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Community CCRx Basic (PDP) (S5803-101-0)
Tier 1 (1399)
Tier 2 (779)
Tier 3 (521)
Tier 4 (320)

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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
Community CCRx Basic (PDP) (S5803-101-0)
Benefit Details           
The Community CCRx Basic (PDP) (S5803-101-0)
Formulary Drugs Starting with the Letter A

in CMS PDP Region 32 which includes: CA
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   1 Generic Drugs $2.00N/ANone
A-METHAPRED INJ 40MG   1 Generic Drugs $2.00N/ANone
ABACAVIR TAB 300MG   3 Non-Preferred Brand Drugs 46%N/ANone
ABELCENT INJECTION SUSPENSION 5MG/ML   4 Specialty Tier Drugs 25%N/AP
ABILIFY 10MG TABLET   3 Non-Preferred Brand Drugs 46%N/AQ:30
/30Days
ABILIFY 15MG TABLET   3 Non-Preferred Brand Drugs 46%N/AQ:30
/30Days
ABILIFY 1MG/ML SOLUTION   3 Non-Preferred Brand Drugs 46%N/AQ:900
/30Days
ABILIFY 20MG TABLET   3 Non-Preferred Brand Drugs 46%N/AQ:30
/30Days
ABILIFY 2MG TABLET   3 Non-Preferred Brand Drugs 46%N/AQ:30
/30Days
ABILIFY 30MG TABLET   3 Non-Preferred Brand Drugs 46%N/AQ:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ABILIFY 5MG TABLET (OTSUKA)   3 Non-Preferred Brand Drugs 46%N/AQ:30
/30Days
ABILIFY DISCMELT 10MG TABLET   3 Non-Preferred Brand Drugs 46%N/AQ:30
/30Days
ABILIFY DISCMELT 15MG TABLET   3 Non-Preferred Brand Drugs 46%N/AQ:60
/30Days
ABILIFY INJ 9.75MG   3 Non-Preferred Brand Drugs 46%N/AQ:4
/1Days
Acarbose 100mg/1 90 TABLET in 1 BOTTLE,   1 Generic Drugs $2.00N/AQ:90
/30Days
acarbose 50 mg tablet   1 Generic Drugs $2.00N/AQ:90
/30Days
ACARBOSE TABLETS   1 Generic Drugs $2.00N/AQ:90
/30Days
ACEBUTOLOL 200MG CAPSULE   1 Generic Drugs $2.00N/ANone
ACEBUTOLOL 400MG CAPSULE   1 Generic Drugs $2.00N/ANone
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE   3 Non-Preferred Brand Drugs 46%N/ANone
Acetaminophen and Codeine Phosphate 300; 60mg/1; mg/1 500 TABLET in 1 BOTTLE   1 Generic Drugs $2.00N/AQ:400
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD   1 Generic Drugs $2.00N/AQ:5000
/30Days
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT)   1 Generic Drugs $2.00N/AQ:400
/30Days
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT)   1 Generic Drugs $2.00N/AQ:400
/30Days
ACETAZOLAMIDE 125MG TABLET   1 Generic Drugs $2.00N/ANone
ACETAZOLAMIDE 250MG TABLET (100 CT)   1 Generic Drugs $2.00N/ANone
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT   2 Preferred Brand Drugs 25%N/ANone
ACETIC ACID 2% SOLUTION NON-ORAL   1 Generic Drugs $2.00N/ANone
ACETYLCYSTEINE 10% VIAL   1 Generic Drugs $2.00N/AP
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN   1 Generic Drugs $2.00N/AP
ACTEMRA INJECTION 200MG/10ML   4 Specialty Tier Drugs 25%N/AP Q:40
/28Days
ACTHIB VACCINE VIAL 10-24UNT/5ML   2 Preferred Brand Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACTICIN 5% CREAM   1 Generic Drugs $2.00N/ANone
ACTIMMUNE SOLUTION FOR INJECTION 100MCG   4 Specialty Tier Drugs 25%N/AP
ACTOPLUS MET 15MG/500MG TABLET   2 Preferred Brand Drugs 25%N/AQ:90
/30Days
ACTOPLUS MET 15MG/850MG TABLET   2 Preferred Brand Drugs 25%N/AQ:90
/30Days
ACTOS 15MG TABLET   2 Preferred Brand Drugs 25%N/AQ:30
/30Days
ACTOS 30MG TABLET (500 CT)   2 Preferred Brand Drugs 25%N/AQ:30
/30Days
ACTOS 45MG TABLET   2 Preferred Brand Drugs 25%N/AQ:30
/30Days
Acyclovir 200mg/1   1 Generic Drugs $2.00N/ANone
Acyclovir 200mg/5mL 473 mL in 1 BOTTLE   1 Generic Drugs $2.00N/ANone
Acyclovir 400mg/1 100 BLISTER PACK in 1 BOX / 1 TABLET in 1 BLISTER PACK   1 Generic Drugs $2.00N/ANone
Acyclovir 800mg/1 100 BLISTER PACK in 1 BOX / 1 TABLET in 1 BLISTER PACK   1 Generic Drugs $2.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACYCLOVIR SODIUM 500MG VIAL   2 Preferred Brand Drugs 25%N/AP
ADACEL VIAL 2UNT/5UNT   2 Preferred Brand Drugs 25%N/ANone
ADAGEN 250U/ML VIAL   4 Specialty Tier Drugs 25%N/ANone
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA]   4 Specialty Tier Drugs 25%N/AP Q:2
/28Days
ADCIRCA TABLETS 20MG 60 BOT   4 Specialty Tier Drugs 25%N/AP Q:60
/30Days
ADVAIR DISKUS MIS 100/50   2 Preferred Brand Drugs 25%N/AQ:60
/30Days
ADVAIR DISKUS MIS 250/50   2 Preferred Brand Drugs 25%N/AQ:60
/30Days
ADVAIR DISKUS MIS 500/50   2 Preferred Brand Drugs 25%N/AQ:60
/30Days
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER   2 Preferred Brand Drugs 25%N/AQ:12
/30Days
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL   2 Preferred Brand Drugs 25%N/AQ:12
/30Days
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL   2 Preferred Brand Drugs 25%N/AQ:12
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AFEDITAB CR 30MG TABLET SA   1 Generic Drugs $2.00N/AS Q:30
/30Days
AFEDITAB CR 60MG TABLET SA   1 Generic Drugs $2.00N/AS Q:30
/30Days
Afinitor 7.5mg/1 28 BLISTER PACK in 1 CARTON / 1 TABLET in 1 BLISTER PACK   4 Specialty Tier Drugs 25%N/AP Q:30
/30Days
AFINITOR TABLETS 10 MG   4 Specialty Tier Drugs 25%N/AP Q:30
/30Days
AFINITOR TABLETS 2.5 MG   4 Specialty Tier Drugs 25%N/AP Q:30
/30Days
AFINITOR TABLETS 5 MG   4 Specialty Tier Drugs 25%N/AP Q:30
/30Days
AGGRENOX 25-200MG CAPSULE   3 Non-Preferred Brand Drugs 46%N/AQ:60
/30Days
AK-CON 0.1% EYE DROPS   1 Generic Drugs $2.00N/ANone
AKNE-MYCIN 2% OINTMENT   3 Non-Preferred Brand Drugs 46%N/ANone
AKTOB 0.3% EYE DROPS   1 Generic Drugs $2.00N/ANone
ALA-CORT 1% CREAM   1 Generic Drugs $2.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALA-CORT 1% LOTION   1 Generic Drugs $2.00N/ANone
ALBENZA 200 MG TABLET   3 Non-Preferred Brand Drugs 46%N/ANone
Albuterol Sulfate 0.63mg/3mL 25 POUCH in 1 CARTON / 5 VIAL in 1 POUCH / 3 mL in 1 VIAL   1 Generic Drugs $2.00N/AP Q:450
/30Days
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER   1 Generic Drugs $2.00N/AP Q:450
/30Days
ALBUTEROL SULFATE 4MG TABLET SR 12HR   1 Generic Drugs $2.00N/ANone
ALBUTEROL SULFATE 8MG TABLET SR 12HR   1 Generic Drugs $2.00N/ANone
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   1 Generic Drugs $2.00N/AP Q:100
/30Days
ALBUTEROL SULFATE SOLUTION FOR INHALATION   1 Generic Drugs $2.00N/AP Q:450
/30Days
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT   1 Generic Drugs $2.00N/ANone
ALBUTEROL SULFATE TABLET 2MG (500 CT)   1 Generic Drugs $2.00N/ANone
ALBUTEROL TABLET 4MG (500 CT)   1 Generic Drugs $2.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALCLOMETASONE DIPROPIONATE 0.05% CREAM   1 Generic Drugs $2.00N/ANone
Alclometasone Dipropionate 0.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE   1 Generic Drugs $2.00N/ANone
ALDACTAZIDE 50/50 TABLET   2 Preferred Brand Drugs 25%N/ANone
ALDURAZYME 2.9MG/5ML VIAL   4 Specialty Tier Drugs 25%N/ANone
ALENDRONATE SODIUM 10MG TABLET   1 Generic Drugs $2.00N/AQ:30
/30Days
ALENDRONATE SODIUM 40MG TABLET   1 Generic Drugs $2.00N/AQ:30
/30Days
ALENDRONATE SODIUM 5MG TABLET   1 Generic Drugs $2.00N/AQ:30
/30Days
ALENDRONATE SODIUM 70mg/1   1 Generic Drugs $2.00N/AQ:4
/28Days
ALENDRONATE SODIUM TABLET 35MG 20 CRTN   1 Generic Drugs $2.00N/AQ:4
/28Days
ALIMTA 500MG VIAL   4 Specialty Tier Drugs 25%N/AP
ALINIA 100MG/5ML SUSPENSION   3 Non-Preferred Brand Drugs 46%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALINIA 500MG TABLET   3 Non-Preferred Brand Drugs 46%N/ANone
Allopurinol 300mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET in 1 BLISTER PACK   1 Generic Drugs $2.00N/ANone
ALLOPURINOL TABLETS   1 Generic Drugs $2.00N/ANone
ALORA 0.025MG PATCH   3 Non-Preferred Brand Drugs 46%N/AQ:8
/28Days
ALORA 0.05MG PATCH   3 Non-Preferred Brand Drugs 46%N/AQ:8
/28Days
ALORA 0.075MG PATCH   3 Non-Preferred Brand Drugs 46%N/AQ:8
/28Days
ALORA 0.1MG PATCH   3 Non-Preferred Brand Drugs 46%N/AQ:8
/28Days
ALPHAGAN P 0.1% DROPS   2 Preferred Brand Drugs 25%N/AQ:10
/30Days
ALPHAGAN P 0.15% EYE DROPS   2 Preferred Brand Drugs 25%N/AQ:10
/30Days
ALREX 0.2% EYE DROPS   2 Preferred Brand Drugs 25%N/ANone
ALVESCO 160MCG/ACT AERS   3 Non-Preferred Brand Drugs 46%N/AQ:12
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALVESCO 80MCG/ACT AERS   3 Non-Preferred Brand Drugs 46%N/AQ:12
/30Days
AMANTADINE 100MG CAPSULE   1 Generic Drugs $2.00N/ANone
Amantadine Hydrochloride 50mg/5mL   1 Generic Drugs $2.00N/ANone
AMCINONIDE 0.1% CREAM   2 Preferred Brand Drugs 25%N/ANone
AMCINONIDE 0.1% LOTION   2 Preferred Brand Drugs 25%N/ANone
AMCINONIDE 0.1% OINTMENT 60GM TUBE   2 Preferred Brand Drugs 25%N/ANone
AMEVIVE ADMISTRATION PACK FOR INTRAMUSCULAR ADMINISTRATION KIT 15MG 1 X 4 PKGCOM   4 Specialty Tier Drugs 25%N/AP Q:4
/28Days
AMIFOSTINE FOR INJECTION 500MG/VIAL   4 Specialty Tier Drugs 25%N/AP
AMIKACIN 250MG/ML VIAL   1 Generic Drugs $2.00N/ANone
AMIKACIN 50MG/ML VIAL   1 Generic Drugs $2.00N/ANone
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET   1 Generic Drugs $2.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT   1 Generic Drugs $2.00N/ANone
AMINOPHYLLINE 100MG TABLET   1 Generic Drugs $2.00N/ANone
AMINOPHYLLINE 200MG TABLET (1000 CT)   1 Generic Drugs $2.00N/ANone
AMINOSYN 10% IV SOLUTION   3 Non-Preferred Brand Drugs 46%N/AP
AMINOSYN 3.5% IV SOLUTION   3 Non-Preferred Brand Drugs 46%N/AP
AMINOSYN 5% IV SOLUTION   3 Non-Preferred Brand Drugs 46%N/AP
AMINOSYN 7% IV SOLUTION   3 Non-Preferred Brand Drugs 46%N/AP
AMINOSYN 8.5% IV SOLUTION   3 Non-Preferred Brand Drugs 46%N/AP
AMINOSYN HBC INJECTION SULFITE FREE 7%   3 Non-Preferred Brand Drugs 46%N/AP
AMINOSYN II 10% IV SOLUTION   3 Non-Preferred Brand Drugs 46%N/AP
AMINOSYN II 3.5% IN D25W IV   3 Non-Preferred Brand Drugs 46%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN II 3.5% IN D5W IV   3 Non-Preferred Brand Drugs 46%N/AP
AMINOSYN II 3.5% M/D5W IV   3 Non-Preferred Brand Drugs 46%N/AP
AMINOSYN II 3.5% W/ELEC DEX   3 Non-Preferred Brand Drugs 46%N/AP
AMINOSYN II 4.25% IN D10W   3 Non-Preferred Brand Drugs 46%N/AP
AMINOSYN II 4.25% IN D20W   3 Non-Preferred Brand Drugs 46%N/AP
AMINOSYN II 4.25% W/ELEC DW   3 Non-Preferred Brand Drugs 46%N/AP
AMINOSYN II 4.25%-D25W IV   3 Non-Preferred Brand Drugs 46%N/AP
AMINOSYN II 5% IN D25W IV   3 Non-Preferred Brand Drugs 46%N/AP
AMINOSYN II 7% IV SOLUTION   3 Non-Preferred Brand Drugs 46%N/AP
AMINOSYN II 8.5% ELECTROLYT   3 Non-Preferred Brand Drugs 46%N/AP
AMINOSYN II 8.5% IV SOLUTION   3 Non-Preferred Brand Drugs 46%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN M 3.5% IV SOLUTION   3 Non-Preferred Brand Drugs 46%N/AP
AMINOSYN PF INJECTION   3 Non-Preferred Brand Drugs 46%N/AP
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5%   3 Non-Preferred Brand Drugs 46%N/AP
AMINOSYN-HF 8% IV SOLUTION   3 Non-Preferred Brand Drugs 46%N/AP
AMINOSYN-PF 7% IV SOLUTION   3 Non-Preferred Brand Drugs 46%N/AP
AMIODARONE HCL 400MG TABLET   2 Preferred Brand Drugs 25%N/ANone
Amiodarone hydrochloride 200mg/1   1 Generic Drugs $2.00N/ANone
AMITIZA 8MCG CAPSULE   2 Preferred Brand Drugs 25%N/AS Q:60
/30Days
AMITIZA CAPSULES 24MCG 60 CAP BOT   2 Preferred Brand Drugs 25%N/AS Q:60
/30Days
AMITRIP/PERPHEN 10-2 TABLET   1 Generic Drugs $2.00N/ANone
AMITRIP/PERPHEN 10-4 TABLET   1 Generic Drugs $2.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITRIP/PERPHEN 25-2 TABLET   1 Generic Drugs $2.00N/ANone
AMITRIP/PERPHEN 25-4 TABLET   1 Generic Drugs $2.00N/ANone
AMITRIP/PERPHEN 50-4 TABLET   1 Generic Drugs $2.00N/ANone
AMITRIPTYLINE HCL 100MG TABLET   1 Generic Drugs $2.00N/ANone
AMITRIPTYLINE HCL 10MG TABLET   1 Generic Drugs $2.00N/ANone
AMITRIPTYLINE HCL 150 MG TAB   1 Generic Drugs $2.00N/ANone
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)   1 Generic Drugs $2.00N/ANone
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)   1 Generic Drugs $2.00N/ANone
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT   1 Generic Drugs $2.00N/ANone
AMLODIPINE BESYLATE 10MG TABLET (90 CT)   1 Generic Drugs $2.00N/AQ:30
/30Days
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)   1 Generic Drugs $2.00N/AQ:45
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE BESYLATE 5MG TABLET (90 CT)   1 Generic Drugs $2.00N/AQ:45
/30Days
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE CAPSULES   2 Preferred Brand Drugs 25%N/AQ:30
/30Days
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE CAPSULES   2 Preferred Brand Drugs 25%N/AQ:30
/30Days
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE   2 Preferred Brand Drugs 25%N/AQ:30
/30Days
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE   2 Preferred Brand Drugs 25%N/AQ:30
/30Days
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE   2 Preferred Brand Drugs 25%N/AQ:30
/30Days
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE   2 Preferred Brand Drugs 25%N/AQ:30
/30Days
AMMONIUM LACTATE 12% CREAM   1 Generic Drugs $2.00N/ANone
AMMONIUM LACTATE 12% LOTION   1 Generic Drugs $2.00N/ANone
Amnesteem 10mg/1 3 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK   2 Preferred Brand Drugs 25%N/AP
Amnesteem 20mg/1 3 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK   2 Preferred Brand Drugs 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Amnesteem 40mg/1 3 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK   2 Preferred Brand Drugs 25%N/AP
AMOX TR-K CLV 500-125 MG TAB   1 Generic Drugs $2.00N/ANone
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL   1 Generic Drugs $2.00N/ANone
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE   1 Generic Drugs $2.00N/ANone
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET   1 Generic Drugs $2.00N/ANone
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE   1 Generic Drugs $2.00N/ANone
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   1 Generic Drugs $2.00N/ANone
AMOXAPINE 100MG TABLET   1 Generic Drugs $2.00N/ANone
AMOXAPINE 150MG TABLET   1 Generic Drugs $2.00N/ANone
AMOXAPINE 25MG TABLET   1 Generic Drugs $2.00N/ANone
AMOXAPINE 50MG TABLET   1 Generic Drugs $2.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN 125MG TABLET CHEW   1 Generic Drugs $2.00N/ANone
AMOXICILLIN 250MG CAPSULE   1 Generic Drugs $2.00N/ANone
Amoxicillin 250mg/1 500 TABLET, CHEWABLE in 1 BOTTLE   1 Generic Drugs $2.00N/ANone
AMOXICILLIN 50 MG/ML / CLAVULANATE 12.5 MG/ML ORAL SUSPENSION   2 Preferred Brand Drugs 25%N/ANone
AMOXICILLIN 500MG TABLET (100 CT)   1 Generic Drugs $2.00N/ANone
AMOXICILLIN 875MG TABLET   1 Generic Drugs $2.00N/ANone
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT   1 Generic Drugs $2.00N/ANone
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS EXTENDED RELEASE 1000;62.5MG;MG   2 Preferred Brand Drugs 25%N/ANone
AMOXICILLIN CAP 500MG   1 Generic Drugs $2.00N/ANone
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT   1 Generic Drugs $2.00N/ANone
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT   1 Generic Drugs $2.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL   1 Generic Drugs $2.00N/ANone
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   1 Generic Drugs $2.00N/ANone
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL   1 Generic Drugs $2.00N/ANone
AMPHETAMINE SALT COMBO 12.5MG TABLET   1 Generic Drugs $2.00N/ANone
AMPHETAMINE SALT COMBO 15MG TABLET   1 Generic Drugs $2.00N/ANone
AMPHETAMINE SALT COMBO 30MG TABLET   1 Generic Drugs $2.00N/ANone
AMPHETAMINE SALT COMBO 7.5MG TABLET   1 Generic Drugs $2.00N/ANone
AMPHETAMINE SALTS 20MG TABLET   1 Generic Drugs $2.00N/ANone
AMPHETAMINE SALTS 5 MG TAB   1 Generic Drugs $2.00N/ANone
amphotericin b 50mg/10mL 10 mL in 1 VIAL   2 Preferred Brand Drugs 25%N/AP
Ampicillin 125mg/1 10 VIAL in 1 BOX / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL   2 Preferred Brand Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPICILLIN AND SULBACTAM FOR INJECTION 2-1 10 VIAL   2 Preferred Brand Drugs 25%N/ANone
AMPICILLIN CAPSULES 250MG 100 BOT   1 Generic Drugs $2.00N/ANone
AMPICILLIN CAPSULES 500MG 100 BOT   1 Generic Drugs $2.00N/ANone
AMPICILLIN FOR INJECTION POWDER   2 Preferred Brand Drugs 25%N/ANone
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT   1 Generic Drugs $2.00N/ANone
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT   1 Generic Drugs $2.00N/ANone
AMPICILLIN POWDER FOR INJECTION 1 GM/ML   2 Preferred Brand Drugs 25%N/ANone
ampicillin-sulbactam 15 gm vl   2 Preferred Brand Drugs 25%N/ANone
AMPYRA ER 10 MG TABLET   4 Specialty Tier Drugs 25%N/AP Q:60
/30Days
Amturnide 150; 5; 12.5mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   2 Preferred Brand Drugs 25%N/AQ:30
/30Days
Amturnide 300; 10; 12.5mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   2 Preferred Brand Drugs 25%N/AQ:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Amturnide 300; 10; 25mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   2 Preferred Brand Drugs 25%N/AQ:30
/30Days
Amturnide 300; 5; 12.5mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   2 Preferred Brand Drugs 25%N/AQ:30
/30Days
Amturnide 300; 5; 25mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   2 Preferred Brand Drugs 25%N/AQ:30
/30Days
ANADROL-50 50MG TABLET (100 CT)   4 Specialty Tier Drugs 25%N/AP
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE in 1 BOTTLE   1 Generic Drugs $2.00N/ANone
Anagrelide Hydrochloride 1mg/1 100 CAPSULE in 1 BOTTLE   1 Generic Drugs $2.00N/ANone
ANASTROZOLE TABLETS   1 Generic Drugs $2.00N/AQ:30
/30Days
ANDRODERM 2 MG/24HR PATCH   2 Preferred Brand Drugs 25%N/AQ:30
/30Days
ANDRODERM 2.5MG/24HR PATCH   2 Preferred Brand Drugs 25%N/AQ:30
/30Days
ANDRODERM 4 MG/24HR PATCH   2 Preferred Brand Drugs 25%N/AQ:30
/30Days
ANDRODERM 5MG/24HR PATCH   2 Preferred Brand Drugs 25%N/AQ:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANTARA CAPSULES   2 Preferred Brand Drugs 25%N/AQ:30
/30Days
ANTARA CAPSULES   2 Preferred Brand Drugs 25%N/AQ:60
/30Days
APOKYN 30mg/3mL 5 CARTRIDGE in 1 CARTON / 3 mL in 1 CARTRIDGE   4 Specialty Tier Drugs 25%N/ANone
Apraclonidine Ophthalmic 5mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 10 mL in 1 BOTTLE, DROPPER   1 Generic Drugs $2.00N/ANone
APRI 0.15-0.03 TABLET   1 Generic Drugs $2.00N/AQ:28
/28Days
APRISO CP24   2 Preferred Brand Drugs 25%N/ANone
APTIVUS 250MG CAPSULE   4 Specialty Tier Drugs 25%N/ANone
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT   4 Specialty Tier Drugs 25%N/ANone
Aralast NP 1 KIT in 1 CARTON   4 Specialty Tier Drugs 25%N/AP
ARANELLE 7-9-5 TABLET   1 Generic Drugs $2.00N/AQ:28
/28Days
ARANESP 100ug/0.5mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE in 1 BLISTER PACK / 0.5 mL in 1 SYRINGE   4 Specialty Tier Drugs 25%N/AP Q:4
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP 100ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE   4 Specialty Tier Drugs 25%N/AP Q:8
/28Days
ARANESP 200MCG/0.4ML SYRINGE   4 Specialty Tier Drugs 25%N/AP Q:3
/28Days
ARANESP 200MCG/ML VIAL   4 Specialty Tier Drugs 25%N/AP Q:8
/28Days
ARANESP 25ug/0.42mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE in 1 BLISTER PACK / 0.42 mL in 1 SYRING   2 Preferred Brand Drugs 25%N/AP Q:3
/28Days
ARANESP 25ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE   2 Preferred Brand Drugs 25%N/AP Q:8
/28Days
ARANESP 300MCG/ML VIAL   4 Specialty Tier Drugs 25%N/AP Q:4
/28Days
ARANESP 500MCG/1ML SYRINGE   4 Specialty Tier Drugs 25%N/AP Q:4
/28Days
ARANESP 60MCG/ML VIAL   4 Specialty Tier Drugs 25%N/AP Q:8
/28Days
ARANESP 60ug/0.3mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE in 1 BLISTER PACK / 0.3 mL in 1 SYRINGE   2 Preferred Brand Drugs 25%N/AP Q:2
/28Days
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR   4 Specialty Tier Drugs 25%N/AP Q:2
/28Days
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR   4 Specialty Tier Drugs 25%N/AP Q:2
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR   2 Preferred Brand Drugs 25%N/AP Q:3
/28Days
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD   2 Preferred Brand Drugs 25%N/AP Q:8
/28Days
ARCALYST INJECTION 220MG/VIAL   4 Specialty Tier Drugs 25%N/AP Q:5
/28Days
ARICEPT TABLETS   2 Preferred Brand Drugs 25%N/AQ:30
/30Days
ASACOL 400mg/1 12 BOTTLE in 1 CASE / 180 TABLET, DELAYED RELEASE in 1 BOTTLE   3 Non-Preferred Brand Drugs 46%N/ANone
ASACOL HD 800mg/1 12 BOTTLE in 1 CASE / 180 TABLET, DELAYED RELEASE in 1 BOTTLE   3 Non-Preferred Brand Drugs 46%N/ANone
ASMANEX 220ug/1 1 POUCH in 1 POUCH / 1 INHALER in 1 POUCH / 14 INHALANT in 1 INHALER   2 Preferred Brand Drugs 25%N/AQ:1
/14Days
ASMANEX TWISTHALER 110 MCG #30   2 Preferred Brand Drugs 25%N/AQ:2
/30Days
ASMANEX TWISTHALER 220MCG #120   2 Preferred Brand Drugs 25%N/AQ:1
/30Days
ASMANEX TWISTHALER 220MCG #30   2 Preferred Brand Drugs 25%N/AQ:1
/30Days
ASMANEX TWISTHALER 220MCG #60   2 Preferred Brand Drugs 25%N/AQ:1
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ASTEPRO 0.15% NASAL SPRAY 30 ML   2 Preferred Brand Drugs 25%N/ANone
ATENOLOL 100mg/1 100 TABLET in 1 BOTTLE, PLASTIC   1 Generic Drugs $2.00N/ANone
Atenolol 25mg/1 100 TABLET in 1 BOTTLE, PLASTIC   1 Generic Drugs $2.00N/ANone
ATENOLOL TABLET USP 50MG (100 CT)   1 Generic Drugs $2.00N/ANone
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT)   1 Generic Drugs $2.00N/ANone
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   1 Generic Drugs $2.00N/ANone
ATORVASTATIN 10 MG TABLET   1 Generic Drugs $2.00N/AQ:30
/30Days
ATORVASTATIN 20 MG TABLET   1 Generic Drugs $2.00N/AQ:30
/30Days
ATORVASTATIN 40 MG TABLET   1 Generic Drugs $2.00N/AQ:30
/30Days
ATORVASTATIN 80 MG TABLET   1 Generic Drugs $2.00N/AQ:30
/30Days
Atovaquone and Proguanil Hydrochloride 250; 100mg/1; mg/1   3 Non-Preferred Brand Drugs 46%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE, PLASTIC   4 Specialty Tier Drugs 25%N/AQ:30
/30Days
ATROVENT HFA AER 17MCG   3 Non-Preferred Brand Drugs 46%N/AQ:26
/30Days
AUGMENTED BETAMETHASONE DIPROPIONATE OINTMENT   2 Preferred Brand Drugs 25%N/ANone
AVASTIN 100MG/4ML VIAL   4 Specialty Tier Drugs 25%N/AP
AVELOX 400MG TABLET   3 Non-Preferred Brand Drugs 46%N/ANone
AVELOX ABC PACK 400MG TABLET   3 Non-Preferred Brand Drugs 46%N/ANone
AVELOX IV 400MG/250ML   3 Non-Preferred Brand Drugs 46%N/ANone
AVIANE 0.1-0.02 TABLET   1 Generic Drugs $2.00N/AQ:28
/28Days
AVINZA 120MG CAPSULE MULTIPHASIC RELEASE 24 HR   3 Non-Preferred Brand Drugs 46%N/AQ:300
/30Days
AVINZA 30MG CAPSULE MULTIPHASIC RELEASE 24 HR   3 Non-Preferred Brand Drugs 46%N/AQ:30
/30Days
AVINZA 60MG CAPSULE MULTIPHASIC RELEASE 24 HR   3 Non-Preferred Brand Drugs 46%N/AQ:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVINZA 90MG CAPSULE MULTIPHASIC RELEASE 24 HR   3 Non-Preferred Brand Drugs 46%N/AQ:30
/30Days
AVINZA CAPSULES EXTENDED RELEASE 45MG 100 BOTPL   3 Non-Preferred Brand Drugs 46%N/AQ:30
/30Days
AVINZA CAPSULES EXTENDED RELEASE 75MG 100 BOTPL   3 Non-Preferred Brand Drugs 46%N/AQ:30
/30Days
AVITA 0.025% CREAM   2 Preferred Brand Drugs 25%N/AP
Avita 0.25mg/g 45 g in 1 TUBE   2 Preferred Brand Drugs 25%N/AP
AVODART 0.5MG SOFTGEL   2 Preferred Brand Drugs 25%N/AQ:30
/30Days
AVONEX ADMIN PACK 30MCG SYR   4 Specialty Tier Drugs 25%N/AP Q:4
/28Days
AVONEX ADMIN PACK 30MCG VL   4 Specialty Tier Drugs 25%N/AP Q:4
/28Days
AZACTAM INJECTION 1GM/50ML   2 Preferred Brand Drugs 25%N/ANone
AZACTAM INJECTION 2GM/50ML   4 Specialty Tier Drugs 25%N/ANone
AZACTAM INJECTION 2GM/VIL   2 Preferred Brand Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZASITE 1% DROPS   2 Preferred Brand Drugs 25%N/ANone
AZATHIOPRINE 50MG TABLET   1 Generic Drugs $2.00N/AP
AZELASTINE 137 MCG NASAL SPRAY   2 Preferred Brand Drugs 25%N/ANone
AZELASTINE HYDROCHLORIDE OPHTHALMIC SOLUTION   1 Generic Drugs $2.00N/AQ:6
/30Days
AZILECT 0.5MG TABLET   2 Preferred Brand Drugs 25%N/AQ:30
/30Days
AZILECT 1MG TABLET   2 Preferred Brand Drugs 25%N/AQ:30
/30Days
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Generic Drugs $2.00N/ANone
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Generic Drugs $2.00N/ANone
AZITHROMYCIN 250 MG TABLET   1 Generic Drugs $2.00N/ANone
Azithromycin 500mg/1 10 VIAL, SINGLE-USE in 1 TRAY / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION   2 Preferred Brand Drugs 25%N/ANone
Azithromycin 500mg/1 30 TABLET, FILM COATED in 1 BOTTLE   1 Generic Drugs $2.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Azithromycin 600mg/1 30 TABLET, FILM COATED in 1 BOTTLE   1 Generic Drugs $2.00N/ANone
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT   2 Preferred Brand Drugs 25%N/AQ:10
/30Days
AZOR 10MG-20MG TABLET   2 Preferred Brand Drugs 25%N/AQ:30
/30Days
AZOR 10MG-40MG TABLET (30 CT)   2 Preferred Brand Drugs 25%N/AQ:30
/30Days
AZOR 5MG-20MG TABLET (30 CT)   2 Preferred Brand Drugs 25%N/AQ:30
/30Days
AZOR 5MG-40MG TABLET   2 Preferred Brand Drugs 25%N/AQ:30
/30Days
AZTREONAM FOR INJECTION   2 Preferred Brand Drugs 25%N/ANone

Chart Legend:

Below are a few notes to help you understand the above 2012 Medicare Part D Community CCRx Basic (PDP) Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region).

  • Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.

  • Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the 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.