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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)

Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
Yes No Show either
Cick on the first letter of your drug name to browse the formulary:

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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 G

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

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
GABAPENTIN 400 MG CAPSULE   2 Generic $5.00$0.00Q:270
/30Days
GABAPENTIN 600MG TABLET   2 Generic $5.00$0.00Q:180
/30Days
GABAPENTIN CAPSULES 100MG 100 BOT   2 Generic $5.00$0.00Q:270
/30Days
GABAPENTIN CAPSULES 300MG   2 Generic $5.00$0.00Q:270
/30Days
GABAPENTIN TABLET 800MG   2 Generic $5.00$0.00Q:180
/30Days
GABITRIL 12MG FILMTAB   4 Non-Preferred Brand 35%35%Q:120
/30Days
GABITRIL 16MG FILMTAB   4 Non-Preferred Brand 35%35%Q:90
/30Days
GABITRIL 2MG FILMTAB   4 Non-Preferred Brand 35%35%Q:90
/30Days
GABITRIL 4MG FILMTAB   4 Non-Preferred Brand 35%35%None
GALANTAMINE HBR 12MG TABLET   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
GALANTAMINE HBR 4MG TABLET   3 Non-Preferred Generic/Preferred Brand 20%20%Q:60
/30Days
GALANTAMINE HBR 8MG TABLET   3 Non-Preferred Generic/Preferred Brand 20%20%Q:60
/30Days
GALANTAMINE HYDROBROMIDE 4 MG/ML ORAL SOLUTION   2 Generic $5.00$0.00Q:200
/30Days
GALANTAMINE HYDROBROMIDE CAPSULES EXTENDED RELEASE 16MG 30 BOT   2 Generic $5.00$0.00Q:30
/30Days
GALANTAMINE HYDROBROMIDE CAPSULES EXTENDED RELEASE 24MG 30 BOT   2 Generic $5.00$0.00Q:30
/30Days
GALANTAMINE HYDROBROMIDE CAPSULES EXTENDED RELEASE 8MG 30 BOT   2 Generic $5.00$0.00Q:30
/30Days
GAMASTAN S/D INJECTION 16.5GM/2ML VIALGL   4 Non-Preferred Brand 35%35%P
GAMMAGARD LIQUID 10% VIAL   4 Non-Preferred Brand 35%35%P
GAMUNEX FOR SOLUTION 10GM/25ML VIALGL   4 Non-Preferred Brand 35%35%P
GANCICLOVIR 250MG CAPSULE   2 Generic $5.00$0.00None
GANCICLOVIR 500MG CAPSULE   2 Generic $5.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
GANCICLOVIR FOR INJECTION   3 Non-Preferred Generic/Preferred Brand 20%20%None
GARDASIL VIAL   4 Non-Preferred Brand 35%35%None
GEMFIBROZIL TABLET 600MG (500 CT)   2 Generic $5.00$0.00Q:60
/30Days
GEMZAR 1GRAM VIAL   4 Non-Preferred Brand 35%35%P
GENERLAC SOLUTION 10G/15 ML 473 ML BOTPL   2 Generic $5.00$0.00None
GENGRAF 100MG CAPSULE U.D.   3 Non-Preferred Generic/Preferred Brand 20%20%P
GENGRAF 100MG/ML SOLUTION   3 Non-Preferred Generic/Preferred Brand 20%20%P
GENGRAF 25MG CAPSULE U.D.   3 Non-Preferred Generic/Preferred Brand 20%20%P
GENTAK 3MG/GM EYE OINTMENT   3 Non-Preferred Generic/Preferred Brand 20%20%None
GENTAK 3MG/ML EYE DROPS   3 Non-Preferred Generic/Preferred Brand 20%20%None
GENTAMICIN 100MG/NS 100ML   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
GENTAMICIN 10MG/ML VIAL   3 Non-Preferred Generic/Preferred Brand 20%20%None
GENTAMICIN 60MG/NS 50ML PB   3 Non-Preferred Generic/Preferred Brand 20%20%None
GENTAMICIN 70MG/NS 50ML PB   3 Non-Preferred Generic/Preferred Brand 20%20%None
GENTAMICIN 80MG/NS 50ML PB   3 Non-Preferred Generic/Preferred Brand 20%20%None
GENTAMICIN 90MG/NS 100ML PB   3 Non-Preferred Generic/Preferred Brand 20%20%None
GENTAMICIN INJECTION USP 40MG 25 X 20ML VIALMD   2 Generic $5.00$0.00None
GENTAMICIN SULFATE CREAM USP 0.1% 15GM TUBE   1 Preferred Generic $2.00$0.00None
GENTAMICIN SULFATE OINTMENT USP 0.1% 15GM TUBE   1 Preferred Generic $2.00$0.00None
GENTAMICIN SULFATE OPHTHALMIC SOLUTION 0.3% 5ML BOT   1 Preferred Generic $2.00$0.00None
GENTASOL 3MG/ML EYE DROPS   1 Preferred Generic $2.00$0.00None
GEODON 20MG CAPSULE   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
GEODON 20MG VIAL   3 Non-Preferred Generic/Preferred Brand 20%20%None
GEODON 40MG CAPSULE   3 Non-Preferred Generic/Preferred Brand 20%20%Q:60
/30Days
GEODON 60MG CAPSULE   3 Non-Preferred Generic/Preferred Brand 20%20%Q:60
/30Days
GEODON 80MG CAPSULE   3 Non-Preferred Generic/Preferred Brand 20%20%Q:60
/30Days
GIANVI TABLETS   2 Generic $5.00$0.00None
GLEEVEC 100MG TABLET (90 CT)   4 Non-Preferred Brand 35%35%P Q:240
/30Days
GLEEVEC 400MG TABLET   4 Non-Preferred Brand 35%35%P Q:60
/30Days
GLIMEPIRIDE 1MG TABLET (100 CT)   1 Preferred Generic $2.00$0.00None
GLIMEPIRIDE 2MG TABLET (100 CT)   1 Preferred Generic $2.00$0.00None
GLIMEPIRIDE 4MG TABLET (100 CT)   1 Preferred Generic $2.00$0.00None
GLIPIZIDE 10MG TABLET (100 CT)   1 Preferred Generic $2.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
GLIPIZIDE 5MG TABLET   1 Preferred Generic $2.00$0.00None
GLIPIZIDE AND METFORMIN HCL 2.5-250MG TABLET (100 CT)   3 Non-Preferred Generic/Preferred Brand 20%20%None
GLIPIZIDE AND METFORMIN HCL 5-500MG TABLET (100 CT)   3 Non-Preferred Generic/Preferred Brand 20%20%None
GLIPIZIDE ER 2.5MG TABLET SR OSMOTIC PUSH 24HR   2 Generic $5.00$0.00None
GLIPIZIDE TABLETS EXTENDED RELEASE   2 Generic $5.00$0.00None
GLIPIZIDE TABLETS EXTENDED RELEASE   1 Preferred Generic $2.00$0.00None
GLIPIZIDE-METFORMIN 2.5-500MG TABLET   3 Non-Preferred Generic/Preferred Brand 20%20%None
GLUCAGEN 1MG HYPOKIT   4 Non-Preferred Brand 35%35%None
GLUCAGON 1MG EMERGENCY KIT   2 Generic $5.00$0.00None
GLUCOTROL 10MG TABLET   4 Non-Preferred Brand 35%35%None
GLUCOTROL 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
GLUCOTROL XL 10MG TABLET SA   4 Non-Preferred Brand 35%35%None
GLUCOTROL XL 2.5MG TABLET SA   4 Non-Preferred Brand 35%35%None
GLUCOTROL XL 5MG TABLET SA   4 Non-Preferred Brand 35%35%None
GLYBURIDE 2.5MG TABLET (100 CT)   1 Preferred Generic $2.00$0.00None
GLYBURIDE AND METFORMIN HCL 1.25-250MG TABLET (100 CT)   2 Generic $5.00$0.00None
GLYBURIDE MICRO 3MG TABLET (100 CT)   1 Preferred Generic $2.00$0.00None
GLYBURIDE MICRONIZED 1.5MG TABLET (100 CT)   2 Generic $5.00$0.00None
GLYBURIDE TABLET MICRONIZED 6MG (500 CT)   1 Preferred Generic $2.00$0.00None
GLYBURIDE TABLETS   2 Generic $5.00$0.00None
GLYBURIDE TABLETS   1 Preferred Generic $2.00$0.00None
GLYBURIDE-METFORMIN HCL 2.5-500MG TABLET   2 Generic $5.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
GLYBURIDE-METFORMIN HCL 5MG-500MG TABLET   2 Generic $5.00$0.00None
GLYCOPYRROLATE 0.2MG/ML VL   3 Non-Preferred Generic/Preferred Brand 20%20%None
GLYCOPYRROLATE TABLET 1MG (100 CT)   3 Non-Preferred Generic/Preferred Brand 20%20%None
GLYCOPYRROLATE TABLET 2MG (100 CT)   3 Non-Preferred Generic/Preferred Brand 20%20%None
GLYCRON 1.5MG TABLET   2 Generic $5.00$0.00None
GLYCRON 3MG TABLET   1 Preferred Generic $2.00$0.00None
GLYCRON 4.5MG TABLET   1 Preferred Generic $2.00$0.00None
GLYCRON 6MG TABLET   1 Preferred Generic $2.00$0.00None
GLYNASE 1.5MG PRESTAB   4 Non-Preferred Brand 35%35%None
GLYNASE PRESTAB TABLET 3MG (100 CT)   4 Non-Preferred Brand 35%35%None
GLYNASE PRESTAB TABLET 6MG (100 CT)   4 Non-Preferred Brand 35%35%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
GLYSET 100MG TABLET   4 Non-Preferred Brand 35%35%None
GLYSET 25MG TABLET   4 Non-Preferred Brand 35%35%None
GLYSET 50MG TABLET   4 Non-Preferred Brand 35%35%None
GOLYTELY PACKET 227.1 GM/2.82 GM   3 Non-Preferred Generic/Preferred Brand 20%20%None
GOLYTELY SOLUTION 236 GM/2.97 GM/6 GM   3 Non-Preferred Generic/Preferred Brand 20%20%None
GRANISETRON 1 MG/ML INJECTABLE SOLUTION   3 Non-Preferred Generic/Preferred Brand 20%20%None
GRANISETRON HCL 1MG TABLET (20 CT)   3 Non-Preferred Generic/Preferred Brand 20%20%Q:28
/28Days
GRANISETRON HYDROCHLORIDE INJECTION   3 Non-Preferred Generic/Preferred Brand 20%20%None
GRANISOL 1MG/5ML SOLUTION ORAL   3 Non-Preferred Generic/Preferred Brand 20%20%Q:150
/28Days
GRIFULVIN V 500MG TABLET   3 Non-Preferred Generic/Preferred Brand 20%20%None
GRIS-PEG 125MG 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
GRIS-PEG 250 MG TABLET   4 Non-Preferred Brand 35%35%None
GRISEOFULVIN ORAL SUSPENSION 125MG/5ML 4 FLOZ CTR   3 Non-Preferred Generic/Preferred Brand 20%20%None
GUANABENZ ACETATE 4MG TABLET   3 Non-Preferred Generic/Preferred Brand 20%20%None
GUANABENZ ACETATE 8MG TABLET   3 Non-Preferred Generic/Preferred Brand 20%20%None
GUANFACINE 1MG TABLET   1 Preferred Generic $2.00$0.00None
GUANFACINE 2MG TABLET (100 CT)   2 Generic $5.00$0.00None
GUANIDINE HCL 125MG TABLET   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.