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Humana Enhanced (PDP) (S5552-003-0)
Tier 1 (224)
Tier 2 (699)
Tier 3 (745)
Tier 4 (1525)
Tier 5 (563)
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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
Humana Enhanced (PDP) (S5552-003-0)
Benefits & Contact Info           
The Humana Enhanced (PDP) (S5552-003-0)
Formulary Drugs Starting with the Letter A

in CMS PDP Region 3 which includes: NY
Plan Monthly Premium: $68.80 Deductible: $0 Qualifies for LIS: No
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 300 MG TABLET   4 Non-Preferred Drug 44%44%Q:60
/30Days
Abacavir Sulfate-Lamivudine-Zidovudine tablets [Trizivir]   5 Specialty Tier 33%N/AQ:60
/30Days
ABACAVIR-LAMIVUDINE 600-300 MG [Epzicom]   5 Specialty Tier 33%N/AQ:30
/30Days
ABELCENT INJECTION SUSPENSION 5MG/ML   5 Specialty Tier 33%N/AP
ABILIFY MAINTENA ER 300 MG SYR   5 Specialty Tier 33%N/AP Q:1
/28Days
ABILIFY MAINTENA ER 300 MG VL   5 Specialty Tier 33%N/AP Q:1
/28Days
ABILIFY MAINTENA ER 400 MG SYR   5 Specialty Tier 33%N/AP Q:1
/28Days
ABRAXANE 100MG VIAL   5 Specialty Tier 33%N/AP
Acamprosate Calcium DR 333 MG tablets [Campral]   4 Non-Preferred Drug 44%44%None
ACARBOSE 100 MG TABLET   3 Preferred Brand $42.00$116.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACARBOSE 25 MG TABLET   3 Preferred Brand $42.00$116.00None
Acarbose 50mg/1 100 TABLET BOTTLE   3 Preferred Brand $42.00$116.00None
ACEBUTOLOL 200MG CAPSULE   2 Generic $7.00$0.00None
ACEBUTOLOL 400MG CAPSULE   2 Generic $7.00$0.00None
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE   4 Non-Preferred Drug 44%44%None
ACETAMINOP-CODEINE 120-12 MG/5   3 Preferred Brand $42.00$116.00Q:2700
/30Days
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT)   3 Preferred Brand $42.00$116.00Q:390
/30Days
ACETAMINOPHEN-COD #3 TABLET   3 Preferred Brand $42.00$116.00Q:360
/30Days
ACETAMINOPHEN-COD #4 TABLET   3 Preferred Brand $42.00$116.00Q:180
/30Days
ACETASOL HC SOLUTION 10ML 10 ML BOT   4 Non-Preferred Drug 44%44%None
ACETAZOLAMIDE 125MG TABLET   3 Preferred Brand $42.00$116.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETAZOLAMIDE 250MG TABLET (100 CT)   3 Preferred Brand $42.00$116.00None
Acetazolamide 500mg/5mL 1 VIAL in 1 CARTON / 5 mL in 1 VIAL   2 Generic $7.00$0.00None
ACETAZOLAMIDE ER CAPSULES 500MG 100 BOT   4 Non-Preferred Drug 44%44%None
ACETIC ACID 2% EAR SOLUTION   2 Generic $7.00$0.00None
ACETYLCYSTEINE 10% VIAL   3 Preferred Brand $42.00$116.00P
ACETYLCYSTEINE 20% VIAL   3 Preferred Brand $42.00$116.00P
ACITRETIN 10 MG CAPSULE [Soriatane]   5 Specialty Tier 33%N/ANone
ACITRETIN 17.5 MG CAPSULE [Soriatane]   5 Specialty Tier 33%N/ANone
ACITRETIN 25 MG CAPSULE [Soriatane]   5 Specialty Tier 33%N/ANone
ACTHIB VACCINE WITH DILUENT   4 Non-Preferred Drug 44%44%None
ACTIMMUNE 100 MCG/0.5 ML VIAL   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Acyclovir 200mg 100 CAPSULE BOTTLE   2 Generic $7.00$0.00None
Acyclovir 200mg/5mL 473 mL BOTTLE   4 Non-Preferred Drug 44%44%None
Acyclovir 400mg/1   2 Generic $7.00$0.00None
Acyclovir 5% Ointment   4 Non-Preferred Drug 44%44%P
ACYCLOVIR 800 MG TABLET   2 Generic $7.00$0.00None
Acyclovir sodium 500 mg vial   4 Non-Preferred Drug 44%44%P
ADACEL VIAL 2UNT/5UNT   4 Non-Preferred Drug 44%44%None
ADAGEN 250U/ML VIAL   5 Specialty Tier 33%N/ANone
ADALAT CC 30 MG TABLET   4 Non-Preferred Drug 44%44%Q:60
/30Days
Adalat CC 60mg 1000 FILM COATED TABLETS in BOTTLE   4 Non-Preferred Drug 44%44%Q:60
/30Days
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA]   5 Specialty Tier 33%N/AP Q:6
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADAPALENE 0.1% GEL   4 Non-Preferred Drug 44%44%None
ADCIRCA TABLETS 20MG 60 BOTTLE   5 Specialty Tier 33%N/AP Q:60
/30Days
ADEFOVIR DIPIVOXIL 10 MG TAB [Hepsera]   5 Specialty Tier 33%N/ANone
ADEMPAS 0.5 MG TABLET   5 Specialty Tier 33%N/AP Q:90
/30Days
ADEMPAS 1 MG TABLET   5 Specialty Tier 33%N/AP Q:90
/30Days
ADEMPAS 1.5 MG TABLET   5 Specialty Tier 33%N/AP Q:90
/30Days
ADEMPAS 2 MG TABLET   5 Specialty Tier 33%N/AP Q:90
/30Days
ADEMPAS 2.5 MG TABLET   5 Specialty Tier 33%N/AP Q:90
/30Days
Adriamycin 20 mg/10 ml vial   4 Non-Preferred Drug 44%44%None
ADVAIR DISKUS MIS 100/50   3 Preferred Brand $42.00$116.00Q:60
/30Days
ADVAIR DISKUS MIS 250/50   3 Preferred Brand $42.00$116.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADVAIR DISKUS MIS 500/50   3 Preferred Brand $42.00$116.00Q:60
/30Days
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER   3 Preferred Brand $42.00$116.00Q:12
/30Days
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL   3 Preferred Brand $42.00$116.00Q:12
/30Days
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL   3 Preferred Brand $42.00$116.00Q:12
/30Days
AFEDITAB CR 30MG TABLET SA   3 Preferred Brand $42.00$116.00Q:60
/30Days
AFEDITAB CR 60MG TABLET SA   3 Preferred Brand $42.00$116.00Q:60
/30Days
Afinitor 7.5mg/1 28 BLISTER PACK per CARTON / 1 TABLET per BLISTER PACK   5 Specialty Tier 33%N/AP Q:30
/30Days
AFINITOR DISPERZ 2 MG TABLET   5 Specialty Tier 33%N/AP
AFINITOR DISPERZ 3 MG TABLET   5 Specialty Tier 33%N/AP
AFINITOR DISPERZ 5 MG TABLET   5 Specialty Tier 33%N/AP
AFINITOR TABLETS 10 MG   5 Specialty Tier 33%N/AP Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AFINITOR TABLETS 2.5 MG   5 Specialty Tier 33%N/AP Q:30
/30Days
AFINITOR TABLETS 5 MG   5 Specialty Tier 33%N/AP Q:30
/30Days
AGGRENOX 25-200MG CAPSULE   4 Non-Preferred Drug 44%44%S
ALA-CORT 1% CREAM   2 Generic $7.00$0.00None
Ala-cort 2.5% cream   4 Non-Preferred Drug 44%44%None
ALBENZA 200 MG TABLET   5 Specialty Tier 33%N/ANone
ALBUTEROL SULFATE 0.75mg/3mL 30 POUCH per CARTON / 1 VIAL, SINGLE-DOSE in 1 POUCH / 3 mL in 1 VIAL   2 Generic $7.00$0.00P
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER   2 Generic $7.00$0.00P
ALBUTEROL SULFATE 4MG TABLET SR 12HR   4 Non-Preferred Drug 44%44%None
ALBUTEROL SULFATE 8MG TABLET SR 12HR   4 Non-Preferred Drug 44%44%None
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   2 Generic $7.00$0.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALBUTEROL SULFATE SOLUTION FOR INHALATION   2 Generic $7.00$0.00P
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT   2 Generic $7.00$0.00None
ALBUTEROL SULFATE TABLET 2MG (500 CT)   4 Non-Preferred Drug 44%44%None
ALBUTEROL TABLET 4MG (500 CT)   4 Non-Preferred Drug 44%44%None
ALCLOMETASONE DIPROPIONATE 0.05% CREAM   3 Preferred Brand $42.00$116.00None
Alclometasone Dipropionate 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE   3 Preferred Brand $42.00$116.00None
ALECENSA 150 MG CAPSULE   5 Specialty Tier 33%N/AP Q:240
/30Days
ALENDRONATE SODIUM 10MG TABLET   1 Preferred Generic $3.00$0.00Q:30
/30Days
ALENDRONATE SODIUM 35 MG TABLET   1 Preferred Generic $3.00$0.00Q:4
/28Days
ALENDRONATE SODIUM 40MG TABLET   1 Preferred Generic $3.00$0.00Q:30
/30Days
ALENDRONATE SODIUM 5MG TABLET   1 Preferred Generic $3.00$0.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALENDRONATE SODIUM 70 MG TAB   1 Preferred Generic $3.00$0.00Q:4
/28Days
ALFUZOSIN HYDROCHLORIDE 10mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE   2 Generic $7.00$0.00Q:30
/30Days
ALIMTA 500MG VIAL   5 Specialty Tier 33%N/AP
ALINIA 100 MG/5 ML SUSPENSION   4 Non-Preferred Drug 44%44%Q:150
/30Days
ALINIA 500 MG TABLET   4 Non-Preferred Drug 44%44%Q:40
/30Days
ALKERAN 50 MG VIAL   4 Non-Preferred Drug 44%44%None
ALLOPURINOL 100 MG TABLETS   2 Generic $7.00$0.00None
Allopurinol 300mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET per BLISTER PACK   2 Generic $7.00$0.00None
Allopurinol sodium 500 mg vial   4 Non-Preferred Drug 44%44%None
ALOPRIM SOLUTION FOR INJECTION 500MG/VIAL 30 ML VIALGL   4 Non-Preferred Drug 44%44%None
ALORA 0.025 MG PATCH   4 Non-Preferred Drug 44%44%Q:8
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALORA 0.05 MG PATCH   4 Non-Preferred Drug 44%44%Q:8
/28Days
ALORA 0.075 MG PATCH   4 Non-Preferred Drug 44%44%Q:8
/28Days
ALORA 0.1 MG PATCH   4 Non-Preferred Drug 44%44%Q:8
/28Days
ALOSETRON HCL 0.5 MG TABLET [Lotronex]   5 Specialty Tier 33%N/AQ:60
/30Days
ALOSETRON HCL 1 MG TABLET [Lotronex]   5 Specialty Tier 33%N/AQ:60
/30Days
ALPHAGAN P 0.1% DROPS   3 Preferred Brand $42.00$116.00None
ALPHAGAN P 0.15% EYE DROPS   3 Preferred Brand $42.00$116.00None
ALPRAZOLAM 0.25 MG TABLET   2 Generic $7.00$0.00Q:120
/30Days
ALPRAZOLAM 0.5 MG TABLET   2 Generic $7.00$0.00Q:120
/30Days
ALPRAZOLAM 1 MG TABLET   2 Generic $7.00$0.00Q:120
/30Days
ALPRAZOLAM 2 MG TABLET   2 Generic $7.00$0.00Q:150
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Alyacen 1-35-28 tablet   4 Non-Preferred Drug 44%44%None
Amabelz 0.5 mg-0.1 mg tablet   4 Non-Preferred Drug 44%44%None
Amabelz 1 mg-0.5 mg tablet   4 Non-Preferred Drug 44%44%None
AMANTADINE 100MG CAPSULE   4 Non-Preferred Drug 44%44%None
AMANTADINE 100MG TABLET   4 Non-Preferred Drug 44%44%None
Amantadine Hydrochloride 50mg/5mL 473 mL in 1 BOTTLE   3 Preferred Brand $42.00$116.00None
AMBISOME 50MG VIAL   4 Non-Preferred Drug 44%44%P
Amethia 0.15-0.03-0.01 mg tab   4 Non-Preferred Drug 44%44%None
Amethia lo tablet   4 Non-Preferred Drug 44%44%Q:91
/90Days
Amethyst 20; 90ug/1; ug/1 1 BLISTER PACK per CARTON / 28 TABLET per BLISTER PACK   4 Non-Preferred Drug 44%44%None
AMIKACIN SULFATE 500 MG/2 ML VIAL   4 Non-Preferred Drug 44%44%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET   2 Generic $7.00$0.00None
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT   3 Preferred Brand $42.00$116.00None
Amino Acids 15% Solution   4 Non-Preferred Drug 44%44%P
Aminophylline 25mg/mL 5 TRAY per CARTON / 5 AMPULE in 1 TRAY / 10 mL in 1 AMPULE   2 Generic $7.00$0.00None
AMINOSYN 7%-ELECTROLYTE SOL   4 Non-Preferred Drug 44%44%P
AMINOSYN HBC INJECTION SULFITE FREE 7%   4 Non-Preferred Drug 44%44%P
AMINOSYN II 10% IV SOLUTION   4 Non-Preferred Drug 44%44%P
AMINOSYN II 15% IV SOLUTION   4 Non-Preferred Drug 44%44%P
AMINOSYN II 7% IV SOLUTION   4 Non-Preferred Drug 44%44%P
AMINOSYN II 8.5% ELECTROLYT   4 Non-Preferred Drug 44%44%P
AMINOSYN II 8.5% ELECTROLYT   4 Non-Preferred Drug 44%44%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN PF INJECTION   4 Non-Preferred Drug 44%44%P
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5%   4 Non-Preferred Drug 44%44%P
AMINOSYN-PF 7% IV SOLUTION   4 Non-Preferred Drug 44%44%P
AMINOSYN-RF 5.2% IV SOLUTION   4 Non-Preferred Drug 44%44%P
Amiodarone 150 mg/3 ml ampule   2 Generic $7.00$0.00None
Amiodarone hcl 100 mg tablet   4 Non-Preferred Drug 44%44%None
AMIODARONE HCL 200MG 60 TABLET BOTTLE   2 Generic $7.00$0.00None
AMIODARONE HCL 400MG TABLET   4 Non-Preferred Drug 44%44%None
AMITIZA 8MCG CAPSULE   3 Preferred Brand $42.00$116.00Q:60
/30Days
AMITIZA CAPSULES 24MCG 60 CAP BOT   3 Preferred Brand $42.00$116.00Q:60
/30Days
AMITRIP/PERPHEN 10-2 TABLET   4 Non-Preferred Drug 44%44%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITRIP/PERPHEN 10-4 TABLET   4 Non-Preferred Drug 44%44%None
AMITRIP/PERPHEN 25-2 TABLET   4 Non-Preferred Drug 44%44%None
AMITRIP/PERPHEN 25-4 TABLET   4 Non-Preferred Drug 44%44%None
AMITRIP/PERPHEN 50-4 TABLET   4 Non-Preferred Drug 44%44%None
AMITRIPTYLINE HCL 100MG TABLET   3 Preferred Brand $42.00$116.00None
AMITRIPTYLINE HCL 10MG TABLET   3 Preferred Brand $42.00$116.00None
AMITRIPTYLINE HCL 150 MG TAB   3 Preferred Brand $42.00$116.00None
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)   3 Preferred Brand $42.00$116.00None
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)   3 Preferred Brand $42.00$116.00None
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT   3 Preferred Brand $42.00$116.00None
AMLODIPINE BESYLATE 10MG TABLET (90 CT)   1 Preferred Generic $3.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)   1 Preferred Generic $3.00$0.00None
AMLODIPINE BESYLATE 5MG TABLET (90 CT)   1 Preferred Generic $3.00$0.00None
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE   3 Preferred Brand $42.00$116.00Q:60
/30Days
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE   3 Preferred Brand $42.00$116.00Q:60
/30Days
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE   3 Preferred Brand $42.00$116.00Q:60
/30Days
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE   3 Preferred Brand $42.00$116.00Q:60
/30Days
AMLODIPINE-BENAZEPRIL 10-40 MG   3 Preferred Brand $42.00$116.00Q:30
/30Days
AMLODIPINE-BENAZEPRIL 5-40 MG   3 Preferred Brand $42.00$116.00Q:30
/30Days
AMLODIPINE-OLMESARTAN 10-20 MG [Azor]   4 Non-Preferred Drug 44%44%Q:30
/30Days
AMLODIPINE-OLMESARTAN 10-40 MG [Azor]   4 Non-Preferred Drug 44%44%Q:30
/30Days
AMLODIPINE-OLMESARTAN 5-20 MG [Azor]   4 Non-Preferred Drug 44%44%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE-OLMESARTAN 5-40 MG [Azor]   4 Non-Preferred Drug 44%44%Q:30
/30Days
AMLODIPINE-VALSARTAN 10-160 MG   4 Non-Preferred Drug 44%44%Q:30
/30Days
AMLODIPINE-VALSARTAN 10-320 MG   4 Non-Preferred Drug 44%44%Q:30
/30Days
AMLODIPINE-VALSARTAN 5-160 MG   4 Non-Preferred Drug 44%44%Q:30
/30Days
AMLODIPINE-VALSARTAN 5-320 MG   4 Non-Preferred Drug 44%44%Q:30
/30Days
AMMONIUM LACTATE 12% CREAM   2 Generic $7.00$0.00None
AMMONIUM LACTATE 12% LOTION   2 Generic $7.00$0.00None
AMOX TR-K CLV 500-125 MG TAB   2 Generic $7.00$0.00None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE   2 Generic $7.00$0.00None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET   2 Generic $7.00$0.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE   2 Generic $7.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   2 Generic $7.00$0.00None
AMOX-CLAV 200-28.5 MG/5 ML SUS   2 Generic $7.00$0.00None
AMOXAPINE 100MG TABLET   4 Non-Preferred Drug 44%44%None
AMOXAPINE 150MG TABLET   4 Non-Preferred Drug 44%44%None
AMOXAPINE 25MG TABLET   4 Non-Preferred Drug 44%44%None
AMOXAPINE 50MG TABLET   4 Non-Preferred Drug 44%44%None
AMOXICILLIN 125MG TABLET CHEW   1 Preferred Generic $3.00$0.00None
AMOXICILLIN 250MG 500 CHEWABLE TABLET in BOTTLE   1 Preferred Generic $3.00$0.00None
AMOXICILLIN 250MG CAPSULE   1 Preferred Generic $3.00$0.00None
AMOXICILLIN 50 MG/ML / CLAVULANATE 12.5 MG/ML ORAL SUSPENSION   2 Generic $7.00$0.00None
AMOXICILLIN 500MG 500 CAPSULE BOTTLE   1 Preferred Generic $3.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN 500MG TABLET (100 CT)   1 Preferred Generic $3.00$0.00None
AMOXICILLIN 875MG TABLET   1 Preferred Generic $3.00$0.00None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT   2 Generic $7.00$0.00None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS EXTENDED RELEASE 1000;62.5MG;MG   4 Non-Preferred Drug 44%44%None
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT   2 Generic $7.00$0.00None
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT   1 Preferred Generic $3.00$0.00None
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL   1 Preferred Generic $3.00$0.00None
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   1 Preferred Generic $3.00$0.00None
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL   1 Preferred Generic $3.00$0.00None
AMPHETAMINE SALT COMBO 12.5MG TABLET   3 Preferred Brand $42.00$116.00Q:90
/30Days
AMPHETAMINE SALT COMBO 15MG TABLET   3 Preferred Brand $42.00$116.00Q:90
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPHETAMINE SALT COMBO 7.5MG TABLET   3 Preferred Brand $42.00$116.00Q:90
/30Days
AMPHETAMINE SALTS 5 MG TAB   3 Preferred Brand $42.00$116.00Q:90
/30Days
amphotericin b 50mg/10mL 10 mL in 1 VIAL   4 Non-Preferred Drug 44%44%P
Ampicillin 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS   4 Non-Preferred Drug 44%44%None
AMPICILLIN CAPSULES 250MG 100 BOT   2 Generic $7.00$0.00None
AMPICILLIN CAPSULES 500MG 100 BOT   2 Generic $7.00$0.00None
AMPICILLIN FOR INJECTION POWDER   4 Non-Preferred Drug 44%44%None
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT   2 Generic $7.00$0.00None
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT   2 Generic $7.00$0.00None
AMPICILLIN POWDER FOR INJECTION 1 GM/ML   4 Non-Preferred Drug 44%44%None
ampicillin-sulbactam 1.5 gm vl   4 Non-Preferred Drug 44%44%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPICILLIN-SULBACTAM 15 GM VIAL   4 Non-Preferred Drug 44%44%None
AMPICILLIN-SULBACTAM 3 GM VIAL   4 Non-Preferred Drug 44%44%None
AMPYRA ER 10 MG TABLET   5 Specialty Tier 33%N/AP Q:60
/30Days
ANADROL-50 TABLET   5 Specialty Tier 33%N/ANone
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE   3 Preferred Brand $42.00$116.00None
Anagrelide Hydrochloride 1mg/1 100 CAPSULE BOTTLE   3 Preferred Brand $42.00$116.00None
Anastrozole 1mg/1 90 FILM COATED TABLETS in BOTTLE, PLASTIC   1 Preferred Generic $3.00$0.00Q:30
/30Days
ANCOBON 250MG CAPSULE   4 Non-Preferred Drug 44%44%None
ANCOBON 500MG CAPSULE   4 Non-Preferred Drug 44%44%None
ANDROGEL 1.62% (1.25G) GEL PCKT   3 Preferred Brand $42.00$116.00Q:38
/30Days
ANDROGEL 1.62% (2.5G) GEL PCKT   3 Preferred Brand $42.00$116.00Q:150
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Androgel 16.2mg/g 1 BOTTLE, PUMP per CARTON / 88 g in 1 BOTTLE, PUMP   3 Preferred Brand $42.00$116.00Q:150
/30Days
ANORO ELLIPTA 62.5-25 MCG INH   3 Preferred Brand $42.00$116.00Q:60
/30Days
ANUSOL-HC 2.5% CREAM   4 Non-Preferred Drug 44%44%None
APOKYN 30 MG/3 ML CARTRIDGE   5 Specialty Tier 33%N/AQ:60
/28Days
Apraclonidine Ophthalmic 5mg/mL 1 BOTTLE, DROPPER per CARTON / 10 mL in 1 BOTTLE, DROPPER   4 Non-Preferred Drug 44%44%None
APREPITANT 125 MG CAPSULE [Emend]   4 Non-Preferred Drug 44%44%P Q:2
/28Days
APREPITANT 125-80-80 MG PACK [Emend]   4 Non-Preferred Drug 44%44%P Q:6
/28Days
APREPITANT 40 MG CAPSULE [Emend]   4 Non-Preferred Drug 44%44%P Q:2
/28Days
APREPITANT 80 MG CAPSULE [Emend]   4 Non-Preferred Drug 44%44%P Q:4
/28Days
APRI 0.15-0.03 TABLET   4 Non-Preferred Drug 44%44%None
APRISO CP24   3 Preferred Brand $42.00$116.00Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
APTIOM 200 MG TABLET   4 Non-Preferred Drug 44%44%P Q:30
/30Days
APTIOM 400 MG TABLET   4 Non-Preferred Drug 44%44%P Q:30
/30Days
APTIOM 600 MG TABLET   4 Non-Preferred Drug 44%44%P Q:60
/30Days
APTIOM 800 MG TABLET   4 Non-Preferred Drug 44%44%P Q:30
/30Days
APTIVUS 250MG CAPSULE   5 Specialty Tier 33%N/AQ:120
/30Days
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT   5 Specialty Tier 33%N/AQ:285
/28Days
ARALAST NP 500 MG VIAL   5 Specialty Tier 33%N/AP
ARANELLE 7-9-5 TABLET   4 Non-Preferred Drug 44%44%None
ARCALYST INJECTION 220MG/VIAL   5 Specialty Tier 33%N/AP
ARIPIPRAZOLE 10 MG TABLET [Abilify]   4 Non-Preferred Drug 44%44%P Q:30
/30Days
ARIPIPRAZOLE 15 MG TABLET [Abilify]   4 Non-Preferred Drug 44%44%P Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARIPIPRAZOLE 2 MG TABLET [Abilify]   4 Non-Preferred Drug 44%44%P Q:30
/30Days
ARIPIPRAZOLE 20 MG TABLET [Abilify]   4 Non-Preferred Drug 44%44%P Q:30
/30Days
ARIPIPRAZOLE 30 MG TABLET [Abilify]   4 Non-Preferred Drug 44%44%P Q:30
/30Days
ARIPIPRAZOLE 5 MG TABLET [Abilify]   4 Non-Preferred Drug 44%44%P Q:30
/30Days
ARIPIPRAZOLE ODT 10 MG TABLET [Abilify]   5 Specialty Tier 33%N/AP Q:60
/30Days
ARIPIPRAZOLE ODT 15 MG TABLET [Abilify]   5 Specialty Tier 33%N/AP Q:60
/30Days
ARISTADA ER 441 MG/1.6 ML SYRN   5 Specialty Tier 33%N/AP Q:2
/28Days
ARISTADA ER 662 MG/2.4 ML SYRN   5 Specialty Tier 33%N/AP Q:2
/28Days
ARISTADA ER 882 MG/3.2 ML SYRN   5 Specialty Tier 33%N/AP Q:3
/28Days
Armodafinil 150 MG TABLET [NUVIGIL]   4 Non-Preferred Drug 44%44%P Q:30
/30Days
Armodafinil 200 MG TABLET [NUVIGIL]   4 Non-Preferred Drug 44%44%P Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Armodafinil 250 MG TABLET [NUVIGIL]   4 Non-Preferred Drug 44%44%P Q:30
/30Days
Armodafinil 50 MG TABLET [NUVIGIL]   4 Non-Preferred Drug 44%44%P Q:60
/30Days
ARNUITY ELLIPTA 100 MCG INH   3 Preferred Brand $42.00$116.00Q:30
/30Days
ARNUITY ELLIPTA 200 MCG INH   3 Preferred Brand $42.00$116.00Q:30
/30Days
ARRANON 250 MG VIAL   5 Specialty Tier 33%N/ANone
Ashlyna 0.15-0.03-0.01 mg tablet   4 Non-Preferred Drug 44%44%None
ASPIRIN-DIPYRIDAM ER 25-200 MG [Aggrenox]   4 Non-Preferred Drug 44%44%S
Atelvia 35mg/1 36 DOSE PACK CASE / 4 TABLET, DELAYED RELEASE in 1 DOSE PACK   4 Non-Preferred Drug 44%44%Q:4
/28Days
ATENOLOL 100 MG100 TABLET BOTTLE   1 Preferred Generic $3.00$0.00None
ATENOLOL 25 MG 100 TABLET BOTTLE   1 Preferred Generic $3.00$0.00None
ATENOLOL TABLET USP 50MG (100 CT)   1 Preferred Generic $3.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATENOLOL-CHLORTHALIDONE 100-25   2 Generic $7.00$0.00None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   2 Generic $7.00$0.00None
ATGAM 50MG/ML AMPUL   4 Non-Preferred Drug 44%44%P
ATORVASTATIN 10 MG TABLET [Lipitor]   1 Preferred Generic $3.00$0.00Q:30
/30Days
ATORVASTATIN 20 MG TABLET [Lipitor]   1 Preferred Generic $3.00$0.00Q:30
/30Days
ATORVASTATIN 40 MG TABLET [Lipitor]   1 Preferred Generic $3.00$0.00Q:30
/30Days
ATORVASTATIN 80 MG TABLET [Lipitor]   1 Preferred Generic $3.00$0.00Q:30
/30Days
ATOVAQUONE 750 MG/5 ML SUSP [Mepron]   5 Specialty Tier 33%N/ANone
Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone]   4 Non-Preferred Drug 44%44%None
Atovaquone-Proguanil 62.5-25 [Malarone]   4 Non-Preferred Drug 44%44%None
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC   5 Specialty Tier 33%N/AQ:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Atropine 1% Eye Drops   2 Generic $7.00$0.00None
ATROVENT HFA AER 17MCG   4 Non-Preferred Drug 44%44%Q:26
/30Days
AUBRA-28 TABLET   4 Non-Preferred Drug 44%44%None
AVANDIA 2 MG TABLET   4 Non-Preferred Drug 44%44%Q:60
/30Days
AVANDIA 4 MG TABLET   4 Non-Preferred Drug 44%44%Q:60
/30Days
AVASTIN 100MG/4ML VIAL   5 Specialty Tier 33%N/AP
AVASTIN 400 MG/16 ML VIAL   5 Specialty Tier 33%N/AP
AVIANE 0.1-0.02 TABLET   4 Non-Preferred Drug 44%44%None
AVODART 0.5MG SOFTGEL   4 Non-Preferred Drug 44%44%P Q:30
/30Days
AVONEX ADMIN PACK 30 MCG VL   5 Specialty Tier 33%N/AP Q:4
/28Days
AVONEX PEN 30 MCG/0.5 ML KIT   5 Specialty Tier 33%N/AP Q:1
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVONEX PREFILLED SYR 30 MCG KT   5 Specialty Tier 33%N/AP Q:1
/28Days
Aygestin 5mg/1 50 TABLET BOTTLE   4 Non-Preferred Drug 44%44%None
Azacitidine 100 mg vial [Vidaza]   5 Specialty Tier 33%N/AP
AZASITE 1% EYE DROPS   3 Preferred Brand $42.00$116.00None
AZATHIOPRINE 50 MG TABLET   2 Generic $7.00$0.00P
AZELASTINE 0.15% NASAL SPRAY   4 Non-Preferred Drug 44%44%Q:30
/25Days
AZELASTINE 137 MCG NASAL SPRAY   3 Preferred Brand $42.00$116.00Q:30
/25Days
AZELASTINE HYDROCHLORIDE OPHTHALMIC SOLUTION   3 Preferred Brand $42.00$116.00None
AZILECT 0.5MG TABLET   3 Preferred Brand $42.00$116.00None
AZILECT 1MG TABLET   3 Preferred Brand $42.00$116.00None
AZITHROMYCIN 1 GM PWD PACKET   3 Preferred Brand $42.00$116.00None
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 $42.00$116.00None
Azithromycin 200mg/5mL 22.5 mL in 1 BOTTLE   3 Preferred Brand $42.00$116.00None
AZITHROMYCIN 250 MG TABLET   2 Generic $7.00$0.00None
AZITHROMYCIN 250 MG TABLET   2 Generic $7.00$0.00None
Azithromycin 500 mg tablet   2 Generic $7.00$0.00None
Azithromycin 500mg/1 10 VIAL, SINGLE-USE in 1 TRAY / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION   3 Preferred Brand $42.00$116.00None
Azithromycin 500mg/1 30 FILM COATED TABLETS in BOTTLE   2 Generic $7.00$0.00None
Azithromycin 600mg/1 30 FILM COATED TABLETS in BOTTLE   2 Generic $7.00$0.00None
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT   3 Preferred Brand $42.00$116.00None
AZOR 10-20 MG TABLET   4 Non-Preferred Drug 44%44%P Q:30
/30Days
AZOR 10MG-40MG TABLET (30 CT)   4 Non-Preferred Drug 44%44%P Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZOR 5-40 MG TABLET   4 Non-Preferred Drug 44%44%P Q:30
/30Days
AZOR 5MG-20MG TABLET (30 CT)   4 Non-Preferred Drug 44%44%P Q:30
/30Days
AZTREONAM FOR INJECTION   4 Non-Preferred Drug 44%44%None
AZULFIDINE 500MG TABLET   4 Non-Preferred Drug 44%44%None


Chart Legend:

What does all this mean? Below are a few notes to help you understand the above 2017 Medicare Part D Humana Enhanced (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 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 wit 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 which tier the drug is in. 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 May 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.