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Humana Walmart-Preferred Rx Plan (PDP) (S5884-114-0)
Tier 1 (352)
Tier 2 (1024)
Tier 3 (900)
Tier 4 (1212)

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2011 Medicare Part D Plan Formulary Information
Humana Walmart-Preferred Rx Plan (PDP) (S5884-114-0)
Benefit Details           
The Humana Walmart-Preferred Rx Plan (PDP) (S5884-114-0)
Formulary Drugs Starting with the Letter C

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

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
CABERGOLINE 0.5 MG TABLET   2 Generic $5.00$0.00Q:16
/28Days
CADUET 10MG/10MG TABLET   4 Non-Preferred Brand 35%35%Q:30
/30Days
CADUET 10MG/20MG TABLET   4 Non-Preferred Brand 35%35%Q:30
/30Days
CADUET 10MG/40MG TABLET   4 Non-Preferred Brand 35%35%Q:30
/30Days
CADUET 10MG/80MG TABLET   4 Non-Preferred Brand 35%35%Q:30
/30Days
CADUET 2.5MG/10MG TABLET   4 Non-Preferred Brand 35%35%Q:30
/30Days
CADUET 2.5MG/20MG TABLET   4 Non-Preferred Brand 35%35%Q:30
/30Days
CADUET 2.5MG/40MG TABLET   4 Non-Preferred Brand 35%35%Q:30
/30Days
CADUET 5MG/10MG TABLET   4 Non-Preferred Brand 35%35%Q:30
/30Days
CADUET 5MG/20MG TABLET   4 Non-Preferred Brand 35%35%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CADUET 5MG/40MG TABLET   4 Non-Preferred Brand 35%35%Q:30
/30Days
CADUET 5MG/80MG TABLET   4 Non-Preferred Brand 35%35%Q:30
/30Days
CALAN 120MG TABLET   4 Non-Preferred Brand 35%35%None
CALAN 80MG TABLET   4 Non-Preferred Brand 35%35%None
CALAN SR 120MG CAPLET SA   4 Non-Preferred Brand 35%35%None
CALAN SR 180MG CAPLET SA   4 Non-Preferred Brand 35%35%None
CALAN SR TABLET 240MG (500 CT)   4 Non-Preferred Brand 35%35%None
CALCIPOTRIENE OINTMENT   3 Non-Preferred Generic/Preferred Brand 20%20%None
CALCIPOTRIENE TOPICAL SOLUTION   3 Non-Preferred Generic/Preferred Brand 20%20%Q:60
/30Days
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY   3 Non-Preferred Generic/Preferred Brand 20%20%Q:4
/28Days
CALCITRIOL 0.00025 MG ORAL CAPSULE [ROCALTROL]   4 Non-Preferred Brand 35%35%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CALCITRIOL 0.0005 MG ORAL CAPSULE [ROCALTROL]   4 Non-Preferred Brand 35%35%None
CALCITRIOL 0.001 MG/ML ORAL SOLUTION [ROCALTROL]   4 Non-Preferred Brand 35%35%None
CALCITRIOL 0.25MCG CAPSULE   2 Generic $5.00$0.00None
CALCITRIOL 0.5MCG CAPSULE   2 Generic $5.00$0.00None
CALCITRIOL 1MCG/ML SOLUTION ORAL   2 Generic $5.00$0.00None
CALCITRIOL 2 MCG/ML VIAL   2 Generic $5.00$0.00None
CALCITRIOL INJECTION SOLUTION 1MCG 50 X 01ML AMP   2 Generic $5.00$0.00None
CALCIUM ACETATE CAPSULE 667 MG   2 Generic $5.00$0.00None
CALCIUM CHLORIDE 0.0014 MEQ/ML / POTASSIUM CHLORIDE 0.004 MEQ/ML / SODIUM CHLORIDE 0.103 MEQ/ML / SO   2 Generic $5.00$0.00None
CAMILA 0.35MG TABLET   2 Generic $5.00$0.00None
CAMPATH 30MG/ML VIAL   4 Non-Preferred Brand 35%35%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CANASA RECTAL SUPPOSITORIES 1000MG 30 BOX   4 Non-Preferred Brand 35%35%Q:30
/30Days
CANCIDAS IV 50MG VIAL   4 Non-Preferred Brand 35%35%P
CANCIDAS IV 70MG VIAL   4 Non-Preferred Brand 35%35%P
CAPITAL W/CODEINE ORAL SUSP   3 Non-Preferred Generic/Preferred Brand 20%20%None
CAPREOMYCIN 500 MG/ML INJECTABLE SOLUTION [CAPASTAT]   4 Non-Preferred Brand 35%35%None
CAPTOPRIL 100MG TABLET   1 Preferred Generic $2.00$0.00None
CAPTOPRIL 12.5MG TABLET   1 Preferred Generic $2.00$0.00None
CAPTOPRIL 25MG TABLET   1 Preferred Generic $2.00$0.00None
CAPTOPRIL 50MG TABLET   1 Preferred Generic $2.00$0.00None
CAPTOPRIL/HCTZ 25/15 TABLET   2 Generic $5.00$0.00None
CAPTOPRIL/HCTZ 25/25 TABLET   2 Generic $5.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CAPTOPRIL/HCTZ 50/15 TABLET   2 Generic $5.00$0.00None
CAPTOPRIL/HCTZ 50/25 TABLET   2 Generic $5.00$0.00None
CARAC CRE 0.5%   4 Non-Preferred Brand 35%35%None
CARAFATE SUCRALFATE 1G TABLET ORAL   4 Non-Preferred Brand 35%35%None
CARAFATE SUS 1GM/10ML   4 Non-Preferred Brand 35%35%None
CARBAMAZEPINE EXTENDED RELEASE TABLETS 200MG   2 Generic $5.00$0.00None
CARBAMAZEPINE EXTENDED RELEASE TABLETS 400MG   2 Generic $5.00$0.00None
CARBAMAZEPINE ORAL SUSPENSION 200 MG   2 Generic $5.00$0.00None
CARBAMAZEPINE TABLET CHEWABLE 100MG (100 CT)   2 Generic $5.00$0.00None
CARBAMAZEPINE TABLET USP 200MG (1000 CT)   1 Preferred Generic $2.00$0.00None
CARBATROL 100MG CAPSULE SA   4 Non-Preferred Brand 35%35%Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARBATROL 200MG CAPSULE SA   4 Non-Preferred Brand 35%35%Q:240
/30Days
CARBATROL 300MG CAPSULE SA   4 Non-Preferred Brand 35%35%Q:150
/30Days
CARBIDOPA AND LEVEDOPA ORALLY DISINTEGRATING TABLETS 10;100MG;MG 100 BOT   3 Non-Preferred Generic/Preferred Brand 20%20%None
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;100MG;MG 100 BOT   3 Non-Preferred Generic/Preferred Brand 20%20%None
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;250MG;MG 100 BOT   3 Non-Preferred Generic/Preferred Brand 20%20%None
CARBIDOPA-LEVODOPA 25MG-100MG TABLET SA   3 Non-Preferred Generic/Preferred Brand 20%20%None
CARBIDOPA-LEVODOPA 50MG-200MG TABLET SA   3 Non-Preferred Generic/Preferred Brand 20%20%None
CARBIDOPA/LEVO 10/100 TABLET   3 Non-Preferred Generic/Preferred Brand 20%20%None
CARBIDOPA/LEVO 25/100 TABLET   3 Non-Preferred Generic/Preferred Brand 20%20%None
CARBIDOPA/LEVO 25/250 TABLET   3 Non-Preferred Generic/Preferred Brand 20%20%None
CARBINOXAMINE 4 MG ORAL TABLET   2 Generic $5.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARBINOXAMINE MALEATE SOLUTION 4MG/5ML 16 OZ BOT   2 Generic $5.00$0.00None
CARBOPLATIN INJECTION   3 Non-Preferred Generic/Preferred Brand 20%20%P
CARIMUNE NF 3GM VIAL   4 Non-Preferred Brand 35%35%P
CARISOPRODOL AND ASPIRIN TABLETS USP 325;200MG;MG 100 BOTPL   2 Generic $5.00$0.00None
CARISOPRODOL ASPIRIN AND CODEINE PHOSPHATE TABLETS USP 325;200;16MG;MG;MG 100 BOTPL   3 Non-Preferred Generic/Preferred Brand 20%20%None
CARISOPRODOL TABLET USP 350MG (100 CT)   2 Generic $5.00$0.00None
CARNITOR 1GM/5ML VIAL   3 Non-Preferred Generic/Preferred Brand 20%20%None
CARTEOLOL HCL OPHTHALMIC SOLUTION USP 1% 15ML BOT   2 Generic $5.00$0.00None
CARTIA XT 120MG CAPSULE SA   1 Preferred Generic $2.00$0.00Q:60
/30Days
CARTIA XT 180MG CAPSULE SA   2 Generic $5.00$0.00Q:60
/30Days
CARTIA XT 240MG CAPSULE SA   2 Generic $5.00$0.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARTIA XT 300MG CAPSULE SR 24 HR   2 Generic $5.00$0.00Q:30
/30Days
CARVEDILOL 12.5MG TABLET (100 CT)   1 Preferred Generic $2.00$0.00None
CARVEDILOL 25MG TABLET (500 CT)   1 Preferred Generic $2.00$0.00None
CARVEDILOL 3.125MG TABLET (100 CT)   1 Preferred Generic $2.00$0.00None
CARVEDILOL 6.25MG TABLET (500 CT)   1 Preferred Generic $2.00$0.00None
CASODEX 50MG TABLET   4 Non-Preferred Brand 35%35%Q:30
/30Days
CATAPRES-TTS DIS 0.3/24HR   4 Non-Preferred Brand 35%35%None
CATAPRES-TTS-1 PATCH 2.52.5MG/UNT 1 X 4 CRTN   4 Non-Preferred Brand 35%35%None
CATAPRES-TTS-2 PATCH 52.5MG/UNT 1 X 4 CRTN   4 Non-Preferred Brand 35%35%None
CAYSTON KIT   4 Non-Preferred Brand 35%35%P Q:84
/28Days
CEENU 100MG CAPSULE   4 Non-Preferred Brand 35%35%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEENU 10MG CAPSULE   4 Non-Preferred Brand 35%35%None
CEENU 40MG CAPSULE   4 Non-Preferred Brand 35%35%None
CEFACLOR 250MG/5ML ORAL SUSP   2 Generic $5.00$0.00None
CEFACLOR 375MG/5ML ORAL SUSP   2 Generic $5.00$0.00None
CEFACLOR CAPSULES   2 Generic $5.00$0.00None
CEFACLOR CAPSULES   2 Generic $5.00$0.00None
CEFACLOR ER 500MG TABLET SR 12HR   3 Non-Preferred Generic/Preferred Brand 20%20%None
CEFACLOR POWDER FOR ORAL SUSPENSION USP 125MG 75ML BOT   2 Generic $5.00$0.00None
CEFADROXIL 1G TABLET   2 Generic $5.00$0.00None
CEFADROXIL 500MG CAPSULE   2 Generic $5.00$0.00None
CEFADROXIL 500MG/5ML SUSPENSION RECONSTITUTED ORAL   2 Generic $5.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFADROXIL FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   2 Generic $5.00$0.00None
CEFAZOLIN 1 GM VIAL   3 Non-Preferred Generic/Preferred Brand 20%20%None
CEFAZOLIN 1GM/D5W BAG   3 Non-Preferred Generic/Preferred Brand 20%20%None
CEFAZOLIN 20GM BULK VIAL   3 Non-Preferred Generic/Preferred Brand 20%20%None
CEFAZOLIN FOR INJECTION   3 Non-Preferred Generic/Preferred Brand 20%20%None
CEFDINIR 250MG/5ML SUSPENSION RECONSTITUTED ORAL   3 Non-Preferred Generic/Preferred Brand 20%20%None
CEFDINIR CAPSULES 300MG (60 CT)   3 Non-Preferred Generic/Preferred Brand 20%20%None
CEFDINIR FOR ORAL SUSPENSION 125MG/5ML (100 CT)   3 Non-Preferred Generic/Preferred Brand 20%20%None
CEFEPIME HCL 2 GRAM VIAL   3 Non-Preferred Generic/Preferred Brand 20%20%None
CEFEPIME INJ 1GM 20ML APX 10x1G VIAL   3 Non-Preferred Generic/Preferred Brand 20%20%None
CEFOTAXIME FOR INJECTION   2 Generic $5.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFOTAXIME FOR INJECTION 1GM 50 BOX VIALGL   2 Generic $5.00$0.00None
CEFOTAXIME FOR INJECTION 2GM 25 VIAL   2 Generic $5.00$0.00None
CEFOTAXIME FOR INJECTION 500MG 10 VIAL   2 Generic $5.00$0.00None
CEFOTETAN 10 GM SOLR   3 Non-Preferred Generic/Preferred Brand 20%20%None
CEFOTETAN 1GM VIAL 1EA x 10   3 Non-Preferred Generic/Preferred Brand 20%20%None
CEFOTETAN 2GM VIAL 1EA x 10   3 Non-Preferred Generic/Preferred Brand 20%20%None
CEFOXITIN 180 MG/ML INJECTABLE SOLUTION   3 Non-Preferred Generic/Preferred Brand 20%20%None
CEFOXITIN 95 MG/ML INJECTABLE SOLUTION   3 Non-Preferred Generic/Preferred Brand 20%20%None
CEFOXITIN FOR INJECTION 1 GM/50ML   2 Generic $5.00$0.00None
CEFOXITIN FOR INJECTION 2MG/50ML 50 ML BOT   2 Generic $5.00$0.00None
CEFOXITIN FOR INJECTION SOLUTION   3 Non-Preferred Generic/Preferred Brand 20%20%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFPODOXIME PROXETIL 200MG TABLET   3 Non-Preferred Generic/Preferred Brand 20%20%None
CEFPODOXIME PROXETIL FILM COATED TABLET 100MG (20 CT)   3 Non-Preferred Generic/Preferred Brand 20%20%None
CEFPODOXIME PROXETIL FOR ORAL SUSPENSION 100MG 50ML BOT   3 Non-Preferred Generic/Preferred Brand 20%20%None
CEFPODOXIME PROXETIL FOR ORAL SUSPENSION 50MG 50ML BOT   3 Non-Preferred Generic/Preferred Brand 20%20%None
CEFPROZIL 250MG TABLET (100 CT)   3 Non-Preferred Generic/Preferred Brand 20%20%None
CEFPROZIL 250MG/5ML SUSPENSION RECONSTITUTED ORAL   3 Non-Preferred Generic/Preferred Brand 20%20%None
CEFPROZIL FOR ORAL SUSPENSION 125MG/5ML 75ML BOT   3 Non-Preferred Generic/Preferred Brand 20%20%None
CEFPROZIL TABLETS 500MG 100 BOT   3 Non-Preferred Generic/Preferred Brand 20%20%None
CEFTAZIDIME FOR INJECTION 1GM/VIAL 1 SINGLE VIAL VIAL   2 Generic $5.00$0.00None
CEFTAZIDIME FOR INJECTION 2GM/VIAL 10 X 2 CRTN   2 Generic $5.00$0.00None
CEFTAZIDIME FOR INJECTION 6GM/VIAL 6 X 6 CRTN   2 Generic $5.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFTRIAXONE 10GM VIAL   3 Non-Preferred Generic/Preferred Brand 20%20%None
CEFTRIAXONE FOR INJECTION   3 Non-Preferred Generic/Preferred Brand 20%20%None
CEFTRIAXONE FOR INJECTION   3 Non-Preferred Generic/Preferred Brand 20%20%None
CEFTRIAXONE FOR INJECTION 250MG BOX OF 10 VIALGL   3 Non-Preferred Generic/Preferred Brand 20%20%None
CEFTRIAXONE FOR INJECTION 500MG BOX OF 10 VIALGL   3 Non-Preferred Generic/Preferred Brand 20%20%None
CEFUROXIME 250MG TABLET   2 Generic $5.00$0.00None
CEFUROXIME AXETIL 125MG/5ML SUSPENSION RECONSTITUTED ORAL   2 Generic $5.00$0.00None
CEFUROXIME AXETIL 500MG TABLET (20 CT)   2 Generic $5.00$0.00None
CEFUROXIME FOR INJECTION   3 Non-Preferred Generic/Preferred Brand 20%20%None
CEFUROXIME FOR INJECTION   3 Non-Preferred Generic/Preferred Brand 20%20%None
CEFUROXIME FOR INJECTION   3 Non-Preferred Generic/Preferred Brand 20%20%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFUROXIME FOR INJECTION AND DEXTROSE INJECTION   2 Generic $5.00$0.00None
CEFUROXIME FOR INJECTION AND DEXTROSE INJECTION   2 Generic $5.00$0.00None
CELLCEPT 200MG/ML ORAL SUSP   4 Non-Preferred Brand 35%35%P
CELLCEPT 500MG TABLET   4 Non-Preferred Brand 35%35%P
CELLCEPT CAPSULES 250MG (500 CT)   4 Non-Preferred Brand 35%35%P
CELLCEPT IV INJ 500MG   4 Non-Preferred Brand 35%35%P
CELONTIN 300MG KAPSEAL   4 Non-Preferred Brand 35%35%None
CENESTIN 0.3MG TABLET   3 Non-Preferred Generic/Preferred Brand 20%20%None
CENESTIN 0.45MG TABLET   3 Non-Preferred Generic/Preferred Brand 20%20%None
CENESTIN 0.625MG TABLET   3 Non-Preferred Generic/Preferred Brand 20%20%None
CENESTIN 0.9MG TABLET   3 Non-Preferred Generic/Preferred Brand 20%20%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CENESTIN 1.25MG TABLET   3 Non-Preferred Generic/Preferred Brand 20%20%None
CEPHALEXIN 250MG CAPSULE   1 Preferred Generic $2.00$0.00None
CEPHALEXIN 250MG TABLET   2 Generic $5.00$0.00None
CEPHALEXIN 250MG/5ML ORAL SUSP   1 Preferred Generic $2.00$0.00None
CEPHALEXIN 500MG TABLET   2 Generic $5.00$0.00None
CEPHALEXIN CAPSULES 500MG (500 CT)   1 Preferred Generic $2.00$0.00None
CEPHALEXIN POWDER FOR SUSPENSION ORAL USP 125MG 200ML BOT   2 Generic $5.00$0.00None
CEREBYX 100 MG PE/2 ML VIAL   2 Generic $5.00$0.00None
CEREDASE 80UNITS/ML VIAL   4 Non-Preferred Brand 35%35%None
CEREZYME INJ 200UNIT   4 Non-Preferred Brand 35%35%None
CERUBIDINE 20MG VIAL   4 Non-Preferred Brand 35%35%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CESIA 7 DAYS X 3 TABLET   2 Generic $5.00$0.00None
CETIRIZINE HCL 5MG/5ML   2 Generic $5.00$0.00Q:300
/30Days
CHANTIX 0.5MG TABLET   4 Non-Preferred Brand 35%35%Q:56
/28Days
CHANTIX 1MG TABLET   4 Non-Preferred Brand 35%35%Q:56
/28Days
CHANTIX STARTING MONTH PAK   4 Non-Preferred Brand 35%35%Q:56
/28Days
CHEMET 100MG CAPSULE   4 Non-Preferred Brand 35%35%None
CHLORAMPHEN NA SUCC 1GM VL   2 Generic $5.00$0.00None
CHLORDIAZEPOXIDE AND AMITRIPTYLINE HCL TABLET 12.5-5MG (500 CT)   2 Generic $5.00$0.00None
CHLORHEXIDINE GLUCONATE 0.12% MOUTHWASH   1 Preferred Generic $2.00$0.00None
CHLOROQUINE PH 500MG TABLET   2 Generic $5.00$0.00None
CHLOROQUINE PHOSPHATE 250MG TABLET (50 CT)   2 Generic $5.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CHLOROTHIAZIDE 250MG TABLET   2 Generic $5.00$0.00None
CHLOROTHIAZIDE 500MG TABLET   2 Generic $5.00$0.00None
CHLOROTHIAZIDE SODIUM FOR INJECTION 500MG/VIAL   2 Generic $5.00$0.00None
CHLORPROMAZINE 100MG TABLET   2 Generic $5.00$0.00None
CHLORPROMAZINE 10MG TABLET   2 Generic $5.00$0.00None
CHLORPROMAZINE 25MG TABLET   2 Generic $5.00$0.00None
CHLORPROMAZINE 25MG/ML AMP   2 Generic $5.00$0.00None
CHLORPROMAZINE 50MG TABLET   2 Generic $5.00$0.00None
CHLORPROMAZINE HCL 200MG TABLET   2 Generic $5.00$0.00None
CHLORPROPAMIDE 100MG TABLET   1 Preferred Generic $2.00$0.00None
CHLORPROPAMIDE 250MG TABLET (1000 CT)   2 Generic $5.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CHLORTHALIDONE 25MG TABLET (100 CT)   1 Preferred Generic $2.00$0.00None
CHLORTHALIDONE 50MG TABLET (1000 CT)   1 Preferred Generic $2.00$0.00None
CHLORZOXAZONE 500MG TABLET   2 Generic $5.00$0.00None
CHOLESTYRAMINE LIGHT POWDER FOR ORAL SUSPENSION   3 Non-Preferred Generic/Preferred Brand 20%20%None
CHORIONIC GONAD 10000U VIAL   4 Non-Preferred Brand 35%35%None
CICLOPIROX 0.77% CREAM   3 Non-Preferred Generic/Preferred Brand 20%20%None
CICLOPIROX 0.77% TOPICAL SUSPENSION   3 Non-Preferred Generic/Preferred Brand 20%20%None
CICLOPIROX 1% SHAMPOO   3 Non-Preferred Generic/Preferred Brand 20%20%None
CICLOPIROX 8% TOPICAL SOLUTION NAIL LACQUER 6.6ML BOT   3 Non-Preferred Generic/Preferred Brand 20%20%None
CICLOPIROX GEL   3 Non-Preferred Generic/Preferred Brand 20%20%None
CILOSTAZOL 50MG TABLET (60 CT)   2 Generic $5.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CILOSTAZOL TABLET 100MG (60 CT)   2 Generic $5.00$0.00None
CIMETIDINE 150MG/ML VIAL   2 Generic $5.00$0.00None
CIMETIDINE 200MG TABLET   2 Generic $5.00$0.00None
CIMETIDINE HCL 300MG/5ML SOL   2 Generic $5.00$0.00None
CIMETIDINE TABLETS   2 Generic $5.00$0.00None
CIMETIDINE TABLETS   2 Generic $5.00$0.00None
CIMETIDINE TABLETS USP   1 Preferred Generic $2.00$0.00None
CIPROFLOXACIN 250MG TABLET (100 CT)   1 Preferred Generic $2.00$0.00None
CIPROFLOXACIN 400 MG/40 ML VL   2 Generic $5.00$0.00None
CIPROFLOXACIN 500MG TABLET   1 Preferred Generic $2.00$0.00None
CIPROFLOXACIN ER 1000MG TABLET (30 CT)   3 Non-Preferred Generic/Preferred Brand 20%20%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CIPROFLOXACIN ER 500MG TABLET (30 CT)   3 Non-Preferred Generic/Preferred Brand 20%20%None
CIPROFLOXACIN HCL 0.3% DROPS   2 Generic $5.00$0.00None
CIPROFLOXACIN HCL 100MG TABLET   2 Generic $5.00$0.00None
CIPROFLOXACIN TABLETS 750MG 100 BOT   2 Generic $5.00$0.00None
CISPLATIN 1 MG/ML INJECTABLE SOLUTION   3 Non-Preferred Generic/Preferred Brand 20%20%P
CITALOPRAM HBR 20 MG TABLET   1 Preferred Generic $2.00$0.00Q:90
/30Days
CITALOPRAM HBR ORAL SOLUTION 10MG 240ML BOTPL   2 Generic $5.00$0.00None
CITALOPRAM HYDROBROMIDE TABLETS 40MG 30 BOT   1 Preferred Generic $2.00$0.00Q:45
/30Days
CITOLOPRAM HBR 10MG TABLET (100 CT)   2 Generic $5.00$0.00Q:30
/30Days
CLADRIBINE 1MG/ML VIAL   2 Generic $5.00$0.00P
CLARITHROMYCIN 250MG TABLET   2 Generic $5.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLARITHROMYCIN 500MG TABLET   2 Generic $5.00$0.00None
CLARITHROMYCIN ER 500MG TABLET (60 CT)   3 Non-Preferred Generic/Preferred Brand 20%20%None
CLARITHROMYCIN FOR ORAL SUSPENSION   2 Generic $5.00$0.00None
CLARITHROMYCIN FOR ORAL SUSPENSION   2 Generic $5.00$0.00None
CLEOCIN 100MG VAGINAL OVULE   4 Non-Preferred Brand 35%35%None
CLEOCIN 2% VAGINAL CREAM   4 Non-Preferred Brand 35%35%None
CLEOCIN 300MG/D5W/GALAXY   4 Non-Preferred Brand 35%35%None
CLEOCIN 600MG/D5W/GALAXY   4 Non-Preferred Brand 35%35%None
CLEOCIN 900MG/D5W/GALAXY   4 Non-Preferred Brand 35%35%None
CLEOCIN HCL 150MG CAPSULE   4 Non-Preferred Brand 35%35%None
CLEOCIN HCL 300MG CAPSULE   4 Non-Preferred Brand 35%35%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLEOCIN HCL 75MG CAPSULE   4 Non-Preferred Brand 35%35%None
CLEOCIN PED SOL 75MG/5ML   4 Non-Preferred Brand 35%35%None
CLEOCIN PHOS 150MG/ML VIAL   4 Non-Preferred Brand 35%35%None
CLEOCIN T 1% GEL   4 Non-Preferred Brand 35%35%None
CLEOCIN T 1% LOTION   4 Non-Preferred Brand 35%35%None
CLEOCIN T 1% PLEDGETS   4 Non-Preferred Brand 35%35%None
CLEOCIN T 1% SOLUTION   4 Non-Preferred Brand 35%35%None
CLINDAMYCIN 150MG/ML ADDVAN   2 Generic $5.00$0.00None
CLINDAMYCIN HCL 150MG CAPSULE   2 Generic $5.00$0.00None
CLINDAMYCIN HYDROCHLORIDE CAPSULES   2 Generic $5.00$0.00None
CLINDAMYCIN PHOSP 1% LOTION   2 Generic $5.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLINDAMYCIN PHOSPHATE 1% SOLUTION NON-ORAL   2 Generic $5.00$0.00None
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE   2 Generic $5.00$0.00None
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX   2 Generic $5.00$0.00None
CLINDAMYCIN PHOSPHATE VAGINAL CREAM   2 Generic $5.00$0.00None
CLINIMIX 2.75%/5% INJECTION 1000ML BAG   4 Non-Preferred Brand 35%35%None
CLINIMIX 4.25/10 SOLUTION   4 Non-Preferred Brand 35%35%None
CLINIMIX 4.25/20 SOLUTION   4 Non-Preferred Brand 35%35%None
CLINIMIX 4.25/25 SOLUTION   4 Non-Preferred Brand 35%35%None
CLINIMIX 4.25/5 SOLUTION   4 Non-Preferred Brand 35%35%None
CLINIMIX 5/15 SOLUTION   4 Non-Preferred Brand 35%35%None
CLINIMIX 5/20 SOLUTION   4 Non-Preferred Brand 35%35%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLINIMIX 5/25 SULFITE FREE INJECTIONS 1035MG-420MEQ 1000ML BAG   4 Non-Preferred Brand 35%35%None
CLINIMIX E 2.75/10 SOLUTION   4 Non-Preferred Brand 35%35%None
CLINIMIX E 2.75/5 SOLUTION   4 Non-Preferred Brand 35%35%None
CLINIMIX E 4.25/25 SOLUTION   4 Non-Preferred Brand 35%35%None
CLINIMIX E 4.25/5 SOLUTION   4 Non-Preferred Brand 35%35%None
CLINIMIX E 5/20 SOLUTION   4 Non-Preferred Brand 35%35%None
CLINIMIX E 5/25 SOLUTION   4 Non-Preferred Brand 35%35%None
CLINIMIX E 5%/15% INJECTION 2000ML BAG   4 Non-Preferred Brand 35%35%None
CLINORIL 200MG TABLET   4 Non-Preferred Brand 35%35%None
CLOBETASOL 0.05% OINTMENT   2 Generic $5.00$0.00None
CLOBETASOL 0.05% SOLUTION   2 Generic $5.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLOBETASOL E 0.05% CREAM   2 Generic $5.00$0.00None
CLOBETASOL PROPIONATE 0.05% FOAM   2 Generic $5.00$0.00None
CLOBETASOL PROPIONATE CRM 0.05% 15GM   2 Generic $5.00$0.00None
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE   2 Generic $5.00$0.00None
CLOBEX 0.05% SHAMPOO   4 Non-Preferred Brand 35%35%None
CLOBEX 0.05% SPRAY NON-AEROSOL   4 Non-Preferred Brand 35%35%None
CLOBEX 0.05% TOPICAL LOTION   4 Non-Preferred Brand 35%35%None
CLOLAR 1MG/ML VIAL   4 Non-Preferred Brand 35%35%P
CLOMIPRAMINE HCL 25MG CAPSULE   2 Generic $5.00$0.00None
CLOMIPRAMINE HCL 50MG CAPSULE   2 Generic $5.00$0.00None
CLOMIPRAMINE HCL 75MG CAPSULE   2 Generic $5.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLONIDINE HCL 0.2MG TABLET (500 CT)   1 Preferred Generic $2.00$0.00None
CLONIDINE HCL TABLET 0.1MG (500 CT)   1 Preferred Generic $2.00$0.00None
CLONIDINE HCL TABLET 0.3MG (100 CT)   2 Generic $5.00$0.00None
CLONIDINE PATCH 0.1MG/DAY   2 Generic $5.00$0.00None
CLONIDINE PATCH 0.2MG/DAY   2 Generic $5.00$0.00None
CLONIDINE PATCH 0.3MG/DAY   2 Generic $5.00$0.00None
CLORPRES 0.1-15 TABLET   4 Non-Preferred Brand 35%35%None
CLORPRES 0.2-15 TABLET   4 Non-Preferred Brand 35%35%None
CLORPRES 0.3-15 TABLET   4 Non-Preferred Brand 35%35%None
CLOTRIMAZOLE-BETAMETHASONE 1-0.05% LOTION   2 Generic $5.00$0.00None
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE CREAM USP .5MG-10GM 45GM TUBE   2 Generic $5.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLOZAPINE 100 MG DISINTEGRATING TABLET [FAZACLO]   4 Non-Preferred Brand 35%35%S
CLOZAPINE 100 MG ORAL TABLET   3 Non-Preferred Generic/Preferred Brand 20%20%None
CLOZAPINE 12.5 MG DISINTEGRATING TABLET [FAZACLO]   4 Non-Preferred Brand 35%35%S
CLOZAPINE 200MG TABLET (500 CT)   3 Non-Preferred Generic/Preferred Brand 20%20%None
CLOZAPINE 25 MG DISINTEGRATING TABLET [FAZACLO]   4 Non-Preferred Brand 35%35%S
CLOZAPINE 25MG TABLET (100 CT)   3 Non-Preferred Generic/Preferred Brand 20%20%None
CLOZAPINE 50MG TABLET (500 CT)   3 Non-Preferred Generic/Preferred Brand 20%20%None
COARTEM 20MG-120MG   4 Non-Preferred Brand 35%35%Q:24
/30Days
CODEINE 60 MG ORAL TABLET   3 Non-Preferred Generic/Preferred Brand 20%20%None
CODEINE SULFATE 30 MG TABLET 3100   3 Non-Preferred Generic/Preferred Brand 20%20%None
CODEINE SULFATE TABLETS   3 Non-Preferred Generic/Preferred Brand 20%20%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COGENTIN 1MG/ML AMPUL   4 Non-Preferred Brand 35%35%None
COLCHICINE 0.6 MG ORAL TABLET [COLCRYS]   3 Non-Preferred Generic/Preferred Brand 20%20%None
COLESTIPOL HCL 1G TABLET   3 Non-Preferred Generic/Preferred Brand 20%20%None
COLESTIPOL HCL 5G GRANULES   3 Non-Preferred Generic/Preferred Brand 20%20%None
COLISTIMETHATE 150MG VIAL   3 Non-Preferred Generic/Preferred Brand 20%20%None
COLLAGENASE SANTYL OINTMENT 250UNT 30GM TUBE   4 Non-Preferred Brand 35%35%None
COLOCORT 100MG ENEMA   2 Generic $5.00$0.00None
COLY MYCIN M FOR INJECTION 150MG/VIAL 5 ML VIALSD   4 Non-Preferred Brand 35%35%None
COMBIVENT INHALER   4 Non-Preferred Brand 35%35%Q:30
/28Days
COMBIVIR TABLETS   4 Non-Preferred Brand 35%35%None
COMPRO 25MG SUPPOSITORY   2 Generic $5.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COMTAN 200MG TABLET   3 Non-Preferred Generic/Preferred Brand 20%20%Q:300
/30Days
COMVAX VACCINE VIAL   4 Non-Preferred Brand 35%35%P
CONSTULOSE 10GM/15ML SYRUP   1 Preferred Generic $2.00$0.00None
COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN   4 Non-Preferred Brand 35%35%P Q:30
/28Days
CORDARONE 200MG TABLET   4 Non-Preferred Brand 35%35%None
CORTEF 10MG TABLET   4 Non-Preferred Brand 35%35%None
CORTEF 20MG TABLET   4 Non-Preferred Brand 35%35%None
CORTEF 5MG TABLET   4 Non-Preferred Brand 35%35%None
CORTIFOAM RECTAL FOAM   4 Non-Preferred Brand 35%35%None
CORTISONE ACETATE 25MG TABLET (100 CT)   2 Generic $5.00$0.00None
CORTOMYCIN EAR SOLUTION   2 Generic $5.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CORTOMYCIN EAR SUSPENSION   2 Generic $5.00$0.00None
CORZIDE 40-5MG TABLET   4 Non-Preferred Brand 35%35%None
CORZIDE 80-5MG TABLET   4 Non-Preferred Brand 35%35%None
COSMEGEN 0.5MG VIAL   4 Non-Preferred Brand 35%35%P
COUMADIN 10MG TABLET   4 Non-Preferred Brand 35%35%None
COUMADIN 1MG TABLET   4 Non-Preferred Brand 35%35%None
COUMADIN 2.5MG TABLET   4 Non-Preferred Brand 35%35%None
COUMADIN 2MG TABLET   4 Non-Preferred Brand 35%35%None
COUMADIN 3MG TABLET   4 Non-Preferred Brand 35%35%None
COUMADIN 4MG TABLET   4 Non-Preferred Brand 35%35%None
COUMADIN 5MG TABLET   4 Non-Preferred Brand 35%35%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COUMADIN 5MG VIAL   4 Non-Preferred Brand 35%35%None
COUMADIN 6MG TABLET   4 Non-Preferred Brand 35%35%None
COUMADIN 7.5MG TABLET   4 Non-Preferred Brand 35%35%None
COVERA-HS 180MG SA TABLET   4 Non-Preferred Brand 35%35%Q:90
/30Days
COVERA-HS 240MG SA TABLET   4 Non-Preferred Brand 35%35%Q:60
/30Days
CREON DELAYED RELEASE CAPSULES 12000MG 100 BOT   3 Non-Preferred Generic/Preferred Brand 20%20%None
CREON DELAYED RELEASE CAPSULES 24000MG 100 BOT   3 Non-Preferred Generic/Preferred Brand 20%20%None
CREON DELAYED RELEASE CAPSULES 6000MG 100 BOT   3 Non-Preferred Generic/Preferred Brand 20%20%None
CRESTOR 10MG TABLET   3 Non-Preferred Generic/Preferred Brand 20%20%Q:30
/30Days
CRESTOR 20MG TABLET   3 Non-Preferred Generic/Preferred Brand 20%20%Q:30
/30Days
CRESTOR 40MG TABLET   3 Non-Preferred Generic/Preferred Brand 20%20%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CRESTOR 5MG TABLET   3 Non-Preferred Generic/Preferred Brand 20%20%Q:30
/30Days
CRINONE GEL 8%   4 Non-Preferred Brand 35%35%None
CRIXIVAN 100MG CAPSULE   3 Non-Preferred Generic/Preferred Brand 20%20%None
CRIXIVAN 200MG CAPSULE   3 Non-Preferred Generic/Preferred Brand 20%20%None
CRIXIVAN 333MG CAPSULE   3 Non-Preferred Generic/Preferred Brand 20%20%None
CRIXIVAN 400MG CAPSULE (120 CT)   3 Non-Preferred Generic/Preferred Brand 20%20%None
CROMOLYN NEBULIZER SOLUTION   2 Generic $5.00$0.00P
CROMOLYN SODIUM 4% 40MG 10ML BOT   2 Generic $5.00$0.00None
CUBICIN 500MG VIAL   4 Non-Preferred Brand 35%35%None
CUPRIMINE CAPSULES 250MG (100 CT)   4 Non-Preferred Brand 35%35%None
CUTIVATE CREAM 0.05%   4 Non-Preferred Brand 35%35%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CUTIVATE LOTION 0.05%   4 Non-Preferred Brand 35%35%None
CUTIVATE OINTMENT 0.005% 60GM TUBE   4 Non-Preferred Brand 35%35%None
CYCLESSA 28 DAY TABLET   4 Non-Preferred Brand 35%35%None
CYCLOBENZAPRINE HCL 10MG TABLET (1000 CT)   1 Preferred Generic $2.00$0.00None
CYCLOBENZAPRINE HCL 5MG TABLET (500 CT)   1 Preferred Generic $2.00$0.00None
CYCLOPHOSPHAMIDE 25MG TABLET   3 Non-Preferred Generic/Preferred Brand 20%20%P
CYCLOPHOSPHAMIDE 50MG TABLET   3 Non-Preferred Generic/Preferred Brand 20%20%P
CYCLOSPORINE 100MG CAPSULE   2 Generic $5.00$0.00P
CYCLOSPORINE 100MG CAPSULE   3 Non-Preferred Generic/Preferred Brand 20%20%P
CYCLOSPORINE 25MG CAPSULE   3 Non-Preferred Generic/Preferred Brand 20%20%P
CYCLOSPORINE 50MG CAPSULE   3 Non-Preferred Generic/Preferred Brand 20%20%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CYCLOSPORINE 50MG/ML AMP   3 Non-Preferred Generic/Preferred Brand 20%20%None
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT   3 Non-Preferred Generic/Preferred Brand 20%20%P
CYKLOKAPRON 100MG/ML AMPUL   3 Non-Preferred Generic/Preferred Brand 20%20%None
CYMBALTA 20MG CAPSULE   3 Non-Preferred Generic/Preferred Brand 20%20%Q:60
/30Days
CYMBALTA 60MG CAPSULE   3 Non-Preferred Generic/Preferred Brand 20%20%Q:60
/30Days
CYMBALTA CAPSULES DELAYED RELEASE 30MG (30 CT)   3 Non-Preferred Generic/Preferred Brand 20%20%Q:60
/30Days
CYPROHEPTADINE HCL 4 MG   2 Generic $5.00$0.00None
CYPROHEPTADINE HYDROCHLORIDE SOLUTION USP SYRUP 2MG 473 ML BOTGL   2 Generic $5.00$0.00None
CYSTADANE POWDER FOR ORAL SOLUTION 180GM   4 Non-Preferred Brand 35%35%None
CYSTAGON 150MG CAPSULE   4 Non-Preferred Brand 35%35%None
CYSTAGON 50MG CAPSULE   4 Non-Preferred Brand 35%35%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CYTARABINE 20MG/ML VIAL   2 Generic $5.00$0.00P
CYTARABINE 500MG VIAL   2 Generic $5.00$0.00P
CYTARABINE SOLUTION INJECTION 100MG 20ML VIALSD   2 Generic $5.00$0.00P
CYTOMEL 25MCG TABLET   4 Non-Preferred Brand 35%35%None
CYTOMEL 50MCG TABLET   4 Non-Preferred Brand 35%35%None
CYTOMEL 5MCG TABLET   4 Non-Preferred Brand 35%35%None
CYTOTEC TABLET 100MCG (120 CT)   4 Non-Preferred Brand 35%35%None
CYTOTEC TABLET 200MCG (60 CT)   4 Non-Preferred Brand 35%35%None
CYTOVENE IV INJECTION   4 Non-Preferred Brand 35%35%None

Chart Legend:

Below are a few notes to help you understand the above 2011 Medicare Part D Humana Walmart-Preferred Rx Plan (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 intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $(2840)) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, on the 2011 Humana Walmart-Preferred Rx Plan the pricing 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 2011 )

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.