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2013 Medicare Part D Plan Formulary Information
Humana Walmart-Preferred Rx Plan (PDP) (S5552-004-0) Benefit Details
The Humana Walmart-Preferred Rx Plan (PDP) (S5552-004-0) Formulary Drugs Starting with the Letter D in CMS PDP Region 3 which includes: NY
Drugs Starting with Letter D Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter D Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DACARBAZINE 200MG VIAL	2	Non-Preferred Generics	$4.00	$0.00	P
DACOGEN FOR INJECTION	5	Specialty	25%	N/A	P
DANAZOL 100MG CAPSULE	4	Non-Preferred Brand	33%	33%	None
DANAZOL 50MG CAPSULE	4	Non-Preferred Brand	33%	33%	None
DANAZOL CAPSULES USP 200MG (100 CT)	4	Non-Preferred Brand	33%	33%	None
DANTROLENE SODIUM 100MG CAPSULE	3	Preferred Brand	20%	20%	None
DANTROLENE SODIUM 25MG CAPSULE	3	Preferred Brand	20%	20%	None
DANTROLENE SODIUM 50MG CAPSULE	3	Preferred Brand	20%	20%	None
DAPSONE TABLETS 100MG 30 BLPK	2	Non-Preferred Generics	$4.00	$0.00	None
DAPSONE TABLETS 25MG 30 BLPK	2	Non-Preferred Generics	$4.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DAPTACEL VACCINE 15;5;5;3; LF/.5ML	4	Non-Preferred Brand	33%	33%	None
DARAPRIM 25mg/1 100 TABLET BOTTLE	4	Non-Preferred Brand	33%	33%	None
daunorubicin hydrochloride 5mg/mL 10 VIAL in 1 CARTON / 4 mL in 1 VIAL	2	Non-Preferred Generics	$4.00	$0.00	P
DAYTRANA PATCH 1.1 MG/HR	4	Non-Preferred Brand	33%	33%	Q:30 /30Days
DAYTRANA PATCH 1.6 MG/HR	4	Non-Preferred Brand	33%	33%	Q:30 /30Days
DAYTRANA PATCH 2.2 MG/HR	4	Non-Preferred Brand	33%	33%	Q:30 /30Days
DAYTRANA PATCH 3.3 MG/HR	4	Non-Preferred Brand	33%	33%	Q:30 /30Days
DECAVAC VACCINE 2;5 UNT/0.5 ML	4	Non-Preferred Brand	33%	33%	None
DEGARELIX INJ	5	Specialty	25%	N/A	P
DEMECLOCYCLINE HCL 150MG TABLET	4	Non-Preferred Brand	33%	33%	None
DEMECLOCYCLINE HCL 300MG TABLET	4	Non-Preferred Brand	33%	33%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DEMSER CAPSULES 250MG (100 CT)	4	Non-Preferred Brand	33%	33%	None
DENAVIR 1% CREAM	4	Non-Preferred Brand	33%	33%	None
DEPO-ESTRADIOL 5MG/ML VIAL	2	Non-Preferred Generics	$4.00	$0.00	P
DESIPRAMINE 10 MG TABLET	3	Preferred Brand	20%	20%	None
DESIPRAMINE 25MG TABLET	3	Preferred Brand	20%	20%	None
DESIPRAMINE 50MG TABLET	3	Preferred Brand	20%	20%	None
DESIPRAMINE 75 MG TABLET	3	Preferred Brand	20%	20%	None
DESIPRAMINE HYDROCHLORIDE TABLETS	3	Preferred Brand	20%	20%	None
DESIPRAMINE HYDROCHLORIDE TABLETS USP 100MG 100 BOT	3	Preferred Brand	20%	20%	None
DESMOPRESSIN AC 4MCG/ML VL	3	Preferred Brand	20%	20%	None
DESMOPRESSIN ACETATE 0.1MG TABLET	3	Preferred Brand	20%	20%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DESMOPRESSIN ACETATE NASAL SOLUTION 0.1% 5 ML BOTSPR	3	Preferred Brand	20%	20%	None
DESMOPRESSIN ACETATE TABLET 0.2MG (100 CT)	3	Preferred Brand	20%	20%	None
DESONIDE 0.05% OINTMENT	2	Non-Preferred Generics	$4.00	$0.00	None
Desonide 0.5mg/g 1 TUBE in 1 TUBE / 60 g in 1 TUBE	2	Non-Preferred Generics	$4.00	$0.00	None
DESONIDE 0.5mg/g 114.1 g in 1 BOTTLE, PLASTIC	2	Non-Preferred Generics	$4.00	$0.00	None
Desoximetasone 0.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE	4	Non-Preferred Brand	33%	33%	None
Desoximetasone 0.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE	4	Non-Preferred Brand	33%	33%	None
Desoximetasone 2.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE	4	Non-Preferred Brand	33%	33%	None
Desoximetasone 2.5mg/g 1 TUBE in 1 TUBE / 60 g in 1 TUBE	4	Non-Preferred Brand	33%	33%	None
DEXAMETHASONE 0.5MG TABLET	1	Preferred Generics	$1.00	$0.00	None
DEXAMETHASONE 0.5MG/0.5ML DROP	3	Preferred Brand	20%	20%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DEXAMETHASONE 0.5MG/5ML ELX	2	Non-Preferred Generics	$4.00	$0.00	None
DEXAMETHASONE 0.75MG TABLET	1	Preferred Generics	$1.00	$0.00	None
DEXAMETHASONE 1.5MG TABLET	2	Non-Preferred Generics	$4.00	$0.00	None
DEXAMETHASONE 1MG TABLET	2	Non-Preferred Generics	$4.00	$0.00	None
DEXAMETHASONE 2MG TABLET	2	Non-Preferred Generics	$4.00	$0.00	None
DEXAMETHASONE 4MG TABLET	1	Preferred Generics	$1.00	$0.00	None
DEXAMETHASONE 6MG TABLET	2	Non-Preferred Generics	$4.00	$0.00	None
DEXAMETHASONE SODIUM PHOSPHATE 0.1% DROPS	2	Non-Preferred Generics	$4.00	$0.00	None
DEXAMETHASONE SODIUM PHOSPHATE INJECTION 4MG 30ML VIALMD	2	Non-Preferred Generics	$4.00	$0.00	None
DEXMETHYLPHENIDATE HCL 10MG TABLET	2	Non-Preferred Generics	$4.00	$0.00	Q:60 /30Days
DEXMETHYLPHENIDATE HCL 2.5MG TABLET	2	Non-Preferred Generics	$4.00	$0.00	Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DEXMETHYLPHENIDATE HCL 5MG TABLET	2	Non-Preferred Generics	$4.00	$0.00	Q:60 /30Days
DEXRAZOXANE 500MG VIAL	3	Preferred Brand	20%	20%	P
DEXTROAMP-AMPHET ER 10 MG CAP	3	Preferred Brand	20%	20%	Q:30 /30Days
DEXTROAMP-AMPHET ER 15 MG CAP	3	Preferred Brand	20%	20%	Q:30 /30Days
DEXTROAMP-AMPHET ER 20 MG CAP	3	Preferred Brand	20%	20%	Q:60 /30Days
DEXTROAMP-AMPHET ER 25 MG CAP	3	Preferred Brand	20%	20%	Q:60 /30Days
DEXTROAMP-AMPHET ER 30 MG CAP	3	Preferred Brand	20%	20%	Q:60 /30Days
DEXTROAMP-AMPHET ER 5 MG CAP	3	Preferred Brand	20%	20%	Q:30 /30Days
DEXTROAMPHETAMINE 10MG TABLET	3	Preferred Brand	20%	20%	Q:180 /30Days
DEXTROAMPHETAMINE 5MG TABLET	3	Preferred Brand	20%	20%	Q:150 /30Days
DEXTROAMPHETAMINE SACCHARATE AND SULFATE AMPHETAMINE ASPARTATE 10MG TABLET (100 CT)	3	Preferred Brand	20%	20%	Q:90 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DEXTROAMPHETAMINE SULFATE CAPSULES EXTENDED RELEASED 15MG 100 CAPSULES BOT	3	Preferred Brand	20%	20%	Q:120 /30Days
DEXTROAMPHETAMINE SULFATE CAPSULES SUSTAINED RELEASE 5MG 100 CAPSULES BOT	3	Preferred Brand	20%	20%	Q:60 /30Days
DEXTROAMPHETAMINE SULFATE CAPSULES SUSTAINED RELEASED 10MG 100 CAPSULES BOT	3	Preferred Brand	20%	20%	Q:180 /30Days
DEXTROSE 10%-1/4NS IV TUBEX	2	Non-Preferred Generics	$4.00	$0.00	None
DEXTROSE 2.5%-1/2NS IV SOLUTION	2	Non-Preferred Generics	$4.00	$0.00	None
DEXTROSE 5%-1/4NS IV SOLUTION	2	Non-Preferred Generics	$4.00	$0.00	None
Dextrose And Sodium Chloride 5; 0.9g/100mL; g/100mL 24 CONTAINER in 1 CASE / 250 mL in 1 CONTAINER	2	Non-Preferred Generics	$4.00	$0.00	None
Dextrose in Lactated Ringers 0.02; 5; 0.03; 0.6; 0.31g 12 CONTAINER in 1 CASE	2	Non-Preferred Generics	$4.00	$0.00	None
DEXTROSE IN SODIUM CHLORIDE INJECTION	2	Non-Preferred Generics	$4.00	$0.00	None
DEXTROSE IN SODIUM CHLORIDE INJECTION	2	Non-Preferred Generics	$4.00	$0.00	None
DEXTROSE IN SODIUM CHLORIDE INJECTION 1000ML X 12 CASE	2	Non-Preferred Generics	$4.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DEXTROSE IN SODIUM CHLORIDE INJECTION 500ML X 24 BAG	2	Non-Preferred Generics	$4.00	$0.00	None
DEXTROSE INJECTION 10 250ML X 24 BOTPL	2	Non-Preferred Generics	$4.00	$0.00	None
DEXTROSE INJECTION USP 5 4 X 100ML CTR	2	Non-Preferred Generics	$4.00	$0.00	None
Diazepam 10mg/1 500 TABLET BOTTLE, PLASTIC	4	Non-Preferred Brand	33%	33%	Q:120 /30Days
Diazepam 10mg/2mL 2 SYRINGE, PLASTIC in 1 PACKAGE / 2 mL in 1 SYRINGE, PLASTIC	4	Non-Preferred Brand	33%	33%	None
Diazepam 2.5mg/0.5mL 2 SYRINGE, PLASTIC in 1 PACKAGE / 0.5 mL in 1 SYRINGE, PLASTIC	4	Non-Preferred Brand	33%	33%	None
Diazepam 20mg/4mL 2 SYRINGE, PLASTIC in 1 PACKAGE / 4 mL in 1 SYRINGE, PLASTIC	4	Non-Preferred Brand	33%	33%	None
Diazepam 2mg/1 100 TABLET BOTTLE	4	Non-Preferred Brand	33%	33%	Q:90 /30Days
Diazepam 5mg/1 100 TABLET BOTTLE	4	Non-Preferred Brand	33%	33%	Q:90 /30Days
Diazepam 5mg/5mL 500 mL in 1 BOTTLE, PLASTIC	4	Non-Preferred Brand	33%	33%	Q:1200 /30Days
Diazepam Intensol 5mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 30 mL in 1 BOTTLE, DROPPER	4	Non-Preferred Brand	33%	33%	Q:1200 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DICLOFENAC 25MG TABLET EC	2	Non-Preferred Generics	$4.00	$0.00	None
DICLOFENAC POTASSIUM 50MG TABLET (500 CT)	2	Non-Preferred Generics	$4.00	$0.00	None
DICLOFENAC SODIUM 0.1% DROPS	2	Non-Preferred Generics	$4.00	$0.00	None
Diclofenac Sodium 100mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC	2	Non-Preferred Generics	$4.00	$0.00	None
DICLOFENAC SODIUM 50MG TABLET DELAYED RELEASE (100 CT)	2	Non-Preferred Generics	$4.00	$0.00	None
Diclofenac Sodium 75mg/1 1000 TABLET, DELAYED RELEASE in 1 BOTTLE	1	Preferred Generics	$1.00	$0.00	None
DICLOXACILLIN 250MG CAPSULE	2	Non-Preferred Generics	$4.00	$0.00	None
DICLOXACILLIN SODIUM 500MG CAP	2	Non-Preferred Generics	$4.00	$0.00	None
DICYCLOMINE 10MG CAPSULE	2	Non-Preferred Generics	$4.00	$0.00	None
DICYCLOMINE HCL 10MG/5ML SYRUP	2	Non-Preferred Generics	$4.00	$0.00	None
DICYCLOMINE HCL 20MG TABLET (500 CT)	2	Non-Preferred Generics	$4.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Didanosine 200mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE	4	Non-Preferred Brand	33%	33%	Q:60 /30Days
Didanosine 250mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE	4	Non-Preferred Brand	33%	33%	Q:30 /30Days
DIDANOSINE 400MG CAPSULE DELAYED RELEASE	4	Non-Preferred Brand	33%	33%	Q:30 /30Days
DIDANOSINE DELAYED RELEASE CAPSULES 125MG 30 BOT	4	Non-Preferred Brand	33%	33%	Q:90 /30Days
Dificid 200mg/1 1 BOTTLE in 1 CARTON / 20 FILM COATED TABLETS in BOTTLE	5	Specialty	25%	N/A	Q:20 /10Days
DIFLORASONE 0.05% CREAM	3	Preferred Brand	20%	20%	None
DIFLORASONE 0.05% OINTMENT	3	Preferred Brand	20%	20%	None
DIFLUNISAL 500MG TABLET	3	Preferred Brand	20%	20%	None
Digoxin 0.05mg/mL 60 mL in 1 BOTTLE, DROPPER	2	Non-Preferred Generics	$4.00	$0.00	P
Digoxin 125ug 100 TABLET BOTTLE	1	Preferred Generics	$1.00	$0.00	Q:30 /30Days
Digoxin 250ug 100 TABLET BOTTLE	1	Preferred Generics	$1.00	$0.00	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DIGOXIN INJECTION 500MCG 25 X 2ML AMP	2	Non-Preferred Generics	$4.00	$0.00	P
Dihydroergotamine Mesylate 1mg/mL 10 VIAL in 1 BOX / 1 mL in 1 VIAL	4	Non-Preferred Brand	33%	33%	None
DILANTIN 50MG INFATAB	4	Non-Preferred Brand	33%	33%	None
DILANTIN CAPSULES EXTENDED RELEASE	4	Non-Preferred Brand	33%	33%	None
DILANTIN EXTENDED ORAL CAPSULE 100MG (100 CT)	4	Non-Preferred Brand	33%	33%	None
DILANTIN-125 SUS 125/5ML	4	Non-Preferred Brand	33%	33%	None
DILATRATE-SR 40 MG CAPSULE	4	Non-Preferred Brand	33%	33%	None
DILT-CD 120MG CAPSULE SR 24 HR	3	Preferred Brand	20%	20%	Q:60 /30Days
DILT-CD DILTIAZEM HCL ER CAPSULES 300MG	3	Preferred Brand	20%	20%	Q:30 /30Days
DILT-XR 180MG CAPSULE DEGRADABLE CONTROLLED-RELEASE	3	Preferred Brand	20%	20%	Q:60 /30Days
DILTIAZEM 30MG TABLET	1	Preferred Generics	$1.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DILTIAZEM 90MG TABLET	1	Preferred Generics	$1.00	$0.00	None
DILTIAZEM CD CAPSULES 120MG (90 CT)	3	Preferred Brand	20%	20%	Q:60 /30Days
DILTIAZEM CD CAPSULES 240MG (90 CT)	3	Preferred Brand	20%	20%	Q:60 /30Days
DILTIAZEM CD CAPSULES 300MG (90 CT)	3	Preferred Brand	20%	20%	Q:30 /30Days
DILTIAZEM ER 240MG CAPSULE SA	3	Preferred Brand	20%	20%	Q:60 /30Days
DILTIAZEM HCL 100MG VIAL	4	Non-Preferred Brand	33%	33%	None
DILTIAZEM HCL 120MG ER CAPSULE	3	Preferred Brand	20%	20%	None
DILTIAZEM HCL 120MG TABLET	1	Preferred Generics	$1.00	$0.00	None
DILTIAZEM HCL 60MG ER CAPSULE	3	Preferred Brand	20%	20%	None
DILTIAZEM HCL 60MG TABLET	1	Preferred Generics	$1.00	$0.00	None
diltiazem hcl er 420 mg cap	3	Preferred Brand	20%	20%	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Diltiazem Hydrochloride 180mg/1 500 CAPSULE, EXTENDED RELEASE in 1 BOTTLE	3	Preferred Brand	20%	20%	Q:60 /30Days
Diltiazem Hydrochloride 90mg EXTENDED RELEASE 100 CAPSULE BOTTLE	3	Preferred Brand	20%	20%	None
DILTIAZEM HYDROCHLORIDE ER 360MG CAPSULES	3	Preferred Brand	20%	20%	Q:30 /30Days
DIOVAN 160MG TABLET	3	Preferred Brand	20%	20%	Q:60 /30Days
DIOVAN 320MG TABLET	3	Preferred Brand	20%	20%	Q:60 /30Days
DIOVAN 40MG TABLET	3	Preferred Brand	20%	20%	Q:60 /30Days
DIOVAN 80MG TABLET	3	Preferred Brand	20%	20%	Q:60 /30Days
DIOVAN HCT 160/12.5MG TABLET	3	Preferred Brand	20%	20%	Q:30 /30Days
DIOVAN HCT 160/25MG TABLET	3	Preferred Brand	20%	20%	Q:30 /30Days
DIOVAN HCT 320/12.5MG TABLET	3	Preferred Brand	20%	20%	Q:30 /30Days
DIOVAN HCT 320/25MG TABLET	3	Preferred Brand	20%	20%	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DIOVAN HCT 80/12.5MG TABLET	3	Preferred Brand	20%	20%	Q:30 /30Days
Diphenoxylate Hydrochloride and Atropine Sulfate 0.025; 2.5mg 100 TABLET BOTTLE	2	Non-Preferred Generics	$4.00	$0.00	None
DIPHENOXYLATE/ATROPINE LIQ	2	Non-Preferred Generics	$4.00	$0.00	None
DISOPYRAMIDE PHOSPHATE 150MG CAPSULE USP (100 CT)	2	Non-Preferred Generics	$4.00	$0.00	P
DISOPYRAMIDE PHOSPHATE CAPSULES 100MG (100 CT)	2	Non-Preferred Generics	$4.00	$0.00	P
Disulfiram 250mg/1	3	Preferred Brand	20%	20%	None
Disulfiram 500mg/1	4	Non-Preferred Brand	33%	33%	None
DIURIL 250MG/5ML SUSPENSION ORAL	3	Preferred Brand	20%	20%	None
DIVALPROEX SODIUM 125 MG CAP	3	Preferred Brand	20%	20%	None
DIVALPROEX SODIUM 125MG TBEC	3	Preferred Brand	20%	20%	None
Divalproex Sodium 250mg/1 500 TABLET, DELAYED RELEASE in 1 BOTTLE	3	Preferred Brand	20%	20%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Divalproex Sodium 500mg/1 500 TABLET, DELAYED RELEASE in 1 BOTTLE	3	Preferred Brand	20%	20%	None
DIVALPROEX SODIUM EXTENDED RELEASE TABLETS 250MG 100 BOT	2	Non-Preferred Generics	$4.00	$0.00	None
DIVALPROEX SODIUM TABLETS EXTENDED RELEASE 500MG 100 BOT	2	Non-Preferred Generics	$4.00	$0.00	None
DOCEFREZ 1 KIT in 1 CARTON	5	Specialty	25%	N/A	P
DOCEFREZ 1 KIT in 1 CARTON	4	Non-Preferred Brand	33%	33%	P
Docetaxel 10mg/mL 1 VIAL, MULTI-DOSE in 1 CARTON / 8 mL in 1 VIAL, MULTI-DOSE	5	Specialty	25%	N/A	P
Docetaxel 80mg/4mL 1 VIAL, GLASS in 1 CARTON / 4 mL in 1 VIAL, GLASS	5	Specialty	25%	N/A	P
Donepezil Hydrochloride 10mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PACK	2	Non-Preferred Generics	$4.00	$0.00	Q:30 /30Days
Donepezil Hydrochloride 5mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PACK	2	Non-Preferred Generics	$4.00	$0.00	Q:30 /30Days
DONEPEZIL HYDROCHLORIDE TABLETS	2	Non-Preferred Generics	$4.00	$0.00	Q:60 /30Days
DONEPEZIL HYDROCHLORIDE TABLETS	2	Non-Preferred Generics	$4.00	$0.00	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DORIBAX FOR INJECTION 500MG/VIAL	4	Non-Preferred Brand	33%	33%	None
DORZOLAMIDE HCL OPHTHALMIC 2% 10 ML BOTDR	3	Preferred Brand	20%	20%	Q:10 /30Days
Dorzolamide Hydrochloride and Timolol Maleate 20; 5mg/mL; mg/mL 1 BOTTLE, DROPPER in 1 BOX / 10 mL	3	Preferred Brand	20%	20%	Q:10 /30Days
Doxazosin 2mg 100 TABLET BOTTLE	1	Preferred Generics	$1.00	$0.00	None
DOXAZOSIN MESYLATE 4MG TABLET	1	Preferred Generics	$1.00	$0.00	None
DOXAZOSIN MESYLATE TABLETS 8 MG	1	Preferred Generics	$1.00	$0.00	None
DOXAZOSIN TABLET 1MG (100 CT)	1	Preferred Generics	$1.00	$0.00	None
DOXEPIN 10MG CAPSULE	1	Preferred Generics	$1.00	$0.00	P
DOXEPIN 10MG/ML ORAL CONC	2	Non-Preferred Generics	$4.00	$0.00	P
DOXEPIN 75MG CAPSULE	1	Preferred Generics	$1.00	$0.00	P
DOXEPIN HCL 25MG CAPSULE (100 CT)	1	Preferred Generics	$1.00	$0.00	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Doxepin Hydrochloride 150mg/1 100 CAPSULE in 1 BOTTLE	2	Non-Preferred Generics	$4.00	$0.00	P
Doxepin Hydrochloride 50mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE in 1 BLISTER PACK	1	Preferred Generics	$1.00	$0.00	P
DOXEPIN HYDROCHLORIDE CAPSULES 100MG 100 BOT	1	Preferred Generics	$1.00	$0.00	P
DOXERCALCIFEROL 0.001 MG ORAL CAPSULE [HECTOROL]	3	Preferred Brand	20%	20%	P
DOXORUBICIN HCL INJECTION USP 200MG/100ML 1 X 100ML VIALMD	3	Preferred Brand	20%	20%	P
Doxorubicin Hydrochloride 2mg/mL 1 VIAL, SINGLE-DOSE in 1 CARTON / 25 mL in 1 VIAL, SINGLE-DOSE	4	Non-Preferred Brand	33%	33%	P
Doxycycline 100mg/1 50 TABLET, COATED in 1 BOTTLE	1	Preferred Generics	$1.00	$0.00	None
DOXYCYCLINE 50MG CAPSULE	1	Preferred Generics	$1.00	$0.00	None
DOXYCYCLINE 50MG TABLET (100 CT)	2	Non-Preferred Generics	$4.00	$0.00	None
Doxycycline 75mg/1	3	Preferred Brand	20%	20%	Q:30 /30Days
DOXYCYCLINE FOR INJECTION 100MG/VIAL 10 X 1 VIAL CRTN	2	Non-Preferred Generics	$4.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Doxycycline Hyclate 100mg/1 100 TABLET, DELAYED RELEASE in 1 BOTTLE, PLASTIC	3	Preferred Brand	20%	20%	None
Doxycycline Hyclate 100mg/1 50 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 50 CAPSULE in 1 BOTTLE, PLAST	1	Preferred Generics	$1.00	$0.00	None
DOXYCYCLINE HYCLATE 20MG TABLET (100 CT)	2	Non-Preferred Generics	$4.00	$0.00	None
Doxycycline Hyclate 75mg/1 60 TABLET, DELAYED RELEASE in 1 BOTTLE, PLASTIC	3	Preferred Brand	20%	20%	None
DOXYCYCLINE MONOHYDRATE 75MG TABLET	2	Non-Preferred Generics	$4.00	$0.00	None
DOXYCYCLINE TABLETS 150MG 30 BOT	2	Non-Preferred Generics	$4.00	$0.00	None
DRONABINOL CAPS 10MG	5	Specialty	25%	N/A	P Q:120 /30Days
DRONABINOL CAPS 2.5MG	4	Non-Preferred Brand	33%	33%	P Q:120 /30Days
DRONABINOL CAPS 5MG	4	Non-Preferred Brand	33%	33%	P Q:120 /30Days
DROSPIRENONE-ETH ESTRADIOL TAB	4	Non-Preferred Brand	33%	33%	None
DROXIA 200MG CAPSULE	4	Non-Preferred Brand	33%	33%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DROXIA 300MG CAPSULE	4	Non-Preferred Brand	33%	33%	None
DROXIA 400MG CAPSULE	4	Non-Preferred Brand	33%	33%	None
DUETACT 30MG-2MG TABLET	4	Non-Preferred Brand	33%	33%	Q:30 /30Days
DUETACT 30MG-4MG TABLET	4	Non-Preferred Brand	33%	33%	Q:30 /30Days
DULERA INHALATION AEROSOL	3	Preferred Brand	20%	20%	Q:13 /30Days
DULERA INHALATION AEROSOL	3	Preferred Brand	20%	20%	Q:13 /30Days
DUONEB INHALATION SOLUTION 3-.5MG 60 X 3ML CRTN	4	Non-Preferred Brand	33%	33%	P
duramorph 0.5 mg/ml ampule	4	Non-Preferred Brand	33%	33%	Q:7200 /30Days
duramorph 1 mg/ml ampule	4	Non-Preferred Brand	33%	33%	Q:3600 /30Days
DUREZOL 0.5mg/mL 5 mL in 1 BOTTLE	3	Preferred Brand	20%	20%	None
DYRENIUM 100MG CAPSULE	4	Non-Preferred Brand	33%	33%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DYRENIUM 50MG CAPSULE	4	Non-Preferred Brand	33%	33%	None

Chart Legend:

Below are a few notes to help you understand the above 2013 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 $325 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 $2970) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2013 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 October 2013 )

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.