Q1Medicare.com 2010 Medicare Part D or Medicare Advantage Plan Formulary Browser

2010 Medicare Part D Plan Formulary Information
MedicareBlue Rx Enhanced (PDP) (S5743-003-0) Benefit Details
The MedicareBlue Rx Enhanced (PDP) (S5743-003-0) Formulary Drugs Starting with the Letter L in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY
Drugs Starting with Letter L Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter L Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LABETALOL HCL 100MG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
LABETALOL HCL 200MG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
LABETALOL HCL 300MG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
LACLOTION 12% LOTION	1	Level 1: Covered Generics	$4.00	$8.00	None
LACRISERT OPTHALMIC INSERT 5MG 60 BLPK	3	Level 3: Covered Brand	50%	50%	None
LACTATED RINGERS INJECTION	1	Level 1: Covered Generics	$4.00	$8.00	None
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT	1	Level 1: Covered Generics	$4.00	$8.00	None
LAMICTAL 25MG TABLET STARTER KIT	3	Level 3: Covered Brand	50%	50%	S
LAMICTAL ODT 100MG TABLET 30 EA	3	Level 3: Covered Brand	50%	50%	S
LAMICTAL ODT 200MG TABLET 30 EA	3	Level 3: Covered Brand	50%	50%	S
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LAMICTAL ODT 25MG TABLET 30 EA	3	Level 3: Covered Brand	50%	50%	S
LAMICTAL ODT 50MG TABLET 30 EA	3	Level 3: Covered Brand	50%	50%	S
LAMICTAL TABLET STARTER KIT	3	Level 3: Covered Brand	50%	50%	S
LAMICTAL TABLET STARTER KIT	3	Level 3: Covered Brand	50%	50%	S
LAMISIL 1% SOLUTION	2	Level 2: Covered Preferred Brand	$35.00	$70.00	None
LAMOTRIGINE 150MG TABLET (60 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
LAMOTRIGINE 200MG TABLET (60 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
LAMOTRIGINE 25MG TABLET (100 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
LAMOTRIGINE 25MG TABLET DISPERSIBLE	1	Level 1: Covered Generics	$4.00	$8.00	None
LAMOTRIGINE 5MG TABLET DISPERSIBLE	1	Level 1: Covered Generics	$4.00	$8.00	None
LAMOTRIGINE TABLET 100MG (100 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LANTUS 100U/ML VIAL	2	Level 2: Covered Preferred Brand	$35.00	$70.00	None
LANTUS INJECTION	2	Level 2: Covered Preferred Brand	$35.00	$70.00	None
LEENA 7-9-5 TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
LEFLUNOMIDE 10MG TABLET (500 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
LEFLUNOMIDE 20MG TABLET (500 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
LESSINA 0.1-0.02 TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
LEUCOVORIN CALCIUM 100MG VL	1	Level 1: Covered Generics	$4.00	$8.00	None
LEUCOVORIN CALCIUM 10MG TABLET	3	Level 3: Covered Brand	50%	50%	None
LEUCOVORIN CALCIUM 15MG TABLET	3	Level 3: Covered Brand	50%	50%	None
LEUCOVORIN CALCIUM 25MG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
LEUCOVORIN CALCIUM 350MG VL	1	Level 1: Covered Generics	$4.00	$8.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LEUCOVORIN CALCIUM 5MG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
LEUKERAN 2MG TABLET	2	Level 2: Covered Preferred Brand	$35.00	$70.00	None
LEUKINE 250MCG VIAL	4	Covered Specialty	28%	28%	None
LEUKINE LIQUID INJECTION 500MCG/VIAL 500 MCG X 5 VILMD CRTN	4	Covered Specialty	28%	28%	None
LEUPROLIDE ACETATE INJECTION 14 DAY PATIENT ADMINISTRATION KIT 1-.7 1 X 2.8ML PKGCOM	1	Level 1: Covered Generics	$4.00	$8.00	None
LEVAQUIN 250MG TABLET	2	Level 2: Covered Preferred Brand	$35.00	$70.00	None
LEVAQUIN 25MG/ML SOLUTION	2	Level 2: Covered Preferred Brand	$35.00	$70.00	None
LEVAQUIN 500MG TABLET	2	Level 2: Covered Preferred Brand	$35.00	$70.00	None
LEVAQUIN 750MG TABLET	2	Level 2: Covered Preferred Brand	$35.00	$70.00	None
LEVAQUIN IV 25MG/ML VIAL	3	Level 3: Covered Brand	50%	50%	None
LEVAQUIN/D5W INJ 250/50ML	3	Level 3: Covered Brand	50%	50%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LEVEMIR 100UNITS/ML VIAL	2	Level 2: Covered Preferred Brand	$35.00	$70.00	None
LEVEMIR FLEXPEN 100UNITS/ML	2	Level 2: Covered Preferred Brand	$35.00	$70.00	None
LEVETIRACETAM 100 MG/ML SOLN 100MG/ML 16 FL OZ BOT	1	Level 1: Covered Generics	$4.00	$8.00	None
LEVETIRACETAM 500 MG TABLET 120 BOT	1	Level 1: Covered Generics	$4.00	$8.00	None
LEVETIRACETAM TABLETS 1000MG 60 BOT	1	Level 1: Covered Generics	$4.00	$8.00	None
LEVETIRACETAM TABLETS 250MG 500 BOT	1	Level 1: Covered Generics	$4.00	$8.00	None
LEVETIRACETAM TABLETS 750MG 500 BOT	1	Level 1: Covered Generics	$4.00	$8.00	None
LEVOBUNOLOL 0.5% EYE DROPS	1	Level 1: Covered Generics	$4.00	$8.00	None
LEVOBUNOLOL HCL OPHTHALMIC SOLUTION 0.25% 10ML BOT	1	Level 1: Covered Generics	$4.00	$8.00	None
LEVOCARNITINE 100MG/ML SOLUTION ORAL	1	Level 1: Covered Generics	$4.00	$8.00	None
LEVOCARNITINE TABLET 330MG 90 BLPK	1	Level 1: Covered Generics	$4.00	$8.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LEVORA-28 TABLET 0.15/30	1	Level 1: Covered Generics	$4.00	$8.00	None
LEVORPHANOL 2MG TABLET	3	Level 3: Covered Brand	50%	50%	None
LEVOTHROID 100MCG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
LEVOTHROID 112MCG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
LEVOTHROID 125MCG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
LEVOTHROID 137MCG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
LEVOTHROID 150MCG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
LEVOTHROID 175MCG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
LEVOTHROID 200MCG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
LEVOTHROID 25MCG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
LEVOTHROID 300MCG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LEVOTHROID 50MCG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
LEVOTHROID 75MCG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
LEVOTHROID 88MCG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
LEVOTHYROXINE SODIUM .075MG TABLET (1000 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
LEVOTHYROXINE SODIUM .150MG TABLET (100 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
LEVOTHYROXINE SODIUM 100MCG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
LEVOTHYROXINE SODIUM 112MCG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
LEVOTHYROXINE SODIUM 125MCG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
LEVOTHYROXINE SODIUM 137MCG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
LEVOTHYROXINE SODIUM 175MCG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
LEVOTHYROXINE SODIUM 200MCG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LEVOTHYROXINE SODIUM 25MCG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
LEVOTHYROXINE SODIUM 300MCG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
LEVOTHYROXINE SODIUM 50MCG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
LEVOTHYROXINE SODIUM 88MCG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
LEVOXYL 100MCG TABLET (1000 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
LEVOXYL 112MCG TABLET (1000 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
LEVOXYL 125MCG TABLET (1000 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
LEVOXYL 137MCG TABLET (1000 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
LEVOXYL 150MCG TABLET (1000 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
LEVOXYL 175MCG TABLET (1000 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
LEVOXYL 200MCG TABLET (1000 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LEVOXYL 25MCG TABLET (1000 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
LEVOXYL 50MCG TABLET (1000 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
LEVOXYL 75MCG TABLET (1000 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
LEVOXYL 88MCG TABLET (1000 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
LEXIVA 50MG/ML SUSPENSION ORAL	2	Level 2: Covered Preferred Brand	$35.00	$70.00	None
LEXIVA 700MG TABLET	2	Level 2: Covered Preferred Brand	$35.00	$70.00	None
LIALDA 1.2G TABLET DELAYED RELEASE	2	Level 2: Covered Preferred Brand	$35.00	$70.00	None
LIDOCAINE 5% OINTMENT	1	Level 1: Covered Generics	$4.00	$8.00	None
LIDOCAINE HCL 0.5% VIAL	1	Level 1: Covered Generics	$4.00	$8.00	None
LIDOCAINE HCL 1% VIAL	1	Level 1: Covered Generics	$4.00	$8.00	None
LIDOCAINE HCL 2% JELLY	1	Level 1: Covered Generics	$4.00	$8.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LIDOCAINE HCL 2% JELLY 30ML TUBE	1	Level 1: Covered Generics	$4.00	$8.00	None
LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT	1	Level 1: Covered Generics	$4.00	$8.00	None
LIDOCAINE HYDROCHLORIDE ORAL TOPICAL SOLUTION 20MG 100 ML BOT	1	Level 1: Covered Generics	$4.00	$8.00	None
LIDOCAINE-PRILOCAINE 2.5%-2.5% CREAM	1	Level 1: Covered Generics	$4.00	$8.00	None
LIDODERM 5% PATCH	2	Level 2: Covered Preferred Brand	$35.00	$70.00	None
LINDANE 1% LOTION	1	Level 1: Covered Generics	$4.00	$8.00	None
LINDANE SHAMPOO 1MG 2 FLO BOT	3	Level 3: Covered Brand	50%	50%	None
LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT	1	Level 1: Covered Generics	$4.00	$8.00	None
LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT	1	Level 1: Covered Generics	$4.00	$8.00	None
LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT	1	Level 1: Covered Generics	$4.00	$8.00	None
LIPITOR 10MG TABLET	2	Level 2: Covered Preferred Brand	$35.00	$70.00	Q:45 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LIPITOR 20MG TABLET (5000 CT)	2	Level 2: Covered Preferred Brand	$35.00	$70.00	Q:45 /30Days
LIPITOR 40MG TABLET (500 CT)	2	Level 2: Covered Preferred Brand	$35.00	$70.00	Q:45 /30Days
LIPITOR 80MG TABLET	2	Level 2: Covered Preferred Brand	$35.00	$70.00	Q:30 /30Days
LISINOPRIL 10MG TABLET (100 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
LISINOPRIL 2.5MG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
LISINOPRIL 20MG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
LISINOPRIL 30MG TABLET (100 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
LISINOPRIL 40MG TABLET (500 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
LISINOPRIL 5MG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
LISINOPRIL-HCTZ 10/12.5 TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
LISINOPRIL-HCTZ 20-25MG TABLET (100 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LISINOPRIL-HCTZ 20/12.5 TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
LITHIUM CARBONATE 150MG CAPSULE	1	Level 1: Covered Generics	$4.00	$8.00	None
LITHIUM CARBONATE 300MG CAPSULE (100 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
LITHIUM CARBONATE 300MG TABLET	3	Level 3: Covered Brand	50%	50%	None
LITHIUM CARBONATE 450MG TABLET SA	1	Level 1: Covered Generics	$4.00	$8.00	None
LITHIUM CARBONATE ER TABLET 300MG (100 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
LITHIUM CIT 8MEQ/5ML SYRUP	1	Level 1: Covered Generics	$4.00	$8.00	None
LOKARA 0.05% LOTION	1	Level 1: Covered Generics	$4.00	$8.00	None
LONOX 2.5MG TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
LOPERAMIDE HCL 2MG CAPSULE	1	Level 1: Covered Generics	$4.00	$8.00	None
LOTEMAX 0.5% EYE DROPS	3	Level 3: Covered Brand	50%	50%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LOTRONEX TABLETS .5MG 30 BOTPL	2	Level 2: Covered Preferred Brand	$35.00	$70.00	None
LOTRONEX TABLETS 1MG 30 BOTPL	2	Level 2: Covered Preferred Brand	$35.00	$70.00	None
LOVASTATIN 10MG TABLET (100 CT)	1	Level 1: Covered Generics	$4.00	$8.00	Q:60 /30Days
LOVASTATIN 20MG TABLET (1000 CT)	1	Level 1: Covered Generics	$4.00	$8.00	Q:60 /30Days
LOVASTATIN 40MG TABLET (100 CT)	1	Level 1: Covered Generics	$4.00	$8.00	Q:60 /30Days
LOVAZA CAPSULES 1GM 120 BOT	2	Level 2: Covered Preferred Brand	$35.00	$70.00	None
LOVENOX 100MG PREFILLED SYR	4	Covered Specialty	28%	28%	Q:30 /90Days
LOVENOX 120MG PREFILLED SYR	4	Covered Specialty	28%	28%	Q:24 /90Days
LOVENOX 150MG PREFILLED SYR	4	Covered Specialty	28%	28%	Q:30 /90Days
LOVENOX 300MG VIAL	4	Covered Specialty	28%	28%	Q:30 /90Days
LOVENOX 30MG PREFILLED SYRN	3	Level 3: Covered Brand	50%	50%	Q:9 /90Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LOVENOX 40MG PREFILLED SYRN	3	Level 3: Covered Brand	50%	50%	Q:12 /90Days
LOVENOX 60MG PREFILLED SYRN	4	Covered Specialty	28%	28%	Q:18 /90Days
LOVENOX 80MG PREFILLED SYRN	4	Covered Specialty	28%	28%	Q:24 /90Days
LOW-OGESTREL-28 TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
LOXAPINE 25MG CAPSULE (100 CT)	1	Level 1: Covered Generics	$4.00	$8.00	None
LOXAPINE CAPSULES 10MG 100 BOT	1	Level 1: Covered Generics	$4.00	$8.00	None
LOXAPINE CAPSULES 50MG 100 BOT	1	Level 1: Covered Generics	$4.00	$8.00	None
LOXAPINE CAPSULES 5MG 100 BOT	1	Level 1: Covered Generics	$4.00	$8.00	None
LUNESTA 2MG TABLET	3	Level 3: Covered Brand	50%	50%	S
LUNESTA 3MG TABLET	3	Level 3: Covered Brand	50%	50%	S
LUNESTA TABLETS 1MG 30 BOT	3	Level 3: Covered Brand	50%	50%	S
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LUPRON DEPOT 3.75MG KIT	3	Level 3: Covered Brand	50%	50%	None
LUPRON DEPOT 7.5MG KIT	4	Covered Specialty	28%	28%	None
LUPRON DEPOT-3 MONTH KIT	3	Level 3: Covered Brand	50%	50%	None
LUPRON DEPOT-3 MONTH KIT	4	Covered Specialty	28%	28%	None
LUPRON DEPOT-4 MONTH KIT	4	Covered Specialty	28%	28%	None
LUPRON DEPOT-PED 11.25MG KT	4	Covered Specialty	28%	28%	None
LUPRON DEPOT-PED 15MG KIT	4	Covered Specialty	28%	28%	None
LUTERA 0.1-0.02 TABLET	1	Level 1: Covered Generics	$4.00	$8.00	None
LYRICA 100MG CAPSULE	3	Level 3: Covered Brand	50%	50%	S
LYRICA 150MG CAPSULE	3	Level 3: Covered Brand	50%	50%	S
LYRICA 200MG CAPSULE	3	Level 3: Covered Brand	50%	50%	S
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LYRICA 225MG CAPSULE	3	Level 3: Covered Brand	50%	50%	S
LYRICA 25MG CAPSULE	3	Level 3: Covered Brand	50%	50%	S
LYRICA 300MG CAPSULE	3	Level 3: Covered Brand	50%	50%	S
LYRICA 50MG CAPSULE	3	Level 3: Covered Brand	50%	50%	S
LYRICA 75MG CAPSULE	3	Level 3: Covered Brand	50%	50%	S
LYSODREN 500MG TABLET	3	Level 3: Covered Brand	50%	50%	None

Chart Legend:

Below are a few notes to help you understand the above 2010 Medicare Part D MedicareBlue Rx Enhanced (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.