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2009 Medicare Part D Plan (PDP Only) Formulary Browser

This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.
Select your search style and criteria below or use this example to get started
Search Criteria
PDP Plans
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Prescriba Rx Platinum (S5597-228-0)
Tier 1 (1759)
Tier 2 (1119)
Tier 3 (345)


Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
Yes No Show either
  *required
 
Cick on the first letter of your drug name to browse the formulary:

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 0-9 
2009 Medicare Part D Plan Formulary Information
Prescriba Rx Platinum (S5597-228-0)
Benefit Details  
The Prescriba Rx Platinum (S5597-228-0)
Formulary Drugs Starting with the Letter M

in CMS PDP Region 31 which includes: ID UT
Drugs Starting with Letter M

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
M-M-R II VACCINE W/DILUENT 1 DOSE/0.5ML   2 Brand $44.00$88.00None
MACRODANTIN 25MG CAPSULE   2 Brand $44.00$88.00None
MAGENSIUM SULFATE IN 5% DEXTROSE INJECTION 5-1 24 X 100ML CTR   2 Brand $44.00$88.00None
MAGNESIUM SULFATE 4% IV SOLUTION   2 Brand $44.00$88.00None
MAGNESIUM SULFATE 8% IV SOLUTION   2 Brand $44.00$88.00None
MAGNESIUM SULFATE INJECTION 5 GM/10ML   1 Generic $6.00$12.00None
MALARONE 250-100MG TABLET   2 Brand $44.00$88.00None
MALARONE 62.5-25MG PED TABLET   2 Brand $44.00$88.00None
MAPROTILINE 25MG TABLET   1 Generic $6.00$12.00None
MAPROTILINE 50MG TABLET   1 Generic $6.00$12.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MAPROTILINE 75MG TABLET   1 Generic $6.00$12.00None
MARGESIC H 5MG-500MG CAPSULE   1 Generic $6.00$12.00Q:240
/30Days
MARINOL 10MG CAPSULE   3 Specialty 33%N/AP Q:60
/30Days
MARINOL 5MG CAPSULE   3 Specialty 33%N/AP Q:90
/30Days
MARPLAN 10MG TABLET (100 CT)   2 Brand $44.00$88.00None
MATULANE 50MG CAPSULE   3 Specialty 33%N/ANone
MAXALT 10MG TABLET 12 CRTN   2 Brand $44.00$88.00Q:12
/30Days
MAXALT 5MG TABLET 12 CRTN   2 Brand $44.00$88.00Q:12
/30Days
MAXALT MLT 10MG TABLET 4X3 UNIT DOSE CASE   2 Brand $44.00$88.00Q:12
/30Days
MAXALT MLT 5MG TABLET 4X3 UNIT CASE   2 Brand $44.00$88.00Q:12
/30Days
MAXIDEX OPHTHALMIC SUSPENSION 0.1% 5ML BOT   2 Brand $44.00$88.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MAXIPIME 2G ADD-VANTAGE VL   3 Specialty 33%N/ANone
MAXIPIME 500MG VIAL   2 Brand $44.00$88.00None
MAXIPIME FOR INJECTION 1GM 10 X 1GM BOX   3 Specialty 33%N/ANone
MEBENDAZOLE 100MG TABLET CHEW   1 Generic $6.00$12.00None
MECLIZINE HCL 12.5MG TABLET   1 Generic $6.00$12.00None
MECLIZINE HCL 25MG TABLET (100 CT)   1 Generic $6.00$12.00None
MECLOFENAMATE 100MG CAPSULE   2 Brand $44.00$88.00None
MECLOFENAMATE 50MG CAPSULE   2 Brand $44.00$88.00None
MEDROL 2MG TABLET   2 Brand $44.00$88.00None
MEDROXYPROGESTERONE 10MG TABLET   1 Generic $6.00$12.00None
MEDROXYPROGESTERONE 2.5MG   1 Generic $6.00$12.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MEDROXYPROGESTERONE 5MG TABLET   1 Generic $6.00$12.00None
MEDROXYPROGESTERONE ACETATE INJECTION SUSPENSION 150MG 1 VIALSD CRTN   1 Generic $6.00$12.00Q:1
/90Days
MEFLOQUINE HCL 250MG TABLET 25 BOT   1 Generic $6.00$12.00None
MEGACE ES 625MG/5ML SUSP   2 Brand $44.00$88.00Q:150
/30Days
MEGESTROL 20MG TABLET   1 Generic $6.00$12.00None
MEGESTROL ACETATE 400MG/10ML SUSPENSION ORAL   1 Generic $6.00$12.00None
MEGESTROL ACETATE 40MG TABLET (250 CT)   1 Generic $6.00$12.00None
MELOXICAM 15MG TABLET (500 CT)   1 Generic $6.00$12.00None
MELOXICAM 7.5MG TABLET   1 Generic $6.00$12.00None
MENACTRA INJECTION 4MCG/0.5ML 5 X .5ML SYR   2 Brand $44.00$88.00None
MENOMUNE-A/C/Y/W-135 VIAL   2 Brand $44.00$88.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MEPERIDINE 50MG/5ML SYRUP   1 Generic $6.00$12.00Q:1200
/30Days
MEPERIDINE HCL 50MG TABLET (100 CT)   1 Generic $6.00$12.00Q:120
/30Days
MEPERIDINE HCL TABLET 100MG (100 CT)   1 Generic $6.00$12.00Q:120
/30Days
MEPERITAB 100MG TABLET   1 Generic $6.00$12.00Q:120
/30Days
MEPERITAB 50MG TABLET   1 Generic $6.00$12.00Q:120
/30Days
MEPROBAMATE 200MG TABLET   2 Brand $44.00$88.00Q:360
/30Days
MEPROBAMATE 400MG TABLET (100 CT)   2 Brand $44.00$88.00Q:180
/30Days
MEPRON 750MG/5ML ORAL SUSP   3 Specialty 33%N/AS Q:300
/30Days
MERCAPTOPURINE 50MG TABLET   1 Generic $6.00$12.00None
MERREM INJECTION 500MG 10X20MLVIALS VIAL   3 Specialty 33%N/ANone
MERREM IV INJECTION 1GM/15ML 30ML X 10 VIAL   3 Specialty 33%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MERUVAX II VACCINE/DILUENT   2 Brand $44.00$88.00None
MESALAMINE 4G/60ML ENEMA   1 Generic $6.00$12.00None
MESNEX 400MG TABLET   3 Specialty 33%N/ANone
MESTINON 180MG TIMESPAN   2 Brand $44.00$88.00None
MESTINON 60MG/5ML SYRUP   2 Brand $44.00$88.00None
METADATE ER 20MG TABLET SA   1 Generic $6.00$12.00None
METFORMIN HCL 1000MG TABLET (500 CT)   1 Generic $6.00$12.00None
METFORMIN HCL 500MG TABLET (1000 CT)   1 Generic $6.00$12.00None
METFORMIN HCL 850MG TABLET   1 Generic $6.00$12.00None
METFORMIN HCL ER 500MG TABLET SR 24HR   1 Generic $6.00$12.00None
METFORMIN HCL ER 750MG TABLET (100 CT)   1 Generic $6.00$12.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METHADONE 10MG/5ML SOLUTION   2 Brand $44.00$88.00Q:3000
/30Days
METHADONE 5MG/5ML SOLUTION   2 Brand $44.00$88.00Q:3000
/30Days
METHADONE HCL 10MG TABLET   1 Generic $6.00$12.00Q:600
/30Days
METHADONE HCL 5MG TABLET (100 CT)   1 Generic $6.00$12.00Q:600
/30Days
METHADONE HCL ORAL CONCENTRATE 10MG 946ML BOT   1 Generic $6.00$12.00Q:600
/30Days
METHADOSE 10MG TABLET   1 Generic $6.00$12.00Q:600
/30Days
METHADOSE 5MG TABLET   1 Generic $6.00$12.00Q:600
/30Days
METHAZOLAMIDE 25MG TABLET   1 Generic $6.00$12.00None
METHAZOLAMIDE 50MG TABLET   1 Generic $6.00$12.00None
METHERGINE 0.2MG TABLET   2 Brand $44.00$88.00None
METHIMAZOLE 10MG TABLET   1 Generic $6.00$12.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METHIMAZOLE 5MG TABLET   1 Generic $6.00$12.00None
METHITEST 10MG TABLET   2 Brand $44.00$88.00None
METHOCARBAMOL 500MG TABLET   1 Generic $6.00$12.00Q:240
/30Days
METHOCARBAMOL 750MG TABLET (500 CT)   1 Generic $6.00$12.00Q:180
/30Days
METHOTREXATE 2.5MG TABLET   1 Generic $6.00$12.00P Q:120
/28Days
METHOTREXATE 25MG/ML VIAL   1 Generic $6.00$12.00None
METHSCOPOLAMINE BROMIDE 2.5MG TABLET   1 Generic $6.00$12.00None
METHSCOPOLAMINE BROMIDE 5MG TABLET   1 Generic $6.00$12.00None
METHYCLOTHIAZIDE 5MG TABLET   2 Brand $44.00$88.00None
METHYLDOPA 250MG TABLET   1 Generic $6.00$12.00None
METHYLDOPA 500MG TABLET   1 Generic $6.00$12.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METHYLDOPA/HCTZ 250-15 TABLET   1 Generic $6.00$12.00None
METHYLDOPA/HCTZ 250-25 TABLET   1 Generic $6.00$12.00None
METHYLIN 10MG TABLET (100 CT)   1 Generic $6.00$12.00None
METHYLIN 20MG TABLET   1 Generic $6.00$12.00None
METHYLIN ER 10MG TABLET SA   1 Generic $6.00$12.00None
METHYLIN ER 20MG TABLET SA   1 Generic $6.00$12.00None
METHYLIN TABLET 5MG (100 CT)   1 Generic $6.00$12.00None
METHYLPHENIDATE 10MG TABLET   1 Generic $6.00$12.00None
METHYLPHENIDATE 20MG TABLET   1 Generic $6.00$12.00None
METHYLPHENIDATE 20MG TABLET SA   1 Generic $6.00$12.00None
METHYLPHENIDATE 5MG TABLET (100 CT)   1 Generic $6.00$12.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METHYLPHENIDATE ER 20MG TABLET   1 Generic $6.00$12.00None
METHYLPR ACE INJ 80MG/ML   1 Generic $6.00$12.00None
METHYLPREDNISOLONE 16MG TABLET   2 Brand $44.00$88.00None
METHYLPREDNISOLONE 1GM VIAL   1 Generic $6.00$12.00None
METHYLPREDNISOLONE 32MG TABLET   2 Brand $44.00$88.00None
METHYLPREDNISOLONE 40MG/ML VL 5ML   1 Generic $6.00$12.00None
METHYLPREDNISOLONE 8MG TABLET   1 Generic $6.00$12.00None
METHYLPREDNISOLONE SODIUM SUCCINATE FOR INJECTION 500 MG/4ML   2 Brand $44.00$88.00None
METHYLPREDNISOLONE SODIUM SUCCINATE POWDER FOR INJECTION 125MG 25X125MG VIAL   1 Generic $6.00$12.00None
METHYLPREDNISOLONE SODIUM SUCCINATE POWDER FOR INJECTION 40MG 25X40MG VIAL   1 Generic $6.00$12.00None
METHYLPREDNISOLONE TABLET 4MG 21 PKGCOM   1 Generic $6.00$12.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METIPRANOLOL 0.3% EYE DROPS   1 Generic $6.00$12.00None
METOCLOPRAMIDE 5MG TABLET 1000 TABLET S BOT   1 Generic $6.00$12.00None
METOCLOPRAMIDE SOLUTION ORAL USP 5MG 1 PT BOT   1 Generic $6.00$12.00None
METOCLOPRAMIDE TABLET USP 10MG (500 CT)   1 Generic $6.00$12.00None
METOLAZONE 10MG TABLET   1 Generic $6.00$12.00None
METOLAZONE 2.5MG TABLET   1 Generic $6.00$12.00None
METOLAZONE 5MG TABLET   1 Generic $6.00$12.00None
METOPROLOL SUCCINATE 100MG TABLET SR 24HR   1 Generic $6.00$12.00Q:45
/30Days
METOPROLOL SUCCINATE 200MG TABLET ER (100 CT)   1 Generic $6.00$12.00Q:60
/30Days
METOPROLOL SUCCINATE 25MG TABLET SR 24HR   1 Generic $6.00$12.00Q:45
/30Days
METOPROLOL SUCCINATE 50MG TABLET SR 24HR   1 Generic $6.00$12.00Q:45
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METOPROLOL TARTRATE 25MG TABLET (100 CT)   1 Generic $6.00$12.00None
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT)   1 Generic $6.00$12.00None
METOPROLOL TARTRATE TABLET USP 100MG (1000 CT)   1 Generic $6.00$12.00None
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET   1 Generic $6.00$12.00None
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET   1 Generic $6.00$12.00None
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET   1 Generic $6.00$12.00None
METRONIDAZOLE 0.75% CREAM   1 Generic $6.00$12.00None
METRONIDAZOLE 0.75% LOTION   1 Generic $6.00$12.00None
METRONIDAZOLE 250MG TABLET (250 CT)   1 Generic $6.00$12.00None
METRONIDAZOLE 375MG CAPSULE   1 Generic $6.00$12.00None
METRONIDAZOLE 500MG TABLET   1 Generic $6.00$12.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METRONIDAZOLE 500MG/100ML   1 Generic $6.00$12.00None
METRONIDAZOLE TOPICAL GEL 0.75% 45GM TUBE   1 Generic $6.00$12.00None
METRONIDAZOLE VAGINAL GEL .75% 70GM TUBE   1 Generic $6.00$12.00None
MEXILETINE 150MG CAPSULE   1 Generic $6.00$12.00None
MEXILETINE 200MG CAPSULE   1 Generic $6.00$12.00None
MEXILETINE 250MG CAPSULE   1 Generic $6.00$12.00None
MICONAZOLE 3 200MG SUPPOS.   1 Generic $6.00$12.00None
MICROGESTIN 1-0.02MG TABLET   1 Generic $6.00$12.00Q:28
/28Days
MICROGESTIN 1.5-0.03MG TABLET   1 Generic $6.00$12.00Q:28
/28Days
MICROGESTIN FE 1.5/30 TABLET   1 Generic $6.00$12.00Q:28
/28Days
MICROGESTIN FE 1/20 TABLET   1 Generic $6.00$12.00Q:28
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MIDODRINE HCL 10MG TABLET   1 Generic $6.00$12.00Q:90
/30Days
MIDODRINE HCL 2.5MG TABLET   1 Generic $6.00$12.00Q:90
/30Days
MIDODRINE HCL 5MG TABLET (100 CT)   1 Generic $6.00$12.00Q:90
/30Days
MINIRIN 0.1 MG/ML SPRAY   1 Generic $6.00$12.00None
MINOCYCLINE 100MG CAPSULE   1 Generic $6.00$12.00None
MINOCYCLINE 50MG CAPSULE   1 Generic $6.00$12.00None
MINOCYCLINE HCL 75MG CAPSULE   1 Generic $6.00$12.00None
MINOXIDIL 10MG TABLET   1 Generic $6.00$12.00None
MINOXIDIL 2.5MG TABLET   1 Generic $6.00$12.00None
MIRAPEX 0.125MG TABLET   2 Brand $44.00$88.00Q:90
/30Days
MIRAPEX 0.25MG TABLET   2 Brand $44.00$88.00Q:90
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MIRAPEX 0.5MG TABLET   2 Brand $44.00$88.00Q:90
/30Days
MIRAPEX 0.75MG TABLET   2 Brand $44.00$88.00Q:90
/30Days
MIRAPEX 1.5MG TABLET   2 Brand $44.00$88.00Q:90
/30Days
MIRAPEX 1MG TABLET   2 Brand $44.00$88.00Q:90
/30Days
MIRTAZAPINE 15MG TABLET (1000 CT)   1 Generic $6.00$12.00None
MIRTAZAPINE 15MG TABLET RAPID DISSOLVE   1 Generic $6.00$12.00None
MIRTAZAPINE 30MG TABLET RAPID DISSOLVE   1 Generic $6.00$12.00None
MIRTAZAPINE 45MG TABLET RAPID DISSOLVE   1 Generic $6.00$12.00None
MIRTAZAPINE TABLET 30MG (30 CT)   1 Generic $6.00$12.00None
MIRTAZAPINE TABLET 45MG   1 Generic $6.00$12.00None
MIRTAZAPINE TABLET 7.5MG (30 CT)   1 Generic $6.00$12.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MISOPROSTOL 100MCG TABLET   1 Generic $6.00$12.00None
MISOPROSTOL 200MCG TABLET   1 Generic $6.00$12.00None
MITOXANTRONE INJECTION 2MG 125ML VIAL   2 Brand $44.00$88.00P
MOBAN 10MG TABLET   2 Brand $44.00$88.00None
MOBAN 25MG TABLET   2 Brand $44.00$88.00None
MOBAN 50MG TABLET   2 Brand $44.00$88.00None
MOBAN 5MG TABLET   2 Brand $44.00$88.00None
MOEXIPRIL HCL 15MG TABLET   1 Generic $6.00$12.00Q:120
/30Days
MOEXIPRIL HCL 7.5MG TABLET   1 Generic $6.00$12.00Q:60
/30Days
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-12.5MG TABLET   1 Generic $6.00$12.00Q:60
/30Days
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-25MG TABLET   1 Generic $6.00$12.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MOEXIPRIL-HYDROCHLOROTHIAZIDE 7.5-12.5MG TABLET   1 Generic $6.00$12.00Q:30
/30Days
MOMETASONE FUROATE CREAM 0.1% 45GM TUBE   1 Generic $6.00$12.00None
MOMETASONE FUROATE OINTMENT 0.1% 45GM TUBE   1 Generic $6.00$12.00None
MOMETASONE FUROATE TOPICAL SOLUTION 0.1%   1 Generic $6.00$12.00None
MONONESSA 0.25-0.035 TABLET   1 Generic $6.00$12.00Q:28
/28Days
MORPHINE SULFATE 100MG TABLET SA   1 Generic $6.00$12.00Q:90
/30Days
MORPHINE SULFATE 15MG TABLET   1 Generic $6.00$12.00Q:180
/30Days
MORPHINE SULFATE 30MG TABLET   1 Generic $6.00$12.00Q:180
/30Days
MORPHINE SULFATE 30MG TABLET SA   1 Generic $6.00$12.00Q:90
/30Days
MORPHINE SULFATE 5MG 25 X 1ML VIAL   1 Generic $6.00$12.00P
MORPHINE SULFATE ORAL SOLUTION   1 Generic $6.00$12.00Q:2700
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MORPHINE SULFATE ORAL SOLUTION   1 Generic $6.00$12.00Q:1350
/30Days
MORPHINE SULFATE TABLET ER 15MG (100 CT)   1 Generic $6.00$12.00Q:90
/30Days
MORPHINE SULFATE TABLET ER 200MG (100 CT)   1 Generic $6.00$12.00Q:180
/30Days
MORPHINE SULFATE TABLET ER 60MG (100 CT)   1 Generic $6.00$12.00Q:90
/30Days
MUPIROCIN 2% OINTMENT   1 Generic $6.00$12.00None
MYCAMINE 50MG VIAL   3 Specialty 33%N/AP
MYCAMINE FOR INJECTION SOLUTION   3 Specialty 33%N/AP
MYCOBUTIN 150MG CAPSULE   2 Brand $44.00$88.00None
MYFORTIC 180MG TABLET   3 Specialty 33%N/AP S
MYFORTIC 360MG TABLET   3 Specialty 33%N/AP S
MYTELASE 10MG CAPLET   2 Brand $44.00$88.00None

Chart Legend:

Below are a few notes to help you understand the above 2009 Medicare Part D Prescriba Rx Platinum 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 standard $295 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 with 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 the drug’s tier. 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:
    • Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the initial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $2700) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2013 Humana Walmart-Preferred Rx Plan the cost-sharing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
    • Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred 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 October 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.







Tips & Disclaimers
  • Q1Medicare®, Q1Rx®, and Q1Group® are registered Service Marks of Q1Group LLC and may not be used in any advertising, publicity, or for commercial purposes without the express authorization of Q1Group.
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDPCompare.com and MACompare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
    Statement required by Medicare:
    "We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options."
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.