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EnvisionRxPlus Silver (PDP) (S7694-012-0)
Tier 1 (556)
Tier 2 (1128)
Tier 3 (355)
Tier 4 (327)
Tier 5 (252)
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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
EnvisionRxPlus Silver (PDP) (S7694-012-0)
Benefit Details           
The EnvisionRxPlus Silver (PDP) (S7694-012-0)
Formulary Drugs Starting with the Letter T

in CMS PDP Region 12 which includes: AL TN
Drugs Starting with Letter T

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Tacrolimus 0.5mg/1 100 CAPSULE in 1 BOTTLE   2 Non-Preferred Generic Drugs 25%N/AP
Tacrolimus 1mg/1 100 CAPSULE in 1 BOTTLE   2 Non-Preferred Generic Drugs 25%N/AP
Tacrolimus 5mg/1 100 CAPSULE in 1 BOTTLE   2 Non-Preferred Generic Drugs 25%N/AP
Tamiflu 30mg/1 1 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK   4 Non-Preferred Brand Drugs 25%N/ANone
Tamiflu 45mg/1 1 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK   4 Non-Preferred Brand Drugs 25%N/ANone
Tamiflu 6mg/mL 1 BOTTLE, GLASS in 1 CARTON / 6 mL in 1 BOTTLE, GLASS   4 Non-Preferred Brand Drugs 25%N/ANone
TAMIFLU 75MG CAPSULE UD   4 Non-Preferred Brand Drugs 25%N/ANone
TAMOXIFEN CITRATE 20MG TABLET (30 CT)   1 Preferred Generic Drugs 25%N/ANone
TAMOXIFEN CITRATE TABLETS 10MG 180 BOT   1 Preferred Generic Drugs 25%N/ANone
TAMSULOSIN HCL 0.4 MG CAPSULE   2 Non-Preferred Generic Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TARCEVA 100MG TABLET   5 Specialty Tier Drugs 25%N/ANone
TARCEVA 150MG TABLET   5 Specialty Tier Drugs 25%N/ANone
TARCEVA 25MG TABLET   5 Specialty Tier Drugs 25%N/ANone
TARGRETIN 1% GEL 60GM TUBE   4 Non-Preferred Brand Drugs 25%N/ANone
TARGRETIN 75MG (100 CT)   3 Preferred Brand Drugs 25%N/ANone
Tasigna 150mg/1 4 BLISTER PACK in 1 CARTON / 28 CAPSULE in 1 BLISTER PACK   5 Specialty Tier Drugs 25%N/ANone
TASIGNA 200MG CAPSULE 28 BLPK   5 Specialty Tier Drugs 25%N/ANone
TAZORAC 0.05% CREAM   4 Non-Preferred Brand Drugs 25%N/ANone
TAZORAC 0.05% GEL   4 Non-Preferred Brand Drugs 25%N/ANone
TAZORAC 0.1% CREAM   4 Non-Preferred Brand Drugs 25%N/ANone
TAZORAC 0.1% GEL   4 Non-Preferred Brand Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES   2 Non-Preferred Generic Drugs 25%N/ANone
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES   2 Non-Preferred Generic Drugs 25%N/ANone
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES   2 Non-Preferred Generic Drugs 25%N/ANone
TAZTIA XT 240MG CAPSULE SA   2 Non-Preferred Generic Drugs 25%N/ANone
TAZTIA XT 360MG CAPSULE SA   2 Non-Preferred Generic Drugs 25%N/ANone
TEGRETOL XR TABLETS 100MG 100 BOT   4 Non-Preferred Brand Drugs 25%N/ANone
TEKTURNA 150MG TABLET   3 Preferred Brand Drugs 25%N/ANone
TEKTURNA 300MG TABLET   3 Preferred Brand Drugs 25%N/ANone
TEKTURNA HCT 150-12.5MG TABLET   3 Preferred Brand Drugs 25%N/ANone
TEKTURNA HCT 150MG-25MG TABLET   3 Preferred Brand Drugs 25%N/ANone
TEKTURNA HCT 300-12.5MG TABLET   3 Preferred Brand Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TEKTURNA HCT 300MG-25MG TABLET   3 Preferred Brand Drugs 25%N/ANone
TERAZOSIN HCL 10MG CAPSULE   1 Preferred Generic Drugs 25%N/ANone
TERAZOSIN HCL 1MG CAPSULE   1 Preferred Generic Drugs 25%N/ANone
TERAZOSIN HCL 2MG CAPSULE   1 Preferred Generic Drugs 25%N/ANone
TERAZOSIN HCL 5MG CAPSULE   1 Preferred Generic Drugs 25%N/ANone
TERBUTALINE SULF 1MG/ML VL   1 Preferred Generic Drugs 25%N/ANone
TERCONAZOLE 0.4% CREAM WITH APPLICATOR   2 Non-Preferred Generic Drugs 25%N/ANone
TERCONAZOLE 80MG SUPPOSITORY VAGINAL   1 Preferred Generic Drugs 25%N/ANone
TERCONAZOLE VAGINAL CREAM   2 Non-Preferred Generic Drugs 25%N/ANone
Testosterone Cypionate 200mg/mL 1 VIAL, MULTI-DOSE in 1 CARTON / 10 mL in 1 VIAL, MULTI-DOSE   2 Non-Preferred Generic Drugs 25%N/ANone
TESTOSTERONE CYPIONATE INJECTION   2 Non-Preferred Generic Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TESTOSTERONE ENANTHATE INJECTION   2 Non-Preferred Generic Drugs 25%N/ANone
Tetanus and Diphtheria Toxoids Adsorbed 2.0; 2.0[Lf]/0.5mL; [Lf]/0.5mL 10 VIAL, SINGLE-DOSE in 1 CA   4 Non-Preferred Brand Drugs 25%N/AP
TETANUS TOXOID ADSORBED VIAL 5LF   4 Non-Preferred Brand Drugs 25%N/AP
TETRACYCLINE 500MG CAPSULE   1 Preferred Generic Drugs 25%N/ANone
Tetracycline Hydrochloride 250mg/1 100 CAPSULE in 1 BOTTLE   1 Preferred Generic Drugs 25%N/ANone
THALOMID 100MG CAPSULE 140 BOX   5 Specialty Tier Drugs 25%N/ANone
Thalomid 150mg/1   5 Specialty Tier Drugs 25%N/ANone
Thalomid 200mg/1   5 Specialty Tier Drugs 25%N/ANone
THALOMID 50MG CAPSULE 280 BOX   5 Specialty Tier Drugs 25%N/ANone
THEOCHRON 100MG TABLET SA   2 Non-Preferred Generic Drugs 25%N/ANone
THEOCHRON TABLETS EXTENDED RELEASE 300MG 100 BOT   2 Non-Preferred Generic Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Theophylline 100mg/1 500 CAPSULE in 1 BOTTLE   2 Non-Preferred Generic Drugs 25%N/ANone
THEOPHYLLINE 600MG TABLET SA   2 Non-Preferred Generic Drugs 25%N/ANone
THEOPHYLLINE ANHYDROUS ER TABLET 200MG (1000 CT)   2 Non-Preferred Generic Drugs 25%N/ANone
THEOPHYLLINE TABLET ER 300MG (100 CT)   2 Non-Preferred Generic Drugs 25%N/ANone
THEOPHYLLINE TABLET ER 450MG (100 CT)   2 Non-Preferred Generic Drugs 25%N/ANone
Thermazene 10mg/g   1 Preferred Generic Drugs 25%N/ANone
THIOGUANINE TABLET LOID 40MG   4 Non-Preferred Brand Drugs 25%N/ANone
THIORIDAZINE 100MG TABLET   2 Non-Preferred Generic Drugs 25%N/ANone
THIORIDAZINE HCL 10MG TABLET (1000 CT)   2 Non-Preferred Generic Drugs 25%N/ANone
THIORIDAZINE HCL 25MG TABLET (1000 CT)   1 Preferred Generic Drugs 25%N/ANone
THIORIDAZINE HCL 50MG TABLET (1000 CT)   1 Preferred Generic Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
THIOTHIXENE 10MG CAPSULE   2 Non-Preferred Generic Drugs 25%N/ANone
THIOTHIXENE 1MG CAPSULE (100 CT)   2 Non-Preferred Generic Drugs 25%N/ANone
THIOTHIXENE 2MG CAPSULE   1 Preferred Generic Drugs 25%N/ANone
THIOTHIXENE 5MG CAPSULE   2 Non-Preferred Generic Drugs 25%N/ANone
THYMOGLOBULIN 25MG VIAL   5 Specialty Tier Drugs 25%N/AP
Ticlopidine Hydrochloride 250mg/1 60 TABLET, FILM COATED in 1 BOTTLE   2 Non-Preferred Generic Drugs 25%N/ANone
TIKOSYN .125MG CAPSULE   4 Non-Preferred Brand Drugs 25%N/ANone
TIKOSYN .250MG CAPSULE   4 Non-Preferred Brand Drugs 25%N/ANone
TIKOSYN .5MG CAPSULE   4 Non-Preferred Brand Drugs 25%N/ANone
TIMOLOL MAL SOL 0.25% OP 15ML BOT   2 Non-Preferred Generic Drugs 25%N/ANone
TIMOLOL MAL SOL 0.5% OP 10ML BOT   2 Non-Preferred Generic Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TIMOLOL MALEATE 10MG TABLET   2 Non-Preferred Generic Drugs 25%N/ANone
TIMOLOL MALEATE 20MG TABLET   1 Preferred Generic Drugs 25%N/ANone
Timolol Maleate 3.4mg/mL 1 BOTTLE, DISPENSING in 1 CARTON / 5 mL in 1 BOTTLE, DISPENSING   2 Non-Preferred Generic Drugs 25%N/ANone
TIMOLOL MALEATE 5MG TABLET   1 Preferred Generic Drugs 25%N/ANone
Timolol Maleate 6.8mg/mL 1 BOTTLE, DISPENSING in 1 CARTON / 5 mL in 1 BOTTLE, DISPENSING   2 Non-Preferred Generic Drugs 25%N/ANone
TIS-U-SOL IRRIGATION SOLUTION   1 Preferred Generic Drugs 25%N/ANone
tizanidine 4mg/1   2 Non-Preferred Generic Drugs 25%N/ANone
TIZANIDINE HCL 2 MG TABLET   2 Non-Preferred Generic Drugs 25%N/ANone
TOBI 300mg/5mL 56 AMPULE in 1 CARTON / 5 mL in 1 AMPULE   5 Specialty Tier Drugs 25%N/ANone
TOBRAMYCIN 10MG/ML VIAL   2 Non-Preferred Generic Drugs 25%N/ANone
TOBRAMYCIN 40MG/ML VIAL   2 Non-Preferred Generic Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TOBRAMYCIN OPHTHALMIC SOLUTION 0.3% 5ML BOT   1 Preferred Generic Drugs 25%N/ANone
TOBRAMYCIN-DEXAMETH OPTH SUSP   2 Non-Preferred Generic Drugs 25%N/ANone
TOBRASOL 0.3% EYE DROPS   1 Preferred Generic Drugs 25%N/ANone
TOLMETIN SODIUM 200MG TABLET   1 Preferred Generic Drugs 25%N/ANone
TOLMETIN SODIUM 400MG CAPSULE   2 Non-Preferred Generic Drugs 25%N/ANone
TOLMETIN SODIUM 600MG TABLET   1 Preferred Generic Drugs 25%N/ANone
TOLVAPTAN 15 MG ORAL TABLET [SAMSCA]   5 Specialty Tier Drugs 25%N/AP
TOLVAPTAN 30 MG ORAL TABLET [SAMSCA]   5 Specialty Tier Drugs 25%N/AP
Topiramate 25mg/1   2 Non-Preferred Generic Drugs 25%N/ANone
TOPIRAMATE SPRINKLE CAPSULES 15MG 60 BOT   2 Non-Preferred Generic Drugs 25%N/ANone
TOPIRAMATE TABLETS 100MG 1000 BOT   2 Non-Preferred Generic Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TOPIRAMATE TABLETS 200MG 1000 BOT   2 Non-Preferred Generic Drugs 25%N/ANone
TOPIRAMATE TABLETS 25MG 1000 BOT   2 Non-Preferred Generic Drugs 25%N/ANone
TOPIRAMATE TABLETS 50MG 1000 BOT   2 Non-Preferred Generic Drugs 25%N/ANone
TOPOTECAN HYDROCHLORIDE FOR INJECTION   2 Non-Preferred Generic Drugs 25%N/AP
Torsemide 100mg/1 12 BOTTLE in 1 CASE / 100 TABLET in 1 BOTTLE   2 Non-Preferred Generic Drugs 25%N/ANone
TORSEMIDE 20mg/1 100 TABLET in 1 BOTTLE, PLASTIC   2 Non-Preferred Generic Drugs 25%N/ANone
TORSEMIDE TABLETS   2 Non-Preferred Generic Drugs 25%N/ANone
TORSEMIDE TABLETS   2 Non-Preferred Generic Drugs 25%N/ANone
TOVIAZ TABLETS 4MG EXTENDED RELEASE   3 Preferred Brand Drugs 25%N/ANone
TOVIAZ TABLETS 8MG EXTENDED RELEASE   3 Preferred Brand Drugs 25%N/ANone
TPN ELECTROLYTES VIAL   1 Preferred Generic Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRACLEER 125MG TABLET   5 Specialty Tier Drugs 25%N/ANone
TRACLEER 62.5MG TABLET   5 Specialty Tier Drugs 25%N/ANone
TRADJENTA 5mg/1 90 TABLET, FILM COATED in 1 BOTTLE   4 Non-Preferred Brand Drugs 25%N/ANone
TRAMADOL HCL 50 MG TABLET   1 Preferred Generic Drugs 25%N/AQ:240
/30Days
TRAMADOL HCL-ACETAMINOPHEN 37.5-325MG TABLET (1000 CT)   2 Non-Preferred Generic Drugs 25%N/AQ:240
/30Days
TRANDOLAPRIL 1MG TABLET   1 Preferred Generic Drugs 25%N/ANone
TRANDOLAPRIL 2MG TABLET   2 Non-Preferred Generic Drugs 25%N/ANone
TRANDOLAPRIL 4MG TABLET   2 Non-Preferred Generic Drugs 25%N/ANone
TRANEXAMIC ACID 1,000 MG/10 ML   2 Non-Preferred Generic Drugs 25%N/ANone
TRANYLCYPROMINE SULFATE 10MG TABLET   2 Non-Preferred Generic Drugs 25%N/ANone
TRAVASOL 10% SOLUTION VIAFLEX   3 Preferred Brand Drugs 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRAVATAN Z 0.04MG DROPS 2.5ML BOT   3 Preferred Brand Drugs 25%N/ANone
TRAZODONE 300MG TABLET   2 Non-Preferred Generic Drugs 25%N/ANone
TRAZODONE HCL TABLET USP 100MG (500 CT)   1 Preferred Generic Drugs 25%N/ANone
TRAZODONE HCL TABLET USP 150MG (100 CT)   1 Preferred Generic Drugs 25%N/ANone
TRAZODONE HCL TABLET USP 50MG (500 CT)   1 Preferred Generic Drugs 25%N/ANone
TRECATOR 250MG TABLET   4 Non-Preferred Brand Drugs 25%N/ANone
Trelstar 22.5mg/2mL 2 mL in 1 VIAL, SINGLE-DOSE   5 Specialty Tier Drugs 25%N/ANone
TRELSTAR DEPOT MIXJET FOR INJECTION 3.75 MG   5 Specialty Tier Drugs 25%N/ANone
TRELSTAR MIXJET FOR INJECTION 11.25 MG   5 Specialty Tier Drugs 25%N/ANone
TRETINOIN 10MG CAPSULE   5 Specialty Tier Drugs 25%N/ANone
TRIAMCINOLONE 0.1% OINTMENT   1 Preferred Generic Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRIAMCINOLONE ACETONIDE 0.025% CREAM 80GM TUBE   1 Preferred Generic Drugs 25%N/ANone
TRIAMCINOLONE ACETONIDE 0.025% LOTION 2 FL OZ BOT   2 Non-Preferred Generic Drugs 25%N/ANone
TRIAMCINOLONE ACETONIDE 0.025% OINTMENT 80GM TUBE   2 Non-Preferred Generic Drugs 25%N/ANone
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE   2 Non-Preferred Generic Drugs 25%N/ANone
TRIAMCINOLONE ACETONIDE 0.1% CREAM 80GM TUBE   1 Preferred Generic Drugs 25%N/ANone
TRIAMCINOLONE ACETONIDE 0.1% LOTION 60ML BOTPL   2 Non-Preferred Generic Drugs 25%N/ANone
Triamcinolone Acetonide 1mg/g 1 TUBE in 1 CARTON / 5 g in 1 TUBE   2 Non-Preferred Generic Drugs 25%N/ANone
Triamcinolone Acetonide 5mg/g 1 TUBE in 1 CARTON / 15 g in 1 TUBE   1 Preferred Generic Drugs 25%N/ANone
Triamterene and Hydrochlorothiazide 25; 37.5mg/1; mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC   1 Preferred Generic Drugs 25%N/ANone
TRIAMTERENE/HCTZ 37.5/25 TABLET   1 Preferred Generic Drugs 25%N/ANone
TRIAMTERENE/HCTZ 75/50 TABLET   1 Preferred Generic Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRICOR 145MG TABLET   3 Preferred Brand Drugs 25%N/ANone
Tricor 48mg/1 90 TABLET in 1 BOTTLE   3 Preferred Brand Drugs 25%N/ANone
TRIDERM 0.1% CREAM   1 Preferred Generic Drugs 25%N/ANone
TRIFLUOPERAZINE 1MG TABLET   2 Non-Preferred Generic Drugs 25%N/ANone
TRIFLUOPERAZINE HCL 2MG TABLET   2 Non-Preferred Generic Drugs 25%N/ANone
TRIFLUOPERAZINE HCL 5MG TABLET   2 Non-Preferred Generic Drugs 25%N/ANone
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT)   2 Non-Preferred Generic Drugs 25%N/ANone
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT   2 Non-Preferred Generic Drugs 25%N/ANone
TRIHEXYPHENIDYL HYDROCHLORIDE 2mg/1   1 Preferred Generic Drugs 25%N/ANone
Trihexyphenidyl Hydrochloride 2mg/5mL 473 mL in 1 BOTTLE   1 Preferred Generic Drugs 25%N/ANone
Trihexyphenidyl Hydrochloride 5mg/1 100 TABLET in 1 BOTTLE   2 Non-Preferred Generic Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRIMETHOPRIM TABLETS   2 Non-Preferred Generic Drugs 25%N/ANone
TRIMIPRAMINE MALEATE 100 MG CAP   2 Non-Preferred Generic Drugs 25%N/ANone
TRIMIPRAMINE MALEATE 25 MG CAP   2 Non-Preferred Generic Drugs 25%N/ANone
TRIMIPRAMINE MALEATE 50 MG CAP   2 Non-Preferred Generic Drugs 25%N/ANone
TRIPEDIA PRESERVATIVE FREE 6.7;23.4; UNT/.5 ML;   4 Non-Preferred Brand Drugs 25%N/ANone
TRISENOX 10MG/10ML AMPULE   4 Non-Preferred Brand Drugs 25%N/ANone
TRIZIVIR 300; 150; 300mg/1; mg/1; mg/1 60 TABLET, FILM COATED in 1 BOTTLE   5 Specialty Tier Drugs 25%N/ANone
TROPICAMIDE 0.5% EYE DROPS   1 Preferred Generic Drugs 25%N/ANone
TROPICAMIDE OPHTHALMIC SOLUTION USP   2 Non-Preferred Generic Drugs 25%N/ANone
TRUVADA TABLET   5 Specialty Tier Drugs 25%N/ANone
TWINRIX TF PF VACCINE 720UNT/20ML 10 X 1ML VIALSD   4 Non-Preferred Brand Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TYKERB 250MG TABLET   5 Specialty Tier Drugs 25%N/ANone
TYPHIM VI 25MCG/0.5ML VIAL   4 Non-Preferred Brand Drugs 25%N/ANone
TYZEKA 600MG TABLET (30 CT)   4 Non-Preferred Brand Drugs 25%N/ANone
TYZINE 0.1% NOSE DROPS   4 Non-Preferred Brand Drugs 25%N/ANone
TYZINE PEDIATRIC 0.05% DROP   4 Non-Preferred Brand Drugs 25%N/ANone

Chart Legend:

Below are a few notes to help you understand the above 2012 Medicare Part D EnvisionRxPlus Silver (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.