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Community CCRx Basic (PDP) (S5803-077-0)
Tier 1 (1399)
Tier 2 (779)
Tier 3 (521)
Tier 4 (320)

Requires Prior Authorization:
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Uses Step Therapy:
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2012 Medicare Part D Plan Formulary Information
Community CCRx Basic (PDP) (S5803-077-0)
Benefit Details           
The Community CCRx Basic (PDP) (S5803-077-0)
Formulary Drugs Starting with the Letter M

in CMS PDP Region 8 which includes: NC
Drugs Starting with Letter M

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
M-M-R II VACCINE W/DILUENT 1 DOSE/0.5ML   2 Preferred Brand Drugs 25%N/ANone
Macrodantin Nitrofurantion crystals 25mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC   2 Preferred Brand Drugs 25%N/ANone
MAGENSIUM SULFATE IN 5% DEXTROSE INJECTION 5-1 24 X 100ML CTR   3 Non-Preferred Brand Drugs 47%N/ANone
MAGNESIUM SULFATE 4% IV SOLUTION   3 Non-Preferred Brand Drugs 47%N/ANone
MAGNESIUM SULFATE 8% IV SOLUTION   3 Non-Preferred Brand Drugs 47%N/ANone
MAGNESIUM SULFATE INJECTION 5 GM/10ML   1 Generic Drugs $2.00N/ANone
MALARONE 62.5-25MG PED TABLET   3 Non-Preferred Brand Drugs 47%N/ANone
Malathion 5mg/mL 1 BOTTLE in 1 CARTON / 59 mL in 1 BOTTLE   2 Preferred Brand Drugs 25%N/ANone
MAPROTILINE 25MG TABLET   1 Generic Drugs $2.00N/ANone
MAPROTILINE 50MG TABLET   1 Generic Drugs $2.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MAPROTILINE 75MG TABLET   1 Generic Drugs $2.00N/ANone
MARGESIC H 5MG-500MG CAPSULE   1 Generic Drugs $2.00N/AQ:240
/30Days
MARLISSA-28 TABLET   1 Generic Drugs $2.00N/AQ:28
/28Days
MARPLAN 10MG TABLET (100 CT)   3 Non-Preferred Brand Drugs 47%N/ANone
MATULANE 50MG CAPSULE   4 Specialty Tier Drugs 25%N/ANone
MAXALT 10MG TABLET 12 CRTN   2 Preferred Brand Drugs 25%N/AQ:12
/30Days
MAXALT 5MG TABLET 12 CRTN   2 Preferred Brand Drugs 25%N/AQ:12
/30Days
MAXALT MLT 10MG TABLET 4X3 UNIT DOSE CASE   2 Preferred Brand Drugs 25%N/AQ:12
/30Days
MAXALT MLT 5MG TABLET 4X3 UNIT CASE   2 Preferred Brand Drugs 25%N/AQ:12
/30Days
MAXIDEX OPHTHALMIC SUSPENSION 0.1% 5ML BOT   3 Non-Preferred Brand Drugs 47%N/ANone
MEBENDAZOLE 100MG TABLET CHEW   1 Generic Drugs $2.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MECLIZINE HYDROCHLORIDE TABLETS 12.5MG 100 BOT   1 Generic Drugs $2.00N/ANone
MECLIZINE HYDROCHLORIDE TABLETS 25MG 100 BOT   1 Generic Drugs $2.00N/ANone
MEDROXYPROGESTERONE 10MG TABLET   1 Generic Drugs $2.00N/ANone
MEDROXYPROGESTERONE 2.5MG   1 Generic Drugs $2.00N/ANone
MEDROXYPROGESTERONE 5MG TABLET   1 Generic Drugs $2.00N/ANone
MEDROXYPROGESTERONE ACETATE INJECTION SUSPENSION 150MG 1 VIALSD CRTN   1 Generic Drugs $2.00N/AQ:1
/90Days
MEFLOQUINE HCL 250MG TABLET 25 BOT   1 Generic Drugs $2.00N/ANone
MEGACE ES 625MG/5ML SUSP   2 Preferred Brand Drugs 25%N/AQ:150
/30Days
MEGESTROL 20MG TABLET   1 Generic Drugs $2.00N/ANone
MEGESTROL ACETATE 400MG/10ML SUSPENSION ORAL   2 Preferred Brand Drugs 25%N/ANone
MEGESTROL ACETATE 40MG TABLET (250 CT)   1 Generic Drugs $2.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Meloxicam 15mg/1   1 Generic Drugs $2.00N/ANone
Meloxicam 7.5mg 500 TABLET BOTTLE   1 Generic Drugs $2.00N/ANone
MENACTRA INJECTION 4MCG/0.5ML 5 X .5ML SYR   2 Preferred Brand Drugs 25%N/ANone
MENEST 0.3MG TABLET   2 Preferred Brand Drugs 25%N/ANone
MENEST 0.625MG TABLET   2 Preferred Brand Drugs 25%N/ANone
MENEST 1.25MG TABLET   2 Preferred Brand Drugs 25%N/ANone
MENEST 2.5MG TABLET   2 Preferred Brand Drugs 25%N/ANone
MENOMUNE-A/C/Y/W-135 VIAL   3 Non-Preferred Brand Drugs 47%N/ANone
MENVEO INJECTION KIT   3 Non-Preferred Brand Drugs 47%N/ANone
MEPRON 750MG/5ML ORAL SUSP   4 Specialty Tier Drugs 25%N/AS
MERCAPTOPURINE 50MG TABLET   1 Generic Drugs $2.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MEROPENEM FOR INJECTION   3 Non-Preferred Brand Drugs 47%N/ANone
MERREM INJECTION 500MG 10X20MLVIALS VIAL   3 Non-Preferred Brand Drugs 47%N/ANone
Mesalamine 4g/60mL 7 BOTTLE, UNIT-DOSE in 1 CARTON / 60 mL in 1 BOTTLE, UNIT-DOSE   2 Preferred Brand Drugs 25%N/ANone
MESNEX 400MG TABLET   4 Specialty Tier Drugs 25%N/ANone
MESTINON 180MG TIMESPAN   2 Preferred Brand Drugs 25%N/ANone
MESTINON 60MG/5ML SYRUP   2 Preferred Brand Drugs 25%N/ANone
METADATE ER 20MG TABLET SA   1 Generic Drugs $2.00N/ANone
METFORMIN HCL 1000MG TABLET (500 CT)   1 Generic Drugs $2.00N/AQ:75
/30Days
METFORMIN HCL 500MG TABLET (1000 CT)   1 Generic Drugs $2.00N/AQ:150
/30Days
METFORMIN HCL 850MG TABLET   1 Generic Drugs $2.00N/AQ:90
/30Days
METFORMIN HCL ER 500MG TABLET SR 24HR   1 Generic Drugs $2.00N/AQ:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METFORMIN HYDROCHLORIDE 750mg/1   1 Generic Drugs $2.00N/AQ:60
/30Days
METHADONE HCL 5MG TABLET (100 CT)   1 Generic Drugs $2.00N/AQ:600
/30Days
METHADONE HYDROCHLORIDE 10mg/1 100 TABLET in 1 BOTTLE   1 Generic Drugs $2.00N/AQ:600
/30Days
Methadone Hydrochloride 10mg/5mL   2 Preferred Brand Drugs 25%N/AQ:3000
/30Days
Methadone Hydrochloride 10mg/mL   1 Generic Drugs $2.00N/AQ:600
/30Days
Methadone Hydrochloride 5mg/5mL   2 Preferred Brand Drugs 25%N/AQ:3000
/30Days
METHADOSE 10MG TABLET   1 Generic Drugs $2.00N/AQ:600
/30Days
METHADOSE 5MG TABLET   1 Generic Drugs $2.00N/AQ:600
/30Days
METHAZOLAMIDE 25MG TABLET   1 Generic Drugs $2.00N/ANone
METHAZOLAMIDE 50MG TABLET   1 Generic Drugs $2.00N/ANone
METHERGINE 0.2MG TABLET   3 Non-Preferred Brand Drugs 47%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Methimazole 10mg/1   1 Generic Drugs $2.00N/ANone
METHIMAZOLE TABLETS   1 Generic Drugs $2.00N/ANone
Methocarbamol 500mg/1 100 TABLET in 1 BOTTLE, PLASTIC   1 Generic Drugs $2.00N/ANone
METHOCARBAMOL 750MG TABLET (500 CT)   1 Generic Drugs $2.00N/ANone
METHOTREXATE 2.5MG TABLET   1 Generic Drugs $2.00N/ANone
METHOTREXATE INJECTION 25 MG/ML   1 Generic Drugs $2.00N/ANone
METHSCOPOLAMINE BROMIDE 2.5MG TABLET   2 Preferred Brand Drugs 25%N/ANone
METHSCOPOLAMINE BROMIDE TABLETS 5MG 60 BOT   2 Preferred Brand Drugs 25%N/ANone
METHYCLOTHIAZIDE 5MG TABLET   1 Generic Drugs $2.00N/ANone
METHYLDOPA 250MG TABLET   1 Generic Drugs $2.00N/ANone
METHYLDOPA 500MG TABLET   1 Generic Drugs $2.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METHYLDOPA/HCTZ 250-15 TABLET   1 Generic Drugs $2.00N/ANone
METHYLDOPA/HCTZ 250-25 TABLET   1 Generic Drugs $2.00N/ANone
Methylergonovine Maleate 0.2mg/1 100 TABLET in 1 BOTTLE   2 Preferred Brand Drugs 25%N/ANone
METHYLIN 10MG TABLET (100 CT)   1 Generic Drugs $2.00N/ANone
METHYLIN 20MG TABLET   1 Generic Drugs $2.00N/ANone
METHYLIN ER 10MG TABLET SA   1 Generic Drugs $2.00N/ANone
METHYLIN ER 20MG TABLET SA   1 Generic Drugs $2.00N/ANone
METHYLIN TABLET 5MG (100 CT)   1 Generic Drugs $2.00N/ANone
METHYLPHENIDATE 10MG TABLET   1 Generic Drugs $2.00N/ANone
METHYLPHENIDATE 20MG TABLET   1 Generic Drugs $2.00N/ANone
METHYLPHENIDATE 5MG TABLET (100 CT)   1 Generic Drugs $2.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METHYLPHENIDATE TABLETS 20MG 100 TABS BOT   1 Generic Drugs $2.00N/ANone
METHYLPREDNISOLONE 16MG TABLET   1 Generic Drugs $2.00N/ANone
METHYLPREDNISOLONE 1GM VIAL   1 Generic Drugs $2.00N/ANone
METHYLPREDNISOLONE 32MG TABLET   1 Generic Drugs $2.00N/ANone
Methylprednisolone 40mg/mL 1 VIAL, MULTI-DOSE in 1 CARTON / 5 mL in 1 VIAL, MULTI-DOSE   1 Generic Drugs $2.00N/ANone
Methylprednisolone 4mg/1 100 TABLET in 1 BOTTLE   1 Generic Drugs $2.00N/ANone
METHYLPREDNISOLONE 8 MG ORAL TABLET   1 Generic Drugs $2.00N/ANone
Methylprednisolone acetate 80mg/mL 25 VIAL, GLASS in 1 CARTON / 1 mL in 1 VIAL, GLASS   1 Generic Drugs $2.00N/ANone
METHYLPREDNISOLONE SODIUM SUCCINATE POWDER FOR INJECTION 125MG 25X125MG VIAL   1 Generic Drugs $2.00N/ANone
METHYLPREDNISOLONE SODIUM SUCCINATE POWDER FOR INJECTION 40MG 25X40MG VIAL   1 Generic Drugs $2.00N/ANone
METHYLPREDNISOLONE TABLET 4MG 21 PKGCOM   1 Generic Drugs $2.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METIPRANOLOL 0.3% EYE DROPS   1 Generic Drugs $2.00N/ANone
METOCLOPRAMIDE 5 MG TABLET   1 Generic Drugs $2.00N/ANone
Metoclopramide 5mg/mL 25 VIAL in 1 TRAY / 2 mL in 1 VIAL   1 Generic Drugs $2.00N/ANone
METOCLOPRAMIDE HYDROCHLORIDE TABLETS 10MG 500 BOTPL   1 Generic Drugs $2.00N/ANone
METOCLOPRAMIDE SOLUTION ORAL USP 5MG 1 PT BOT   1 Generic Drugs $2.00N/ANone
METOLAZONE 10MG TABLET   1 Generic Drugs $2.00N/ANone
METOLAZONE 2.5MG TABLET   1 Generic Drugs $2.00N/ANone
METOLAZONE 5MG TABLET   1 Generic Drugs $2.00N/ANone
METOPROLOL SUCCINATE 25MG TABLET SR 24HR   1 Generic Drugs $2.00N/AQ:45
/30Days
METOPROLOL SUCCINATE 50MG TABLET SR 24HR   1 Generic Drugs $2.00N/AQ:45
/30Days
METOPROLOL SUCCINATE TABLETS EXTENDED RELEASE 100MG 100 BOT   1 Generic Drugs $2.00N/AQ:45
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METOPROLOL SUCINNATE TABLETS EXTENDED RELEASE 200MG 1000 BOT   1 Generic Drugs $2.00N/AQ:60
/30Days
METOPROLOL TARTRATE 25MG TABLET (100 CT)   1 Generic Drugs $2.00N/ANone
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT)   1 Generic Drugs $2.00N/ANone
METOPROLOL TARTRATE TABLET USP 100MG (1000 CT)   1 Generic Drugs $2.00N/ANone
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET   1 Generic Drugs $2.00N/ANone
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET   1 Generic Drugs $2.00N/ANone
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET   1 Generic Drugs $2.00N/ANone
METRONIDAZOLE 0.75% CREAM   1 Generic Drugs $2.00N/ANone
METRONIDAZOLE 0.75% LOTION   1 Generic Drugs $2.00N/ANone
Metronidazole 375mg/1 50 CAPSULE in 1 BOTTLE   1 Generic Drugs $2.00N/ANone
Metronidazole 500mg/100mL 24 BAG in 1 CARTON / 100 mL in 1 BAG   1 Generic Drugs $2.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METRONIDAZOLE TABLETS USP 250MG 250 BOTPL   1 Generic Drugs $2.00N/ANone
METRONIDAZOLE TABLETS USP 500MG 100 BOTPL   1 Generic Drugs $2.00N/ANone
METRONIDAZOLE TOPICAL GEL 0.75% 45GM TUBE   1 Generic Drugs $2.00N/ANone
METRONIDAZOLE VAGINAL GEL   1 Generic Drugs $2.00N/ANone
MEXILETINE 150MG CAPSULE   1 Generic Drugs $2.00N/ANone
MEXILETINE 200MG CAPSULE   1 Generic Drugs $2.00N/ANone
MEXILETINE 250MG CAPSULE   1 Generic Drugs $2.00N/ANone
MICONAZOLE 3 200MG SUPPOS.   1 Generic Drugs $2.00N/ANone
MICROGESTIN 1-0.02MG TABLET   1 Generic Drugs $2.00N/AQ:28
/28Days
MICROGESTIN 1.5-0.03MG TABLET   1 Generic Drugs $2.00N/AQ:28
/28Days
MICROGESTIN FE 1.5/30 TABLET   1 Generic Drugs $2.00N/AQ:28
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MICROGESTIN FE 1/20 TABLET   1 Generic Drugs $2.00N/AQ:28
/28Days
MIDODRINE HCL 10MG TABLET   2 Preferred Brand Drugs 25%N/ANone
MIDODRINE HCL 2.5MG TABLET   2 Preferred Brand Drugs 25%N/ANone
MIDODRINE HCL 5MG TABLET (100 CT)   2 Preferred Brand Drugs 25%N/ANone
MILLIPRED TABLETS 5MG   1 Generic Drugs $2.00N/ANone
MINOCYCLINE 100MG CAPSULE   1 Generic Drugs $2.00N/ANone
MINOCYCLINE 50MG CAPSULE   1 Generic Drugs $2.00N/ANone
MINOCYCLINE HCL 75MG CAPSULE   1 Generic Drugs $2.00N/ANone
MINOXIDIL 10MG TABLET   1 Generic Drugs $2.00N/ANone
MINOXIDIL 2.5MG TABLET   1 Generic Drugs $2.00N/ANone
MIRTAZAPINE 15MG TABLET RAPID DISSOLVE   1 Generic Drugs $2.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Mirtazapine 15mg/1 1000 TABLET, FILM COATED in 1 BOTTLE, PLASTIC   1 Generic Drugs $2.00N/ANone
MIRTAZAPINE 30MG TABLET RAPID DISSOLVE   1 Generic Drugs $2.00N/ANone
mirtazapine 45mg/1 1000 TABLET, FILM COATED in 1 BOTTLE   1 Generic Drugs $2.00N/ANone
Mirtazapine 7.5mg/1   1 Generic Drugs $2.00N/ANone
MIRTAZAPINE ORALLY DISINTEGRATING TABLETS 45MG 10 X 3 BOX   1 Generic Drugs $2.00N/ANone
MIRTAZAPINE TABLET 30MG (30 CT)   1 Generic Drugs $2.00N/ANone
MISOPROSTOL 100MCG TABLET   1 Generic Drugs $2.00N/ANone
MISOPROSTOL 200MCG TABLET   1 Generic Drugs $2.00N/ANone
MITOXANTRONE INJECTION 2MG 125ML VIAL   2 Preferred Brand Drugs 25%N/AP
MOEXIPRIL HCL 15MG TABLET   1 Generic Drugs $2.00N/AQ:120
/30Days
MOEXIPRIL HCL 7.5MG TABLET   1 Generic Drugs $2.00N/AQ:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-12.5MG TABLET   1 Generic Drugs $2.00N/AQ:60
/30Days
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-25MG TABLET   1 Generic Drugs $2.00N/AQ:60
/30Days
MOEXIPRIL-HYDROCHLOROTHIAZIDE 7.5-12.5MG TABLET   1 Generic Drugs $2.00N/AQ:30
/30Days
Mometasone Furoate 1mg/g   1 Generic Drugs $2.00N/ANone
MOMETASONE FUROATE OINTMENT 0.1% 45GM TUBE   1 Generic Drugs $2.00N/ANone
MOMETASONE FUROATE TOPICAL SOLUTION 0.1%   1 Generic Drugs $2.00N/ANone
MONONESSA TABLETS .250;.035MG; MG 6 X 28 CRTN   1 Generic Drugs $2.00N/AQ:28
/28Days
MORPHINE SULFATE 100MG TABLET SA   1 Generic Drugs $2.00N/AQ:90
/30Days
Morphine Sulfate 100mg/5mL 15 mL in 1 BOTTLE   1 Generic Drugs $2.00N/ANone
MORPHINE SULFATE 15MG TABLET SA   1 Generic Drugs $2.00N/AQ:90
/30Days
MORPHINE SULFATE 200MG TABLET SA   1 Generic Drugs $2.00N/AQ:180
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MORPHINE SULFATE 30MG TABLET SA   1 Generic Drugs $2.00N/AQ:90
/30Days
MORPHINE SULFATE INJECTION 0.5MG 5X10ML VIALGL   1 Generic Drugs $2.00N/AP
MORPHINE SULFATE INJECTION 1MG 5X10ML VIALGL   1 Generic Drugs $2.00N/AP
MORPHINE SULFATE ORAL SOLUTION   1 Generic Drugs $2.00N/AQ:2700
/30Days
MORPHINE SULFATE ORAL SOLUTION   1 Generic Drugs $2.00N/ANone
MORPHINE SULFATE TABLET ER 60MG (100 CT)   1 Generic Drugs $2.00N/AQ:120
/30Days
MORPHINE SULFATE TABLETS   1 Generic Drugs $2.00N/AQ:180
/30Days
MORPHINE SULFATE TABLETS   1 Generic Drugs $2.00N/AQ:180
/30Days
MOVIPREP 7.5-2.691G POWDER IN PACKET   3 Non-Preferred Brand Drugs 47%N/ANone
MOXEZA 5.45mg/mL 3 mL in 1 BOTTLE   2 Preferred Brand Drugs 25%N/ANone
MOZOBIL SOLUTION 24MG/1.2ML   4 Specialty Tier Drugs 25%N/AP Q:10
/4Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Multaq 400mg/1 60 TABLET, FILM COATED in 1 BOTTLE   2 Preferred Brand Drugs 25%N/AQ:60
/30Days
MUPIROCIN 2% OINTMENT   1 Generic Drugs $2.00N/ANone
MYCAMINE 50MG VIAL   4 Specialty Tier Drugs 25%N/AP
MYCAMINE FOR INJECTION SOLUTION   4 Specialty Tier Drugs 25%N/AP
MYCOBUTIN 150MG CAPSULE   2 Preferred Brand Drugs 25%N/ANone
Mycophenolate Mofetil 250mg/1   1 Generic Drugs $2.00N/AP
MYCOPHENOLATE MOFETIL TABLETS 500MG 500 BOT   1 Generic Drugs $2.00N/AP
MYFORTIC 180MG TABLET   3 Non-Preferred Brand Drugs 47%N/AP
MYFORTIC 360MG TABLET   4 Specialty Tier Drugs 25%N/AP
MYTELASE 10MG CAPLET   3 Non-Preferred Brand Drugs 47%N/ANone

Chart Legend:

Below are a few notes to help you understand the above 2012 Medicare Part D Community CCRx Basic (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 $320 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 $2930) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2012 Humana Walmart-Preferred Rx Plan the cost-sharing 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 September 2012 )

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.







Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.