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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 P in CMS PDP Region 6 which includes: PA WV
Drugs Starting with Letter P Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter P Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PACERONE 100MG TABLET	4	Non-Preferred Brand	35%	35%	None
PACERONE 200MG TABLET	4	Non-Preferred Brand	35%	35%	None
PACERONE 400MG TABLET	4	Non-Preferred Brand	35%	35%	None
PACLITAXEL INJECTION SOLUTION 6MG 50ML VIALMD	3	Non-Preferred Generic/Preferred Brand	20%	20%	P
PALIPERIDONE PALMITATE 156 MG/ML PREFILLED SYRINGE [INVEGA]	4	Non-Preferred Brand	35%	35%	Q:1 /30Days
PALIPERIDONE PALMITATE 156 MG/ML PREFILLED SYRINGE [INVEGA]	4	Non-Preferred Brand	35%	35%	Q:1 /30Days
PALIPERIDONE PALMITATE 156 MG/ML PREFILLED SYRINGE [INVEGA]	4	Non-Preferred Brand	35%	35%	Q:1 /30Days
PALIPERIDONE PALMITATE 156 MG/ML PREFILLED SYRINGE [INVEGA]	4	Non-Preferred Brand	35%	35%	Q:1 /30Days
PALIPERIDONE PALMITATE 156 MG/ML PREFILLED SYRINGE [INVEGA]	4	Non-Preferred Brand	35%	35%	Q:1 /30Days
PAMIDRONATE 60MG/10ML VIAL	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
PAMIDRONATE DISODIUM INJECTION 3MG 10ML VIALSD	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
PAMIDRONATE DISODIUM INJECTION 9MG 10ML VIALSD	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
PANCREAZE 10,500 UNIT CAP DR	4	Non-Preferred Brand	35%	35%	None
PANCREAZE 16,800 UNIT CAP DR	4	Non-Preferred Brand	35%	35%	None
PANCREAZE 21,000 UNIT CAP DR	4	Non-Preferred Brand	35%	35%	None
PANCREAZE 4,200 UNIT CAP DR	4	Non-Preferred Brand	35%	35%	None
PANITUMUMAB 20 MG/ML INJECTABLE SOLUTION [VECTIBIX]	4	Non-Preferred Brand	35%	35%	P
PANRETIN 0.1% GEL 60GM TUBE	4	Non-Preferred Brand	35%	35%	None
PANTOPRAZOLE SODIUM 20MG TABLET DELAYED RELEASE	4	Non-Preferred Brand	35%	35%	Q:30 /30Days
PANTOPRAZOLE SODIUM 40MG TABLET DELAYED RELEASE 90 CRC BOT	4	Non-Preferred Brand	35%	35%	Q:30 /30Days
PARAFON FORTE DSC 500MG CPT	4	Non-Preferred Brand	35%	35%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PARCAINE 0.5% DROPS	2	Generic	$5.00	$0.00	None
PARNATE 10MG TABLET	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
PAROMOMYCIN 250MG CAPSULE	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
PAROXETINE 40MG TABLET (500 CT)	2	Generic	$5.00	$0.00	Q:60 /30Days
PAROXETINE FILM COATED 20MG TABLET (100 CT)	1	Preferred Generic	$2.00	$0.00	Q:30 /30Days
PAROXETINE HCL 10MG/5ML SUSPENSION ORAL	2	Generic	$5.00	$0.00	None
PAROXETINE HCL TABLET 24 12.5MG	3	Non-Preferred Generic/Preferred Brand	20%	20%	Q:60 /30Days
PAROXETINE HCL TABLET 24 25MG	3	Non-Preferred Generic/Preferred Brand	20%	20%	Q:90 /30Days
PAROXETINE TABLETS	1	Preferred Generic	$2.00	$0.00	Q:30 /30Days
PAROXETINE TABLETS 30MG 90 BOT	2	Generic	$5.00	$0.00	Q:60 /30Days
PASER GRANULES 4GM PACKET	2	Generic	$5.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PATADAY 0.2% DROPS	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
PATANOL 0.1% EYE DROPS	4	Non-Preferred Brand	35%	35%	None
PAZOPANIB 200 MG ORAL TABLET [VOTRIENT]	4	Non-Preferred Brand	35%	35%	P Q:120 /30Days
PCE 333MG DISPERTAB	4	Non-Preferred Brand	35%	35%	None
PCE 500MG DISPERTAB	4	Non-Preferred Brand	35%	35%	None
PEDI-DRI TOPICAL POWDER	2	Generic	$5.00	$0.00	None
PEDIAPRED 6.7MG/5ML TUBEX	4	Non-Preferred Brand	35%	35%	None
PEDIARIX SOLUTION INJECTION 25-25-10 10 X .5ML VIAL	4	Non-Preferred Brand	35%	35%	None
PEDVAXHIB VACCINE VIAL	4	Non-Preferred Brand	35%	35%	None
PEG-INTRON 100MCG KIT	4	Non-Preferred Brand	35%	35%	P Q:4 /28Days
PEG-INTRON REDIPEN 120MCG	4	Non-Preferred Brand	35%	35%	P Q:4 /28Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PEG-INTRON REDIPEN 150MCG	4	Non-Preferred Brand	35%	35%	P Q:4 /28Days
PEG-INTRON REDIPEN 50MCG	4	Non-Preferred Brand	35%	35%	P Q:4 /28Days
PEG-INTRON REDIPEN 80MCG	4	Non-Preferred Brand	35%	35%	P Q:4 /28Days
PEGANONE 250MG TABLET	4	Non-Preferred Brand	35%	35%	None
PEGASYS 180MCG/0.5ML CONV.PK	4	Non-Preferred Brand	35%	35%	P Q:4 /28Days
PEGASYS INJECTION	4	Non-Preferred Brand	35%	35%	P Q:4 /28Days
PENICILLIN G POTASSIUM 2MMUNITS/50ML ISO-OSM	2	Generic	$5.00	$0.00	None
PENICILLIN G POTASSIUM 3MMUNITS/50ML ISO-OSM	2	Generic	$5.00	$0.00	None
PENICILLIN G POTASSIUM FOR INJECTION	2	Generic	$5.00	$0.00	None
PENICILLIN G POTASSIUM FOR INJECTION 5000000UNIT/VIAL	2	Generic	$5.00	$0.00	None
PENICILLIN G PROCAINE 1200000UNT 2ML CTG	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
PENICILLIN G SODIUM FOR INJECTION 5000000UNT 1 VIAL	2	Generic	$5.00	$0.00	None
PENICILLIN V POTASSIUM 250MG TABLET (1000 CT)	1	Preferred Generic	$2.00	$0.00	None
PENICILLIN V POTASSIUM 250MG/5ML LIQUID	1	Preferred Generic	$2.00	$0.00	None
PENICILLIN V POTASSIUM 500MG TABLET	2	Generic	$5.00	$0.00	None
PENICILLIN V POTASSIUM FOR ORAL SOLUTION CONCENTRATE 125MG 200ML BOT	1	Preferred Generic	$2.00	$0.00	None
PENTAZOCINE/ACETAMIN TABLET	3	Non-Preferred Generic/Preferred Brand	20%	20%	Q:180 /30Days
PENTAZOCINE/NALOXONE TABLET	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
PENTOPAK 400MG TABLET SA	2	Generic	$5.00	$0.00	None
PENTOSTATIN FOR INJECTION 10MG/VIAL	2	Generic	$5.00	$0.00	P
PENTOXIFYLLINE 400MG TABLET SA	2	Generic	$5.00	$0.00	None
PEPCID 20MG 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
PEPCID 40MG TABLET	4	Non-Preferred Brand	35%	35%	None
PEPCID IV INJECTION 10MG/ML 10X2ML VIALSD	2	Generic	$5.00	$0.00	None
PEPCID PREMX SOL 20MG/50M	2	Generic	$5.00	$0.00	None
PEPCID SOLUTION 40MG 24 X 400MG BOT	4	Non-Preferred Brand	35%	35%	None
PERINDOPRIL ERBUMINE 2 MG ORAL TABLET	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
PERINDOPRIL ERBUMINE 4 MG ORAL TABLET	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
PERINDOPRIL ERBUMINE 8 MG ORAL TABLET	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
PERIOGARD 0.12% ORAL RINSE	1	Preferred Generic	$2.00	$0.00	None
PERMETHRIN 5% CREAM	2	Generic	$5.00	$0.00	None
PERPHENAZINE TABLETS 16MG 100 BOT	2	Generic	$5.00	$0.00	None
PERPHENAZINE TABLETS 4MG 100 BOXUD	2	Generic	$5.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PERPHENAZINE TABLETS 8MG 100 BOT	2	Generic	$5.00	$0.00	None
PERPHENAZINE TABLETS USP 2MG 100 BOT	2	Generic	$5.00	$0.00	None
PERSANTINE 25MG TABLET	4	Non-Preferred Brand	35%	35%	None
PERSANTINE 50MG TABLET	4	Non-Preferred Brand	35%	35%	None
PERSANTINE 75MG TABLET	4	Non-Preferred Brand	35%	35%	None
PFIZERPEN 20MMU VIAL	2	Generic	$5.00	$0.00	None
PHENADOZ 12.5MG SUPPOSITORY	2	Generic	$5.00	$0.00	None
PHENADOZ 25MG SUPPOSITORY	2	Generic	$5.00	$0.00	None
PHENERGAN 25MG/ML VIAL	4	Non-Preferred Brand	35%	35%	None
PHENERGAN 50MG/ML VIAL	4	Non-Preferred Brand	35%	35%	None
PHENYTEK 200 MG CAPSULE	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
PHENYTEK 300 MG CAPSULE	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT	2	Generic	$5.00	$0.00	None
PHENYTOIN SOD EXT 200 MG CAP	2	Generic	$5.00	$0.00	None
PHENYTOIN SODIUM EXTENDED CAPSULES 100MG (100 CT)	2	Generic	$5.00	$0.00	None
PHENYTOIN SODIUM INJECTION 50MG 25 X 2ML AMP	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
PHOSPHOLINE IODIDE 0.125%	4	Non-Preferred Brand	35%	35%	None
PHOTOFRIN 75MG VIAL	4	Non-Preferred Brand	35%	35%	P
PHYSIOLYTE SOLUTION FOR IRRIGATION	2	Generic	$5.00	$0.00	None
PHYSIOSOL IRRIGATION SOL	2	Generic	$5.00	$0.00	None
PILOCARPINE HCL 5MG TABLET (100 CT)	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
PILOCARPINE HCL 7.5MG TABLET	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
PILOPINE HS 4% EYE GEL	4	Non-Preferred Brand	35%	35%	None
PINDOLOL 10MG TABLET	1	Preferred Generic	$2.00	$0.00	None
PINDOLOL 5MG TABLET	1	Preferred Generic	$2.00	$0.00	None
PIPERACILLIN 200 MG/ML / TAZOBACTAM 25 MG/ML INJECTABLE SOLUTION	2	Generic	$5.00	$0.00	None
PIPERACILLIN 3GM VIAL	2	Generic	$5.00	$0.00	None
PIPERACILLIN 40GM BULK VIAL	2	Generic	$5.00	$0.00	None
PIROXICAM 10 MG CAPSULE	2	Generic	$5.00	$0.00	None
PIROXICAM 20MG CAPSULE (500 CT)	1	Preferred Generic	$2.00	$0.00	None
PLAQUENIL 200MG TABLET	4	Non-Preferred Brand	35%	35%	None
PLASMA-LYTE 148 IV SOLUTION	4	Non-Preferred Brand	35%	35%	None
PLASMA-LYTE 148/DEXTROSE 5%	4	Non-Preferred Brand	35%	35%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PLASMA-LYTE 56 INJECTION 32;128 MG/100ML;	4	Non-Preferred Brand	35%	35%	None
PLASMA-LYTE 56/DEXTROSE 5%	4	Non-Preferred Brand	35%	35%	None
PLASMA-LYTE A PH 7.4 SOLUTION 37;368; MG/100ML;	4	Non-Preferred Brand	35%	35%	None
PLASMA-LYTE INJ-R	4	Non-Preferred Brand	35%	35%	None
PLAVIX 75MG TABLET	4	Non-Preferred Brand	35%	35%	Q:30 /30Days
PLAVIX TABLETS 300MG	4	Non-Preferred Brand	35%	35%	Q:1 /30Days
PLETAL 100MG TABLET	4	Non-Preferred Brand	35%	35%	None
PLETAL 50MG TABLET	4	Non-Preferred Brand	35%	35%	None
PODOFILOX 0.5% TOPICAL TUBEX	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
POLY-DEX 0.1% SUSPENSION DROPS	2	Generic	$5.00	$0.00	None
POLY-DEX 3.5-10K-.1 OINTMENT	2	Generic	$5.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
POLYCIN-B 500-10KU/G OINTMENT	2	Generic	$5.00	$0.00	None
POLYETH GLYC NF POWDER FOR ORAL SOLUTION 17GM (527 CT)	2	Generic	$5.00	$0.00	None
POLYETHYLENE GLYCOL 3350 105 MG/ML / POTASSIUM CHLORIDE 0.005 MEQ/ML / SODIUM BICARBONATE 0.017 MEQ/	2	Generic	$5.00	$0.00	None
POLYETHYLENE GLYCOL 3350 59 MG/ML / POTASSIUM CHLORIDE 0.1 MEQ/ML / SODIUM BICARBONATE 0.02 MEQ/ML /	2	Generic	$5.00	$0.00	None
POLYETHYLENE GLYCOL 3350 60 MG/ML / POTASSIUM CHLORIDE 0.01 MEQ/ML / SODIUM BICARBONATE 0.02 MEQ/ML	2	Generic	$5.00	$0.00	None
POLYMYXIN B SUL-TRIMETHOPRIM 10K U-0.1%	1	Preferred Generic	$2.00	$0.00	None
POLYMYXIN B SULFATE VIAL	2	Generic	$5.00	$0.00	None
POLYTRIM EYE DROP	4	Non-Preferred Brand	35%	35%	None
PORTIA 0.15-0.03 TABLET	2	Generic	$5.00	$0.00	None
POTASSIUM CHLORIDE 0.075%/D5W/SODIUM CHLORIDE 0.2%	2	Generic	$5.00	$0.00	None
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.3%	2	Generic	$5.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.45%	2	Generic	$5.00	$0.00	None
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.9% 1000ML	2	Generic	$5.00	$0.00	None
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.2%	2	Generic	$5.00	$0.00	None
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.45% 1000ML BAG	2	Generic	$5.00	$0.00	None
POTASSIUM CHLORIDE 10MEQ/100ML SOL	2	Generic	$5.00	$0.00	None
POTASSIUM CHLORIDE 10MEQ/50ML SOL	2	Generic	$5.00	$0.00	None
POTASSIUM CHLORIDE 20MEQ IN D5W LACT RNG	2	Generic	$5.00	$0.00	None
POTASSIUM CHLORIDE 20MEQ IN D5W/NACL 0.225%	2	Generic	$5.00	$0.00	None
POTASSIUM CHLORIDE 20MEQ/50ML SOL	2	Generic	$5.00	$0.00	None
POTASSIUM CHLORIDE 30MEQ/100ML SOL	2	Generic	$5.00	$0.00	None
POTASSIUM CHLORIDE 40MEQ IN D5W LACT RNG	2	Generic	$5.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
POTASSIUM CHLORIDE 40MEQ IN D5W/NACL 0.9%	2	Generic	$5.00	$0.00	None
POTASSIUM CHLORIDE 40MEQ/NS 1000ML IV SOLUTION	2	Generic	$5.00	$0.00	None
POTASSIUM CHLORIDE 8 MEQ EXTENDED RELEASE TABLET	1	Preferred Generic	$2.00	$0.00	None
POTASSIUM CHLORIDE ER CAPSULES 10MEQ	2	Generic	$5.00	$0.00	None
POTASSIUM CHLORIDE ER CPCR 8MEQ	2	Generic	$5.00	$0.00	None
POTASSIUM CHLORIDE EXTENDED RELEASE TABLETS	1	Preferred Generic	$2.00	$0.00	None
POTASSIUM CHLORIDE FOR INJECTION CONCENTRATE	2	Generic	$5.00	$0.00	None
POTASSIUM CHLORIDE IN 10% DEXTROSE AND NACL SOLUTION FOR INJECTION	2	Generic	$5.00	$0.00	None
POTASSIUM CHLORIDE IN 5% DEXTROSE AND 0.2% NACL SOLUTION FOR INJECTION USP 0.15% 250ML X 24 CASE	2	Generic	$5.00	$0.00	None
POTASSIUM CHLORIDE IN 5% DEXTROSE AND NACL SOLUTION FOR INJECTION 0.075% 1000ML PLASTIC BAGS X 12 CA	2	Generic	$5.00	$0.00	None
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION	2	Generic	$5.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION	2	Generic	$5.00	$0.00	None
POTASSIUM CHLORIDE IN 5% DEXTROSE INJECTION 40 12 X 1000ML CTR	2	Generic	$5.00	$0.00	None
POTASSIUM CHLORIDE IN DEXTROSE INJECTION 5GM/75MG	2	Generic	$5.00	$0.00	None
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION	2	Generic	$5.00	$0.00	None
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION 0.15%-0.9% 12 X 1000ML BAG	2	Generic	$5.00	$0.00	None
POTASSIUM CHLORIDE TABLET EXTENED RELEASE	2	Generic	$5.00	$0.00	None
POTASSIUM CITRATE 10MEQ TABLET SA	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
POTASSIUM CITRATE 5MEQ TABLET SA	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
PRAMIPEXOLE 0.125 MG TABLET	2	Generic	$5.00	$0.00	None
PRAMIPEXOLE 0.25 MG TABLET	2	Generic	$5.00	$0.00	None
PRAMIPEXOLE 0.5 MG 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
PRAMIPEXOLE 1 MG TABLET	2	Generic	$5.00	$0.00	None
PRAMIPEXOLE 1.5 MG TABLET	2	Generic	$5.00	$0.00	None
PRAMIPEXOLE DIHYDROCHLORIDE TABLETS	2	Generic	$5.00	$0.00	None
PRANDIN 0.5MG TABLET	4	Non-Preferred Brand	35%	35%	None
PRANDIN 1MG TABLET	4	Non-Preferred Brand	35%	35%	None
PRANDIN 2MG TABLET	4	Non-Preferred Brand	35%	35%	None
PRASUGREL 10 MG ORAL TABLET	4	Non-Preferred Brand	35%	35%	Q:30 /30Days
PRASUGREL 5 MG ORAL TABLET	4	Non-Preferred Brand	35%	35%	Q:30 /30Days
PRAVASTATIN SODIUM 20MG TABLET 500 BOT	1	Preferred Generic	$2.00	$0.00	Q:30 /30Days
PRAVASTATIN SODIUM 40MG TABLET (500 CT)	1	Preferred Generic	$2.00	$0.00	Q:60 /30Days
PRAVASTATIN SODIUM 80MG TABLET (90 CT)	2	Generic	$5.00	$0.00	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PRAVASTATIN SODIUM TABLETS 10MG 90 BOT	1	Preferred Generic	$2.00	$0.00	Q:30 /30Days
PRAZOSIN 5MG CAPSULE	1	Preferred Generic	$2.00	$0.00	None
PRAZOSIN HCL 1MG CAPSULE	1	Preferred Generic	$2.00	$0.00	None
PRAZOSIN HCL 2MG CAPSULE	1	Preferred Generic	$2.00	$0.00	None
PRED FORTE 1% EYE DROPS	4	Non-Preferred Brand	35%	35%	None
PRED G OPHTHALMIC SUSPENSION 1;0.3%;% 5 ML BOTDR	4	Non-Preferred Brand	35%	35%	None
PRED MILD 0.12% EYE DROPS	4	Non-Preferred Brand	35%	35%	None
PRED-G S.O.P. EYE OINTMENT	4	Non-Preferred Brand	35%	35%	None
PREDNICARBATE 0.1% OINTMENT	2	Generic	$5.00	$0.00	None
PREDNICARBATE 1 MG/ML TOPICAL CREAM	2	Generic	$5.00	$0.00	None
PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION 1.0% STERILE 10ML BOTDR	2	Generic	$5.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PREDNISOLONE SOD 1% EYE DROP	2	Generic	$5.00	$0.00	None
PREDNISOLONE SODIUM PHOSPHATE 15MG/5ML SOLUTION ORAL	2	Generic	$5.00	$0.00	None
PREDNISOLONE SODIUM PHOSPHATE ORAL SOLUTION	2	Generic	$5.00	$0.00	None
PREDNISONE 10MG TABLET (100 CT)	1	Preferred Generic	$2.00	$0.00	None
PREDNISONE 1MG TABLET	2	Generic	$5.00	$0.00	None
PREDNISONE 2.5MG TABLET	1	Preferred Generic	$2.00	$0.00	None
PREDNISONE 20MG TABLET (1000 CT)	1	Preferred Generic	$2.00	$0.00	None
PREDNISONE 5 MG TABLET	1	Preferred Generic	$2.00	$0.00	None
PREDNISONE 50MG TABLET	2	Generic	$5.00	$0.00	None
PREDNISONE 5MG/5ML SOLUTION	2	Generic	$5.00	$0.00	None
PREDNISONE 5MG/ML SOLUTION	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
PRELONE 15MG/5ML SOLUTION ORAL	4	Non-Preferred Brand	35%	35%	None
PREMARIN 0.3MG (100 CT)	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
PREMARIN 0.45MG TABLET	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
PREMARIN 0.625MG (100 CT)	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
PREMARIN 0.9MG TABLET	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
PREMARIN 1.25MG (100 CT)	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
PREMARIN VAGINAL CREAM /APPL	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
PREMASOL 10% IV SOLUTION	2	Generic	$5.00	$0.00	None
PREMASOL 6% IV SOLUTION	2	Generic	$5.00	$0.00	None
PREMPHASE 0.625/5MG TABLET	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
PREMPRO 0.3 MG-1.5 MG TABLET #28 EA	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
PREMPRO 0.45-1.5 MG TABLET 28 EA	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
PRENATABS OBN TABLETS 200;1;150;MG;MG;MCG; 90 BOT	2	Generic	$5.00	$0.00	None
PREVALITE POW 4GM	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
PREVIFEM TABLETS .035;.25MG;MG 28 BLPK	2	Generic	$5.00	$0.00	None
PREZISTA TABLET 600MG	4	Non-Preferred Brand	35%	35%	None
PREZISTA TABLET 75MG	4	Non-Preferred Brand	35%	35%	None
PREZISTA TABLETS	4	Non-Preferred Brand	35%	35%	None
PREZISTA TABLETS 400MG 60 TABLETS BOT	4	Non-Preferred Brand	35%	35%	None
PRIFTIN 150MG TABLET	4	Non-Preferred Brand	35%	35%	None
PRIMAXIN I.M. 500MG VIAL	4	Non-Preferred Brand	35%	35%	None
PRIMAXIN IV 250MG VIAL	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
PRIMAXIN IV INJ 500MG	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
PRIMIDONE 250MG TABLET (100 CT)	2	Generic	$5.00	$0.00	None
PRIMIDONE 50MG TABLET (500 CT)	2	Generic	$5.00	$0.00	None
PRIMSOL 50MG/5ML ORAL SOLUTION	2	Generic	$5.00	$0.00	None
PRINIVIL 10MG TABLET	4	Non-Preferred Brand	35%	35%	None
PRINIVIL 20MG TABLET	4	Non-Preferred Brand	35%	35%	None
PRINIVIL TABLETS	4	Non-Preferred Brand	35%	35%	None
PRINZIDE 10/12.5 TABLET	4	Non-Preferred Brand	35%	35%	None
PRINZIDE 20/12.5 TABLET	4	Non-Preferred Brand	35%	35%	None
PRISTIQ 100MG TABLET SR 24HR	4	Non-Preferred Brand	35%	35%	Q:30 /30Days
PRISTIQ 50MG TABLET SR 24HR	4	Non-Preferred Brand	35%	35%	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PRIVIGEN 10% VIAL	4	Non-Preferred Brand	35%	35%	P
PROAIR HFA 90MCG HFA AEROSOL WITH ADAPTER	3	Non-Preferred Generic/Preferred Brand	20%	20%	Q:36 /30Days
PROAMATINE 10MG TABLET	4	Non-Preferred Brand	35%	35%	None
PROAMATINE 2.5MG TABLET	4	Non-Preferred Brand	35%	35%	None
PROAMATINE 5MG TABLET	4	Non-Preferred Brand	35%	35%	None
PROBENECID 500MG TABLET	2	Generic	$5.00	$0.00	None
PROBENECID/COLCHICINE TABLET S	2	Generic	$5.00	$0.00	None
PROCAINAMIDE 100MG/ML VIAL	2	Generic	$5.00	$0.00	None
PROCAINAMIDE 500MG/ML VIAL	2	Generic	$5.00	$0.00	None
PROCALAMINE INJECTION 210MG-290MG-26MG 6 X 1000ML BOT	4	Non-Preferred Brand	35%	35%	None
PROCARDIA 10MG CAPSULE	4	Non-Preferred Brand	35%	35%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PROCHLORPERAZINE EDISYLATE INJECTION 10MG 10 X 2ML VIALS CRTN	2	Generic	$5.00	$0.00	None
PROCHLORPERAZINE MALEATE 10MG TABLET (100 CT)	1	Preferred Generic	$2.00	$0.00	None
PROCHLORPERAZINE MALEATE 5MG TABLET (100 CT)	2	Generic	$5.00	$0.00	None
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX	2	Generic	$5.00	$0.00	None
PROCRIT 10000U/ML VIAL	4	Non-Preferred Brand	35%	35%	P Q:14 /30Days
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL	4	Non-Preferred Brand	35%	35%	P Q:14 /30Days
PROCRIT 3000U/ML VIAL	4	Non-Preferred Brand	35%	35%	P Q:14 /30Days
PROCRIT 40000U/ML VIAL PR	4	Non-Preferred Brand	35%	35%	P Q:14 /30Days
PROCRIT 4000U/ML VIAL 25 X 1ML VIAL	4	Non-Preferred Brand	35%	35%	P Q:14 /30Days
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY	4	Non-Preferred Brand	35%	35%	P Q:14 /30Days
PROCTO-PAK 1% CREAM	1	Preferred Generic	$2.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PROCTOCORT 1% CREAM	1	Preferred Generic	$2.00	$0.00	None
PROCTOCREAM-HC 2.5% CREAM	1	Preferred Generic	$2.00	$0.00	None
PROCTOSOL-HC 2.5% CREAM	1	Preferred Generic	$2.00	$0.00	None
PROCTOZONE-HC 2.5% CREAM	1	Preferred Generic	$2.00	$0.00	None
PROGLYCEM 50MG/ML ORAL SUSP	4	Non-Preferred Brand	35%	35%	None
PROGRAF 0.5MG CAPSULE	4	Non-Preferred Brand	35%	35%	P
PROGRAF 1MG CAPSULE	4	Non-Preferred Brand	35%	35%	P
PROGRAF 5MG CAPSULE	4	Non-Preferred Brand	35%	35%	P
PROGRAF 5MG/ML AMPULE	4	Non-Preferred Brand	35%	35%	P
PROLASTIN 500MG VIAL	4	Non-Preferred Brand	35%	35%	P
PROLEUKIN 22 MILLION UNITS VL	4	Non-Preferred Brand	35%	35%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PROLIA INJECTION	4	Non-Preferred Brand	35%	35%	P Q:2 /365Days
PROMACTA TABLETS	4	Non-Preferred Brand	35%	35%	P Q:30 /30Days
PROMACTA TABLETS	4	Non-Preferred Brand	35%	35%	P Q:30 /30Days
PROMACTA TABLETS 25 MG	4	Non-Preferred Brand	35%	35%	P Q:90 /30Days
PROMETHAZINE 50MG/ML VIAL	2	Generic	$5.00	$0.00	None
PROMETHAZINE HCL 12.5MG TABLET	2	Generic	$5.00	$0.00	None
PROMETHAZINE HCL 25MG TABLET (1000 CT)	1	Preferred Generic	$2.00	$0.00	None
PROMETHAZINE HCL 50MG TABLET (100 CT)	2	Generic	$5.00	$0.00	None
PROMETHAZINE HCL 6.25MG/5ML SYRUP	1	Preferred Generic	$2.00	$0.00	None
PROMETHAZINE HCL INJECTION 25MG 10 X 1ML VIAL	2	Generic	$5.00	$0.00	None
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 12.5MG 12 BOX	2	Generic	$5.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 25MG 12 BOX	2	Generic	$5.00	$0.00	None
PROMETHAZINE VC PLAIN 6.25-5MG 16 FL OZ BOT	2	Generic	$5.00	$0.00	None
PROMETHEGAN 25MG SUPP	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
PROMETHEGAN 50MG SUPPOS	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
PROPAFENONE HCL 150MG TABLET (100 CT)	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
PROPAFENONE HCL 225MG TABLET	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
PROPAFENONE HCL 300MG TABLET (100 CT)	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
PROPAFENONE HYDROCHLORIDE CAPSULES EXTENDED RELEASE	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
PROPAFENONE HYDROCHLORIDE CAPSULES EXTENDED RELEASE	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
PROPAFENONE HYDROCHLORIDE CAPSULES EXTENDED RELEASE	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
PROPARACAINE 0.5% EYE DROPS	2	Generic	$5.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PROPINE 0.1% EYE DROPS	4	Non-Preferred Brand	35%	35%	None
PROPRANOLOL 20MG/5ML TUBEX	2	Generic	$5.00	$0.00	None
PROPRANOLOL 40MG/5ML TUBEX	2	Generic	$5.00	$0.00	None
PROPRANOLOL 60MG TABLET	2	Generic	$5.00	$0.00	None
PROPRANOLOL 80 MG TABLET	1	Preferred Generic	$2.00	$0.00	None
PROPRANOLOL HCL 20MG TABLET (1000 CT)	1	Preferred Generic	$2.00	$0.00	None
PROPRANOLOL HCL CAPSULES ER 120MG (1000 CT)	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
PROPRANOLOL HCL CAPSULES ER 160MG (1000 CT)	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
PROPRANOLOL HCL CAPSULES ER 60MG (100 CT)	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
PROPRANOLOL HCL CAPSULES ER 80MG (1000 CT)	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
PROPRANOLOL HCL INJECTION 1MG 10 PKG OF 10 CRTN	2	Generic	$5.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PROPRANOLOL HCL TABLET USP 10MG (1000 CT)	1	Preferred Generic	$2.00	$0.00	None
PROPRANOLOL HCL TABLET USP 40MG (1000 CT)	1	Preferred Generic	$2.00	$0.00	None
PROPRANOLOL/HCTZ 40/25 TABLET	2	Generic	$5.00	$0.00	None
PROPRANOLOL/HCTZ 80/25 TABLET	2	Generic	$5.00	$0.00	None
PROPYLTHIOURACIL 50MG TABLET	2	Generic	$5.00	$0.00	None
PROQUAD VIAL	4	Non-Preferred Brand	35%	35%	None
PROTONIX IV 40MG VIAL	4	Non-Preferred Brand	35%	35%	None
PROTRIPTYLINE HYDROCHLORIDE TABLETS	2	Generic	$5.00	$0.00	None
PROTRIPTYLINE HYDROCHLORIDE TABLETS 5MG	2	Generic	$5.00	$0.00	None
PROVERA 10MG TABLET	4	Non-Preferred Brand	35%	35%	None
PROVERA 2.5MG TABLET (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
PROVERA 5MG TABLET	4	Non-Preferred Brand	35%	35%	None
PROZAC WEEKLY 90MG CAPSULE	4	Non-Preferred Brand	35%	35%	Q:4 /28Days
PULMOZYME 1MG/ML AMPUL	4	Non-Preferred Brand	35%	35%	P Q:150 /30Days
PYRAZINAMIDE 500MG TABLET	2	Generic	$5.00	$0.00	None
PYRIDOSTIGMINE BROMIDE 60MG TABLET	2	Generic	$5.00	$0.00	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.