CAP 36000UNT
00024576105SOLIQUA INJ 100/33
00032122401CREON CAP 24000UNT
00597010061SPIRIVA SPR 2.5MCG
00006027754JANUVIA TAB 100MG
45802004475ACYCLOVIR CRE 5%
66869020490LIVALO TAB 2MG
00006027731JANUVIA TAB 100MG
00597016061SPIRIVA AER 1.25MCG
00456120130LINZESS CAP 145MCG
00169643810LEVEMIR INJ FLEXTOUC
00023320503LUMIGAN SOL 0.01%
00169406013VICTOZA INJ 18MG/3ML
00597015330JARDIANCE TAB 25MG
00009519101DETROL LA CAP 4MG
00006008131JANUMET XR TAB 100-1000
00078065920ENTRESTO TAB 24-26MG
50458057830XARELTO TAB 15MG
00024586903TOUJEO SOLO INJ 300IU/ML
00173085910BREO ELLIPTA INH 100-25
61958100401RANEXA TAB 1000MG
00186077760BRILINTA TAB 90MG
00006057782JANUMET TAB 50-1000
72733590102PRALUENT INJ 75MG/ML
00169413602OZEMPIC INJ 2/1.5ML
69865026002NUCYNTA ER TAB 200MG
00597036055PRADAXA CAP 150MG
50458057930XARELTO TAB 20MG
00002879759HUMALOG MIX INJ 75/25KWP
24510029160NUCYNTA ER TAB 250MG
00002771227HUMALOG KWIK INJ 200/ML
00024414260MULTAQ TAB 400MG
00069024430TOVIAZ TAB 8MG
65597011630TRIBENZOR40- TAB 5-25MG
00310075190CRESTOR TAB 10MG
00173069500ADVAIR DISKU AER 100/50
00023614230RAPAFLO CAP 8MG
00006057762JANUMET TAB 50-1000
65976010001ARESTIN MIS 1MG
00186037020SYMBICORT AER 160-4.5
50458058030XARELTO TAB 10MG
00597014030TRADJENTA TAB 5MG
00456122830NAMZARIC CAP 28-10MG
00310626060XIGDUO XR TAB 5-1000MG
00456112030VIIBRYD TAB 20MG
00002751001HUMALOG INJ 100/ML
00597014090TRADJENTA TAB 5MG
00078051205TEGRETOL-XR TAB 400MG
64764075030TRINTELLIX TAB 20MG
00173069600ADVAIR DISKU AER 250/50
00591292418TESTOSTERONE GEL 1.62%
49884000702ASA/DIPYRIDA CAP 25-200MG
00054033425CEVIMELINE CAP 30MG
58160082311SHINGRIX INJ 50MCG
00024590102PRALUENT INJ 75MG/ML
57664066383CARVEDILOL CAP 10MG ER
00173088210BREO ELLIPTA INH 200-25
00597028090SYNJARDY XR TAB 10-1000
00591352530LIDOCAINE PAD 5%
24208060203PROLENSA SOL 0.07%
00093301756TADALAFIL TAB 5MG
55513080060CORLANOR TAB 5MG
50458014030INVOKANA TAB 100MG
00597029578SYNJARDY XR TAB 25-1000
68180022301NIACIN ER TAB 1000MG

&"Arial,Bold"&12 26-P-67TF Exhibit A, Attachment A.3 - Medicare Part D Drug List

COUNTY OF VOLUSIA - MEDICAL AND PHARMACY PLAN FOR MEDICARE ELIGIBLE RETIREES

DRUG LIST

drop down box

Drug Plan TypePCP RequiredRX NetworkMedical Plan Type
Partial Part DYesMajor ChainsHMO
100% Part DNoLimited NetworkPPO/EPO/POS
Part D EnhancedFee for Service
Supplement plansDrug listOOP ExclusionsMedicare Part B Drugs
AGenericNoneCovered under Medical
BBrand PreferredPrescription DrugsCovered under Pharmacy
CBrand Non-preferred
DSpecialty
FNot Covered
F with a high deductible
G
K
L
M
N

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