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Humana Walmart Value Rx Plan (PDP) (S5884-195-0)
Tier 1 (161)
Tier 2 (677)
Tier 3 (701)
Tier 4 (1072)
Tier 5 (611)
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:

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2021 Medicare Part D Plan Formulary Information
Humana Walmart Value Rx Plan (PDP) (S5884-195-0)
Benefit Details           
The Humana Walmart Value Rx Plan (PDP) (S5884-195-0)
Formulary Drugs Starting with the Letter B

in CMS PDP Region 16 which includes: WI
Plan Monthly Premium: $17.20 Deductible: $445 Qualifies for LIS: No
Drugs Starting with Letter B

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Bacitracin 500 unit/gm Eye Ointment   4 Non-Preferred Drug 35%35%None
BACITRACIN/POLYMYXIN B OINT 500UNT/10000UNT   2* Generic $4.00$12.00None
BACLOFEN 10 MG TABLET   2* Generic $4.00$12.00None
BACLOFEN 20 MG TABLET [Lioresal]   2* Generic $4.00$12.00None
BACLOFEN 5 MG TABLET   2* Generic $4.00$12.00Q:90
/30Days
BALSALAZIDE DISODIUM 750 MG CAPSULE [Colazal]   4 Non-Preferred Drug 35%35%None
BALVERSA 3 MG TABLET   5 Specialty Tier 25%N/AP Q:90
/30Days
BALVERSA 4 MG TABLET   5 Specialty Tier 25%N/AP Q:60
/30Days
BALVERSA 5 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
Banzel 200mg/1   5 Specialty Tier 25%N/AP Q:480
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BANZEL 400MG TABLET   5 Specialty Tier 25%N/AP Q:240
/30Days
Banzel 40mg/mL   5 Specialty Tier 25%N/AP Q:2760
/30Days
BAQSIMI 3 MG SPRAY TWO PACK   3 Preferred Brand 19%19%None
BARACLUDE 0.05mg/mL 1 BOTTLE per CARTON / 210 mL in 1 BOTTLE   4 Non-Preferred Drug 35%35%Q:630
/30Days
BCG VACCINE 50mg/1 1 VIAL per CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL   4 Non-Preferred Drug 35%35%None
BELBUCA 150 MCG FILM   4 Non-Preferred Drug 35%35%Q:60
/30Days
BELBUCA 300 MCG FILM   4 Non-Preferred Drug 35%35%Q:60
/30Days
BELBUCA 450 MCG FILM   4 Non-Preferred Drug 35%35%Q:60
/30Days
BELBUCA 600 MCG FILM   4 Non-Preferred Drug 35%35%Q:60
/30Days
BELBUCA 75 MCG FILM   4 Non-Preferred Drug 35%35%Q:60
/30Days
BELBUCA 750 MCG FILM   4 Non-Preferred Drug 35%35%Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BELBUCA 900 MCG FILM   4 Non-Preferred Drug 35%35%Q:60
/30Days
BELSOMRA 10 MG TABLET   3 Preferred Brand 19%19%Q:60
/30Days
BELSOMRA 15 MG TABLET   3 Preferred Brand 19%19%Q:30
/30Days
BELSOMRA 20 MG TABLET   3 Preferred Brand 19%19%Q:30
/30Days
BELSOMRA 5 MG TABLET   3 Preferred Brand 19%19%Q:120
/30Days
BENAZEPRIL HCL 10 MG TABLET   2* Generic $4.00$12.00None
BENAZEPRIL HCL 20 MG TABLET   1* Preferred Generic $1.00$3.00None
BENAZEPRIL HCL 40 MG TABLET   1* Preferred Generic $1.00$3.00None
BENAZEPRIL HCL 5 MG TABLET   2* Generic $4.00$12.00None
BENAZEPRIL-HCTZ 10-12.5 MG TABLET [Lotensin HCT]   2* Generic $4.00$12.00None
BENAZEPRIL-HCTZ 20-12.5 MG TABLET [Lotensin HCT]   2* Generic $4.00$12.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BENAZEPRIL-HCTZ 20-25 MG TABLET [Lotensin HCT]   2* Generic $4.00$12.00None
BENAZEPRIL-HCTZ 5-6.25 MG TABLET [Lotensin HCT]   2* Generic $4.00$12.00None
BENLYSTA 200 MG/ML AUTOINJECT   5 Specialty Tier 25%N/AP Q:8
/28Days
BENLYSTA 200 MG/ML SYRINGE   5 Specialty Tier 25%N/AP Q:8
/28Days
BENZTROPINE MES 0.5 MG TABLET [Cogentin]   2* Generic $4.00$12.00None
BENZTROPINE MES 1 MG TABLET [Cogentin]   2* Generic $4.00$12.00None
BENZTROPINE MES 2 MG TABLET [Cogentin]   2* Generic $4.00$12.00None
Betamethasone Dipropionate 0.64mg/g / 45 g TUBE   3 Preferred Brand 19%19%Q:90
/30Days
BETAMETHASONE DP 0.05% LOTION   3 Preferred Brand 19%19%Q:120
/30Days
BETAMETHASONE DP 0.05% OINTMENT [Maxivate]   4 Non-Preferred Drug 35%35%Q:90
/30Days
BETAMETHASONE DP AUG 0.05% CREAM (g) [RRB Pak]   2* Generic $4.00$12.00Q:100
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BETAMETHASONE DP AUG 0.05% GEL   4 Non-Preferred Drug 35%35%Q:100
/30Days
BETAMETHASONE DP AUG 0.05% LOTION   4 Non-Preferred Drug 35%35%Q:120
/30Days
BETAMETHASONE DP AUG 0.05% OINTMENT [Diprolene]   4 Non-Preferred Drug 35%35%Q:100
/30Days
BETAMETHASONE VA 0.1% CREAM (G) [Valisone]   2* Generic $4.00$12.00Q:180
/30Days
BETAMETHASONE VALER 0.1% LOTION [Valisone]   3 Preferred Brand 19%19%Q:120
/30Days
BETAMETHASONE VALER 0.1% OINTMENT [Valisone]   2* Generic $4.00$12.00Q:180
/30Days
BETASERON 0.3 MG KIT   5 Specialty Tier 25%N/AP Q:15
/30Days
BETAXOLOL HCL 0.5% EYE DROPS   3 Preferred Brand 19%19%None
BETHANECHOL 10 MG TABLET   3 Preferred Brand 19%19%None
BETHANECHOL 25 MG TABLET   3 Preferred Brand 19%19%None
BETHANECHOL 5 MG TABLET   3 Preferred Brand 19%19%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BETHANECHOL 50 MG TABLET   4 Non-Preferred Drug 35%35%None
BETHKIS 300 MG/4 ML AMPULE   5 Specialty Tier 25%N/AP
BEVESPI AEROSPHERE INHALER   4 Non-Preferred Drug 35%35%Q:11
/30Days
BEXAROTENE 75 MG CAPSULE [Targretin]   5 Specialty Tier 25%N/AP Q:300
/30Days
BEXSERO PREFILLED SYRINGE   4 Non-Preferred Drug 35%35%None
BICALUTAMIDE 50 MG TABLET   3 Preferred Brand 19%19%Q:30
/30Days
BICILL LA PFS 600MU 1ML PED   4 Non-Preferred Drug 35%35%None
BICILLIN LA PFS 1200MU 2ML   4 Non-Preferred Drug 35%35%None
BICILLIN LA. 600000UNIT/ML 1ML   4 Non-Preferred Drug 35%35%None
BIDIL TABLET   4 Non-Preferred Drug 35%35%Q:180
/30Days
BIKTARVY 50-200-25 MG TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BISOPROLOL FUMARATE 10 MG TABLET   2* Generic $4.00$12.00None
BISOPROLOL FUMARATE 5 MG TABLET   2* Generic $4.00$12.00None
BISOPROLOL-HCTZ 10-6.25 MG TABLET   2* Generic $4.00$12.00None
BISOPROLOL-HCTZ 2.5-6.25 MG TABLET   2* Generic $4.00$12.00None
BISOPROLOL-HCTZ 5-6.25 MG TABLET   2* Generic $4.00$12.00None
BLISOVI 24 FE TABLET [Tarina Fe 1/20]   4 Non-Preferred Drug 35%35%None
BLISOVI FE 1.5-30 TABLET [Microgestin Fe 1.5/30]   4 Non-Preferred Drug 35%35%None
BOOSTRIX TDAP VACCINE SYRINGE   4 Non-Preferred Drug 35%35%None
BOOSTRIX TDAP VACCINE VIAL   4 Non-Preferred Drug 35%35%None
BOSENTAN 125 MG TABLET [Tracleer]   5 Specialty Tier 25%N/AP Q:60
/30Days
BOSENTAN 62.5 MG TABLET [Tracleer]   5 Specialty Tier 25%N/AP Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BOSULIF 100 MG TABLET   5 Specialty Tier 25%N/AP Q:120
/30Days
BOSULIF 400 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
BOSULIF 500 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
BRAFTOVI 75 MG CAPSULE   5 Specialty Tier 25%N/AP Q:180
/30Days
BREZTRI AEROSPHERE INHALER HFA AER AD   3 Preferred Brand 19%19%Q:11
/30Days
BRILINTA 60 MG TABLET   3 Preferred Brand 19%19%Q:60
/30Days
BRILINTA 90mg/1 60 TABLET BOTTLE   3 Preferred Brand 19%19%Q:60
/30Days
BRIMONIDINE 0.2% EYE DROPS [Alphagan]   2* Generic $4.00$12.00None
BRIMONIDINE TARTRATE 0.15% DROPS   3 Preferred Brand 19%19%None
BRIVIACT 10 MG TABLET   5 Specialty Tier 25%N/AP Q:60
/30Days
BRIVIACT 10 MG/ML ORAL SOLUTION   5 Specialty Tier 25%N/AP Q:600
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BRIVIACT 100 MG TABLET   5 Specialty Tier 25%N/AP Q:60
/30Days
BRIVIACT 25 MG TABLET   5 Specialty Tier 25%N/AP Q:60
/30Days
BRIVIACT 50 MG TABLET   5 Specialty Tier 25%N/AP Q:60
/30Days
BRIVIACT 75 MG TABLET   5 Specialty Tier 25%N/AP Q:60
/30Days
BROMFENAC SODIUM 0.09% EYE DROPS [Xibrom]   4 Non-Preferred Drug 35%35%Q:2
/30Days
BROMOCRIPTINE 2.5 MG TABLET [Parlodel]   4 Non-Preferred Drug 35%35%None
BRUKINSA 80 MG CAPSULE   5 Specialty Tier 25%N/AP Q:120
/30Days
BUDESONIDE 0.25 MG/2 ML SUSP AMPUL-NEB [Pulmicort]   4 Non-Preferred Drug 35%35%P
BUDESONIDE 0.5 MG/2 ML SUSP AMPUL-NEB [Pulmicort]   4 Non-Preferred Drug 35%35%P
BUDESONIDE EC 3 MG CAPSULE DR - ER [Entocort EC]   4 Non-Preferred Drug 35%35%P
BUDESONIDE ER 9 MG TABLETDR - ER [UCERIS]   5 Specialty Tier 25%N/AP Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BUMETANIDE 0.5 MG TABLET [Bumex]   2* Generic $4.00$12.00None
BUMETANIDE 1 MG TABLET [Bumex]   2* Generic $4.00$12.00None
BUMETANIDE 2 MG TABLET [Bumex]   2* Generic $4.00$12.00None
BUPRENORP-NALOX 12-3 MG SL FILM [Suboxone]   2* Generic $4.00$12.00Q:60
/30Days
BUPRENORP-NALOX 2-0.5 MG SL FILM [Suboxone]   2* Generic $4.00$12.00Q:90
/30Days
BUPRENORP-NALOX 4-1 MG SL FILM [Suboxone]   2* Generic $4.00$12.00Q:90
/30Days
BUPRENORP-NALOX 8-2 MG SL FILM [Suboxone]   2* Generic $4.00$12.00Q:90
/30Days
BUPRENORPHINE 10 MCG/HR PATCH [Butrans]   4 Non-Preferred Drug 35%35%Q:4
/28Days
BUPRENORPHINE 15 MCG/HR PATCH [Butrans]   4 Non-Preferred Drug 35%35%Q:4
/28Days
BUPRENORPHINE 2 MG TABLET SUSLIGUAL [Subutex]   2* Generic $4.00$12.00Q:90
/30Days
BUPRENORPHINE 20 MCG/HR PATCH [Butrans]   4 Non-Preferred Drug 35%35%Q:4
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BUPRENORPHINE 5 MCG/HR PATCH [Butrans]   4 Non-Preferred Drug 35%35%Q:4
/28Days
BUPRENORPHINE 7.5 MCG/HR PATCH [Butrans]   4 Non-Preferred Drug 35%35%Q:4
/28Days
BUPRENORPHINE 8 MG TABLET SUSLIGUAL [Subutex]   2* Generic $4.00$12.00Q:90
/30Days
BUPROPION HCL 100 MG TABLET   3 Preferred Brand 19%19%Q:180
/30Days
BUPROPION HCL 75 MG TABLET   3 Preferred Brand 19%19%Q:180
/30Days
BUPROPION HCL SR 100 MG TABLET SR 12H [Wellbutrin SR]   3 Preferred Brand 19%19%Q:120
/30Days
BUPROPION HCL SR 150 MG TABLET   3 Preferred Brand 19%19%Q:90
/30Days
BUPROPION HCL SR 150 MG TABLET SR 12H [Wellbutrin SR]   3 Preferred Brand 19%19%Q:90
/30Days
BUPROPION HCL SR 200 MG TABLET   3 Preferred Brand 19%19%Q:60
/30Days
BUPROPION HCL XL 150 MG TABLET   3 Preferred Brand 19%19%Q:90
/30Days
BUPROPION HCL XL 300 MG TABLET   3 Preferred Brand 19%19%Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BUSPIRONE HCL 15 MG TABLET   2* Generic $4.00$12.00None
BUSPIRONE HCL 30 MG TABLET   2* Generic $4.00$12.00None
BUSPIRONE HCL 5 MG TABLET   1* Preferred Generic $1.00$3.00None
BUSPIRONE HCL 7.5 MG TABLET   2* Generic $4.00$12.00None
BUSPIRONE HYDROCHLORIDE 10 MG TABLET   1* Preferred Generic $1.00$3.00None
BUTALB-ACETAMIN-CAFF 50-325-40 TABLET [Repan]   4 Non-Preferred Drug 35%35%Q:180
/30Days
BUTALB-CAFF-ACETAMINOPH-CODEIN   4 Non-Preferred Drug 35%35%Q:360
/30Days
BUTALBITAL COMP-CODEINE #3 CAPSULE [Fiorinal with Codeine]   3 Preferred Brand 19%19%Q:360
/30Days
BUTALBITAL-ASA-CAFFEINE CAPSULE [Fiorinal]   4 Non-Preferred Drug 35%35%Q:180
/30Days
BUTALBITAL/ACETAMINOPHEN 325; 50mg/1; mg/1 100 TABLET BOTTLE   4 Non-Preferred Drug 35%35%Q:180
/30Days
BUTALBITAL/ACETAMINOPHEN/CAFFEINE CAPSULE   4 Non-Preferred Drug 35%35%Q:180
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BUTORPHANOL 10 MG/ML SPRAY [Stadol NS]   4 Non-Preferred Drug 35%35%Q:5
/28Days
BYDUREON BCISE 2 MG AUTOINJECT   4 Non-Preferred Drug 35%35%Q:3
/28Days
Bystolic 10mg/1 30 TABLET BOTTLE   3 Preferred Brand 19%19%Q:120
/30Days
Bystolic 2.5mg/1 30 TABLET BOTTLE   3 Preferred Brand 19%19%Q:30
/30Days
BYSTOLIC 20 MG TABLET   3 Preferred Brand 19%19%Q:60
/30Days
Bystolic 5mg 30 TABLET BOTTLE   3 Preferred Brand 19%19%Q:30
/30Days

Chart Legend:

Below are a few notes to help you understand the above 2021 Medicare Part D Humana Walmart Value Rx Plan (PDP) Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug or Medicare Advantage 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 $445 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.
    • Tier Number* - Some Part D drug plans exclude one or more drug tiers from the plan’s 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 - This is what you will pay for formulary drugs in 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 initial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $4,130) 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.

      * When the insulin copay is in green, example: $35.00, this Part D plan may offer particular forms of insulin as part of the Senior Savings Model.  The Senior Savings Model stipulates that some insulin will cost no more than $35 in the deductible, initial coverage, and coverage gap phases of your Part D plan. Please contact the drug plan for more details.

    • 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 2021 )

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 Medicare plan provider.