A non-government resource for the Medicare community
Powered by Q1Group LLC
A non-government Medicare community resource
  • Menu
  • Home
  • Contact
  • MAPD
  • PDP
  • 2024
  • 2025
  • FAQs
  • Articles
  • Search
  • Contact
  • 2024
  • 2025
  • FAQs
  • Articles
  • Latest Medicare News
  • Search

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
Scroll down to see formulary results.

SierraRx Basic (S5917-018-0)
Tier 1 (1709)
Tier 2 (547)
Tier 3 (213)


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
SierraRx Basic (S5917-018-0)
Benefit Details  
The SierraRx Basic (S5917-018-0)
Formulary Drugs Starting with the Letter D

in CMS PDP Region 15 which includes: IN KY
Drugs Starting with Letter D

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
DANAZOL 100MG CAPSULE   1 Tier 1 25%25%Q:90
/30Days
DANAZOL 50MG CAPSULE   1 Tier 1 25%25%Q:90
/30Days
DANAZOL CAPSULES USP 200MG (100 CT)   1 Tier 1 25%25%Q:120
/30Days
DANTROLENE SODIUM 100MG CAPSULE   1 Tier 1 25%25%None
DANTROLENE SODIUM 25MG CAPSULE   1 Tier 1 25%25%None
DANTROLENE SODIUM 50MG CAPSULE   1 Tier 1 25%25%None
DAPSONE 100MG TABLET   2 Tier 2 25%25%None
DAPSONE 25MG TABLET   2 Tier 2 25%25%None
DAPTACEL VACCINE 15;5;5;3; LF/.5ML   2 Tier 2 25%25%None
DEL-BETA 0.05% LOTION   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEMECLOCYCLINE HCL 150MG TABLET   1 Tier 1 25%25%Q:84
/30Days
DEMECLOCYCLINE HCL 300MG TABLET   1 Tier 1 25%25%Q:63
/30Days
DEPADE 50MG TABLET   1 Tier 1 25%25%None
DEPAKOTE 125MG SPRINKLE CAP   2 Tier 2 25%25%None
DEPAKOTE 125MG TABLET EC   2 Tier 2 25%25%None
DEPAKOTE 250MG TABLET EC   2 Tier 2 25%25%None
DEPAKOTE 500MG TABLET EC   2 Tier 2 25%25%None
DEPAKOTE ER 250MG TABLET SA   2 Tier 2 25%25%None
DEPAKOTE ER 500MG TABLET   2 Tier 2 25%25%None
DEPO-PROVERA 400MG/ML VIAL   2 Tier 2 25%25%P
DEPO-SQ PROV INJ 104   2 Tier 2 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DERMOTIC 0.01% DROPS   2 Tier 2 25%25%Q:20
/30Days
DESIPRAMINE 10MG TABLET   1 Tier 1 25%25%None
DESIPRAMINE 150MG TABLET   1 Tier 1 25%25%None
DESIPRAMINE 25MG TABLET   1 Tier 1 25%25%None
DESIPRAMINE 50MG TABLET   1 Tier 1 25%25%None
DESIPRAMINE HCL 75MG TABLET (100 CT)   1 Tier 1 25%25%None
DESIPRAMINE HCL TABLET 100MG (500 CT)   1 Tier 1 25%25%None
DESMOPRESSIN 0.1MG/ML SOL   1 Tier 1 25%25%Q:15
/30Days
DESMOPRESSIN AC 4MCG/ML VL   1 Tier 1 25%25%Q:30
/30Days
DESMOPRESSIN ACETATE 0.1MG TABLET   1 Tier 1 25%25%None
DESMOPRESSIN ACETATE TABLET 0.2MG (100 CT)   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DESONIDE 0.05% CREAM   1 Tier 1 25%25%None
DESONIDE 0.05% LOTION   1 Tier 1 25%25%None
DESONIDE 0.05% OINTMENT 60GM TUBE   1 Tier 1 25%25%None
DESOXIMETASONE 0.05% CREAM   1 Tier 1 25%25%None
DESOXIMETASONE 0.05% GEL   1 Tier 1 25%25%None
DESOXIMETASONE 0.25% CREAM   1 Tier 1 25%25%None
DESOXIMETASONE 0.25% OINT   1 Tier 1 25%25%None
DETROL 1MG TABLET   2 Tier 2 25%25%Q:60
/30Days
DETROL 2MG TABLET   2 Tier 2 25%25%Q:60
/30Days
DETROL LA 2MG CAPSULE SA   2 Tier 2 25%25%Q:30
/30Days
DETROL LA 4MG CAPSULE SA   2 Tier 2 25%25%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEXAMETHASONE 0.5MG TABLET   1 Tier 1 25%25%None
DEXAMETHASONE 0.5MG/5ML ELX   1 Tier 1 25%25%None
DEXAMETHASONE 0.75MG TABLET   1 Tier 1 25%25%None
DEXAMETHASONE 1.5MG TABLET   1 Tier 1 25%25%None
DEXAMETHASONE 1MG TABLET   1 Tier 1 25%25%None
DEXAMETHASONE 2MG TABLET   1 Tier 1 25%25%None
DEXAMETHASONE 4MG TABLET   1 Tier 1 25%25%None
DEXAMETHASONE 6MG TABLET   1 Tier 1 25%25%None
DEXAMETHASONE SODIUM PHOSPHATE 0.1% DROPS   1 Tier 1 25%25%None
DEXASPORIN EYE DROPS   1 Tier 1 25%25%None
DEXTROAMPHETAMINE 10MG TABLET   1 Tier 1 25%25%Q:180
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEXTROAMPHETAMINE 5MG TABLET   1 Tier 1 25%25%Q:360
/30Days
DEXTROAMPHETAMINE SACCHARATE AMPHETAMINE ASPARATE   1 Tier 1 25%25%Q:60
/30Days
DEXTROAMPHETAMINE SACCHARATE AND SULFATE AMPHETAMINE ASPARTATE 10MG TABLET (100 CT)   1 Tier 1 25%25%Q:60
/30Days
DEXTROAMPHETAMINE SULFATE 10MG CAPSULE SA   1 Tier 1 25%25%Q:180
/30Days
DEXTROAMPHETAMINE SULFATE 15MG CAPSULE SA   1 Tier 1 25%25%Q:120
/30Days
DEXTROAMPHETAMINE SULFATE 5MG CAPSULE SA   1 Tier 1 25%25%Q:360
/30Days
DEXTROSE 10%-1/4NS IV TUBEX   1 Tier 1 25%25%None
DEXTROSE 2.5%-1/2NS IV SOLUTION   1 Tier 1 25%25%None
DEXTROSE 5% AND 0.45% NACL INJECTION 5-450 24 X 500ML BAG   1 Tier 1 25%25%None
DEXTROSE 5% AND 0.9% NACL INJECTION 5-900 24 X 500ML BAG   1 Tier 1 25%25%None
DEXTROSE 5%-1/3NS IV SOLUTION   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEXTROSE 5%-1/4NS IV SOLUTION   1 Tier 1 25%25%None
DEXTROSE 5%-1/4NS IV SOLUTION   1 Tier 1 25%25%None
DEXTROSE 5%-LR IV SOLUTION   1 Tier 1 25%25%None
DEXTROSE 5%-NS IV SOLUTION   1 Tier 1 25%25%None
DEXTROSE IN LACTATED RINGERS SOLUTION FOR INJECTION 1000ML PLASTIC BAG X 12 CASE   1 Tier 1 25%25%None
DEXTROSE IN SODIUM CHLORIDE INJECTION   1 Tier 1 25%25%None
DEXTROSE IN SODIUM CHLORIDE INJECTION   1 Tier 1 25%25%None
DEXTROSE IN SODIUM CHLORIDE INJECTION   1 Tier 1 25%25%None
DEXTROSE IN SODIUM CHLORIDE INJECTION 1000ML X 12 CASE   1 Tier 1 25%25%None
DEXTROSE IN SODIUM CHLORIDE INJECTION 500ML X 24 BAG   1 Tier 1 25%25%None
DEXTROSE INJECTION 10 250ML X 24 BOTPL   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEXTROSE INJECTION USP 5 4 X 100ML CTR   1 Tier 1 25%25%None
DEXTROSTAT 5MG TABLET   1 Tier 1 25%25%Q:360
/30Days
DIABETIC SUPPLIES, MISC 0 N/A INJC   2 Tier 2 25%25%None
DICLOFENAC 25MG TABLET EC   1 Tier 1 25%25%Q:120
/30Days
DICLOFENAC POTASSIUM 50MG TABLET (500 CT)   1 Tier 1 25%25%Q:120
/30Days
DICLOFENAC SOD 100MG TABLET SA   1 Tier 1 25%25%Q:60
/30Days
DICLOFENAC SOD 100MG TABLET SA   1 Tier 1 25%25%Q:60
/30Days
DICLOFENAC SODIUM 50MG TABLET DELAYED RELEASE   1 Tier 1 25%25%Q:120
/30Days
DICLOFENAC SODIUM 50MG TABLET DELAYED RELEASE (100 CT)   1 Tier 1 25%25%Q:120
/30Days
DICLOFENAC SODIUM 75MG TABLET DELAYED RELEASE   1 Tier 1 25%25%Q:90
/30Days
DICLOXACILLIN 250MG CAPSULE   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DICLOXACILLIN SODIUM 500MG CAP   1 Tier 1 25%25%None
DICYCLOMINE 10MG CAPSULE   1 Tier 1 25%25%None
DICYCLOMINE HCL 20MG TABLET (500 CT)   1 Tier 1 25%25%None
DIDANOSINE 200MG CAPSULE DELAYED RELEASE   1 Tier 1 25%25%Q:60
/30Days
DIDANOSINE 250MG CAPSULE DELAYED RELEASE   1 Tier 1 25%25%Q:30
/30Days
DIDANOSINE 400MG CAPSULE DELAYED RELEASE   1 Tier 1 25%25%Q:30
/30Days
DIDANOSINE DELAYED RELEASE CAPSULES 125MG 30 BOT   1 Tier 1 25%25%Q:60
/30Days
DIFLORASONE 0.05% CREAM   1 Tier 1 25%25%None
DIFLORASONE 0.05% OINTMENT   1 Tier 1 25%25%None
DIGITEK 125MCG TABLET   1 Tier 1 25%25%None
DIGITEK 250MCG TABLET   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DIGOXIN 125MCG TABLET   1 Tier 1 25%25%None
DIGOXIN 250MCG TABLET (1000 CT)   1 Tier 1 25%25%None
DIGOXIN 50MCG/ML SOLUTION ORAL   1 Tier 1 25%25%None
DIHYDROERGOTAMINE 1MG/ML AM   1 Tier 1 25%25%None
DILACOR XR 120MG CAPSULE SA   1 Tier 1 25%25%Q:30
/30Days
DILACOR XR 180MG CAPSULE SA   1 Tier 1 25%25%Q:90
/30Days
DILACOR XR 240MG CAPSULE SA   1 Tier 1 25%25%Q:60
/30Days
DILANTIN 30MG KAPSEAL   2 Tier 2 25%25%None
DILANTIN 50MG INFATAB   2 Tier 2 25%25%Q:360
/30Days
DILANTIN EXTENDED ORAL CAPSULE 100MG (100 CT)   2 Tier 2 25%25%None
DILANTIN-125 SUS 125/5ML   2 Tier 2 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DILT-CD 120MG CAPSULE SR 24 HR   1 Tier 1 25%25%Q:30
/30Days
DILT-CD 180MG CAPSULE SR 24 HR   1 Tier 1 25%25%Q:90
/30Days
DILT-CD 240MG CAPSULE SR 24 HR   1 Tier 1 25%25%Q:60
/30Days
DILT-CD DILTIAZEM HCL ER CAPSULES 300MG   1 Tier 1 25%25%Q:30
/30Days
DILT-XR 120MG CAPSULE DEGRADABLE CONTROLLED-RELEASE   1 Tier 1 25%25%Q:30
/30Days
DILT-XR 180MG CAPSULE DEGRADABLE CONTROLLED-RELEASE   1 Tier 1 25%25%Q:90
/30Days
DILTIAZEM 30MG TABLET   1 Tier 1 25%25%Q:120
/30Days
DILTIAZEM 90MG TABLET   1 Tier 1 25%25%Q:120
/30Days
DILTIAZEM CD CAPSULES 120MG (90 CT)   1 Tier 1 25%25%Q:30
/30Days
DILTIAZEM CD CAPSULES 240MG (90 CT)   1 Tier 1 25%25%Q:60
/30Days
DILTIAZEM CD CAPSULES 300MG (90 CT)   1 Tier 1 25%25%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DILTIAZEM ER 120MG CAPSULE SA   1 Tier 1 25%25%Q:30
/30Days
DILTIAZEM ER 180MG CAPSULE SA   1 Tier 1 25%25%Q:90
/30Days
DILTIAZEM ER 180MG CAPSULE SA   1 Tier 1 25%25%Q:90
/30Days
DILTIAZEM ER 240MG CAPSULE SA   1 Tier 1 25%25%Q:60
/30Days
DILTIAZEM ER 240MG CAPSULE SA   1 Tier 1 25%25%Q:60
/30Days
DILTIAZEM ER 300MG CAPSULE SA   1 Tier 1 25%25%Q:30
/30Days
DILTIAZEM ER 360MG CAPSULE SA   1 Tier 1 25%25%Q:30
/30Days
DILTIAZEM ER 420MG CAPSULE SA   1 Tier 1 25%25%Q:30
/30Days
DILTIAZEM HCL 120MG ER CAPSULE   1 Tier 1 25%25%None
DILTIAZEM HCL 120MG ER CAPSULE (90 CT)   1 Tier 1 25%25%Q:30
/30Days
DILTIAZEM HCL 120MG TABLET   1 Tier 1 25%25%Q:90
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DILTIAZEM HCL 180MG CAPSULE SA   1 Tier 1 25%25%Q:90
/30Days
DILTIAZEM HCL 240MG ER CAPSULE (90 CT)   1 Tier 1 25%25%Q:60
/30Days
DILTIAZEM HCL 300MG ER CAPSULE (90 CT)   1 Tier 1 25%25%Q:30
/30Days
DILTIAZEM HCL 360MG ER CAPSULE (30 CT)   1 Tier 1 25%25%Q:30
/30Days
DILTIAZEM HCL 60MG ER CAPSULE   1 Tier 1 25%25%None
DILTIAZEM HCL 60MG TABLET   1 Tier 1 25%25%Q:120
/30Days
DILTIAZEM HCL 90MG ER CAPSULE   1 Tier 1 25%25%None
DIPHENHYDRAMINE 25MG CAPSULE   1 Tier 1 25%25%Q:180
/30Days
DIPHENHYDRAMINE 50MG CAPS   1 Tier 1 25%25%Q:180
/30Days
DIPHENHYDRAMINE ELIXIR BOTTLE   1 Tier 1 25%25%Q:3600
/30Days
DIPHENHYDRAMINE HCL INJECTION 50MG 1 VIAL   1 Tier 1 25%25%Q:240
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DIPHENOXYLATE HC/ATROPINE SULFATE TABLET 25-0.25MG (1000 CT)   1 Tier 1 25%25%Q:240
/30Days
DIPHENOXYLATE/ATROPINE LIQ   1 Tier 1 25%25%Q:2400
/30Days
DIPHTHERIA-TETANUS TOX-PED .17;6.7;5 MG/5ML;LF   2 Tier 2 25%25%None
DIPIVEFRIN 0.1% EYE DROPS   1 Tier 1 25%25%None
DIPYRIDAMOLE 25MG TABLET (100 CT)   1 Tier 1 25%25%Q:120
/30Days
DIPYRIDAMOLE 50MG TABLET (100 CT)   1 Tier 1 25%25%Q:240
/30Days
DIPYRIDAMOLE 75MG TABLET (100 CT)   1 Tier 1 25%25%Q:120
/30Days
DISOPYRAMIDE 150MG CAPSULE SA   1 Tier 1 25%25%None
DISOPYRAMIDE PHOSPHATE 150MG CAPSULE USP (100 CT)   1 Tier 1 25%25%None
DISOPYRAMIDE PHOSPHATE CAPSULES 100MG (100 CT)   1 Tier 1 25%25%None
DIVALPROEX SODIUM 125MG TBEC   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DIVALPROEX SODIUM 250MG TBEC   1 Tier 1 25%25%None
DIVALPROEX SODIUM 500MG TBEC   1 Tier 1 25%25%None
DIVALPROEX SODIUM COATED PARTICLES IN CAPSULES 125MG 100 BOT   1 Tier 1 25%25%None
DIVALPROEX SODIUM EXTENDED RELEASE TABLETS 250MG 100 BOT   1 Tier 1 25%25%None
DIVALPROEX SODIUM TABLETS EXTENDED RELEASE 500MG 100 BOT   1 Tier 1 25%25%None
DORZOLAMIDE HCL OPHTHALMIC 2% 10 ML BOTDR   1 Tier 1 25%25%Q:10
/30Days
DOVONEX 0.005% CREAM   2 Tier 2 25%25%Q:100
/30Days
DOXAZOSIN MESYLATE TABLET 2MG (500 CT)   1 Tier 1 25%25%Q:60
/30Days
DOXAZOSIN MESYLATE TABLET 4MG (500 CT)   1 Tier 1 25%25%Q:60
/30Days
DOXAZOSIN MESYLATE TABLET 8MG (500 CT)   1 Tier 1 25%25%Q:60
/30Days
DOXAZOSIN TABLET 1MG (100 CT)   1 Tier 1 25%25%Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DOXEPIN 100MG CAPSULE   1 Tier 1 25%25%None
DOXEPIN 10MG CAPSULE   1 Tier 1 25%25%None
DOXEPIN 10MG/ML ORAL CONC   1 Tier 1 25%25%None
DOXEPIN 150MG CAPSULE   1 Tier 1 25%25%None
DOXEPIN 75MG CAPSULE   1 Tier 1 25%25%None
DOXEPIN HCL 25MG CAPSULE (100 CT)   1 Tier 1 25%25%None
DOXEPIN HCL 50MG CAPSULE   1 Tier 1 25%25%None
DOXYCYCLINE 100MG CAPSULE   1 Tier 1 25%25%None
DOXYCYCLINE 100MG VIAL   1 Tier 1 25%25%None
DOXYCYCLINE 50MG CAPSULE   1 Tier 1 25%25%None
DOXYCYCLINE HYCLATE 100MG CAPSULE DELAYED RELEASE   1 Tier 1 25%25%Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DOXYCYCLINE HYCLATE 75MG CAPSULE DELAYED RELEASE (60 CT)   1 Tier 1 25%25%Q:60
/30Days
DUETACT 30MG-2MG TABLET   2 Tier 2 25%25%Q:30
/30Days
DUETACT 30MG-4MG TABLET   2 Tier 2 25%25%Q:30
/30Days
DURAMORPH 0.5MG/ML AMPUL   1 Tier 1 25%25%P
DURAMORPH 1MG/ML AMPUL   1 Tier 1 25%25%P
DYGASE 30-2.4-30 CAPSULE   2 Tier 2 25%25%None

Chart Legend:

Below are a few notes to help you understand the above 2009 Medicare Part D SierraRx Basic 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.