q1medicare.com
Powered by Q1Group LLC
A non-government resource for the Medicare community
Powered by Q1Group LLC
A non-government Medicare community resource
  • Menu ☰
  • Home
  • Contact
  • MAPD
  • PDP
  • 2024
  • 2025
  • FAQs
  • Articles
  • Search ⌕
  • Contact
  • 2024
  • 2025
  • FAQs
  • Articles
  • Latest Medicare News
  • Search ⌕

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.
Select your search style and criteria below or use this example to get started

Search by:
State & Plan   ZIP & Plan   PlanID   FormularyID

Search Criteria
PDP     MAPD
Scroll down to see formulary results.

First Health Part D-Premier (PDP) (S5768-082-0)
Tier 1 (1436)
Tier 2 (376)
Tier 3 (959)
Tier 4 (260)

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
First Health Part D-Premier (PDP) (S5768-082-0)
Benefit Details  
The First Health Part D-Premier (PDP) (S5768-082-0)
Formulary Drugs Starting with the Letter D
in CMS PDP Region 32 which includes: CA
Drugs Starting with Letter D

Drug Name		 Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order
D5W/KCL 20MEQ/L IV SOLUTION   1 Preferred Generic $7.00$21.00None
D5W/KCL 30MEQ/L IV SOLUTION   1 Preferred Generic $7.00$21.00None
DACOGEN INJ 50MG   4 Specialty - Generic and Brand 29%N/AP
DANAZOL 100MG CAPSULE   1 Preferred Generic $7.00$21.00None
DANAZOL 50MG CAPSULE   1 Preferred Generic $7.00$21.00None
DANAZOL CAPSULES USP 200MG (100 CT)   1 Preferred Generic $7.00$21.00None
DANTROLENE SODIUM 100MG CAPSULE   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
DANTROLENE SODIUM 25MG CAPSULE   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
DANTROLENE SODIUM 50MG CAPSULE   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
DAPSONE TABLETS 100MG 30 BLPK   2 Preferred Brand 12%12%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DAPSONE TABLETS 25MG 30 BLPK   2 Preferred Brand 12%12%None
DAPTACEL VACCINE 15;5;5;3; LF/.5ML   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
DARAPRIM 25MG TABLET   2 Preferred Brand 12%12%None
DARVON-N 100MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
DECAVAC VACCINE 2;5 UNT/0.5 ML   2 Preferred Brand 12%12%None
DEGARELIX INJ   4 Specialty - Generic and Brand 29%N/AP Q:2
/28Days
DEGARELIX SOLR   3 Non-Preferred Generic/Non-Preferred Brand 42%42%P Q:1
/28Days
DEMECLOCYCLINE HCL 150MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
DEMECLOCYCLINE HCL 300MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
DEMSER CAPSULES 250MG (100 CT)   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
DENAVIR 1% CREAM   2 Preferred Brand 12%12%Q:2
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DEPEN 250MG TITRATAB   2 Preferred Brand 12%12%None
DEPO-ESTRADIOL 5MG/ML VIAL   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
DERMA-SMOOTHE/FS 0.01% BODY OIL   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
DERMOTIC 0.01% DROPS   2 Preferred Brand 12%12%None
DESIPRAMINE 25MG TABLET   1 Preferred Generic $7.00$21.00None
DESIPRAMINE 50MG TABLET   1 Preferred Generic $7.00$21.00None
DESIPRAMINE HCL 75MG TABLET (100 CT)   1 Preferred Generic $7.00$21.00None
DESIPRAMINE HYDROCHLORIDE TABLETS 10MG 100 BOT   1 Preferred Generic $7.00$21.00None
DESIPRAMINE HYDROCHLORIDE TABLETS 150MG 50 BOT   1 Preferred Generic $7.00$21.00None
DESIPRAMINE HYDROCHLORIDE TABLETS USP 100MG 100 BOT   1 Preferred Generic $7.00$21.00None
DESMOPRESSIN 0.1MG/ML SOL   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DESMOPRESSIN AC 4MCG/ML VL   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
DESMOPRESSIN ACETATE 0.1MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
DESMOPRESSIN ACETATE TABLET 0.2MG (100 CT)   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
DESONIDE 0.05% CREAM   1 Preferred Generic $7.00$21.00None
DESONIDE 0.05% LOTION   1 Preferred Generic $7.00$21.00None
DESONIDE 0.05% OINTMENT 60GM TUBE   1 Preferred Generic $7.00$21.00None
DESOXIMETASONE 0.05% CREAM   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
DESOXIMETASONE 0.05% GEL   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
DESOXIMETASONE 0.25% CREAM   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
DESOXIMETASONE 0.25% OINT   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
DETROL 1MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DETROL 2MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
DETROL LA 2MG CAPSULE SA   3 Non-Preferred Generic/Non-Preferred Brand 42%42%Q:30
/30Days
DETROL LA 4MG CAPSULE SA   3 Non-Preferred Generic/Non-Preferred Brand 42%42%Q:30
/30Days
DEXAMETHASONE 0.5MG TABLET   1 Preferred Generic $7.00$21.00None
DEXAMETHASONE 0.5MG/0.5ML DROP   1 Preferred Generic $7.00$21.00None
DEXAMETHASONE 0.5MG/5ML ELX   1 Preferred Generic $7.00$21.00None
DEXAMETHASONE 0.75MG TABLET   1 Preferred Generic $7.00$21.00None
DEXAMETHASONE 1.5MG TABLET   1 Preferred Generic $7.00$21.00None
DEXAMETHASONE 1MG TABLET   1 Preferred Generic $7.00$21.00None
DEXAMETHASONE 2MG TABLET   1 Preferred Generic $7.00$21.00None
DEXAMETHASONE 4MG TABLET   1 Preferred Generic $7.00$21.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DEXAMETHASONE 6MG TABLET   1 Preferred Generic $7.00$21.00None
DEXAMETHASONE SODIUM PHOSPHATE 0.1% DROPS   1 Preferred Generic $7.00$21.00None
DEXAMETHASONE SODIUM PHOSPHATE INJECTION 4MG 30ML VIALMD   1 Preferred Generic $7.00$21.00None
DEXCHLORPHEN 2MG/5ML SYRUP   1 Preferred Generic $7.00$21.00None
DEXMETHYLPHENIDATE HCL 10MG TABLET   1 Preferred Generic $7.00$21.00None
DEXMETHYLPHENIDATE HCL 2.5MG TABLET   1 Preferred Generic $7.00$21.00None
DEXMETHYLPHENIDATE HCL 5MG TABLET   1 Preferred Generic $7.00$21.00None
DEXTROAMPHETAMINE 10MG TABLET   1 Preferred Generic $7.00$21.00None
DEXTROAMPHETAMINE 5MG TABLET   1 Preferred Generic $7.00$21.00None
DEXTROAMPHETAMINE SACCHARATE AND SULFATE AMPHETAMINE ASPARTATE 10MG TABLET (100 CT)   1 Preferred Generic $7.00$21.00None
DEXTROAMPHETAMINE SULFATE CAPSULES EXTENDED RELEASED 15MG 100 CAPSULES BOT   1 Preferred Generic $7.00$21.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DEXTROAMPHETAMINE SULFATE CAPSULES SUSTAINED RELEASE 5MG 100 CAPSULES BOT   1 Preferred Generic $7.00$21.00None
DEXTROAMPHETAMINE SULFATE CAPSULES SUSTAINED RELEASED 10MG 100 CAPSULES BOT   1 Preferred Generic $7.00$21.00None
DEXTROSE 10%-1/4NS IV TUBEX   1 Preferred Generic $7.00$21.00None
DEXTROSE 2.5%-1/2NS IV SOLUTION   1 Preferred Generic $7.00$21.00None
DEXTROSE 5% AND 0.9% NACL INJECTION 5-900 24 X 500ML BAG   1 Preferred Generic $7.00$21.00None
DEXTROSE 5%-1/4NS IV SOLUTION   1 Preferred Generic $7.00$21.00None
DEXTROSE AND ELECTROLYTE NO 48 INJECTION 5% 500ML BAG   1 Preferred Generic $7.00$21.00None
DEXTROSE IN SODIUM CHLORIDE INJECTION   1 Preferred Generic $7.00$21.00None
DEXTROSE IN SODIUM CHLORIDE INJECTION   1 Preferred Generic $7.00$21.00None
DEXTROSE IN SODIUM CHLORIDE INJECTION 1000ML X 12 CASE   1 Preferred Generic $7.00$21.00None
DEXTROSE IN SODIUM CHLORIDE INJECTION 500ML X 24 BAG   1 Preferred Generic $7.00$21.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DEXTROSE INJECTION 10 250ML X 24 BOTPL   1 Preferred Generic $7.00$21.00None
DEXTROSE INJECTION USP 5 4 X 100ML CTR   1 Preferred Generic $7.00$21.00None
DIBENZYLINE 10MG CAPSULE   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
DICLOFENAC 25MG TABLET EC   1 Preferred Generic $7.00$21.00None
DICLOFENAC POTASSIUM 50MG TABLET (500 CT)   1 Preferred Generic $7.00$21.00None
DICLOFENAC SOD 100MG TABLET SA   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
DICLOFENAC SODIUM 0.1% DROPS   1 Preferred Generic $7.00$21.00None
DICLOFENAC SODIUM 50MG TABLET DELAYED RELEASE (100 CT)   1 Preferred Generic $7.00$21.00None
DICLOFENAC SODIUM 75MG TABLET DELAYED RELEASE   1 Preferred Generic $7.00$21.00None
DICLOXACILLIN 250MG CAPSULE   1 Preferred Generic $7.00$21.00None
DICLOXACILLIN SODIUM 500MG CAP   1 Preferred Generic $7.00$21.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DICYCLOMINE 10MG CAPSULE   1 Preferred Generic $7.00$21.00None
DICYCLOMINE 10MG/ML VIAL   1 Preferred Generic $7.00$21.00None
DICYCLOMINE HCL 10MG/5ML SYRUP   1 Preferred Generic $7.00$21.00None
DICYCLOMINE HCL 20MG TABLET (500 CT)   1 Preferred Generic $7.00$21.00None
DIDANOSINE 200MG CAPSULE DELAYED RELEASE   1 Preferred Generic $7.00$21.00None
DIDANOSINE 250MG CAPSULE DELAYED RELEASE   1 Preferred Generic $7.00$21.00None
DIDANOSINE 400MG CAPSULE DELAYED RELEASE   1 Preferred Generic $7.00$21.00None
DIDANOSINE DELAYED RELEASE CAPSULES 125MG 30 BOT   1 Preferred Generic $7.00$21.00None
DIFLORASONE 0.05% CREAM   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
DIFLORASONE 0.05% OINTMENT   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
DIFLUNISAL 500MG TABLET   1 Preferred Generic $7.00$21.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DIGOXIN 125MCG TABLET   1 Preferred Generic $7.00$21.00None
DIGOXIN 250MCG TABLET (1000 CT)   1 Preferred Generic $7.00$21.00None
DIGOXIN 50MCG/ML SOLUTION ORAL   1 Preferred Generic $7.00$21.00None
DIGOXIN INJECTION 500MCG 25 X 2ML AMP   1 Preferred Generic $7.00$21.00None
DIHYDROERGOTAMINE 1MG/ML AM   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
DILANTIN 30MG KAPSEAL   2 Preferred Brand 12%12%None
DILANTIN 50MG INFATAB   2 Preferred Brand 12%12%None
DILANTIN EXTENDED ORAL CAPSULE 100MG (100 CT)   2 Preferred Brand 12%12%None
DILANTIN-125 SUS 125/5ML   2 Preferred Brand 12%12%None
DILATRATE-SR 40MG CAPSULE   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
DILT-CD 180MG CAPSULE SR 24 HR   1 Preferred Generic $7.00$21.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DILTIAZEM 30MG TABLET   1 Preferred Generic $7.00$21.00None
DILTIAZEM 90MG TABLET   1 Preferred Generic $7.00$21.00None
DILTIAZEM CD CAPSULES 120MG (90 CT)   1 Preferred Generic $7.00$21.00None
DILTIAZEM CD CAPSULES 240MG (90 CT)   1 Preferred Generic $7.00$21.00None
DILTIAZEM CD CAPSULES 300MG (90 CT)   1 Preferred Generic $7.00$21.00None
DILTIAZEM ER 240MG CAPSULE SA   1 Preferred Generic $7.00$21.00None
DILTIAZEM ER 360MG CAPSULE SA   1 Preferred Generic $7.00$21.00None
DILTIAZEM ER 420MG CAPSULE SA   1 Preferred Generic $7.00$21.00None
DILTIAZEM HCL 120MG ER CAPSULE   1 Preferred Generic $7.00$21.00None
DILTIAZEM HCL 120MG TABLET   1 Preferred Generic $7.00$21.00None
DILTIAZEM HCL 60MG ER CAPSULE   1 Preferred Generic $7.00$21.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DILTIAZEM HCL 60MG TABLET   1 Preferred Generic $7.00$21.00None
DILTIAZEM HCL INJECTION 5MG 10 5ML VIAL   1 Preferred Generic $7.00$21.00None
DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES USP 90MG 1 BLPK   1 Preferred Generic $7.00$21.00None
DIOVAN 160MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 42%42%S Q:30
/30Days
DIOVAN 320MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 42%42%S Q:30
/30Days
DIOVAN 40MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 42%42%S Q:30
/30Days
DIOVAN 80MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 42%42%S Q:30
/30Days
DIOVAN HCT 160/12.5MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 42%42%S Q:30
/30Days
DIOVAN HCT 160/25MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 42%42%S Q:30
/30Days
DIOVAN HCT 320/12.5MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 42%42%S Q:30
/30Days
DIOVAN HCT 320/25MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 42%42%S Q:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DIOVAN HCT 80/12.5MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 42%42%S Q:30
/30Days
DIPENTUM 250MG CAPSULE 125EA   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
DIPHENHYDRAMINE 50MG CAPS   1 Preferred Generic $7.00$21.00None
DIPHENOXYLATE HC/ATROPINE SULFATE TABLET 25-0.25MG (1000 CT)   1 Preferred Generic $7.00$21.00None
DIPHENOXYLATE/ATROPINE LIQ   1 Preferred Generic $7.00$21.00None
DIPHTHERIA-TETANUS TOX-PED .17;6.7;5 MG/5ML;LF   2 Preferred Brand 12%12%None
DIPIVEFRIN 0.1% EYE DROPS   1 Preferred Generic $7.00$21.00None
DIPYRIDAMOLE TABETS 25MG 100 BOT   1 Preferred Generic $7.00$21.00None
DIPYRIDAMOLE TABLETS 50MG 100 BOT   1 Preferred Generic $7.00$21.00None
DIPYRIDAMOLE TABLETS 75MG 100 BOT   1 Preferred Generic $7.00$21.00None
DISOPYRAMIDE PHOSPHATE 150MG CAPSULE USP (100 CT)   1 Preferred Generic $7.00$21.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DISOPYRAMIDE PHOSPHATE CAPSULES 100MG (100 CT)   1 Preferred Generic $7.00$21.00None
DIVALPROEX SODIUM 125MG TBEC   1 Preferred Generic $7.00$21.00None
DIVALPROEX SODIUM 250MG TBEC   1 Preferred Generic $7.00$21.00None
DIVALPROEX SODIUM 500MG TBEC   1 Preferred Generic $7.00$21.00None
DIVALPROEX SODIUM COATED PARTICLES IN CAPSULES 125MG 100 BOT   1 Preferred Generic $7.00$21.00None
DIVALPROEX SODIUM EXTENDED RELEASE TABLETS 250MG 100 BOT   1 Preferred Generic $7.00$21.00None
DIVALPROEX SODIUM TABLETS EXTENDED RELEASE 500MG 100 BOT   1 Preferred Generic $7.00$21.00None
DIVIGEL 1MG(0.1%) GEL IN PACKET   3 Non-Preferred Generic/Non-Preferred Brand 42%42%Q:30
/30Days
DORZOLAMIDE HCL OPHTHALMIC 2% 10 ML BOTDR   1 Preferred Generic $7.00$21.00None
DORZOLAMIDE HCL TIMOLOL MALEATE OPHTHALMIC SOLUTION 22.3;6.8MG/ML;   3 Non-Preferred Generic/Non-Preferred Brand 42%42%Q:10
/30Days
DOVONEX 0.005% CREAM   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DOXAZOSIN MESYLATE 4MG TABLET   1 Preferred Generic $7.00$21.00None
DOXAZOSIN MESYLATE TABLET 2MG (500 CT)   1 Preferred Generic $7.00$21.00None
DOXAZOSIN MESYLATE TABLET 8MG (500 CT)   1 Preferred Generic $7.00$21.00None
DOXAZOSIN TABLET 1MG (100 CT)   1 Preferred Generic $7.00$21.00None
DOXEPIN 10MG CAPSULE   1 Preferred Generic $7.00$21.00None
DOXEPIN 10MG/ML ORAL CONC   1 Preferred Generic $7.00$21.00None
DOXEPIN 150MG CAPSULE   1 Preferred Generic $7.00$21.00None
DOXEPIN 50MG CAPSULE 100 EA   1 Preferred Generic $7.00$21.00None
DOXEPIN 75MG CAPSULE   1 Preferred Generic $7.00$21.00None
DOXEPIN HCL 25MG CAPSULE (100 CT)   1 Preferred Generic $7.00$21.00None
DOXEPIN HYDROCHLORIDE CAPSULES 100MG 100 BOT   1 Preferred Generic $7.00$21.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DOXYCYCLINE 100MG CAPSULE   1 Preferred Generic $7.00$21.00None
DOXYCYCLINE 100MG VIAL   1 Preferred Generic $7.00$21.00None
DOXYCYCLINE 50MG CAPSULE   1 Preferred Generic $7.00$21.00None
DOXYCYCLINE 50MG TABLET (100 CT)   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
DOXYCYCLINE HYCLATE 100MG TABLET USP (500 CT)   1 Preferred Generic $7.00$21.00None
DOXYCYCLINE HYCLATE 20MG TABLET (100 CT)   1 Preferred Generic $7.00$21.00None
DOXYCYCLINE MONOHYDRATE 25MG/5ML SUSR   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
DOXYCYCLINE MONOHYDRATE 75MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
DRONABINOL CAPS 10MG   4 Specialty - Generic and Brand 29%N/AP Q:60
/30Days
DRONABINOL CAPS 2.5MG   3 Non-Preferred Generic/Non-Preferred Brand 42%42%P Q:60
/30Days
DRONABINOL CAPS 5MG   4 Specialty - Generic and Brand 29%N/AP Q:60
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DROXIA 200MG CAPSULE   2 Preferred Brand 12%12%None
DROXIA 300MG CAPSULE   2 Preferred Brand 12%12%None
DROXIA 400MG CAPSULE   2 Preferred Brand 12%12%None
DUETACT 30MG-2MG TABLET   2 Preferred Brand 12%12%S Q:30
/30Days
DUETACT 30MG-4MG TABLET   2 Preferred Brand 12%12%S Q:30
/30Days
DUREZOL OPHTHALMIC EMULSION 0.05% 5 ML BOTDR   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
DYNACIRC CR 10MG TABLET SA   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
DYNACIRC CR 5MG TABLET SA   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
DYRENIUM 100MG CAPSULE   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None
DYRENIUM 50MG CAPSULE   3 Non-Preferred Generic/Non-Preferred Brand 42%42%None

Chart Legend:

Below are a few notes to help you understand the above 2010 Medicare Part D First Health Part D-Premier (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.





 
 


Medicare Supplements
fill the gaps in your
Original Medicare
1. Enter Your ZIP Code:
» Medicare Supplement FAQs





Ask a Pharmacist*
Have questions about your medication?

» Answers to Your Medication Questions, Free!
Available Monday - Friday
8am to 5pm MST
*A free service included with your no cost drug discount card.


© Q1Group LLC 2005 - 2024  



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.
.