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2012 Medicare Part D and Medicare Advantage Plan Formulary Browser

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Blue Cross MedicareRx Plus (PDP) (S5596-034-0)
Tier 1 (407)
Tier 2 (1277)
Tier 3 (451)
Tier 4 (270)
Tier 5 (604)
Tier 6 (434)
Requires Prior Authorization:
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Uses Step Therapy:
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Cick on the first letter of your drug name to browse the formulary:

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M N O P Q R S T U V W X Y Z 0-9 
2012 Medicare Part D Plan Formulary Information
Blue Cross MedicareRx Plus (PDP) (S5596-034-0)
Benefit Details           
The Blue Cross MedicareRx Plus (PDP) (S5596-034-0)
Formulary Drugs Starting with the Letter N

in CMS PDP Region 32 which includes: CA
Drugs Starting with Letter N

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
NABUMETONE 500MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
NABUMETONE 750MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
NADOLOL 20MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
Nadolol and Bendroflumethiazide 5; 40mg/1; mg/1 100 TABLET in 1 BOTTLE, PLASTIC   2 Non-Preferred Generic Drugs $7.00$10.50None
Nadolol and Bendroflumethiazide 5; 80mg/1; mg/1 100 TABLET in 1 BOTTLE, PLASTIC   2 Non-Preferred Generic Drugs $7.00$10.50None
NADOLOL TABLETS   2 Non-Preferred Generic Drugs $7.00$10.50None
NADOLOL TABLETS   2 Non-Preferred Generic Drugs $7.00$10.50None
Nafcillin 10g/100mL   5 Injectable Drug 33%33%None
NAFCILLIN 1GM/50ML INJ   5 Injectable Drug 33%33%None
NAFCILLIN FOR INJECTION 1 GM/ML   5 Injectable Drug 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NAGLAZYME 5MG/5ML VIAL   6 Specialty Tier Drugs 33%N/AP
Nalbuphine Hydrochloride 10mg/mL 1 VIAL, MULTI-DOSE in 1 CARTON / 10 mL in 1 VIAL, MULTI-DOSE   5 Injectable Drug 33%33%None
Nalbuphine Hydrochloride 20mg/mL 25 VIAL, MULTI-DOSE in 1 CARTON / 10 mL in 1 VIAL, MULTI-DOSE   5 Injectable Drug 33%33%None
NALOXONE 1MG/ML SYRINGE   5 Injectable Drug 33%33%None
NALOXONE HCL INJECTION 0.4MG 10 X 1ML CTG   5 Injectable Drug 33%33%None
NALTREXONE HCL 50MG TABLET 100 BLPK   2 Non-Preferred Generic Drugs $7.00$10.50None
NAMENDA 10MG TABLET   3 Preferred Brand Drugs $45.00$112.50Q:60
/30Days
NAMENDA 10MG/5ML SOLUTION   3 Preferred Brand Drugs $45.00$112.50Q:300
/30Days
NAMENDA 5-10MG TITRATION PK   3 Preferred Brand Drugs $45.00$112.50Q:60
/30Days
NAMENDA 5MG TABLET   3 Preferred Brand Drugs $45.00$112.50Q:60
/30Days
NAPROXEN 125MG/5ML SUSPEN   2 Non-Preferred Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NAPROXEN 250 MG ORAL TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
NAPROXEN 375MG TABLET EC   2 Non-Preferred Generic Drugs $7.00$10.50None
NAPROXEN 500MG TABLET EC   2 Non-Preferred Generic Drugs $7.00$10.50None
Naproxen 500mg/1 500 TABLET in 1 BOTTLE   2 Non-Preferred Generic Drugs $7.00$10.50None
NAPROXEN SODIUM 275 MG ORAL TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
Naproxen Sodium 550mg/1   2 Non-Preferred Generic Drugs $7.00$10.50None
NAPROXEN TABLET 375MG (500 CT)   2 Non-Preferred Generic Drugs $7.00$10.50None
NARATRIPTAN TABLETS   2 Non-Preferred Generic Drugs $7.00$10.50Q:9
/30Days
NARATRIPTAN TABLETS   2 Non-Preferred Generic Drugs $7.00$10.50Q:9
/30Days
NASACORT AQ AER 55MCG/AC   4 Non-Preferred Brand Drugs $90.00$225.00S Q:34
/30Days
NASONEX 50ug/1 120 SPRAY, METERED in 1 BOTTLE, PUMP   3 Preferred Brand Drugs $45.00$112.50Q:34
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NATACYN EYE DROPS   3 Preferred Brand Drugs $45.00$112.50None
Nateglinide 120mg/1 90 TABLET in 1 BOTTLE   2 Non-Preferred Generic Drugs $7.00$10.50None
Nateglinide 60mg/1 90 TABLET in 1 BOTTLE   2 Non-Preferred Generic Drugs $7.00$10.50None
NEBUPENT 300MG INHAL POWDER   3 Preferred Brand Drugs $45.00$112.50P
NECON 0.5/35-28 TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
NECON 1/35-28 TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
NECON 10/11-28 TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
NECON 7 DAYS X 3 TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
NEFAZODONE HCL 150MG TABLET (60 CT)   2 Non-Preferred Generic Drugs $7.00$10.50Q:60
/30Days
NEFAZODONE HCL 250MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50Q:60
/30Days
NEFAZODONE HCL 50MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NEFAZODONE HYDROCHLORIDE TABLETS 100MG 60 BOT   2 Non-Preferred Generic Drugs $7.00$10.50Q:60
/30Days
NEFAZODONE HYDROCHLORIDE TABLETS 200MG 60 BOT   2 Non-Preferred Generic Drugs $7.00$10.50Q:60
/30Days
NEO/POLYMYXIN/HC EAR TUBEX 10MG/3.5MG/100UNT   1 Preferred Generic Drugs $2.00$3.00None
Neomycin and Polymyxin B Sulfates 40; 200000mg/mL; 1/mL 10 AMPULE in 1 CARTON / 1 mL in 1 AMPULE   5 Injectable Drug 33%33%None
Neomycin and Polymyxin B Sulfates and Dexamethasone 1; 3.5; 10000mg/g; mg/g; [USP'U]/g 1 TUBE in 1   1 Preferred Generic Drugs $2.00$3.00None
NEOMYCIN SULFATE 500MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
NEOMYCIN-BACITRACIN-POLY-HC 3.5-10K-1 OINTMENT   1 Preferred Generic Drugs $2.00$3.00None
NEOMYCIN-POLYMYXIN-HC 3.5-10K-10 SUSPENSION DROPS   1 Preferred Generic Drugs $2.00$3.00None
NEOMYCIN/POLYMY/DEXA EYE DROPS 3.5MG/1ML   1 Preferred Generic Drugs $2.00$3.00None
NEOMYCIN/POLYMY/GRAM EYE DROPS 0.025MG/ML 1.75MG/M   1 Preferred Generic Drugs $2.00$3.00None
NEOMYCIN/POLYMY/HYDRO OTIC SUS   1 Preferred Generic Drugs $2.00$3.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NEPHRAMINE SOLUTION FOR INJECTION   5 Injectable Drug 33%33%None
NEULASTA 6MG/0.6ML SYRINGE   6 Specialty Tier Drugs 33%N/AP Q:2
/28Days
NEUPOGEN 300MCG/ML VIAL   6 Specialty Tier Drugs 33%N/AP
NEUPOGEN 300ug/0.5mL 10 SYRINGE in 1 BOX / 0.5 mL in 1 SYRINGE   6 Specialty Tier Drugs 33%N/AP
NEUPOGEN INJECTION 480MCG/0.8ML 10 X 0.8ML SYR   6 Specialty Tier Drugs 33%N/AP
NEVANAC 0.1% DROPTAINER   3 Preferred Brand Drugs $45.00$112.50None
nevirapine 200 mg tablet   4 Non-Preferred Brand Drugs $90.00$225.00None
NEXAVAR TABLETS 200MG 120 BOT   6 Specialty Tier Drugs 33%N/AP
NEXIUM 10mg/1 30 GRANULE, DELAYED RELEASE in 1 CARTON   3 Preferred Brand Drugs $45.00$112.50Q:30
/30Days
NEXIUM 20MG CAPSULE   3 Preferred Brand Drugs $45.00$112.50Q:30
/30Days
NEXIUM 20MG SUSP FOR RECON DELAYED REL. IN A PACKET   3 Preferred Brand Drugs $45.00$112.50Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NEXIUM 40MG CAPSULE   3 Preferred Brand Drugs $45.00$112.50Q:30
/30Days
NEXIUM 40MG SUSP FOR RECON DELAYED REL. IN A PACKET   3 Preferred Brand Drugs $45.00$112.50Q:30
/30Days
NEXIUM IV 20MG VIAL   5 Injectable Drug 33%33%None
NEXIUM IV 40MG VIAL   5 Injectable Drug 33%33%None
NIACOR 500MG TABLET   3 Preferred Brand Drugs $45.00$112.50None
NIASPAN 1000MG TABLET (90 CT)   3 Preferred Brand Drugs $45.00$112.50None
NIASPAN ER 500MG TABLET (90 CT)   3 Preferred Brand Drugs $45.00$112.50None
NIASPAN ER 750MG TABLET (90 CT)   3 Preferred Brand Drugs $45.00$112.50None
NICARDIPINE HYDROCHLORIDE 2.5mg/mL   5 Injectable Drug 33%33%None
NICARDIPINE HYDROCHLORIDE CAPSULES   2 Non-Preferred Generic Drugs $7.00$10.50None
NICARDIPINE HYDROCHLORIDE CAPSULES 30MG 500 BOT   2 Non-Preferred Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NICOTROL NS NASAL SPRAY BOTTLE 10MG 4 X 10MG/ML INHL   3 Preferred Brand Drugs $45.00$112.50None
NIFEDIAC CC 30MG TABLET SA   2 Non-Preferred Generic Drugs $7.00$10.50None
NIFEDIAC CC 60MG TABLET SA   2 Non-Preferred Generic Drugs $7.00$10.50None
NIFEDIAC CC 90MG TABLET SA   2 Non-Preferred Generic Drugs $7.00$10.50None
NIFEDICAL XL 30MG TABLET SR OSMOTIC PUSH 24HR   2 Non-Preferred Generic Drugs $7.00$10.50None
NIFEDICAL XL 60MG TABLET SR OSMOTIC PUSH 24HR   2 Non-Preferred Generic Drugs $7.00$10.50None
Nifedipine 10mg/1 100 CAPSULE in 1 BOTTLE   2 Non-Preferred Generic Drugs $7.00$10.50None
NIFEDIPINE 20MG CAPSULE   2 Non-Preferred Generic Drugs $7.00$10.50None
NIFEDIPINE TABLETS EXTENDED RELEASE   2 Non-Preferred Generic Drugs $7.00$10.50None
NIFEDIPINE TABLETS EXTENDED RELEASE   2 Non-Preferred Generic Drugs $7.00$10.50None
NIFEDIPINE TABLETS EXTENDED RELEASE   2 Non-Preferred Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NILANDRON 150MG TABLET   3 Preferred Brand Drugs $45.00$112.50None
NIMODIPINE 30MG CAPSULE   2 Non-Preferred Generic Drugs $7.00$10.50None
NIPENT FOR INJECTION 10MG VIALS   6 Specialty Tier Drugs 33%N/AP
NISOLDIPINE 20MG TB24   2 Non-Preferred Generic Drugs $7.00$10.50None
NISOLDIPINE 30MG TB24   2 Non-Preferred Generic Drugs $7.00$10.50None
NISOLDIPINE 40MG TB24   2 Non-Preferred Generic Drugs $7.00$10.50None
NITRO-BID 20mg/g 48 PACKET in 1 BOX / 1 g in 1 PACKET   2 Non-Preferred Generic Drugs $7.00$10.50None
NITROFURANTOIN MCR 50MG CAP   2 Non-Preferred Generic Drugs $7.00$10.50None
Nitrofurantoin Monohydrate/Macrocrystals 25; 75mg/1; mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC   2 Non-Preferred Generic Drugs $7.00$10.50None
NITROGLYCERIN .2MG/HR PATCH   2 Non-Preferred Generic Drugs $7.00$10.50None
NITROGLYCERIN .4MG/HR PATCH   2 Non-Preferred Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NITROGLYCERIN .6MG/HR PATCH   2 Non-Preferred Generic Drugs $7.00$10.50None
Nitroglycerin 5mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 10 mL in 1 VIAL, SINGLE-DOSE   5 Injectable Drug 33%33%None
NITROGLYCERIN TRANSOERMAL SYSTEM .1MG/HR 30 SYSTEM BOX   2 Non-Preferred Generic Drugs $7.00$10.50None
NITROSTAT 0.3MG TABLET SL   3 Preferred Brand Drugs $45.00$112.50None
NITROSTAT 0.4MG TABLET SL   3 Preferred Brand Drugs $45.00$112.50None
NITROSTAT 0.6MG TABLET SL   3 Preferred Brand Drugs $45.00$112.50None
NIZATIDINE 150MG CAPSULE   2 Non-Preferred Generic Drugs $7.00$10.50None
NIZATIDINE 300 MG CAPSULE (100 CAPS)   2 Non-Preferred Generic Drugs $7.00$10.50None
NIZATIDINE ORAL SOLUTION 15MG/ML   2 Non-Preferred Generic Drugs $7.00$10.50None
NORA-BE 0.35MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
Norditropin 10mg/1.5mL 1 SYRINGE, PLASTIC in 1 CARTON / 1.5 mL in 1 SYRINGE, PLASTIC   6 Specialty Tier Drugs 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Norditropin 15mg/1.5mL 1 SYRINGE, PLASTIC in 1 CARTON / 1.5 mL in 1 SYRINGE, PLASTIC   6 Specialty Tier Drugs 33%N/AP
Norditropin 5mg/1.5mL 1 SYRINGE, PLASTIC in 1 CARTON / 1.5 mL in 1 SYRINGE, PLASTIC   6 Specialty Tier Drugs 33%N/AP
NORDITROPIN NORDIFLEX INJECTION   6 Specialty Tier Drugs 33%N/AP
NORETHINDRONE 5MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
NORMOSOL -R INJ /D5W   5 Injectable Drug 33%33%None
NORMOSOL-M AND DEXTROSE 5%   5 Injectable Drug 33%33%None
NORMOSOL-R PH 7.4 IV SOLUTION   5 Injectable Drug 33%33%None
Nortrel (21 Day Regimen) 0.035; 1mg/1; mg/1 3 BLISTER PACK in 1 CARTON / 21 TABLET in 1 BLISTER PACK   2 Non-Preferred Generic Drugs $7.00$10.50None
Nortrel (28 Day Regimen) 3 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK   2 Non-Preferred Generic Drugs $7.00$10.50None
NORTREL 1-0.035MG TABLET 28DAY   2 Non-Preferred Generic Drugs $7.00$10.50None
Nortrel 7/7/7 (28 Day Regimen) 6 POUCH in 1 CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT in 1 BLISTER   2 Non-Preferred Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NORTRIPTYLINE 10MG/5ML SOL   2 Non-Preferred Generic Drugs $7.00$10.50None
NORTRIPTYLINE HCL 25MG CAP   2 Non-Preferred Generic Drugs $7.00$10.50None
NORTRIPTYLINE HCL 75MG CAPSULE   2 Non-Preferred Generic Drugs $7.00$10.50None
Nortriptyline Hydrochloride 10mg/1 100 CAPSULE in 1 BOTTLE   2 Non-Preferred Generic Drugs $7.00$10.50None
Nortriptyline Hydrochloride 50mg/1 500 CAPSULE in 1 BOTTLE   2 Non-Preferred Generic Drugs $7.00$10.50None
NORVIR 100 MG TABLET   4 Non-Preferred Brand Drugs $90.00$225.00None
NORVIR 100mg/1 30 CAPSULE in 1 BOTTLE   4 Non-Preferred Brand Drugs $90.00$225.00None
NORVIR 80MG/ML ORAL SOLUTION   6 Specialty Tier Drugs 33%N/ANone
NOVANTRONE 2MG/ML VIAL   5 Injectable Drug 33%33%P
Novolin 100[iU]/mL 1 VIAL in 1 CARTON / 10 mL in 1 VIAL   3 Preferred Brand Drugs $45.00$112.50None
Novolin 100[USP'U]/mL 1 VIAL in 1 CARTON / 10 mL in 1 VIAL   3 Preferred Brand Drugs $45.00$112.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Novolin R 100[iU]/mL 1 VIAL in 1 CARTON / 10 mL in 1 VIAL   3 Preferred Brand Drugs $45.00$112.50None
NOVOLOG 100U/ML VIAL   3 Preferred Brand Drugs $45.00$112.50None
NOVOLOG FLEXPEN SYRINGE   3 Preferred Brand Drugs $45.00$112.50None
NOVOLOG MIX 70/30 SYRINGE 70-30U/ML   3 Preferred Brand Drugs $45.00$112.50None
NOVOLOG MIX 70/30 VIAL   3 Preferred Brand Drugs $45.00$112.50None
NULOJIX 250mg/1 1 VIAL, SINGLE-USE in 1 CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in   6 Specialty Tier Drugs 33%N/AP
NUTROPIN 10 MG VIAL   6 Specialty Tier Drugs 33%N/AP
NUTROPIN AQ 20MG/2ML PEN CART SOMATROPIN   6 Specialty Tier Drugs 33%N/AP
NUTROPIN AQ NUSPIN SOLUTION   6 Specialty Tier Drugs 33%N/AP
NUTROPIN AQ PEN CARTRIDGE 10MG/2 ML   6 Specialty Tier Drugs 33%N/AP
NUVIGIL 150 MG ORAL TABLET   3 Preferred Brand Drugs $45.00$112.50P Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NUVIGIL 250 MG ORAL TABLET   3 Preferred Brand Drugs $45.00$112.50P Q:30
/30Days
NUVIGIL 50 MG ORAL TABLET   3 Preferred Brand Drugs $45.00$112.50P Q:60
/30Days
NYAMYC 100000 U/G POWDER   2 Non-Preferred Generic Drugs $7.00$10.50None
Nystatin 100000[USP'U]/g   2 Non-Preferred Generic Drugs $7.00$10.50None
Nystatin 100000[USP'U]/g 1 TUBE in 1 CARTON / 30 g in 1 TUBE   1 Preferred Generic Drugs $2.00$3.00None
Nystatin 100000[USP'U]/g 1 TUBE in 1 CARTON / 30 g in 1 TUBE   1 Preferred Generic Drugs $2.00$3.00None
Nystatin 100000[USP'U]/mL   1 Preferred Generic Drugs $2.00$3.00None
NYSTATIN TABLET 500000U (100 CT)   1 Preferred Generic Drugs $2.00$3.00None
NYSTATIN/TRIAMCINOLONE CRM   1 Preferred Generic Drugs $2.00$3.00None
NYSTATIN/TRIAMCINOLONE OINT 10000UNT/1MG   1 Preferred Generic Drugs $2.00$3.00None
NYSTOP 100000U/GM POWDER   2 Non-Preferred Generic Drugs $7.00$10.50None

Chart Legend:

Below are a few notes to help you understand the above 2012 Medicare Part D Blue Cross MedicareRx Plus (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.