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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
Scroll down to see formulary results.

Windsor Rx (S2505-001-0)
Tier 1 (1600)
Tier 2 (462)
Tier 3 (532)
Tier 4 (238)

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
Windsor Rx (S2505-001-0)
Benefit Details  
The Windsor Rx (S2505-001-0)
Formulary Drugs Starting with the Letter A

in CMS PDP Region 12 which includes: AL TN
Drugs Starting with Letter A

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
ABILIFY 10MG TABLET   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/ANone
ABILIFY 15MG TABLET   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/ANone
ABILIFY 1MG/ML SOLUTION   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/ANone
ABILIFY 20MG TABLET   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/ANone
ABILIFY 2MG TABLET   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/ANone
ABILIFY 30MG TABLET   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/ANone
ABILIFY 5MG TABLET (OTSUKA)   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/ANone
ABILIFY DISCMELT 10MG TABLET   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/ANone
ABILIFY DISCMELT 15MG TABLET   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/ANone
ABILIFY INJ 9.75MG   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ABRAXANE 100MG VIAL   2 Tier 2 - Preferred Brand $25.00N/ANone
ACARBOSE 100MG TABLET S   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/ANone
ACARBOSE 25MG TABLET S   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/ANone
ACARBOSE 50MG TABLET S   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/ANone
ACCOLATE 10MG TABLET   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/AQ:60
/23Days
ACCOLATE 20MG TABLET   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/AQ:60
/23Days
ACEBUTOLOL 200MG CAPSULE   1 Tier 1 - Preferred Generics $10.00N/ANone
ACEBUTOLOL 400MG CAPSULE   1 Tier 1 - Preferred Generics $10.00N/ANone
ACETADOTE 200MG/ML VIAL   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/AP
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-15MG (1000 CT)   1 Tier 1 - Preferred Generics $10.00N/AQ:390
/25Days
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT)   1 Tier 1 - Preferred Generics $10.00N/AQ:390
/25Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT)   1 Tier 1 - Preferred Generics $10.00N/AQ:390
/25Days
ACETAMINOPHEN/COD SOLUTION   1 Tier 1 - Preferred Generics $10.00N/AQ:960
/30Days
ACETAZOLAMIDE 125MG TABLET   1 Tier 1 - Preferred Generics $10.00N/ANone
ACETAZOLAMIDE 250MG TABLET (100 CT)   1 Tier 1 - Preferred Generics $10.00N/ANone
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT   1 Tier 1 - Preferred Generics $10.00N/ANone
ACETIC ACID 2% SOLUTION NON-ORAL   1 Tier 1 - Preferred Generics $10.00N/ANone
ACETIC ACID-HYDROCORTISONE 2%-1% DROPS   1 Tier 1 - Preferred Generics $10.00N/ANone
ACETYLCYSTEINE 10% VIAL   1 Tier 1 - Preferred Generics $10.00N/ANone
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN   1 Tier 1 - Preferred Generics $10.00N/ANone
ACTHIB VACCINE VIAL 10-24UNT/5ML   2 Tier 2 - Preferred Brand $25.00N/ANone
ACTIMMUNE SOLUTION FOR INJECTION 100MCG   4 Tier 4 - Speciality (Brand or Generic) 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACTONEL 150MG TABLET   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/ANone
ACTONEL 30MG TABLET   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/AQ:30
/23Days
ACTONEL 35MG TABLET   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/AQ:4
/23Days
ACTONEL 5MG TABLET   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/AQ:30
/23Days
ACTONEL 75MG TABLET   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/AQ:4
/23Days
ACTONEL WITH CALCIUM TABLET   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/AQ:28
/23Days
ACTOPLUS MET 15MG/500MG TABLET   2 Tier 2 - Preferred Brand $25.00N/ANone
ACTOPLUS MET 15MG/850MG TABLET   2 Tier 2 - Preferred Brand $25.00N/ANone
ACTOS 15MG TABLET   2 Tier 2 - Preferred Brand $25.00N/ANone
ACTOS 30MG TABLET (500 CT)   2 Tier 2 - Preferred Brand $25.00N/ANone
ACTOS 45MG TABLET   2 Tier 2 - Preferred Brand $25.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACULAR 0.5% EYE DROPS   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/ANone
ACYCLOVIR 200MG CAPSULE (1000 CT)   1 Tier 1 - Preferred Generics $10.00N/ANone
ACYCLOVIR 200MG/5ML SUSP   1 Tier 1 - Preferred Generics $10.00N/ANone
ACYCLOVIR 400MG TABLET (100 CT)   1 Tier 1 - Preferred Generics $10.00N/ANone
ACYCLOVIR SOD 50MG/ML VIAL   1 Tier 1 - Preferred Generics $10.00N/AP
ACYCLOVIR SODIUM 1GM VIAL   1 Tier 1 - Preferred Generics $10.00N/AP
ACYCLOVIR SODIUM 500MG VIAL   1 Tier 1 - Preferred Generics $10.00N/AP
ACYCLOVIR TABLET USP 800MG (100 CT)   1 Tier 1 - Preferred Generics $10.00N/ANone
ADACEL VIAL 2UNT/5UNT   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/ANone
ADAGEN 250U/ML VIAL   4 Tier 4 - Speciality (Brand or Generic) 25%N/AP
ADDERALL XR 10MG CAPSULE SA   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADDERALL XR 15MG CAPSULE SA   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/AP
ADDERALL XR 20MG CAPSULE SA   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/AP
ADDERALL XR 25MG CAPSULE SA   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/AP
ADDERALL XR 30MG CAPSULE SA   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/AP
ADDERALL XR 5MG CAPSULE SA   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/AP
ADVAIR DISKU MIS 100/50   2 Tier 2 - Preferred Brand $25.00N/AQ:60
/23Days
ADVAIR DISKU MIS 250/50   2 Tier 2 - Preferred Brand $25.00N/AQ:60
/23Days
ADVAIR DISKU MIS 500/50   2 Tier 2 - Preferred Brand $25.00N/AQ:60
/23Days
ADVAIR HFA 115/21MCG INHALER   2 Tier 2 - Preferred Brand $25.00N/AQ:60
/23Days
ADVAIR HFA 230/21MCG INHALER   2 Tier 2 - Preferred Brand $25.00N/AQ:60
/23Days
ADVAIR HFA 45/21MCG INHALER   2 Tier 2 - Preferred Brand $25.00N/AQ:60
/23Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AFINITOR TABLETS   4 Tier 4 - Speciality (Brand or Generic) 25%N/AP
AFINITOR TABLETS 5 MG   4 Tier 4 - Speciality (Brand or Generic) 25%N/AP
AGGRENOX 25-200MG CAPSULE   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/ANone
AK-CON 0.1% EYE DROPS   1 Tier 1 - Preferred Generics $10.00N/ANone
AK-POLY-BAC EYE OINTMENT 500UNT/1000UNT   1 Tier 1 - Preferred Generics $10.00N/ANone
AK-SPORE EYE OINTMENT 3.5 MG   1 Tier 1 - Preferred Generics $10.00N/ANone
AKTOB 0.3% EYE DROPS   1 Tier 1 - Preferred Generics $10.00N/ANone
ALAMAST 0.1% DROPS   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/ANone
ALBUTEROL SULFATE 0.63MG/3ML VIAL NEBULIZER   1 Tier 1 - Preferred Generics $10.00N/AP
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER   1 Tier 1 - Preferred Generics $10.00N/AP
ALBUTEROL SULFATE 2.5MG/3ML VIAL NEBULIZER   1 Tier 1 - Preferred Generics $10.00N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALBUTEROL SULFATE 4MG TABLET SR 12HR   1 Tier 1 - Preferred Generics $10.00N/ANone
ALBUTEROL SULFATE 8MG TABLET SR 12HR   1 Tier 1 - Preferred Generics $10.00N/ANone
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   1 Tier 1 - Preferred Generics $10.00N/AP
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT   1 Tier 1 - Preferred Generics $10.00N/ANone
ALBUTEROL SULFATE TABLET 2MG (500 CT)   1 Tier 1 - Preferred Generics $10.00N/ANone
ALBUTEROL TABLET 4MG (500 CT)   1 Tier 1 - Preferred Generics $10.00N/ANone
ALCLOMETASONE DIPROPIONATE 0.05% CREAM   1 Tier 1 - Preferred Generics $10.00N/ANone
ALCLOMETASONE DIPROPIONATE 0.05% OINTMENT   1 Tier 1 - Preferred Generics $10.00N/ANone
ALCOHOL ANTISEPTIC PADS   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/ANone
ALDARA 5% CREAM   2 Tier 2 - Preferred Brand $25.00N/ANone
ALDURAZYME 2.9MG/5ML VIAL   4 Tier 4 - Speciality (Brand or Generic) 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALENDRONATE SODIUM 10MG TABLET   1 Tier 1 - Preferred Generics $10.00N/AQ:30
/23Days
ALENDRONATE SODIUM 40MG TABLET   1 Tier 1 - Preferred Generics $10.00N/AQ:30
/23Days
ALENDRONATE SODIUM 5MG TABLET   1 Tier 1 - Preferred Generics $10.00N/AQ:30
/23Days
ALENDRONATE SODIUM 70MG TABLET 4 BLPK   1 Tier 1 - Preferred Generics $10.00N/AQ:4
/23Days
ALENDRONATE SODIUM TABLET 35MG 20 CRTN   1 Tier 1 - Preferred Generics $10.00N/AQ:4
/23Days
ALIMTA 500MG VIAL   2 Tier 2 - Preferred Brand $25.00N/AP
ALIMTA INJECTION   2 Tier 2 - Preferred Brand $25.00N/AP
ALINIA 100MG/5ML SUSPENSION   2 Tier 2 - Preferred Brand $25.00N/ANone
ALINIA 500MG TABLET   2 Tier 2 - Preferred Brand $25.00N/ANone
ALKERAN 50MG VIAL   2 Tier 2 - Preferred Brand $25.00N/AP
ALLOPURINOL SODIUM 500MG VIAL   1 Tier 1 - Preferred Generics $10.00N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALLOPURINOL TABLET 300MG (1000 CT)   1 Tier 1 - Preferred Generics $10.00N/ANone
ALLOPURINOL TABLET USP 100MG (1000 CT)   1 Tier 1 - Preferred Generics $10.00N/ANone
ALOCRIL 2% EYE DROPS   2 Tier 2 - Preferred Brand $25.00N/ANone
ALOMIDE 0.1% EYE DROPS   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/ANone
ALPHAGAN P 0.1% DROPS   2 Tier 2 - Preferred Brand $25.00N/ANone
ALPHAGAN P 0.15% EYE DROPS   2 Tier 2 - Preferred Brand $25.00N/ANone
ALREX 0.2% EYE DROPS   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/ANone
AMANTADINE 100MG CAPSULE   1 Tier 1 - Preferred Generics $10.00N/ANone
AMCINONIDE 0.1% CREAM   1 Tier 1 - Preferred Generics $10.00N/ANone
AMCINONIDE 0.1% LOTION   1 Tier 1 - Preferred Generics $10.00N/ANone
AMCINONIDE 0.1% OINTMENT 60GM TUBE   1 Tier 1 - Preferred Generics $10.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMIFOSTINE FOR INJECTION 500MG/VIAL   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/AP
AMILORIDE HCL 5MG TABLET   1 Tier 1 - Preferred Generics $10.00N/ANone
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET   1 Tier 1 - Preferred Generics $10.00N/ANone
AMINOPHYLLINE 100MG TABLET (100 CT)   1 Tier 1 - Preferred Generics $10.00N/ANone
AMINOPHYLLINE 200MG TABLET (1000 CT)   1 Tier 1 - Preferred Generics $10.00N/ANone
AMINOPHYLLINE INJECTION 250MG 10ML X 25 VIALSD   1 Tier 1 - Preferred Generics $10.00N/ANone
AMINOSYN 10% IV SOLUTION   2 Tier 2 - Preferred Brand $25.00N/AP
AMINOSYN 3.5% IV SOLUTION   2 Tier 2 - Preferred Brand $25.00N/AP
AMINOSYN 5% IV SOLUTION   2 Tier 2 - Preferred Brand $25.00N/AP
AMINOSYN 7% IV SOLUTION   2 Tier 2 - Preferred Brand $25.00N/AP
AMINOSYN 7%-ELECTROLYTE SOL   2 Tier 2 - Preferred Brand $25.00N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN 8.5% IV SOLUTION   2 Tier 2 - Preferred Brand $25.00N/AP
AMINOSYN II 10% IV SOLUTION   2 Tier 2 - Preferred Brand $25.00N/AP
AMINOSYN II 15% IV SOLUTION   2 Tier 2 - Preferred Brand $25.00N/AP
AMINOSYN II 3.5% IN D25W IV   2 Tier 2 - Preferred Brand $25.00N/AP
AMINOSYN II 3.5% IN D5W IV   2 Tier 2 - Preferred Brand $25.00N/AP
AMINOSYN II 3.5% M/D5W IV   2 Tier 2 - Preferred Brand $25.00N/AP
AMINOSYN II 3.5% W/ELEC DEX   2 Tier 2 - Preferred Brand $25.00N/AP
AMINOSYN II 4.25% IN D10W   2 Tier 2 - Preferred Brand $25.00N/AP
AMINOSYN II 4.25% IN D20W   2 Tier 2 - Preferred Brand $25.00N/AP
AMINOSYN II 4.25% M/D10W IV   2 Tier 2 - Preferred Brand $25.00N/AP
AMINOSYN II 4.25% W/ELEC DW   2 Tier 2 - Preferred Brand $25.00N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN II 4.25%-D25W IV   2 Tier 2 - Preferred Brand $25.00N/AP
AMINOSYN II 5% IN D25W IV   2 Tier 2 - Preferred Brand $25.00N/AP
AMINOSYN II 7% IV SOLUTION   2 Tier 2 - Preferred Brand $25.00N/AP
AMINOSYN II 8.5% ELECTROLYT   2 Tier 2 - Preferred Brand $25.00N/AP
AMINOSYN M 3.5% IV SOLUTION   2 Tier 2 - Preferred Brand $25.00N/AP
AMINOSYN PF INJECTION   2 Tier 2 - Preferred Brand $25.00N/AP
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5%   2 Tier 2 - Preferred Brand $25.00N/AP
AMINOSYN-HBC 7% IV SOLUTION   2 Tier 2 - Preferred Brand $25.00N/AP
AMINOSYN-HF 8% IV SOLUTION   2 Tier 2 - Preferred Brand $25.00N/AP
AMINOSYN-PF 7% IV SOLUTION   2 Tier 2 - Preferred Brand $25.00N/AP
AMIODARONE HCL 200MG TABLET (60 CT)   1 Tier 1 - Preferred Generics $10.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMIODARONE HCL 400MG TABLET   1 Tier 1 - Preferred Generics $10.00N/ANone
AMIODARONE HCL INJECTION   1 Tier 1 - Preferred Generics $10.00N/ANone
AMITRIP/CDP 25-10 TABLET   1 Tier 1 - Preferred Generics $10.00N/ANone
AMITRIP/PERPHEN 10-2 TABLET   1 Tier 1 - Preferred Generics $10.00N/ANone
AMITRIP/PERPHEN 10-4 TABLET   1 Tier 1 - Preferred Generics $10.00N/ANone
AMITRIP/PERPHEN 25-2 TABLET   1 Tier 1 - Preferred Generics $10.00N/ANone
AMITRIP/PERPHEN 25-4 TABLET   1 Tier 1 - Preferred Generics $10.00N/ANone
AMITRIP/PERPHEN 50-4 TABLET   1 Tier 1 - Preferred Generics $10.00N/ANone
AMITRIPTYLINE HCL 100MG TABLET   1 Tier 1 - Preferred Generics $10.00N/ANone
AMITRIPTYLINE HCL 10MG TABLET   1 Tier 1 - Preferred Generics $10.00N/ANone
AMITRIPTYLINE HCL 150MG TABLET (100 CT)   1 Tier 1 - Preferred Generics $10.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)   1 Tier 1 - Preferred Generics $10.00N/ANone
AMITRIPTYLINE HCL 50MG TABLET   1 Tier 1 - Preferred Generics $10.00N/ANone
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)   1 Tier 1 - Preferred Generics $10.00N/ANone
AMLODIPINE BESYLATE 10MG TABLET (90 CT)   1 Tier 1 - Preferred Generics $10.00N/ANone
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)   1 Tier 1 - Preferred Generics $10.00N/ANone
AMLODIPINE BESYLATE 5MG TABLET (90 CT)   1 Tier 1 - Preferred Generics $10.00N/ANone
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE   1 Tier 1 - Preferred Generics $10.00N/ANone
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE   1 Tier 1 - Preferred Generics $10.00N/ANone
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE   1 Tier 1 - Preferred Generics $10.00N/ANone
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE   1 Tier 1 - Preferred Generics $10.00N/ANone
AMMONIUM CHLORIDE 5 MEQ/ML   1 Tier 1 - Preferred Generics $10.00N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMMONIUM LACTATE 12% CREAM   1 Tier 1 - Preferred Generics $10.00N/ANone
AMMONIUM LACTATE 12% LOTION   1 Tier 1 - Preferred Generics $10.00N/ANone
AMOCLAN 200-28.5/5 SUSPENSION RECONSTITUTED ORAL   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/ANone
AMOCLAN 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/ANone
AMOX TR-K CLV 400-57 CHW TABLET   1 Tier 1 - Preferred Generics $10.00N/ANone
AMOX TR-K CLV 400-57/5 SUSP   1 Tier 1 - Preferred Generics $10.00N/ANone
AMOX TR-K CLV 500-125MG TABLET   1 Tier 1 - Preferred Generics $10.00N/ANone
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE   1 Tier 1 - Preferred Generics $10.00N/ANone
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET   1 Tier 1 - Preferred Generics $10.00N/ANone
AMOXAPINE 100MG TABLET   1 Tier 1 - Preferred Generics $10.00N/ANone
AMOXAPINE 150MG TABLET   1 Tier 1 - Preferred Generics $10.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXAPINE 25MG TABLET   1 Tier 1 - Preferred Generics $10.00N/ANone
AMOXAPINE 50MG TABLET   1 Tier 1 - Preferred Generics $10.00N/ANone
AMOXICIILIN CLAVULNATE POTASSIUM FOR ORAL SUSPENSION   1 Tier 1 - Preferred Generics $10.00N/ANone
AMOXICILLIN 125MG TABLET CHEW   1 Tier 1 - Preferred Generics $10.00N/ANone
AMOXICILLIN 200MG TABLET CHEW   1 Tier 1 - Preferred Generics $10.00N/ANone
AMOXICILLIN 250MG CAPSULE   1 Tier 1 - Preferred Generics $10.00N/ANone
AMOXICILLIN 400MG TABLET CHEW   1 Tier 1 - Preferred Generics $10.00N/ANone
AMOXICILLIN 500MG CAPSULE   1 Tier 1 - Preferred Generics $10.00N/ANone
AMOXICILLIN 500MG TABLET (100 CT)   1 Tier 1 - Preferred Generics $10.00N/ANone
AMOXICILLIN 875MG TABLET   1 Tier 1 - Preferred Generics $10.00N/ANone
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT   1 Tier 1 - Preferred Generics $10.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN CLAVULANATE POTASSIUM TABLET 875-125MG 1 BLPK   1 Tier 1 - Preferred Generics $10.00N/ANone
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT   1 Tier 1 - Preferred Generics $10.00N/ANone
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL   1 Tier 1 - Preferred Generics $10.00N/ANone
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   1 Tier 1 - Preferred Generics $10.00N/ANone
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL   1 Tier 1 - Preferred Generics $10.00N/ANone
AMOXICILLIN TABLET USP CHEWABLE 250MG (250 CT)   1 Tier 1 - Preferred Generics $10.00N/ANone
AMPHET ASP/ AMPHET/ D-AMPHET 10MG TABLET   1 Tier 1 - Preferred Generics $10.00N/ANone
AMPHET ASP/ AMPHET/ D-AMPHET 5MG TABLET   1 Tier 1 - Preferred Generics $10.00N/ANone
AMPHETAMINE SALT COMBO 12.5MG TABLET   1 Tier 1 - Preferred Generics $10.00N/ANone
AMPHETAMINE SALT COMBO 15MG TABLET   1 Tier 1 - Preferred Generics $10.00N/ANone
AMPHETAMINE SALT COMBO 7.5MG TABLET   1 Tier 1 - Preferred Generics $10.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPHETAMINE SALTS 20MG TABLET   1 Tier 1 - Preferred Generics $10.00N/ANone
AMPHETAMINE SALTS 30MG TABLET   1 Tier 1 - Preferred Generics $10.00N/ANone
AMPHOTERICIN B FOR INJECTION 50 MG   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/AP
AMPICILLIN FOR INJECTION   1 Tier 1 - Preferred Generics $10.00N/ANone
AMPICILLIN FOR INJECTION 2GM/ML 10 VIAL   1 Tier 1 - Preferred Generics $10.00N/ANone
AMPICILLIN FOR INJECTION 500MG VIAL   1 Tier 1 - Preferred Generics $10.00N/ANone
AMPICILLIN FOR INJECTION POWDER   1 Tier 1 - Preferred Generics $10.00N/ANone
AMPICILLIN FOR INJECTION USP 125MG/ML 1 VIAL   1 Tier 1 - Preferred Generics $10.00N/ANone
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT   1 Tier 1 - Preferred Generics $10.00N/ANone
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT   1 Tier 1 - Preferred Generics $10.00N/ANone
AMPICILLIN POWDER FOR INJECTION 1 GM/ML   1 Tier 1 - Preferred Generics $10.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPICILLIN SODIUM STERILE 2 GM/VIAL   1 Tier 1 - Preferred Generics $10.00N/ANone
AMPICILLIN TR 250MG CAPSULE   1 Tier 1 - Preferred Generics $10.00N/ANone
AMPICILLIN TR 500MG CAPSULE   1 Tier 1 - Preferred Generics $10.00N/ANone
ANADROL-50 50MG TABLET (100 CT)   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/AP
ANAGRELIDE HCL 0.5MG CAPSULE   1 Tier 1 - Preferred Generics $10.00N/ANone
ANAGRELIDE HCL 1MG CAPSULE   1 Tier 1 - Preferred Generics $10.00N/ANone
ANCOBON 250MG CAPSULE   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/ANone
ANCOBON 500MG CAPSULE   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/ANone
ANDRODERM 2.5MG/24HR PATCH   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/AP
ANDRODERM 5MG/24HR PATCH   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/AP
ANTABUSE 250MG TABLET   2 Tier 2 - Preferred Brand $25.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANTABUSE 500MG TABLET   2 Tier 2 - Preferred Brand $25.00N/ANone
APIDRA 100UNITS/ML VIAL   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/AQ:80
/23Days
APOKYN FOR INJECTION 30MG 5 CTG   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/AP
APTIVUS 250MG CAPSULE   4 Tier 4 - Speciality (Brand or Generic) 25%N/ANone
ARALAST 1000MG VIAL   4 Tier 4 - Speciality (Brand or Generic) 25%N/AP
ARALAST 500MG VIAL   4 Tier 4 - Speciality (Brand or Generic) 25%N/AP
ARANESP 100MCG/ML VIAL   4 Tier 4 - Speciality (Brand or Generic) 25%N/AP
ARANESP 200MCG/0.4ML SYRINGE   4 Tier 4 - Speciality (Brand or Generic) 25%N/AP
ARANESP 200MCG/ML VIAL   4 Tier 4 - Speciality (Brand or Generic) 25%N/AP
ARANESP 25MCG/ML VIAL   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/AP
ARANESP 300MCG/ML VIAL   4 Tier 4 - Speciality (Brand or Generic) 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP 500MCG/1ML SYRINGE   4 Tier 4 - Speciality (Brand or Generic) 25%N/AP
ARANESP 60MCG/ML VIAL   4 Tier 4 - Speciality (Brand or Generic) 25%N/AP
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR   4 Tier 4 - Speciality (Brand or Generic) 25%N/AP
ARANESP PREFILLED SYRINGE SINGLE USE 25MCG/0.42ML SYR   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/AP
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR   4 Tier 4 - Speciality (Brand or Generic) 25%N/AP
ARANESP SINGLE USE PREFILLED AUTOINJECTOR SOLUTION 100MCG/.5ML   4 Tier 4 - Speciality (Brand or Generic) 25%N/AP
ARANESP SINGLE USE PREFILLED SURECLICK AUTOINJECTOR SOLUTION 500MCG/ML   4 Tier 4 - Speciality (Brand or Generic) 25%N/AP
ARANESP SINGLE USE PREFILLED SURECLIK AUTOINJECTOR 60MCG/.3ML   4 Tier 4 - Speciality (Brand or Generic) 25%N/AP
ARANESP SINGLE USE VIAL 150MCG 4 X 150MCG/ 0.75ML VIALSD   4 Tier 4 - Speciality (Brand or Generic) 25%N/AP
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD   4 Tier 4 - Speciality (Brand or Generic) 25%N/AP
ARICEPT 10MG TABLET   2 Tier 2 - Preferred Brand $25.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARICEPT 5MG TABLET   2 Tier 2 - Preferred Brand $25.00N/ANone
ARICEPT ODT 10MG TABLET   2 Tier 2 - Preferred Brand $25.00N/ANone
ARICEPT ODT 5MG TABLET   2 Tier 2 - Preferred Brand $25.00N/ANone
ARIMIDEX 1MG TABLET   2 Tier 2 - Preferred Brand $25.00N/ANone
ARIXTRA 10MG SYRINGE   4 Tier 4 - Speciality (Brand or Generic) 25%N/AP
ARIXTRA 2.5MG SYRINGE   4 Tier 4 - Speciality (Brand or Generic) 25%N/AP
ARIXTRA 5MG SYRINGE   4 Tier 4 - Speciality (Brand or Generic) 25%N/AP
ARIXTRA 7.5MG SYRINGE   4 Tier 4 - Speciality (Brand or Generic) 25%N/AP
AROMASIN 25MG TABLET   2 Tier 2 - Preferred Brand $25.00N/ANone
ARRANON 250MG VIAL   2 Tier 2 - Preferred Brand $25.00N/AP
ASACOL 400MG TABLET EC   2 Tier 2 - Preferred Brand $25.00N/AQ:240
/23Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ASTELIN 137MCG AEROSOL SPRAY W/PUMP   2 Tier 2 - Preferred Brand $25.00N/AQ:30
/23Days
ATENOLOL 25MG TABLET (100 CT)   1 Tier 1 - Preferred Generics $10.00N/ANone
ATENOLOL TABLET 100MG (100 CT)   1 Tier 1 - Preferred Generics $10.00N/ANone
ATENOLOL TABLET USP 50MG (100 CT)   1 Tier 1 - Preferred Generics $10.00N/ANone
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT)   1 Tier 1 - Preferred Generics $10.00N/ANone
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   1 Tier 1 - Preferred Generics $10.00N/ANone
ATRIPLA TABLET 600MG/200MG   4 Tier 4 - Speciality (Brand or Generic) 25%N/ANone
ATROVENT HFA AER 17MCG   2 Tier 2 - Preferred Brand $25.00N/ANone
ATTENUVAX VACCINE W/DILUENT 1 DOSE/0.5ML   2 Tier 2 - Preferred Brand $25.00N/ANone
AVANDIA 2MG TABLET   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/ANone
AVANDIA 4MG TABLET (90 CT)   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVANDIA 8MG TABLET (90 CT)   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/ANone
AVASTIN 100MG/4ML VIAL   4 Tier 4 - Speciality (Brand or Generic) 25%N/AP
AVELOX 400MG TABLET   2 Tier 2 - Preferred Brand $25.00N/AQ:21
/23Days
AVELOX ABC PACK 400MG TABLET   2 Tier 2 - Preferred Brand $25.00N/AQ:21
/30Days
AVELOX IV 400MG/250ML   2 Tier 2 - Preferred Brand $25.00N/ANone
AVODART 0.5MG SOFTGEL   2 Tier 2 - Preferred Brand $25.00N/ANone
AVONEX ADMIN PACK 30MCG SYR   4 Tier 4 - Speciality (Brand or Generic) 25%N/AP
AVONEX ADMIN PACK 30MCG VL   4 Tier 4 - Speciality (Brand or Generic) 25%N/AP
AZACTAM 1GM VIAL   2 Tier 2 - Preferred Brand $25.00N/ANone
AZACTAM 2GM VIAL   2 Tier 2 - Preferred Brand $25.00N/ANone
AZACTAM INJECTION 1GM 50ML BAG   2 Tier 2 - Preferred Brand $25.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZACTAM/ISO-OSMOT 2GM/50ML   2 Tier 2 - Preferred Brand $25.00N/ANone
AZATHIOPRINE 50MG TABLET   1 Tier 1 - Preferred Generics $10.00N/AP
AZATHIOPRINE SOD 100MG VIAL   1 Tier 1 - Preferred Generics $10.00N/AP
AZELEX 20% CREAM 30GM TUBE   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/ANone
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Tier 1 - Preferred Generics $10.00N/ANone
AZITHROMYCIN 1G PACKET   1 Tier 1 - Preferred Generics $10.00N/ANone
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Tier 1 - Preferred Generics $10.00N/ANone
AZITHROMYCIN 250MG TABLET (30 CT)   1 Tier 1 - Preferred Generics $10.00N/AQ:30
/23Days
AZITHROMYCIN 500MG TABLET (30 CT)   1 Tier 1 - Preferred Generics $10.00N/AQ:30
/23Days
AZITHROMYCIN FOR INJECTION 500MG 10 VIALSD   1 Tier 1 - Preferred Generics $10.00N/AP
AZITHROMYCIN TABLET 600MG (30 CT)   1 Tier 1 - Preferred Generics $10.00N/AQ:30
/23Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZMACORT AER 75MCG   3 Tier 3 - NonPreferred Brand, NonPreferred Generic $50.00N/ANone
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT   2 Tier 2 - Preferred Brand $25.00N/ANone

Chart Legend:

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