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2017 Medicare Part D and Medicare Advantage Plan Formulary Browser

This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.
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SecureRx - Option 1 (PDP) (S8067-003-0)
Tier 1 (474)
Tier 2 (1863)
Tier 3 (295)
Tier 4 (869)
Tier 5 (779)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
Yes No Show either
  *required
 
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 
2017 Medicare Part D Plan Formulary Information
SecureRx - Option 1 (PDP) (S8067-003-0)
Benefit Details           
The SecureRx - Option 1 (PDP) (S8067-003-0)
Formulary Drugs Starting with the Letter C

in CMS PDP Region 6 which includes: PA WV
Plan Monthly Premium: $124.10 Deductible: $0 Qualifies for LIS: No
Drugs Starting with Letter C

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
CABERGOLINE 0.5 MG TABLET   2 Generic $15.00$45.00None
CABOMETYX 20 MG TABLET   5 Specialty Tier 33%N/AP
CABOMETYX 40 MG TABLET   5 Specialty Tier 33%N/AP
CABOMETYX 60 MG TABLET   5 Specialty Tier 33%N/AP
CALCIPOTRIENE 0.005% CREAM   2 Generic $15.00$45.00None
CALCIPOTRIENE TOPICAL SOLUTION   2 Generic $15.00$45.00None
Calcipotriene-Betamethasone Dipropionate Ointment [Taclonex]   2 Generic $15.00$45.00None
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY   2 Generic $15.00$45.00P
CALCITRIOL 0.25MCG CAPSULE   2 Generic $15.00$45.00P
CALCITRIOL 0.5 MCG CAPSULE   2 Generic $15.00$45.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Calcitriol 1 mcg/ml ampul   2 Generic $15.00$45.00P
CALCITRIOL 1MCG/ML SOLUTION ORAL   2 Generic $15.00$45.00P
CALCITRIOL 3 MCG/G OINTMENT   2 Generic $15.00$45.00None
Calcium Acetate 667 mg tablet   2 Generic $15.00$45.00None
CALCIUM ACETATE CAPSULE 667 MG   2 Generic $15.00$45.00None
CAMILA 0.35 MG TABLET   2 Generic $15.00$45.00None
Camrese Lo tablet   2 Generic $15.00$45.00None
CANASA 1,000 MG SUPPOSITORY   5 Specialty Tier 33%N/ANone
CANCIDAS IV 50MG VIAL   5 Specialty Tier 33%N/ANone
CANCIDAS IV 70MG VIAL   5 Specialty Tier 33%N/ANone
CANDESARTAN CILEXETIL 16 MG TABLET [Atacand]   1 Preferred Generic $4.00$12.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CANDESARTAN CILEXETIL 32 MG TABLET [Atacand]   1 Preferred Generic $4.00$12.00None
CANDESARTAN CILEXETIL 4 MG TABLET [Atacand]   1 Preferred Generic $4.00$12.00None
CANDESARTAN CILEXETIL 8 MG TABLET [Atacand]   1 Preferred Generic $4.00$12.00None
candesartan-hctz 16-12.5 mg tablet   1 Preferred Generic $4.00$12.00None
candesartan-hctz 32-12.5 mg tablet   1 Preferred Generic $4.00$12.00None
candesartan-hctz 32-25 mg   1 Preferred Generic $4.00$12.00None
CAPASTAT SULFATE 1g/1 1 INJECTION, POWDER, FOR SOLUTION per CARTON   4 Non-Preferred Drug $89.00$267.00None
CAPEX SHA 0.01%   4 Non-Preferred Drug $89.00$267.00None
CAPRELSA 100mg/1 30 TABLET BOTTLE   5 Specialty Tier 33%N/AP
CAPRELSA 300mg/1 30 TABLET BOTTLE   5 Specialty Tier 33%N/AP
CAPTOPRIL 100MG TABLET   1 Preferred Generic $4.00$12.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CAPTOPRIL 12.5MG TABLET   1 Preferred Generic $4.00$12.00None
CAPTOPRIL 25MG TABLET   1 Preferred Generic $4.00$12.00None
CAPTOPRIL 50MG TABLET   1 Preferred Generic $4.00$12.00None
Captopril and Hydrochlorothiazide 25; 15mg 100 TABLET BOTTLE   1 Preferred Generic $4.00$12.00None
Captopril and Hydrochlorothiazide 25; 25mg 100 TABLET BOTTLE   1 Preferred Generic $4.00$12.00None
Captopril and Hydrochlorothiazide 50; 15mg 100 TABLET BOTTLE   1 Preferred Generic $4.00$12.00None
Captopril and Hydrochlorothiazide 50; 25mg 100 TABLET BOTTLE   1 Preferred Generic $4.00$12.00None
CARAFATE SUS 1GM/10ML   4 Non-Preferred Drug $89.00$267.00None
Carbaglu 200mg/1 5 TABLET BOTTLE   5 Specialty Tier 33%N/AP
CARBAMAZEPINE 100 MG/5 ML SUSP   2 Generic $15.00$45.00None
Carbamazepine 100mg, CHEWABLE 100 TABLET BOTTLE   2 Generic $15.00$45.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Carbamazepine 100mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE   2 Generic $15.00$45.00None
Carbamazepine 200mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE   2 Generic $15.00$45.00None
Carbamazepine 300mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE   2 Generic $15.00$45.00None
CARBAMAZEPINE ER 100 MG TABLET   2 Generic $15.00$45.00None
CARBAMAZEPINE TABLET USP 200MG (1000 CT)   2 Generic $15.00$45.00None
CARBAMAZEPINE XR 200 MG TABLET   2 Generic $15.00$45.00None
CARBAMAZEPINE XR 400 MG TABLET   2 Generic $15.00$45.00None
CARBIDOPA 25 MG TABLET [Lodosyn]   5 Specialty Tier 33%N/ANone
CARBIDOPA AND LEVEDOPA ORALLY DISINTEGRATING TABLETS 10;100MG;MG 100 BOT   2 Generic $15.00$45.00None
Carbidopa and Levodopa 25; 100mg/1; mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, EXTENDED   2 Generic $15.00$45.00None
Carbidopa and Levodopa 50; 200mg/1; mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, EXTENDED   2 Generic $15.00$45.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;100MG;MG 100 BOT   2 Generic $15.00$45.00None
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;250MG;MG 100 BOT   2 Generic $15.00$45.00None
CARBIDOPA-LEVODOPA 10-100 TAB   2 Generic $15.00$45.00None
CARBIDOPA-LEVODOPA 25-100 TAB   2 Generic $15.00$45.00None
CARBIDOPA-LEVODOPA 25-250 TAB   2 Generic $15.00$45.00None
Carbidopa-Levodopa-Entacapone 100 MG [Stalevo]   2 Generic $15.00$45.00None
Carbidopa-Levodopa-Entacapone 125 MG [Stalevo]   2 Generic $15.00$45.00None
Carbidopa-Levodopa-Entacapone 150 MG [Stalevo]   2 Generic $15.00$45.00None
Carbidopa-Levodopa-Entacapone 200 MG [Stalevo]   2 Generic $15.00$45.00None
Carbidopa-Levodopa-Entacapone 50 MG [Stalevo]   2 Generic $15.00$45.00None
Carbidopa-Levodopa-Entacapone 75 MG [Stalevo]   2 Generic $15.00$45.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Carboplatin 10mg/mL   2 Generic $15.00$45.00P
CARDIZEM LA 120 MG TABLET   4 Non-Preferred Drug $89.00$267.00None
CARDURA XL 4MG TABLET   4 Non-Preferred Drug $89.00$267.00None
CARDURA XL 8MG TABLET   4 Non-Preferred Drug $89.00$267.00None
CARIMUNE NF 6GM VIAL   5 Specialty Tier 33%N/AP
CARTEOLOL HCL OPHTHALMIC SOLUTION USP 1% 15ML BOT   2 Generic $15.00$45.00None
CARTIA XT 120MG CAPSULE SA   2 Generic $15.00$45.00None
CARTIA XT 180MG CAPSULE SA   2 Generic $15.00$45.00None
CARTIA XT 240MG CAPSULE SA   2 Generic $15.00$45.00None
CARTIA XT 300MG CAPSULE SR 24 HR   2 Generic $15.00$45.00None
Carvedilol 12.5mg 100 FILM COATED TABLETS in BOTTLE, PLASTIC   1 Preferred Generic $4.00$12.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Carvedilol 25mg 100 FILM COATED TABLETS in BOTTLE, PLASTIC   1 Preferred Generic $4.00$12.00None
Carvedilol 3.125mg 100 FILM COATED TABLETS in BOTTLE, PLASTIC   1 Preferred Generic $4.00$12.00None
Carvedilol 6.25mg 100 FILM COATED TABLETS in BOTTLE, PLASTIC   1 Preferred Generic $4.00$12.00None
CAYSTON KIT 75 MG/VIAL   5 Specialty Tier 33%N/AP
CAZIANT 28 DAY TABLET   2 Generic $15.00$45.00None
CEFACLOR 250 MG CAPSULES   2 Generic $15.00$45.00None
CEFACLOR 250 MG/5 ML SUSP   2 Generic $15.00$45.00None
Cefaclor 375 mg/5 ml suspen   2 Generic $15.00$45.00None
CEFACLOR 500 MG CAPSULES   2 Generic $15.00$45.00None
CEFACLOR ER 500MG TABLET SR 12HR   3 Preferred Brand $38.00$114.00None
CEFACLOR SUS 125 MG/5ML   2 Generic $15.00$45.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFADROXIL 1G TABLET   2 Generic $15.00$45.00None
CEFADROXIL 250 MG/5 ML SUSP   2 Generic $15.00$45.00None
CEFADROXIL 500 MG CAPSULE   1 Preferred Generic $4.00$12.00None
Cefadroxil 500mg/5mL   2 Generic $15.00$45.00None
Cefazolin 1 gm vial   2 Generic $15.00$45.00None
Cefazolin 10g/1 10 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 PACKAGE   2 Generic $15.00$45.00None
CEFAZOLIN 500MG FOR INJECTION   2 Generic $15.00$45.00None
CEFDINIR 250MG/5ML SUSPENSION RECONSTITUTED ORAL   2 Generic $15.00$45.00None
CEFDINIR CAPSULES 300MG (60 CT)   2 Generic $15.00$45.00None
CEFDINIR FOR ORAL SUSPENSION 125MG/5ML (100 CT)   2 Generic $15.00$45.00None
CEFEPIME HCL 2 GRAM VIAL   2 Generic $15.00$45.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFEPIME INJ 1GM 20ML APX 10x1G VIAL   2 Generic $15.00$45.00None
CEFIXIME 100 MG/5 ML SUSP [Suprax]   2 Generic $15.00$45.00None
CEFIXIME 200 MG/5 ML SUSP [Suprax]   2 Generic $15.00$45.00None
Cefotaxime sodium 1 gm vial   2 Generic $15.00$45.00None
Cefotaxime sodium 2 gm vial   2 Generic $15.00$45.00None
Cefotaxime sodium 500 mg vial   2 Generic $15.00$45.00None
CEFOTETAN 1GM VIAL 1EA x 10   2 Generic $15.00$45.00None
CEFOTETAN 2GM VIAL 1EA x 10   2 Generic $15.00$45.00None
Cefoxitin 1g/1 10 POWDER per CARTON   2 Generic $15.00$45.00None
Cefoxitin 2g/1 10 POWDER per CARTON   2 Generic $15.00$45.00None
CEFOXITIN FOR INJECTION SOLUTION   2 Generic $15.00$45.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFPODOXIME 100 MG/5 ML SUSP   2 Generic $15.00$45.00None
CEFPODOXIME 200 MG TABLET   2 Generic $15.00$45.00None
CEFPODOXIME 50 MG/5 ML SUSP   2 Generic $15.00$45.00None
CEFPODOXIME PROXETIL FILM COATED TABLET 100MG (20 CT)   2 Generic $15.00$45.00None
CEFPROZIL 125 MG/5 ML SUSP   2 Generic $15.00$45.00None
cefprozil 250 mg/5 ml susp   2 Generic $15.00$45.00None
Cefprozil 250mg 100 FILM COATED TABLETS in BOTTLE   2 Generic $15.00$45.00None
CEFPROZIL TABLETS 500MG 100 BOT   2 Generic $15.00$45.00None
CEFTAZIDIME 1g 25 VIAL per CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL   2 Generic $15.00$45.00None
CEFTAZIDIME FOR INJECTION 2GM/VIAL 10 X 2 CRTN   2 Generic $15.00$45.00None
CEFTAZIDIME FOR INJECTION 6GM/VIAL 6 X 6 CRTN   2 Generic $15.00$45.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFTIN 125mg/5mL 100 mL in 1 BOTTLE, GLASS   4 Non-Preferred Drug $89.00$267.00None
CEFTIN 250MG/5ML ORAL SUSP   4 Non-Preferred Drug $89.00$267.00None
CEFTRIAXONE 10GM VIAL   2 Generic $15.00$45.00None
CEFTRIAXONE 250 MG VIAL   2 Generic $15.00$45.00None
CEFTRIAXONE FOR INJECTION   2 Generic $15.00$45.00None
CEFTRIAXONE FOR INJECTION   2 Generic $15.00$45.00None
Ceftriaxone Sodium 500mg   2 Generic $15.00$45.00None
CEFUROXIME 1.5 GM/VIAL FOR INJECTION   2 Generic $15.00$45.00None
CEFUROXIME 7.5 GM FOR INJECTION   2 Generic $15.00$45.00None
CEFUROXIME 750 MG FOR INJECTION   2 Generic $15.00$45.00None
Cefuroxime Axetil 250 MG   2 Generic $15.00$45.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFUROXIME AXETIL 500 MG TAB   2 Generic $15.00$45.00None
CELECOXIB 100 MG CAPSULE [Celebrex]   2 Generic $15.00$45.00Q:120
/30Days
CELECOXIB 200 MG CAPSULE [Celebrex]   2 Generic $15.00$45.00Q:60
/30Days
CELECOXIB 400 MG CAPSULE [Celebrex]   2 Generic $15.00$45.00Q:30
/30Days
CELECOXIB 50 MG CAPSULE [Celebrex]   2 Generic $15.00$45.00Q:240
/30Days
CELLCEPT IV INJ 500 MG   4 Non-Preferred Drug $89.00$267.00P
CELONTIN 300 MG KAPSEAL   4 Non-Preferred Drug $89.00$267.00None
Cephalexin 125mg/5mL 200 mL in 1 BOTTLE   2 Generic $15.00$45.00None
CEPHALEXIN 250 MG CAPSULE   1 Preferred Generic $4.00$12.00None
CEPHALEXIN 250 MG TABLET   2 Generic $15.00$45.00None
CEPHALEXIN 250 MG/5ML ORAL SUSP   2 Generic $15.00$45.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEPHALEXIN 500 MG TABLET   2 Generic $15.00$45.00None
CEPHALEXIN 750 MG CAPSULE   2 Generic $15.00$45.00None
CEPHALEXIN CAPSULES 500 MG (500 CT)   1 Preferred Generic $4.00$12.00None
CERDELGA 84 MG CAPSULE   5 Specialty Tier 33%N/AP
CEREZYME 400 UNITS VIAL   5 Specialty Tier 33%N/AP
CESAMET 1 MG CAPSULES   5 Specialty Tier 33%N/AP Q:60
/30Days
CETIRIZINE HCL 1 MG/ML SOLN   2 Generic $15.00$45.00None
CEVIMELINE HCL 30 MG CAPSULE [Evoxac]   2 Generic $15.00$45.00None
CHANTIX 0.5 MG TABLET   4 Non-Preferred Drug $89.00$267.00P
CHANTIX 1 MG CONT MONTH BOX   4 Non-Preferred Drug $89.00$267.00P
CHANTIX 1 MG TABLET   4 Non-Preferred Drug $89.00$267.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CHANTIX STARTING MONTH BOX   4 Non-Preferred Drug $89.00$267.00P
CHEMET 100 MG CAPSULE   4 Non-Preferred Drug $89.00$267.00None
CHLORHEXIDINE GLUCONATE 0.12% RINSE   1 Preferred Generic $4.00$12.00None
CHLOROQUINE PH 250 MG TABLET   2 Generic $15.00$45.00None
CHLOROQUINE PH 500 MG TABLET   2 Generic $15.00$45.00None
CHLOROTHIAZIDE 250 MG TABLET   2 Generic $15.00$45.00None
Chlorothiazide 500mg 100 TABLET BOTTLE   2 Generic $15.00$45.00None
CHLORPROMAZINE 10 MG TABLET   2 Generic $15.00$45.00None
CHLORPROMAZINE 25 MG TABLET   2 Generic $15.00$45.00None
CHLORPROMAZINE 25 MG/ML AMP   4 Non-Preferred Drug $89.00$267.00None
CHLORPROMAZINE 50 MG TABLET   2 Generic $15.00$45.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CHLORPROMAZINE HCL 200 MG TABLET   2 Generic $15.00$45.00None
Chlorpromazine Hydrochloride 100mg SUGAR COATED 1000 TABLET BOTTLE   2 Generic $15.00$45.00None
CHLORTHALIDONE 25 MG TABLET (100 CT)   2 Generic $15.00$45.00None
CHLORTHALIDONE 50 MG TABLET (1000 CT)   2 Generic $15.00$45.00None
CHOLESTYRAMINE LIGHT POWDER   2 Generic $15.00$45.00None
CHOLESTYRAMINE LIGHT POWDER FOR ORAL SUSPENSION   2 Generic $15.00$45.00None
CHORIONIC GONAD 10000U VIAL   2 Generic $15.00$45.00P
CICLOPIROX 0.77% TOPICAL SUSP   2 Generic $15.00$45.00None
CICLOPIROX 1% SHAMPOO   2 Generic $15.00$45.00None
CICLOPIROX GEL   2 Generic $15.00$45.00None
Ciclopirox Olamine 7.7mg/g 1 TUBE in 1 TUBE / 15 g in 1 TUBE   2 Generic $15.00$45.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
cidofovir 375 mg/5 ml vial [Vistide]   5 Specialty Tier 33%N/ANone
Cilostazol 50mg/1 60 TABLET BOTTLE   2 Generic $15.00$45.00None
CILOSTAZOL TABLET 100MG (60 CT)   2 Generic $15.00$45.00None
CILOXAN 0.3% OINTMENT   3 Preferred Brand $38.00$114.00None
Cimetidine 200mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC   2 Generic $15.00$45.00None
CIMETIDINE 300 MG TABLETS   2 Generic $15.00$45.00None
Cimetidine 400mg/1 100 FILM COATED TABLETS in BOTTLE   2 Generic $15.00$45.00None
Cimetidine 800mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC   2 Generic $15.00$45.00None
Cimetidine Hydrochloride Oral Solution 300mg/5mL 237 mL in 1 BOTTLE   2 Generic $15.00$45.00None
Cinryze 500[iU]/5mL 1 VIAL per CARTON / 5 mL in 1 VIAL   5 Specialty Tier 33%N/AP
CIPRO HC OTIC SUSPENSION   4 Non-Preferred Drug $89.00$267.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CIPRODEX OTIC SUSPENSION   3 Preferred Brand $38.00$114.00None
CIPROFLOXACIN 0.3% EYE DROP   1 Preferred Generic $4.00$12.00None
CIPROFLOXACIN 250 MG TABLET (100 CT)   1 Preferred Generic $4.00$12.00None
CIPROFLOXACIN 250 MG/5 ML SUSP   2 Generic $15.00$45.00None
Ciprofloxacin 400 mg/40 ml vl   2 Generic $15.00$45.00None
CIPROFLOXACIN 500 MG/5 ML SUSP   2 Generic $15.00$45.00None
Ciprofloxacin and Dextrose 2mg/mL 24 BAG in 1 CASE / 100 mL in 1 BAG   2 Generic $15.00$45.00None
Ciprofloxacin ER 212.6; 287.5mg/1; mg/1 50 TABLET, FILM COATED, in 1 BOTTLE, PLASTIC   2 Generic $15.00$45.00None
Ciprofloxacin ER 425.2; 574.9mg/1; mg/1 50 TABLET, FILM COATED, in 1 BOTTLE, PLASTIC   2 Generic $15.00$45.00None
CIPROFLOXACIN HCL 100 MG TABLET   1 Preferred Generic $4.00$12.00None
CIPROFLOXACIN HCL 500 MG TAB   1 Preferred Generic $4.00$12.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CIPROFLOXACIN TABLETS 750 MG 100 BOT   1 Preferred Generic $4.00$12.00None
Cisplatin 100mg/100mL 1 VIAL per CARTON / 100 mL in 1 VIAL   2 Generic $15.00$45.00P
CITALOPRAM HBR 10 MG TABLET   1 Preferred Generic $4.00$12.00None
CITALOPRAM HBR 10 MG/5 ML SOLN   2 Generic $15.00$45.00None
CITALOPRAM HBR 20 MG TABLET   1 Preferred Generic $4.00$12.00None
CITALOPRAM HYDROBROMIDE TABLETS 40 MG 30 BOT   1 Preferred Generic $4.00$12.00None
Cladribine 10 mg/10 ml vial   5 Specialty Tier 33%N/AP
CLARAVIS 10 MG CAPSULE   2 Generic $15.00$45.00P
CLARAVIS 20 MG CAPSULE   2 Generic $15.00$45.00P
Claravis 30mg 3 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK   2 Generic $15.00$45.00P
CLARAVIS 40MG CAPSULE   2 Generic $15.00$45.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Clarinex 0.5mg/mL 473 mL in 1 BOTTLE   4 Non-Preferred Drug $89.00$267.00None
CLARINEX-D 12 HOUR TABLET   4 Non-Preferred Drug $89.00$267.00None
CLARITHROMYCIN 125 MG/5ML FOR ORAL SUSPENSION   2 Generic $15.00$45.00None
CLARITHROMYCIN 250 MG TABLET   2 Generic $15.00$45.00None
CLARITHROMYCIN 250 MG/5MLFOR ORAL SUSPENSION   2 Generic $15.00$45.00None
CLARITHROMYCIN 500 MG TABLET   2 Generic $15.00$45.00None
CLARITHROMYCIN ER 500 MG TAB   2 Generic $15.00$45.00None
CLEOCIN 100 MG VAGINAL OVULE   4 Non-Preferred Drug $89.00$267.00None
CLINDACIN PAC KIT   2 Generic $15.00$45.00None
CLINDAGEL 1% GEL   5 Specialty Tier 33%N/ANone
CLINDAMAX 1% GEL   2 Generic $15.00$45.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Clindamycin 150 MG/ML 2ml   2 Generic $15.00$45.00None
Clindamycin 150 MG/ML 6ml   2 Generic $15.00$45.00None
CLINDAMYCIN 600 MG/4 ML ADDVAN   2 Generic $15.00$45.00None
CLINDAMYCIN HCL 150 MG CAPSULE   1 Preferred Generic $4.00$12.00None
CLINDAMYCIN HCL 300 MG 100 CAPSULE in 1 BOTTLE   1 Preferred Generic $4.00$12.00None
CLINDAMYCIN HCL 75 MG 200 CAPSULE BOTTLE   1 Preferred Generic $4.00$12.00None
CLINDAMYCIN PEDIATR 75 MG/5 ML   2 Generic $15.00$45.00None
CLINDAMYCIN PHOSP 1% LOTION   2 Generic $15.00$45.00None
CLINDAMYCIN PHOSPHATE 1% FOAM   2 Generic $15.00$45.00None
clindamycin phosphate 10mg/mL 1 BOTTLE per CARTON / 60 mL in 1 BOTTLE   2 Generic $15.00$45.00None
Clindamycin Phosphate and Benzoyl Peroxide 1 KIT   2 Generic $15.00$45.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE   2 Generic $15.00$45.00None
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX   2 Generic $15.00$45.00None
CLINDAMYCIN PHOSPHATE VAGINAL CREAM   2 Generic $15.00$45.00None
Clindamycin Phosphate-Benzoyl Peroxide 1.2-5% [Benzaclin]   2 Generic $15.00$45.00None
clindamycin-d5w 300 mg/50 ml   2 Generic $15.00$45.00None
clindamycin-d5w 600 mg/50 ml   2 Generic $15.00$45.00None
clindamycin-d5w 900 mg/50 ml   2 Generic $15.00$45.00None
CLINDAMYCIN-TRETINOIN 1.2%-0.025% [Veltin, Ziana]   2 Generic $15.00$45.00None
CLINDESSE 2% VAGINAL CREAM   4 Non-Preferred Drug $89.00$267.00None
CLINIMIX 2.75%/5% INJECTION 1000ML BAG   4 Non-Preferred Drug $89.00$267.00P
CLINIMIX 4.25/10 SOLUTION   4 Non-Preferred Drug $89.00$267.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLINIMIX 4.25/20 SOLUTION   4 Non-Preferred Drug $89.00$267.00P
CLINIMIX 4.25/25 SOLUTION   4 Non-Preferred Drug $89.00$267.00P
CLINIMIX 4.25/5 SOLUTION   4 Non-Preferred Drug $89.00$267.00P
CLINIMIX 5/15 SOLUTION   4 Non-Preferred Drug $89.00$267.00P
CLINIMIX 5/20 SOLUTION   4 Non-Preferred Drug $89.00$267.00P
CLINIMIX 5/25 SULFITE FREE INJECTIONS 1035MG-420MEQ 1000ML BAG   4 Non-Preferred Drug $89.00$267.00P
CLINIMIX E 2.75/10 SOLUTION   4 Non-Preferred Drug $89.00$267.00P
CLINIMIX E 2.75/5 SOLUTION   4 Non-Preferred Drug $89.00$267.00P
CLINIMIX E 4.25/25 SOLUTION   4 Non-Preferred Drug $89.00$267.00P
CLINIMIX E 4.25/5 SOLUTION   4 Non-Preferred Drug $89.00$267.00P
CLINIMIX E 4.25%-10% SOLUTION   4 Non-Preferred Drug $89.00$267.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLINIMIX E 5/20 SOLUTION   4 Non-Preferred Drug $89.00$267.00P
CLINIMIX E 5/25 SOLUTION   4 Non-Preferred Drug $89.00$267.00P
CLINIMIX E 5%/15% INJECTION 2000ML BAG   4 Non-Preferred Drug $89.00$267.00P
CLINISOL 15% SOLUTION   2 Generic $15.00$45.00P
Clofarabine 20 mg/20 ml vial [Clolar]   5 Specialty Tier 33%N/AP
CLOLAR 20 MG/20 ML VIAL   5 Specialty Tier 33%N/AP
CLOMIPRAMINE HCL 25MG CAPSULE   4 Non-Preferred Drug $89.00$267.00P
CLOMIPRAMINE HCL 50MG CAPSULE   4 Non-Preferred Drug $89.00$267.00P
CLOMIPRAMINE HCL 75MG CAPSULE   4 Non-Preferred Drug $89.00$267.00P
Clonazepam 0.125mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PAC   2 Generic $15.00$45.00Q:960
/30Days
Clonazepam 0.25mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING per BLISTER PACK   2 Generic $15.00$45.00Q:480
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Clonazepam 0.5mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING per BLISTER PACK   2 Generic $15.00$45.00Q:240
/30Days
Clonazepam 0.5mg/1 100 TABLET BOTTLE   1 Preferred Generic $4.00$12.00Q:240
/30Days
CLONAZEPAM 1 MG TABLET   1 Preferred Generic $4.00$12.00Q:120
/30Days
Clonazepam 1mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING per BLISTER PACK   2 Generic $15.00$45.00Q:120
/30Days
Clonazepam 2mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING per BLISTER PACK   2 Generic $15.00$45.00Q:300
/30Days
Clonazepam 2mg/1 100 TABLET BOTTLE   1 Preferred Generic $4.00$12.00Q:300
/30Days
Clonidine 0.1mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH   2 Generic $15.00$45.00None
Clonidine 0.2mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH   2 Generic $15.00$45.00None
Clonidine 0.3mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH   2 Generic $15.00$45.00None
CLONIDINE HCL 0.1 MG TABLET   1 Preferred Generic $4.00$12.00None
CLONIDINE HCL 0.2MG TABLET (500 CT)   1 Preferred Generic $4.00$12.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLONIDINE HCL TABLET 0.3MG (100 CT)   1 Preferred Generic $4.00$12.00None
CLOPIDOGREL 300 MG TABLET [Plavix]   2 Generic $15.00$45.00None
CLOPIDOGREL 75 MG TABLET [Plavix]   1 Preferred Generic $4.00$12.00None
CLORAZEPATE 15 MG TABLET   2 Generic $15.00$45.00P Q:180
/30Days
Clorazepate Dipotassium 3.75mg/1 500 TABLET BOTTLE, PLASTIC   2 Generic $15.00$45.00P Q:120
/30Days
Clorazepate Dipotassium 7.5mg/1 500 TABLET BOTTLE, PLASTIC   2 Generic $15.00$45.00P Q:120
/30Days
CLORPRES 0.1-15 TABLET   2 Generic $15.00$45.00None
CLORPRES 0.2-15 TABLET   2 Generic $15.00$45.00None
CLORPRES 0.3-15 TABLET   2 Generic $15.00$45.00None
CLOTRIMAZOLE 1% CREAM   2 Generic $15.00$45.00None
CLOTRIMAZOLE 1% SOLUTION   2 Generic $15.00$45.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLOTRIMAZOLE 10MG TROCHE   2 Generic $15.00$45.00None
Clozapine 100 MG Disintegrating Oral Tablet   2 Generic $15.00$45.00P Q:270
/30Days
Clozapine 100mg/1 100 TABLET BOTTLE   2 Generic $15.00$45.00Q:270
/30Days
CLOZAPINE 200MG TABLET (500 CT)   2 Generic $15.00$45.00Q:135
/30Days
Clozapine 25 MG Disintegrating Oral Tablet   2 Generic $15.00$45.00P
CLOZAPINE 25MG TABLET (100 CT)   2 Generic $15.00$45.00None
CLOZAPINE 50MG TABLET (500 CT)   2 Generic $15.00$45.00None
CLOZAPINE ODT 12.5 MG TABLET   2 Generic $15.00$45.00P
CLOZAPINE ODT 150 MG TABLET   2 Generic $15.00$45.00P Q:180
/30Days
CLOZAPINE ODT 200 MG TABLET   5 Specialty Tier 33%N/AP Q:135
/30Days
COARTEM 20MG-120MG   4 Non-Preferred Drug $89.00$267.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CODEINE SULFATE 15 mg tablet   2 Generic $15.00$45.00Q:720
/30Days
CODEINE SULFATE 30 mg tablet   2 Generic $15.00$45.00Q:360
/30Days
CODEINE SULFATE 60 mg tablet   2 Generic $15.00$45.00Q:180
/30Days
COLCRYS 0.6 MG TABLET   3 Preferred Brand $38.00$114.00Q:120
/30Days
COLESTIPOL HCL 1G TABLET   2 Generic $15.00$45.00None
COLESTIPOL HYDROCHLORIDE 5g/1 100 SUSPENSION in 1 BOTTLE   2 Generic $15.00$45.00None
colistimethate 150mg/2mL 1 VIAL per CARTON / 2 mL in 1 VIAL   2 Generic $15.00$45.00None
COLOCORT 100MG ENEMA   2 Generic $15.00$45.00None
COLY-MYCIN S OTIC SUSP DROP   4 Non-Preferred Drug $89.00$267.00None
COMBIGAN 0.2%-0.5% DROPS   3 Preferred Brand $38.00$114.00None
COMBIVENT RESPIMAT INHAL SPRAY   4 Non-Preferred Drug $89.00$267.00Q:8
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COMETRIQ 100 MG DAILY-DOSE PK   5 Specialty Tier 33%N/AP
COMETRIQ 140 MG DAILY-DOSE PK   5 Specialty Tier 33%N/AP
COMETRIQ 60 MG DAILY-DOSE PACK   5 Specialty Tier 33%N/AP
COMPLERA 200; 27.5; 300mg/1; mg/1; mg/1   5 Specialty Tier 33%N/ANone
COMPRO 25MG SUPPOSITORY   2 Generic $15.00$45.00None
CONDYLOX GEL 0.5% 3.5 GM CRTN   4 Non-Preferred Drug $89.00$267.00None
CONSTULOSE 10 GM/15 ML SOLN   2 Generic $15.00$45.00None
COPAXONE 40 MG/ML SYRINGE   5 Specialty Tier 33%N/AP Q:12
/28Days
CORDRAN 4 MCG/SQ CM TAPE LARGE   4 Non-Preferred Drug $89.00$267.00None
COREG CR 10MG CAPSULE MULTIPHASIC RELEASE 24 HR   4 Non-Preferred Drug $89.00$267.00None
COREG CR 20MG CAPSULE MULTIPHASIC RELEASE 24 HR   4 Non-Preferred Drug $89.00$267.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COREG CR 40MG CAPSULE MULTIPHASIC RELEASE 24 HR   4 Non-Preferred Drug $89.00$267.00None
COREG CR 80MG CAPSULE MULTIPHASIC RELEASE 24 HR   4 Non-Preferred Drug $89.00$267.00None
CORLANOR 5 MG TABLET   4 Non-Preferred Drug $89.00$267.00None
CORLANOR 7.5 MG TABLET   4 Non-Preferred Drug $89.00$267.00None
Cortisone 25 MG Tablet   2 Generic $15.00$45.00None
CORTISPORIN CRE 0.5%   4 Non-Preferred Drug $89.00$267.00None
CORTISPORIN OINTMENT   4 Non-Preferred Drug $89.00$267.00None
COSMEGEN 0.5 MG VIAL   5 Specialty Tier 33%N/AP
COSOPT PF EYE DROPS   4 Non-Preferred Drug $89.00$267.00None
COTELLIC 20 MG TABLET   5 Specialty Tier 33%N/AP
COUMADIN 1 MG TABLET   4 Non-Preferred Drug $89.00$267.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COUMADIN 10MG TABLET   4 Non-Preferred Drug $89.00$267.00None
COUMADIN 2.5MG TABLET   4 Non-Preferred Drug $89.00$267.00None
COUMADIN 2MG TABLET   4 Non-Preferred Drug $89.00$267.00None
COUMADIN 3mg/1 1 BOTTLE per CARTON / 100 TABLET BOTTLE   4 Non-Preferred Drug $89.00$267.00None
COUMADIN 4mg/1 1 BOTTLE in 1 CARTON / 100 TABLET BOTTLE   4 Non-Preferred Drug $89.00$267.00None
COUMADIN 5MG TABLET   4 Non-Preferred Drug $89.00$267.00None
COUMADIN 6MG TABLET   4 Non-Preferred Drug $89.00$267.00None
COUMADIN 7.5MG TABLET   4 Non-Preferred Drug $89.00$267.00None
Creon 256.11mg/1 1 BOTTLE per CARTON / 70 CAPSULE, DELAYED RELEASE in 1 BOTTLE   3 Preferred Brand $38.00$114.00None
CREON DELAYED RELEASE CAPSULES 12000MG 100 BOT   3 Preferred Brand $38.00$114.00None
CREON DELAYED RELEASE CAPSULES 24000MG 100 BOT   3 Preferred Brand $38.00$114.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CREON DELAYED RELEASE CAPSULES 6000MG 100 BOT   3 Preferred Brand $38.00$114.00None
CREON DR 36,000 UNITS CAPSULE   3 Preferred Brand $38.00$114.00None
CRESEMBA 186 MG CAPSULE   5 Specialty Tier 33%N/ANone
CRESEMBA 372 MG VIAL   5 Specialty Tier 33%N/ANone
CRINONE 4% GEL   4 Non-Preferred Drug $89.00$267.00P
CRINONE 8% GEL   4 Non-Preferred Drug $89.00$267.00P
CRIXIVAN 200MG CAPSULE   4 Non-Preferred Drug $89.00$267.00None
CRIXIVAN 400mg, 180 CAPSULE BOTTLE   4 Non-Preferred Drug $89.00$267.00None
CROMOLYN 20 MG/2 ML NEB SOLN   2 Generic $15.00$45.00P
CROMOLYN SODIUM 100 MG/5 ML   5 Specialty Tier 33%N/ANone
CROMOLYN SODIUM 4% 40MG 10ML BOT   1 Preferred Generic $4.00$12.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CUBICIN 500MG VIAL   5 Specialty Tier 33%N/ANone
CUVPOSA 1 MG/5 ML SOLUTION   4 Non-Preferred Drug $89.00$267.00None
Cyclafem 1/35 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK   2 Generic $15.00$45.00None
Cyclafem 7/7/7 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK   2 Generic $15.00$45.00None
CYCLOBENZAPRINE HCL 10MG TABLET (1000 CT)   4 Non-Preferred Drug $89.00$267.00P
Cyclobenzaprine Hydrochloride 5mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC   4 Non-Preferred Drug $89.00$267.00P
CYCLOPHOSPHAMIDE 25 MG CAPSULE   4 Non-Preferred Drug $89.00$267.00P
CYCLOPHOSPHAMIDE 50 MG CAPSULE   4 Non-Preferred Drug $89.00$267.00P
CYCLOSPORINE 100MG CAPSULE   2 Generic $15.00$45.00P
CYCLOSPORINE 25MG CAPSULE   2 Generic $15.00$45.00P
Cyclosporine 50 mg/ml vial   2 Generic $15.00$45.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CYCLOSPORINE MODIFIED 100 MG   2 Generic $15.00$45.00P
CYCLOSPORINE MODIFIED 25 MG   2 Generic $15.00$45.00P
CYCLOSPORINE MODIFIED 50 MG   2 Generic $15.00$45.00P
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT   2 Generic $15.00$45.00P
CYPROHEPTADINE HCL 4 MG   4 Non-Preferred Drug $89.00$267.00P
CYPROHEPTADINE HYDROCHLORIDE SOLUTION USP SYRUP 2MG 473 ML BOTGL   4 Non-Preferred Drug $89.00$267.00P
CYSTADANE 1 GRAM/1.7 ML POWDER   5 Specialty Tier 33%N/ANone
CYSTAGON 150MG CAPSULE   4 Non-Preferred Drug $89.00$267.00P
CYSTAGON 50MG CAPSULE   4 Non-Preferred Drug $89.00$267.00P
CYSTARAN 0.44% EYE DROPS   5 Specialty Tier 33%N/AP
CYTARABINE 20MG/ML VIAL   2 Generic $15.00$45.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CYTARABINE SOLUTION INJECTION 100MG 20ML VIALSD   2 Generic $15.00$45.00P

Chart Legend:

Below are a few notes to help you understand the above 2017 Medicare Part D SecureRx - Option 1 (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 $400 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 $3700) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2017 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 2017 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Part D plan provider.







Tips & Disclaimers
  • Q1Medicare®, Q1Rx®, and Q1Group® are registered Service Marks of Q1Group LLC and may not be used in any advertising, publicity, or for commercial purposes without the express authorization of Q1Group.
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDPCompare.com and MACompare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
    Statement required by Medicare:
    "We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options."
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.