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2009 Medicare Part D Plan Formulary Information
MedicareBlue Rx Option 3 (S5743-004-0) Benefit Details
The MedicareBlue Rx Option 3 (S5743-004-0) Formulary Drugs Starting with the Letter M in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY
Drugs Starting with Letter M Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter M Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
M-M-R II VACCINE W/DILUENT 1 DOSE/0.5ML	3	Level 3: Covered Brand	50%	50%	None
MALARONE 250-100MG TABLET	3	Level 3: Covered Brand	50%	50%	None
MALARONE 62.5-25MG PED TABLET	3	Level 3: Covered Brand	50%	50%	None
MAPROTILINE 25MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
MAPROTILINE 50MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
MAPROTILINE 75MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
MARGESIC H 5MG-500MG CAPSULE	1	Level 1: Covered Generic	$3.00	$6.00	None
MARPLAN 10MG TABLET (100 CT)	3	Level 3: Covered Brand	50%	50%	None
MATULANE 50MG CAPSULE	4	Covered Specialty	33%	33%	None
MAXALT 10MG TABLET 12 CRTN	2	Level 2: Covered Preferred Brand	$37.00	$74.00	Q:24 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
MAXALT 5MG TABLET 12 CRTN	2	Level 2: Covered Preferred Brand	$37.00	$74.00	Q:24 /30Days
MAXALT MLT 10MG TABLET 4X3 UNIT DOSE CASE	2	Level 2: Covered Preferred Brand	$37.00	$74.00	Q:24 /30Days
MAXALT MLT 5MG TABLET 4X3 UNIT CASE	2	Level 2: Covered Preferred Brand	$37.00	$74.00	Q:24 /30Days
MAXIPIME 1G VIAL	3	Level 3: Covered Brand	50%	50%	None
MAXIPIME 2G ADD-VANTAGE VL	4	Covered Specialty	33%	33%	None
MAXIPIME 2G VIAL	4	Covered Specialty	33%	33%	None
MAXIPIME 500MG VIAL	3	Level 3: Covered Brand	50%	50%	None
MAXIPIME FOR INJECTION 1GM 10 X 1GM BOX	3	Level 3: Covered Brand	50%	50%	None
MEBENDAZOLE 100MG TABLET CHEW	1	Level 1: Covered Generic	$3.00	$6.00	None
MECLIZINE HCL 12.5MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
MECLIZINE HCL 25MG TABLET (100 CT)	1	Level 1: Covered Generic	$3.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
MEDROXYPROGESTERONE 10MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
MEDROXYPROGESTERONE 2.5MG	1	Level 1: Covered Generic	$3.00	$6.00	None
MEDROXYPROGESTERONE 5MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
MEDROXYPROGESTERONE ACETATE INJECTION SUSPENSION 150MG 1 VIALSD CRTN	1	Level 1: Covered Generic	$3.00	$6.00	None
MEFLOQUINE HCL 250MG TABLET 25 BOT	1	Level 1: Covered Generic	$3.00	$6.00	None
MEFOXIN 1GM/50ML PIGGYBACK	3	Level 3: Covered Brand	50%	50%	None
MEFOXIN 2GM/50ML PIGGYBACK	3	Level 3: Covered Brand	50%	50%	None
MEGESTROL 20MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
MEGESTROL ACETATE 400MG/10ML SUSPENSION ORAL	1	Level 1: Covered Generic	$3.00	$6.00	None
MEGESTROL ACETATE 40MG TABLET (250 CT)	1	Level 1: Covered Generic	$3.00	$6.00	None
MELOXICAM 15MG TABLET (500 CT)	1	Level 1: Covered Generic	$3.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
MELOXICAM 7.5MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
MENACTRA INJECTION 4MCG/0.5ML 5 X .5ML SYR	3	Level 3: Covered Brand	50%	50%	None
MENOMUNE-A/C/Y/W-135 VIAL	3	Level 3: Covered Brand	50%	50%	None
MEPRON 750MG/5ML ORAL SUSP	2	Level 2: Covered Preferred Brand	$37.00	$74.00	None
MERCAPTOPURINE 50MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
MERREM INJECTION 500MG 10X20MLVIALS VIAL	4	Covered Specialty	33%	33%	None
MERREM IV INJECTION 1GM/15ML 30ML X 10 VIAL	4	Covered Specialty	33%	33%	None
MERUVAX II VACCINE/DILUENT	3	Level 3: Covered Brand	50%	50%	None
MESALAMINE 4G/60ML ENEMA	1	Level 1: Covered Generic	$3.00	$6.00	None
MESNA INJECTION 1GM/ML 10ML VIALMD CRTN	4	Covered Specialty	33%	33%	None
MESNEX 100MG/ML VIAL	4	Covered Specialty	33%	33%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
MESNEX 400MG TABLET	4	Covered Specialty	33%	33%	None
MESTINON 180MG TIMESPAN	3	Level 3: Covered Brand	50%	50%	None
MESTINON 60MG/5ML SYRUP	3	Level 3: Covered Brand	50%	50%	None
METADATE ER 20MG TABLET SA	1	Level 1: Covered Generic	$3.00	$6.00	None
METAPROTERENOL 10MG/5ML SYR	1	Level 1: Covered Generic	$3.00	$6.00	None
METFORMIN HCL 1000MG TABLET (500 CT)	1	Level 1: Covered Generic	$3.00	$6.00	None
METFORMIN HCL 500MG TABLET (1000 CT)	1	Level 1: Covered Generic	$3.00	$6.00	None
METFORMIN HCL 850MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
METFORMIN HCL ER 500MG TABLET SR 24HR	1	Level 1: Covered Generic	$3.00	$6.00	None
METFORMIN HCL ER 750MG TABLET (100 CT)	1	Level 1: Covered Generic	$3.00	$6.00	None
METHADONE HCL 10MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
METHADONE HCL 5MG TABLET (100 CT)	1	Level 1: Covered Generic	$3.00	$6.00	None
METHADOSE 10MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
METHADOSE 5MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
METHAZOLAMIDE 25MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
METHAZOLAMIDE 50MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
METHENAMINE HIPPURATE 1G TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
METHERGINE 0.2MG TABLET	2	Level 2: Covered Preferred Brand	$37.00	$74.00	None
METHIMAZOLE 10MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
METHIMAZOLE 5MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
METHOCARBAMOL 500MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
METHOCARBAMOL 750MG TABLET (500 CT)	1	Level 1: Covered Generic	$3.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
METHOTREXATE 1GM VIAL	1	Level 1: Covered Generic	$3.00	$6.00	None
METHOTREXATE 2.5MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	P
METHOTREXATE 25MG/ML VIAL	1	Level 1: Covered Generic	$3.00	$6.00	None
METHSCOPOLAMINE BROMIDE 2.5MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
METHSCOPOLAMINE BROMIDE 5MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
METHYLDOPA 250MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
METHYLDOPA 500MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
METHYLIN 10MG TABLET (100 CT)	1	Level 1: Covered Generic	$3.00	$6.00	None
METHYLIN 20MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
METHYLIN ER 10MG TABLET SA	1	Level 1: Covered Generic	$3.00	$6.00	None
METHYLIN ER 20MG TABLET SA	1	Level 1: Covered Generic	$3.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
METHYLIN TABLET 5MG (100 CT)	1	Level 1: Covered Generic	$3.00	$6.00	None
METHYLPHENIDATE 10MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
METHYLPHENIDATE 20MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
METHYLPHENIDATE 20MG TABLET SA	1	Level 1: Covered Generic	$3.00	$6.00	None
METHYLPHENIDATE 5MG TABLET (100 CT)	1	Level 1: Covered Generic	$3.00	$6.00	None
METHYLPHENIDATE ER 20MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
METHYLPREDNISOLONE 16MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	P
METHYLPREDNISOLONE 32MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	P
METHYLPREDNISOLONE 8MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	P
METHYLPREDNISOLONE TABLET 4MG 21 PKGCOM	1	Level 1: Covered Generic	$3.00	$6.00	P
METIPRANOLOL 0.3% EYE DROPS	1	Level 1: Covered Generic	$3.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
METOCLOPRAMIDE 5MG TABLET 1000 TABLET S BOT	1	Level 1: Covered Generic	$3.00	$6.00	None
METOCLOPRAMIDE SOLUTION ORAL USP 5MG 1 PT BOT	1	Level 1: Covered Generic	$3.00	$6.00	None
METOCLOPRAMIDE TABLET USP 10MG (500 CT)	1	Level 1: Covered Generic	$3.00	$6.00	None
METOLAZONE 10MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
METOLAZONE 2.5MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
METOLAZONE 5MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
METOPROLOL SUCCINATE 100MG TABLET SR 24HR	1	Level 1: Covered Generic	$3.00	$6.00	None
METOPROLOL SUCCINATE 200MG TABLET ER (100 CT)	1	Level 1: Covered Generic	$3.00	$6.00	None
METOPROLOL SUCCINATE 25MG TABLET SR 24HR	1	Level 1: Covered Generic	$3.00	$6.00	None
METOPROLOL SUCCINATE 50MG TABLET SR 24HR	1	Level 1: Covered Generic	$3.00	$6.00	None
METOPROLOL TARTRATE 25MG TABLET (100 CT)	1	Level 1: Covered Generic	$3.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT)	1	Level 1: Covered Generic	$3.00	$6.00	None
METOPROLOL TARTRATE TABLET USP 100MG (1000 CT)	1	Level 1: Covered Generic	$3.00	$6.00	None
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
METROGEL TOPICAL 1% GEL	3	Level 3: Covered Brand	50%	50%	None
METRONIDAZOLE 0.75% CREAM	1	Level 1: Covered Generic	$3.00	$6.00	None
METRONIDAZOLE 0.75% LOTION	1	Level 1: Covered Generic	$3.00	$6.00	None
METRONIDAZOLE 250MG TABLET (250 CT)	1	Level 1: Covered Generic	$3.00	$6.00	None
METRONIDAZOLE 375MG CAPSULE	1	Level 1: Covered Generic	$3.00	$6.00	None
METRONIDAZOLE 500MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
METRONIDAZOLE 500MG/100ML	1	Level 1: Covered Generic	$3.00	$6.00	None
METRONIDAZOLE INJECTION	3	Level 3: Covered Brand	50%	50%	None
METRONIDAZOLE TOPICAL GEL 0.75% 45GM TUBE	1	Level 1: Covered Generic	$3.00	$6.00	None
METRONIDAZOLE VAGINAL GEL .75% 70GM TUBE	1	Level 1: Covered Generic	$3.00	$6.00	None
MEXILETINE 150MG CAPSULE	3	Level 3: Covered Brand	50%	50%	None
MEXILETINE 200MG CAPSULE	3	Level 3: Covered Brand	50%	50%	None
MEXILETINE 250MG CAPSULE	3	Level 3: Covered Brand	50%	50%	None
MICROGESTIN 1-0.02MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
MICROGESTIN 1.5-0.03MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
MICROGESTIN FE 1.5/30 TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
MICROGESTIN FE 1/20 TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
MIDODRINE HCL 10MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
MIDODRINE HCL 2.5MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
MIDODRINE HCL 5MG TABLET (100 CT)	1	Level 1: Covered Generic	$3.00	$6.00	None
MIGERGOT 2-100MG SUPPOSITORY RECTAL	3	Level 3: Covered Brand	50%	50%	None
MIGRANAL 0.5MG/SPRY AEROSOL SPRAY W/PUMP	3	Level 3: Covered Brand	50%	50%	None
MINIRIN 0.1 MG/ML SPRAY	1	Level 1: Covered Generic	$3.00	$6.00	None
MINITRAN 0.1MG/HR PATCH	1	Level 1: Covered Generic	$3.00	$6.00	None
MINITRAN 0.2MG/HR PATCH	1	Level 1: Covered Generic	$3.00	$6.00	None
MINITRAN 0.4MG/HR PATCH	1	Level 1: Covered Generic	$3.00	$6.00	None
MINITRAN 0.6MG/HR PATCH	1	Level 1: Covered Generic	$3.00	$6.00	None
MINOCYCLINE 100MG CAPSULE	1	Level 1: Covered Generic	$3.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
MINOCYCLINE 50MG CAPSULE	1	Level 1: Covered Generic	$3.00	$6.00	None
MINOCYCLINE HCL 100MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
MINOCYCLINE HCL 50MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
MINOCYCLINE HCL 75MG CAPSULE	1	Level 1: Covered Generic	$3.00	$6.00	None
MINOCYCLINE HCL 75MG TABLET (100 CT)	1	Level 1: Covered Generic	$3.00	$6.00	None
MINOXIDIL 10MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
MINOXIDIL 2.5MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
MIRAPEX 0.125MG TABLET	3	Level 3: Covered Brand	50%	50%	None
MIRAPEX 0.25MG TABLET	3	Level 3: Covered Brand	50%	50%	None
MIRAPEX 0.5MG TABLET	3	Level 3: Covered Brand	50%	50%	None
MIRAPEX 0.75MG TABLET	3	Level 3: Covered Brand	50%	50%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
MIRAPEX 1.5MG TABLET	3	Level 3: Covered Brand	50%	50%	None
MIRAPEX 1MG TABLET	3	Level 3: Covered Brand	50%	50%	None
MIRTAZAPINE 15MG TABLET (1000 CT)	1	Level 1: Covered Generic	$3.00	$6.00	None
MIRTAZAPINE 15MG TABLET RAPID DISSOLVE	1	Level 1: Covered Generic	$3.00	$6.00	None
MIRTAZAPINE 30MG TABLET RAPID DISSOLVE	1	Level 1: Covered Generic	$3.00	$6.00	None
MIRTAZAPINE 45MG TABLET RAPID DISSOLVE	1	Level 1: Covered Generic	$3.00	$6.00	None
MIRTAZAPINE TABLET 30MG (30 CT)	1	Level 1: Covered Generic	$3.00	$6.00	None
MIRTAZAPINE TABLET 45MG	1	Level 1: Covered Generic	$3.00	$6.00	None
MIRTAZAPINE TABLET 7.5MG (30 CT)	1	Level 1: Covered Generic	$3.00	$6.00	None
MISOPROSTOL 100MCG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
MISOPROSTOL 200MCG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
MITOMYCIN 40MG VIAL	1	Level 1: Covered Generic	$3.00	$6.00	None
MITOMYCIN POWDER FOR INJECTION USP 20MG VIAL	1	Level 1: Covered Generic	$3.00	$6.00	None
MITOMYCIN POWDER FOR INJECTION USP 5MG VIAL	1	Level 1: Covered Generic	$3.00	$6.00	None
MITOXANTRONE INJECTION 2MG 125ML VIAL	4	Covered Specialty	33%	33%	None
MOBAN 10MG TABLET	3	Level 3: Covered Brand	50%	50%	None
MOBAN 25MG TABLET	3	Level 3: Covered Brand	50%	50%	None
MOBAN 50MG TABLET	3	Level 3: Covered Brand	50%	50%	None
MOBAN 5MG TABLET	3	Level 3: Covered Brand	50%	50%	None
MOEXIPRIL HCL 15MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
MOEXIPRIL HCL 7.5MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-12.5MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-25MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
MOEXIPRIL-HYDROCHLOROTHIAZIDE 7.5-12.5MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
MOMETASONE FUROATE CREAM 0.1% 45GM TUBE	1	Level 1: Covered Generic	$3.00	$6.00	None
MOMETASONE FUROATE OINTMENT 0.1% 45GM TUBE	1	Level 1: Covered Generic	$3.00	$6.00	None
MOMETASONE FUROATE TOPICAL SOLUTION 0.1%	1	Level 1: Covered Generic	$3.00	$6.00	None
MONONESSA 0.25-0.035 TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
MORPHINE SULFATE 100MG TABLET SA	1	Level 1: Covered Generic	$3.00	$6.00	None
MORPHINE SULFATE 15MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
MORPHINE SULFATE 30MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
MORPHINE SULFATE 30MG TABLET SA	1	Level 1: Covered Generic	$3.00	$6.00	None
MORPHINE SULFATE INJECTION 0.5MG 5X10ML VIALGL	1	Level 1: Covered Generic	$3.00	$6.00	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
MORPHINE SULFATE INJECTION 1MG 5X10ML VIALGL	1	Level 1: Covered Generic	$3.00	$6.00	P
MORPHINE SULFATE ORAL SOLUTION	3	Level 3: Covered Brand	50%	50%	P
MORPHINE SULFATE ORAL SOLUTION	3	Level 3: Covered Brand	50%	50%	P
MORPHINE SULFATE TABLET ER 15MG (100 CT)	1	Level 1: Covered Generic	$3.00	$6.00	None
MORPHINE SULFATE TABLET ER 200MG (100 CT)	1	Level 1: Covered Generic	$3.00	$6.00	None
MORPHINE SULFATE TABLET ER 60MG (100 CT)	1	Level 1: Covered Generic	$3.00	$6.00	None
MUPIROCIN 2% OINTMENT	1	Level 1: Covered Generic	$3.00	$6.00	None
MUSTARGEN 10MG VIAL	3	Level 3: Covered Brand	50%	50%	None
MYCAMINE 50MG VIAL	4	Covered Specialty	33%	33%	None
MYCAMINE FOR INJECTION SOLUTION	4	Covered Specialty	33%	33%	None
MYCOBUTIN 150MG CAPSULE	2	Level 2: Covered Preferred Brand	$37.00	$74.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
MYDRAL 0.5% DROPS	1	Level 1: Covered Generic	$3.00	$6.00	None
MYDRAL 1% DROPS	1	Level 1: Covered Generic	$3.00	$6.00	None
MYFORTIC 180MG TABLET	4	Covered Specialty	33%	33%	P
MYFORTIC 360MG TABLET	4	Covered Specialty	33%	33%	P
MYLOTARG 5MG VIAL	4	Covered Specialty	33%	33%	None
MYOZYME 50MG VIAL	4	Covered Specialty	33%	33%	None
MYRAC 100MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
MYRAC 50MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
MYRAC 75MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None

Chart Legend:

Below are a few notes to help you understand the above 2009 Medicare Part D MedicareBlue Rx Option 3 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.