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2012 Medicare Part D and Medicare Advantage Plan Formulary Browser

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First Health Part D Premier (PDP) (S5768-082-0)
Tier 1 (1471)
Tier 2 (309)
Tier 3 (1252)
Tier 4 (215)

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2012 Medicare Part D Plan Formulary Information
First Health Part D Premier (PDP) (S5768-082-0)
Benefit Details           
The First Health Part D Premier (PDP) (S5768-082-0)
Formulary Drugs Starting with the Letter S

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

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
SANCTURA XR 60MG CAPSULE SR 24 HR   2 Preferred Brand Drugs 19%17%Q:30
/30Days
SANCUSO TRANSDERMAL SYSTEM 3.1MG/24HRS 1 PATCH CRTN   3 Non-Preferred Brand Drugs 36%36%Q:4
/28Days
SANDIMMUNE 100MG CAPSULE   3 Non-Preferred Brand Drugs 36%36%P
SANDIMMUNE 100MG/ML TUBEX   3 Non-Preferred Brand Drugs 36%36%P
SANDIMMUNE 25MG CAPSULE   3 Non-Preferred Brand Drugs 36%36%P
SAPHRIS 10mg/1 6 CASE in 1 CARTON / 1 BLISTER PACK in 1 CASE / 10 TABLET in 1 BLISTER PACK   3 Non-Preferred Brand Drugs 36%36%Q:60
/30Days
SAPHRIS 5mg/1 6 CASE in 1 CARTON / 1 BLISTER PACK in 1 CASE / 10 TABLET in 1 BLISTER PACK   3 Non-Preferred Brand Drugs 36%36%Q:60
/30Days
SEASONIQUE 150-30(84) TABLET DOSE PACK 3 MONTHS   3 Non-Preferred Brand Drugs 36%36%Q:91
/90Days
SELEGILINE HCL 5MG CAPSULE   1 Preferred Generic Drugs $6.00$15.00None
Selegiline Hydrochloride 5mg/1 60 TABLET in 1 BOTTLE, PLASTIC   1 Preferred Generic Drugs $6.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SELFEMRA CAPSULES 10MG 28 CAPSULE BLPK   1 Preferred Generic Drugs $6.00$15.00None
SELFEMRA CAPSULES 20MG 28 CAPSULE 4X7 BLPK   1 Preferred Generic Drugs $6.00$15.00None
SELZENTRY 150mg/1 60 TABLET, FILM COATED in 1 BOTTLE   2 Preferred Brand Drugs 19%17%Q:60
/30Days
SELZENTRY 300mg/1 60 TABLET, FILM COATED in 1 BOTTLE   2 Preferred Brand Drugs 19%17%Q:120
/30Days
SEMPREX-D 60/8 CAPSULE   3 Non-Preferred Brand Drugs 36%36%None
SENSIPAR 30MG TABLET   3 Non-Preferred Brand Drugs 36%36%P Q:60
/30Days
SENSIPAR 60MG TABLET   4 Specialty Tier Drugs 26%N/AP Q:60
/30Days
SENSIPAR 90MG TABLET   4 Specialty Tier Drugs 26%N/AP Q:120
/30Days
SEREVENT DIS AER 50MCG   3 Non-Preferred Brand Drugs 36%36%Q:60
/30Days
SEROMYCIN 250mg/250mg 40 CAPSULE in 1 BOTTLE / 250 mg in 1 CAPSULE   3 Non-Preferred Brand Drugs 36%36%None
SEROQUEL TABLETS EXTENDED RELEASE 150MG 100 CRTN   2 Preferred Brand Drugs 19%17%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SEROQUEL TABLETS EXTENDED RELEASE 200MG 100 X 200 MG CRTN   2 Preferred Brand Drugs 19%17%Q:30
/30Days
SEROQUEL TABLETS EXTENDED RELEASE 400MG 100 X 400 MG CRTN   2 Preferred Brand Drugs 19%17%Q:60
/30Days
SEROQUEL TABLETS EXTENDED RELEASE 50MG 100 TABS CRTN   2 Preferred Brand Drugs 19%17%Q:60
/30Days
SEROQUEL XR 300MG TABLET 60X300MG BOT   2 Preferred Brand Drugs 19%17%Q:60
/30Days
Serostim 4mg/mL 1 INJECTION, POWDER, FOR SOLUTION in 1 CARTON   4 Specialty Tier Drugs 26%N/AP
Serostim 5mg/mL 1 INJECTION, POWDER, FOR SOLUTION in 1 CARTON   4 Specialty Tier Drugs 26%N/AP
SERTRALINE HCL 100MG TABLET (30 CT)   1 Preferred Generic Drugs $6.00$15.00None
SERTRALINE HCL 25 MG TABLET   1 Preferred Generic Drugs $6.00$15.00None
SERTRALINE HCL 50MG TABLET (30 CT)   1 Preferred Generic Drugs $6.00$15.00None
SERTRALINE HYDROCHLORIDE ORAL CONCENTRATE   1 Preferred Generic Drugs $6.00$15.00None
SEVELAMER CARBONATE 40 MG/ML ORAL SUSPENSION [RENVELA]   2 Preferred Brand Drugs 19%17%Q:90
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Silenor 3mg/1 30 TABLET in 1 BLISTER PACK   3 Non-Preferred Brand Drugs 36%36%Q:30
/30Days
Silenor 6mg/1 30 TABLET in 1 BLISTER PACK   3 Non-Preferred Brand Drugs 36%36%Q:30
/30Days
SILVER SULFADIAZINE 1% CRM   1 Preferred Generic Drugs $6.00$15.00None
Simvastatin 10mg/1 30 TABLET, FILM COATED in 1 BOTTLE   1 Preferred Generic Drugs $6.00$15.00None
SIMVASTATIN 20MG TABLET 10000 BOT   1 Preferred Generic Drugs $6.00$15.00None
SIMVASTATIN 40MG TABLET (500 CT)   1 Preferred Generic Drugs $6.00$15.00None
Simvastatin 5mg/1   1 Preferred Generic Drugs $6.00$15.00None
SIMVASTATIN 80MG TABLET (1000 CT)   1 Preferred Generic Drugs $6.00$15.00P
SINGULAIR 10MG TABLET   2 Preferred Brand Drugs 19%17%Q:30
/30Days
SINGULAIR 4MG GRANULES   2 Preferred Brand Drugs 19%17%Q:30
/30Days
SINGULAIR 4MG TABLET CHEW   2 Preferred Brand Drugs 19%17%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SINGULAIR 5MG TABLET CHEW   2 Preferred Brand Drugs 19%17%Q:30
/30Days
SKELID 200MG TABLET   3 Non-Preferred Brand Drugs 36%36%None
SOD POLY SUL SUS 15GM/60   1 Preferred Generic Drugs $6.00$15.00None
SODIUM CHLORIDE 0.45% TUBEX   1 Preferred Generic Drugs $6.00$15.00None
Sodium Chloride 900mg/100mL 9 BOTTLE, PLASTIC in 1 CASE / 1500 mL in 1 BOTTLE, PLASTIC   1 Preferred Generic Drugs $6.00$15.00None
Sodium Chloride 9g/1000mL 4 BAG in 1 PACKAGE / 100 mL in 1 BAG   1 Preferred Generic Drugs $6.00$15.00None
SOLARAZE 3% GEL   3 Non-Preferred Brand Drugs 36%36%Q:100
/30Days
SOLIA 0.15-0.03 TABLET   3 Non-Preferred Brand Drugs 36%36%Q:28
/28Days
SOMATULINE 60 MG/0.2 ML SYRING   4 Specialty Tier Drugs 26%N/AP Q:1
/28Days
Somatuline Depot 90mg/0.3mL 1 POUCH in 1 CARTON / 1 SYRINGE in 1 POUCH / 0.3 mL in 1 SYRINGE   4 Specialty Tier Drugs 26%N/AP Q:1
/28Days
SOMAVERT 10MG VIAL   3 Non-Preferred Brand Drugs 36%36%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SOMAVERT 15MG VIAL   3 Non-Preferred Brand Drugs 36%36%P
SOMAVERT 20MG VIAL   3 Non-Preferred Brand Drugs 36%36%P
SORIATANE 17.5 MG CAPSULE   3 Non-Preferred Brand Drugs 36%36%Q:60
/30Days
SORIATANE CAPSULES   3 Non-Preferred Brand Drugs 36%36%Q:60
/30Days
SORIATANE CAPSULES   3 Non-Preferred Brand Drugs 36%36%Q:60
/30Days
SORINE SOLTALOL HCL TABLETS 240MG 100 BOXUD   1 Preferred Generic Drugs $6.00$15.00None
SORINE SOTALOL HCL TABLETS 120MG 100 BOXUD   1 Preferred Generic Drugs $6.00$15.00None
SORINE SOTALOL HCL TABLETS 160MG 100 BOXUD   1 Preferred Generic Drugs $6.00$15.00None
SORINE SOTALOL HCL TABLETS 80MG 100 BOXUD   1 Preferred Generic Drugs $6.00$15.00None
SOTALOL HCL 120MG TABLET 100 BOT   1 Preferred Generic Drugs $6.00$15.00None
SOTALOL HCL 160MG TABLET (100 CT)   1 Preferred Generic Drugs $6.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SOTALOL HCL 80MG TABLET   1 Preferred Generic Drugs $6.00$15.00None
SOTALOL HCL TABLET 240MG   1 Preferred Generic Drugs $6.00$15.00None
SOTRET 10MG CAPSULE   3 Non-Preferred Brand Drugs 36%36%None
SOTRET 20MG CAPSULE   3 Non-Preferred Brand Drugs 36%36%None
SOTRET 30MG CAPSULE   3 Non-Preferred Brand Drugs 36%36%None
SOTRET 40MG CAPSULE   3 Non-Preferred Brand Drugs 36%36%None
SPIRIVA 18MCG CP-HANDIHALER 90 (9 X 10) BLPK   2 Preferred Brand Drugs 19%17%Q:30
/30Days
SPIRONOLACTONE 100MG TABLET   1 Preferred Generic Drugs $6.00$15.00None
SPIRONOLACTONE 25MG TABLET (100 CT)   1 Preferred Generic Drugs $6.00$15.00None
SPIRONOLACTONE 50MG TABLET (100 CT)   1 Preferred Generic Drugs $6.00$15.00None
SPIRONOLACTONE/HCTZ TABLET 25-25MG (500 CT)   1 Preferred Generic Drugs $6.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SPORANOX 10MG/ML SOLUTION   3 Non-Preferred Brand Drugs 36%36%P
SPRINTEC 0.25-0.035 TABLET   3 Non-Preferred Brand Drugs 36%36%Q:28
/28Days
SPRYCEL 100mg/1 1 BOTTLE in 1 CARTON / 30 TABLET in 1 BOTTLE   4 Specialty Tier Drugs 26%N/AP Q:30
/30Days
SPRYCEL 140mg/1 1 BOTTLE in 1 CARTON / 30 TABLET in 1 BOTTLE   4 Specialty Tier Drugs 26%N/AP Q:30
/30Days
SPRYCEL 20MG TABLET   4 Specialty Tier Drugs 26%N/AP Q:60
/30Days
SPRYCEL 50MG TABLET   4 Specialty Tier Drugs 26%N/AP Q:60
/30Days
SPRYCEL 70MG TABLET   4 Specialty Tier Drugs 26%N/AP Q:60
/30Days
SPRYCEL 80mg/1 1 BOTTLE in 1 CARTON / 30 TABLET in 1 BOTTLE   4 Specialty Tier Drugs 26%N/AP Q:60
/30Days
SRONYX 0.1-0.02 TABLET   3 Non-Preferred Brand Drugs 36%36%Q:28
/28Days
SSD Cream 10g/1000g 85 g in 1 TUBE   1 Preferred Generic Drugs $6.00$15.00None
STAGESIC 5MG-500MG CAPSULE   1 Preferred Generic Drugs $6.00$15.00Q:240
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
STALEVO 100 TABLET   3 Non-Preferred Brand Drugs 36%36%None
STALEVO 125/200 MG/MG TABLETS   3 Non-Preferred Brand Drugs 36%36%None
STALEVO 150 TABLET   3 Non-Preferred Brand Drugs 36%36%None
STALEVO 18.75/75 MG/MG TABLETS   3 Non-Preferred Brand Drugs 36%36%None
STALEVO 200 50-200-200 TABLET   3 Non-Preferred Brand Drugs 36%36%None
STALEVO 50 TABLET   3 Non-Preferred Brand Drugs 36%36%None
STAVUDINE CAPSULES 15MG 60 BOT   1 Preferred Generic Drugs $6.00$15.00None
STAVUDINE CAPSULES 20MG 60 BOT   1 Preferred Generic Drugs $6.00$15.00None
STAVUDINE CAPSULES 30MG 60 BOT   1 Preferred Generic Drugs $6.00$15.00None
STAVUDINE CAPSULES 40MG 60 BOT   1 Preferred Generic Drugs $6.00$15.00None
STAVUDINE SOL 1MG/ML   1 Preferred Generic Drugs $6.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Sterile Water 6mg/mL 1 INJECTION, SOLUTION in 1 CARTON   4 Specialty Tier Drugs 26%N/AP
STROMECTOL 3MG TABLET   3 Non-Preferred Brand Drugs 36%36%None
Suboxone 2; 0.5mg/1; mg/1 30 POUCH in 1 CARTON / 1 FILM, SOLUBLE in 1 POUCH   3 Non-Preferred Brand Drugs 36%36%P Q:90
/30Days
Suboxone 8; 2mg/1; mg/1 30 POUCH in 1 CARTON / 1 FILM, SOLUBLE in 1 POUCH   3 Non-Preferred Brand Drugs 36%36%P Q:90
/30Days
SUCRAID 8500[iU]/mL   4 Specialty Tier Drugs 26%N/AP
SUCRALFATE 1GM TABLET   1 Preferred Generic Drugs $6.00$15.00None
SULFACETAMIDE 10% EYE OINTMENT   3 Non-Preferred Brand Drugs 36%36%None
Sulfacetamide Sodium 100mg/mL 118 mL in 1 BOTTLE   3 Non-Preferred Brand Drugs 36%36%None
SULFACETAMIDE SODIUM OPHTHALMIC SOLUTION USP 10% 15 ML BOT   1 Preferred Generic Drugs $6.00$15.00None
SULFACETAMIDE-PREDNISOLONE 10-0.25% DROPS   1 Preferred Generic Drugs $6.00$15.00None
SULFADIAZINE 500MG TABLET   1 Preferred Generic Drugs $6.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Sulfamethoxazole and Trimethoprim 200; 40mg/5mL; mg/5mL 473 mL in 1 BOTTLE   1 Preferred Generic Drugs $6.00$15.00None
SULFAMETHOXAZOLE W/TMP 800-160MG TABLET (100 CT)   1 Preferred Generic Drugs $6.00$15.00None
SULFAMETHOXAZOLE W/TMP VIAL 80MG-16ML 10 X 10ML VIAL   1 Preferred Generic Drugs $6.00$15.00None
SULFAMETHOXAZOLE-TRIMETHOPRIM TABLET 400-80MG (500 CT)   1 Preferred Generic Drugs $6.00$15.00None
SULFAMYLON 50G PACKET   3 Non-Preferred Brand Drugs 36%36%None
SULFAMYLON CREAM 85GM 4 OZ TUBE   3 Non-Preferred Brand Drugs 36%36%None
SULFASALAZINE 500MG TABLET   1 Preferred Generic Drugs $6.00$15.00None
SULFAZINE EC 500MG TABLET DELAYED RELEASE   1 Preferred Generic Drugs $6.00$15.00None
SULINDAC 150MG TABLET (100 CT)   1 Preferred Generic Drugs $6.00$15.00None
SULINDAC 200MG TABLET   1 Preferred Generic Drugs $6.00$15.00None
SUMATRIPTAN   3 Non-Preferred Brand Drugs 36%36%Q:8
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Sumatriptan Succinate 6mg/0.5mL 2 SYRINGE in 1 PACKAGE / 0.5 mL in 1 SYRINGE   3 Non-Preferred Brand Drugs 36%36%Q:8
/30Days
SUMATRIPTAN SUCCINATE INJECTION 4MG/0.5ML 0.5 ML VIALSD   3 Non-Preferred Brand Drugs 36%36%Q:8
/30Days
SUMATRIPTAN SUCCINATE TABLETS 100MG 9 BOXUD   3 Non-Preferred Brand Drugs 36%36%Q:9
/30Days
SUMATRIPTAN SUCCINATE TABLETS 25MG 9 BOX   3 Non-Preferred Brand Drugs 36%36%Q:9
/30Days
SUMATRIPTAN SUCCINATE TABLETS 50MG 9 (3 CARDS OF 3) BOX   3 Non-Preferred Brand Drugs 36%36%Q:9
/30Days
SUPRAX 100MG/5ML SUSPENSION RECONSTITUTED ORAL 50ML BOT   3 Non-Preferred Brand Drugs 36%36%None
SUPRAX 200MG/5ML SUSPENSION RECONSTITUTED ORAL   3 Non-Preferred Brand Drugs 36%36%None
SUPRAX 400 MG TABLET   3 Non-Preferred Brand Drugs 36%36%Q:60
/30Days
SUPREP bowel prep 1.6; 3.13; 17.5g/mL; g/mL; g/mL 2 BOTTLE, PLASTIC in 1 CARTON / 177.4 mL in 1 BOT   3 Non-Preferred Brand Drugs 36%36%Q:1
/30Days
SURMONTIL 100MG CAPSULE   3 Non-Preferred Brand Drugs 36%36%None
SURMONTIL 25MG CAPSULE   3 Non-Preferred Brand Drugs 36%36%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Surmontil 50mg/1 100 CAPSULE in 1 BOTTLE   3 Non-Preferred Brand Drugs 36%36%None
SUSTIVA 200MG CAPSULE   3 Non-Preferred Brand Drugs 36%36%None
SUSTIVA 50MG CAPSULE   3 Non-Preferred Brand Drugs 36%36%None
SUSTIVA 600MG TABLET   3 Non-Preferred Brand Drugs 36%36%None
SUTENT 12.5MG CAPSULE   4 Specialty Tier Drugs 26%N/AP Q:30
/30Days
SUTENT 25mg/1 28 CAPSULE in 1 BOTTLE   4 Specialty Tier Drugs 26%N/AP Q:30
/30Days
SUTENT 50MG CAPSULE   4 Specialty Tier Drugs 26%N/AP Q:30
/30Days
SYLATRON 296 MCG KIT 1 KIT in 1 CARTON   4 Specialty Tier Drugs 26%N/AP Q:4
/28Days
SYLATRON 444 MCG KIT 1 KIT in 1 CARTON   4 Specialty Tier Drugs 26%N/AP Q:4
/28Days
SYMBICORT 160-4.5MCG HFA AEROSOL WITH ADAPTER   2 Preferred Brand Drugs 19%17%Q:10
/30Days
SYMBICORT 80-4.5MCG HFA AEROSOL WITH ADAPTER 60 INHL   2 Preferred Brand Drugs 19%17%Q:10
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SYMBYAX 12-25MG CAPSULE   3 Non-Preferred Brand Drugs 36%36%P Q:30
/30Days
SYMBYAX 12-50MG CAPSULE   3 Non-Preferred Brand Drugs 36%36%P Q:30
/30Days
Symbyax 25; 3mg/1; mg/1 30 CAPSULE in 1 BOTTLE   3 Non-Preferred Brand Drugs 36%36%P Q:30
/30Days
SYMBYAX 6-25MG CAPSULE   3 Non-Preferred Brand Drugs 36%36%P Q:30
/30Days
SYMBYAX 6-50MG CAPSULE   3 Non-Preferred Brand Drugs 36%36%P Q:30
/30Days
SYMLIN 0.6MG/ML VIAL   3 Non-Preferred Brand Drugs 36%36%P Q:20
/30Days
SYMLINPEN 120 1000MCG/ML PEN INJECTOR   3 Non-Preferred Brand Drugs 36%36%P Q:4
/30Days
SYMLINPEN 60 1000MCG/ML PEN INJECTOR   3 Non-Preferred Brand Drugs 36%36%P Q:8
/30Days
SYNAREL 2MG/ML NASAL SPRAY   2 Preferred Brand Drugs 19%17%P
SYNTHROID 100MCG TABLET   3 Non-Preferred Brand Drugs 36%36%None
SYNTHROID 112 MCG TABLET   3 Non-Preferred Brand Drugs 36%36%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SYNTHROID 125MCG TABLET   3 Non-Preferred Brand Drugs 36%36%None
Synthroid 137ug/1 90 TABLET in 1 BOTTLE   3 Non-Preferred Brand Drugs 36%36%None
SYNTHROID 150MCG TABLET   3 Non-Preferred Brand Drugs 36%36%None
SYNTHROID 175MCG TABLET   3 Non-Preferred Brand Drugs 36%36%None
SYNTHROID 200MCG TABLET   3 Non-Preferred Brand Drugs 36%36%None
SYNTHROID 25MCG TABLET   3 Non-Preferred Brand Drugs 36%36%None
SYNTHROID 300MCG TABLET   3 Non-Preferred Brand Drugs 36%36%None
SYNTHROID 50MCG TABLET   3 Non-Preferred Brand Drugs 36%36%None
SYNTHROID 75MCG TABLET   3 Non-Preferred Brand Drugs 36%36%None
SYNTHROID 88 MCG TABLET   3 Non-Preferred Brand Drugs 36%36%None
SYPRINE 250MG CAPSULE (100 CT)   3 Non-Preferred Brand Drugs 36%36%None

Chart Legend:

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