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2012 Medicare Part D and Medicare Advantage Plan Formulary Browser

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Blue MedicareRx Value (PDP) (S5726-013-0)
Tier 1 (407)
Tier 2 (1221)
Tier 3 (410)
Tier 4 (231)
Tier 5 (539)
Tier 6 (404)
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Cick on the first letter of your drug name to browse the formulary:

A B C D E F G H I J K L 
M N O P Q R S T U V W X Y Z 0-9 
2012 Medicare Part D Plan Formulary Information
Blue MedicareRx Value (PDP) (S5726-013-0)
Benefit Details           
The Blue MedicareRx Value (PDP) (S5726-013-0)
Formulary Drugs Starting with the Letter A

in CMS PDP Region 24 which includes: KS
Drugs Starting with Letter A

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
A METHAPRED METHLYPREDNISOLONE SODIUM SUCCINATE FOR INJECTION 125 MG   5 Injectable Drugs 25%25%None
A-HYDROCORT 100MG VIAL   5 Injectable Drugs 25%25%None
A-METHAPRED INJ 40MG   5 Injectable Drugs 25%25%None
ABACAVIR TAB 300MG   4 Non-Preferred Brand Drugs $85.00$212.50None
ABELCENT INJECTION SUSPENSION 5MG/ML   6 Specialty Tier Drugs 25%N/ANone
ABILIFY 10MG TABLET   3 Preferred Brand Drugs $33.00$82.50Q:30
/30Days
ABILIFY 15MG TABLET   3 Preferred Brand Drugs $33.00$82.50Q:30
/30Days
ABILIFY 1MG/ML SOLUTION   3 Preferred Brand Drugs $33.00$82.50Q:900
/30Days
ABILIFY 20MG TABLET   6 Specialty Tier Drugs 25%N/AQ:60
/30Days
ABILIFY 2MG TABLET   3 Preferred Brand Drugs $33.00$82.50Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ABILIFY 30MG TABLET   6 Specialty Tier Drugs 25%N/AQ:30
/30Days
ABILIFY 5MG TABLET (OTSUKA)   3 Preferred Brand Drugs $33.00$82.50Q:30
/30Days
ABILIFY DISCMELT 10MG TABLET   3 Preferred Brand Drugs $33.00$82.50Q:60
/30Days
ABILIFY DISCMELT 15MG TABLET   3 Preferred Brand Drugs $33.00$82.50Q:60
/30Days
ABILIFY INJ 9.75MG   5 Injectable Drugs 25%25%None
ABRAXANE 100MG VIAL   6 Specialty Tier Drugs 25%N/AP
Abstral 100ug/1 32 TABLET in 1 BLISTER PACK   6 Specialty Tier Drugs 25%N/AP Q:120
/30Days
Abstral 200ug/1 32 TABLET in 1 BLISTER PACK   6 Specialty Tier Drugs 25%N/AP Q:120
/30Days
Abstral 300ug/1 32 TABLET in 1 BLISTER PACK   6 Specialty Tier Drugs 25%N/AP Q:120
/30Days
Abstral 400ug/1 32 TABLET in 1 BLISTER PACK   6 Specialty Tier Drugs 25%N/AP Q:120
/30Days
Abstral 600ug/1 32 TABLET in 1 BLISTER PACK   6 Specialty Tier Drugs 25%N/AP Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Abstral 800ug/1 32 TABLET in 1 BLISTER PACK   6 Specialty Tier Drugs 25%N/AP Q:120
/30Days
Acarbose 100mg/1 90 TABLET in 1 BOTTLE,   2 Non-Preferred Generic Drugs $7.00$10.50None
acarbose 50 mg tablet   2 Non-Preferred Generic Drugs $7.00$10.50None
ACARBOSE TABLETS   2 Non-Preferred Generic Drugs $7.00$10.50None
ACEBUTOLOL 200MG CAPSULE   2 Non-Preferred Generic Drugs $7.00$10.50None
ACEBUTOLOL 400MG CAPSULE   2 Non-Preferred Generic Drugs $7.00$10.50None
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE   3 Preferred Brand Drugs $33.00$82.50None
Acetaminophen and Codeine Phosphate 300; 60mg/1; mg/1 500 TABLET in 1 BOTTLE   2 Non-Preferred Generic Drugs $7.00$10.50Q:390
/30Days
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD   2 Non-Preferred Generic Drugs $7.00$10.50Q:4500
/30Days
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT)   2 Non-Preferred Generic Drugs $7.00$10.50Q:390
/30Days
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT)   2 Non-Preferred Generic Drugs $7.00$10.50Q:390
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETASOL HC SOLUTION 10ML 10 ML BOT   2 Non-Preferred Generic Drugs $7.00$10.50None
ACETAZOLAMIDE 125MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
ACETAZOLAMIDE 250MG TABLET (100 CT)   2 Non-Preferred Generic Drugs $7.00$10.50None
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT   2 Non-Preferred Generic Drugs $7.00$10.50None
ACETAZOLAMIDE SOD 500MG VL   5 Injectable Drugs 25%25%None
ACETIC ACID 2% SOLUTION NON-ORAL   1* Preferred Generic Drugs $4.00$6.00None
ACETYLCYSTEINE 10% VIAL   2 Non-Preferred Generic Drugs $7.00$10.50P
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN   2 Non-Preferred Generic Drugs $7.00$10.50P
ACTEMRA INJECTION 200MG/10ML   6 Specialty Tier Drugs 25%N/AP
ACTHIB VACCINE VIAL 10-24UNT/5ML   3 Preferred Brand Drugs $33.00$82.50None
ACTICIN 5% CREAM   1* Preferred Generic Drugs $4.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACTIMMUNE SOLUTION FOR INJECTION 100MCG   6 Specialty Tier Drugs 25%N/AP
ACTOPLUS MET 15MG/500MG TABLET   3 Preferred Brand Drugs $33.00$82.50Q:90
/30Days
ACTOPLUS MET 15MG/850MG TABLET   3 Preferred Brand Drugs $33.00$82.50Q:90
/30Days
ACTOPLUS MET XR TABLETS EXTENDED RELEASE 15;1000 MG;MG   3 Preferred Brand Drugs $33.00$82.50Q:60
/30Days
ACTOPLUS MET XR TABLETS EXTENDED RELEASE 30;1000 MG;MG   3 Preferred Brand Drugs $33.00$82.50Q:30
/30Days
ACTOS 15MG TABLET   3 Preferred Brand Drugs $33.00$82.50Q:30
/30Days
ACTOS 30MG TABLET (500 CT)   3 Preferred Brand Drugs $33.00$82.50Q:30
/30Days
ACTOS 45MG TABLET   3 Preferred Brand Drugs $33.00$82.50Q:30
/30Days
Acyclovir 200mg/1   2 Non-Preferred Generic Drugs $7.00$10.50None
Acyclovir 200mg/5mL 473 mL in 1 BOTTLE   2 Non-Preferred Generic Drugs $7.00$10.50None
Acyclovir 400mg/1 100 BLISTER PACK in 1 BOX / 1 TABLET in 1 BLISTER PACK   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
Acyclovir 800mg/1 100 BLISTER PACK in 1 BOX / 1 TABLET in 1 BLISTER PACK   2 Non-Preferred Generic Drugs $7.00$10.50None
ACYCLOVIR SODIUM 500MG VIAL   5 Injectable Drugs 25%25%None
ADACEL VIAL 2UNT/5UNT   3 Preferred Brand Drugs $33.00$82.50None
ADAGEN 250U/ML VIAL   6 Specialty Tier Drugs 25%N/ANone
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA]   6 Specialty Tier Drugs 25%N/AP Q:2
/28Days
ADAPALENE GEL   2 Non-Preferred Generic Drugs $7.00$10.50None
ADCIRCA TABLETS 20MG 60 BOT   6 Specialty Tier Drugs 25%N/AP Q:60
/30Days
ADVAIR DISKUS MIS 100/50   3 Preferred Brand Drugs $33.00$82.50Q:60
/30Days
ADVAIR DISKUS MIS 250/50   3 Preferred Brand Drugs $33.00$82.50Q:60
/30Days
ADVAIR DISKUS MIS 500/50   3 Preferred Brand Drugs $33.00$82.50Q:60
/30Days
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER   3 Preferred Brand Drugs $33.00$82.50Q:12
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL   3 Preferred Brand Drugs $33.00$82.50Q:12
/30Days
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL   3 Preferred Brand Drugs $33.00$82.50Q:12
/30Days
AFEDITAB CR 30MG TABLET SA   2 Non-Preferred Generic Drugs $7.00$10.50None
AFEDITAB CR 60MG TABLET SA   2 Non-Preferred Generic Drugs $7.00$10.50None
Afinitor 7.5mg/1 28 BLISTER PACK in 1 CARTON / 1 TABLET in 1 BLISTER PACK   6 Specialty Tier Drugs 25%N/AP
AFINITOR TABLETS 10 MG   6 Specialty Tier Drugs 25%N/AP
AFINITOR TABLETS 2.5 MG   6 Specialty Tier Drugs 25%N/AP
AFINITOR TABLETS 5 MG   6 Specialty Tier Drugs 25%N/AP
AGGRENOX 25-200MG CAPSULE   3 Preferred Brand Drugs $33.00$82.50Q:60
/30Days
AK-CON 0.1% EYE DROPS   1* Preferred Generic Drugs $4.00$6.00None
AKTOB 0.3% EYE DROPS   1* Preferred Generic Drugs $4.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALBENZA 200 MG TABLET   4 Non-Preferred Brand Drugs $85.00$212.50None
Albuterol Sulfate 0.63mg/3mL 25 POUCH in 1 CARTON / 5 VIAL in 1 POUCH / 3 mL in 1 VIAL   2 Non-Preferred Generic Drugs $7.00$10.50P Q:360
/30Days
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER   2 Non-Preferred Generic Drugs $7.00$10.50P Q:360
/30Days
ALBUTEROL SULFATE 4MG TABLET SR 12HR   2 Non-Preferred Generic Drugs $7.00$10.50None
ALBUTEROL SULFATE 8MG TABLET SR 12HR   2 Non-Preferred Generic Drugs $7.00$10.50None
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   2 Non-Preferred Generic Drugs $7.00$10.50P Q:60
/30Days
ALBUTEROL SULFATE SOLUTION FOR INHALATION   2 Non-Preferred Generic Drugs $7.00$10.50P Q:360
/30Days
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT   2 Non-Preferred Generic Drugs $7.00$10.50None
ALBUTEROL SULFATE TABLET 2MG (500 CT)   2 Non-Preferred Generic Drugs $7.00$10.50None
ALBUTEROL TABLET 4MG (500 CT)   2 Non-Preferred Generic Drugs $7.00$10.50None
ALCLOMETASONE DIPROPIONATE 0.05% CREAM   1* Preferred Generic Drugs $4.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Alclometasone Dipropionate 0.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE   1* Preferred Generic Drugs $4.00$6.00None
ALDURAZYME 2.9MG/5ML VIAL   6 Specialty Tier Drugs 25%N/AP
ALENDRONATE SODIUM 10MG TABLET   1* Preferred Generic Drugs $4.00$6.00Q:30
/30Days
ALENDRONATE SODIUM 40MG TABLET   1* Preferred Generic Drugs $4.00$6.00Q:30
/30Days
ALENDRONATE SODIUM 5MG TABLET   1* Preferred Generic Drugs $4.00$6.00Q:30
/30Days
ALENDRONATE SODIUM 70mg/1   1* Preferred Generic Drugs $4.00$6.00Q:4
/28Days
ALENDRONATE SODIUM TABLET 35MG 20 CRTN   1* Preferred Generic Drugs $4.00$6.00Q:4
/28Days
ALFUZOSIN HYDROCHLORIDE 10mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE   2 Non-Preferred Generic Drugs $7.00$10.50None
ALIMTA 500MG VIAL   6 Specialty Tier Drugs 25%N/ANone
Allopurinol 300mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET in 1 BLISTER PACK   1* Preferred Generic Drugs $4.00$6.00None
ALLOPURINOL SODIUM 500MG VIAL   5 Injectable Drugs 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALLOPURINOL TABLETS   1* Preferred Generic Drugs $4.00$6.00None
ALOXI 0.25MG/5ML   5 Injectable Drugs 25%25%None
ALPHAGAN P 0.1% DROPS   3 Preferred Brand Drugs $33.00$82.50None
AMANTADINE 100MG CAPSULE   2 Non-Preferred Generic Drugs $7.00$10.50None
AMANTADINE 100MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
Amantadine Hydrochloride 50mg/5mL   2 Non-Preferred Generic Drugs $7.00$10.50None
AMBISOME 50MG VIAL   6 Specialty Tier Drugs 25%N/ANone
AMCINONIDE 0.1% CREAM   2 Non-Preferred Generic Drugs $7.00$10.50None
AMCINONIDE 0.1% LOTION   2 Non-Preferred Generic Drugs $7.00$10.50None
AMCINONIDE 0.1% OINTMENT 60GM TUBE   2 Non-Preferred Generic Drugs $7.00$10.50None
AMEVIVE ADMISTRATION PACK FOR INTRAMUSCULAR ADMINISTRATION KIT 15MG 1 X 4 PKGCOM   6 Specialty Tier Drugs 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMIFOSTINE FOR INJECTION 500MG/VIAL   6 Specialty Tier Drugs 25%N/ANone
AMIKACIN 250MG/ML VIAL   5 Injectable Drugs 25%25%None
AMIKACIN 50MG/ML VIAL   5 Injectable Drugs 25%25%None
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET   1* Preferred Generic Drugs $4.00$6.00None
AMINOPHYLLINE 100MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
AMINOPHYLLINE 200MG TABLET (1000 CT)   2 Non-Preferred Generic Drugs $7.00$10.50None
Aminophylline 25mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 10 mL in 1 VIA   5 Injectable Drugs 25%25%None
AMINOSYN 10% IV SOLUTION   5 Injectable Drugs 25%25%None
AMINOSYN 3.5% IV SOLUTION   5 Injectable Drugs 25%25%None
AMINOSYN 5% IV SOLUTION   5 Injectable Drugs 25%25%None
AMINOSYN 7% IV SOLUTION   5 Injectable Drugs 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN 8.5% IV SOLUTION   5 Injectable Drugs 25%25%None
AMINOSYN HBC INJECTION SULFITE FREE 7%   5 Injectable Drugs 25%25%None
AMINOSYN II 10% IV SOLUTION   5 Injectable Drugs 25%25%None
AMINOSYN II 15% IV SOLUTION   5 Injectable Drugs 25%25%None
AMINOSYN II 3.5% IN D25W IV   5 Injectable Drugs 25%25%None
AMINOSYN II 3.5% IN D5W IV   5 Injectable Drugs 25%25%None
AMINOSYN II 3.5% M/D5W IV   5 Injectable Drugs 25%25%None
AMINOSYN II 3.5% W/ELEC DEX   5 Injectable Drugs 25%25%None
AMINOSYN II 4.25% IN D10W   5 Injectable Drugs 25%25%None
AMINOSYN II 4.25% IN D20W   5 Injectable Drugs 25%25%None
AMINOSYN II 4.25% W/ELEC DW   5 Injectable Drugs 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN II 4.25%-D25W IV   5 Injectable Drugs 25%25%None
AMINOSYN II 5% IN D25W IV   5 Injectable Drugs 25%25%None
AMINOSYN II 7% IV SOLUTION   5 Injectable Drugs 25%25%None
AMINOSYN II 8.5% ELECTROLYT   5 Injectable Drugs 25%25%None
AMINOSYN II 8.5% IV SOLUTION   5 Injectable Drugs 25%25%None
AMINOSYN M 3.5% IV SOLUTION   5 Injectable Drugs 25%25%None
AMINOSYN PF INJECTION   5 Injectable Drugs 25%25%None
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5%   5 Injectable Drugs 25%25%None
AMINOSYN-HF 8% IV SOLUTION   5 Injectable Drugs 25%25%None
AMINOSYN-PF 7% IV SOLUTION   5 Injectable Drugs 25%25%None
AMIODARONE HCL 400MG TABLET   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
AMIODARONE HCL INJECTION   5 Injectable Drugs 25%25%None
Amiodarone hydrochloride 200mg/1   2 Non-Preferred Generic Drugs $7.00$10.50None
AMITIZA 8MCG CAPSULE   3 Preferred Brand Drugs $33.00$82.50None
AMITIZA CAPSULES 24MCG 60 CAP BOT   3 Preferred Brand Drugs $33.00$82.50None
AMITRIP/CDP 25-10 TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
AMITRIP/PERPHEN 10-2 TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
AMITRIP/PERPHEN 10-4 TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
AMITRIP/PERPHEN 25-2 TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
AMITRIP/PERPHEN 25-4 TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
AMITRIP/PERPHEN 50-4 TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
AMITRIPTYLINE HCL 100MG TABLET   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
AMITRIPTYLINE HCL 10MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
AMITRIPTYLINE HCL 150 MG TAB   2 Non-Preferred Generic Drugs $7.00$10.50None
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)   2 Non-Preferred Generic Drugs $7.00$10.50None
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)   2 Non-Preferred Generic Drugs $7.00$10.50None
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT   2 Non-Preferred Generic Drugs $7.00$10.50None
AMLODIPINE BESYLATE 10MG TABLET (90 CT)   1* Preferred Generic Drugs $4.00$6.00Q:30
/30Days
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)   1* Preferred Generic Drugs $4.00$6.00Q:30
/30Days
AMLODIPINE BESYLATE 5MG TABLET (90 CT)   1* Preferred Generic Drugs $4.00$6.00Q:45
/30Days
AMMONIUM CHLORIDE 5 MEQ/ML   5 Injectable Drugs 25%25%None
AMMONIUM LACTATE 12% CREAM   1* Preferred Generic Drugs $4.00$6.00None
AMMONIUM LACTATE 12% LOTION   1* Preferred Generic Drugs $4.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Amnesteem 10mg/1 3 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK   2 Non-Preferred Generic Drugs $7.00$10.50None
Amnesteem 20mg/1 3 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK   2 Non-Preferred Generic Drugs $7.00$10.50None
Amnesteem 40mg/1 3 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK   2 Non-Preferred Generic Drugs $7.00$10.50None
AMOX TR-K CLV 500-125 MG TAB   2 Non-Preferred Generic Drugs $7.00$10.50None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL   2 Non-Preferred Generic Drugs $7.00$10.50None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE   2 Non-Preferred Generic Drugs $7.00$10.50None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE   2 Non-Preferred Generic Drugs $7.00$10.50None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   2 Non-Preferred Generic Drugs $7.00$10.50None
AMOXAPINE 100MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
AMOXAPINE 150MG TABLET   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
AMOXAPINE 25MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
AMOXAPINE 50MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
AMOXICILLIN 125MG TABLET CHEW   1* Preferred Generic Drugs $4.00$6.00None
AMOXICILLIN 200MG TABLET CHEW   1* Preferred Generic Drugs $4.00$6.00None
AMOXICILLIN 250MG CAPSULE   1* Preferred Generic Drugs $4.00$6.00None
Amoxicillin 250mg/1 500 TABLET, CHEWABLE in 1 BOTTLE   1* Preferred Generic Drugs $4.00$6.00None
AMOXICILLIN 50 MG/ML / CLAVULANATE 12.5 MG/ML ORAL SUSPENSION   2 Non-Preferred Generic Drugs $7.00$10.50None
AMOXICILLIN 500MG TABLET (100 CT)   1* Preferred Generic Drugs $4.00$6.00None
AMOXICILLIN 875MG TABLET   1* Preferred Generic Drugs $4.00$6.00None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT   2 Non-Preferred Generic Drugs $7.00$10.50None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS EXTENDED RELEASE 1000;62.5MG;MG   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
AMOXICILLIN CAP 500MG   1* Preferred Generic Drugs $4.00$6.00None
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT   2 Non-Preferred Generic Drugs $7.00$10.50None
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT   1* Preferred Generic Drugs $4.00$6.00None
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL   1* Preferred Generic Drugs $4.00$6.00None
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   1* Preferred Generic Drugs $4.00$6.00None
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL   1* Preferred Generic Drugs $4.00$6.00None
AMPHETAMINE SALT COMBO 12.5MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50Q:120
/30Days
AMPHETAMINE SALT COMBO 15MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50Q:30
/30Days
AMPHETAMINE SALT COMBO 30MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50Q:60
/30Days
AMPHETAMINE SALT COMBO 7.5MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50Q:60
/30Days
AMPHETAMINE SALTS 20MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50Q:90
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPHETAMINE SALTS 5 MG TAB   2 Non-Preferred Generic Drugs $7.00$10.50Q:30
/30Days
AMPHOTEC FOR INJECTION 50MG/VIAL   5 Injectable Drugs 25%25%None
amphotericin b 50mg/10mL 10 mL in 1 VIAL   5 Injectable Drugs 25%25%None
Ampicillin 125mg/1 10 VIAL in 1 BOX / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL   5 Injectable Drugs 25%25%None
AMPICILLIN AND SULBACTAM FOR INJECTION 2-1 10 VIAL   5 Injectable Drugs 25%25%None
AMPICILLIN CAPSULES 250MG 100 BOT   1* Preferred Generic Drugs $4.00$6.00None
AMPICILLIN CAPSULES 500MG 100 BOT   1* Preferred Generic Drugs $4.00$6.00None
AMPICILLIN FOR INJECTION POWDER   5 Injectable Drugs 25%25%None
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT   1* Preferred Generic Drugs $4.00$6.00None
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT   1* Preferred Generic Drugs $4.00$6.00None
AMPICILLIN POWDER FOR INJECTION 1 GM/ML   5 Injectable Drugs 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ampicillin-sulbactam 15 gm vl   5 Injectable Drugs 25%25%None
AMPYRA ER 10 MG TABLET   6 Specialty Tier Drugs 25%N/AP Q:60
/30Days
ANADROL-50 50MG TABLET (100 CT)   6 Specialty Tier Drugs 25%N/AP
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE in 1 BOTTLE   2 Non-Preferred Generic Drugs $7.00$10.50None
Anagrelide Hydrochloride 1mg/1 100 CAPSULE in 1 BOTTLE   2 Non-Preferred Generic Drugs $7.00$10.50None
ANASTROZOLE TABLETS   2 Non-Preferred Generic Drugs $7.00$10.50None
ANCOBON 250MG CAPSULE   6 Specialty Tier Drugs 25%N/ANone
ANCOBON 500MG CAPSULE   6 Specialty Tier Drugs 25%N/ANone
ANDROGEL 1%(50MG) GEL PACKET   3 Preferred Brand Drugs $33.00$82.50P Q:300
/30Days
Androgel 16.2mg/g 1 BOTTLE, PUMP in 1 CARTON / 88 g in 1 BOTTLE, PUMP   3 Preferred Brand Drugs $33.00$82.50P Q:150
/30Days
ANTABUSE 250MG TABLET   3 Preferred Brand Drugs $33.00$82.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANTABUSE 500MG TABLET   3 Preferred Brand Drugs $33.00$82.50None
ANZEMET 20MG/ML VIAL   5 Injectable Drugs 25%25%None
APAP-CAFFEINE-DIHYDROCODE TAB 30 EA   2 Non-Preferred Generic Drugs $7.00$10.50Q:180
/30Days
APOKYN 30mg/3mL 5 CARTRIDGE in 1 CARTON / 3 mL in 1 CARTRIDGE   6 Specialty Tier Drugs 25%N/ANone
Apraclonidine Ophthalmic 5mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 10 mL in 1 BOTTLE, DROPPER   2 Non-Preferred Generic Drugs $7.00$10.50None
APRI 0.15-0.03 TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
APRISO CP24   3 Preferred Brand Drugs $33.00$82.50None
APTIVUS 250MG CAPSULE   6 Specialty Tier Drugs 25%N/ANone
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT   6 Specialty Tier Drugs 25%N/ANone
Aralast NP 1 KIT in 1 CARTON   5 Injectable Drugs 25%25%None
ARANELLE 7-9-5 TABLET   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
ARANESP 100ug/0.5mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE in 1 BLISTER PACK / 0.5 mL in 1 SYRINGE   6 Specialty Tier Drugs 25%N/AP
ARANESP 100ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE   6 Specialty Tier Drugs 25%N/AP
ARANESP 200MCG/0.4ML SYRINGE   6 Specialty Tier Drugs 25%N/AP
ARANESP 200MCG/ML VIAL   6 Specialty Tier Drugs 25%N/AP
ARANESP 25ug/0.42mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE in 1 BLISTER PACK / 0.42 mL in 1 SYRING   5 Injectable Drugs 25%25%P
ARANESP 25ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE   5 Injectable Drugs 25%25%P
ARANESP 300MCG/ML VIAL   6 Specialty Tier Drugs 25%N/AP
ARANESP 500MCG/1ML SYRINGE   6 Specialty Tier Drugs 25%N/AP
ARANESP 60MCG/ML VIAL   6 Specialty Tier Drugs 25%N/AP
ARANESP 60ug/0.3mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE in 1 BLISTER PACK / 0.3 mL in 1 SYRINGE   5 Injectable Drugs 25%25%P
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR   6 Specialty Tier Drugs 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR   6 Specialty Tier Drugs 25%N/AP
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR   5 Injectable Drugs 25%25%P
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD   5 Injectable Drugs 25%25%P
ARCALYST INJECTION 220MG/VIAL   6 Specialty Tier Drugs 25%N/AP
ARICEPT TABLETS   3 Preferred Brand Drugs $33.00$82.50S Q:30
/30Days
ARIXTRA 10MG SYRINGE   6 Specialty Tier Drugs 25%N/AS
ARIXTRA 2.5MG SYRINGE   5 Injectable Drugs 25%25%S
ARIXTRA 5MG SYRINGE   6 Specialty Tier Drugs 25%N/AS
ARIXTRA 7.5MG SYRINGE   6 Specialty Tier Drugs 25%N/AS
ARRANON 250MG VIAL   5 Injectable Drugs 25%25%P
ARZERRA 20mg/mL 3 VIAL in 1 CARTON / 5 mL in 1 VIAL   6 Specialty Tier Drugs 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ASACOL 400mg/1 12 BOTTLE in 1 CASE / 180 TABLET, DELAYED RELEASE in 1 BOTTLE   3 Preferred Brand Drugs $33.00$82.50None
ASACOL HD 800mg/1 12 BOTTLE in 1 CASE / 180 TABLET, DELAYED RELEASE in 1 BOTTLE   3 Preferred Brand Drugs $33.00$82.50None
Ascomp with Codeine 325; 50; 40; 30mg/1; mg/1; mg/1; mg/1 500 CAPSULE in 1 BOTTLE, PLASTIC   2 Non-Preferred Generic Drugs $7.00$10.50None
ASTEPRO 0.15% NASAL SPRAY 30 ML   3 Preferred Brand Drugs $33.00$82.50Q:30
/25Days
ATENOLOL 100mg/1 100 TABLET in 1 BOTTLE, PLASTIC   1* Preferred Generic Drugs $4.00$6.00None
Atenolol 25mg/1 100 TABLET in 1 BOTTLE, PLASTIC   1* Preferred Generic Drugs $4.00$6.00None
ATENOLOL TABLET USP 50MG (100 CT)   1* Preferred Generic Drugs $4.00$6.00None
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT)   2 Non-Preferred Generic Drugs $7.00$10.50None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   2 Non-Preferred Generic Drugs $7.00$10.50None
ATORVASTATIN 10 MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50Q:30
/30Days
ATORVASTATIN 20 MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATORVASTATIN 40 MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50Q:30
/30Days
ATORVASTATIN 80 MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50Q:30
/30Days
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE, PLASTIC   6 Specialty Tier Drugs 25%N/ANone
ATROPINE 0.05MG/ML SYRINGE   5 Injectable Drugs 25%25%None
ATROPINE 0.1MG/ML SYRINGE   5 Injectable Drugs 25%25%None
ATROVENT HFA AER 17MCG   4 Non-Preferred Brand Drugs $85.00$212.50Q:39
/30Days
AUGMENTED BETAMETHASONE DIPROPIONATE OINTMENT   2 Non-Preferred Generic Drugs $7.00$10.50None
AVANDAMET 1000; 2mg/1; mg/1 60 TABLET, FILM COATED in 1 BOTTLE   4 Non-Preferred Brand Drugs $85.00$212.50P Q:60
/30Days
AVANDAMET 1000; 4mg/1; mg/1 60 TABLET, FILM COATED in 1 BOTTLE   4 Non-Preferred Brand Drugs $85.00$212.50P Q:60
/30Days
AVANDAMET 500; 2mg/1; mg/1 60 TABLET, FILM COATED in 1 BOTTLE   4 Non-Preferred Brand Drugs $85.00$212.50P Q:120
/30Days
AVANDAMET 500; 4mg/1; mg/1 60 TABLET, FILM COATED in 1 BOTTLE   4 Non-Preferred Brand Drugs $85.00$212.50P Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVANDARYL 1; 4mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   4 Non-Preferred Brand Drugs $85.00$212.50P Q:60
/30Days
AVANDARYL 2; 4mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   4 Non-Preferred Brand Drugs $85.00$212.50P Q:60
/30Days
AVANDARYL 2; 8mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   4 Non-Preferred Brand Drugs $85.00$212.50P Q:30
/30Days
AVANDARYL 4; 4mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   4 Non-Preferred Brand Drugs $85.00$212.50P Q:30
/30Days
AVANDARYL 4; 8mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   4 Non-Preferred Brand Drugs $85.00$212.50P Q:30
/30Days
AVANDIA 2mg/1 60 TABLET, FILM COATED in 1 BOTTLE   4 Non-Preferred Brand Drugs $85.00$212.50P Q:60
/30Days
AVANDIA 4mg/1 30 TABLET, FILM COATED in 1 BOTTLE   4 Non-Preferred Brand Drugs $85.00$212.50P Q:60
/30Days
AVANDIA 8mg/1 30 TABLET, FILM COATED in 1 BOTTLE   4 Non-Preferred Brand Drugs $85.00$212.50P Q:30
/30Days
AVASTIN 100MG/4ML VIAL   6 Specialty Tier Drugs 25%N/AP
AVELOX IV 400MG/250ML   5 Injectable Drugs 25%25%None
AVIANE 0.1-0.02 TABLET   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
AVODART 0.5MG SOFTGEL   3 Preferred Brand Drugs $33.00$82.50None
AVONEX ADMIN PACK 30MCG SYR   6 Specialty Tier Drugs 25%N/AP
AVONEX ADMIN PACK 30MCG VL   6 Specialty Tier Drugs 25%N/AP
AZACTAM INJECTION 1GM/50ML   5 Injectable Drugs 25%25%None
AZACTAM INJECTION 2GM/50ML   5 Injectable Drugs 25%25%None
AZACTAM INJECTION 2GM/VIL   5 Injectable Drugs 25%25%None
AZATHIOPRINE 50MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50P
AZATHIOPRINE SOD 100MG VIAL   5 Injectable Drugs 25%25%P
AZELASTINE 137 MCG NASAL SPRAY   2 Non-Preferred Generic Drugs $7.00$10.50Q:30
/25Days
AZELASTINE HYDROCHLORIDE OPHTHALMIC SOLUTION   2 Non-Preferred Generic Drugs $7.00$10.50None
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL   2 Non-Preferred Generic Drugs $7.00$10.50Q:15
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL   2 Non-Preferred Generic Drugs $7.00$10.50Q:46
/1Days
AZITHROMYCIN 250 MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50Q:6
/1Days
Azithromycin 500mg/1 10 VIAL, SINGLE-USE in 1 TRAY / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION   5 Injectable Drugs 25%25%None
Azithromycin 500mg/1 30 TABLET, FILM COATED in 1 BOTTLE   2 Non-Preferred Generic Drugs $7.00$10.50Q:3
/1Days
Azithromycin 600mg/1 30 TABLET, FILM COATED in 1 BOTTLE   2 Non-Preferred Generic Drugs $7.00$10.50Q:8
/1Days
AZTREONAM FOR INJECTION   5 Injectable Drugs 25%25%None

Chart Legend:

Below are a few notes to help you understand the above 2012 Medicare Part D Blue MedicareRx Value (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 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 wit 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 which tier the drug is in. 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.