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CVS Caremark Complete (PDP) (S5601-103-0)
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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
CVS Caremark Complete (PDP) (S5601-103-0)
Benefit Details  
The CVS Caremark Complete (PDP) (S5601-103-0)
Formulary Drugs Starting with the Letter L

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

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
LABETALOL HCL 100MG TABLET   2 Generic Tier $7.50$19.00None
LABETALOL HCL 200MG TABLET   2 Generic Tier $7.50$19.00None
LABETALOL HCL 300MG TABLET   2 Generic Tier $7.50$19.00None
LABETALOL HCL 5MG/20ML VIAL   2 Generic Tier $7.50$19.00None
LACLOTION 12% LOTION   2 Generic Tier $7.50$19.00None
LACRISERT OPTHALMIC INSERT 5MG 60 BLPK   3 Preferred Brand Tier $39.00$98.00None
LACTATED RINGERS INJECTION   2 Generic Tier $7.50$19.00None
LACTATED RINGERS IRRIGATION 20-30-600MG 3000ML BAG   2 Generic Tier $7.50$19.00None
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT   2 Generic Tier $7.50$19.00None
LAMOTRIGINE 150MG TABLET (60 CT)   2 Generic Tier $7.50$19.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LAMOTRIGINE 200MG TABLET (60 CT)   2 Generic Tier $7.50$19.00None
LAMOTRIGINE 25MG TABLET (100 CT)   2 Generic Tier $7.50$19.00None
LAMOTRIGINE 25MG TABLET DISPERSIBLE   2 Generic Tier $7.50$19.00None
LAMOTRIGINE 5MG TABLET DISPERSIBLE   2 Generic Tier $7.50$19.00None
LAMOTRIGINE TABLET 100MG (100 CT)   2 Generic Tier $7.50$19.00None
LANOXIN 0.125MG TABLET   3 Preferred Brand Tier $39.00$98.00None
LANOXIN 0.25MG TABLET   3 Preferred Brand Tier $39.00$98.00None
LANREOTIDE INJECTION 30MG   5 Specialty Tier 33%N/AP
LANTUS 100U/ML VIAL   3 Preferred Brand Tier $39.00$98.00None
LANTUS INJECTION   3 Preferred Brand Tier $39.00$98.00None
LEENA 7-9-5 TABLET   2 Generic Tier $7.50$19.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEFLUNOMIDE 10MG TABLET (500 CT)   2 Generic Tier $7.50$19.00None
LEFLUNOMIDE 20MG TABLET (500 CT)   2 Generic Tier $7.50$19.00None
LESCOL 20MG CAPSULE   4 Non-Preferred Brand Tier $98.00$270.00None
LESCOL 40MG CAPSULE   4 Non-Preferred Brand Tier $98.00$270.00None
LESCOL XL 80MG TABLET SA   4 Non-Preferred Brand Tier $98.00$270.00None
LESSINA 0.1-0.02 TABLET   2 Generic Tier $7.50$19.00None
LETAIRIS 10MG TABLET   5 Specialty Tier 33%N/AP
LETAIRIS 5MG TABLET   5 Specialty Tier 33%N/AP
LEUCOVORIN CALCIUM 100MG VL   2 Generic Tier $7.50$19.00None
LEUCOVORIN CALCIUM 10MG TABLET   2 Generic Tier $7.50$19.00None
LEUCOVORIN CALCIUM 15MG TABLET   2 Generic Tier $7.50$19.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEUCOVORIN CALCIUM 25MG TABLET   2 Generic Tier $7.50$19.00None
LEUCOVORIN CALCIUM 350MG VL   2 Generic Tier $7.50$19.00None
LEUCOVORIN CALCIUM 5MG TABLET   2 Generic Tier $7.50$19.00None
LEUKERAN 2MG TABLET   3 Preferred Brand Tier $39.00$98.00None
LEUPROLIDE ACETATE INJECTION 14 DAY PATIENT ADMINISTRATION KIT 1-.7 1 X 2.8ML PKGCOM   2 Generic Tier $7.50$19.00None
LEVAQUIN 250MG TABLET   3 Preferred Brand Tier $39.00$98.00None
LEVAQUIN 25MG/ML SOLUTION   3 Preferred Brand Tier $39.00$98.00None
LEVAQUIN 500MG TABLET   3 Preferred Brand Tier $39.00$98.00None
LEVAQUIN 750MG TABLET   3 Preferred Brand Tier $39.00$98.00None
LEVAQUIN IV 25MG/ML VIAL   3 Preferred Brand Tier $39.00$98.00None
LEVAQUIN/D5W INJ 250/50ML   3 Preferred Brand Tier $39.00$98.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEVEMIR 100UNITS/ML VIAL   3 Preferred Brand Tier $39.00$98.00None
LEVEMIR FLEXPEN 100UNITS/ML   3 Preferred Brand Tier $39.00$98.00None
LEVETIRACETAM 100 MG/ML SOLN 100MG/ML 16 FL OZ BOT   2 Generic Tier $7.50$19.00None
LEVETIRACETAM 500 MG TABLET 120 BOT   2 Generic Tier $7.50$19.00None
LEVETIRACETAM TABLETS 1000MG 60 BOT   2 Generic Tier $7.50$19.00None
LEVETIRACETAM TABLETS 250MG 500 BOT   2 Generic Tier $7.50$19.00None
LEVETIRACETAM TABLETS 750MG 500 BOT   2 Generic Tier $7.50$19.00None
LEVOBUNOLOL 0.5% EYE DROPS   2 Generic Tier $7.50$19.00None
LEVOBUNOLOL HCL OPHTHALMIC SOLUTION 0.25% 10ML BOT   2 Generic Tier $7.50$19.00None
LEVOCARNITINE 100MG/ML SOLUTION ORAL   2 Generic Tier $7.50$19.00None
LEVOCARNITINE 200MG/ML VIAL   2 Generic Tier $7.50$19.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEVOCARNITINE TABLET 330MG 90 BLPK   2 Generic Tier $7.50$19.00None
LEVORA-28 TABLET 0.15/30   2 Generic Tier $7.50$19.00None
LEVORPHANOL 2MG TABLET   2 Generic Tier $7.50$19.00None
LEVOTHROID 100MCG TABLET   2 Generic Tier $7.50$19.00None
LEVOTHROID 112MCG TABLET   2 Generic Tier $7.50$19.00None
LEVOTHROID 125MCG TABLET   2 Generic Tier $7.50$19.00None
LEVOTHROID 137MCG TABLET   2 Generic Tier $7.50$19.00None
LEVOTHROID 150MCG TABLET   2 Generic Tier $7.50$19.00None
LEVOTHROID 175MCG TABLET   2 Generic Tier $7.50$19.00None
LEVOTHROID 200MCG TABLET   2 Generic Tier $7.50$19.00None
LEVOTHROID 25MCG TABLET   2 Generic Tier $7.50$19.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEVOTHROID 300MCG TABLET   2 Generic Tier $7.50$19.00None
LEVOTHROID 50MCG TABLET   2 Generic Tier $7.50$19.00None
LEVOTHROID 75MCG TABLET   2 Generic Tier $7.50$19.00None
LEVOTHROID 88MCG TABLET   2 Generic Tier $7.50$19.00None
LEVOTHYROXINE SODIUM .075MG TABLET (1000 CT)   2 Generic Tier $7.50$19.00None
LEVOTHYROXINE SODIUM .150MG TABLET (100 CT)   2 Generic Tier $7.50$19.00None
LEVOTHYROXINE SODIUM 100MCG TABLET   2 Generic Tier $7.50$19.00None
LEVOTHYROXINE SODIUM 112MCG TABLET   2 Generic Tier $7.50$19.00None
LEVOTHYROXINE SODIUM 125MCG TABLET   2 Generic Tier $7.50$19.00None
LEVOTHYROXINE SODIUM 137MCG TABLET   2 Generic Tier $7.50$19.00None
LEVOTHYROXINE SODIUM 175MCG TABLET   2 Generic Tier $7.50$19.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEVOTHYROXINE SODIUM 200MCG TABLET   2 Generic Tier $7.50$19.00None
LEVOTHYROXINE SODIUM 25MCG TABLET   2 Generic Tier $7.50$19.00None
LEVOTHYROXINE SODIUM 300MCG TABLET   2 Generic Tier $7.50$19.00None
LEVOTHYROXINE SODIUM 50MCG TABLET   2 Generic Tier $7.50$19.00None
LEVOTHYROXINE SODIUM 88MCG TABLET   2 Generic Tier $7.50$19.00None
LEVOXYL 100MCG TABLET (1000 CT)   2 Generic Tier $7.50$19.00None
LEVOXYL 112MCG TABLET (1000 CT)   2 Generic Tier $7.50$19.00None
LEVOXYL 125MCG TABLET (1000 CT)   2 Generic Tier $7.50$19.00None
LEVOXYL 137MCG TABLET (1000 CT)   2 Generic Tier $7.50$19.00None
LEVOXYL 150MCG TABLET (1000 CT)   2 Generic Tier $7.50$19.00None
LEVOXYL 175MCG TABLET (1000 CT)   2 Generic Tier $7.50$19.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEVOXYL 200MCG TABLET (1000 CT)   2 Generic Tier $7.50$19.00None
LEVOXYL 25MCG TABLET (1000 CT)   2 Generic Tier $7.50$19.00None
LEVOXYL 50MCG TABLET (1000 CT)   2 Generic Tier $7.50$19.00None
LEVOXYL 75MCG TABLET (1000 CT)   2 Generic Tier $7.50$19.00None
LEVOXYL 88MCG TABLET (1000 CT)   2 Generic Tier $7.50$19.00None
LEXAPRO 10MG TABLET   3 Preferred Brand Tier $39.00$98.00None
LEXAPRO 20MG TABLET   3 Preferred Brand Tier $39.00$98.00None
LEXAPRO 5MG TABLET   3 Preferred Brand Tier $39.00$98.00None
LEXAPRO 5MG/5ML SOLUTION   3 Preferred Brand Tier $39.00$98.00None
LEXIVA 50MG/ML SUSPENSION ORAL   3 Preferred Brand Tier $39.00$98.00None
LEXIVA 700MG TABLET   3 Preferred Brand Tier $39.00$98.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LIALDA 1.2G TABLET DELAYED RELEASE   3 Preferred Brand Tier $39.00$98.00None
LIDOCAINE 5% OINTMENT   2 Generic Tier $7.50$19.00None
LIDOCAINE HCL 0.5% VIAL   2 Generic Tier $7.50$19.00None
LIDOCAINE HCL 1% VIAL   2 Generic Tier $7.50$19.00None
LIDOCAINE HCL 2% JELLY 30ML TUBE   2 Generic Tier $7.50$19.00None
LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT   2 Generic Tier $7.50$19.00None
LIDOCAINE HYDROCHLORIDE ORAL TOPICAL SOLUTION 20MG 100 ML BOT   2 Generic Tier $7.50$19.00None
LIDOCAINE-PRILOCAINE 2.5%-2.5% CREAM   2 Generic Tier $7.50$19.00None
LIDODERM 5% PATCH   3 Preferred Brand Tier $39.00$98.00P
LINDANE 1% LOTION   2 Generic Tier $7.50$19.00None
LINDANE SHAMPOO 1MG 2 FLO BOT   2 Generic Tier $7.50$19.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LIOTHYRONINE SODIUM INJECTION 10MCG   2 Generic Tier $7.50$19.00None
LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT   2 Generic Tier $7.50$19.00None
LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT   2 Generic Tier $7.50$19.00None
LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT   2 Generic Tier $7.50$19.00None
LIPITOR 10MG TABLET   3 Preferred Brand Tier $39.00$98.00None
LIPITOR 20MG TABLET (5000 CT)   3 Preferred Brand Tier $39.00$98.00None
LIPITOR 40MG TABLET (500 CT)   3 Preferred Brand Tier $39.00$98.00None
LIPITOR 80MG TABLET   3 Preferred Brand Tier $39.00$98.00None
LIPRAM 4500 CAPSULE EC   3 Preferred Brand Tier $39.00$98.00None
LIPRAM-PN10 CAPSULE EC   3 Preferred Brand Tier $39.00$98.00None
LIPRAM-PN16 CAPSULE EC   3 Preferred Brand Tier $39.00$98.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LIPRAM-PN20 CAPSULE EC   3 Preferred Brand Tier $39.00$98.00None
LIPRAM-UL12 CAPSULE EC   3 Preferred Brand Tier $39.00$98.00None
LIPRAM-UL18 CAPSULE EC   3 Preferred Brand Tier $39.00$98.00None
LIPRAM-UL20 CAPSULE EC   3 Preferred Brand Tier $39.00$98.00None
LISINOPRIL 10MG TABLET (100 CT)   2 Generic Tier $7.50$19.00None
LISINOPRIL 2.5MG TABLET   2 Generic Tier $7.50$19.00None
LISINOPRIL 20MG TABLET   2 Generic Tier $7.50$19.00None
LISINOPRIL 30MG TABLET (100 CT)   2 Generic Tier $7.50$19.00None
LISINOPRIL 40MG TABLET (500 CT)   2 Generic Tier $7.50$19.00None
LISINOPRIL 5MG TABLET   2 Generic Tier $7.50$19.00None
LISINOPRIL-HCTZ 10/12.5 TABLET   2 Generic Tier $7.50$19.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LISINOPRIL-HCTZ 20-25MG TABLET (100 CT)   2 Generic Tier $7.50$19.00None
LISINOPRIL-HCTZ 20/12.5 TABLET   2 Generic Tier $7.50$19.00None
LITHIUM CARBONATE 150MG CAPSULE   2 Generic Tier $7.50$19.00None
LITHIUM CARBONATE 300MG CAPSULE (100 CT)   2 Generic Tier $7.50$19.00None
LITHIUM CARBONATE 300MG TABLET   2 Generic Tier $7.50$19.00None
LITHIUM CARBONATE 450MG TABLET SA   2 Generic Tier $7.50$19.00None
LITHIUM CARBONATE 600MG CAP   2 Generic Tier $7.50$19.00None
LITHIUM CARBONATE ER TABLET 300MG (100 CT)   2 Generic Tier $7.50$19.00None
LITHIUM CIT 8MEQ/5ML SYRUP   2 Generic Tier $7.50$19.00None
LOCOID LIPOCREAM CREAM 0.1% 15 GM TUBE   4 Non-Preferred Brand Tier $98.00$270.00None
LOKARA 0.05% LOTION   2 Generic Tier $7.50$19.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LONOX 2.5MG TABLET   2 Generic Tier $7.50$19.00None
LOPERAMIDE HCL 2MG CAPSULE   1 Value Generic Tier $2.50$5.00None
LOPROX 1% SHAMPOO   3 Preferred Brand Tier $39.00$98.00None
LOTEMAX 0.5% EYE DROPS   4 Non-Preferred Brand Tier $98.00$270.00None
LOTREL 10/40MG CAPSULE   3 Preferred Brand Tier $39.00$98.00None
LOTREL 5/40MG CAPSULE   3 Preferred Brand Tier $39.00$98.00None
LOTRONEX TABLETS .5MG 30 BOTPL   3 Preferred Brand Tier $39.00$98.00P
LOTRONEX TABLETS 1MG 30 BOTPL   3 Preferred Brand Tier $39.00$98.00P
LOVASTATIN 10MG TABLET (100 CT)   2 Generic Tier $7.50$19.00None
LOVASTATIN 20MG TABLET (1000 CT)   2 Generic Tier $7.50$19.00None
LOVASTATIN 40MG TABLET (100 CT)   2 Generic Tier $7.50$19.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LOVENOX 100MG PREFILLED SYR   3 Preferred Brand Tier $39.00$98.00None
LOVENOX 120MG PREFILLED SYR   3 Preferred Brand Tier $39.00$98.00None
LOVENOX 150MG PREFILLED SYR   3 Preferred Brand Tier $39.00$98.00None
LOVENOX 300MG VIAL   3 Preferred Brand Tier $39.00$98.00None
LOVENOX 30MG PREFILLED SYRN   3 Preferred Brand Tier $39.00$98.00None
LOVENOX 40MG PREFILLED SYRN   3 Preferred Brand Tier $39.00$98.00None
LOVENOX 60MG PREFILLED SYRN   3 Preferred Brand Tier $39.00$98.00None
LOVENOX 80MG PREFILLED SYRN   3 Preferred Brand Tier $39.00$98.00None
LOW-OGESTREL-28 TABLET   2 Generic Tier $7.50$19.00None
LOXAPINE 25MG CAPSULE (100 CT)   2 Generic Tier $7.50$19.00None
LOXAPINE CAPSULES 10MG 100 BOT   2 Generic Tier $7.50$19.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LOXAPINE CAPSULES 50MG 100 BOT   2 Generic Tier $7.50$19.00None
LOXAPINE CAPSULES 5MG 100 BOT   2 Generic Tier $7.50$19.00None
LUMIGAN 0.03% EYE DROPS   3 Preferred Brand Tier $39.00$98.00None
LUNESTA 2MG TABLET   4 Non-Preferred Brand Tier $98.00$270.00Q:180
/365Days
LUNESTA 3MG TABLET   4 Non-Preferred Brand Tier $98.00$270.00Q:180
/365Days
LUNESTA TABLETS 1MG 30 BOT   4 Non-Preferred Brand Tier $98.00$270.00Q:180
/365Days
LUPRON DEPOT 3.75MG KIT   3 Preferred Brand Tier $39.00$98.00P
LUPRON DEPOT 7.5MG KIT   5 Specialty Tier 33%N/AP
LUPRON DEPOT-3 MONTH KIT   3 Preferred Brand Tier $39.00$98.00P
LUPRON DEPOT-3 MONTH KIT   5 Specialty Tier 33%N/AP
LUPRON DEPOT-4 MONTH KIT   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LUPRON DEPOT-PED 11.25MG KT   5 Specialty Tier 33%N/AP
LUPRON DEPOT-PED 15MG KIT   5 Specialty Tier 33%N/AP
LUTERA 0.1-0.02 TABLET   2 Generic Tier $7.50$19.00None
LUXIQ 0.12% FOAM   4 Non-Preferred Brand Tier $98.00$270.00None
LYRICA 100MG CAPSULE   3 Preferred Brand Tier $39.00$98.00Q:120
/25Days
LYRICA 150MG CAPSULE   3 Preferred Brand Tier $39.00$98.00Q:120
/25Days
LYRICA 200MG CAPSULE   3 Preferred Brand Tier $39.00$98.00Q:120
/25Days
LYRICA 225MG CAPSULE   3 Preferred Brand Tier $39.00$98.00Q:120
/25Days
LYRICA 25MG CAPSULE   3 Preferred Brand Tier $39.00$98.00Q:120
/25Days
LYRICA 300MG CAPSULE   3 Preferred Brand Tier $39.00$98.00Q:60
/25Days
LYRICA 50MG CAPSULE   3 Preferred Brand Tier $39.00$98.00Q:120
/25Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LYRICA 75MG CAPSULE   3 Preferred Brand Tier $39.00$98.00Q:120
/25Days
LYSODREN 500MG TABLET   3 Preferred Brand Tier $39.00$98.00None

Chart Legend:

Below are a few notes to help you understand the above 2010 Medicare Part D CVS Caremark Complete (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.