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Humana Walmart-Preferred Rx Plan (PDP) (S5884-139-0)
Tier 1 (260)
Tier 2 (1060)
Tier 3 (945)
Tier 4 (1012)

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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
Humana Walmart-Preferred Rx Plan (PDP) (S5884-139-0)
Benefit Details           
The Humana Walmart-Preferred Rx Plan (PDP) (S5884-139-0)
Formulary Drugs Starting with the Letter A
in CMS PDP Region 16 which includes: WI
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   2 Non-Preferred Generic Drugs $5.00$0.00None
A-HYDROCORT 100MG VIAL   2 Non-Preferred Generic Drugs $5.00$0.00None
A-METHAPRED INJ 40MG   2 Non-Preferred Generic Drugs $5.00$0.00None
ABACAVIR TAB 300MG   3 Preferred Brand Drugs 20%20%None
ABILIFY 10MG TABLET   4 Non-Preferred Brand Drugs 35%35%Q:30
/30Days
ABILIFY 15MG TABLET   4 Non-Preferred Brand Drugs 35%35%Q:30
/30Days
ABILIFY 1MG/ML SOLUTION   4 Non-Preferred Brand Drugs 35%35%None
ABILIFY 20MG TABLET   4 Non-Preferred Brand Drugs 35%35%Q:30
/30Days
ABILIFY 2MG TABLET   4 Non-Preferred Brand Drugs 35%35%Q:30
/30Days
ABILIFY 30MG TABLET   4 Non-Preferred Brand Drugs 35%35%Q:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ABILIFY 5MG TABLET (OTSUKA)   4 Non-Preferred Brand Drugs 35%35%Q:30
/30Days
ABILIFY DISCMELT 10MG TABLET   4 Non-Preferred Brand Drugs 35%35%Q:60
/30Days
ABILIFY DISCMELT 15MG TABLET   4 Non-Preferred Brand Drugs 35%35%Q:60
/30Days
ABILIFY INJ 9.75MG   4 Non-Preferred Brand Drugs 35%35%None
ABRAXANE 100MG VIAL   4 Non-Preferred Brand Drugs 35%35%P Q:700
/21Days
Acarbose 100mg/1 90 TABLET in 1 BOTTLE,   3 Preferred Brand Drugs 20%20%None
acarbose 50 mg tablet   3 Preferred Brand Drugs 20%20%None
ACARBOSE TABLETS   3 Preferred Brand Drugs 20%20%None
ACEBUTOLOL 200MG CAPSULE   2 Non-Preferred Generic Drugs $5.00$0.00None
ACEBUTOLOL 400MG CAPSULE   2 Non-Preferred Generic Drugs $5.00$0.00None
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE   4 Non-Preferred Brand Drugs 35%35%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Acetaminophen and Codeine Phosphate 300; 60mg/1; mg/1 500 TABLET in 1 BOTTLE   3 Preferred Brand Drugs 20%20%Q:390
/30Days
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD   3 Preferred Brand Drugs 20%20%None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT)   3 Preferred Brand Drugs 20%20%Q:390
/30Days
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT)   3 Preferred Brand Drugs 20%20%Q:390
/30Days
ACETASOL HC SOLUTION 10ML 10 ML BOT   3 Preferred Brand Drugs 20%20%None
ACETAZOLAMIDE 125MG TABLET   2 Non-Preferred Generic Drugs $5.00$0.00None
ACETAZOLAMIDE 250MG TABLET (100 CT)   2 Non-Preferred Generic Drugs $5.00$0.00None
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT   2 Non-Preferred Generic Drugs $5.00$0.00None
ACETAZOLAMIDE SOD 500MG VL   2 Non-Preferred Generic Drugs $5.00$0.00None
ACETIC ACID 2% SOLUTION NON-ORAL   2 Non-Preferred Generic Drugs $5.00$0.00None
ACETYLCYSTEINE 10% VIAL   2 Non-Preferred Generic Drugs $5.00$0.00P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN   2 Non-Preferred Generic Drugs $5.00$0.00P
ACTHIB VACCINE VIAL 10-24UNT/5ML   4 Non-Preferred Brand Drugs 35%35%None
ACTICIN 5% CREAM   2 Non-Preferred Generic Drugs $5.00$0.00None
ACTIMMUNE SOLUTION FOR INJECTION 100MCG   4 Non-Preferred Brand Drugs 35%35%P
Actonel 150mg/1 36 DOSE PACK in 1 CASE / 1 TRAY in 1 DOSE PACK / 1 TABLET, FILM COATED in 1 TRAY   4 Non-Preferred Brand Drugs 35%35%Q:2
/30Days
Actonel 30mg/1 12 BOTTLE in 1 CASE / 30 TABLET, FILM COATED in 1 BOTTLE   4 Non-Preferred Brand Drugs 35%35%Q:30
/30Days
Actonel 35mg/1 36 DOSE PACK in 1 CASE / 1 TRAY in 1 DOSE PACK / 4 TABLET, FILM COATED in 1 TRAY   4 Non-Preferred Brand Drugs 35%35%Q:4
/28Days
Actonel 5mg/1 12 BOTTLE in 1 CASE / 30 TABLET, FILM COATED in 1 BOTTLE   4 Non-Preferred Brand Drugs 35%35%Q:30
/30Days
ACTOPLUS MET 15MG/500MG TABLET   4 Non-Preferred Brand Drugs 35%35%Q:90
/30Days
ACTOPLUS MET 15MG/850MG TABLET   4 Non-Preferred Brand Drugs 35%35%Q:90
/30Days
ACTOPLUS MET XR TABLETS EXTENDED RELEASE 15;1000 MG;MG   4 Non-Preferred Brand Drugs 35%35%Q:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ACTOPLUS MET XR TABLETS EXTENDED RELEASE 30;1000 MG;MG   4 Non-Preferred Brand Drugs 35%35%Q:30
/30Days
ACTOS 15MG TABLET   3 Preferred Brand Drugs 20%20%S Q:30
/30Days
ACTOS 30MG TABLET (500 CT)   3 Preferred Brand Drugs 20%20%S Q:30
/30Days
ACTOS 45MG TABLET   3 Preferred Brand Drugs 20%20%S Q:30
/30Days
ACUVAIL 0.45% OPHTH SOLUTION #30X0.4 EA   4 Non-Preferred Brand Drugs 35%35%None
Acyclovir 200mg/1   1 Preferred Generic Drugs $1.00$0.00None
Acyclovir 200mg/5mL 473 mL in 1 BOTTLE   2 Non-Preferred Generic Drugs $5.00$0.00None
Acyclovir 400mg/1 100 BLISTER PACK in 1 BOX / 1 TABLET in 1 BLISTER PACK   2 Non-Preferred Generic Drugs $5.00$0.00None
Acyclovir 800mg/1 100 BLISTER PACK in 1 BOX / 1 TABLET in 1 BLISTER PACK   2 Non-Preferred Generic Drugs $5.00$0.00None
ACYCLOVIR SODIUM 500MG VIAL   2 Non-Preferred Generic Drugs $5.00$0.00None
ACZONE 50mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE   4 Non-Preferred Brand Drugs 35%35%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ADACEL VIAL 2UNT/5UNT   4 Non-Preferred Brand Drugs 35%35%None
ADAGEN 250U/ML VIAL   4 Non-Preferred Brand Drugs 35%35%None
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA]   4 Non-Preferred Brand Drugs 35%35%P Q:6
/28Days
ADAPALENE CREAM   3 Preferred Brand Drugs 20%20%None
ADAPALENE GEL   3 Preferred Brand Drugs 20%20%None
ADCIRCA TABLETS 20MG 60 BOT   4 Non-Preferred Brand Drugs 35%35%P Q:60
/30Days
ADVAIR DISKUS MIS 100/50   3 Preferred Brand Drugs 20%20%Q:60
/30Days
ADVAIR DISKUS MIS 250/50   3 Preferred Brand Drugs 20%20%Q:60
/30Days
ADVAIR DISKUS MIS 500/50   3 Preferred Brand Drugs 20%20%Q:60
/30Days
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER   3 Preferred Brand Drugs 20%20%Q:12
/30Days
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL   3 Preferred Brand Drugs 20%20%Q:12
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL   3 Preferred Brand Drugs 20%20%Q:12
/30Days
AFEDITAB CR 30MG TABLET SA   3 Preferred Brand Drugs 20%20%Q:60
/30Days
AFEDITAB CR 60MG TABLET SA   3 Preferred Brand Drugs 20%20%Q:60
/30Days
Afinitor 7.5mg/1 28 BLISTER PACK in 1 CARTON / 1 TABLET in 1 BLISTER PACK   4 Non-Preferred Brand Drugs 35%35%P Q:30
/30Days
AFINITOR TABLETS 10 MG   4 Non-Preferred Brand Drugs 35%35%P Q:30
/30Days
AFINITOR TABLETS 2.5 MG   4 Non-Preferred Brand Drugs 35%35%P Q:30
/30Days
AFINITOR TABLETS 5 MG   4 Non-Preferred Brand Drugs 35%35%P Q:30
/30Days
AGGRENOX 25-200MG CAPSULE   4 Non-Preferred Brand Drugs 35%35%None
AK-CON 0.1% EYE DROPS   2 Non-Preferred Generic Drugs $5.00$0.00None
AKTOB 0.3% EYE DROPS   2 Non-Preferred Generic Drugs $5.00$0.00None
ALA-CORT 1% LOTION   2 Non-Preferred Generic Drugs $5.00$0.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ALA-SCALP HP 2% LOTION   2 Non-Preferred Generic Drugs $5.00$0.00None
ALBENZA 200 MG TABLET   4 Non-Preferred Brand Drugs 35%35%None
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 $5.00$0.00P
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER   2 Non-Preferred Generic Drugs $5.00$0.00P
ALBUTEROL SULFATE 4MG TABLET SR 12HR   3 Preferred Brand Drugs 20%20%None
ALBUTEROL SULFATE 8MG TABLET SR 12HR   3 Preferred Brand Drugs 20%20%None
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   1 Preferred Generic Drugs $1.00$0.00P
ALBUTEROL SULFATE SOLUTION FOR INHALATION   1 Preferred Generic Drugs $1.00$0.00P
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT   1 Preferred Generic Drugs $1.00$0.00None
ALBUTEROL SULFATE TABLET 2MG (500 CT)   1 Preferred Generic Drugs $1.00$0.00None
ALBUTEROL TABLET 4MG (500 CT)   1 Preferred Generic Drugs $1.00$0.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ALCLOMETASONE DIPROPIONATE 0.05% CREAM   2 Non-Preferred Generic Drugs $5.00$0.00None
Alclometasone Dipropionate 0.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE   2 Non-Preferred Generic Drugs $5.00$0.00None
ALDURAZYME 2.9MG/5ML VIAL   4 Non-Preferred Brand Drugs 35%35%None
ALENDRONATE SODIUM 10MG TABLET   2 Non-Preferred Generic Drugs $5.00$0.00Q:30
/30Days
ALENDRONATE SODIUM 40MG TABLET   2 Non-Preferred Generic Drugs $5.00$0.00Q:30
/30Days
ALENDRONATE SODIUM 5MG TABLET   2 Non-Preferred Generic Drugs $5.00$0.00Q:30
/30Days
ALENDRONATE SODIUM 70mg/1   1 Preferred Generic Drugs $1.00$0.00Q:4
/28Days
ALENDRONATE SODIUM TABLET 35MG 20 CRTN   1 Preferred Generic Drugs $1.00$0.00Q:4
/28Days
ALFUZOSIN HYDROCHLORIDE 10mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE   3 Preferred Brand Drugs 20%20%Q:30
/30Days
ALIMTA 500MG VIAL   4 Non-Preferred Brand Drugs 35%35%P
ALINIA 100MG/5ML SUSPENSION   4 Non-Preferred Brand Drugs 35%35%Q:150
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ALINIA 500MG TABLET   4 Non-Preferred Brand Drugs 35%35%Q:40
/30Days
ALKERAN 1 KIT in 1 CARTON   4 Non-Preferred Brand Drugs 35%35%P
Allopurinol 300mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET in 1 BLISTER PACK   1 Preferred Generic Drugs $1.00$0.00None
ALLOPURINOL SODIUM 500MG VIAL   2 Non-Preferred Generic Drugs $5.00$0.00None
ALLOPURINOL TABLETS   1 Preferred Generic Drugs $1.00$0.00None
ALTABAX 10mg/g 30 g in 1 TUBE   4 Non-Preferred Brand Drugs 35%35%None
AMANTADINE 100MG CAPSULE   2 Non-Preferred Generic Drugs $5.00$0.00None
AMANTADINE 100MG TABLET   2 Non-Preferred Generic Drugs $5.00$0.00None
Amantadine Hydrochloride 50mg/5mL   2 Non-Preferred Generic Drugs $5.00$0.00None
AMCINONIDE 0.1% CREAM   2 Non-Preferred Generic Drugs $5.00$0.00None
AMCINONIDE 0.1% LOTION   2 Non-Preferred Generic Drugs $5.00$0.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
AMCINONIDE 0.1% OINTMENT 60GM TUBE   2 Non-Preferred Generic Drugs $5.00$0.00None
AMIFOSTINE FOR INJECTION 500MG/VIAL   3 Preferred Brand Drugs 20%20%P
AMIKACIN 250MG/ML VIAL   3 Preferred Brand Drugs 20%20%None
AMIKACIN 50MG/ML VIAL   3 Preferred Brand Drugs 20%20%None
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET   1 Preferred Generic Drugs $1.00$0.00None
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT   2 Non-Preferred Generic Drugs $5.00$0.00None
AMINOPHYLLINE 100MG TABLET   2 Non-Preferred Generic Drugs $5.00$0.00None
AMINOPHYLLINE 200MG TABLET (1000 CT)   2 Non-Preferred Generic Drugs $5.00$0.00None
Aminophylline 25mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 10 mL in 1 VIA   2 Non-Preferred Generic Drugs $5.00$0.00None
AMINOSYN 10% IV SOLUTION   4 Non-Preferred Brand Drugs 35%35%P
AMINOSYN 3.5% IV SOLUTION   4 Non-Preferred Brand Drugs 35%35%P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
AMINOSYN 5% IV SOLUTION   4 Non-Preferred Brand Drugs 35%35%P
AMINOSYN 7% IV SOLUTION   4 Non-Preferred Brand Drugs 35%35%P
AMINOSYN 8.5% IV SOLUTION   4 Non-Preferred Brand Drugs 35%35%P
AMINOSYN HBC INJECTION SULFITE FREE 7%   4 Non-Preferred Brand Drugs 35%35%P
AMINOSYN II 10% IV SOLUTION   4 Non-Preferred Brand Drugs 35%35%P
AMINOSYN II 15% IV SOLUTION   4 Non-Preferred Brand Drugs 35%35%P
AMINOSYN II 3.5% IN D25W IV   4 Non-Preferred Brand Drugs 35%35%P
AMINOSYN II 3.5% IN D5W IV   4 Non-Preferred Brand Drugs 35%35%P
AMINOSYN II 3.5% M/D5W IV   4 Non-Preferred Brand Drugs 35%35%P
AMINOSYN II 3.5% W/ELEC DEX   4 Non-Preferred Brand Drugs 35%35%P
AMINOSYN II 4.25% IN D10W   4 Non-Preferred Brand Drugs 35%35%P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
AMINOSYN II 4.25% IN D20W   4 Non-Preferred Brand Drugs 35%35%P
AMINOSYN II 4.25% W/ELEC DW   4 Non-Preferred Brand Drugs 35%35%P
AMINOSYN II 4.25%-D25W IV   4 Non-Preferred Brand Drugs 35%35%P
AMINOSYN II 5% IN D25W IV   4 Non-Preferred Brand Drugs 35%35%P
AMINOSYN II 7% IV SOLUTION   4 Non-Preferred Brand Drugs 35%35%P
AMINOSYN II 8.5% ELECTROLYT   4 Non-Preferred Brand Drugs 35%35%P
AMINOSYN II 8.5% IV SOLUTION   4 Non-Preferred Brand Drugs 35%35%P
AMINOSYN M 3.5% IV SOLUTION   4 Non-Preferred Brand Drugs 35%35%P
AMINOSYN PF INJECTION   4 Non-Preferred Brand Drugs 35%35%P
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5%   4 Non-Preferred Brand Drugs 35%35%P
AMINOSYN-HF 8% IV SOLUTION   4 Non-Preferred Brand Drugs 35%35%P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
AMINOSYN-PF 7% IV SOLUTION   4 Non-Preferred Brand Drugs 35%35%P
AMIODARONE HCL 400MG TABLET   2 Non-Preferred Generic Drugs $5.00$0.00None
AMIODARONE HCL INJECTION   2 Non-Preferred Generic Drugs $5.00$0.00None
Amiodarone hydrochloride 200mg/1   2 Non-Preferred Generic Drugs $5.00$0.00None
AMITIZA 8MCG CAPSULE   4 Non-Preferred Brand Drugs 35%35%None
AMITIZA CAPSULES 24MCG 60 CAP BOT   4 Non-Preferred Brand Drugs 35%35%None
AMITRIP/PERPHEN 10-2 TABLET   2 Non-Preferred Generic Drugs $5.00$0.00None
AMITRIP/PERPHEN 10-4 TABLET   2 Non-Preferred Generic Drugs $5.00$0.00None
AMITRIP/PERPHEN 25-2 TABLET   2 Non-Preferred Generic Drugs $5.00$0.00None
AMITRIP/PERPHEN 25-4 TABLET   2 Non-Preferred Generic Drugs $5.00$0.00None
AMITRIP/PERPHEN 50-4 TABLET   2 Non-Preferred Generic Drugs $5.00$0.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
AMITRIPTYLINE HCL 100MG TABLET   1 Preferred Generic Drugs $1.00$0.00None
AMITRIPTYLINE HCL 10MG TABLET   1 Preferred Generic Drugs $1.00$0.00None
AMITRIPTYLINE HCL 150 MG TAB   2 Non-Preferred Generic Drugs $5.00$0.00None
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)   1 Preferred Generic Drugs $1.00$0.00None
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)   1 Preferred Generic Drugs $1.00$0.00None
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT   1 Preferred Generic Drugs $1.00$0.00None
AMLODIPINE BESYLATE 10MG TABLET (90 CT)   2 Non-Preferred Generic Drugs $5.00$0.00None
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)   2 Non-Preferred Generic Drugs $5.00$0.00None
AMLODIPINE BESYLATE 5MG TABLET (90 CT)   2 Non-Preferred Generic Drugs $5.00$0.00None
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE CAPSULES   3 Preferred Brand Drugs 20%20%Q:30
/30Days
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE CAPSULES   3 Preferred Brand Drugs 20%20%Q:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE   3 Preferred Brand Drugs 20%20%Q:60
/30Days
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE   3 Preferred Brand Drugs 20%20%Q:60
/30Days
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE   3 Preferred Brand Drugs 20%20%Q:60
/30Days
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE   3 Preferred Brand Drugs 20%20%Q:60
/30Days
AMMONIUM CHLORIDE 5 MEQ/ML   2 Non-Preferred Generic Drugs $5.00$0.00None
AMMONIUM LACTATE 12% CREAM   2 Non-Preferred Generic Drugs $5.00$0.00None
AMMONIUM LACTATE 12% LOTION   2 Non-Preferred Generic Drugs $5.00$0.00None
AMOX TR-K CLV 500-125 MG TAB   2 Non-Preferred Generic Drugs $5.00$0.00None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL   2 Non-Preferred Generic Drugs $5.00$0.00None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE   2 Non-Preferred Generic Drugs $5.00$0.00None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET   3 Preferred Brand Drugs 20%20%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE   2 Non-Preferred Generic Drugs $5.00$0.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   2 Non-Preferred Generic Drugs $5.00$0.00None
AMOXAPINE 100MG TABLET   2 Non-Preferred Generic Drugs $5.00$0.00None
AMOXAPINE 150MG TABLET   2 Non-Preferred Generic Drugs $5.00$0.00None
AMOXAPINE 25MG TABLET   2 Non-Preferred Generic Drugs $5.00$0.00None
AMOXAPINE 50MG TABLET   2 Non-Preferred Generic Drugs $5.00$0.00None
AMOXICILLIN 125MG TABLET CHEW   2 Non-Preferred Generic Drugs $5.00$0.00None
AMOXICILLIN 200MG TABLET CHEW   2 Non-Preferred Generic Drugs $5.00$0.00None
AMOXICILLIN 250MG CAPSULE   1 Preferred Generic Drugs $1.00$0.00None
Amoxicillin 250mg/1 500 TABLET, CHEWABLE in 1 BOTTLE   2 Non-Preferred Generic Drugs $5.00$0.00None
AMOXICILLIN 50 MG/ML / CLAVULANATE 12.5 MG/ML ORAL SUSPENSION   2 Non-Preferred Generic Drugs $5.00$0.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
AMOXICILLIN 500MG TABLET (100 CT)   2 Non-Preferred Generic Drugs $5.00$0.00None
AMOXICILLIN 875MG TABLET   2 Non-Preferred Generic Drugs $5.00$0.00None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT   2 Non-Preferred Generic Drugs $5.00$0.00None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS EXTENDED RELEASE 1000;62.5MG;MG   3 Preferred Brand Drugs 20%20%None
AMOXICILLIN CAP 500MG   1 Preferred Generic Drugs $1.00$0.00None
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT   3 Preferred Brand Drugs 20%20%None
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT   1 Preferred Generic Drugs $1.00$0.00None
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL   1 Preferred Generic Drugs $1.00$0.00None
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   1 Preferred Generic Drugs $1.00$0.00None
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL   1 Preferred Generic Drugs $1.00$0.00None
AMPHOTEC FOR INJECTION 50MG/VIAL   4 Non-Preferred Brand Drugs 35%35%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
amphotericin b 50mg/10mL 10 mL in 1 VIAL   3 Preferred Brand Drugs 20%20%None
Ampicillin 125mg/1 10 VIAL in 1 BOX / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL   3 Preferred Brand Drugs 20%20%None
AMPICILLIN AND SULBACTAM FOR INJECTION 2-1 10 VIAL   3 Preferred Brand Drugs 20%20%None
AMPICILLIN CAPSULES 250MG 100 BOT   2 Non-Preferred Generic Drugs $5.00$0.00None
AMPICILLIN CAPSULES 500MG 100 BOT   2 Non-Preferred Generic Drugs $5.00$0.00None
AMPICILLIN FOR INJECTION POWDER   3 Preferred Brand Drugs 20%20%None
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT   2 Non-Preferred Generic Drugs $5.00$0.00None
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT   2 Non-Preferred Generic Drugs $5.00$0.00None
AMPICILLIN POWDER FOR INJECTION 1 GM/ML   3 Preferred Brand Drugs 20%20%None
ampicillin-sulbactam 15 gm vl   3 Preferred Brand Drugs 20%20%None
AMPYRA ER 10 MG TABLET   4 Non-Preferred Brand Drugs 35%35%P Q:60
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Amturnide 150; 5; 12.5mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   3 Preferred Brand Drugs 20%20%Q:30
/30Days
Amturnide 300; 10; 12.5mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   3 Preferred Brand Drugs 20%20%Q:30
/30Days
Amturnide 300; 10; 25mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   3 Preferred Brand Drugs 20%20%Q:30
/30Days
Amturnide 300; 5; 12.5mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   3 Preferred Brand Drugs 20%20%Q:30
/30Days
Amturnide 300; 5; 25mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   3 Preferred Brand Drugs 20%20%Q:30
/30Days
ANADROL-50 50MG TABLET (100 CT)   4 Non-Preferred Brand Drugs 35%35%None
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE in 1 BOTTLE   2 Non-Preferred Generic Drugs $5.00$0.00None
Anagrelide Hydrochloride 1mg/1 100 CAPSULE in 1 BOTTLE   2 Non-Preferred Generic Drugs $5.00$0.00None
ANASTROZOLE TABLETS   2 Non-Preferred Generic Drugs $5.00$0.00Q:30
/30Days
ANCOBON 250MG CAPSULE   4 Non-Preferred Brand Drugs 35%35%None
ANCOBON 500MG CAPSULE   4 Non-Preferred Brand Drugs 35%35%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ANDROGEL 1%(50MG) GEL PACKET   3 Preferred Brand Drugs 20%20%Q:300
/30Days
Androgel 16.2mg/g 1 BOTTLE, PUMP in 1 CARTON / 88 g in 1 BOTTLE, PUMP   3 Preferred Brand Drugs 20%20%Q:176
/30Days
ANTIZOL INJECTION 1GM 4 X 1.5ML VIAL CRTN   2 Non-Preferred Generic Drugs $5.00$0.00None
APAP-CAFFEINE-DIHYDROCODE TAB 30 EA   2 Non-Preferred Generic Drugs $5.00$0.00Q:180
/30Days
APOKYN 30mg/3mL 5 CARTRIDGE in 1 CARTON / 3 mL in 1 CARTRIDGE   4 Non-Preferred Brand Drugs 35%35%Q:60
/30Days
Apraclonidine Ophthalmic 5mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 10 mL in 1 BOTTLE, DROPPER   2 Non-Preferred Generic Drugs $5.00$0.00None
APRI 0.15-0.03 TABLET   2 Non-Preferred Generic Drugs $5.00$0.00None
APRISO CP24   4 Non-Preferred Brand Drugs 35%35%Q:120
/30Days
APTIVUS 250MG CAPSULE   4 Non-Preferred Brand Drugs 35%35%None
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT   4 Non-Preferred Brand Drugs 35%35%None
Aralast NP 1 KIT in 1 CARTON   4 Non-Preferred Brand Drugs 35%35%P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ARANELLE 7-9-5 TABLET   2 Non-Preferred Generic Drugs $5.00$0.00None
ARCALYST INJECTION 220MG/VIAL   4 Non-Preferred Brand Drugs 35%35%P
ARGATROBAN 100mg/mL 1 VIAL in 1 CARTON / 2.5 mL in 1 VIAL   2 Non-Preferred Generic Drugs $5.00$0.00P
ARIMIDEX 1MG TABLET   4 Non-Preferred Brand Drugs 35%35%P Q:30
/30Days
ARIXTRA 10MG SYRINGE   4 Non-Preferred Brand Drugs 35%35%Q:14
/30Days
ARIXTRA 2.5MG SYRINGE   4 Non-Preferred Brand Drugs 35%35%Q:14
/30Days
ARIXTRA 5MG SYRINGE   4 Non-Preferred Brand Drugs 35%35%Q:14
/30Days
ARIXTRA 7.5MG SYRINGE   4 Non-Preferred Brand Drugs 35%35%Q:14
/30Days
AROMASIN 25MG TABLET   4 Non-Preferred Brand Drugs 35%35%P
ARRANON 250MG VIAL   4 Non-Preferred Brand Drugs 35%35%P
ARZERRA 20mg/mL 3 VIAL in 1 CARTON / 5 mL in 1 VIAL   4 Non-Preferred Brand Drugs 35%35%P Q:400
/28Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Ascomp with Codeine 325; 50; 40; 30mg/1; mg/1; mg/1; mg/1 500 CAPSULE in 1 BOTTLE, PLASTIC   3 Preferred Brand Drugs 20%20%None
ASMANEX 220ug/1 1 POUCH in 1 POUCH / 1 INHALER in 1 POUCH / 14 INHALANT in 1 INHALER   3 Preferred Brand Drugs 20%20%Q:6
/30Days
ASMANEX TWISTHALER 110 MCG #30   3 Preferred Brand Drugs 20%20%Q:7
/30Days
ASMANEX TWISTHALER 220MCG #120   3 Preferred Brand Drugs 20%20%Q:53
/30Days
ASMANEX TWISTHALER 220MCG #30   3 Preferred Brand Drugs 20%20%Q:13
/30Days
ASMANEX TWISTHALER 220MCG #60   3 Preferred Brand Drugs 20%20%Q:26
/30Days
ASTRAMORPH PF INJECTION 0.5MG/ML   3 Preferred Brand Drugs 20%20%None
ASTRAMORPH PF INJECTION 1MG/ML   3 Preferred Brand Drugs 20%20%None
Atelvia 35mg/1 36 DOSE PACK in 1 CASE / 4 TABLET, DELAYED RELEASE in 1 DOSE PACK   4 Non-Preferred Brand Drugs 35%35%Q:4
/28Days
ATENOLOL 100mg/1 100 TABLET in 1 BOTTLE, PLASTIC   1 Preferred Generic Drugs $1.00$0.00None
Atenolol 25mg/1 100 TABLET in 1 BOTTLE, PLASTIC   1 Preferred Generic Drugs $1.00$0.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ATENOLOL TABLET USP 50MG (100 CT)   1 Preferred Generic Drugs $1.00$0.00None
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT)   1 Preferred Generic Drugs $1.00$0.00None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   1 Preferred Generic Drugs $1.00$0.00None
ATORVASTATIN 10 MG TABLET   3 Preferred Brand Drugs 20%20%Q:30
/30Days
ATORVASTATIN 20 MG TABLET   3 Preferred Brand Drugs 20%20%Q:30
/30Days
ATORVASTATIN 40 MG TABLET   3 Preferred Brand Drugs 20%20%Q:30
/30Days
ATORVASTATIN 80 MG TABLET   3 Preferred Brand Drugs 20%20%Q:30
/30Days
Atovaquone and Proguanil Hydrochloride 250; 100mg/1; mg/1   4 Non-Preferred Brand Drugs 35%35%None
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE, PLASTIC   4 Non-Preferred Brand Drugs 35%35%None
ATROPINE 0.05MG/ML SYRINGE   2 Non-Preferred Generic Drugs $5.00$0.00None
ATROPINE 0.1MG/ML SYRINGE   2 Non-Preferred Generic Drugs $5.00$0.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ATROVENT HFA AER 17MCG   4 Non-Preferred Brand Drugs 35%35%Q:30
/30Days
AUGMENTED BETAMETHASONE DIPROPIONATE OINTMENT   2 Non-Preferred Generic Drugs $5.00$0.00None
AVALIDE 12.5; 150mg/1; mg/1 90 TABLET, FILM COATED in 1 BOTTLE   3 Preferred Brand Drugs 20%20%Q:30
/30Days
AVALIDE 12.5; 300mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   3 Preferred Brand Drugs 20%20%Q:30
/30Days
AVALIDE 300-25MG TABLET   3 Preferred Brand Drugs 20%20%Q:30
/30Days
AVANDARYL 1; 4mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   4 Non-Preferred Brand Drugs 35%35%Q:60
/30Days
AVANDARYL 2; 4mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   4 Non-Preferred Brand Drugs 35%35%Q:60
/30Days
AVANDARYL 2; 8mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   4 Non-Preferred Brand Drugs 35%35%Q:30
/30Days
AVANDARYL 4; 4mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   4 Non-Preferred Brand Drugs 35%35%Q:60
/30Days
AVANDARYL 4; 8mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   4 Non-Preferred Brand Drugs 35%35%Q:30
/30Days
AVAPRO 150MG TABLET   3 Preferred Brand Drugs 20%20%Q:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
AVAPRO 300MG TABLET   3 Preferred Brand Drugs 20%20%Q:30
/30Days
AVAPRO 75MG TABLET (30 CT)   3 Preferred Brand Drugs 20%20%Q:30
/30Days
AVASTIN 100MG/4ML VIAL   4 Non-Preferred Brand Drugs 35%35%P
AVELOX IV 400MG/250ML   4 Non-Preferred Brand Drugs 35%35%None
AVIANE 0.1-0.02 TABLET   2 Non-Preferred Generic Drugs $5.00$0.00None
AVODART 0.5MG SOFTGEL   3 Preferred Brand Drugs 20%20%Q:30
/30Days
AVONEX ADMIN PACK 30MCG SYR   4 Non-Preferred Brand Drugs 35%35%P Q:4
/28Days
AVONEX ADMIN PACK 30MCG VL   4 Non-Preferred Brand Drugs 35%35%P Q:4
/28Days
AZASITE 1% DROPS   3 Preferred Brand Drugs 20%20%None
AZATHIOPRINE 50MG TABLET   2 Non-Preferred Generic Drugs $5.00$0.00P
AZATHIOPRINE SOD 100MG VIAL   2 Non-Preferred Generic Drugs $5.00$0.00P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
AZELASTINE HYDROCHLORIDE OPHTHALMIC SOLUTION   3 Preferred Brand Drugs 20%20%None
AZILECT 0.5MG TABLET   3 Preferred Brand Drugs 20%20%Q:30
/30Days
AZILECT 1MG TABLET   3 Preferred Brand Drugs 20%20%Q:30
/30Days
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL   2 Non-Preferred Generic Drugs $5.00$0.00None
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL   2 Non-Preferred Generic Drugs $5.00$0.00None
AZITHROMYCIN 250 MG TABLET   2 Non-Preferred Generic Drugs $5.00$0.00None
Azithromycin 500mg/1 10 VIAL, SINGLE-USE in 1 TRAY / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION   2 Non-Preferred Generic Drugs $5.00$0.00None
Azithromycin 500mg/1 30 TABLET, FILM COATED in 1 BOTTLE   2 Non-Preferred Generic Drugs $5.00$0.00None
Azithromycin 600mg/1 30 TABLET, FILM COATED in 1 BOTTLE   2 Non-Preferred Generic Drugs $5.00$0.00None
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT   3 Preferred Brand Drugs 20%20%None
AZTREONAM FOR INJECTION   2 Non-Preferred Generic Drugs $5.00$0.00None

Chart Legend:

Below are a few notes to help you understand the above 2012 Medicare Part D Humana Walmart-Preferred Rx Plan (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.