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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 R in CMS PDP Region 32 which includes: CA
Drugs Starting with Letter R Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter R Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RABIES VACCINE RABAVERT INJECTION 2.5UNT/ML 1 DOSE VIAL	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
RALOXIFENE 60 MG ORAL TABLET	3	Non-Preferred Generic/Preferred Brand	20%	20%	Q:30 /30Days
RAMIPRIL 1.25MG CAPSULE	2	Generic	$5.00	$0.00	None
RAMIPRIL 10MG CAPSULE	2	Generic	$5.00	$0.00	None
RAMIPRIL 2.5MG CAPSULE	2	Generic	$5.00	$0.00	None
RAMIPRIL 5MG CAPSULE	2	Generic	$5.00	$0.00	None
RANEXA 1,000 MG TABLET	3	Non-Preferred Generic/Preferred Brand	20%	20%	S Q:120 /30Days
RANEXA 500 MG TABLET	3	Non-Preferred Generic/Preferred Brand	20%	20%	S Q:120 /30Days
RANITIDINE 150MG CAPSULE	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
RANITIDINE HCL 15MG/ML SYRUP	2	Generic	$5.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RANITIDINE HCL 25MG/ML VIAL	2	Generic	$5.00	$0.00	None
RANITIDINE HCL 300MG CAPSULE (30 CT)	2	Generic	$5.00	$0.00	None
RANITIDINE TABLET 300MG (100 CT)	1	Preferred Generic	$2.00	$0.00	None
RANITIDINE TABLET USP 150MG (500 CT)	1	Preferred Generic	$2.00	$0.00	None
RAPAMUNE 1MG TABLET	4	Non-Preferred Brand	35%	35%	P
RAPAMUNE 1MG/ML ORAL TUBEX	4	Non-Preferred Brand	35%	35%	P
RAPAMUNE 2MG TABLET	4	Non-Preferred Brand	35%	35%	P
RAPAMUNE TABLETS	4	Non-Preferred Brand	35%	35%	P
REBETOL 40MG/ML SOLUTION	4	Non-Preferred Brand	35%	35%	P Q:1000 /30Days
REBIF 22MCG/0.5ML SYRINGE	4	Non-Preferred Brand	35%	35%	P Q:12 /30Days
REBIF 44MCG/0.5ML SYRINGE	4	Non-Preferred Brand	35%	35%	P Q:12 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
REBIF TITRTN SOL PACK 8.8MCG/22 VIAL	4	Non-Preferred Brand	35%	35%	P Q:12 /30Days
RECLAST INJECTION	4	Non-Preferred Brand	35%	35%	P Q:1 /365Days
RECLIPSEN 0.15-0.03 TABLET	2	Generic	$5.00	$0.00	None
RECOMBIVAX HB 40MCG/ML VIAL	4	Non-Preferred Brand	35%	35%	None
REGRANEX 0.01% GEL	4	Non-Preferred Brand	35%	35%	None
RELENZA 5MG DISKHALER	4	Non-Preferred Brand	35%	35%	Q:60 /180Days
RELION R INJ 100/ML	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
RELISTOR SOLUTION	4	Non-Preferred Brand	35%	35%	P Q:36 /30Days
REMICADE 100MG VIAL	4	Non-Preferred Brand	35%	35%	P
REMODULIN 10MG/ML VIAL	4	Non-Preferred Brand	35%	35%	P
REMODULIN 1MG/ML VIAL	4	Non-Preferred Brand	35%	35%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
REMODULIN 2.5MG/ML VIAL	4	Non-Preferred Brand	35%	35%	P
REMODULIN 5MG/ML VIAL	4	Non-Preferred Brand	35%	35%	P
RENAMIN 6.5% IV SOLUTION	4	Non-Preferred Brand	35%	35%	None
RENVELA 800MG TABLET	3	Non-Preferred Generic/Preferred Brand	20%	20%	Q:540 /30Days
RESCRIPTOR 100MG TABLET	4	Non-Preferred Brand	35%	35%	None
RESCRIPTOR 200MG TABLET	4	Non-Preferred Brand	35%	35%	None
RESERPINE 0.1MG TABLET	2	Generic	$5.00	$0.00	None
RESERPINE 0.25MG TABLET	2	Generic	$5.00	$0.00	None
RESTASIS CYCLOSPORINE OPTHALMIC EMULSION .05% 30 X 0.4 ML VIALSU	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
RETAPAMULIN 0.01 MG/MG TOPICAL OINTMENT [ALTABAX]	4	Non-Preferred Brand	35%	35%	None
RETROVIR 100MG 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
RETROVIR 10MGML SYRUP	4	Non-Preferred Brand	35%	35%	None
RETROVIR 300MG TABLET	4	Non-Preferred Brand	35%	35%	None
RETROVIR IV INFUSION VIAL	4	Non-Preferred Brand	35%	35%	None
REVATIO 10 MG/12.5 ML VIAL	4	Non-Preferred Brand	35%	35%	P Q:1125 /30Days
REVATIO 20MG TABLET	3	Non-Preferred Generic/Preferred Brand	20%	20%	P Q:90 /30Days
REVLIMID 10MG CAPSULE (100 CT)	4	Non-Preferred Brand	35%	35%	P Q:30 /30Days
REVLIMID 15MG CAPSULE 21 BOT	4	Non-Preferred Brand	35%	35%	P Q:30 /30Days
REVLIMID 25MG CAPSULE (100 CT)	4	Non-Preferred Brand	35%	35%	P Q:30 /30Days
REVLIMID 5MG CAPSULE	4	Non-Preferred Brand	35%	35%	P Q:30 /30Days
REYATAZ 100MG CAPSULE	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
REYATAZ 150MG 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
REYATAZ 200MG CAPSULE	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
REYATAZ 300MG CAPSULE	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
RHEUMATREX 2.5MG TABLET DOSE PACK	4	Non-Preferred Brand	35%	35%	None
RIBAVIRIN 200MG CAPSULE	4	Non-Preferred Brand	35%	35%	P
RIBAVIRIN 200MG TABLET 168 BOT	2	Generic	$5.00	$0.00	P
RIBAVIRIN TABLETS 400MG 56 TABS BOT	3	Non-Preferred Generic/Preferred Brand	20%	20%	Q:112 /30Days
RIBAVIRIN TABLETS 600MG 56 TABS BOT	3	Non-Preferred Generic/Preferred Brand	20%	20%	Q:60 /30Days
RIDAURA 3MG CAPSULE	4	Non-Preferred Brand	35%	35%	None
RIFAMATE CAPSULE	4	Non-Preferred Brand	35%	35%	None
RIFAMPIN 150MG CAPSULE (30 CT)	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
RIFAMPIN 300MG 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
RIFAMPIN 600MG VIAL	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
RILUTEK 50MG TABLET	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
RIMANTADINE 100MG TABLET	2	Generic	$5.00	$0.00	None
RINGERS INJECTION 1000ML BAG	2	Generic	$5.00	$0.00	None
RINGERS IRRIGATION 860-30 12X1000ML BAG	2	Generic	$5.00	$0.00	None
RISPERDAL 1MG M-TAB	4	Non-Preferred Brand	35%	35%	Q:60 /30Days
RISPERDAL 1MG/ML SOLUTION	4	Non-Preferred Brand	35%	35%	None
RISPERDAL 2MG M-TAB	4	Non-Preferred Brand	35%	35%	Q:60 /30Days
RISPERDAL 3MG M-TAB	4	Non-Preferred Brand	35%	35%	Q:60 /30Days
RISPERDAL 4MG M-TAB	4	Non-Preferred Brand	35%	35%	Q:60 /30Days
RISPERDAL CONSTA 25MG SYR	4	Non-Preferred Brand	35%	35%	Q:2 /28Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RISPERDAL CONSTA 37.5MG SYR	4	Non-Preferred Brand	35%	35%	None
RISPERDAL CONSTA 50MG SYR	4	Non-Preferred Brand	35%	35%	None
RISPERDAL CONSTA FOR INJECTION 12.5MG/VIAL	4	Non-Preferred Brand	35%	35%	Q:2 /28Days
RISPERDAL M TABLET 0.5MG	4	Non-Preferred Brand	35%	35%	Q:120 /30Days
RISPERIDONE 1 MG DISINTEGRATING TABLET	3	Non-Preferred Generic/Preferred Brand	20%	20%	Q:60 /30Days
RISPERIDONE ORAL SOLUTION 1MG 30 ML BOTDR	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
RISPERIDONE TABLET	2	Generic	$5.00	$0.00	Q:60 /30Days
RISPERIDONE TABLET 0.25MG 4 IN 1 BLPK	3	Non-Preferred Generic/Preferred Brand	20%	20%	Q:60 /30Days
RISPERIDONE TABLET 1 MG	2	Generic	$5.00	$0.00	Q:60 /30Days
RISPERIDONE TABLET 2 MG	2	Generic	$5.00	$0.00	Q:60 /30Days
RISPERIDONE TABLET 3 MG	2	Generic	$5.00	$0.00	Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
RISPERIDONE TABLET 4 MG	2	Generic	$5.00	$0.00	Q:60 /30Days
RISPERIDONE TABLETS 3MG 4 IN 1 BLPK	3	Non-Preferred Generic/Preferred Brand	20%	20%	Q:60 /30Days
RISPERIDONE TABLETS 4MG 4 IN 1 BLPK	3	Non-Preferred Generic/Preferred Brand	20%	20%	Q:60 /30Days
RISPERIDONE TABLETS ORALLY DISINTEGRATING 0.5MG 30 BLPK	3	Non-Preferred Generic/Preferred Brand	20%	20%	Q:120 /30Days
RISPERIDONE TABLETS ORALLY DISINTEGRATING 2MG 30 BLPK	3	Non-Preferred Generic/Preferred Brand	20%	20%	Q:60 /30Days
RISPERIODONE TABLET	2	Generic	$5.00	$0.00	Q:120 /30Days
RITUXAN 10MG/ML VIAL	3	Non-Preferred Generic/Preferred Brand	20%	20%	P
RIVASTIGMINE TARTRATE CAPSULES	2	Generic	$5.00	$0.00	Q:90 /30Days
RIVASTIGMINE TARTRATE CAPSULES	2	Generic	$5.00	$0.00	Q:90 /30Days
RIVASTIGMINE TARTRATE CAPSULES	2	Generic	$5.00	$0.00	Q:60 /30Days
RIVASTIGMINE TARTRATE CAPSULES	2	Generic	$5.00	$0.00	Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ROBAXIN 100MG/ML VIAL	4	Non-Preferred Brand	35%	35%	None
ROBAXIN 500MG TABLET	4	Non-Preferred Brand	35%	35%	None
ROBINUL 0.2MG/ML VIAL	4	Non-Preferred Brand	35%	35%	None
ROBINUL 1MG TABLET	4	Non-Preferred Brand	35%	35%	None
ROBINUL FORTE 2MG TABLET	4	Non-Preferred Brand	35%	35%	None
ROCEPHIN FOR INJECTION	4	Non-Preferred Brand	35%	35%	None
ROMYCIN 5MG/G OINTMENT	1	Preferred Generic	$2.00	$0.00	None
ROPINIROLE HCL TABLET	2	Generic	$5.00	$0.00	None
ROPINIROLE HCL TABLET 1 MG	2	Generic	$5.00	$0.00	None
ROPINIROLE HCL TABLET 2 MG	2	Generic	$5.00	$0.00	None
ROPINIROLE HCL TABLET 3 MG	2	Generic	$5.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ROPINIROLE HCL TABLET 4 MG	2	Generic	$5.00	$0.00	None
ROPINIROLE HCL TABLET 5 MG	2	Generic	$5.00	$0.00	None
ROPINIROLE HYDROCLORIDE TABLET	2	Generic	$5.00	$0.00	None
ROTATEQ VACCINE	4	Non-Preferred Brand	35%	35%	None
ROXICET 5/325 TABLET	3	Non-Preferred Generic/Preferred Brand	20%	20%	Q:360 /30Days
ROXICET 5/500 CAPLET	3	Non-Preferred Generic/Preferred Brand	20%	20%	Q:240 /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.