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CIGNA Medicare Rx Plan One (PDP) (S5617-008-0)
Tier 1 (1397)
Tier 2 (1150)
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2011 Medicare Part D Plan Formulary Information
CIGNA Medicare Rx Plan One (PDP) (S5617-008-0)
Benefit Details           
The CIGNA Medicare Rx Plan One (PDP) (S5617-008-0)
Formulary Drugs Starting with the Letter N
in CMS PDP Region 2 which includes: CT MA RI VT
Drugs Starting with Letter N

Drug Name		 Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order
NABUMETONE 500MG TABLET   1 Preferred Generic/Preferred Brand $3.00$7.50None
NABUMETONE 750MG TABLET   1 Preferred Generic/Preferred Brand $3.00$7.50None
NADOLOL 20MG TABLET   1 Preferred Generic/Preferred Brand $3.00$7.50None
NADOLOL TABLETS   1 Preferred Generic/Preferred Brand $3.00$7.50None
NADOLOL TABLETS   1 Preferred Generic/Preferred Brand $3.00$7.50None
NADOLOL-BENDROFLUMETHIAZIDE 40-5MG TABLET   1 Preferred Generic/Preferred Brand $3.00$7.50None
NADOLOL-BENDROFLUMETHIAZIDE 80-5MG TABLET   1 Preferred Generic/Preferred Brand $3.00$7.50None
NAFAZAIR 0.1% EYE DROPS   1 Preferred Generic/Preferred Brand $3.00$7.50None
NAFCILLIN 1GM/50ML INJ   2 Non-Preferred Generic/Preferred Brand $34.00$85.00None
NAFCILLIN FOR INJECTION 1 GM/ML   2 Non-Preferred Generic/Preferred Brand $34.00$85.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NAFCILLIN FOR INJECTION 10GM/ML 1 VIAL   2 Non-Preferred Generic/Preferred Brand $34.00$85.00None
NAFTIN HCL GEL 1% 60GM TUBE   2 Non-Preferred Generic/Preferred Brand $34.00$85.00None
NAFTIN 1% CREAM   2 Non-Preferred Generic/Preferred Brand $34.00$85.00None
NAGLAZYME 5MG/5ML VIAL   4 Specialty Tier 25%25%P
NALBUPHINE 10MG/ML VIAL   2 Non-Preferred Generic/Preferred Brand $34.00$85.00P
NALBUPHINE 20MG/ML VIAL   2 Non-Preferred Generic/Preferred Brand $34.00$85.00P
NALLPEN 2GM/50ML 2.4% DEX   2 Non-Preferred Generic/Preferred Brand $34.00$85.00None
NALOXONE 1MG/ML SYRINGE   1 Preferred Generic/Preferred Brand $3.00$7.50None
NALOXONE HCL INJECTION 0.4MG 10 X 1ML CTG   1 Preferred Generic/Preferred Brand $3.00$7.50None
NALTREXONE HCL 50MG TABLET 100 BLPK   1 Preferred Generic/Preferred Brand $3.00$7.50None
NAMENDA 10MG TABLET   2 Non-Preferred Generic/Preferred Brand $34.00$85.00Q:60
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NAMENDA 10MG/5ML SOLUTION   2 Non-Preferred Generic/Preferred Brand $34.00$85.00Q:300
/30Days
NAMENDA 5-10MG TITRATION PK   2 Non-Preferred Generic/Preferred Brand $34.00$85.00Q:49
/30Days
NAMENDA 5MG TABLET   2 Non-Preferred Generic/Preferred Brand $34.00$85.00Q:60
/30Days
NAPROXEN 125MG/5ML SUSPEN   1 Preferred Generic/Preferred Brand $3.00$7.50None
NAPROXEN 250 MG ORAL TABLET   1 Preferred Generic/Preferred Brand $3.00$7.50None
NAPROXEN 375MG TABLET EC   1 Preferred Generic/Preferred Brand $3.00$7.50None
NAPROXEN 500MG TABLET EC   1 Preferred Generic/Preferred Brand $3.00$7.50None
NAPROXEN SODIUM 275 MG ORAL TABLET   1 Preferred Generic/Preferred Brand $3.00$7.50None
NAPROXEN SODIUM 550 MG ORAL TABLET   1 Preferred Generic/Preferred Brand $3.00$7.50None
NAPROXEN TABLET 375MG (500 CT)   1 Preferred Generic/Preferred Brand $3.00$7.50None
NARDIL 15MG TABLET   2 Non-Preferred Generic/Preferred Brand $34.00$85.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NASACORT AQ AER 55MCG/AC   2 Non-Preferred Generic/Preferred Brand $34.00$85.00None
NATACYN EYE DROPS   2 Non-Preferred Generic/Preferred Brand $34.00$85.00None
NATEGLINIDE 120 MG ORAL TABLET   2 Non-Preferred Generic/Preferred Brand $34.00$85.00None
NATEGLINIDE 60 MG ORAL TABLET   2 Non-Preferred Generic/Preferred Brand $34.00$85.00None
NECON 0.5/35-28 TABLET   2 Non-Preferred Generic/Preferred Brand $34.00$85.00None
NECON 1/35-28 TABLET   2 Non-Preferred Generic/Preferred Brand $34.00$85.00None
NECON 10/11-28 TABLET   2 Non-Preferred Generic/Preferred Brand $34.00$85.00None
NECON 7 DAYS X 3 TABLET   2 Non-Preferred Generic/Preferred Brand $34.00$85.00None
NEFAZODONE HCL 150MG TABLET (60 CT)   1 Preferred Generic/Preferred Brand $3.00$7.50None
NEFAZODONE HCL 250MG TABLET   1 Preferred Generic/Preferred Brand $3.00$7.50None
NEFAZODONE HCL 50MG TABLET   1 Preferred Generic/Preferred Brand $3.00$7.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NEFAZODONE HYDROCHLORIDE TABLETS 100MG 60 BOT   1 Preferred Generic/Preferred Brand $3.00$7.50None
NEFAZODONE HYDROCHLORIDE TABLETS 200MG 60 BOT   1 Preferred Generic/Preferred Brand $3.00$7.50None
NEO/POLYMYXIN/HC EAR TUBEX 10MG/3.5MG/100UNT   1 Preferred Generic/Preferred Brand $3.00$7.50None
NEOMYCIN AND POLYMYXIN B SULFATES AND DEXAMETHASONE OPHTHALMIC OINTMENT   1 Preferred Generic/Preferred Brand $3.00$7.50None
NEOMYCIN AND POLYMYXIN B SULFATES SOLUTION FOR IRRIGATION 40MG/20000UNT   2 Non-Preferred Generic/Preferred Brand $34.00$85.00None
NEOMYCIN SULFATE 500MG TABLET   1 Preferred Generic/Preferred Brand $3.00$7.50None
NEOMYCIN-BACITRACIN-POLY-HC 3.5-10K-1 OINTMENT   1 Preferred Generic/Preferred Brand $3.00$7.50None
NEOMYCIN-POLYMYXIN-HC 3.5-10K-10 SUSPENSION DROPS   1 Preferred Generic/Preferred Brand $3.00$7.50None
NEOMYCIN/POLYMY/DEXA EYE DROPS 3.5MG/1ML   1 Preferred Generic/Preferred Brand $3.00$7.50None
NEOMYCIN/POLYMY/GRAM EYE DROPS 0.025MG/ML 1.75MG/M   1 Preferred Generic/Preferred Brand $3.00$7.50None
NEOMYCIN/POLYMY/HYDRO OTIC SUS   1 Preferred Generic/Preferred Brand $3.00$7.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NEORAL 100MG GELATN CAPSULE   3 Non-Preferred Generic/Non-Preferred Brand $80.00$200.00P
NEORAL 100MG/ML SOLUTION   3 Non-Preferred Generic/Non-Preferred Brand $80.00$200.00P
NEORAL 25MG GELATIN CAPSULE   3 Non-Preferred Generic/Non-Preferred Brand $80.00$200.00P
NEPHRAMINE SOLUTION FOR INJECTION   2 Non-Preferred Generic/Preferred Brand $34.00$85.00P
NEUPOGEN 300MCG/ML VIAL   4 Specialty Tier 25%25%P
NEUPOGEN INJECTION 300MCG/0.5ML 0.5ML SYR   4 Specialty Tier 25%25%P
NEUPOGEN INJECTION 480MCG/0.8ML 10 X 0.8ML SYR   4 Specialty Tier 25%25%P
NEURONTIN 250MG/5ML TUBEX   3 Non-Preferred Generic/Non-Preferred Brand $80.00$200.00None
NEVANAC 0.1% DROPTAINER   2 Non-Preferred Generic/Preferred Brand $34.00$85.00None
NEXAVAR TABLETS 200MG 120 BOT   4 Specialty Tier 25%25%P
NEXIUM 10MG PACKET   2 Non-Preferred Generic/Preferred Brand $34.00$85.00Q:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NEXIUM 20MG CAPSULE   2 Non-Preferred Generic/Preferred Brand $34.00$85.00Q:30
/30Days
NEXIUM 20MG SUSP FOR RECON DELAYED REL. IN A PACKET   2 Non-Preferred Generic/Preferred Brand $34.00$85.00Q:30
/30Days
NEXIUM 40MG CAPSULE   2 Non-Preferred Generic/Preferred Brand $34.00$85.00Q:30
/30Days
NEXIUM 40MG SUSP FOR RECON DELAYED REL. IN A PACKET   2 Non-Preferred Generic/Preferred Brand $34.00$85.00Q:30
/30Days
NEXIUM IV 20MG VIAL   2 Non-Preferred Generic/Preferred Brand $34.00$85.00None
NEXIUM IV 40MG VIAL   2 Non-Preferred Generic/Preferred Brand $34.00$85.00None
NEXT CHOICE 0.75 MG TABLET   1 Preferred Generic/Preferred Brand $3.00$7.50None
NIASPAN 1000MG TABLET (90 CT)   2 Non-Preferred Generic/Preferred Brand $34.00$85.00Q:60
/30Days
NIASPAN ER 500MG TABLET (90 CT)   2 Non-Preferred Generic/Preferred Brand $34.00$85.00Q:30
/30Days
NIASPAN ER 750MG TABLET (90 CT)   2 Non-Preferred Generic/Preferred Brand $34.00$85.00Q:30
/30Days
NICARDIPINE HYDROCHLORIDE CAPSULES   1 Preferred Generic/Preferred Brand $3.00$7.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NICARDIPINE HYDROCHLORIDE CAPSULES 30MG 500 BOT   1 Preferred Generic/Preferred Brand $3.00$7.50None
NICARDIPINE HYDROCHLORIDE INJECTION   2 Non-Preferred Generic/Preferred Brand $34.00$85.00None
NICOTROL INHALER 10MG 168 X 10MG/CARTRIDGE INHL   3 Non-Preferred Generic/Non-Preferred Brand $80.00$200.00None
NIFEDIAC CC 30MG TABLET SA   1 Preferred Generic/Preferred Brand $3.00$7.50None
NIFEDIAC CC 60MG TABLET SA   1 Preferred Generic/Preferred Brand $3.00$7.50None
NIFEDIAC CC 90MG TABLET SA   1 Preferred Generic/Preferred Brand $3.00$7.50None
NIFEDICAL XL 30MG TABLET SR OSMOTIC PUSH 24HR   1 Preferred Generic/Preferred Brand $3.00$7.50None
NIFEDICAL XL 60MG TABLET SR OSMOTIC PUSH 24HR   1 Preferred Generic/Preferred Brand $3.00$7.50None
NIFEDIPINE 10MG CAPSULE   1 Preferred Generic/Preferred Brand $3.00$7.50None
NIFEDIPINE 20MG CAPSULE   1 Preferred Generic/Preferred Brand $3.00$7.50None
NIFEDIPINE TABLETS EXTENDED RELEASE   1 Preferred Generic/Preferred Brand $3.00$7.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NIFEDIPINE TABLETS EXTENDED RELEASE   1 Preferred Generic/Preferred Brand $3.00$7.50None
NIFEDIPINE TABLETS EXTENDED RELEASE   1 Preferred Generic/Preferred Brand $3.00$7.50None
NILANDRON 150MG TABLET   2 Non-Preferred Generic/Preferred Brand $34.00$85.00None
NIMODIPINE 30MG CAPSULE   4 Specialty Tier 25%25%None
NIPENT FOR INJECTION 10MG VIALS   4 Specialty Tier 25%25%P
NISOLDIPINE 20MG TB24   2 Non-Preferred Generic/Preferred Brand $34.00$85.00Q:30
/30Days
NISOLDIPINE 30MG TB24   2 Non-Preferred Generic/Preferred Brand $34.00$85.00Q:30
/30Days
NISOLDIPINE 40MG TB24   2 Non-Preferred Generic/Preferred Brand $34.00$85.00Q:30
/30Days
NITRO BID OINTMENT 2% 1 GRAM X 48 PKG   3 Non-Preferred Generic/Non-Preferred Brand $80.00$200.00None
NITRO-DUR 0.3MG/HR PATCH   3 Non-Preferred Generic/Non-Preferred Brand $80.00$200.00None
NITRO-DUR 0.8MG/HR PATCH INST.   3 Non-Preferred Generic/Non-Preferred Brand $80.00$200.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NITROFURANTOIN 100MG CAPSULE (100 CT)   1 Preferred Generic/Preferred Brand $3.00$7.50None
NITROFURANTOIN MCR 50MG CAP   1 Preferred Generic/Preferred Brand $3.00$7.50None
NITROGLYCERIN .2MG/HR PATCH   1 Preferred Generic/Preferred Brand $3.00$7.50None
NITROGLYCERIN .4MG/HR PATCH   1 Preferred Generic/Preferred Brand $3.00$7.50None
NITROGLYCERIN .6MG/HR PATCH   1 Preferred Generic/Preferred Brand $3.00$7.50None
NITROGLYCERIN 5MG/ML VIAL   1 Preferred Generic/Preferred Brand $3.00$7.50None
NITROGLYCERIN TRANSOERMAL SYSTEM .1MG/HR 30 SYSTEM BOX   1 Preferred Generic/Preferred Brand $3.00$7.50None
NITROLINGUAL SPR PUMPSPRA   2 Non-Preferred Generic/Preferred Brand $34.00$85.00None
NITROSTAT 0.3MG TABLET SL   2 Non-Preferred Generic/Preferred Brand $34.00$85.00None
NITROSTAT 0.4MG TABLET SL   2 Non-Preferred Generic/Preferred Brand $34.00$85.00None
NITROSTAT 0.6MG TABLET SL   2 Non-Preferred Generic/Preferred Brand $34.00$85.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NOR-QD TABLET 0.35MG   3 Non-Preferred Generic/Non-Preferred Brand $80.00$200.00None
NORA-BE 0.35MG TABLET   2 Non-Preferred Generic/Preferred Brand $34.00$85.00None
NORDITROPIN NORDIFLEX 10MG/1.5   4 Specialty Tier 25%25%P
NORDITROPIN NORDIFLEX INJECTION   4 Specialty Tier 25%25%P
NORDITROPIN NORDIFLEX INJECTION   4 Specialty Tier 25%25%P
NORDITROPIN NORDIFLEX INJECTION   4 Specialty Tier 25%25%P
NORETHINDRONE 5MG TABLET   1 Preferred Generic/Preferred Brand $3.00$7.50None
NORMOSOL -R INJ /D5W   2 Non-Preferred Generic/Preferred Brand $34.00$85.00P
NORMOSOL-M AND DEXTROSE 5%   2 Non-Preferred Generic/Preferred Brand $34.00$85.00P
NORMOSOL-R PH 7.4 IV SOLUTION   2 Non-Preferred Generic/Preferred Brand $34.00$85.00P
NOROXIN 400MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $80.00$200.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NORTREL 0.5-0.035 TABLET   2 Non-Preferred Generic/Preferred Brand $34.00$85.00None
NORTREL 1-0.035MG TABLET 21DAY   2 Non-Preferred Generic/Preferred Brand $34.00$85.00None
NORTREL 1-0.035MG TABLET 28DAY   2 Non-Preferred Generic/Preferred Brand $34.00$85.00None
NORTREL 7 DAYS X 3 TABLET   2 Non-Preferred Generic/Preferred Brand $34.00$85.00None
NORTRIPTYLINE 10MG/5ML SOL   1 Preferred Generic/Preferred Brand $3.00$7.50None
NORTRIPTYLINE HCL 10MG CAPSULE   1 Preferred Generic/Preferred Brand $3.00$7.50None
NORTRIPTYLINE HCL 25MG CAP   1 Preferred Generic/Preferred Brand $3.00$7.50None
NORTRIPTYLINE HCL 50MG CAPSULE   1 Preferred Generic/Preferred Brand $3.00$7.50None
NORTRIPTYLINE HCL 75MG CAPSULE   1 Preferred Generic/Preferred Brand $3.00$7.50None
NORVIR 100 MG TABLET   3 Non-Preferred Generic/Non-Preferred Brand $80.00$200.00None
NORVIR 100MG SOFTGEL CAP   3 Non-Preferred Generic/Non-Preferred Brand $80.00$200.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NORVIR 80MG/ML ORAL SOLUTION   4 Specialty Tier 25%25%None
NOVAMINE 15% 500ML IV   1 Preferred Generic/Preferred Brand $3.00$7.50P
NOVANTRONE 2MG/ML VIAL   4 Specialty Tier 25%25%P
NOVOLIN 70/30 100U/ML VIAL   2 Non-Preferred Generic/Preferred Brand $34.00$85.00None
NOVOLIN 70/INJ 30 INNLT   2 Non-Preferred Generic/Preferred Brand $34.00$85.00None
NOVOLIN N 100U/ML VIAL   2 Non-Preferred Generic/Preferred Brand $34.00$85.00None
NOVOLIN N INJ INNOLET   2 Non-Preferred Generic/Preferred Brand $34.00$85.00None
NOVOLIN R 100U/ML VIAL   2 Non-Preferred Generic/Preferred Brand $34.00$85.00None
NOVOLOG 100U/ML VIAL   2 Non-Preferred Generic/Preferred Brand $34.00$85.00None
NOVOLOG FLEXPEN SYRINGE   2 Non-Preferred Generic/Preferred Brand $34.00$85.00None
NOVOLOG MIX 70/30 SYRINGE 70-30U/ML   2 Non-Preferred Generic/Preferred Brand $34.00$85.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NOVOLOG MIX 70/30 VIAL   2 Non-Preferred Generic/Preferred Brand $34.00$85.00None
NOXAFIL 200MG/5ML SUSPENSION ORAL   4 Specialty Tier 25%25%None
NULYTELY WITH FLAVOR PACKS POWDER FOR SOLUTION 420;1.48;MG;MG;GM; 4 L BOT   2 Non-Preferred Generic/Preferred Brand $34.00$85.00None
NUTROPIN AQ 20MG/2ML PEN CART SOMATROPIN   4 Specialty Tier 25%25%P
NUTROPIN AQ INJ 10MG/2ML   4 Specialty Tier 25%25%P
NUTROPIN AQ NUSPIN SOLUTION   4 Specialty Tier 25%25%P
NUTROPIN AQ PEN CARTRIDGE 10MG/2 ML   4 Specialty Tier 25%25%P
NUTROPIN FOR INJECTION   4 Specialty Tier 25%25%P
NUTROPIN SOMATROPIN RDNAORIGIN FOR INJECTION 5MG 1 VIAL   4 Specialty Tier 25%25%P
NUVARING 0.12-0.015 RING VAGINAL   3 Non-Preferred Generic/Non-Preferred Brand $80.00$200.00None
NYAMYC 100000 U/G POWDER   1 Preferred Generic/Preferred Brand $3.00$7.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NYSTATIN 100000 UNT/ML ORAL SUSPENSION   1 Preferred Generic/Preferred Brand $3.00$7.50None
NYSTATIN 100000U/G POWDER   1 Preferred Generic/Preferred Brand $3.00$7.50None
NYSTATIN 100000U/GM CREAM   1 Preferred Generic/Preferred Brand $3.00$7.50None
NYSTATIN OINTMENT 100000UNT/GM 15 GM TUBE   1 Preferred Generic/Preferred Brand $3.00$7.50None
NYSTATIN TABLET 500000U (100 CT)   1 Preferred Generic/Preferred Brand $3.00$7.50None
NYSTATIN/TRIAMCINOLONE CRM   1 Preferred Generic/Preferred Brand $3.00$7.50None
NYSTATIN/TRIAMCINOLONE OINT 10000UNT/1MG   1 Preferred Generic/Preferred Brand $3.00$7.50None
NYSTOP 100000U/GM POWDER   1 Preferred Generic/Preferred Brand $3.00$7.50None

Chart Legend:

Below are a few notes to help you understand the above 2011 Medicare Part D CIGNA Medicare Rx Plan One (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.