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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 V in CMS PDP Region 32 which includes: CA
Drugs Starting with Letter V Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter V Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VALACYCLOVIR 1000 MG ORAL TABLET	3	Non-Preferred Generic/Preferred Brand	20%	20%	Q:90 /30Days
VALACYCLOVIR 500 MG ORAL TABLET	3	Non-Preferred Generic/Preferred Brand	20%	20%	Q:60 /30Days
VALCYTE 450MG TABLET	4	Non-Preferred Brand	35%	35%	Q:120 /30Days
VALCYTE FOR ORAL SOLUTION 50MG/ML	4	Non-Preferred Brand	35%	35%	Q:540 /30Days
VALPROATE SOD 500MG/5ML VL	2	Generic	$5.00	$0.00	None
VALPROIC ACID 250MG CAPSULE	2	Generic	$5.00	$0.00	None
VALPROIC ACID SYRUP USP 250MG 16 FL OZ BOT	2	Generic	$5.00	$0.00	None
VANCOCIN HCL 125MG PULVULE	4	Non-Preferred Brand	35%	35%	None
VANCOCIN HCL 250MG PULVULE	4	Non-Preferred Brand	35%	35%	None
VANCOMYCIN HCL 10GM 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
VANTIN 200MG TABLET (20 CT)	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
VAQTA 25 UNITS/0.5ML VIAL	4	Non-Preferred Brand	35%	35%	None
VARIVAX VACCINE W/DILUENT	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
VASERETIC 10MG-25MG TABLET	4	Non-Preferred Brand	35%	35%	None
VASOTEC 10MG TABLET	4	Non-Preferred Brand	35%	35%	None
VASOTEC 2.5MG TABLET	4	Non-Preferred Brand	35%	35%	None
VASOTEC 20MG TABLET	4	Non-Preferred Brand	35%	35%	None
VASOTEC 5MG TABLET	4	Non-Preferred Brand	35%	35%	None
VELCADE 3.5MG VIAL	4	Non-Preferred Brand	35%	35%	P
VELIVET 7 DAYS X 3 TABLET	2	Generic	$5.00	$0.00	None
VENLAFAXINE HCL 100MG 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
VENLAFAXINE HCL 25MG TABLET	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
VENLAFAXINE HCL 37.5MG TABLET	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
VENLAFAXINE HCL 50MG TABLET	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
VENLAFAXINE HCL 75MG TABLET	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
VENLAFAXINE HCL ER TAB 225 MG	4	Non-Preferred Brand	35%	35%	Q:30 /30Days
VENLAFAXINE HYDROCHLORIDE CAPSULES EXTENDED RELEASE	3	Non-Preferred Generic/Preferred Brand	20%	20%	Q:60 /30Days
VENLAFAXINE HYDROCHLORIDE CAPSULES EXTENDED RELEASE	3	Non-Preferred Generic/Preferred Brand	20%	20%	Q:30 /30Days
VENLAFAXINE HYDROCHLORIDE CAPSULES EXTENDED RELEASE	3	Non-Preferred Generic/Preferred Brand	20%	20%	Q:90 /30Days
VENLAFAXINE HYDROCHLORIDE TABLETS EXTENDED RELEASE	4	Non-Preferred Brand	35%	35%	Q:30 /30Days
VENLAFAXINE HYDROCHLORIDE TABLETS EXTENDED RELEASE	4	Non-Preferred Brand	35%	35%	Q:30 /30Days
VENLAFAXINE HYDROCHLORIDE TABLETS EXTENDED RELEASE	4	Non-Preferred Brand	35%	35%	Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VENTOLIN HFA 90MCG INHALER	3	Non-Preferred Generic/Preferred Brand	20%	20%	Q:36 /30Days
VERAMYST 27.5MCG SPRAY SUSPENSION	3	Non-Preferred Generic/Preferred Brand	20%	20%	Q:10 /30Days
VERAPAMIL 120MG CAP PELLET	2	Generic	$5.00	$0.00	None
VERAPAMIL 180MG CAP PELLET	2	Generic	$5.00	$0.00	None
VERAPAMIL 2.5MG/ML AMPUL	2	Generic	$5.00	$0.00	None
VERAPAMIL 240MG CAP PELLET	2	Generic	$5.00	$0.00	None
VERAPAMIL 40MG TABLET	2	Generic	$5.00	$0.00	None
VERAPAMIL ER 100MG CAPSULE 24HR SR PELLETS	2	Generic	$5.00	$0.00	None
VERAPAMIL ER 180 MG TABLET	2	Generic	$5.00	$0.00	None
VERAPAMIL ER 200MG CAPSULE 24HR SR PELLETS (100 CT)	2	Generic	$5.00	$0.00	None
VERAPAMIL ER 300MG CAPSULE 24HR SR PELLETS	2	Generic	$5.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VERAPAMIL HCL 120MG TABLET	1	Preferred Generic	$2.00	$0.00	None
VERAPAMIL HCL 80MG TABLET	1	Preferred Generic	$2.00	$0.00	None
VERAPAMIL HCL ER TABLETS	2	Generic	$5.00	$0.00	None
VERAPAMIL HCL TABLETS ER 240 MG	2	Generic	$5.00	$0.00	None
VEREGEN 15% OINTMENT	4	Non-Preferred Brand	35%	35%	None
VERELAN 120MG CAP PELLET	4	Non-Preferred Brand	35%	35%	None
VERELAN 180MG CAP PELLET	4	Non-Preferred Brand	35%	35%	None
VERELAN 240MG CAP PELLET	4	Non-Preferred Brand	35%	35%	None
VERELAN 360MG CAP PELLET	4	Non-Preferred Brand	35%	35%	None
VERIPRED 20 ORAL SOLUTION 20MG/5ML 8 FL OZ BOT	4	Non-Preferred Brand	35%	35%	None
VFEND 200MG TABLET	4	Non-Preferred Brand	35%	35%	P Q:120 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VFEND 40MG/ML SUSPENSION	4	Non-Preferred Brand	35%	35%	P Q:400 /30Days
VFEND 50MG TABLET	4	Non-Preferred Brand	35%	35%	P Q:120 /30Days
VFEND IV 200MG VIAL	4	Non-Preferred Brand	35%	35%	None
VIBRA-TAB S 100MG TABLET	1	Preferred Generic	$2.00	$0.00	None
VIBRAMYCIN 100MG CAPSULE	4	Non-Preferred Brand	35%	35%	None
VIBRAMYCIN 25MG/5ML SUSP	4	Non-Preferred Brand	35%	35%	None
VIBRAMYCIN 50MG/5ML SYRUP	4	Non-Preferred Brand	35%	35%	None
VICTOZA 3-PAK 18 MG/3 ML PEN	4	Non-Preferred Brand	35%	35%	P Q:9 /30Days
VIDAZA FOR INJECTION 100MG/VIAL 1 VIALSU	4	Non-Preferred Brand	35%	35%	P
VIDEX 2GM PEDIATRIC TUBEX	4	Non-Preferred Brand	35%	35%	None
VIDEX EC 125MG CAPSULE SA	4	Non-Preferred Brand	35%	35%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VIDEX EC 200MG CAPSULE SA	4	Non-Preferred Brand	35%	35%	None
VIDEX EC 250MG CAPSULE SA	4	Non-Preferred Brand	35%	35%	None
VIDEX EC 400MG CAPSULE SA	4	Non-Preferred Brand	35%	35%	None
VIGABATRIN 50 MG/ML ORAL SOLUTION [SABRIL]	4	Non-Preferred Brand	35%	35%	P Q:180 /30Days
VIGABATRIN 500 MG ORAL TABLET [SABRIL]	4	Non-Preferred Brand	35%	35%	P Q:180 /30Days
VIGAMOX 0.5% EYE DROPS	4	Non-Preferred Brand	35%	35%	None
VIMPAT 10 MG/ML SOLUTION	4	Non-Preferred Brand	35%	35%	P Q:3 /30Days
VIMPAT INJECTION 10MG/ML 10 X 20ML VIALGL	4	Non-Preferred Brand	35%	35%	P
VIMPAT TABLETS 100MG 60 BOTPL	4	Non-Preferred Brand	35%	35%	P Q:90 /30Days
VIMPAT TABLETS 150MG 60 BOTPL	4	Non-Preferred Brand	35%	35%	P Q:90 /30Days
VIMPAT TABLETS 200MG 60 BOTPL	4	Non-Preferred Brand	35%	35%	P Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VIMPAT TABLETS 50MG 60 BOTPL	4	Non-Preferred Brand	35%	35%	P Q:90 /30Days
VINBLASTINE SULF 10MG VIAL	2	Generic	$5.00	$0.00	P
VINCRISTINE 1MG/ML VIAL	2	Generic	$5.00	$0.00	P
VINCRISTINE 1MG/ML VIAL	2	Generic	$5.00	$0.00	P
VINORELBINE 10MG/ML VIAL 5ML VIAL	3	Non-Preferred Generic/Preferred Brand	20%	20%	None
VIRACEPT 250MG TABLET	4	Non-Preferred Brand	35%	35%	None
VIRACEPT 50MG/GM ORAL POWDER	4	Non-Preferred Brand	35%	35%	None
VIRACEPT 625MG TABLET	4	Non-Preferred Brand	35%	35%	None
VIRAMUNE 200MG TABLET	4	Non-Preferred Brand	35%	35%	None
VIRAMUNE 50MG/5ML SUSP	4	Non-Preferred Brand	35%	35%	None
VIREAD 300MG 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
VIROPTIC 1% EYE DROPS	4	Non-Preferred Brand	35%	35%	None
VISTARIL 25MG CAPSULE	4	Non-Preferred Brand	35%	35%	None
VISTARIL 50MG CAPSULE	4	Non-Preferred Brand	35%	35%	None
VIVACTIL 10MG TABLET	4	Non-Preferred Brand	35%	35%	None
VIVACTIL 5MG TABLET	4	Non-Preferred Brand	35%	35%	None
VIVAGLOBIN SOL 160MG/ML 10ML VIAL	4	Non-Preferred Brand	35%	35%	P
VOSPIRE ER 4MG TABLET SR 12HR	4	Non-Preferred Brand	35%	35%	None
VOSPIRE ER 8MG TABLET SR 12HR	4	Non-Preferred Brand	35%	35%	None
VPRIV INJECTION SOLUTION 2.5 MG/ML	4	Non-Preferred Brand	35%	35%	P
VYTORIN 10/10MG TABLET (1000 CT)	3	Non-Preferred Generic/Preferred Brand	20%	20%	Q:30 /30Days
VYTORIN 10/20MG TABLET (1000 CT)	3	Non-Preferred Generic/Preferred Brand	20%	20%	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VYTORIN 10/40MG TABLET (500 CT)	3	Non-Preferred Generic/Preferred Brand	20%	20%	Q:30 /30Days
VYTORIN 10/80MG TABLET 2500 BOT	3	Non-Preferred Generic/Preferred Brand	20%	20%	Q:30 /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.