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BravoRx (PDP) (S5998-013-0)
Tier 1 (2082)
Tier 2 (982)
Tier 3 (57)


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2012 Medicare Part D Plan Formulary Information
BravoRx (PDP) (S5998-013-0)
Benefit Details           
The BravoRx (PDP) (S5998-013-0)
Formulary Drugs Starting with the Letter M

in CMS PDP Region 32 which includes: CA
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 Tier 2 25%25%None
MAGNESIUM SULFATE INJECTION 5 GM/10ML   1 Tier 1 25%25%P
Malathion 5mg/mL 1 BOTTLE in 1 CARTON / 59 mL in 1 BOTTLE   1 Tier 1 25%25%None
MAPROTILINE 25MG TABLET   1 Tier 1 25%25%None
MAPROTILINE 50MG TABLET   1 Tier 1 25%25%None
MAPROTILINE 75MG TABLET   1 Tier 1 25%25%None
MARGESIC H 5MG-500MG CAPSULE   1 Tier 1 25%25%Q:240
/30Days
MARPLAN 10MG TABLET (100 CT)   2 Tier 2 25%25%None
MATULANE 50MG CAPSULE   2 Tier 2 25%25%None
Matzim LA 240mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MAXIDEX OPHTHALMIC SUSPENSION 0.1% 5ML BOT   2 Tier 2 25%25%None
MEBENDAZOLE 100MG TABLET CHEW   1 Tier 1 25%25%None
MECLIZINE HYDROCHLORIDE TABLETS 12.5MG 100 BOT   1 Tier 1 25%25%None
MECLIZINE HYDROCHLORIDE TABLETS 25MG 100 BOT   1 Tier 1 25%25%None
MECLOFENAMATE 100MG CAPSULE   1 Tier 1 25%25%None
MECLOFENAMATE 50MG CAPSULE   1 Tier 1 25%25%None
MEDROXYPROGESTERONE 10MG TABLET   1 Tier 1 25%25%None
MEDROXYPROGESTERONE 2.5MG   1 Tier 1 25%25%None
MEDROXYPROGESTERONE 5MG TABLET   1 Tier 1 25%25%None
MEDROXYPROGESTERONE ACETATE INJECTION SUSPENSION 150MG 1 VIALSD CRTN   1 Tier 1 25%25%Q:1
/90Days
MEFLOQUINE HCL 250MG TABLET 25 BOT   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MEGACE ES 625MG/5ML SUSP   2 Tier 2 25%25%Q:150
/30Days
MEGESTROL 20MG TABLET   1 Tier 1 25%25%None
MEGESTROL ACETATE 400MG/10ML SUSPENSION ORAL   1 Tier 1 25%25%None
MEGESTROL ACETATE 40MG TABLET (250 CT)   1 Tier 1 25%25%None
Meloxicam 15mg/1   1 Tier 1 25%25%None
Meloxicam 7.5mg 500 TABLET BOTTLE   1 Tier 1 25%25%None
MELPHALAN 5 MG/ML INJECTABLE SOLUTION   1 Tier 1 25%25%P
MENACTRA INJECTION 4MCG/0.5ML 5 X .5ML SYR   2 Tier 2 25%25%None
MENEST 0.3MG TABLET   2 Tier 2 25%25%None
MENEST 0.625MG TABLET   2 Tier 2 25%25%None
MENEST 1.25MG TABLET   2 Tier 2 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MENEST 2.5MG TABLET   2 Tier 2 25%25%None
MENOMUNE-A/C/Y/W-135 VIAL   2 Tier 2 25%25%None
MENVEO INJECTION KIT   2 Tier 2 25%25%None
MEPERIDINE 10MG/ML SYRINGE   1 Tier 1 25%25%None
MEPERIDINE 50MG/5ML SYRUP   1 Tier 1 25%25%Q:900
/30Days
MEPERIDINE HCL 50MG TABLET (100 CT)   1 Tier 1 25%25%Q:180
/30Days
MEPERIDINE HCL TABLET 100MG (100 CT)   1 Tier 1 25%25%Q:180
/30Days
Meperidine Hydrochloride 25mg/mL 25 VIAL in 1 CARTON / 1 mL in 1 VIAL   1 Tier 1 25%25%None
Meperidine Hydrochloride 50mg/mL 25 VIAL in 1 CARTON / 1 mL in 1 VIAL   1 Tier 1 25%25%None
Meprobamate 200mg/1 100 TABLET in 1 BOTTLE   1 Tier 1 25%25%Q:180
/30Days
Meprobamate 400mg/1 100 TABLET in 1 BOTTLE   1 Tier 1 25%25%Q:180
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MEPRON 750MG/5ML ORAL SUSP   2 Tier 2 25%25%None
MERCAPTOPURINE 50MG TABLET   1 Tier 1 25%25%None
MEROPENEM FOR INJECTION   1 Tier 1 25%25%None
Mesalamine 4g/60mL 7 BOTTLE, UNIT-DOSE in 1 CARTON / 60 mL in 1 BOTTLE, UNIT-DOSE   1 Tier 1 25%25%None
MESNA INJECTION 1GM/ML 10ML VIALMD CRTN   1 Tier 1 25%25%P
MESNEX 400MG TABLET   2 Tier 2 25%25%None
MESTINON 180MG TIMESPAN   2 Tier 2 25%25%None
METADATE ER 20MG TABLET SA   1 Tier 1 25%25%Q:90
/30Days
METAPROTERENOL 10MG TABLET   1 Tier 1 25%25%None
METAPROTERENOL 20MG TABLET   1 Tier 1 25%25%None
Metaproterenol Sulfate 10mg/5mL 473 mL in 1 BOTTLE, PLASTIC   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METAXALONE 800 MG TABLET   1 Tier 1 25%25%Q:120
/30Days
METFORMIN HCL 1000MG TABLET (500 CT)   1 Tier 1 25%25%None
METFORMIN HCL 500MG TABLET (1000 CT)   1 Tier 1 25%25%None
METFORMIN HCL 850MG TABLET   1 Tier 1 25%25%None
METFORMIN HCL ER 500MG TABLET SR 24HR   1 Tier 1 25%25%None
METFORMIN HYDROCHLORIDE 750mg/1   1 Tier 1 25%25%None
METHADONE HCL 5MG TABLET (100 CT)   1 Tier 1 25%25%Q:360
/30Days
METHADONE HYDROCHLORIDE 10mg/1 100 TABLET in 1 BOTTLE   1 Tier 1 25%25%Q:360
/30Days
Methadone Hydrochloride 10mg/5mL   1 Tier 1 25%25%Q:2000
/30Days
Methadone Hydrochloride 10mg/mL   1 Tier 1 25%25%Q:500
/30Days
Methadone Hydrochloride 5mg/5mL   1 Tier 1 25%25%Q:4000
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METHADONE HYDROCHLORIDE INJECTION 10MG/ML   1 Tier 1 25%25%P
METHADOSE 10MG TABLET   1 Tier 1 25%25%Q:360
/30Days
METHADOSE 5MG TABLET   1 Tier 1 25%25%Q:360
/30Days
METHAZOLAMIDE 25MG TABLET   1 Tier 1 25%25%None
METHAZOLAMIDE 50MG TABLET   1 Tier 1 25%25%None
Methenamine Hippurate 1g/1   1 Tier 1 25%25%None
Methimazole 10mg/1   1 Tier 1 25%25%None
METHIMAZOLE TABLETS   1 Tier 1 25%25%None
Methocarbamol 500mg/1 100 TABLET in 1 BOTTLE, PLASTIC   1 Tier 1 25%25%None
METHOCARBAMOL 750MG TABLET (500 CT)   1 Tier 1 25%25%None
METHOTREXATE 2.5MG TABLET   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METHOTREXATE FOR INJECTION 1 GM/ML   1 Tier 1 25%25%None
METHOTREXATE INJECTION 25 MG/ML   1 Tier 1 25%25%None
METHSCOPOLAMINE BROMIDE 2.5MG TABLET   1 Tier 1 25%25%None
METHSCOPOLAMINE BROMIDE TABLETS 5MG 60 BOT   1 Tier 1 25%25%None
METHYLDOPA 250MG TABLET   1 Tier 1 25%25%None
METHYLDOPA 500MG TABLET   1 Tier 1 25%25%None
METHYLDOPA/HCTZ 250-15 TABLET   1 Tier 1 25%25%None
METHYLDOPA/HCTZ 250-25 TABLET   1 Tier 1 25%25%None
METHYLDOPATE 250MG/5ML VIAL   1 Tier 1 25%25%None
METHYLIN 10 MG CHEWABLE   1 Tier 1 25%25%Q:180
/30Days
METHYLIN 10MG TABLET (100 CT)   1 Tier 1 25%25%Q:90
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METHYLIN 2.5 MG CHEWABLE TAB   1 Tier 1 25%25%Q:720
/30Days
METHYLIN 20MG TABLET   1 Tier 1 25%25%Q:90
/30Days
METHYLIN 5 MG CHEWABLE TABLET   1 Tier 1 25%25%Q:360
/30Days
METHYLIN ER 10MG TABLET SA   1 Tier 1 25%25%Q:60
/30Days
METHYLIN ER 20MG TABLET SA   1 Tier 1 25%25%Q:90
/30Days
METHYLIN SOLUTION 5MG/5ML 500 ML BOT   1 Tier 1 25%25%Q:1800
/30Days
METHYLIN TABLET 5MG (100 CT)   1 Tier 1 25%25%Q:90
/30Days
METHYLPHENIDATE 10MG TABLET   1 Tier 1 25%25%Q:90
/30Days
METHYLPHENIDATE 2 MG/ML ORAL SOLUTION [METHYLIN]   1 Tier 1 25%25%Q:900
/30Days
METHYLPHENIDATE 20MG TABLET   1 Tier 1 25%25%Q:90
/30Days
METHYLPHENIDATE 5MG TABLET (100 CT)   1 Tier 1 25%25%Q:90
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METHYLPHENIDATE TABLETS 20MG 100 TABS BOT   1 Tier 1 25%25%Q:90
/30Days
METHYLPREDNISOLONE 16MG TABLET   1 Tier 1 25%25%None
METHYLPREDNISOLONE 1GM VIAL   1 Tier 1 25%25%None
METHYLPREDNISOLONE 32MG TABLET   1 Tier 1 25%25%None
Methylprednisolone 40mg/mL 1 VIAL, MULTI-DOSE in 1 CARTON / 5 mL in 1 VIAL, MULTI-DOSE   1 Tier 1 25%25%None
Methylprednisolone 4mg/1 100 TABLET in 1 BOTTLE   1 Tier 1 25%25%None
METHYLPREDNISOLONE 8 MG ORAL TABLET   1 Tier 1 25%25%None
Methylprednisolone acetate 80mg/mL 25 VIAL, GLASS in 1 CARTON / 1 mL in 1 VIAL, GLASS   1 Tier 1 25%25%None
METHYLPREDNISOLONE SODIUM SUCCINATE POWDER FOR INJECTION 125MG 25X125MG VIAL   1 Tier 1 25%25%None
METHYLPREDNISOLONE SODIUM SUCCINATE POWDER FOR INJECTION 40MG 25X40MG VIAL   1 Tier 1 25%25%None
METHYLPREDNISOLONE TABLET 4MG 21 PKGCOM   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METIPRANOLOL 0.3% EYE DROPS   1 Tier 1 25%25%None
METOCLOPRAMIDE 5 MG TABLET   1 Tier 1 25%25%None
Metoclopramide 5mg/mL 25 VIAL in 1 TRAY / 2 mL in 1 VIAL   1 Tier 1 25%25%None
METOCLOPRAMIDE HYDROCHLORIDE TABLETS 10MG 500 BOTPL   1 Tier 1 25%25%None
METOCLOPRAMIDE SOLUTION ORAL USP 5MG 1 PT BOT   1 Tier 1 25%25%None
METOLAZONE 10MG TABLET   1 Tier 1 25%25%None
METOLAZONE 2.5MG TABLET   1 Tier 1 25%25%None
METOLAZONE 5MG TABLET   1 Tier 1 25%25%None
METOPROLOL SUCCINATE 25MG TABLET SR 24HR   1 Tier 1 25%25%None
METOPROLOL SUCCINATE 50MG TABLET SR 24HR   1 Tier 1 25%25%None
METOPROLOL SUCCINATE TABLETS EXTENDED RELEASE 100MG 100 BOT   1 Tier 1 25%25%None
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 Tier 1 25%25%None
METOPROLOL TARTRATE 25MG TABLET (100 CT)   1 Tier 1 25%25%None
METOPROLOL TARTRATE INJECTION USP 5MG 10X5ML VIALSD   1 Tier 1 25%25%None
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT)   1 Tier 1 25%25%None
METOPROLOL TARTRATE TABLET USP 100MG (1000 CT)   1 Tier 1 25%25%None
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET   1 Tier 1 25%25%None
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET   1 Tier 1 25%25%None
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET   1 Tier 1 25%25%None
METROGEL TOPICAL 1% GEL   2 Tier 2 25%25%None
METRONIDAZOLE 0.75% CREAM   1 Tier 1 25%25%None
METRONIDAZOLE 0.75% LOTION   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Metronidazole 375mg/1 50 CAPSULE in 1 BOTTLE   1 Tier 1 25%25%None
Metronidazole 500mg/100mL 24 BAG in 1 CARTON / 100 mL in 1 BAG   1 Tier 1 25%25%None
METRONIDAZOLE TABLETS USP 250MG 250 BOTPL   1 Tier 1 25%25%None
METRONIDAZOLE TABLETS USP 500MG 100 BOTPL   1 Tier 1 25%25%None
METRONIDAZOLE TOPICAL GEL 0.75% 45GM TUBE   1 Tier 1 25%25%None
METRONIDAZOLE VAGINAL GEL   1 Tier 1 25%25%None
MEXILETINE 150MG CAPSULE   1 Tier 1 25%25%None
MEXILETINE 200MG CAPSULE   1 Tier 1 25%25%None
MEXILETINE 250MG CAPSULE   1 Tier 1 25%25%None
MIACALCIN 200IU/ML VIAL   2 Tier 2 25%25%None
MICROGESTIN 1-0.02MG TABLET   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MICROGESTIN 1.5-0.03MG TABLET   1 Tier 1 25%25%None
MICROGESTIN FE 1.5/30 TABLET   1 Tier 1 25%25%None
MICROGESTIN FE 1/20 TABLET   1 Tier 1 25%25%None
MIDODRINE HCL 10MG TABLET   1 Tier 1 25%25%None
MIDODRINE HCL 2.5MG TABLET   1 Tier 1 25%25%None
MIDODRINE HCL 5MG TABLET (100 CT)   1 Tier 1 25%25%None
MIGERGOT 2-100MG SUPPOSITORY RECTAL   2 Tier 2 25%25%None
MINITRAN 0.1 MG/HR PATCH   1 Tier 1 25%25%None
MINITRAN 0.2 MG/HR PATCH   1 Tier 1 25%25%None
MINITRAN 0.4 MG/HR PATCH   1 Tier 1 25%25%None
MINITRAN 0.6 MG/HR PATCH   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MINOCYCLINE 100MG CAPSULE   1 Tier 1 25%25%None
MINOCYCLINE 50MG CAPSULE   1 Tier 1 25%25%None
MINOCYCLINE HCL 75MG CAPSULE   1 Tier 1 25%25%None
Minocycline Hydrochloride 100mg/1 60 TABLET, FILM COATED in 1 BOTTLE   1 Tier 1 25%25%None
Minocycline Hydrochloride 75mg/1 100 TABLET, FILM COATED in 1 BOTTLE   1 Tier 1 25%25%None
MINOCYCLINE HYDROCHLORIDE TABLETS 50MG   1 Tier 1 25%25%None
MINOXIDIL 10MG TABLET   1 Tier 1 25%25%None
MINOXIDIL 2.5MG TABLET   1 Tier 1 25%25%None
MIRTAZAPINE 15MG TABLET RAPID DISSOLVE   1 Tier 1 25%25%Q:30
/30Days
Mirtazapine 15mg/1 1000 TABLET, FILM COATED in 1 BOTTLE, PLASTIC   1 Tier 1 25%25%Q:30
/30Days
MIRTAZAPINE 30MG TABLET RAPID DISSOLVE   1 Tier 1 25%25%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
mirtazapine 45mg/1 1000 TABLET, FILM COATED in 1 BOTTLE   1 Tier 1 25%25%Q:30
/30Days
Mirtazapine 7.5mg/1   1 Tier 1 25%25%Q:30
/30Days
MIRTAZAPINE ORALLY DISINTEGRATING TABLETS 45MG 10 X 3 BOX   1 Tier 1 25%25%Q:30
/30Days
MIRTAZAPINE TABLET 30MG (30 CT)   1 Tier 1 25%25%Q:30
/30Days
MISOPROSTOL 100MCG TABLET   1 Tier 1 25%25%None
MISOPROSTOL 200MCG TABLET   1 Tier 1 25%25%None
MITOMYCIN POWDER FOR INJECTION USP 20MG VIAL   1 Tier 1 25%25%P
MITOXANTRONE INJECTION 2MG 125ML VIAL   1 Tier 1 25%25%P
MOEXIPRIL HCL 15MG TABLET   1 Tier 1 25%25%None
MOEXIPRIL HCL 7.5MG TABLET   1 Tier 1 25%25%None
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-12.5MG TABLET   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-25MG TABLET   1 Tier 1 25%25%None
MOEXIPRIL-HYDROCHLOROTHIAZIDE 7.5-12.5MG TABLET   1 Tier 1 25%25%None
Mometasone Furoate 1mg/g   1 Tier 1 25%25%None
MOMETASONE FUROATE OINTMENT 0.1% 45GM TUBE   1 Tier 1 25%25%None
MOMETASONE FUROATE TOPICAL SOLUTION 0.1%   1 Tier 1 25%25%None
MONONESSA TABLETS .250;.035MG; MG 6 X 28 CRTN   1 Tier 1 25%25%None
MORPHINE SULFATE 100MG TABLET SA   1 Tier 1 25%25%Q:90
/30Days
Morphine Sulfate 100mg/5mL 15 mL in 1 BOTTLE   1 Tier 1 25%25%Q:540
/30Days
MORPHINE SULFATE 15MG TABLET SA   1 Tier 1 25%25%Q:90
/30Days
MORPHINE SULFATE 200MG TABLET SA   1 Tier 1 25%25%Q:90
/30Days
MORPHINE SULFATE 30MG TABLET SA   1 Tier 1 25%25%Q:90
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MORPHINE SULFATE INJECTION 0.5MG 5X10ML VIALGL   1 Tier 1 25%25%None
MORPHINE SULFATE INJECTION 1MG 5X10ML VIALGL   1 Tier 1 25%25%None
MORPHINE SULFATE ORAL SOLUTION   1 Tier 1 25%25%Q:5400
/30Days
MORPHINE SULFATE ORAL SOLUTION   1 Tier 1 25%25%Q:2700
/30Days
MORPHINE SULFATE TABLET ER 60MG (100 CT)   1 Tier 1 25%25%Q:90
/30Days
MORPHINE SULFATE TABLETS   1 Tier 1 25%25%Q:360
/30Days
MORPHINE SULFATE TABLETS   1 Tier 1 25%25%Q:360
/30Days
MOVIPREP 7.5-2.691G POWDER IN PACKET   2 Tier 2 25%25%None
MOXEZA 5.45mg/mL 3 mL in 1 BOTTLE   2 Tier 2 25%25%None
MOZOBIL SOLUTION 24MG/1.2ML   2 Tier 2 25%25%P Q:8
/30Days
Multaq 400mg/1 60 TABLET, FILM COATED in 1 BOTTLE   2 Tier 2 25%25%Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MUPIROCIN 2% OINTMENT   1 Tier 1 25%25%None
MUSTARGEN 10MG VIAL   2 Tier 2 25%25%P
MYCOBUTIN 150MG CAPSULE   2 Tier 2 25%25%None
Mycophenolate Mofetil 250mg/1   1 Tier 1 25%25%P
MYCOPHENOLATE MOFETIL TABLETS 500MG 500 BOT   1 Tier 1 25%25%P
MYFORTIC 180MG TABLET   3 Tier 3 25%25%P
MYFORTIC 360MG TABLET   3 Tier 3 25%25%P
MYTELASE 10MG CAPLET   2 Tier 2 25%25%None

Chart Legend:

Below are a few notes to help you understand the above 2012 Medicare Part D BravoRx (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.