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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 T

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

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
TACROLIMUS 0.5 MG ORAL CAPSULE   2 Generic $5.00$0.00P
TACROLIMUS 1 MG ORAL CAPSULE   2 Generic $5.00$0.00P
TACROLIMUS 5 MG ORAL CAPSULE   2 Generic $5.00$0.00P
TALACEN CAPLET   4 Non-Preferred Brand 35%35%Q:180
/30Days
TALWIN NX TABLET   4 Non-Preferred Brand 35%35%None
TAMBOCOR 100MG TABLET   4 Non-Preferred Brand 35%35%None
TAMBOCOR 150MG TABLET 100 EA   4 Non-Preferred Brand 35%35%None
TAMBOCOR 50MG TABLET 100 EA   4 Non-Preferred Brand 35%35%None
TAMIFLU 30MG CAPSULE   4 Non-Preferred Brand 35%35%Q:112
/365Days
TAMIFLU 45MG CAPSULE   4 Non-Preferred Brand 35%35%Q:56
/365Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TAMIFLU 75MG CAPSULE UD   4 Non-Preferred Brand 35%35%Q:56
/365Days
TAMIFLU ORAL SUSPENSION   4 Non-Preferred Brand 35%35%Q:350
/365Days
TAMOXIFEN CITRATE 20MG TABLET (30 CT)   1 Preferred Generic $2.00$0.00None
TAMOXIFEN CITRATE TABLETS 10MG 180 BOT   1 Preferred Generic $2.00$0.00None
TAMSULOSIN HCL 0.4 MG CAPSULE   2 Generic $5.00$0.00Q:60
/30Days
TAPAZOLE 10MG TABLET   4 Non-Preferred Brand 35%35%None
TAPAZOLE 5MG TABLET   4 Non-Preferred Brand 35%35%None
TARCEVA 100MG TABLET   4 Non-Preferred Brand 35%35%P Q:30
/30Days
TARCEVA 150MG TABLET   4 Non-Preferred Brand 35%35%P Q:30
/30Days
TARCEVA 25MG TABLET   4 Non-Preferred Brand 35%35%P Q:90
/30Days
TARGRETIN 1% GEL 60GM TUBE   4 Non-Preferred Brand 35%35%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TARGRETIN 75MG (100 CT)   4 Non-Preferred Brand 35%35%P
TASIGNA 200MG CAPSULE 28 BLPK   4 Non-Preferred Brand 35%35%P Q:120
/30Days
TASMAR 100MG TABLET   4 Non-Preferred Brand 35%35%P
TAXOTERE 80MG/2ML VIAL   4 Non-Preferred Brand 35%35%P
TAZICEF 1GM VIAL   3 Non-Preferred Generic/Preferred Brand 20%20%None
TAZICEF 2GM ADD-VANTAGE   3 Non-Preferred Generic/Preferred Brand 20%20%None
TAZICEF 6GM/100ML VIAL   3 Non-Preferred Generic/Preferred Brand 20%20%None
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES   3 Non-Preferred Generic/Preferred Brand 20%20%Q:60
/30Days
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES   3 Non-Preferred Generic/Preferred Brand 20%20%Q:60
/30Days
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES   3 Non-Preferred Generic/Preferred Brand 20%20%Q:30
/30Days
TAZTIA XT 240MG CAPSULE SA   3 Non-Preferred Generic/Preferred Brand 20%20%Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TAZTIA XT 360MG CAPSULE SA   3 Non-Preferred Generic/Preferred Brand 20%20%Q:30
/30Days
TEGRETOL XR TABLETS 100MG 100 BOT   4 Non-Preferred Brand 35%35%None
TEGRETOL XR TABLETS 200MG 100 BOT   4 Non-Preferred Brand 35%35%None
TEGRETOL XR TABLETS 400MG 100 BOT   4 Non-Preferred Brand 35%35%None
TEKTURNA 150MG TABLET   3 Non-Preferred Generic/Preferred Brand 20%20%Q:30
/30Days
TEKTURNA 300MG TABLET   3 Non-Preferred Generic/Preferred Brand 20%20%Q:30
/30Days
TEKTURNA HCT 150-12.5MG TABLET   3 Non-Preferred Generic/Preferred Brand 20%20%Q:30
/30Days
TEKTURNA HCT 150MG-25MG TABLET   3 Non-Preferred Generic/Preferred Brand 20%20%Q:30
/30Days
TEKTURNA HCT 300-12.5MG TABLET   3 Non-Preferred Generic/Preferred Brand 20%20%Q:30
/30Days
TEKTURNA HCT 300MG-25MG TABLET   3 Non-Preferred Generic/Preferred Brand 20%20%Q:30
/30Days
TELAVANCIN 15 MG/ML INJECTABLE SOLUTION [VIBATIV]   4 Non-Preferred Brand 35%35%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TENEX 1MG TABLET   4 Non-Preferred Brand 35%35%None
TENEX 2MG TABLET   4 Non-Preferred Brand 35%35%None
TENORETIC 100 TABLET   4 Non-Preferred Brand 35%35%None
TENORETIC 50 TABLET   4 Non-Preferred Brand 35%35%None
TENORMIN 100MG TABLET   4 Non-Preferred Brand 35%35%None
TENORMIN 25MG TABLET   4 Non-Preferred Brand 35%35%None
TENORMIN 50MG TABLET   4 Non-Preferred Brand 35%35%None
TERAZOSIN HCL 10MG CAPSULE   1 Preferred Generic $2.00$0.00None
TERAZOSIN HCL 1MG CAPSULE   1 Preferred Generic $2.00$0.00None
TERAZOSIN HCL 2MG CAPSULE   1 Preferred Generic $2.00$0.00None
TERAZOSIN HCL 5MG CAPSULE   1 Preferred Generic $2.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TERBINAFINE HCL 250MG TABLET   1 Preferred Generic $2.00$0.00Q:90
/365Days
TERBUTALINE SULF 1MG/ML VL   3 Non-Preferred Generic/Preferred Brand 20%20%None
TERBUTALINE SULF 2.5MG TABLET   3 Non-Preferred Generic/Preferred Brand 20%20%None
TERBUTALINE SULFATE 5MG TABLET   3 Non-Preferred Generic/Preferred Brand 20%20%None
TERCONAZOLE 0.4% CREAM WITH APPLICATOR   2 Generic $5.00$0.00None
TERCONAZOLE 80MG SUPPOSITORY VAGINAL   2 Generic $5.00$0.00None
TERCONAZOLE VAGINAL CREAM   2 Generic $5.00$0.00None
TESTOSTERONE CYPIONATE INJECTION   2 Generic $5.00$0.00None
TESTOSTERONE ENANTHATE INJECTION   3 Non-Preferred Generic/Preferred Brand 20%20%None
TESTRED 10MG CAPSULE   4 Non-Preferred Brand 35%35%None
TETANUS AND DIPHTHERIA TOXOIDS ADSORBED FOR ADULT USE 2 UNT/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
TETANUS TOXOID ADSORBED VIAL 5LF   4 Non-Preferred Brand 35%35%None
TETRACYCLINE 250 MG ORAL CAPSULE   1 Preferred Generic $2.00$0.00None
TETRACYCLINE 500MG CAPSULE   1 Preferred Generic $2.00$0.00None
TEV-TROPIN 5MG VIAL   4 Non-Preferred Brand 35%35%P Q:28
/30Days
THALOMID 100MG CAPSULE 140 BOX   3 Non-Preferred Generic/Preferred Brand 20%20%P Q:30
/30Days
THALOMID 150MG CAPSULE   4 Non-Preferred Brand 35%35%P Q:30
/30Days
THALOMID 200MG CAPSULE 28 BLPK   4 Non-Preferred Brand 35%35%P Q:30
/30Days
THALOMID 50MG CAPSULE 280 BOX   3 Non-Preferred Generic/Preferred Brand 20%20%P Q:30
/30Days
THEOCHRON 100MG TABLET SA   2 Generic $5.00$0.00None
THEOPHYLLINE 400MG TABLET SA   2 Generic $5.00$0.00None
THEOPHYLLINE 600MG TABLET SA   2 Generic $5.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
THEOPHYLLINE ANHYDROUS ER TABLET 200MG (1000 CT)   2 Generic $5.00$0.00None
THEOPHYLLINE TABLET ER 300MG (100 CT)   2 Generic $5.00$0.00None
THEOPHYLLINE TABLET ER 450MG (100 CT)   2 Generic $5.00$0.00None
THERMAZENE 50GM CREAM   1 Preferred Generic $2.00$0.00None
THIOGUANINE TABLET LOID 40MG   2 Generic $5.00$0.00None
THIORIDAZINE 100MG TABLET   2 Generic $5.00$0.00None
THIORIDAZINE HCL 10MG TABLET (1000 CT)   2 Generic $5.00$0.00None
THIORIDAZINE HCL 25MG TABLET (1000 CT)   1 Preferred Generic $2.00$0.00None
THIORIDAZINE HCL 50MG TABLET (1000 CT)   1 Preferred Generic $2.00$0.00None
THIOTEPA POWDER FOR INJECTION 15MG/VIL 1 VIAL SINGLE DOSE CRTN   2 Generic $5.00$0.00P
THIOTHIXENE 10MG CAPSULE   2 Generic $5.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
THIOTHIXENE 1MG CAPSULE (100 CT)   2 Generic $5.00$0.00None
THIOTHIXENE 2MG CAPSULE   1 Preferred Generic $2.00$0.00None
THIOTHIXENE 5MG CAPSULE   2 Generic $5.00$0.00None
THYMOGLOBULIN 25MG VIAL   3 Non-Preferred Generic/Preferred Brand 20%20%P
THYROLAR-1 60MG TABLET   2 Generic $5.00$0.00None
THYROLAR-1/4 15MG TABLET   2 Generic $5.00$0.00None
THYROLAR-2 120MG TABLET   2 Generic $5.00$0.00None
THYROLAR-3 180MG TABLET   2 Generic $5.00$0.00None
TIAZAC 120MG E.R. CAPSULE   4 Non-Preferred Brand 35%35%Q:60
/30Days
TIAZAC 180MG E.R. CAPSULE   4 Non-Preferred Brand 35%35%Q:60
/30Days
TIAZAC 240MG E.R. CAPSULE   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
TIAZAC 300MG E.R. CAPSULE   4 Non-Preferred Brand 35%35%Q:30
/30Days
TIAZAC 360MG E.R. CAPSULE   4 Non-Preferred Brand 35%35%Q:30
/30Days
TIAZAC 420MG CAPSULE SA   4 Non-Preferred Brand 35%35%Q:30
/30Days
TICLOPIDINE 250 MG ORAL TABLET   2 Generic $5.00$0.00None
TIGAN 300MG CAPSULE   4 Non-Preferred Brand 35%35%None
TIGAN INJECTION 100MG/ML 20 ML VIALMD   4 Non-Preferred Brand 35%35%None
TIKOSYN .125MG CAPSULE   4 Non-Preferred Brand 35%35%Q:240
/30Days
TIKOSYN .250MG CAPSULE   4 Non-Preferred Brand 35%35%Q:120
/30Days
TIKOSYN .5MG CAPSULE   4 Non-Preferred Brand 35%35%Q:60
/30Days
TIMENTIN 3.1GM VIAL   4 Non-Preferred Brand 35%35%None
TIMOLOL 0.0025 MG/MG OPHTHALMIC GEL   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
TIMOLOL 0.005 MG/MG OPHTHALMIC GEL   3 Non-Preferred Generic/Preferred Brand 20%20%None
TIMOLOL 2.5 MG/ML OPHTHALMIC SOLUTION [TIMOPTIC]   4 Non-Preferred Brand 35%35%None
TIMOLOL 5 MG/ML OPHTHALMIC SOLUTION [TIMOPTIC]   4 Non-Preferred Brand 35%35%None
TIMOLOL MAL SOL 0.25% OP 15ML BOT   1 Preferred Generic $2.00$0.00None
TIMOLOL MAL SOL 0.5% OP 10ML BOT   1 Preferred Generic $2.00$0.00None
TIMOLOL MALEATE 10MG TABLET   2 Generic $5.00$0.00None
TIMOLOL MALEATE 20MG TABLET   2 Generic $5.00$0.00None
TIMOLOL MALEATE 5MG TABLET   2 Generic $5.00$0.00None
TIMOPTIC-XE 0.25% EYE SOLUTION   4 Non-Preferred Brand 35%35%None
TIMOPTIC-XE 0.5% EYE SOLUTION   4 Non-Preferred Brand 35%35%None
TIS-U-SOL IRRIGATION SOLUTION   2 Generic $5.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TIZANIDINE HCL 2MG TABLET (150 CT)   2 Generic $5.00$0.00None
TIZANIDINE HCL 4MG TABLET 150 BOT   2 Generic $5.00$0.00None
TOBRADEX EYE OINTMENT   4 Non-Preferred Brand 35%35%None
TOBRADEX SUSPENSION OPHTHALMIC 0.1%/0.3% 5ML BOT   4 Non-Preferred Brand 35%35%None
TOBRAMYCIN 10MG/ML VIAL   2 Generic $5.00$0.00None
TOBRAMYCIN 40MG/ML VIAL   2 Generic $5.00$0.00None
TOBRAMYCIN 60MG/0.9% NACL   2 Generic $5.00$0.00None
TOBRAMYCIN 80MG/0.9% NACL   2 Generic $5.00$0.00None
TOBRAMYCIN INHALATION SOLUTION   4 Non-Preferred Brand 35%35%P Q:280
/28Days
TOBRAMYCIN OPHTHALMIC SOLUTION 0.3% 5ML BOT   1 Preferred Generic $2.00$0.00None
TOBRAMYCIN-DEXAMETH OPTH SUSP   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
TOBRASOL 0.3% EYE DROPS   1 Preferred Generic $2.00$0.00None
TOBREX 0.3% EYE DROPS   4 Non-Preferred Brand 35%35%None
TOBREX 0.3% EYE OINTMENT   4 Non-Preferred Brand 35%35%None
TOLAZAMIDE TABLETS 250MG 100 BOT   2 Generic $5.00$0.00None
TOLAZAMIDE TABLETS 500MG 100 BOT   2 Generic $5.00$0.00None
TOLBUTAMIDE 500MG TABLET   2 Generic $5.00$0.00None
TOLMETIN SODIUM 200MG TABLET   3 Non-Preferred Generic/Preferred Brand 20%20%None
TOLMETIN SODIUM 400MG CAPSULE   3 Non-Preferred Generic/Preferred Brand 20%20%None
TOLMETIN SODIUM 600MG TABLET   3 Non-Preferred Generic/Preferred Brand 20%20%None
TOLVAPTAN 15 MG ORAL TABLET [SAMSCA]   4 Non-Preferred Brand 35%35%Q:60
/30Days
TOLVAPTAN 30 MG ORAL TABLET [SAMSCA]   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
TOPAMAX 15 MG SPRINKLE CAP   4 Non-Preferred Brand 35%35%None
TOPAMAX 25 MG SPRINKLE CAP   4 Non-Preferred Brand 35%35%None
TOPAMAX TABLETS 100MG 60 BOT   4 Non-Preferred Brand 35%35%Q:120
/30Days
TOPAMAX TABLETS 200MG 60 BOT   4 Non-Preferred Brand 35%35%Q:120
/30Days
TOPAMAX TABLETS 25MG 60 BOT   4 Non-Preferred Brand 35%35%Q:90
/30Days
TOPAMAX TABLETS 50MG 60 BOT   4 Non-Preferred Brand 35%35%Q:120
/30Days
TOPICORT 0.05% GEL   4 Non-Preferred Brand 35%35%None
TOPICORT 0.25% CREAM   4 Non-Preferred Brand 35%35%None
TOPICORT 0.25% OINTMENT   4 Non-Preferred Brand 35%35%None
TOPICORT LP 0.05% CREAM   4 Non-Preferred Brand 35%35%None
TOPIRAMATE 25 MG SPRINKLE CAP   2 Generic $5.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TOPIRAMATE SPRINKLE CAPSULES 15MG 60 BOT   2 Generic $5.00$0.00None
TOPIRAMATE TABLETS 100MG 1000 BOT   2 Generic $5.00$0.00Q:120
/30Days
TOPIRAMATE TABLETS 200MG 1000 BOT   2 Generic $5.00$0.00Q:120
/30Days
TOPIRAMATE TABLETS 25MG 1000 BOT   2 Generic $5.00$0.00Q:90
/30Days
TOPIRAMATE TABLETS 50MG 1000 BOT   2 Generic $5.00$0.00Q:120
/30Days
TOPOSAR INJECTION 20MG/ML 50ML VIAL MD CRTN   4 Non-Preferred Brand 35%35%None
TOPOTECAN HYDROCHLORIDE FOR INJECTION   4 Non-Preferred Brand 35%35%P
TOPROL XL 100MG TABLET SA   4 Non-Preferred Brand 35%35%Q:60
/30Days
TOPROL XL 200MG TABLET SA   4 Non-Preferred Brand 35%35%Q:60
/30Days
TOPROL XL 25MG TABLET SA   4 Non-Preferred Brand 35%35%Q:60
/30Days
TOPROL XL 50MG TABLET 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
TORISEL SOL 25MG/ML   4 Non-Preferred Brand 35%35%P
TORSEMIDE 100 MG ORAL TABLET   2 Generic $5.00$0.00None
TORSEMIDE 20 MG ORAL TABLET   2 Generic $5.00$0.00None
TORSEMIDE INJECTION 20MG/2ML   2 Generic $5.00$0.00None
TORSEMIDE TABLETS 10 MG   2 Generic $5.00$0.00None
TORSEMIDE TABLETS 5 MG   2 Generic $5.00$0.00None
TPN ELECTROLYTES VIAL   4 Non-Preferred Brand 35%35%None
TRACLEER 125MG TABLET   4 Non-Preferred Brand 35%35%P Q:60
/30Days
TRACLEER 62.5MG TABLET   4 Non-Preferred Brand 35%35%P Q:60
/30Days
TRAMADOL HCL 50 MG TABLET   1 Preferred Generic $2.00$0.00Q:240
/30Days
TRAMADOL HCL-ACETAMINOPHEN 37.5-325MG TABLET (1000 CT)   3 Non-Preferred Generic/Preferred Brand 20%20%Q:240
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRANDATE TABLETS 100MG 100 BOTPL   4 Non-Preferred Brand 35%35%None
TRANDATE TABLETS 200MG 100 BOT   4 Non-Preferred Brand 35%35%None
TRANDATE TABLETS 300MG 100 BOTPL   4 Non-Preferred Brand 35%35%None
TRANDOLAPRIL 1MG TABLET   2 Generic $5.00$0.00None
TRANDOLAPRIL 2MG TABLET   2 Generic $5.00$0.00None
TRANDOLAPRIL 4MG TABLET   2 Generic $5.00$0.00None
TRANSDERM-SCOP 1.5MG 24 PKG   4 Non-Preferred Brand 35%35%Q:4
/12Days
TRANYLCYPROMINE SULFATE 10MG TABLET   3 Non-Preferred Generic/Preferred Brand 20%20%None
TRAVASOL 10% SOLUTION VIAFLEX   4 Non-Preferred Brand 35%35%None
TRAVATAN Z 0.04MG DROPS 2.5ML BOT   3 Non-Preferred Generic/Preferred Brand 20%20%Q:3
/25Days
TRAZODONE 300MG TABLET   2 Generic $5.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRAZODONE HCL TABLET USP 100MG (500 CT)   1 Preferred Generic $2.00$0.00None
TRAZODONE HCL TABLET USP 150MG (100 CT)   1 Preferred Generic $2.00$0.00None
TRAZODONE HCL TABLET USP 50MG (500 CT)   1 Preferred Generic $2.00$0.00None
TREANDA FOR INJECTION 100MG/VIAL   4 Non-Preferred Brand 35%35%P
TRECATOR 250MG TABLET   4 Non-Preferred Brand 35%35%None
TRELSTAR DEPOT MIXJET FOR INJECTION 3.75 MG   4 Non-Preferred Brand 35%35%P
TRELSTAR MIXJET FOR INJECTION 11.25 MG   4 Non-Preferred Brand 35%35%P
TRENTAL 400MG TABLET SA   4 Non-Preferred Brand 35%35%None
TRETINOIN 0.01% GEL 45GM TUBE   3 Non-Preferred Generic/Preferred Brand 20%20%P
TRETINOIN 0.025% GEL 45GM TUBE   3 Non-Preferred Generic/Preferred Brand 20%20%P
TRETINOIN 0.05% CREAM 45GM TUBE   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
TRETINOIN 0.1% CREAM 45GM TUBE   3 Non-Preferred Generic/Preferred Brand 20%20%P
TRETINOIN 10MG CAPSULE   3 Non-Preferred Generic/Preferred Brand 20%20%None
TRETINOIN CREAM   3 Non-Preferred Generic/Preferred Brand 20%20%P
TREXALL 10MG TABLET   4 Non-Preferred Brand 35%35%None
TREXALL 15MG TABLET   4 Non-Preferred Brand 35%35%None
TREXALL 5MG TABLET   4 Non-Preferred Brand 35%35%None
TREXALL 7.5MG TABLET   4 Non-Preferred Brand 35%35%None
TRI PREVIFEM TABLETS   2 Generic $5.00$0.00None
TRI-LEGEST FE 5-7-9-7 TABLET   4 Non-Preferred Brand 35%35%None
TRI-SPRINTEC 7DAYSX3 28 TABLET   2 Generic $5.00$0.00None
TRIAMCINOLONE 0.1% OINTMENT   1 Preferred Generic $2.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRIAMCINOLONE 0.1% PASTE   2 Generic $5.00$0.00None
TRIAMCINOLONE ACETONIDE 0.025% OINTMENT 80GM TUBE   2 Generic $5.00$0.00None
TRIAMCINOLONE ACETONIDE 0.1% LOTION 60ML BOTPL   2 Generic $5.00$0.00None
TRIAMCINOLONE ACETONIDE 0.025% CREAM 80GM TUBE   1 Preferred Generic $2.00$0.00None
TRIAMCINOLONE ACETONIDE 0.025% LOTION 2 FL OZ BOT   2 Generic $5.00$0.00None
TRIAMCINOLONE ACETONIDE 0.05% CREAM 15GM TUBE   1 Preferred Generic $2.00$0.00None
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT   2 Generic $5.00$0.00None
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE   2 Generic $5.00$0.00None
TRIAMCINOLONE ACETONIDE 0.1% CREAM 80GM TUBE   1 Preferred Generic $2.00$0.00None
TRIAMTERENE/HCTZ 25/37.5MG CAPSULES (100 CT)   1 Preferred Generic $2.00$0.00None
TRIAMTERENE/HCTZ 37.5/25 TABLET   1 Preferred Generic $2.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRIAMTERENE/HCTZ 75/50 TABLET   1 Preferred Generic $2.00$0.00None
TRICOR 145MG TABLET   3 Non-Preferred Generic/Preferred Brand 20%20%Q:30
/30Days
TRICOR 48MG TABLET   3 Non-Preferred Generic/Preferred Brand 20%20%Q:60
/30Days
TRIDERM 0.1% CREAM   1 Preferred Generic $2.00$0.00None
TRIDERM 0.1% OINTMENT   1 Preferred Generic $2.00$0.00None
TRIFLUOPERAZINE 1MG TABLET   2 Generic $5.00$0.00None
TRIFLUOPERAZINE HCL 2MG TABLET   2 Generic $5.00$0.00None
TRIFLUOPERAZINE HCL 5MG TABLET   2 Generic $5.00$0.00None
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT)   2 Generic $5.00$0.00None
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT   3 Non-Preferred Generic/Preferred Brand 20%20%None
TRIHEXYPHENIDYL HCL 5MG TABLET (100 CT)   2 Generic $5.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRIHEXYPHENIDYL HCL ELIXIR 5%/2 16 FLO BOT   2 Generic $5.00$0.00None
TRIHEXYPHENIDYL HCL TABLET 2MG (1000 CT)   1 Preferred Generic $2.00$0.00None
TRIHIBIT PRESERVATIVE FREE   4 Non-Preferred Brand 35%35%None
TRILEPTAL 300MG/5ML SUSP   4 Non-Preferred Brand 35%35%None
TRIMETHOBENZAMIDE 100MG/ML   3 Non-Preferred Generic/Preferred Brand 20%20%None
TRIMETHOBENZAMIDE HCL 300MG CAPSULE   3 Non-Preferred Generic/Preferred Brand 20%20%None
TRIMETHOPRIM TABLETS   2 Generic $5.00$0.00None
TRINESSA TABLET   1 Preferred Generic $2.00$0.00None
TRIPEDIA PRESERVATIVE FREE 6.7;23.4; UNT/.5 ML;   4 Non-Preferred Brand 35%35%None
TRISENOX 10MG/10ML AMPULE   4 Non-Preferred Brand 35%35%P
TRIVORA-28 TABLET   2 Generic $5.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRIZIVIR TABLET   3 Non-Preferred Generic/Preferred Brand 20%20%None
TROPHAMINE INJECTION SOLUTION   4 Non-Preferred Brand 35%35%None
TROPHAMINE INJECTION SOLUTION 6%   4 Non-Preferred Brand 35%35%None
TROPICAMIDE 0.5% EYE DROPS   2 Generic $5.00$0.00None
TROPICAMIDE OPHTHALMIC SOLUTION USP   2 Generic $5.00$0.00None
TROSPIUM CHLORIDE TABLETS   3 Non-Preferred Generic/Preferred Brand 20%20%None
TRUVADA TABLET   4 Non-Preferred Brand 35%35%None
TWINJECT AUTO INJECTOR INJECTION 1% AUTO INJECTOR TWO PACK SYR   4 Non-Preferred Brand 35%35%None
TWINJECT AUTO INJECTOR INJECTION 1% AUTO TWO PACK SYR   4 Non-Preferred Brand 35%35%None
TWINRIX TF PF VACCINE 720UNT/20ML 10 X 1ML VIALSD   4 Non-Preferred Brand 35%35%None
TYGACIL 50MG VIAL 10 VILSU BOX   4 Non-Preferred Brand 35%35%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TYKERB 250MG TABLET   4 Non-Preferred Brand 35%35%P Q:150
/30Days
TYPHIM VI 25MCG/0.5ML VIAL   4 Non-Preferred Brand 35%35%None
TYZEKA 600MG TABLET (30 CT)   4 Non-Preferred Brand 35%35%Q:30
/30Days
TYZINE 0.1% NOSE DROPS   3 Non-Preferred Generic/Preferred Brand 20%20%None
TYZINE PEDIATRIC 0.05% DROP   3 Non-Preferred Generic/Preferred Brand 20%20%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.