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2011 Medicare Part D Plan Formulary Information
Humana Walmart-Preferred Rx Plan (PDP) (S5884-104-0) Benefit Details
The Humana Walmart-Preferred Rx Plan (PDP) (S5884-104-0) Formulary Drugs Starting with the Letter B in CMS PDP Region 6 which includes: PA WV
Drugs Starting with Letter B Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter B Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BACITRACIN 500U/GM EYE OINT	2	Generic	$5.00	$0.00	None
BACITRACIN INJ 50000UNT	2	Generic	$5.00	$0.00	None
BACITRACIN/POLYMYXIN B OINT 500UNT/10000UNT	2	Generic	$5.00	$0.00	None
BACLOFEN 10MG TABLET	1	Preferred Generic	$2.00	$0.00	None
BACLOFEN 20MG TABLET	2	Generic	$5.00	$0.00	None
BACTRIM 400-80MG TABLET	4	Non-Preferred Brand	35%	35%	None
BACTRIM DS TABLET 800-160	4	Non-Preferred Brand	35%	35%	None
BACTROBAN 2% CREAM	4	Non-Preferred Brand	35%	35%	None
BALSALAZIDE DISODIUM 750MG CAPSULE (280 CT)	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
BANZEL TABLET	4	Non-Preferred Brand	35%	35%	P Q:480 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BANZEL TABLET	4	Non-Preferred Brand	35%	35%	P Q:240 /30Days
BARACLUDE 0.05MG/ML SOLUTION	4	Non-Preferred Brand	35%	35%	Q:630 /30Days
BARACLUDE 0.5MG TABLET	4	Non-Preferred Brand	35%	35%	Q:30 /30Days
BARACLUDE 1MG TABLET	4	Non-Preferred Brand	35%	35%	Q:30 /30Days
BENAZEPRIL HCL 10MG TABLET	1	Preferred Generic	$2.00	$0.00	None
BENAZEPRIL HCL 20MG TABLET (100 CT)	1	Preferred Generic	$2.00	$0.00	None
BENAZEPRIL HCL 40MG TABLET	1	Preferred Generic	$2.00	$0.00	None
BENAZEPRIL HCL 5MG TABLET	1	Preferred Generic	$2.00	$0.00	None
BENAZEPRIL HCL-HCTZ TABLET 10-12.5MG (100 CT)	2	Generic	$5.00	$0.00	None
BENAZEPRIL HCL-HCTZ TABLET 20-12.5MG (100 CT)	2	Generic	$5.00	$0.00	None
BENAZEPRIL HCL-HCTZ TABLET 20-25MG (100 CT)	2	Generic	$5.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BENAZEPRIL HCL-HCTZ TABLET 5-6.25MG (100 CT)	2	Generic	$5.00	$0.00	None
BENTYL 10MG CAPSULE	4	Non-Preferred Brand	35%	35%	None
BENTYL 10MG/5ML SYRUP	4	Non-Preferred Brand	35%	35%	None
BENTYL 20MG TABLET	4	Non-Preferred Brand	35%	35%	None
BENTYL INJECTION 20MG/2ML AMP	4	Non-Preferred Brand	35%	35%	None
BENZOYL PEROXIDE 0.05 MG/MG / CLINDAMYCIN 0.01 MG/MG TOPICAL GEL	2	Generic	$5.00	$0.00	None
BENZTROPINE MES TABLET 1MG (1000 CT)	2	Generic	$5.00	$0.00	None
BENZTROPINE MES TABLET 2MG (1000 CT)	1	Preferred Generic	$2.00	$0.00	None
BENZTROPINE MESYLATE INJECTION 2MG/2ML	2	Generic	$5.00	$0.00	None
BENZTROPINE MESYLATE TABLETS	2	Generic	$5.00	$0.00	None
BESIVANCE BESIFLOACIN OPTHALMIC SUSPENSION 0.6% 5 ML BOTDR	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
BETAMETHASONE DIPROPIONATE 0.05% CREAM	2	Generic	$5.00	$0.00	None
BETAMETHASONE DIPROPIONATE 0.05% GEL	2	Generic	$5.00	$0.00	None
BETAMETHASONE DIPROPIONATE CREAM USP	1	Preferred Generic	$2.00	$0.00	None
BETAMETHASONE DIPROPIONATE LOTION	2	Generic	$5.00	$0.00	None
BETAMETHASONE DIPROPIONATE LOTION 60ML	2	Generic	$5.00	$0.00	None
BETAMETHASONE DIPROPIONATE OINTMENT AUGMENTED	2	Generic	$5.00	$0.00	None
BETAMETHASONE DP 0.05% OINTMENT	2	Generic	$5.00	$0.00	None
BETAMETHASONE VA 0.1% LOTION	2	Generic	$5.00	$0.00	None
BETAMETHASONE VALERATE CREAM USP	1	Preferred Generic	$2.00	$0.00	None
BETAMETHASONE VALERATE OINTMENT USP	1	Preferred Generic	$2.00	$0.00	None
BETASERON KIT 0.3MG/VIAL 14 TRAY BOX PKGCOM	4	Non-Preferred Brand	35%	35%	P Q:15 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BETAXOLOL HCL 0.5% EYE DROP	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
BETAXOLOL TABLETS 10MG 100 BOT	2	Generic	$5.00	$0.00	None
BETAXOLOL TABLETS 20MG 100 BOT	2	Generic	$5.00	$0.00	None
BETHANECHOL CHLORICDE TABLET	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
BETHANECHOL CHLORIDE 50MG TABLET (100 CT)	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
BETHANECHOL CHLORIDE 5MG TABLET	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
BETHANECHOL CHLORIDE TABLETS	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
BETIMOL 0.5% EYE DROPS	4	Non-Preferred Brand	35%	35%	None
BETIMOL SOLUTION 2.5MG 5 ML BOT	4	Non-Preferred Brand	35%	35%	None
BICALUTAMIDE TABLETS 50MG 100 BOT	2	Generic	$5.00	$0.00	Q:30 /30Days
BICNU INJECTION 100MG/VIL	4	Non-Preferred Brand	35%	35%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BIDIL TABLET 20MG/37.5MG	3	Non-Preferred Generic/Preferred Brand	20%	20%	Q:180 /30Days
BILTRICIDE 600MG TABLET	4	Non-Preferred Brand	35%	35%	None
BISOPROLOL FUMARATE 10MG TABLET (100 CT)	2	Generic	$5.00	$0.00	None
BISOPROLOL FUMARATE 5MG TABLET (100 CT)	2	Generic	$5.00	$0.00	None
BISOPROLOL FUMARATE-HCTZ TABLET 10-6.25MG (500 CT)	1	Preferred Generic	$2.00	$0.00	None
BISOPROLOL FUMARATE-HCTZ TABLET 2.5-6.25MG (100 CT)	1	Preferred Generic	$2.00	$0.00	None
BISOPROLOL FUMARATE-HCTZ TABLET 5-6.25MG (100 CT)	1	Preferred Generic	$2.00	$0.00	None
BLEOMYCIN SULFATE 30UNITS VIA	3	Non-Preferred Generic/Preferred Brand	20%	20%	P
BLEPH-10 10% EYE DROPS	4	Non-Preferred Brand	35%	35%	None
BLEPHAMIDE 0.2% EYE DROPS	4	Non-Preferred Brand	35%	35%	None
BLEPHAMIDE 10-0.2% EYE OINT	4	Non-Preferred Brand	35%	35%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BONIVA 150MG TABLET	4	Non-Preferred Brand	35%	35%	Q:1 /28Days
BOOSTRIX INJECTION	4	Non-Preferred Brand	35%	35%	None
BOROFAIR SOL 2% OTIC	2	Generic	$5.00	$0.00	None
BOTOX 100UNITS VIAL	4	Non-Preferred Brand	35%	35%	P
BREVICON TABLET 0.5/35	4	Non-Preferred Brand	35%	35%	None
BRIMONIDINE TARTRATE OPHTHALMIC SOLUTION 0.2% 10ML BOTPL	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
BROMOCRIPTINE MESYLATE 2.5MG TABLET	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
BROMOCRIPTINE MESYLATE 5MG CAPSULE	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
BUDEPRION SR 100MG TABLET SA	3	Non-Preferred Generic/Preferred Brand	20%	20%	Q:120 /30Days
BUDEPRION SR 150MG TABLET SA	3	Non-Preferred Generic/Preferred Brand	20%	20%	Q:120 /30Days
BUDEPRION XL 300MG TABLET SR 24HR	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
BUDEPRION XL TABLETS 150MG 500 TABLETS BOT	3	Non-Preferred Generic/Preferred Brand	20%	20%	Q:90 /30Days
BUDESONIDE 0.25 MG/2 ML SUSP	2	Generic	$5.00	$0.00	P
BUDESONIDE 0.5 MG/2 ML SUSP	2	Generic	$5.00	$0.00	P
BUMETANIDE 0.25MG/ML VIAL	2	Generic	$5.00	$0.00	None
BUMETANIDE 0.5MG TABLET USP (500 CT)	1	Preferred Generic	$2.00	$0.00	None
BUMETANIDE 1MG TABLET USP (500 CT)	1	Preferred Generic	$2.00	$0.00	None
BUMETANIDE 2MG TABLET USP (500 CT)	2	Generic	$5.00	$0.00	None
BUPHENYL 500MG TABLET	4	Non-Preferred Brand	35%	35%	None
BUPHENYL POWDER	4	Non-Preferred Brand	35%	35%	None
BUPRENORPHINE 0.3MG/ML SYRN	4	Non-Preferred Brand	35%	35%	None
BUPRENORPHINE 2 MG SUBLINGUAL TABLET	3	Non-Preferred Generic/Preferred Brand	20%	20%	P Q:90 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BUPRENORPHINE 8 MG SUBLINGUAL TABLET	3	Non-Preferred Generic/Preferred Brand	20%	20%	P Q:90 /30Days
BUPROBAN ER TABLET	1	Preferred Generic	$2.00	$0.00	Q:90 /30Days
BUPROPION HCL 150 MG TABLET SA	1	Preferred Generic	$2.00	$0.00	Q:120 /30Days
BUPROPION HCL 75MG TABLET	2	Generic	$5.00	$0.00	None
BUPROPION HCL SR 100 MG TABLET	3	Non-Preferred Generic/Preferred Brand	20%	20%	Q:120 /30Days
BUPROPION HCL SR 200MG TABLET SA	3	Non-Preferred Generic/Preferred Brand	20%	20%	Q:60 /30Days
BUPROPION HCL TABLET 100MG	2	Generic	$5.00	$0.00	None
BUSPIRONE HCL 15MG TABLET (180 CT)	2	Generic	$5.00	$0.00	None
BUSPIRONE HCL 30MG TABLET (60 CT)	2	Generic	$5.00	$0.00	None
BUSPIRONE HCL 5 MG TABLET	1	Preferred Generic	$2.00	$0.00	None
BUSPIRONE HCL 7.5MG TABLET	2	Generic	$5.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BUSPIRONE HYDROCHLORIDE TABLETS	1	Preferred Generic	$2.00	$0.00	None
BUTALBITAL/CAFF/APAP/COD CP	3	Non-Preferred Generic/Preferred Brand	20%	20%	Q:360 /30Days
BUTORPHANOL 10MG/ML SPRAY	3	Non-Preferred Generic/Preferred Brand	20%	20%	Q:5 /28Days
BUTORPHANOL TARTRATE INJECTION 1MG 10 X 1ML VIAL	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
BUTORPHANOL TARTRATE INJECTION 2MG 10 X 1ML VIAL	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
BYETTA 10MCG/0.04ML PEN INJ	4	Non-Preferred Brand	35%	35%	P Q:3 /30Days
BYETTA 5MCG/0.02ML PEN INJ	4	Non-Preferred Brand	35%	35%	P Q:3 /30Days

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.