Q1Medicare.com 2009 Medicare Part D or Medicare Advantage Plan Formulary Browser

2009 Medicare Part D Plan Formulary Information
First Health Part D-Premier (S5768-123-0) Benefit Details
The First Health Part D-Premier (S5768-123-0) Formulary Drugs Starting with the Letter N in CMS PDP Region 30 which includes: OR WA
Drugs Starting with Letter N Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter N Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NABUMETONE 500MG TABLET	1	Preferred Generic	$7.00	N/A	None
NABUMETONE 750MG TABLET	1	Preferred Generic	$7.00	N/A	None
NADOLOL 160MG TABLET	1	Preferred Generic	$7.00	N/A	None
NADOLOL 20MG TABLET	1	Preferred Generic	$7.00	N/A	None
NADOLOL 40MG TABLET	1	Preferred Generic	$7.00	N/A	None
NADOLOL 80MG TABLET	1	Preferred Generic	$7.00	N/A	None
NAFAZAIR 0.1% EYE DROPS	1	Preferred Generic	$7.00	N/A	None
NAFCILLIN FOR INJECTION 1 GM/ML	1	Preferred Generic	$7.00	N/A	None
NAFCILLIN FOR INJECTION 10GM/ML 1 VIAL	1	Preferred Generic	$7.00	N/A	None
NAFCILLIN SODIUM INJECTION 1GM VIAL	1	Preferred Generic	$7.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NAFCILLIN SODIUM INJECTION 2GM VIL ADD VANTAGE VIAL	1	Preferred Generic	$7.00	N/A	None
NAFTIN HCL GEL 1% 60GM TUBE	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	Q:40 /30Days
NAFTIN 1% CREAM	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
NAFTIN 1% CREAM	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
NAGLAZYME 5MG/5ML VIAL	4	Specialty-Generic and Brand	33%	N/A	P
NALBUPHINE 10MG/ML VIAL	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
NALBUPHINE 20MG/ML VIAL	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
NALFON 200MG CAPSULE	2	Preferred Brand	$26.00	N/A	None
NALOXONE 1MG/ML SYRINGE	1	Preferred Generic	$7.00	N/A	None
NALOXONE HCL INJECTION 0.4MG 10 X 1ML CTG	1	Preferred Generic	$7.00	N/A	None
NALTREXONE HCL 50MG TABLET 100 BLPK	1	Preferred Generic	$7.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NAMENDA 10MG TABLET	2	Preferred Brand	$26.00	N/A	Q:60 /30Days
NAMENDA 10MG/5ML SOLUTION	2	Preferred Brand	$26.00	N/A	Q:360 /30Days
NAMENDA 5-10MG TITRATION PK	2	Preferred Brand	$26.00	N/A	Q:49 /28Days
NAMENDA 5MG TABLET	2	Preferred Brand	$26.00	N/A	Q:60 /30Days
NAPROXEN 125MG/5ML SUSPEN	1	Preferred Generic	$7.00	N/A	None
NAPROXEN 375MG TABLET EC	1	Preferred Generic	$7.00	N/A	None
NAPROXEN 500MG TABLET EC	1	Preferred Generic	$7.00	N/A	None
NAPROXEN SODIUM 275MG TABLET (100 CT)	1	Preferred Generic	$7.00	N/A	None
NAPROXEN SODIUM 500MG TABLET SA	1	Preferred Generic	$7.00	N/A	None
NAPROXEN SODIUM 550MG TABLET (500 CT)	1	Preferred Generic	$7.00	N/A	None
NAPROXEN TABLET 250MG (500 CT)	1	Preferred Generic	$7.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NAPROXEN TABLET 375MG (500 CT)	1	Preferred Generic	$7.00	N/A	None
NAPROXEN TABLET 500MG (50 CT)	1	Preferred Generic	$7.00	N/A	None
NARDIL 15MG TABLET	2	Preferred Brand	$26.00	N/A	None
NASACORT AQ AER 55MCG/AC	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	Q:33 /30Days
NASONEX 50MCG NASAL SPRAY	2	Preferred Brand	$26.00	N/A	Q:34 /30Days
NATACYN EYE DROPS	2	Preferred Brand	$26.00	N/A	None
NAVANE 20MG CAPSULE	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
NEBUPENT 300MG INHAL POWDER	2	Preferred Brand	$26.00	N/A	P
NECON 0.5/35-28 TABLET	1	Preferred Generic	$7.00	N/A	None
NECON 1-0.05MG TABLET	1	Preferred Generic	$7.00	N/A	None
NECON 1/35-28 TABLET	1	Preferred Generic	$7.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NECON 7 DAYS X 3 TABLET	1	Preferred Generic	$7.00	N/A	None
NEFAZODONE HCL 100MG TABLET	1	Preferred Generic	$7.00	N/A	None
NEFAZODONE HCL 150MG TABLET (60 CT)	1	Preferred Generic	$7.00	N/A	None
NEFAZODONE HCL 200MG TABLET	1	Preferred Generic	$7.00	N/A	None
NEFAZODONE HCL 250MG TABLET (60 CT)	1	Preferred Generic	$7.00	N/A	None
NEFAZODONE HCL 50MG TABLET	1	Preferred Generic	$7.00	N/A	None
NEO-FRADIN 125MG/5ML SOLUTION ORAL	2	Preferred Brand	$26.00	N/A	None
NEO/POLY/DEXAMET EYE OINT	1	Preferred Generic	$7.00	N/A	None
NEO/POLYMYXIN/HC EAR TUBEX 10MG/3.5MG/100UNT	1	Preferred Generic	$7.00	N/A	None
NEOMYCIN AND POLYMYXIN B SULFATES SOLUTION FOR IRRIGATION 40MG/20000UNT	1	Preferred Generic	$7.00	N/A	None
NEOMYCIN SULFATE 500MG TABLET	1	Preferred Generic	$7.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NEOMYCIN-BACITRACIN-POLY-HC 3.5-10K-1 OINTMENT	1	Preferred Generic	$7.00	N/A	None
NEOMYCIN-POLYMYXIN-HC 3.5-10K-1 SOLUTION NON-ORAL	1	Preferred Generic	$7.00	N/A	None
NEOMYCIN-POLYMYXIN-HC 3.5-10K-10 SUSPENSION DROPS	1	Preferred Generic	$7.00	N/A	None
NEOMYCIN/POLYMY/DEXA EYE DROPS 3.5MG/1ML	1	Preferred Generic	$7.00	N/A	None
NEOMYCIN/POLYMY/GRAM EYE DROPS 0.025MG/ML 1.75MG/M	1	Preferred Generic	$7.00	N/A	None
NEOMYCIN/POLYMY/HYDRO OTIC SUS	1	Preferred Generic	$7.00	N/A	None
NEORAL 100MG GELATN CAPSULE	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	P
NEORAL 100MG/ML SOLUTION	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	P
NEORAL 25MG GELATIN CAPSULE	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	P
NEULASTA 6MG/0.6ML SYRINGE	4	Specialty-Generic and Brand	33%	N/A	P
NEUMEGA 5MG VIAL	2	Preferred Brand	$26.00	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NEUPOGEN 300MCG/ML VIAL	4	Specialty-Generic and Brand	33%	N/A	P
NEUPOGEN INJECTION 300MCG/0.5ML 0.5ML SYR	4	Specialty-Generic and Brand	33%	N/A	P
NEUPOGEN INJECTION 480MCG/0.8ML 10 X 0.8ML SYR	4	Specialty-Generic and Brand	33%	N/A	P
NEUPOGEN SOLUTION FOR INJECTION 300MCG/ML 10 X 1ML VIALSD	4	Specialty-Generic and Brand	33%	N/A	P
NEURONTIN 250MG/5ML TUBEX	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
NEUTREXIN 25MG VIAL	4	Specialty-Generic and Brand	33%	N/A	P
NEVANAC 0.1% DROPTAINER	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
NEXAVAR 200MG TABLET	4	Specialty-Generic and Brand	33%	N/A	P Q:120 /30Days
NEXIUM 10MG PACKET	2	Preferred Brand	$26.00	N/A	Q:30 /30Days
NEXIUM 20MG CAPSULE	2	Preferred Brand	$26.00	N/A	Q:30 /30Days
NEXIUM 20MG SUSP FOR RECON DELAYED REL. IN A PACKET	2	Preferred Brand	$26.00	N/A	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NEXIUM 40MG CAPSULE	2	Preferred Brand	$26.00	N/A	Q:30 /30Days
NEXIUM 40MG SUSP FOR RECON DELAYED REL. IN A PACKET	2	Preferred Brand	$26.00	N/A	Q:30 /30Days
NIACOR 500MG TABLET	1	Preferred Generic	$7.00	N/A	None
NIASPAN 1000MG TABLET (90 CT)	2	Preferred Brand	$26.00	N/A	Q:60 /30Days
NIASPAN ER 500MG TABLET (90 CT)	2	Preferred Brand	$26.00	N/A	Q:30 /30Days
NIASPAN ER 750MG TABLET (90 CT)	2	Preferred Brand	$26.00	N/A	Q:60 /30Days
NICARDIPINE HCL 20MG CAPSULE (100 CT)	1	Preferred Generic	$7.00	N/A	None
NICARDIPINE HCL 30MG CAPSULE (100 CT)	1	Preferred Generic	$7.00	N/A	None
NICOTROL NS NASAL SPRAY BOTTLE 10MG 4 X 10MG/ML INHL	2	Preferred Brand	$26.00	N/A	Q:40 /30Days
NIFEDIAC CC 30MG TABLET SA	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
NIFEDIAC CC 60MG TABLET SA	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NIFEDIAC CC 90MG TABLET SA	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
NIFEDICAL XL 30MG TABLET SR OSMOTIC PUSH 24HR	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
NIFEDICAL XL 60MG TABLET SR OSMOTIC PUSH 24HR	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
NIFEDIPINE 10MG CAPSULE	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
NIFEDIPINE 20MG CAPSULE	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
NIFEDIPINE ER 30MG TABLET SA	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
NIFEDIPINE ER 60MG TABLET SA	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
NIFEDIPINE ER 90MG TABLET SA	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
NILANDRON 150MG TABLET	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
NIMODIPINE 30MG CAPSULE	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
NISOLDIPINE 20MG TB24	1	Preferred Generic	$7.00	N/A	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NISOLDIPINE 30MG TB24	1	Preferred Generic	$7.00	N/A	Q:60 /30Days
NISOLDIPINE 40MG TB24	1	Preferred Generic	$7.00	N/A	Q:30 /30Days
NITRO-DUR 0.1MG/HR PATCH TRANSDERMAL 24 HOURS	1	Preferred Generic	$7.00	N/A	Q:30 /30Days
NITRO-DUR 0.3MG/HR PATCH	1	Preferred Generic	$7.00	N/A	Q:30 /30Days
NITRO-DUR 0.6MG 30 BOX	1	Preferred Generic	$7.00	N/A	Q:30 /30Days
NITRO-DUR 0.8MG/HR PATCH INST.	1	Preferred Generic	$7.00	N/A	Q:30 /30Days
NITRO-DUR NITROGLYCERIN 0.4MG/HR PATCH TRANSDERMAL 24 HOURS	1	Preferred Generic	$7.00	N/A	Q:30 /30Days
NITRO-DUR PATCHES 0.2MG 30 BOX	1	Preferred Generic	$7.00	N/A	Q:30 /30Days
NITROFURANTOIN 100MG CAPSULE (100 CT)	1	Preferred Generic	$7.00	N/A	None
NITROFURANTOIN MACROCRYSTAL USP 100MG CAPSULE (100 CT)	1	Preferred Generic	$7.00	N/A	None
NITROFURANTOIN MCR 50MG CAP	1	Preferred Generic	$7.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NITROGLYCERIN 5MG/ML VIAL	1	Preferred Generic	$7.00	N/A	None
NITROLINGUAL SPR PUMPSPRA	2	Preferred Brand	$26.00	N/A	None
NITROSTAT 0.3MG TABLET SL	2	Preferred Brand	$26.00	N/A	None
NITROSTAT 0.4MG TABLET SL	2	Preferred Brand	$26.00	N/A	None
NITROSTAT 0.6MG TABLET SL	2	Preferred Brand	$26.00	N/A	None
NIZATIDINE 150MG CAPSULE	1	Preferred Generic	$7.00	N/A	None
NIZATIDINE 300MG CAPSULE	1	Preferred Generic	$7.00	N/A	None
NORA-BE 0.35MG TABLET	1	Preferred Generic	$7.00	N/A	None
NORDITROPIN 15MG/1.5ML CRTG	4	Specialty-Generic and Brand	33%	N/A	P
NORDITROPIN 5MG/1.5ML CRTG	4	Specialty-Generic and Brand	33%	N/A	P
NORDITROPIN NORDIFLEX 10MG/1.5	4	Specialty-Generic and Brand	33%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NORDITROPIN NORDIFLEX 15MG/1.5	4	Specialty-Generic and Brand	33%	N/A	P
NORDITROPIN NORDIFLEX 5MG/1.5	4	Specialty-Generic and Brand	33%	N/A	P
NORETHINDRONE 5MG TABLET	1	Preferred Generic	$7.00	N/A	None
NORITATE 1% CREAM	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
NORPACE CR 100MG CAPSULE SA	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
NORTREL .035-1MG TABLET 21DAY BLPK	1	Preferred Generic	$7.00	N/A	None
NORTREL 0.035-0.5MG TABLET 28DAY BLPK	1	Preferred Generic	$7.00	N/A	None
NORTREL 1-0.035MG TABLET 28DAY	1	Preferred Generic	$7.00	N/A	None
NORTREL 7 DAYS X 3 TABLET	1	Preferred Generic	$7.00	N/A	None
NORTRIPTYLINE 10MG/5ML SOL	1	Preferred Generic	$7.00	N/A	None
NORTRIPTYLINE HCL 10MG CAPSULE	1	Preferred Generic	$7.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NORTRIPTYLINE HCL 25MG CAP	1	Preferred Generic	$7.00	N/A	None
NORTRIPTYLINE HCL 50MG CAPSULE	1	Preferred Generic	$7.00	N/A	None
NORTRIPTYLINE HCL 75MG CAPSULE	1	Preferred Generic	$7.00	N/A	None
NORVIR 100MG SOFTGEL CAP 120 CAPS BOTPL	2	Preferred Brand	$26.00	N/A	None
NORVIR 80MG/ML ORAL SOLUTION	2	Preferred Brand	$26.00	N/A	None
NOVOLIN 70/30 100U/ML VIAL	2	Preferred Brand	$26.00	N/A	None
NOVOLIN 70/30 U100 CARTRIDG	2	Preferred Brand	$26.00	N/A	P
NOVOLIN 70/INJ 30 INNLT	2	Preferred Brand	$26.00	N/A	P
NOVOLIN N 100U/ML CARTRIDGE	2	Preferred Brand	$26.00	N/A	P
NOVOLIN N 100U/ML VIAL	2	Preferred Brand	$26.00	N/A	None
NOVOLIN N INJ INNOLET	2	Preferred Brand	$26.00	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NOVOLIN R 100U/ML CARTRIDGE	2	Preferred Brand	$26.00	N/A	P
NOVOLIN R 100U/ML VIAL	2	Preferred Brand	$26.00	N/A	None
NOVOLIN R 100UNIT/ML INNOLET	2	Preferred Brand	$26.00	N/A	P
NOVOLOG 100U/ML CARTRIDGE	2	Preferred Brand	$26.00	N/A	P
NOVOLOG 100U/ML VIAL	2	Preferred Brand	$26.00	N/A	None
NOVOLOG MIX 70/30 CARTRIDGE	2	Preferred Brand	$26.00	N/A	P
NOVOLOG MIX 70/30 SYRINGE 70-30U/ML	2	Preferred Brand	$26.00	N/A	P
NOVOLOG MIX 70/30 VIAL	2	Preferred Brand	$26.00	N/A	None
NOXAFIL 200MG/5ML SUSPENSION ORAL	4	Specialty-Generic and Brand	33%	N/A	P Q:630 /30Days
NULYTELY POWDER FOR ORAL SOLUTION 420GM-1.48GM-5GM 4L BOT	2	Preferred Brand	$26.00	N/A	None
NULYTELY WITH FLAVOR PACKS POWDER FOR SOLUTION 420;1.48;MG;MG;GM; 4 L BOT	2	Preferred Brand	$26.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NYSTATIN 100000U/G POWDER	1	Preferred Generic	$7.00	N/A	None
NYSTATIN 100000U/GM CREAM	1	Preferred Generic	$7.00	N/A	None
NYSTATIN 100000U/GM OINT	1	Preferred Generic	$7.00	N/A	None
NYSTATIN ORAL SUSPENSION 100000U 473ML BOT	1	Preferred Generic	$7.00	N/A	None
NYSTATIN TABLET 500000U (100 CT)	1	Preferred Generic	$7.00	N/A	None
NYSTATIN/TRIAMCINOLONE CRM	1	Preferred Generic	$7.00	N/A	None
NYSTATIN/TRIAMCINOLONE OINT 10000UNT/1MG	1	Preferred Generic	$7.00	N/A	None

Chart Legend:

Below are a few notes to help you understand the above 2009 Medicare Part D First Health Part D-Premier 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.