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2010 Medicare Part D Plan (PDP Only) Formulary Browser

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

Search by:
State & Plan   ZIP & Plan   PlanID   FormularyID

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PDP     MAPD
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Blue Cross MedicareRx Gold (PDP) (S5596-035-0)
Tier 1 (1670)
Tier 2 (594)
Tier 3 (1387)
Tier 4 (608)
Tier 5 (364)
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
Blue Cross MedicareRx Gold (PDP) (S5596-035-0)
Benefit Details  
The Blue Cross MedicareRx Gold (PDP) (S5596-035-0)
Formulary Drugs Starting with the Letter B

in CMS PDP Region 32 which includes: CA
Drugs Starting with Letter B

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
BACIIM POWDER FOR INJECTION SOLUTION 50000UNT/VIAL   4 Tier 4 Non-Specialty Injectable Drugs 33%33%None
BACITRACIN 500U/GM EYE OINT   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BACITRACIN INJ 50000UNT   4 Tier 4 Non-Specialty Injectable Drugs 33%33%None
BACITRACIN/POLYMYXIN B OINT 500UNT/10000UNT   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BACLOFEN 10MG TABLET   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BACLOFEN 20MG TABLET   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BACTRIM 400-80MG TABLET   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50None
BACTRIM DS TABLET 800-160   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50None
BACTROBAN 2% CREAM   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50None
BACTROBAN 2% OINTMENT   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BACTROBAN NASAL 2% OINTMENT   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50None
BALACET 325 TABLET   1 Tier 1 Preferred Generic Drugs $7.00$10.50Q:360
/30Days
BALSALAZIDE DISODIUM 750MG CAPSULE (280 CT)   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BALZIVA 0.4-0.035 TABLET   1 Tier 1 Preferred Generic Drugs $7.00$10.50Q:28
/28Days
BANZEL TABLET   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50None
BANZEL TABLET   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50None
BARACLUDE 0.05MG/ML SOLUTION   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50None
BARACLUDE 0.5MG TABLET   5 Tier 5 Specialty Drugs 33%N/ANone
BARACLUDE 1MG TABLET   5 Tier 5 Specialty Drugs 33%N/ANone
BECONASE AQ 0.042% SPRAY   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50Q:50
/30Days
BENAZEPRIL HCL 10MG TABLET   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BENAZEPRIL HCL 20MG TABLET (100 CT)   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BENAZEPRIL HCL 40MG TABLET   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BENAZEPRIL HCL 5MG TABLET   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BENAZEPRIL HCL-HCTZ TABLET 10-12.5MG (100 CT)   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BENAZEPRIL HCL-HCTZ TABLET 20-12.5MG (100 CT)   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BENAZEPRIL HCL-HCTZ TABLET 20-25MG (100 CT)   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BENAZEPRIL HCL-HCTZ TABLET 5-6.25MG (100 CT)   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BENICAR 20MG TABLET   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50None
BENICAR 40MG TABLET   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50None
BENICAR 5MG TABLET   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50None
BENICAR HCT 20-12.5MG TABLET   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BENICAR HCT 40-25MG TABLET   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50None
BENICAR HCT TABLET 12.5-40MG (30 CT)   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50None
BENTYL 10MG CAPSULE   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50None
BENTYL 10MG/5ML SYRUP   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50None
BENTYL 20MG TABLET   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50None
BENTYL INJECTION 20MG/2ML AMP   4 Tier 4 Non-Specialty Injectable Drugs 33%33%None
BENZACLIN CARE KIT 50;10MG;MG 50 GM PUMP W/VISCONTOUR PKGCOM   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50None
BENZAMYCIN GEL   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50Q:47
/30Days
BENZTROPINE MES 0.5MG TABLET   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BENZTROPINE MES TABLET 1MG (1000 CT)   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BENZTROPINE MES TABLET 2MG (1000 CT)   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BETA-VAL 0.1% CREAM   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BETA-VAL 0.1% LOTION   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BETAGAN 0.25% EYE DROPS   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50Q:30
/30Days
BETAGAN 0.5% EYE DROPS   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50Q:30
/30Days
BETAMETHASONE DIPROPIONATE 0.05% CREAM   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BETAMETHASONE DIPROPIONATE 0.05% GEL   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BETAMETHASONE DIPROPIONATE 0.05% GEL   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BETAMETHASONE DIPROPIONATE 0.05% OINT   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BETAMETHASONE DIPROPIONATE LOTION 60ML   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BETAMETHASONE DP 0.05% CREAM   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BETAMETHASONE DP 0.05% OINTMENT   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BETAMETHASONE VA 0.1% CREAM   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BETAMETHASONE VA 0.1% LOTION   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BETAMETHASONE VA 0.1% OINTMENT   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BETAPACE 120MG TABLET   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50None
BETAPACE 160MG TABLET   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50None
BETAPACE 240MG TABLET   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50None
BETAPACE AF 80MG TABLET   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50None
BETASERON KIT 0.3MG/VIAL 14 TRAY BOX PKGCOM   5 Tier 5 Specialty Drugs 33%N/AP
BETAXOLOL HCL 0.5% EYE DROP   1 Tier 1 Preferred Generic Drugs $7.00$10.50Q:30
/30Days
BETAXOLOL TABLETS 10MG 100 BOT   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BETAXOLOL TABLETS 20MG 100 BOT   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BETHANECHOL CHLORIDE 10MG TABLET (100 CT)   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BETHANECHOL CHLORIDE 25MG TABLET (100 CT)   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BETHANECHOL CHLORIDE 50MG TABLET (100 CT)   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BETHANECHOL CHLORIDE 5MG TABLET   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BETIMOL 0.5% EYE DROPS   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50None
BETIMOL SOLUTION 2.5MG 5 ML BOT   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50None
BETOPTIC S OPHTHALMIC SUSPENSION 0.25% 10 ML BOT   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50Q:30
/30Days
BIAXIN 125MG/5ML SUSPENSION   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50Q:200
/1Days
BIAXIN 250MG TABLET   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50Q:42
/1Days
BIAXIN 250MG/5ML SUSPENSION   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50Q:100
/1Days
BIAXIN 500MG TABLET   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50Q:28
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BIAXIN XL 500MG TABLET 56 BOX   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50Q:28
/1Days
BIAXIN XL 500MG TABLET SA   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50Q:28
/1Days
BICALUTAMIDE TABLETS 50MG 100 BOT   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BICILL LA PFS 600MU 1ML PED   4 Tier 4 Non-Specialty Injectable Drugs 33%33%None
BICILLIN C-R 1.2MM UNITS SYR 2ML x 10   4 Tier 4 Non-Specialty Injectable Drugs 33%33%None
BICILLIN C-R 900/300 SYRINGE 2ML x 10   4 Tier 4 Non-Specialty Injectable Drugs 33%33%None
BICILLIN LA PFS 1200MU 2ML   4 Tier 4 Non-Specialty Injectable Drugs 33%33%None
BICILLIN LA. 600000UNIT/ML 1ML   4 Tier 4 Non-Specialty Injectable Drugs 33%33%None
BICNU INJECTION 100MG/VIL   4 Tier 4 Non-Specialty Injectable Drugs 33%33%P
BIDIL TABLET 20MG/37.5MG   2 Tier 2 Preferred Brand Certain Generic Drugs $43.00$107.50None
BILTRICIDE 600MG TABLET   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BISOPROLOL FUMARATE 10MG TABLET (100 CT)   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BISOPROLOL FUMARATE 5MG TABLET (100 CT)   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BISOPROLOL FUMARATE-HCTZ TABLET 10-6.25MG (500 CT)   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BISOPROLOL FUMARATE-HCTZ TABLET 2.5-6.25MG (100 CT)   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BISOPROLOL FUMARATE-HCTZ TABLET 5-6.25MG (100 CT)   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BLEOMYCIN SULFATE 30UNITS VIA   4 Tier 4 Non-Specialty Injectable Drugs 33%33%P
BLEPH-10 10% EYE DROPS   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50Q:30
/30Days
BLEPHAMIDE 0.2% EYE DROPS   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50Q:20
/30Days
BLEPHAMIDE 10-0.2% EYE OINT   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50None
BONIVA 150MG TABLET   2 Tier 2 Preferred Brand Certain Generic Drugs $43.00$107.50Q:1
/28Days
BONIVA 2.5MG TABLET   2 Tier 2 Preferred Brand Certain Generic Drugs $43.00$107.50Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BONIVA 3MG/3ML SYRINGE   4 Tier 4 Non-Specialty Injectable Drugs 33%33%None
BOOSTRIX INJECTION SUSPENSION 2.5UNT-5ML 5 X .5ML SYR   2 Tier 2 Preferred Brand Certain Generic Drugs $43.00$107.50None
BOROFAIR SOL 2% OTIC   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BOTOX 100UNITS VIAL   4 Tier 4 Non-Specialty Injectable Drugs 33%33%P
BRETHINE 1MG/ML VIAL   4 Tier 4 Non-Specialty Injectable Drugs 33%33%None
BRETHINE 2.5MG TABLET   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50None
BRETHINE 5MG TABLET   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50None
BREVICON TABLET 0.5/35   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50Q:28
/28Days
BRIMONIDINE TARTRATE OPHTHALMIC SOLUTION 0.2% 10ML BOTPL   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BROMOCRIPTINE MESYLATE 2.5MG TABLET   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BROMOCRIPTINE MESYLATE 5MG CAPSULE   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BROVANA 15MCG/2ML VIAL NEBULIZER   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50P Q:120
/30Days
BUDEPRION SR 100MG TABLET SA   1 Tier 1 Preferred Generic Drugs $7.00$10.50Q:60
/30Days
BUDEPRION SR 150MG TABLET SA   1 Tier 1 Preferred Generic Drugs $7.00$10.50Q:60
/30Days
BUDEPRION XL 300MG TABLET SR 24HR   1 Tier 1 Preferred Generic Drugs $7.00$10.50Q:30
/30Days
BUDEPRION XL TABLETS 150MG 500 TABLETS BOT   1 Tier 1 Preferred Generic Drugs $7.00$10.50Q:90
/30Days
BUMETANIDE 0.25MG/ML VIAL   4 Tier 4 Non-Specialty Injectable Drugs 33%33%None
BUMETANIDE 0.5MG TABLET USP (500 CT)   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BUMETANIDE 1MG TABLET USP (500 CT)   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BUMETANIDE 2MG TABLET USP (500 CT)   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BUMEX 0.5MG TABLET   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50None
BUMEX 2MG TABLET   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BUPHENYL 500MG TABLET   5 Tier 5 Specialty Drugs 33%N/ANone
BUPHENYL POWDER   5 Tier 5 Specialty Drugs 33%N/ANone
BUPRENEX 0.3MG/ML AMPUL   4 Tier 4 Non-Specialty Injectable Drugs 33%33%None
BUPRENORPHINE 0.3MG/ML SYRN   4 Tier 4 Non-Specialty Injectable Drugs 33%33%None
BUPROBAN ER TABLET   1 Tier 1 Preferred Generic Drugs $7.00$10.50Q:60
/30Days
BUPROPION HCL 100MG ER TABLET (60 CT)   1 Tier 1 Preferred Generic Drugs $7.00$10.50Q:60
/30Days
BUPROPION HCL 75MG TABLET   1 Tier 1 Preferred Generic Drugs $7.00$10.50Q:120
/30Days
BUPROPION HCL SR 200MG TABLET SA   1 Tier 1 Preferred Generic Drugs $7.00$10.50Q:60
/30Days
BUPROPION HCL TABLET 100MG   1 Tier 1 Preferred Generic Drugs $7.00$10.50Q:120
/30Days
BUPROPION HCL TABLET SUSTAINED RELEASE   1 Tier 1 Preferred Generic Drugs $7.00$10.50Q:60
/30Days
BUSPAR 15MG TABLET   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BUSPAR 30MG DIVIDOSE TABLET   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50None
BUSPAR TABLETS 10MG 100 BOT   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50None
BUSPAR TABLETS 5MG 100 BOT   3 Tier 3 Non-Preferred Brand Certain Generic Drugs $85.00$212.50None
BUSPIRONE HCL 10MG TABLET   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BUSPIRONE HCL 15MG TABLET (180 CT)   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BUSPIRONE HCL 30MG TABLET (60 CT)   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BUSPIRONE HCL 5MG TABLET   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BUSPIRONE HCL 7.5MG TABLET   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BUTALBITAL/CAFF/APAP/COD CP   1 Tier 1 Preferred Generic Drugs $7.00$10.50Q:180
/30Days
BUTORPHANOL 10MG/ML SPRAY   1 Tier 1 Preferred Generic Drugs $7.00$10.50None
BUTORPHANOL TARTRATE INJECTION 1MG 10 X 1ML VIAL   4 Tier 4 Non-Specialty Injectable Drugs 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BUTORPHANOL TARTRATE INJECTION 2MG 10 X 1ML VIAL   4 Tier 4 Non-Specialty Injectable Drugs 33%33%None
BYETTA 10MCG/0.04ML PEN INJ   2 Tier 2 Preferred Brand Certain Generic Drugs $43.00$107.50Q:3
/30Days

Chart Legend:

Below are a few notes to help you understand the above 2010 Medicare Part D Blue Cross MedicareRx Gold (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
  • 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 PDP-Compare.com and MA-Compare.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.
  • 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.