Q1Medicare.com 2012 Medicare Part D or Medicare Advantage Plan Formulary Browser

2012 Medicare Part D Plan Formulary Information
Health First Essential Prescription Drug Plan (PDP) (S0223-001-0) Benefit Details
The Health First Essential Prescription Drug Plan (PDP) (S0223-001-0) Formulary Drugs Starting with the Letter S in CMS PDP Region 11 which includes: FL
Drugs Starting with Letter S Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter S Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SANCTURA XR 60MG CAPSULE SR 24 HR	3	Preferred Brand Drugs	$42.50	$127.50	None
SANDOSTATIN LAR 10MG KIT	5	Specialty Tier Drugs	25%	N/A	P
SANDOSTATIN LAR 20MG KIT	5	Specialty Tier Drugs	25%	N/A	P
SANDOSTATIN LAR 30MG KIT	5	Specialty Tier Drugs	25%	N/A	P
SAPHRIS 10mg/1 6 CASE in 1 CARTON / 1 BLISTER PACK in 1 CASE / 10 TABLET in 1 BLISTER PACK	3	Preferred Brand Drugs	$42.50	$127.50	None
SAPHRIS 5mg/1 6 CASE in 1 CARTON / 1 BLISTER PACK in 1 CASE / 10 TABLET in 1 BLISTER PACK	3	Preferred Brand Drugs	$42.50	$127.50	None
SAVELLA TABLETS 100MG 60 COUNT BOT	3	Preferred Brand Drugs	$42.50	$127.50	Q:60 /30Days
SAVELLA TABLETS 12.5MG 60 COUNT BOT	3	Preferred Brand Drugs	$42.50	$127.50	Q:60 /30Days
SAVELLA TABLETS 25MG 60 COUNT BOT	3	Preferred Brand Drugs	$42.50	$127.50	Q:60 /30Days
SAVELLA TABLETS TITRATION PACK KIT 12.5;25;50MG;MG;MG 55 COUNT PKGCOM	3	Preferred Brand Drugs	$42.50	$127.50	Q:55 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SAVELLA TALBETS 50MG 60 COUNT BOT	3	Preferred Brand Drugs	$42.50	$127.50	Q:60 /30Days
SELEGILINE HCL 5MG CAPSULE	2	Non-Preferred Generic Drugs	$10.00	$30.00	None
Selegiline Hydrochloride 5mg/1 60 TABLET in 1 BOTTLE, PLASTIC	3	Preferred Brand Drugs	$42.50	$127.50	None
SELENIUM SULFIDE 2.5mg/100mL 118 mL in 1 BOTTLE	2	Non-Preferred Generic Drugs	$10.00	$30.00	None
SELZENTRY 150mg/1 60 TABLET, FILM COATED in 1 BOTTLE	4	Non-Preferred Brand Drugs	$95.00	$285.00	Q:123 /30Days
SELZENTRY 300mg/1 60 TABLET, FILM COATED in 1 BOTTLE	4	Non-Preferred Brand Drugs	$95.00	$285.00	Q:123 /30Days
SENSIPAR 30MG TABLET	3	Preferred Brand Drugs	$42.50	$127.50	None
SENSIPAR 60MG TABLET	3	Preferred Brand Drugs	$42.50	$127.50	None
SENSIPAR 90MG TABLET	3	Preferred Brand Drugs	$42.50	$127.50	None
SEREVENT DIS AER 50MCG	3	Preferred Brand Drugs	$42.50	$127.50	Q:60 /30Days
SEROMYCIN 250mg/250mg 40 CAPSULE in 1 BOTTLE / 250 mg in 1 CAPSULE	3	Preferred Brand Drugs	$42.50	$127.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SEROQUEL 100MG TABLET	3	Preferred Brand Drugs	$42.50	$127.50	Q:240 /30Days
SEROQUEL 200MG TABLET	3	Preferred Brand Drugs	$42.50	$127.50	Q:120 /30Days
SEROQUEL 25MG TABLET	3	Preferred Brand Drugs	$42.50	$127.50	Q:960 /30Days
SEROQUEL 300MG TABLET	3	Preferred Brand Drugs	$42.50	$127.50	Q:60 /30Days
SEROQUEL 400MG TABLET	3	Preferred Brand Drugs	$42.50	$127.50	Q:60 /30Days
SEROQUEL 50MG TABLET (100 CT)	3	Preferred Brand Drugs	$42.50	$127.50	Q:480 /30Days
SEROQUEL TABLETS EXTENDED RELEASE 150MG 100 CRTN	3	Preferred Brand Drugs	$42.50	$127.50	Q:30 /30Days
SEROQUEL TABLETS EXTENDED RELEASE 200MG 100 X 200 MG CRTN	3	Preferred Brand Drugs	$42.50	$127.50	Q:30 /30Days
SEROQUEL TABLETS EXTENDED RELEASE 400MG 100 X 400 MG CRTN	3	Preferred Brand Drugs	$42.50	$127.50	Q:60 /30Days
SEROQUEL TABLETS EXTENDED RELEASE 50MG 100 TABS CRTN	3	Preferred Brand Drugs	$42.50	$127.50	Q:120 /30Days
SEROQUEL XR 300MG TABLET 60X300MG BOT	3	Preferred Brand Drugs	$42.50	$127.50	Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Serostim 4mg/mL 1 INJECTION, POWDER, FOR SOLUTION in 1 CARTON	5	Specialty Tier Drugs	25%	N/A	P
Serostim 5mg/mL 1 INJECTION, POWDER, FOR SOLUTION in 1 CARTON	5	Specialty Tier Drugs	25%	N/A	P
SERTRALINE HCL 100MG TABLET (30 CT)	2	Non-Preferred Generic Drugs	$10.00	$30.00	None
SERTRALINE HCL 25 MG TABLET	2	Non-Preferred Generic Drugs	$10.00	$30.00	Q:45 /30Days
SERTRALINE HCL 50MG TABLET (30 CT)	2	Non-Preferred Generic Drugs	$10.00	$30.00	Q:45 /30Days
SERTRALINE HYDROCHLORIDE ORAL CONCENTRATE	2	Non-Preferred Generic Drugs	$10.00	$30.00	None
SILVER SULFADIAZINE 1% CRM	2	Non-Preferred Generic Drugs	$10.00	$30.00	None
Simvastatin 10mg/1 30 TABLET, FILM COATED in 1 BOTTLE	1	Preferred Generic Drugs	$2.00	$6.00	None
SIMVASTATIN 20MG TABLET 10000 BOT	1	Preferred Generic Drugs	$2.00	$6.00	None
SIMVASTATIN 40MG TABLET (500 CT)	1	Preferred Generic Drugs	$2.00	$6.00	None
Simvastatin 5mg/1	1	Preferred Generic Drugs	$2.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SIMVASTATIN 80MG TABLET (1000 CT)	1	Preferred Generic Drugs	$2.00	$6.00	None
SINGULAIR 10MG TABLET	3	Preferred Brand Drugs	$42.50	$127.50	None
SINGULAIR 4MG GRANULES	3	Preferred Brand Drugs	$42.50	$127.50	None
SINGULAIR 4MG TABLET CHEW	3	Preferred Brand Drugs	$42.50	$127.50	None
SINGULAIR 5MG TABLET CHEW	3	Preferred Brand Drugs	$42.50	$127.50	None
SOD POLY SUL SUS 15GM/60	2	Non-Preferred Generic Drugs	$10.00	$30.00	None
Sodium Chloride 3g/100mL	2	Non-Preferred Generic Drugs	$10.00	$30.00	None
Sodium Chloride 900mg/100mL 9 BOTTLE, PLASTIC in 1 CASE / 1500 mL in 1 BOTTLE, PLASTIC	2	Non-Preferred Generic Drugs	$10.00	$30.00	None
Sodium Chloride 9g/1000mL 4 BAG in 1 PACKAGE / 100 mL in 1 BAG	2	Non-Preferred Generic Drugs	$10.00	$30.00	None
SODIUM CHLORIDE INJECTION USP 5%	2	Non-Preferred Generic Drugs	$10.00	$30.00	None
SODIUM CL 2.5 MEQ/ML VIAL	2	Non-Preferred Generic Drugs	$10.00	$30.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SOLARAZE 3% GEL	4	Non-Preferred Brand Drugs	$95.00	$285.00	None
SOLIA 0.15-0.03 TABLET	2	Non-Preferred Generic Drugs	$10.00	$30.00	None
SOMATULINE 60 MG/0.2 ML SYRING	5	Specialty Tier Drugs	25%	N/A	P
Somatuline Depot 90mg/0.3mL 1 POUCH in 1 CARTON / 1 SYRINGE in 1 POUCH / 0.3 mL in 1 SYRINGE	5	Specialty Tier Drugs	25%	N/A	P
SOMAVERT 10MG VIAL	3	Preferred Brand Drugs	$42.50	$127.50	None
SOMAVERT 15MG VIAL	3	Preferred Brand Drugs	$42.50	$127.50	None
SOMAVERT 20MG VIAL	3	Preferred Brand Drugs	$42.50	$127.50	None
SOTALOL HCL 120MG TABLET 100 BOT	2	Non-Preferred Generic Drugs	$10.00	$30.00	None
SOTALOL HCL 160MG TABLET (100 CT)	2	Non-Preferred Generic Drugs	$10.00	$30.00	None
SOTALOL HCL 80MG TABLET	2	Non-Preferred Generic Drugs	$10.00	$30.00	None
SOTALOL HCL TABLET 240MG	2	Non-Preferred Generic Drugs	$10.00	$30.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SPIRIVA 18MCG CP-HANDIHALER 90 (9 X 10) BLPK	3	Preferred Brand Drugs	$42.50	$127.50	Q:30 /30Days
SPIRONOLACTONE 100MG TABLET	2	Non-Preferred Generic Drugs	$10.00	$30.00	None
SPIRONOLACTONE 25MG TABLET (100 CT)	2	Non-Preferred Generic Drugs	$10.00	$30.00	None
SPIRONOLACTONE 50MG TABLET (100 CT)	2	Non-Preferred Generic Drugs	$10.00	$30.00	None
SPRYCEL 100mg/1 1 BOTTLE in 1 CARTON / 30 TABLET in 1 BOTTLE	5	Specialty Tier Drugs	25%	N/A	None
SPRYCEL 140mg/1 1 BOTTLE in 1 CARTON / 30 TABLET in 1 BOTTLE	5	Specialty Tier Drugs	25%	N/A	None
SPRYCEL 20MG TABLET	5	Specialty Tier Drugs	25%	N/A	None
SPRYCEL 50MG TABLET	5	Specialty Tier Drugs	25%	N/A	None
SPRYCEL 70MG TABLET	5	Specialty Tier Drugs	25%	N/A	None
SPRYCEL 80mg/1 1 BOTTLE in 1 CARTON / 30 TABLET in 1 BOTTLE	5	Specialty Tier Drugs	25%	N/A	None
STAGESIC 5MG-500MG CAPSULE	2	Non-Preferred Generic Drugs	$10.00	$30.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
STARLIX 120MG TABLET	3	Preferred Brand Drugs	$42.50	$127.50	None
STARLIX 60MG TABLET	3	Preferred Brand Drugs	$42.50	$127.50	None
STAVUDINE CAPSULES 15MG 60 BOT	2	Non-Preferred Generic Drugs	$10.00	$30.00	None
STAVUDINE CAPSULES 20MG 60 BOT	2	Non-Preferred Generic Drugs	$10.00	$30.00	None
STAVUDINE CAPSULES 30MG 60 BOT	2	Non-Preferred Generic Drugs	$10.00	$30.00	None
STAVUDINE CAPSULES 40MG 60 BOT	2	Non-Preferred Generic Drugs	$10.00	$30.00	None
STAVUDINE SOL 1MG/ML	2	Non-Preferred Generic Drugs	$10.00	$30.00	None
STAVZOR 125MG CPDR	4	Non-Preferred Brand Drugs	$95.00	$285.00	None
STAVZOR 250MG CPDR	4	Non-Preferred Brand Drugs	$95.00	$285.00	None
STAVZOR 500MG CPDR	4	Non-Preferred Brand Drugs	$95.00	$285.00	None
Sterile Water 6mg/mL 1 INJECTION, SOLUTION in 1 CARTON	5	Specialty Tier Drugs	25%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
STERILE WATER FOR IRRIGATION	2	Non-Preferred Generic Drugs	$10.00	$30.00	None
STREPTOMYCIN FOR INJECTION 1GM/VIL	3	Preferred Brand Drugs	$42.50	$127.50	None
SUBOXONE 2MG-0.5MG TABLET	3	Preferred Brand Drugs	$42.50	$127.50	None
SUBOXONE 8MG-2MG TABLET	3	Preferred Brand Drugs	$42.50	$127.50	None
SUBUTEX 2MG TABLET	4	Non-Preferred Brand Drugs	$95.00	$285.00	None
SUBUTEX 8MG TABLET	4	Non-Preferred Brand Drugs	$95.00	$285.00	None
SUCRAID 8500[iU]/mL	3	Preferred Brand Drugs	$42.50	$127.50	None
SUCRALFATE 1GM TABLET	2	Non-Preferred Generic Drugs	$10.00	$30.00	None
SULFACETAMIDE SODIUM OPHTHALMIC SOLUTION USP 10% 15 ML BOT	2	Non-Preferred Generic Drugs	$10.00	$30.00	None
SULFADIAZINE 500MG TABLET	3	Preferred Brand Drugs	$42.50	$127.50	None
Sulfamethoxazole and Trimethoprim 200; 40mg/5mL; mg/5mL 473 mL in 1 BOTTLE	1	Preferred Generic Drugs	$2.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SULFAMETHOXAZOLE W/TMP 800-160MG TABLET (100 CT)	1	Preferred Generic Drugs	$2.00	$6.00	None
SULFAMETHOXAZOLE W/TMP VIAL 80MG-16ML 10 X 10ML VIAL	3	Preferred Brand Drugs	$42.50	$127.50	None
SULFAMETHOXAZOLE-TRIMETHOPRIM TABLET 400-80MG (500 CT)	1	Preferred Generic Drugs	$2.00	$6.00	None
SULFASALAZINE 500MG TABLET	2	Non-Preferred Generic Drugs	$10.00	$30.00	None
SULFAZINE EC 500MG TABLET DELAYED RELEASE	2	Non-Preferred Generic Drugs	$10.00	$30.00	None
SULINDAC 150MG TABLET (100 CT)	1	Preferred Generic Drugs	$2.00	$6.00	None
SULINDAC 200MG TABLET	1	Preferred Generic Drugs	$2.00	$6.00	None
SUMATRIPTAN	2	Non-Preferred Generic Drugs	$10.00	$30.00	Q:24 /30Days
SUMATRIPTAN SUCCINATE TABLETS 100MG 9 BOXUD	2	Non-Preferred Generic Drugs	$10.00	$30.00	Q:12 /30Days
SUMATRIPTAN SUCCINATE TABLETS 25MG 9 BOX	2	Non-Preferred Generic Drugs	$10.00	$30.00	Q:12 /30Days
SUMATRIPTAN SUCCINATE TABLETS 50MG 9 (3 CARDS OF 3) BOX	2	Non-Preferred Generic Drugs	$10.00	$30.00	Q:12 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SUPRAX 100MG/5ML SUSPENSION RECONSTITUTED ORAL 50ML BOT	4	Non-Preferred Brand Drugs	$95.00	$285.00	None
SURMONTIL 100MG CAPSULE	4	Non-Preferred Brand Drugs	$95.00	$285.00	None
SURMONTIL 25MG CAPSULE	4	Non-Preferred Brand Drugs	$95.00	$285.00	None
Surmontil 50mg/1 100 CAPSULE in 1 BOTTLE	4	Non-Preferred Brand Drugs	$95.00	$285.00	None
SUSTIVA 200MG CAPSULE	3	Preferred Brand Drugs	$42.50	$127.50	None
SUSTIVA 50MG CAPSULE	3	Preferred Brand Drugs	$42.50	$127.50	None
SUSTIVA 600MG TABLET	3	Preferred Brand Drugs	$42.50	$127.50	None
SUTENT 12.5MG CAPSULE	5	Specialty Tier Drugs	25%	N/A	P
SUTENT 25mg/1 28 CAPSULE in 1 BOTTLE	5	Specialty Tier Drugs	25%	N/A	P
SUTENT 50MG CAPSULE	5	Specialty Tier Drugs	25%	N/A	P
SYLATRON 296 MCG KIT 1 KIT in 1 CARTON	5	Specialty Tier Drugs	25%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SYLATRON 444 MCG KIT 1 KIT in 1 CARTON	5	Specialty Tier Drugs	25%	N/A	P
SYLATRON 888 MCG KIT 1 KIT in 1 CARTON	5	Specialty Tier Drugs	25%	N/A	P
SYMBICORT 160-4.5MCG HFA AEROSOL WITH ADAPTER	3	Preferred Brand Drugs	$42.50	$127.50	None
SYMBICORT 80-4.5MCG HFA AEROSOL WITH ADAPTER 60 INHL	3	Preferred Brand Drugs	$42.50	$127.50	None
SYMBYAX 12-25MG CAPSULE	3	Preferred Brand Drugs	$42.50	$127.50	None
SYMBYAX 12-50MG CAPSULE	3	Preferred Brand Drugs	$42.50	$127.50	None
Symbyax 25; 3mg/1; mg/1 30 CAPSULE in 1 BOTTLE	3	Preferred Brand Drugs	$42.50	$127.50	None
SYMBYAX 6-25MG CAPSULE	3	Preferred Brand Drugs	$42.50	$127.50	None
SYMBYAX 6-50MG CAPSULE	3	Preferred Brand Drugs	$42.50	$127.50	None
SYMLIN 0.6MG/ML VIAL	3	Preferred Brand Drugs	$42.50	$127.50	None
SYMLINPEN 60 1000MCG/ML PEN INJECTOR	3	Preferred Brand Drugs	$42.50	$127.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SYNAREL 2MG/ML NASAL SPRAY	5	Specialty Tier Drugs	25%	N/A	None
SYNTHROID 100MCG TABLET	3	Preferred Brand Drugs	$42.50	$127.50	None
SYNTHROID 112 MCG TABLET	3	Preferred Brand Drugs	$42.50	$127.50	None
SYNTHROID 125MCG TABLET	3	Preferred Brand Drugs	$42.50	$127.50	None
Synthroid 137ug/1 90 TABLET in 1 BOTTLE	3	Preferred Brand Drugs	$42.50	$127.50	None
SYNTHROID 150MCG TABLET	3	Preferred Brand Drugs	$42.50	$127.50	None
SYNTHROID 175MCG TABLET	3	Preferred Brand Drugs	$42.50	$127.50	None
SYNTHROID 200MCG TABLET	3	Preferred Brand Drugs	$42.50	$127.50	None
SYNTHROID 25MCG TABLET	3	Preferred Brand Drugs	$42.50	$127.50	None
SYNTHROID 300MCG TABLET	3	Preferred Brand Drugs	$42.50	$127.50	None
SYNTHROID 50MCG TABLET	3	Preferred Brand Drugs	$42.50	$127.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SYNTHROID 75MCG TABLET	3	Preferred Brand Drugs	$42.50	$127.50	None
SYNTHROID 88 MCG TABLET	3	Preferred Brand Drugs	$42.50	$127.50	None
SYPRINE 250MG CAPSULE (100 CT)	4	Non-Preferred Brand Drugs	$95.00	$285.00	None

Chart Legend:

Below are a few notes to help you understand the above 2012 Medicare Part D Health First Essential Prescription Drug 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.