Q1GROUP LLC | Q1Medicare.com - a non-government resource for the Medicare community
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

Select your search style and criteria below or use this example to get started

Search by:
State & Plan   ZIP & Plan   PlanID   FormularyID

Search Criteria
PDP     MAPD
Scroll down to see formulary results.

HumanaChoice H5216-078 (PPO) (H5216-078-1)
Tier 1 (291)
Tier 2 (545)
Tier 3 (728)
Tier 4 (1316)
Tier 5 (639)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
Yes No Show either
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 
2019 Medicare Part D Plan Formulary Information
HumanaChoice H5216-078 (PPO) (H5216-078-1)
Benefit Details           
The HumanaChoice H5216-078 (PPO) (H5216-078-1)
Formulary Drugs Starting with the Letter A

in Grand County, CO: CMS MA Region 20 which includes: CO
Plan Monthly Premium: $49.00 Deductible: $195
Drugs Starting with Letter A

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
ABACAVIR 20 MG/ML SOLUTION   4 Non-Preferred Drug $100.00$290.00Q:960
/30Days
ABACAVIR 300 MG TABLET   4 Non-Preferred Drug $100.00$290.00Q:60
/30Days
Abacavir Sulfate-Lamivudine-Zidovudine tablets [Trizivir]   5 Specialty Tier 29%N/AQ:60
/30Days
ABACAVIR-LAMIVUDINE 600-300 MG   4 Non-Preferred Drug $100.00$290.00Q:30
/30Days
ABELCET INJECTION SUSPENSION 5MG/ML   5 Specialty Tier 29%N/AP
ABILIFY MAINTENA ER 300 MG SYR   5 Specialty Tier 29%N/AQ:1
/28Days
ABILIFY MAINTENA ER 300 MG VL   5 Specialty Tier 29%N/AQ:1
/28Days
ABILIFY MAINTENA ER 400 MG SUSER VIAL   5 Specialty Tier 29%N/AQ:1
/28Days
ABILIFY MAINTENA ER 400 MG SYR   5 Specialty Tier 29%N/AQ:1
/28Days
ABIRATERONE ACETATE 250 MG TABLET [ZYTIGA]   5 Specialty Tier 29%N/AP Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Acamprosate Calcium DR 333 MG tablets [Campral]   4 Non-Preferred Drug $100.00$290.00None
ACARBOSE 100 MG TABLET   3 Preferred Brand $47.00$131.00None
ACARBOSE 25 MG TABLET   3 Preferred Brand $47.00$131.00None
ACARBOSE 50 MG TABLET   3 Preferred Brand $47.00$131.00None
ACEBUTOLOL 200 MG CAPSULE   2* Generic $8.00$0.00None
ACEBUTOLOL 400 MG CAPSULE   2* Generic $8.00$0.00None
ACETAMINOP-CODEINE 120-12 MG/5   3 Preferred Brand $47.00$131.00Q:2700
/30Days
ACETAMINOPHEN-COD #2 TABLET   3 Preferred Brand $47.00$131.00Q:390
/30Days
ACETAMINOPHEN-COD #3 TABLET   3 Preferred Brand $47.00$131.00Q:360
/30Days
ACETAMINOPHEN-COD #4 TABLET   3 Preferred Brand $47.00$131.00Q:180
/30Days
ACETAZOLAMIDE 125MG TABLET   4 Non-Preferred Drug $100.00$290.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETAZOLAMIDE 250MG TABLET (100 CT)   4 Non-Preferred Drug $100.00$290.00None
ACETAZOLAMIDE ER 500 MG CAP   3 Preferred Brand $47.00$131.00None
ACETIC ACID 2% EAR SOLUTION   2* Generic $8.00$0.00None
ACETYLCYSTEINE 10% VIAL   4 Non-Preferred Drug $100.00$290.00P
Acetylcysteine 200 MG/ML Inhalant Solution   4 Non-Preferred Drug $100.00$290.00P
ACITRETIN 10 MG CAPSULE [Soriatane]   5 Specialty Tier 29%N/ANone
ACITRETIN 17.5 MG CAPSULE [Soriatane]   5 Specialty Tier 29%N/ANone
ACITRETIN 25 MG CAPSULE [Soriatane]   5 Specialty Tier 29%N/ANone
ACTHIB VACCINE WITH DILUENT   4 Non-Preferred Drug $100.00$290.00None
ACTIMMUNE 100 MCG/0.5 ML VIAL   5 Specialty Tier 29%N/AP
ACYCLOVIR 200 MG CAPSULE   2* Generic $8.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACYCLOVIR 400 MG TABLET   2* Generic $8.00$0.00None
Acyclovir 5% Ointment   4 Non-Preferred Drug $100.00$290.00P
ACYCLOVIR 800 MG TABLET   2* Generic $8.00$0.00None
Acyclovir sodium 500 mg vial   4 Non-Preferred Drug $100.00$290.00P
ADACEL TDAP SYRINGE   4 Non-Preferred Drug $100.00$290.00None
ADACEL VIAL 2UNT/5UNT   4 Non-Preferred Drug $100.00$290.00None
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA]   5 Specialty Tier 29%N/AP Q:6
/28Days
ADAPALENE 0.1% GEL   4 Non-Preferred Drug $100.00$290.00None
ADCIRCA TABLETS 20MG 60 BOTTLE   5 Specialty Tier 29%N/AP Q:60
/30Days
ADEFOVIR DIPIVOXIL 10 MG TAB [Hepsera]   5 Specialty Tier 29%N/ANone
ADEMPAS 0.5 MG TABLET   5 Specialty Tier 29%N/AP Q:90
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADEMPAS 1 MG TABLET   5 Specialty Tier 29%N/AP Q:90
/30Days
ADEMPAS 1.5 MG TABLET   5 Specialty Tier 29%N/AP Q:90
/30Days
ADEMPAS 2 MG TABLET   5 Specialty Tier 29%N/AP Q:90
/30Days
ADEMPAS 2.5 MG TABLET   5 Specialty Tier 29%N/AP Q:90
/30Days
ADVAIR DISKUS MIS 100/50   3 Preferred Brand $47.00$131.00Q:60
/30Days
ADVAIR DISKUS MIS 250/50   3 Preferred Brand $47.00$131.00Q:60
/30Days
ADVAIR DISKUS MIS 500/50   3 Preferred Brand $47.00$131.00Q:60
/30Days
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER   3 Preferred Brand $47.00$131.00Q:12
/30Days
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL   3 Preferred Brand $47.00$131.00Q:12
/30Days
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL   3 Preferred Brand $47.00$131.00Q:12
/30Days
Afinitor 7.5mg/1 28 BLISTER PACK per CARTON / 1 TABLET per BLISTER PACK   5 Specialty Tier 29%N/AP Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AFINITOR DISPERZ 2 MG TABLET   5 Specialty Tier 29%N/AP
AFINITOR DISPERZ 3 MG TABLET   5 Specialty Tier 29%N/AP
AFINITOR DISPERZ 5 MG TABLET   5 Specialty Tier 29%N/AP
AFINITOR TABLETS 10 MG   5 Specialty Tier 29%N/AP Q:30
/30Days
AFINITOR TABLETS 2.5 MG   5 Specialty Tier 29%N/AP Q:30
/30Days
AFINITOR TABLETS 5 MG   5 Specialty Tier 29%N/AP Q:30
/30Days
AIMOVIG 140 MG/ML AUTOINJECTOR   4 Non-Preferred Drug $100.00$290.00P Q:1
/30Days
AIMOVIG 70 MG/ML AUTOINJECTOR   4 Non-Preferred Drug $100.00$290.00P Q:2
/30Days
ALBENDAZOLE 200 MG TABLET [Albenza]   5 Specialty Tier 29%N/ANone
ALBENZA 200 MG TABLET   5 Specialty Tier 29%N/ANone
ALBUTEROL SUL 2.5 MG/3 ML SOLN   2* Generic $8.00$0.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALBUTEROL SULFATE 0.75mg/3mL 30 POUCH per CARTON / 1 VIAL, SINGLE-DOSE in 1 POUCH / 3 mL in 1 VIAL   2* Generic $8.00$0.00P
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER   2* Generic $8.00$0.00P
ALBUTEROL SULFATE 2 MG TAB   4 Non-Preferred Drug $100.00$290.00None
ALBUTEROL SULFATE 4 MG TAB   4 Non-Preferred Drug $100.00$290.00None
ALBUTEROL SULFATE 4MG TABLET SR 12HR   4 Non-Preferred Drug $100.00$290.00None
ALBUTEROL SULFATE 8MG TABLET SR 12HR   4 Non-Preferred Drug $100.00$290.00None
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   2* Generic $8.00$0.00P
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT   2* Generic $8.00$0.00None
ALECENSA 150 MG CAPSULE   5 Specialty Tier 29%N/AP Q:240
/30Days
ALENDRONATE SODIUM 10 MG TAB   1* Preferred Generic $2.00$0.00Q:30
/30Days
ALENDRONATE SODIUM 35 MG TABLET [Fosamax]   1* Preferred Generic $2.00$0.00Q:4
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALENDRONATE SODIUM 40 MG TABLET   1* Preferred Generic $2.00$0.00Q:30
/30Days
ALENDRONATE SODIUM 5 MG TABLET   1* Preferred Generic $2.00$0.00Q:30
/30Days
ALENDRONATE SODIUM 70 MG TABLET [Fosamax]   1* Preferred Generic $2.00$0.00Q:4
/28Days
ALFUZOSIN HCL ER 10 MG TABLET   2* Generic $8.00$0.00Q:30
/30Days
ALINIA 100 MG/5 ML SUSPENSION   5 Specialty Tier 29%N/AQ:150
/30Days
ALINIA 500 MG TABLET   5 Specialty Tier 29%N/AQ:40
/30Days
Aliskiren 150 MG / Hydrochlorothiazide 12.5 MG Oral Tablet [Tekturna HCT]   3 Preferred Brand $47.00$131.00Q:30
/30Days
Aliskiren 150 MG / Hydrochlorothiazide 25 MG Oral Tablet [Tekturna HCT]   3 Preferred Brand $47.00$131.00Q:30
/30Days
ALISKIREN 150 MG TABLET [Tekturna]   3 Preferred Brand $47.00$131.00Q:30
/30Days
Aliskiren 300 MG / Hydrochlorothiazide 12.5 MG Oral Tablet [Tekturna HCT]   3 Preferred Brand $47.00$131.00Q:30
/30Days
ALISKIREN 300 MG TABLET [Tekturna]   3 Preferred Brand $47.00$131.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALLOPURINOL 100 MG TABLET   1* Preferred Generic $2.00$0.00None
ALLOPURINOL 300 MG TABLET   1* Preferred Generic $2.00$0.00None
ALMOTRIPTAN MALATE 12.5 MG TAB [Axert]   4 Non-Preferred Drug $100.00$290.00S Q:9
/30Days
ALMOTRIPTAN MALATE 6.25 MG TAB [Axert]   4 Non-Preferred Drug $100.00$290.00S Q:9
/30Days
ALPHAGAN P 0.1% DROPS   3 Preferred Brand $47.00$131.00None
ALPRAZOLAM 0.25 MG TABLET   2* Generic $8.00$0.00Q:120
/30Days
ALPRAZOLAM 0.5 MG TABLET   2* Generic $8.00$0.00Q:120
/30Days
ALPRAZOLAM 1 MG TABLET   2* Generic $8.00$0.00Q:120
/30Days
ALPRAZOLAM 2 MG TABLET   2* Generic $8.00$0.00Q:150
/30Days
ALTAVERA-28 TABLET [Portia]   4 Non-Preferred Drug $100.00$290.00None
ALUNBRIG 180 MG TABLET   5 Specialty Tier 29%N/AP Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALUNBRIG 30 MG TABLET   5 Specialty Tier 29%N/AP Q:180
/30Days
ALUNBRIG 90 MG TABLET   5 Specialty Tier 29%N/AP Q:30
/30Days
ALUNBRIG 90 MG-180 MG TABLET PACK   5 Specialty Tier 29%N/AP Q:30
/30Days
ALYACEN 1-35-28 TABLET   4 Non-Preferred Drug $100.00$290.00None
ALYQ 20 MG TABLET   4 Non-Preferred Drug $100.00$290.00P Q:60
/30Days
Amabelz 0.5 MG/0.1 MG 28 TABLET/BLISTER PACK 3 PER CARTON   4 Non-Preferred Drug $100.00$290.00None
Amabelz 1 MG/0.5 MG 28 TABLET/BLISTER PACK 3 PER CARTON   4 Non-Preferred Drug $100.00$290.00None
AMANTADINE 100 MG CAPSULE   4 Non-Preferred Drug $100.00$290.00None
AMANTADINE 100 MG TABLET   4 Non-Preferred Drug $100.00$290.00None
AMANTADINE 50 MG/5 ML SOLUTION   3 Preferred Brand $47.00$131.00None
AMBISOME 50MG VIAL   5 Specialty Tier 29%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMBRISENTAN 10 MG TABLET [LETAIRIS]   5 Specialty Tier 29%N/AP Q:30
/30Days
AMBRISENTAN 5 MG TABLET [LETAIRIS]   5 Specialty Tier 29%N/AP Q:30
/30Days
AMETHIA 0.15-0.03-0.01 MG TABLET   4 Non-Preferred Drug $100.00$290.00Q:91
/90Days
AMETHIA LO TABLET   4 Non-Preferred Drug $100.00$290.00Q:91
/90Days
AMIKACIN SULF 500 MG/2 ML VIAL   4 Non-Preferred Drug $100.00$290.00None
AMILORIDE HCL 5 MG TABLET [Midamor]   3 Preferred Brand $47.00$131.00None
AMILORIDE HCL-HCTZ 5-50 MG TABLET   2* Generic $8.00$0.00None
Amino Acids 15% Solution   4 Non-Preferred Drug $100.00$290.00P
Amino acids 4.25% in dextrose 10% Injectable Solution [Clinimix 4.25/10]   4 Non-Preferred Drug $100.00$290.00P
Amino acids 4.25% in dextrose 5% Injectable Solution [Clinimix 4.25/5]   4 Non-Preferred Drug $100.00$290.00P
Amino acids 4.25% with electrolytes in dextrose 10% Injectable Solution [Clinimix E 4.25/10]   4 Non-Preferred Drug $100.00$290.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN II 10% SOL 6X2000 ML   4 Non-Preferred Drug $100.00$290.00P
AMINOSYN II 15% IV SOLUTION   4 Non-Preferred Drug $100.00$290.00P
AMINOSYN PF INJECTION   4 Non-Preferred Drug $100.00$290.00P
AMINOSYN-PF 7% IV SOLUTION   4 Non-Preferred Drug $100.00$290.00P
AMIODARONE HCL 100 MG TABLET   4 Non-Preferred Drug $100.00$290.00None
AMIODARONE HCL 200 MG TABLET   2* Generic $8.00$0.00None
AMIODARONE HCL 400 MG TABLET   4 Non-Preferred Drug $100.00$290.00None
AMITRIP/PERPHEN 10-4 TABLET   4 Non-Preferred Drug $100.00$290.00P
AMITRIP/PERPHEN 50-4 TABLET   4 Non-Preferred Drug $100.00$290.00P
AMITRIPTYLINE HCL 10 MG TAB   3 Preferred Brand $47.00$131.00P
AMITRIPTYLINE HCL 100 MG TAB   3 Preferred Brand $47.00$131.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITRIPTYLINE HCL 150 MG TAB   3 Preferred Brand $47.00$131.00P
AMITRIPTYLINE HCL 25 MG TAB   3 Preferred Brand $47.00$131.00P
AMITRIPTYLINE HCL 50 MG TAB   3 Preferred Brand $47.00$131.00P
AMITRIPTYLINE HCL 75 MG TAB   3 Preferred Brand $47.00$131.00P
AMLODIPINE BESYLATE 10 MG TABLET [Norvasc]   1* Preferred Generic $2.00$0.00None
AMLODIPINE BESYLATE 2.5 MG TAB   1* Preferred Generic $2.00$0.00None
AMLODIPINE BESYLATE 5 MG TABLET [Norvasc]   1* Preferred Generic $2.00$0.00None
AMLODIPINE-ATORVAST 10-20 MG [Caduet]   4 Non-Preferred Drug $100.00$290.00Q:30
/30Days
AMLODIPINE-ATORVAST 10-40 MG [Caduet]   4 Non-Preferred Drug $100.00$290.00Q:30
/30Days
Amlodipine-Atorvastatin 10-10 mg [Caduet]   4 Non-Preferred Drug $100.00$290.00Q:30
/30Days
Amlodipine-Atorvastatin 10-80 mg [Caduet]   4 Non-Preferred Drug $100.00$290.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Amlodipine-Atorvastatin 2.5-10 mg [Caduet]   4 Non-Preferred Drug $100.00$290.00Q:30
/30Days
Amlodipine-Atorvastatin 2.5-20 mg [Caduet]   4 Non-Preferred Drug $100.00$290.00Q:30
/30Days
Amlodipine-Atorvastatin 2.5-40 mg [Caduet]   4 Non-Preferred Drug $100.00$290.00Q:30
/30Days
Amlodipine-Atorvastatin 5-10 mg [Caduet]   4 Non-Preferred Drug $100.00$290.00Q:30
/30Days
Amlodipine-Atorvastatin 5-20 mg [Caduet]   4 Non-Preferred Drug $100.00$290.00Q:30
/30Days
Amlodipine-Atorvastatin 5-40 mg [Caduet]   4 Non-Preferred Drug $100.00$290.00Q:30
/30Days
Amlodipine-Atorvastatin 5-80 mg [Caduet]   4 Non-Preferred Drug $100.00$290.00Q:30
/30Days
AMLODIPINE-BENAZEPRIL 10-20 MG Capsule [Lotrel]   1* Preferred Generic $2.00$0.00Q:60
/30Days
AMLODIPINE-BENAZEPRIL 10-40 MG Capsule [Lotrel]   1* Preferred Generic $2.00$0.00Q:30
/30Days
AMLODIPINE-BENAZEPRIL 2.5-10 Capsule [Lotrel]   1* Preferred Generic $2.00$0.00Q:60
/30Days
AMLODIPINE-BENAZEPRIL 5-10 MG Capsule [Lotrel]   1* Preferred Generic $2.00$0.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE-BENAZEPRIL 5-20 MG Capsule [Lotrel]   1* Preferred Generic $2.00$0.00Q:60
/30Days
AMLODIPINE-BENAZEPRIL 5-40 MG Capsule [Lotrel]   1* Preferred Generic $2.00$0.00Q:30
/30Days
AMLODIPINE-OLMESARTAN 10-20 MG [Azor]   4 Non-Preferred Drug $100.00$290.00Q:30
/30Days
AMLODIPINE-OLMESARTAN 10-40 MG [Azor]   4 Non-Preferred Drug $100.00$290.00Q:30
/30Days
AMLODIPINE-OLMESARTAN 5-20 MG [Azor]   4 Non-Preferred Drug $100.00$290.00Q:30
/30Days
AMLODIPINE-OLMESARTAN 5-40 MG [Azor]   4 Non-Preferred Drug $100.00$290.00Q:30
/30Days
AMLODIPINE-VALSARTAN 10-160 MG   2* Generic $8.00$0.00Q:30
/30Days
AMLODIPINE-VALSARTAN 10-320 MG   2* Generic $8.00$0.00Q:30
/30Days
AMLODIPINE-VALSARTAN 5-160 MG   2* Generic $8.00$0.00Q:30
/30Days
AMLODIPINE-VALSARTAN 5-320 MG   2* Generic $8.00$0.00Q:30
/30Days
AMMONIUM LACTATE 12% CREAM   2* Generic $8.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMMONIUM LACTATE 12% LOTION   2* Generic $8.00$0.00None
AMNESTEEM 10 MG CAPSULE   4 Non-Preferred Drug $100.00$290.00Q:60
/30Days
AMNESTEEM 20 MG CAPSULE   4 Non-Preferred Drug $100.00$290.00Q:60
/30Days
AMNESTEEM 40 MG CAPSULE   4 Non-Preferred Drug $100.00$290.00Q:120
/30Days
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET [Augmentin]   2* Generic $8.00$0.00None
AMOX-CLAV 200-28.5 MG/5 ML SUS   2* Generic $8.00$0.00None
AMOX-CLAV 250-62.5 MG/5 ML SUS   2* Generic $8.00$0.00None
AMOX-CLAV 400-57 MG/5 ML SUSP   2* Generic $8.00$0.00None
AMOX-CLAV 500-125 MG TABLET [Augmentin]   2* Generic $8.00$0.00None
AMOX-CLAV 600-42.9 MG/5 ML SUS   2* Generic $8.00$0.00None
AMOX-CLAV 875-125 MG TABLET [Augmentin]   2* Generic $8.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXAPINE 100MG TABLET   4 Non-Preferred Drug $100.00$290.00P
AMOXAPINE 150MG TABLET   4 Non-Preferred Drug $100.00$290.00P
AMOXAPINE 25MG TABLET   4 Non-Preferred Drug $100.00$290.00P
AMOXAPINE 50MG TABLET   4 Non-Preferred Drug $100.00$290.00P
AMOXICILLIN 125 MG/5 ML SUSP   1* Preferred Generic $2.00$0.00None
AMOXICILLIN 125MG TABLET CHEW   1* Preferred Generic $2.00$0.00None
AMOXICILLIN 200 MG/5 ML SUSP   1* Preferred Generic $2.00$0.00None
AMOXICILLIN 250 MG CAPSULE   1* Preferred Generic $2.00$0.00None
AMOXICILLIN 250 MG TAB CHEW   1* Preferred Generic $2.00$0.00None
AMOXICILLIN 250 MG/5 ML SUSP   1* Preferred Generic $2.00$0.00None
AMOXICILLIN 400 MG/5 ML SUSP   1* Preferred Generic $2.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN 500 MG CAPSULE   1* Preferred Generic $2.00$0.00None
AMOXICILLIN 500 MG TABLET   1* Preferred Generic $2.00$0.00None
AMOXICILLIN 875 MG TABLET   1* Preferred Generic $2.00$0.00None
AMPHETAMINE SALT COMBO 12.5MG TABLET   3 Preferred Brand $47.00$131.00Q:90
/30Days
AMPHETAMINE SALT COMBO 15MG TABLET   3 Preferred Brand $47.00$131.00Q:90
/30Days
AMPHETAMINE SALT COMBO 7.5MG TABLET   3 Preferred Brand $47.00$131.00Q:90
/30Days
AMPHETAMINE SALTS 5 MG TAB   3 Preferred Brand $47.00$131.00Q:90
/30Days
amphotericin b 50mg/10mL 10 mL in 1 VIAL   4 Non-Preferred Drug $100.00$290.00P
AMPICILLIN 10 GM VIAL   4 Non-Preferred Drug $100.00$290.00None
Ampicillin 1000 MG / Sulbactam 500 MG Injection   4 Non-Preferred Drug $100.00$290.00None
Ampicillin 1000 MG Injection   4 Non-Preferred Drug $100.00$290.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Ampicillin 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS   4 Non-Preferred Drug $100.00$290.00None
Ampicillin 2000 MG / Sulbactam 1000 MG Injection   4 Non-Preferred Drug $100.00$290.00None
AMPICILLIN CAPSULES 500MG 100 BOT   1* Preferred Generic $2.00$0.00None
AMPICILLIN-SULBACTAM 15 GM VL   4 Non-Preferred Drug $100.00$290.00None
AMPYRA ER 10 MG TABLET   5 Specialty Tier 29%N/AP Q:60
/30Days
AMRIX 30 MG   4 Non-Preferred Drug $100.00$290.00P Q:21
/30Days
AMRIX CAPSULES EXTENDED RELEASE 15MG 60 CAPSULES BOT   4 Non-Preferred Drug $100.00$290.00P Q:21
/30Days
ANADROL-50 TABLET   5 Specialty Tier 29%N/ANone
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE   4 Non-Preferred Drug $100.00$290.00None
Anagrelide Hydrochloride 1mg/1 100 CAPSULE BOTTLE   4 Non-Preferred Drug $100.00$290.00None
ANASTROZOLE 1 MG TABLET   1* Preferred Generic $2.00$0.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANDROGEL 1.62% (1.25G) GEL PCKT   3 Preferred Brand $47.00$131.00P Q:38
/30Days
ANDROGEL 1.62% (2.5G) GEL PCKT   3 Preferred Brand $47.00$131.00P Q:150
/30Days
Androgel 16.2mg/g 1 BOTTLE, PUMP per CARTON / 88 g in 1 BOTTLE, PUMP   3 Preferred Brand $47.00$131.00P Q:150
/30Days
ANORO ELLIPTA 62.5-25 MCG INH   3 Preferred Brand $47.00$131.00Q:60
/30Days
APOKYN 30 MG/3 ML CARTRIDGE   5 Specialty Tier 29%N/AQ:84
/28Days
Apraclonidine 5 MG/ML Ophthalmic Solution   4 Non-Preferred Drug $100.00$290.00None
APREPITANT 125 MG CAPSULE [Emend]   4 Non-Preferred Drug $100.00$290.00P Q:2
/28Days
APREPITANT 125-80-80 MG PACK [Emend]   4 Non-Preferred Drug $100.00$290.00P Q:6
/28Days
APREPITANT 40 MG CAPSULE [Emend]   4 Non-Preferred Drug $100.00$290.00P Q:2
/28Days
APREPITANT 80 MG CAPSULE [Emend]   4 Non-Preferred Drug $100.00$290.00P Q:4
/28Days
APRI 0.15-0.03 TABLET   4 Non-Preferred Drug $100.00$290.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
APRISO CP24   3 Preferred Brand $47.00$131.00Q:120
/30Days
APTIOM 200 MG TABLET   5 Specialty Tier 29%N/AP Q:30
/30Days
APTIOM 400 MG TABLET   5 Specialty Tier 29%N/AP Q:30
/30Days
APTIOM 600 MG TABLET   5 Specialty Tier 29%N/AP Q:60
/30Days
APTIOM 800 MG TABLET   5 Specialty Tier 29%N/AP Q:60
/30Days
APTIVUS 250MG CAPSULE   5 Specialty Tier 29%N/AQ:120
/30Days
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT   5 Specialty Tier 29%N/AQ:285
/28Days
ARALAST NP 1,000 MG VIAL   5 Specialty Tier 29%N/AP
ARANELLE 7-9-5 TABLET   4 Non-Preferred Drug $100.00$290.00None
ARCALYST INJECTION 220MG/VIAL   5 Specialty Tier 29%N/AP
ARIPIPRAZOLE 1 MG/ML SOLUTION [Abilify]   4 Non-Preferred Drug $100.00$290.00Q:750
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARIPIPRAZOLE 10 MG TABLET [Abilify]   4 Non-Preferred Drug $100.00$290.00Q:30
/30Days
ARIPIPRAZOLE 15 MG TABLET [Abilify]   4 Non-Preferred Drug $100.00$290.00Q:30
/30Days
ARIPIPRAZOLE 2 MG TABLET [Abilify]   4 Non-Preferred Drug $100.00$290.00Q:30
/30Days
ARIPIPRAZOLE 20 MG TABLET [Abilify]   4 Non-Preferred Drug $100.00$290.00Q:30
/30Days
ARIPIPRAZOLE 30 MG TABLET [Abilify]   4 Non-Preferred Drug $100.00$290.00Q:30
/30Days
ARIPIPRAZOLE 5 MG TABLET [Abilify]   4 Non-Preferred Drug $100.00$290.00Q:30
/30Days
ARIPIPRAZOLE ODT 10 MG TABLET RAPDIS [Abilify Discmelt]   4 Non-Preferred Drug $100.00$290.00Q:60
/30Days
ARIPIPRAZOLE ODT 15 MG TABLET RAPDIS [Abilify Discmelt]   4 Non-Preferred Drug $100.00$290.00Q:60
/30Days
ARISTADA ER 1064 MG/3.9 ML SYR   5 Specialty Tier 29%N/AQ:4
/56Days
ARISTADA ER 441 MG/1.6 ML SYRN   5 Specialty Tier 29%N/AQ:2
/28Days
ARISTADA ER 662 MG/2.4 ML SYRN   5 Specialty Tier 29%N/AQ:2
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARISTADA ER 882 MG/3.2 ML SYRN   5 Specialty Tier 29%N/AQ:3
/28Days
ARISTADA INITIO ER 675 MG/2.4 SUSER SYR   5 Specialty Tier 29%N/AQ:2
/42Days
ARNUITY ELLIPTA 100 MCG INH   3 Preferred Brand $47.00$131.00Q:30
/30Days
ARNUITY ELLIPTA 200 MCG INH   3 Preferred Brand $47.00$131.00Q:30
/30Days
ARNUITY ELLIPTA 50 MCG INH BLST W/DEV   3 Preferred Brand $47.00$131.00Q:30
/30Days
ASHLYNA 0.15-0.03-0.01 MG TAB   4 Non-Preferred Drug $100.00$290.00Q:91
/90Days
Aspirin-Diphenhydramine ER 25-200 MG   4 Non-Preferred Drug $100.00$290.00S
ASPIRIN/BUTALBITAL/CAFFEINE/CODEINE   4 Non-Preferred Drug $100.00$290.00P Q:180
/30Days
ATAZANAVIR SULFATE 150 MG CAP [Reyataz]   5 Specialty Tier 29%N/AQ:60
/30Days
ATAZANAVIR SULFATE 200 MG CAP [Reyataz]   5 Specialty Tier 29%N/AQ:60
/30Days
ATAZANAVIR SULFATE 300 MG CAP [Reyataz]   5 Specialty Tier 29%N/AQ:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATENOLOL 100 MG TABLET   1* Preferred Generic $2.00$0.00None
ATENOLOL 25 MG TABLET   1* Preferred Generic $2.00$0.00None
ATENOLOL 50 MG TABLET   1* Preferred Generic $2.00$0.00None
ATENOLOL-CHLORTHALIDONE 100-25   1* Preferred Generic $2.00$0.00None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   1* Preferred Generic $2.00$0.00None
ATOMOXETINE HCL 10 MG CAPSULE [Strattera]   3 Preferred Brand $47.00$131.00Q:60
/30Days
ATOMOXETINE HCL 100 MG CAPSULE [Strattera]   3 Preferred Brand $47.00$131.00Q:30
/30Days
ATOMOXETINE HCL 18 MG CAPSULE [Strattera]   3 Preferred Brand $47.00$131.00Q:60
/30Days
ATOMOXETINE HCL 25 MG CAPSULE [Strattera]   3 Preferred Brand $47.00$131.00Q:60
/30Days
ATOMOXETINE HCL 40 MG CAPSULE [Strattera]   3 Preferred Brand $47.00$131.00Q:60
/30Days
ATOMOXETINE HCL 60 MG CAPSULE [Strattera]   3 Preferred Brand $47.00$131.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATOMOXETINE HCL 80 MG CAPSULE [Strattera]   3 Preferred Brand $47.00$131.00Q:30
/30Days
ATORVASTATIN 10 MG TABLET [Lipitor]   1* Preferred Generic $2.00$0.00Q:30
/30Days
ATORVASTATIN 20 MG TABLET [Lipitor]   1* Preferred Generic $2.00$0.00Q:30
/30Days
ATORVASTATIN 40 MG TABLET [Lipitor]   1* Preferred Generic $2.00$0.00Q:30
/30Days
ATORVASTATIN 80 MG TABLET [Lipitor]   1* Preferred Generic $2.00$0.00Q:30
/30Days
ATOVAQUONE 750 MG/5 ML SUSP [Mepron]   5 Specialty Tier 29%N/ANone
Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone]   4 Non-Preferred Drug $100.00$290.00None
ATOVAQUONE-PROGUANIL 62.5-25 [Malarone]   4 Non-Preferred Drug $100.00$290.00None
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC   5 Specialty Tier 29%N/AQ:30
/30Days
ATROPINE 1% EYE DROPS   2* Generic $8.00$0.00None
AUBRA-28 TABLET   4 Non-Preferred Drug $100.00$290.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AURYXIA 210 MG TABLET   4 Non-Preferred Drug $100.00$290.00P Q:360
/30Days
AUSTEDO 12 MG TABLET   5 Specialty Tier 29%N/AP Q:120
/30Days
AUSTEDO 6 MG TABLET   5 Specialty Tier 29%N/AP Q:60
/30Days
AUSTEDO 9 MG TABLET   5 Specialty Tier 29%N/AP Q:120
/30Days
AVIANE 0.1-0.02 TABLET   4 Non-Preferred Drug $100.00$290.00None
AZATHIOPRINE 50 MG TABLET   1* Preferred Generic $2.00$0.00P
AZELAIC ACID 15% GEL [Finacea]   4 Non-Preferred Drug $100.00$290.00S
AZELASTINE 0.15% NASAL SPRAY   4 Non-Preferred Drug $100.00$290.00Q:30
/25Days
AZELASTINE 137 MCG NASAL SPRAY   3 Preferred Brand $47.00$131.00Q:30
/25Days
AZELASTINE HCL 0.05% DROPS   3 Preferred Brand $47.00$131.00None
AZITHROMYCIN 1 GM PWD PACKET   3 Preferred Brand $47.00$131.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZITHROMYCIN 100 MG/5 ML SUSP   3 Preferred Brand $47.00$131.00None
AZITHROMYCIN 200 MG/5 ML SUSP   3 Preferred Brand $47.00$131.00None
AZITHROMYCIN 250 MG TABLET   2* Generic $8.00$0.00None
AZITHROMYCIN 250 MG TABLET   2* Generic $8.00$0.00None
AZITHROMYCIN 500 MG TABLET   2* Generic $8.00$0.00None
AZITHROMYCIN 500 MG TABLET [Zithromax Tri-Pak]   2* Generic $8.00$0.00None
AZITHROMYCIN 600 MG TABLET   2* Generic $8.00$0.00Q:16
/60Days
AZITHROMYCIN I.V. 500 MG VIAL   2* Generic $8.00$0.00None
AZTREONAM FOR INJECTION   4 Non-Preferred Drug $100.00$290.00None

Chart Legend:

Below are a few notes to help you understand the above 2019 Medicare Part D HumanaChoice H5216-078 (PPO) 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). The plan name is followed by the plan type (PDP, HMO, HMO-POS, PPO, PFFS, etc.)

  • 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 $415 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 five (5) tiers 1=Preferred Generics, 2=Generics, 3=Preferred Brands, 4=Non-preferred Brands, 5=Specialty Drugs. *Some Part D plans exclude one or more drug tiers from the deductible. If the drug tier field above is followed by * (example: 2*), then this drug tier is excluded from the plan’s deductible.
    • Tier 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 $3820) at a "Preferred" network pharmacy. In most cases, the "Preferred" network pharmacy cost-sharing is lower than the standard (non-preferred) network pharmacy cost-sharing.
    • 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 2019 )

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.