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First Health Part D Premier Plus (PDP) (S5674-059-0)
Tier 1 (1176)
Tier 2 (349)
Tier 3 (388)
Tier 4 (1025)
Tier 5 (197)
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M N O P Q R S T U V W X Y Z 0-9 
2011 Medicare Part D Plan Formulary Information
First Health Part D Premier Plus (PDP) (S5674-059-0)
Benefit Details           
The First Health Part D Premier Plus (PDP) (S5674-059-0)
Formulary Drugs Starting with the Letter A

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

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
A METHAPRED METHLYPREDNISOLONE SODIUM SUCCINATE FOR INJECTION 125 MG   2 Generic $25.00$62.50None
A-HYDROCORT 100MG VIAL   1 Preferred Generic $0.00$0.00None
A-METHAPRED 40MG UNIVIAL   2 Generic $25.00$62.50None
ABILIFY 10MG TABLET   4 Non-Preferred Generic and Non-Preferred Brand 55%55%Q:30
/30Days
ABILIFY 15MG TABLET   4 Non-Preferred Generic and Non-Preferred Brand 55%55%Q:30
/30Days
ABILIFY 1MG/ML SOLUTION   4 Non-Preferred Generic and Non-Preferred Brand 55%55%Q:900
/30Days
ABILIFY 20MG TABLET   4 Non-Preferred Generic and Non-Preferred Brand 55%55%Q:30
/30Days
ABILIFY 2MG TABLET   4 Non-Preferred Generic and Non-Preferred Brand 55%55%Q:30
/30Days
ABILIFY 30MG TABLET   4 Non-Preferred Generic and Non-Preferred Brand 55%55%Q:30
/30Days
ABILIFY 5MG TABLET (OTSUKA)   4 Non-Preferred Generic and Non-Preferred Brand 55%55%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ABILIFY DISCMELT 10MG TABLET   4 Non-Preferred Generic and Non-Preferred Brand 55%55%P Q:60
/30Days
ABILIFY DISCMELT 15MG TABLET   4 Non-Preferred Generic and Non-Preferred Brand 55%55%P Q:60
/30Days
ABILIFY INJ 9.75MG   4 Non-Preferred Generic and Non-Preferred Brand 55%55%None
ACARBOSE 100MG TABLET S   2 Generic $25.00$62.50None
ACARBOSE 50MG TABLET S   2 Generic $25.00$62.50None
ACARBOSE TABLETS   2 Generic $25.00$62.50None
ACCOLATE 10MG TABLET   4 Non-Preferred Generic and Non-Preferred Brand 55%55%Q:60
/30Days
ACCOLATE 20MG TABLET   4 Non-Preferred Generic and Non-Preferred Brand 55%55%Q:60
/30Days
ACEBUTOLOL 200MG CAPSULE   1 Preferred Generic $0.00$0.00None
ACEBUTOLOL 400MG CAPSULE   1 Preferred Generic $0.00$0.00None
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE   3 Preferred Brand 30%27%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD   1 Preferred Generic $0.00$0.00None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT)   1 Preferred Generic $0.00$0.00None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT)   1 Preferred Generic $0.00$0.00None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT)   1 Preferred Generic $0.00$0.00None
ACETASOL HC SOLUTION 10ML 10 ML BOT   4 Non-Preferred Generic and Non-Preferred Brand 55%55%None
ACETAZOLAMIDE 125MG TABLET   1 Preferred Generic $0.00$0.00None
ACETAZOLAMIDE 250MG TABLET (100 CT)   1 Preferred Generic $0.00$0.00None
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT   2 Generic $25.00$62.50None
ACETIC ACID 2% SOLUTION NON-ORAL   1 Preferred Generic $0.00$0.00None
ACETYLCYSTEINE 10% VIAL   1 Preferred Generic $0.00$0.00P
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN   1 Preferred Generic $0.00$0.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACIPHEX 20MG TABLET EC   4 Non-Preferred Generic and Non-Preferred Brand 55%55%S Q:30
/30Days
ACTHIB VACCINE VIAL 10-24UNT/5ML   4 Non-Preferred Generic and Non-Preferred Brand 55%55%None
ACTICIN 5% CREAM   1 Preferred Generic $0.00$0.00None
ACTIMMUNE SOLUTION FOR INJECTION 100MCG   5 Specialty Tier 33%N/ANone
ACTIVELLA 0.5-0.1MG TABLET 28 DLPK   4 Non-Preferred Generic and Non-Preferred Brand 55%55%None
ACTONEL 150MG TABLET   4 Non-Preferred Generic and Non-Preferred Brand 55%55%S Q:1
/30Days
ACTONEL 30MG TABLET   4 Non-Preferred Generic and Non-Preferred Brand 55%55%S Q:30
/30Days
ACTONEL 35MG TABLET   4 Non-Preferred Generic and Non-Preferred Brand 55%55%S Q:4
/28Days
ACTONEL 5MG TABLET   4 Non-Preferred Generic and Non-Preferred Brand 55%55%S Q:30
/30Days
ACTOPLUS MET 15MG/500MG TABLET   3 Preferred Brand 30%27%S Q:90
/30Days
ACTOPLUS MET 15MG/850MG TABLET   3 Preferred Brand 30%27%S Q:90
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACTOS 15MG TABLET   3 Preferred Brand 30%27%S Q:30
/30Days
ACTOS 30MG TABLET (500 CT)   3 Preferred Brand 30%27%S Q:30
/30Days
ACTOS 45MG TABLET   3 Preferred Brand 30%27%S Q:30
/30Days
ACUVAIL 0.45% OPHTH SOLUTION #30X0.4 EA   4 Non-Preferred Generic and Non-Preferred Brand 55%55%Q:60
/30Days
ACYCLOVIR 200MG CAPSULE (1000 CT)   1 Preferred Generic $0.00$0.00None
ACYCLOVIR 200MG/5ML SUSP   1 Preferred Generic $0.00$0.00None
ACYCLOVIR 400MG TABLET (100 CT)   1 Preferred Generic $0.00$0.00None
ACYCLOVIR 800 MG ORAL TABLET   1 Preferred Generic $0.00$0.00None
ADACEL VIAL 2UNT/5UNT   4 Non-Preferred Generic and Non-Preferred Brand 55%55%None
ADAGEN 250U/ML VIAL   5 Specialty Tier 33%N/AP
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA]   5 Specialty Tier 33%N/AP Q:2
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADCIRCA TABLETS 20MG 60 BOT   5 Specialty Tier 33%N/AP Q:60
/30Days
ADVAIR DISKU MIS 100/50   3 Preferred Brand 30%27%Q:60
/30Days
ADVAIR DISKU MIS 250/50   3 Preferred Brand 30%27%Q:60
/30Days
ADVAIR DISKU MIS 500/50   3 Preferred Brand 30%27%Q:60
/30Days
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL   3 Preferred Brand 30%27%Q:12
/30Days
ADVAIR HFA INHALER 230;21MCG;MCG   3 Preferred Brand 30%27%Q:12
/30Days
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL   3 Preferred Brand 30%27%Q:12
/30Days
ADVICOR ER 20-750MG TABLET (90 CT)   4 Non-Preferred Generic and Non-Preferred Brand 55%55%Q:60
/30Days
ADVICOR EXTENDED RELEASE TABLETS 20;1000MG;MG 90 BOTPL   4 Non-Preferred Generic and Non-Preferred Brand 55%55%Q:60
/30Days
ADVICOR EXTENDED RELEASE TABLETS 20;500MG;MG 90 BOTPL   4 Non-Preferred Generic and Non-Preferred Brand 55%55%Q:30
/30Days
ADVICOR EXTENDED RELEASE TABLETS 40;1000MG;MG 90 BOTPL   4 Non-Preferred Generic and Non-Preferred Brand 55%55%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AEROBID-M AEROSOL W/ADAPTER   4 Non-Preferred Generic and Non-Preferred Brand 55%55%Q:21
/30Days
AFEDITAB CR 30MG TABLET SA   1 Preferred Generic $0.00$0.00None
AFEDITAB CR 60MG TABLET SA   1 Preferred Generic $0.00$0.00None
AFINITOR TABLETS   5 Specialty Tier 33%N/AP Q:30
/30Days
AFINITOR TABLETS   5 Specialty Tier 33%N/AP Q:30
/30Days
AFINITOR TABLETS 5 MG   5 Specialty Tier 33%N/AP Q:30
/30Days
AGGRENOX 25-200MG CAPSULE   4 Non-Preferred Generic and Non-Preferred Brand 55%55%Q:60
/30Days
AK-CON 0.1% EYE DROPS   1 Preferred Generic $0.00$0.00None
AKNE-MYCIN 2% OINTMENT   4 Non-Preferred Generic and Non-Preferred Brand 55%55%None
AKTOB 0.3% EYE DROPS   1 Preferred Generic $0.00$0.00None
ALAMAST 0.1% DROPS   4 Non-Preferred Generic and Non-Preferred Brand 55%55%Q:20
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALBENZA 200MG TABLET   4 Non-Preferred Generic and Non-Preferred Brand 55%55%None
ALBUTEROL SULFATE 0.63MG/3ML VIAL NEBULIZER   4 Non-Preferred Generic and Non-Preferred Brand 55%55%P
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER   4 Non-Preferred Generic and Non-Preferred Brand 55%55%P
ALBUTEROL SULFATE 4MG TABLET SR 12HR   2 Generic $25.00$62.50None
ALBUTEROL SULFATE 8MG TABLET SR 12HR   2 Generic $25.00$62.50None
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   1 Preferred Generic $0.00$0.00P
ALBUTEROL SULFATE SOLUTION FOR INHALATION   1 Preferred Generic $0.00$0.00P
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT   1 Preferred Generic $0.00$0.00None
ALBUTEROL SULFATE TABLET 2MG (500 CT)   1 Preferred Generic $0.00$0.00None
ALBUTEROL TABLET 4MG (500 CT)   1 Preferred Generic $0.00$0.00None
ALCLOMETASONE DIPROPIONATE 0.05% CREAM   1 Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALCLOMETASONE DIPROPIONATE 0.05% OINTMENT   1 Preferred Generic $0.00$0.00None
ALDURAZYME 2.9MG/5ML VIAL   5 Specialty Tier 33%N/AP
ALENDRONATE SODIUM 10MG TABLET   1 Preferred Generic $0.00$0.00None
ALENDRONATE SODIUM 40MG TABLET   1 Preferred Generic $0.00$0.00None
ALENDRONATE SODIUM 5MG TABLET   1 Preferred Generic $0.00$0.00None
ALENDRONATE SODIUM TABLET 35MG 20 CRTN   1 Preferred Generic $0.00$0.00None
ALENDRONATE SODIUM TABLETS 70 MG   1 Preferred Generic $0.00$0.00None
ALIMTA 500MG VIAL   5 Specialty Tier 33%N/AP
ALINIA 100MG/5ML SUSPENSION   4 Non-Preferred Generic and Non-Preferred Brand 55%55%None
ALINIA 500MG TABLET   4 Non-Preferred Generic and Non-Preferred Brand 55%55%None
ALLOPURINOL TABLET 300MG (1000 CT)   1 Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALLOPURINOL TABLETS   1 Preferred Generic $0.00$0.00None
ALOCRIL 2% EYE DROPS   4 Non-Preferred Generic and Non-Preferred Brand 55%55%Q:10
/30Days
ALOMIDE 0.1% EYE DROPS   4 Non-Preferred Generic and Non-Preferred Brand 55%55%None
ALORA 0.025MG PATCH   4 Non-Preferred Generic and Non-Preferred Brand 55%55%Q:8
/28Days
ALORA 0.05MG PATCH   4 Non-Preferred Generic and Non-Preferred Brand 55%55%Q:8
/28Days
ALORA 0.075MG PATCH   4 Non-Preferred Generic and Non-Preferred Brand 55%55%Q:8
/28Days
ALORA 0.1MG PATCH   4 Non-Preferred Generic and Non-Preferred Brand 55%55%Q:8
/28Days
ALPHA-1-PROTEINASE INHIBITOR,HUMAN 16 MG/ML INJECTABLE SOLUTION [ARALAST]   5 Specialty Tier 33%N/AP
ALPHAGAN P 0.1% DROPS   3 Preferred Brand 30%27%Q:10
/30Days
ALPHAGAN P 0.15% EYE DROPS   3 Preferred Brand 30%27%Q:10
/30Days
ALREX 0.2% EYE DROPS   3 Preferred Brand 30%27%Q:15
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALTOPREV 20MG TABLET SR 24HR   4 Non-Preferred Generic and Non-Preferred Brand 55%55%S Q:30
/30Days
ALTOPREV 40MG TABLET SR 24HR   4 Non-Preferred Generic and Non-Preferred Brand 55%55%S Q:30
/30Days
ALTOPREV 60MG TABLET SR 24HR   4 Non-Preferred Generic and Non-Preferred Brand 55%55%S Q:30
/30Days
ALVESCO 160MCG/ACT AERS   4 Non-Preferred Generic and Non-Preferred Brand 55%55%Q:12
/30Days
ALVESCO 80MCG/ACT AERS   4 Non-Preferred Generic and Non-Preferred Brand 55%55%Q:12
/30Days
AMANTADINE 100MG CAPSULE   2 Generic $25.00$62.50None
AMANTADINE 100MG TABLET   2 Generic $25.00$62.50None
AMCINONIDE 0.1% CREAM   1 Preferred Generic $0.00$0.00None
AMCINONIDE 0.1% LOTION   1 Preferred Generic $0.00$0.00None
AMCINONIDE 0.1% OINTMENT 60GM TUBE   1 Preferred Generic $0.00$0.00None
AMERGE 1MG TABLET   4 Non-Preferred Generic and Non-Preferred Brand 55%55%S Q:9
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMERGE 2.5MG TABLET   4 Non-Preferred Generic and Non-Preferred Brand 55%55%S Q:9
/30Days
AMIFOSTINE FOR INJECTION 500MG/VIAL   5 Specialty Tier 33%N/ANone
AMIKACIN 250MG/ML VIAL   2 Generic $25.00$62.50None
AMIKACIN 50MG/ML VIAL   2 Generic $25.00$62.50None
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET   1 Preferred Generic $0.00$0.00None
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT   2 Generic $25.00$62.50None
AMINOPHYLLINE 100MG TABLET   1 Preferred Generic $0.00$0.00None
AMINOPHYLLINE 200MG TABLET (1000 CT)   1 Preferred Generic $0.00$0.00None
AMINOPHYLLINE INJECTION 250MG 10ML X 25 VIALSD   1 Preferred Generic $0.00$0.00None
AMINOSYN 10% IV SOLUTION   4 Non-Preferred Generic and Non-Preferred Brand 55%55%P
AMINOSYN 3.5% IV SOLUTION   4 Non-Preferred Generic and Non-Preferred Brand 55%55%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN 5% IV SOLUTION   4 Non-Preferred Generic and Non-Preferred Brand 55%55%P
AMINOSYN 7% IV SOLUTION   4 Non-Preferred Generic and Non-Preferred Brand 55%55%P
AMINOSYN 7%-ELECTROLYTE SOL   4 Non-Preferred Generic and Non-Preferred Brand 55%55%P
AMINOSYN 8.5% IV SOLUTION   4 Non-Preferred Generic and Non-Preferred Brand 55%55%P
AMINOSYN HBC INJECTION SULFITE FREE 7%   4 Non-Preferred Generic and Non-Preferred Brand 55%55%P
AMINOSYN II 10% IV SOLUTION   4 Non-Preferred Generic and Non-Preferred Brand 55%55%P
AMINOSYN II 15% IV SOLUTION   4 Non-Preferred Generic and Non-Preferred Brand 55%55%P
AMINOSYN II 3.5% IN D25W IV   4 Non-Preferred Generic and Non-Preferred Brand 55%55%P
AMINOSYN II 3.5% IN D5W IV   4 Non-Preferred Generic and Non-Preferred Brand 55%55%P
AMINOSYN II 3.5% M/D5W IV   4 Non-Preferred Generic and Non-Preferred Brand 55%55%P
AMINOSYN II 3.5% W/ELEC DEX   4 Non-Preferred Generic and Non-Preferred Brand 55%55%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN II 4.25% IN D10W   4 Non-Preferred Generic and Non-Preferred Brand 55%55%P
AMINOSYN II 4.25% IN D20W   4 Non-Preferred Generic and Non-Preferred Brand 55%55%P
AMINOSYN II 4.25% W/ELEC DW   4 Non-Preferred Generic and Non-Preferred Brand 55%55%P
AMINOSYN II 4.25%-D25W IV   4 Non-Preferred Generic and Non-Preferred Brand 55%55%P
AMINOSYN II 5% IN D25W IV   4 Non-Preferred Generic and Non-Preferred Brand 55%55%P
AMINOSYN II 7% IV SOLUTION   4 Non-Preferred Generic and Non-Preferred Brand 55%55%P
AMINOSYN II 8.5% ELECTROLYT   4 Non-Preferred Generic and Non-Preferred Brand 55%55%P
AMINOSYN II 8.5% IV SOLUTION   4 Non-Preferred Generic and Non-Preferred Brand 55%55%P
AMINOSYN M 3.5% IV SOLUTION   4 Non-Preferred Generic and Non-Preferred Brand 55%55%P
AMINOSYN PF INJECTION   4 Non-Preferred Generic and Non-Preferred Brand 55%55%P
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5%   4 Non-Preferred Generic and Non-Preferred Brand 55%55%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN-HF 8% IV SOLUTION   4 Non-Preferred Generic and Non-Preferred Brand 55%55%P
AMINOSYN-PF 7% IV SOLUTION   4 Non-Preferred Generic and Non-Preferred Brand 55%55%P
AMIODARONE HCL 400MG TABLET   1 Preferred Generic $0.00$0.00None
AMIODARONE HYDROCHLORIDE TABLETS   1 Preferred Generic $0.00$0.00None
AMITIZA 8MCG CAPSULE   4 Non-Preferred Generic and Non-Preferred Brand 55%55%S Q:60
/30Days
AMITIZA CAPSULES 24MCG 60 CAP BOT   4 Non-Preferred Generic and Non-Preferred Brand 55%55%S Q:60
/30Days
AMITRIP/CDP 25-10 TABLET   4 Non-Preferred Generic and Non-Preferred Brand 55%55%None
AMITRIP/PERPHEN 10-2 TABLET   1 Preferred Generic $0.00$0.00None
AMITRIP/PERPHEN 10-4 TABLET   1 Preferred Generic $0.00$0.00None
AMITRIP/PERPHEN 25-2 TABLET   1 Preferred Generic $0.00$0.00None
AMITRIP/PERPHEN 25-4 TABLET   1 Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITRIP/PERPHEN 50-4 TABLET   1 Preferred Generic $0.00$0.00None
AMITRIPTYLINE HCL 100MG TABLET   1 Preferred Generic $0.00$0.00None
AMITRIPTYLINE HCL 10MG TABLET   1 Preferred Generic $0.00$0.00None
AMITRIPTYLINE HCL 150 MG TAB   1 Preferred Generic $0.00$0.00None
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)   1 Preferred Generic $0.00$0.00None
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)   1 Preferred Generic $0.00$0.00None
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT   1 Preferred Generic $0.00$0.00None
AMLODIPINE 10 MG / TELMISARTAN 40 MG ORAL TABLET [TWYNSTA 40/10]   4 Non-Preferred Generic and Non-Preferred Brand 55%55%Q:30
/30Days
AMLODIPINE 10 MG / TELMISARTAN 80 MG ORAL TABLET [TWYNSTA 80/10]   4 Non-Preferred Generic and Non-Preferred Brand 55%55%Q:30
/30Days
AMLODIPINE 5 MG / TELMISARTAN 40 MG ORAL TABLET [TWYNSTA 40/5]   4 Non-Preferred Generic and Non-Preferred Brand 55%55%Q:30
/30Days
AMLODIPINE 5 MG / TELMISARTAN 80 MG ORAL TABLET [TWYNSTA 80/5]   4 Non-Preferred Generic and Non-Preferred Brand 55%55%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE BESYLATE 10MG TABLET (90 CT)   1 Preferred Generic $0.00$0.00None
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)   1 Preferred Generic $0.00$0.00None
AMLODIPINE BESYLATE 5MG TABLET (90 CT)   1 Preferred Generic $0.00$0.00None
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE CAPSULES   4 Non-Preferred Generic and Non-Preferred Brand 55%55%Q:30
/30Days
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE CAPSULES   4 Non-Preferred Generic and Non-Preferred Brand 55%55%Q:30
/30Days
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE   4 Non-Preferred Generic and Non-Preferred Brand 55%55%Q:30
/30Days
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE   4 Non-Preferred Generic and Non-Preferred Brand 55%55%Q:30
/30Days
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE   4 Non-Preferred Generic and Non-Preferred Brand 55%55%Q:30
/30Days
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE   4 Non-Preferred Generic and Non-Preferred Brand 55%55%Q:60
/30Days
AMMONIUM LACTATE 12% CREAM   1 Preferred Generic $0.00$0.00None
AMMONIUM LACTATE 12% LOTION   1 Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMNESTEEM 10MG CAPSULE   4 Non-Preferred Generic and Non-Preferred Brand 55%55%None
AMNESTEEM 20MG CAPSULE   4 Non-Preferred Generic and Non-Preferred Brand 55%55%None
AMNESTEEM 40MG CAPSULE   4 Non-Preferred Generic and Non-Preferred Brand 55%55%None
AMOX TR-K CLV 500-125 MG TAB   2 Generic $25.00$62.50None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL   2 Generic $25.00$62.50None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE   2 Generic $25.00$62.50None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET   2 Generic $25.00$62.50None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE   2 Generic $25.00$62.50None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   2 Generic $25.00$62.50None
AMOXAPINE 100MG TABLET   2 Generic $25.00$62.50None
AMOXAPINE 150MG TABLET   2 Generic $25.00$62.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXAPINE 25MG TABLET   2 Generic $25.00$62.50None
AMOXAPINE 50MG TABLET   2 Generic $25.00$62.50None
AMOXICILLIN 125MG TABLET CHEW   1 Preferred Generic $0.00$0.00None
AMOXICILLIN 200MG TABLET CHEW   1 Preferred Generic $0.00$0.00None
AMOXICILLIN 250MG CAPSULE   1 Preferred Generic $0.00$0.00None
AMOXICILLIN 400MG TABLET CHEW   1 Preferred Generic $0.00$0.00None
AMOXICILLIN 50 MG/ML / CLAVULANATE 12.5 MG/ML ORAL SUSPENSION   2 Generic $25.00$62.50None
AMOXICILLIN 500MG CAPSULE   1 Preferred Generic $0.00$0.00None
AMOXICILLIN 500MG TABLET (100 CT)   1 Preferred Generic $0.00$0.00None
AMOXICILLIN 875MG TABLET   1 Preferred Generic $0.00$0.00None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT   2 Generic $25.00$62.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS EXTENDED RELEASE 1000;62.5MG;MG   4 Non-Preferred Generic and Non-Preferred Brand 55%55%None
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT   2 Generic $25.00$62.50None
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT   1 Preferred Generic $0.00$0.00None
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL   1 Preferred Generic $0.00$0.00None
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   1 Preferred Generic $0.00$0.00None
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL   1 Preferred Generic $0.00$0.00None
AMOXICILLIN TABLET USP CHEWABLE 250MG (250 CT)   1 Preferred Generic $0.00$0.00None
AMPHETAMINE SALT COMBO 12.5MG TABLET   2 Generic $25.00$62.50None
AMPHETAMINE SALT COMBO 15MG TABLET   2 Generic $25.00$62.50None
AMPHETAMINE SALT COMBO 30MG TABLET   2 Generic $25.00$62.50None
AMPHETAMINE SALT COMBO 7.5MG TABLET   2 Generic $25.00$62.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPHETAMINE SALTS 20MG TABLET   2 Generic $25.00$62.50None
AMPHETAMINE SALTS 5 MG TAB   2 Generic $25.00$62.50None
AMPICILLIN AND SULBACTAM FOR INJECTION 10-5 1 VIAL   4 Non-Preferred Generic and Non-Preferred Brand 55%55%None
AMPICILLIN AND SULBACTAM FOR INJECTION 2-1 10 VIAL   4 Non-Preferred Generic and Non-Preferred Brand 55%55%None
AMPICILLIN CAPSULES 250MG 100 BOT   1 Preferred Generic $0.00$0.00None
AMPICILLIN CAPSULES 500MG 100 BOT   1 Preferred Generic $0.00$0.00None
AMPICILLIN FOR INJECTION POWDER   2 Generic $25.00$62.50None
AMPICILLIN FOR INJECTION USP 125MG/ML 1 VIAL   2 Generic $25.00$62.50None
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT   1 Preferred Generic $0.00$0.00None
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT   1 Preferred Generic $0.00$0.00None
AMPICILLIN POWDER FOR INJECTION 1 GM/ML   2 Generic $25.00$62.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMYLASES 109000 UNT / ENDOPEPTIDASES 68000 UNT / LIPASE 20000 UNT ENTERIC COATED CAPSULE [ZENPEP 20]   3 Preferred Brand 30%27%None
AMYLASES 27000 UNT / ENDOPEPTIDASES 17000 UNT / LIPASE 5000 UNT ENTERIC COATED CAPSULE [ZENPEP 5]   3 Preferred Brand 30%27%None
AMYLASES 55000 UNT / ENDOPEPTIDASES 34000 UNT / LIPASE 10000 UNT ENTERIC COATED CAPSULE [ZENPEP 10]   3 Preferred Brand 30%27%None
AMYLASES 82000 UNT / ENDOPEPTIDASES 51000 UNT / LIPASE 15000 UNT ENTERIC COATED CAPSULE [ZENPEP 15]   3 Preferred Brand 30%27%None
ANADROL-50 50MG TABLET (100 CT)   3 Preferred Brand 30%27%P
ANAGRELIDE HCL 0.5MG CAPSULE   2 Generic $25.00$62.50None
ANAGRELIDE HCL 1MG CAPSULE   2 Generic $25.00$62.50None
ANASTROZOLE TABLETS   2 Generic $25.00$62.50Q:30
/30Days
ANCOBON 250MG CAPSULE   5 Specialty Tier 33%N/ANone
ANCOBON 500MG CAPSULE   5 Specialty Tier 33%N/ANone
ANDROGEL 1%(50MG) GEL PACKET   3 Preferred Brand 30%27%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANESTACON 15ML   1 Preferred Generic $0.00$0.00None
ANGELIQ 1-0.5MG TABLET   4 Non-Preferred Generic and Non-Preferred Brand 55%55%Q:30
/30Days
ANTABUSE 250MG TABLET   3 Preferred Brand 30%27%None
ANTABUSE 500MG TABLET   3 Preferred Brand 30%27%None
ANTARA CAPSULES   4 Non-Preferred Generic and Non-Preferred Brand 55%55%Q:30
/30Days
ANTARA CAPSULES   4 Non-Preferred Generic and Non-Preferred Brand 55%55%Q:30
/30Days
APAP-CAFFEINE-DIHYDROCODE TAB 30 EA   4 Non-Preferred Generic and Non-Preferred Brand 55%55%None
APHTHASOL 5% PASTE   3 Preferred Brand 30%27%None
APOKYN 30 MG/3 ML CARTRIDGE   5 Specialty Tier 33%N/AP
APRACLONIDINE 5 MG/ML OPHTHALMIC SOLUTION   2 Generic $25.00$62.50None
APRI 0.15-0.03 TABLET   4 Non-Preferred Generic and Non-Preferred Brand 55%55%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
APRISO CP24   4 Non-Preferred Generic and Non-Preferred Brand 55%55%Q:120
/30Days
APTIVUS 250MG CAPSULE   5 Specialty Tier 33%N/ANone
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT   5 Specialty Tier 33%N/ANone
ARANELLE 7-9-5 TABLET   4 Non-Preferred Generic and Non-Preferred Brand 55%55%None
ARCALYST INJECTION 220MG/VIAL   5 Specialty Tier 33%N/AP Q:8
/30Days
ARICEPT ODT 10MG TABLET   3 Preferred Brand 30%27%Q:30
/30Days
ARICEPT ODT 5MG TABLET   3 Preferred Brand 30%27%Q:30
/30Days
ARIMIDEX 1MG TABLET   3 Preferred Brand 30%27%Q:30
/30Days
ARIXTRA 10MG SYRINGE   5 Specialty Tier 33%N/AP
ARIXTRA 2.5MG SYRINGE   4 Non-Preferred Generic and Non-Preferred Brand 55%55%P
ARIXTRA 5MG SYRINGE   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARIXTRA 7.5MG SYRINGE   5 Specialty Tier 33%N/AP
ARMODAFINIL 150 MG ORAL TABLET [NUVIGIL]   4 Non-Preferred Generic and Non-Preferred Brand 55%55%P Q:30
/30Days
ARMODAFINIL 250 MG ORAL TABLET [NUVIGIL]   4 Non-Preferred Generic and Non-Preferred Brand 55%55%P Q:30
/30Days
ARMODAFINIL 50 MG ORAL TABLET [NUVIGIL]   4 Non-Preferred Generic and Non-Preferred Brand 55%55%P Q:30
/30Days
AROMASIN 25MG TABLET   4 Non-Preferred Generic and Non-Preferred Brand 55%55%None
ARTHROTEC 50 50MG TABLET -200MCG (60 CT)   4 Non-Preferred Generic and Non-Preferred Brand 55%55%S
ARTHROTEC 75 TABLET EC   4 Non-Preferred Generic and Non-Preferred Brand 55%55%S
ASACOL 400MG TABLET EC   3 Preferred Brand 30%27%None
ASCOMP W/CODEINE 30-50-325 CAPSULE   4 Non-Preferred Generic and Non-Preferred Brand 55%55%None
ASENAPINE 10 MG SUBLINGUAL TABLET [SAPHRIS]   4 Non-Preferred Generic and Non-Preferred Brand 55%55%Q:60
/30Days
ASENAPINE 5 MG SUBLINGUAL TABLET [SAPHRIS]   4 Non-Preferred Generic and Non-Preferred Brand 55%55%Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ASMANEX TWISTHALER 110 MCG #30   3 Preferred Brand 30%27%Q:1
/30Days
ASMANEX TWISTHALER 220MCG #120   3 Preferred Brand 30%27%Q:1
/30Days
ASMANEX TWISTHALER 220MCG #30   3 Preferred Brand 30%27%Q:1
/30Days
ASMANEX TWISTHALER 220MCG #60   3 Preferred Brand 30%27%Q:1
/30Days
ASTEPRO 0.15% NASAL SPRAY 30 ML   3 Preferred Brand 30%27%Q:30
/25Days
ATACAND 16MG TABLET   4 Non-Preferred Generic and Non-Preferred Brand 55%55%S Q:30
/30Days
ATACAND 32MG TABLET   4 Non-Preferred Generic and Non-Preferred Brand 55%55%S Q:30
/30Days
ATACAND 4MG TABLET   4 Non-Preferred Generic and Non-Preferred Brand 55%55%S Q:30
/30Days
ATACAND 8MG TABLET   4 Non-Preferred Generic and Non-Preferred Brand 55%55%S Q:30
/30Days
ATACAND HCT 16/12.5MG TABLET   4 Non-Preferred Generic and Non-Preferred Brand 55%55%S Q:30
/30Days
ATACAND HCT 32/12.5MG TABLET   4 Non-Preferred Generic and Non-Preferred Brand 55%55%S Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATACAND HCT TABLETS 32;25MG;MG 90 TABLETS BOT   4 Non-Preferred Generic and Non-Preferred Brand 55%55%S Q:30
/30Days
ATENOLOL 25MG TABLET (100 CT)   1 Preferred Generic $0.00$0.00None
ATENOLOL TABLET USP 50MG (100 CT)   1 Preferred Generic $0.00$0.00None
ATENOLOL TABLETS USP 100MG 1 BLPK   1 Preferred Generic $0.00$0.00None
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT)   1 Preferred Generic $0.00$0.00None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   1 Preferred Generic $0.00$0.00None
ATRIPLA TABLET 600MG/200MG   5 Specialty Tier 33%N/AQ:30
/30Days
ATROPINE 0.025 MG / DIPHENOXYLATE 2.5 MG ORAL TABLET   1 Preferred Generic $0.00$0.00None
ATROVENT HFA AER 17MCG   3 Preferred Brand 30%27%Q:26
/30Days
ATTENUVAX VACCINE W/DILUENT 1 DOSE/0.5ML   4 Non-Preferred Generic and Non-Preferred Brand 55%55%None
AVALIDE 150-12.5MG TABLET   3 Preferred Brand 30%27%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVALIDE 300-12.5MG TABLET   3 Preferred Brand 30%27%Q:30
/30Days
AVALIDE 300-25MG TABLET   3 Preferred Brand 30%27%Q:30
/30Days
AVANDAMET 2MG/1000MG TABLET   3 Preferred Brand 30%27%S Q:60
/30Days
AVANDAMET 2MG/500MG TABLET   3 Preferred Brand 30%27%S Q:60
/30Days
AVANDAMET 4MG/500MG TABLET   3 Preferred Brand 30%27%S Q:60
/30Days
AVANDAMET TABLET 4-1000MG   3 Preferred Brand 30%27%S Q:60
/30Days
AVANDARYL 4MG/1MG TABLET   3 Preferred Brand 30%27%S Q:60
/30Days
AVANDARYL 4MG/2MG TABLET   3 Preferred Brand 30%27%S Q:60
/30Days
AVANDARYL 4MG/4MG TABLET   3 Preferred Brand 30%27%S Q:60
/30Days
AVANDARYL 8MG-2MG TABLET   3 Preferred Brand 30%27%S Q:30
/30Days
AVANDARYL 8MG-4MG TABLET   3 Preferred Brand 30%27%S Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVANDIA 2MG TABLET   3 Preferred Brand 30%27%S Q:60
/30Days
AVANDIA 4MG TABLET (90 CT)   3 Preferred Brand 30%27%S Q:60
/30Days
AVANDIA 8MG TABLET (90 CT)   3 Preferred Brand 30%27%S Q:30
/30Days
AVAPRO 150MG TABLET   3 Preferred Brand 30%27%Q:30
/30Days
AVAPRO 300MG TABLET   3 Preferred Brand 30%27%Q:30
/30Days
AVAPRO 75MG TABLET (30 CT)   3 Preferred Brand 30%27%Q:30
/30Days
AVASTIN 100MG/4ML VIAL   5 Specialty Tier 33%N/AP
AVELOX 400MG TABLET   4 Non-Preferred Generic and Non-Preferred Brand 55%55%Q:30
/30Days
AVELOX ABC PACK 400MG TABLET   4 Non-Preferred Generic and Non-Preferred Brand 55%55%Q:30
/30Days
AVELOX IV 400MG/250ML   4 Non-Preferred Generic and Non-Preferred Brand 55%55%None
AVIANE 0.1-0.02 TABLET   4 Non-Preferred Generic and Non-Preferred Brand 55%55%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVITA 0.025% CREAM   2 Generic $25.00$62.50None
AVODART 0.5MG SOFTGEL   3 Preferred Brand 30%27%Q:30
/30Days
AVONEX ADMIN PACK 30MCG SYR   5 Specialty Tier 33%N/AP Q:4
/30Days
AVONEX ADMIN PACK 30MCG VL   5 Specialty Tier 33%N/AP Q:4
/30Days
AXERT 12.5MG TABLET   4 Non-Preferred Generic and Non-Preferred Brand 55%55%S Q:8
/30Days
AXERT 6.25MG TABLET   4 Non-Preferred Generic and Non-Preferred Brand 55%55%S Q:8
/30Days
AZACTAM INJECTION   3 Preferred Brand 30%27%None
AZACTAM INJECTION 1GM/50ML   3 Preferred Brand 30%27%None
AZACTAM INJECTION 2GM/VIL   3 Preferred Brand 30%27%None
AZASITE 1% DROPS   3 Preferred Brand 30%27%Q:3
/14Days
AZATHIOPRINE 50MG TABLET   1 Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZELASTINE 137 MCG NASAL SPRAY   4 Non-Preferred Generic and Non-Preferred Brand 55%55%None
AZELASTINE HYDROCHLORIDE OPHTHALMIC SOLUTION   4 Non-Preferred Generic and Non-Preferred Brand 55%55%None
AZELEX 20% CREAM 30GM TUBE   4 Non-Preferred Generic and Non-Preferred Brand 55%55%None
AZILECT 0.5MG TABLET   4 Non-Preferred Generic and Non-Preferred Brand 55%55%S Q:30
/30Days
AZILECT 1MG TABLET   4 Non-Preferred Generic and Non-Preferred Brand 55%55%S Q:30
/30Days
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Preferred Generic $0.00$0.00None
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Preferred Generic $0.00$0.00None
AZITHROMYCIN 250 MG TABLET   1 Preferred Generic $0.00$0.00None
AZITHROMYCIN 500MG TABLET (30 CT)   1 Preferred Generic $0.00$0.00None
AZITHROMYCIN FOR INJECTION 500MG 10 VIALSD   1 Preferred Generic $0.00$0.00None
AZITHROMYCIN TABLETS   1 Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT   4 Non-Preferred Generic and Non-Preferred Brand 55%55%None
AZTREONAM FOR INJECTION   2 Generic $25.00$62.50None

Chart Legend:

Below are a few notes to help you understand the above 2011 Medicare Part D First Health Part D Premier Plus (PDP) Plan Formulary.
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  • 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 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 wit 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 which tier the drug is in. 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.