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2010 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.
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EnvisionRxPlus Silver (PDP) (S7694-025-0)
Tier 1 (1359)
Tier 2 (198)
Tier 3 (298)
Tier 4 (347)
Tier 5 (116)
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 
2010 Medicare Part D Plan Formulary Information
EnvisionRxPlus Silver (PDP) (S7694-025-0)
Benefit Details  
The EnvisionRxPlus Silver (PDP) (S7694-025-0)
Formulary Drugs Starting with the Letter C

in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY
Drugs Starting with Letter C

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
CALCIPOTRIENE TOPICAL SOLUTION   2 Tier 2 25%25%None
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY   1 Tier 1 25%25%None
CALCITRIOL 0.25MCG CAPSULE   1 Tier 1 25%25%None
CALCITRIOL 0.5MCG CAPSULE   1 Tier 1 25%25%None
CALCITRIOL 1MCG/ML SOLUTION ORAL   1 Tier 1 25%25%None
CALCITRIOL 2 MCG/ML VIAL   1 Tier 1 25%25%None
CALCITRIOL INJECTION SOLUTION 1MCG 50 X 01ML AMP   1 Tier 1 25%25%None
CALCIUM ACETATE CAPSULE 667 MG   1 Tier 1 25%25%None
CAMPATH 30MG/ML VIAL   5 Tier 5 25%25%None
CAPASTAT SULFATE 1GM VIAL   5 Tier 5 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CAPTOPRIL 100MG TABLET   1 Tier 1 25%25%None
CAPTOPRIL 12.5MG TABLET   1 Tier 1 25%25%None
CAPTOPRIL 25MG TABLET   1 Tier 1 25%25%None
CAPTOPRIL 50MG TABLET   1 Tier 1 25%25%None
CAPTOPRIL/HCTZ 25/15 TABLET   1 Tier 1 25%25%None
CAPTOPRIL/HCTZ 25/25 TABLET   1 Tier 1 25%25%None
CAPTOPRIL/HCTZ 50/15 TABLET   1 Tier 1 25%25%None
CAPTOPRIL/HCTZ 50/25 TABLET   1 Tier 1 25%25%None
CARAFATE SUS 1GM/10ML   3 Tier 3 25%25%None
CARBAMAZEPINE 100MG/5ML SUSPENSION ORAL   1 Tier 1 25%25%None
CARBAMAZEPINE EXTENDED RELEASE TABLETS 200MG   2 Tier 2 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARBAMAZEPINE EXTENDED RELEASE TABLETS 400MG   2 Tier 2 25%25%None
CARBAMAZEPINE TABLET CHEWABLE 100MG (100 CT)   1 Tier 1 25%25%None
CARBAMAZEPINE TABLET USP 200MG (1000 CT)   1 Tier 1 25%25%None
CARBATROL 100MG CAPSULE SA   4 Tier 4 25%25%None
CARBATROL 200MG CAPSULE SA   4 Tier 4 25%25%None
CARBATROL 300MG CAPSULE SA   4 Tier 4 25%25%None
CARBIDOPA AND LEVEDOPA ORALLY DISINTEGRATING TABLETS 10;100MG;MG 100 BOT   2 Tier 2 25%25%None
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;100MG;MG 100 BOT   2 Tier 2 25%25%None
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;250MG;MG 100 BOT   2 Tier 2 25%25%None
CARBIDOPA-LEVODOPA 25MG-100MG TABLET SA   1 Tier 1 25%25%None
CARBIDOPA-LEVODOPA 50MG-200MG TABLET SA   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARBIDOPA/LEVO 10/100 TABLET   1 Tier 1 25%25%None
CARBIDOPA/LEVO 25/100 TABLET   1 Tier 1 25%25%None
CARBIDOPA/LEVO 25/250 TABLET   1 Tier 1 25%25%None
CARIMUNE NF 3GM VIAL   5 Tier 5 25%25%P
CARTEOLOL HCL OPHTHALMIC SOLUTION USP 1% 15ML BOT   1 Tier 1 25%25%None
CARTIA XT 120MG CAPSULE SA   1 Tier 1 25%25%None
CARTIA XT 180MG CAPSULE SA   1 Tier 1 25%25%None
CARTIA XT 240MG CAPSULE SA   1 Tier 1 25%25%None
CARTIA XT 300MG CAPSULE SR 24 HR   1 Tier 1 25%25%None
CARVEDILOL 12.5MG TABLET (100 CT)   1 Tier 1 25%25%None
CARVEDILOL 25MG TABLET (500 CT)   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARVEDILOL 3.125MG TABLET (100 CT)   1 Tier 1 25%25%None
CARVEDILOL 6.25MG TABLET (500 CT)   1 Tier 1 25%25%None
CEENU 100MG CAPSULE   4 Tier 4 25%25%None
CEENU 10MG CAPSULE   4 Tier 4 25%25%None
CEENU 40MG CAPSULE   4 Tier 4 25%25%None
CEFACLOR 250MG/5ML ORAL SUSP   1 Tier 1 25%25%None
CEFACLOR 375MG/5ML ORAL SUSP   1 Tier 1 25%25%None
CEFACLOR CAPSULES USP 250MG (100 CT)   1 Tier 1 25%25%None
CEFACLOR CAPSULES USP 500MG (100 CT)   1 Tier 1 25%25%None
CEFACLOR ER 500MG TABLET SR 12HR   1 Tier 1 25%25%None
CEFACLOR POWDER FOR ORAL SUSPENSION USP 125MG 75ML BOT   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFAZOLIN 1GM/D5W BAG   1 Tier 1 25%25%None
CEFAZOLIN 20GM BULK VIAL   1 Tier 1 25%25%None
CEFAZOLIN 500MG/D5W BAG   1 Tier 1 25%25%None
CEFAZOLIN FOR INJECTION   1 Tier 1 25%25%None
CEFAZOLIN FOR INJECTION 1MG 25 VIALGL   1 Tier 1 25%25%None
CEFDINIR 250MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Tier 1 25%25%None
CEFDINIR CAPSULES 300MG (60 CT)   1 Tier 1 25%25%None
CEFDINIR FOR ORAL SUSPENSION 125MG/5ML (100 CT)   1 Tier 1 25%25%None
CEFEPIME HCL 2 GRAM VIAL   2 Tier 2 25%25%None
CEFEPIME INJ 1GM 20ML APX 10x1G VIAL   2 Tier 2 25%25%None
CEFOXITIN FOR INJECTION 10GM 10 X 100ML VIAL   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFOXITIN FOR INJECTION 1GM 25 X 20ML VIAL   1 Tier 1 25%25%None
CEFOXITIN FOR INJECTION 2GM 20ML VIAL   1 Tier 1 25%25%None
CEFTRIAXONE 10GM VIAL   2 Tier 2 25%25%None
CEFTRIAXONE FOR INJECTION 250MG BOX OF 10 VIALGL   2 Tier 2 25%25%None
CEFTRIAXONE FOR INJECTION 500MG BOX OF 10 VIALGL   2 Tier 2 25%25%None
CEFUROXIME 250MG TABLET   1 Tier 1 25%25%None
CEFUROXIME AXETIL 125MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Tier 1 25%25%None
CEFUROXIME AXETIL 250MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Tier 1 25%25%None
CEFUROXIME AXETIL 500MG TABLET (20 CT)   1 Tier 1 25%25%None
CEFUROXIME FOR INJECTION   1 Tier 1 25%25%None
CEFUROXIME FOR INJECTION   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFUROXIME FOR INJECTION 7.5GM 10 X 7.5 VIALPHR   1 Tier 1 25%25%None
CELLCEPT 200MG/ML ORAL SUSP   3 Tier 3 25%25%P
CELLCEPT IV INJ 500MG   3 Tier 3 25%25%P
CELONTIN 300MG KAPSEAL   4 Tier 4 25%25%None
CEPHALEXIN 250MG CAPSULE   1 Tier 1 25%25%None
CEPHALEXIN 250MG TABLET   1 Tier 1 25%25%None
CEPHALEXIN 250MG/5ML ORAL SUSP   1 Tier 1 25%25%None
CEPHALEXIN 500MG TABLET   1 Tier 1 25%25%None
CEPHALEXIN CAPSULES 500MG (500 CT)   1 Tier 1 25%25%None
CEPHALEXIN POWDER FOR SUSPENSION ORAL USP 125MG 200ML BOT   1 Tier 1 25%25%None
CEREDASE 80UNITS/ML VIAL   5 Tier 5 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEREZYME INJ 200UNIT   5 Tier 5 25%25%None
CETIRIZINE HCL 5MG/5ML   1 Tier 1 25%25%None
CHANTIX 0.5MG TABLET   4 Tier 4 25%25%Q:11
/30Days
CHANTIX 1MG TABLET   4 Tier 4 25%25%Q:180
/90Days
CHANTIX STARTING MONTH PAK   4 Tier 4 25%25%Q:53
/30Days
CHLORDIAZEPOXIDE AND AMITRIPTYLINE HCL TABLET 12.5-5MG (500 CT)   1 Tier 1 25%25%None
CHLORHEXIDINE GLUCONATE 0.12% MOUTHWASH   1 Tier 1 25%25%None
CHLOROQUINE PH 500MG TABLET   1 Tier 1 25%25%None
CHLOROQUINE PHOSPHATE 250MG TABLET (50 CT)   1 Tier 1 25%25%None
CHLOROTHIAZIDE 250MG TABLET   1 Tier 1 25%25%None
CHLOROTHIAZIDE 500MG TABLET   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CHLORPROMAZINE 100MG TABLET   1 Tier 1 25%25%None
CHLORPROMAZINE 10MG TABLET   1 Tier 1 25%25%None
CHLORPROMAZINE 25MG TABLET   1 Tier 1 25%25%None
CHLORPROMAZINE 25MG/ML AMP   1 Tier 1 25%25%None
CHLORPROMAZINE 50MG TABLET   1 Tier 1 25%25%None
CHLORPROMAZINE HCL 200MG TABLET   1 Tier 1 25%25%None
CHLORTHALIDONE 25MG TABLET (100 CT)   1 Tier 1 25%25%None
CHLORTHALIDONE 50MG TABLET (1000 CT)   1 Tier 1 25%25%None
CHOLESTYRAMINE LIGHT ORAL SUSP USP POWDER 4GM 210GM CAN   1 Tier 1 25%25%None
CHOLESTYRAMINE POWDER FOR ORAL SUSPENSION USP 4GM 60 X 9GM SINGLE DOSE CRTN   1 Tier 1 25%25%None
CHOLESTYRAMINE POWDER FOR ORAL SUSPENSION USP 4GM 378GM CAN   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CHORIONIC GONAD 10000U VIAL   3 Tier 3 25%25%None
CICLOPIROX 0.77% CREAM   1 Tier 1 25%25%None
CICLOPIROX 0.77% GEL   2 Tier 2 25%25%None
CICLOPIROX 0.77% TOPICAL SUSPENSION   1 Tier 1 25%25%None
CICLOPIROX 8% TOPICAL SOLUTION NAIL LACQUER 6.6ML BOT   2 Tier 2 25%25%None
CILOSTAZOL 50MG TABLET (60 CT)   1 Tier 1 25%25%None
CILOSTAZOL TABLET 100MG (60 CT)   1 Tier 1 25%25%None
CIPROFLOXACIN 10MG/ML VIAL   1 Tier 1 25%25%None
CIPROFLOXACIN 250MG TABLET (100 CT)   1 Tier 1 25%25%None
CIPROFLOXACIN 500MG TABLET   1 Tier 1 25%25%None
CIPROFLOXACIN ER 1000MG TABLET (30 CT)   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CIPROFLOXACIN ER 500MG TABLET (30 CT)   1 Tier 1 25%25%None
CIPROFLOXACIN HCL 0.3% DROPS   1 Tier 1 25%25%None
CIPROFLOXACIN HCL 100MG TABLET   1 Tier 1 25%25%None
CIPROFLOXACIN TABLETS 750MG 100 BOT   1 Tier 1 25%25%None
CITALOPRAM HBR 20MG TABLET (100 CT)   1 Tier 1 25%25%None
CITALOPRAM HBR ORAL SOLUTION 10MG 240ML BOTPL   1 Tier 1 25%25%None
CITALOPRAM HYDROBROMIDE TABLETS 40MG 30 BOT   1 Tier 1 25%25%None
CITOLOPRAM HBR 10MG TABLET (100 CT)   1 Tier 1 25%25%None
CLEMASTINE FUM 2.68MG TABLET   1 Tier 1 25%25%None
CLEMASTINE FUMARATE 0.67MG/5ML SYRUP   1 Tier 1 25%25%None
CLINDAMYCIN 150MG/ML ADDVAN   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLINDAMYCIN HCL 150MG CAPSULE   1 Tier 1 25%25%None
CLINDAMYCIN HCL 300MG CAPS   1 Tier 1 25%25%None
CLINDAMYCIN PHOSP 1% LOTION   1 Tier 1 25%25%None
CLINDAMYCIN PHOSPHATE 1% SOLUTION NON-ORAL   1 Tier 1 25%25%None
CLINDAMYCIN PHOSPHATE 2% CREAM WITH APPLICATOR   1 Tier 1 25%25%None
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE   1 Tier 1 25%25%None
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX   1 Tier 1 25%25%None
CLINIMIX 2.75%/5% INJECTION 1000ML BAG   3 Tier 3 25%25%P
CLINIMIX 4.25/10 SOLUTION   3 Tier 3 25%25%P
CLINIMIX 4.25/20 SOLUTION   3 Tier 3 25%25%P
CLINIMIX 4.25/25 SOLUTION   3 Tier 3 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLINIMIX 4.25/5 SOLUTION   3 Tier 3 25%25%P
CLINIMIX 5/15 SOLUTION   3 Tier 3 25%25%P
CLINIMIX 5/20 SOLUTION   3 Tier 3 25%25%P
CLINIMIX 5/25 SULFITE FREE INJECTIONS 1035MG-420MEQ 1000ML BAG   3 Tier 3 25%25%P
CLINIMIX E 2.75/10 SOLUTION   3 Tier 3 25%25%P
CLINIMIX E 2.75/5 SOLUTION   3 Tier 3 25%25%P
CLINIMIX E 4.25/25 SOLUTION   3 Tier 3 25%25%P
CLINIMIX E 4.25/5 SOLUTION   3 Tier 3 25%25%P
CLINIMIX E 5/20 SOLUTION   3 Tier 3 25%25%P
CLINIMIX E 5/25 SOLUTION   3 Tier 3 25%25%P
CLINIMIX E 5/35 SOLUTION   3 Tier 3 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLINIMIX E 5%/15% INJECTION 2000ML BAG   3 Tier 3 25%25%P
CLINISOL 15% SOLUTION   1 Tier 1 25%25%P
CLOBETASOL 0.05% OINTMENT   1 Tier 1 25%25%None
CLOBETASOL 0.05% SOLUTION   1 Tier 1 25%25%None
CLOBETASOL E 0.05% CREAM   1 Tier 1 25%25%None
CLOBETASOL PROPIONATE CRM 0.05% 15GM   1 Tier 1 25%25%None
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE   1 Tier 1 25%25%None
CLOMIPRAMINE HCL 25MG CAPSULE   1 Tier 1 25%25%None
CLOMIPRAMINE HCL 50MG CAPSULE   1 Tier 1 25%25%None
CLOMIPRAMINE HCL 75MG CAPSULE   1 Tier 1 25%25%None
CLONIDINE HCL 0.2MG TABLET (500 CT)   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLONIDINE HCL TABLET 0.1MG (500 CT)   1 Tier 1 25%25%None
CLONIDINE HCL TABLET 0.3MG (100 CT)   1 Tier 1 25%25%None
CLOTRIMAZOLE 1% CREAM   1 Tier 1 25%25%None
CLOTRIMAZOLE SOLUTION TOPICAL 1% 30ML BOTPL   1 Tier 1 25%25%None
CLOTRIMAZOLE-BETAMETHASONE 1-0.05% LOTION   1 Tier 1 25%25%None
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE CREAM USP .5MG-10GM 45GM TUBE   1 Tier 1 25%25%None
CLOZAPINE 200MG TABLET (500 CT)   2 Tier 2 25%25%None
CLOZAPINE 25MG TABLET (100 CT)   2 Tier 2 25%25%None
CLOZAPINE 50MG TABLET (500 CT)   2 Tier 2 25%25%None
CO-GESIC 5/500 TABLET   1 Tier 1 25%25%None
COLCHICINE TABLET USP 0.6MG (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
COLESTIPOL HCL 1G TABLET   1 Tier 1 25%25%None
COLESTIPOL HCL 5G GRANULES   1 Tier 1 25%25%None
COLISTIMETHATE 150MG VIAL   1 Tier 1 25%25%None
COLLAGENASE SANTYL OINTMENT 250UNT 30GM TUBE   3 Tier 3 25%25%None
COMBIGAN 0.2%-0.5% DROPS   4 Tier 4 25%25%None
COMBIVIR TABLET   3 Tier 3 25%25%None
COMPRO 25MG SUPPOSITORY   1 Tier 1 25%25%None
COMTAN 200MG TABLET   3 Tier 3 25%25%None
COMVAX VACCINE VIAL   4 Tier 4 25%25%None
CONDYLOX GEL 0.5% 3.5 GM CRTN   4 Tier 4 25%25%None
CONSTULOSE 10GM/15ML SYRUP   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN   5 Tier 5 25%25%None
CORMAX 0.05% CREAM   1 Tier 1 25%25%None
CORTOMYCIN EAR SOLUTION   1 Tier 1 25%25%None
CORTOMYCIN EAR SUSPENSION   1 Tier 1 25%25%None
CRIXIVAN 100MG CAPSULE   3 Tier 3 25%25%None
CRIXIVAN 200MG CAPSULE   3 Tier 3 25%25%None
CRIXIVAN 333MG CAPSULE   3 Tier 3 25%25%None
CRIXIVAN 400MG CAPSULE (120 CT)   3 Tier 3 25%25%None
CROMOLYN NEBULIZER SOLUTION   1 Tier 1 25%25%P
CROMOLYN SODIUM 4% 40MG 10ML BOT   1 Tier 1 25%25%None
CUPRIMINE 125MG CAPSULE   3 Tier 3 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CUPRIMINE CAPSULES 250MG (100 CT)   3 Tier 3 25%25%None
CYCLOBENZAPRINE HCL 10MG TABLET (1000 CT)   1 Tier 1 25%25%None
CYCLOBENZAPRINE HCL 5MG TABLET (500 CT)   1 Tier 1 25%25%None
CYCLOSPORINE 100MG CAPSULE   2 Tier 2 25%25%P
CYCLOSPORINE 100MG CAPSULE   4 Tier 4 25%25%None
CYCLOSPORINE 25MG CAPSULE   2 Tier 2 25%25%P
CYCLOSPORINE 50MG CAPSULE   2 Tier 2 25%25%P
CYCLOSPORINE 50MG/ML AMP   2 Tier 2 25%25%P
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT   2 Tier 2 25%25%P
CYKLOKAPRON 100MG/ML AMPUL   3 Tier 3 25%25%None
CYMBALTA 20MG CAPSULE   4 Tier 4 25%25%Q:90
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CYMBALTA 60MG CAPSULE   4 Tier 4 25%25%Q:30
/30Days
CYMBALTA CAPSULES DELAYED RELEASE 30MG (30 CT)   4 Tier 4 25%25%Q:60
/30Days
CYSTADANE POWDER FOR ORAL SOLUTION 180GM   3 Tier 3 25%25%None
CYSTAGON 150MG CAPSULE   3 Tier 3 25%25%None
CYSTAGON 50MG CAPSULE   3 Tier 3 25%25%None
CYTOXAN 500MG VIAL   4 Tier 4 25%25%None

Chart Legend:

Below are a few notes to help you understand the above 2010 Medicare Part D EnvisionRxPlus Silver (PDP) 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 $310 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 $2830) 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 2010 )

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.