Q1Medicare.com 2014 Medicare Part D or Medicare Advantage Plan Formulary Browser

2014 Medicare Part D Plan Formulary Information
First Health Part D Value Plus (PDP) (S5768-148-0) Benefit Details
The First Health Part D Value Plus (PDP) (S5768-148-0) Formulary Drugs Starting with the Letter N in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY Plan Monthly Premium: $39.90 Deductible: $0 Qualifies for LIS: No
Drugs Starting with Letter N Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter N Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NABUMETONE 500MG TABLET	2	Non-Preferred Generic	$11.00	N/A	None
NABUMETONE 750MG TABLET	2	Non-Preferred Generic	$11.00	N/A	None
NADOLOL 20MG TABLET	1	Preferred Generic	$3.00	N/A	None
NADOLOL 40MG TABLETS	1	Preferred Generic	$3.00	N/A	None
NADOLOL 80MG TABLETS	1	Preferred Generic	$3.00	N/A	None
NADOLOL-BENDROFLU 40-5 MG TAB	1	Preferred Generic	$3.00	N/A	None
NADOLOL-BENDROFLU 80-5 MG TAB	1	Preferred Generic	$3.00	N/A	None
Nafcillin 10g/100mL	4	Non-Preferred Brand	$88.00	N/A	None
NAFCILLIN FOR INJECTION 1 GM/ML	4	Non-Preferred Brand	$88.00	N/A	None
NAFTIN 1% CREAM	4	Non-Preferred Brand	$88.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NAFTIN 2% CREAM	4	Non-Preferred Brand	$88.00	N/A	None
NAFTIN 2% GEL	4	Non-Preferred Brand	$88.00	N/A	None
NAFTIN HCL GEL 1% 60GM TUBE	4	Non-Preferred Brand	$88.00	N/A	None
NAGLAZYME 5MG/5ML VIAL	5	Specialty Tier	33%	N/A	P
Nalbuphine Hydrochloride 10mg/mL 1 VIAL, MULTI-DOSE per CARTON / 10 mL in 1 VIAL, MULTI-DOSE	4	Non-Preferred Brand	$88.00	N/A	None
Nalbuphine Hydrochloride 20mg/mL 25 VIAL, MULTI-DOSE per CARTON / 10 mL in 1 VIAL, MULTI-DOSE	4	Non-Preferred Brand	$88.00	N/A	None
NALFON 400 MG CAPSULE	4	Non-Preferred Brand	$88.00	N/A	None
naloxone 1 mg/ml syringe	1	Preferred Generic	$3.00	N/A	None
NALTREXONE HCL 50MG TABLET 100 BLPK	2	Non-Preferred Generic	$11.00	N/A	None
NAMENDA 10MG TABLET	3	Preferred Brand	$37.00	N/A	Q:60 /30Days
NAMENDA 10MG/5ML SOLUTION	3	Preferred Brand	$37.00	N/A	Q:360 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NAMENDA 5-10MG TITRATION PK	3	Preferred Brand	$37.00	N/A	Q:49 /28Days
NAMENDA 5MG TABLET	3	Preferred Brand	$37.00	N/A	Q:60 /30Days
NAMENDA XR 14 MG CAPSULE	3	Preferred Brand	$37.00	N/A	Q:30 /30Days
NAMENDA XR 21 MG CAPSULE	3	Preferred Brand	$37.00	N/A	Q:30 /30Days
NAMENDA XR 28 MG CAPSULE	3	Preferred Brand	$37.00	N/A	Q:30 /30Days
NAMENDA XR 7 MG CAPSULE	3	Preferred Brand	$37.00	N/A	Q:30 /30Days
NAMENDA XR TITRATION PACK	3	Preferred Brand	$37.00	N/A	Q:28 /28Days
NAPROXEN 125 MG/5 ML SUSPEN	1	Preferred Generic	$3.00	N/A	None
NAPROXEN 250 MG ORAL TABLET	1	Preferred Generic	$3.00	N/A	None
NAPROXEN 375MG TABLET EC	1	Preferred Generic	$3.00	N/A	None
NAPROXEN 500MG TABLET EC	1	Preferred Generic	$3.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Naproxen 500mg/1 500 TABLET BOTTLE	1	Preferred Generic	$3.00	N/A	None
NAPROXEN SODIUM 275 MG ORAL TABLET	1	Preferred Generic	$3.00	N/A	None
Naproxen Sodium 550mg/1	1	Preferred Generic	$3.00	N/A	None
NAPROXEN TABLET 375MG (500 CT)	1	Preferred Generic	$3.00	N/A	None
NARATRIPTAN 1MG TABLETS	4	Non-Preferred Brand	$88.00	N/A	S Q:9 /30Days
NARATRIPTAN 2.5MG TABLETS	4	Non-Preferred Brand	$88.00	N/A	S Q:9 /30Days
NASONEX 50ug/1 120 SPRAY, METERED in 1 BOTTLE, PUMP	3	Preferred Brand	$37.00	N/A	Q:34 /30Days
NATACYN EYE DROPS	3	Preferred Brand	$37.00	N/A	None
Nateglinide 120mg/1 90 TABLET BOTTLE	4	Non-Preferred Brand	$88.00	N/A	Q:90 /30Days
Nateglinide 60mg/1 90 TABLET BOTTLE	4	Non-Preferred Brand	$88.00	N/A	Q:90 /30Days
NEBUPENT 300MG INHAL POWDER	3	Preferred Brand	$37.00	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NECON 0.5/35-28 TABLET	4	Non-Preferred Brand	$88.00	N/A	None
NECON 1/35-28 TABLET	4	Non-Preferred Brand	$88.00	N/A	None
NECON 10/11-28 TABLET	4	Non-Preferred Brand	$88.00	N/A	None
NECON 7 DAYS X 3 TABLET	4	Non-Preferred Brand	$88.00	N/A	None
NEFAZODONE HCL 150MG TABLET (60 CT)	1	Preferred Generic	$3.00	N/A	None
NEFAZODONE HCL 250MG TABLET	1	Preferred Generic	$3.00	N/A	None
NEFAZODONE HCL 50MG TABLET	1	Preferred Generic	$3.00	N/A	None
NEFAZODONE HYDROCHLORIDE TABLETS 100MG 60 BOT	1	Preferred Generic	$3.00	N/A	None
NEFAZODONE HYDROCHLORIDE TABLETS 200MG 60 BOT	1	Preferred Generic	$3.00	N/A	None
NEO/POLYMYXIN/HC EAR TUBEX 10MG/3.5MG/100UNT	2	Non-Preferred Generic	$11.00	N/A	None
Neomycin and Polymyxin B Sulfates and Dexamethasone 1; 3.5; 10000mg/g; mg/g; [USP'U]/g 1 TUBE in 1	2	Non-Preferred Generic	$11.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NEOMYCIN SULFATE 500MG TABLET	2	Non-Preferred Generic	$11.00	N/A	None
NEOMYCIN-BACITRACIN-POLY-HC 3.5-10K-1 OINTMENT	2	Non-Preferred Generic	$11.00	N/A	None
NEOMYCIN-POLYMYXIN-HC 3.5-10K-10 SUSPENSION DROPS	2	Non-Preferred Generic	$11.00	N/A	None
NEOMYCIN/POLYMY/DEXA EYE DROPS 3.5MG/1ML	2	Non-Preferred Generic	$11.00	N/A	None
NEOMYCIN/POLYMY/GRAM EYE DROPS 0.025MG/ML 1.75MG/M	2	Non-Preferred Generic	$11.00	N/A	None
NEOMYCIN/POLYMY/HYDRO OTIC SUS	2	Non-Preferred Generic	$11.00	N/A	None
NEORAL 100MG GELATN CAPSULE	4	Non-Preferred Brand	$88.00	N/A	P
NEORAL 100MG/ML SOLUTION	4	Non-Preferred Brand	$88.00	N/A	P
NEORAL 25MG GELATIN CAPSULE	4	Non-Preferred Brand	$88.00	N/A	P
NEPHRAMINE SOLUTION FOR INJECTION	4	Non-Preferred Brand	$88.00	N/A	P
NEULASTA 6MG/0.6ML SYRINGE	5	Specialty Tier	33%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NEUPOGEN 300MCG/ML VIAL	5	Specialty Tier	33%	N/A	P
NEUPOGEN 300ug/0.5mL 10 SYRINGE in 1 BOX / 0.5 mL in 1 SYRINGE	5	Specialty Tier	33%	N/A	P
NEUPOGEN INJECTION 480MCG/0.8ML 10 X 0.8ML SYR	5	Specialty Tier	33%	N/A	P
NEUPRO 1 MG/24 HR PATCH	4	Non-Preferred Brand	$88.00	N/A	Q:30 /30Days
NEUPRO 2 MG/24 HR PATCH	4	Non-Preferred Brand	$88.00	N/A	Q:30 /30Days
NEUPRO 3 MG/24 HR PATCH	4	Non-Preferred Brand	$88.00	N/A	Q:30 /30Days
NEUPRO 4 MG/24 HR PATCH	4	Non-Preferred Brand	$88.00	N/A	Q:30 /30Days
NEUPRO 6 MG/24 HR PATCH	4	Non-Preferred Brand	$88.00	N/A	Q:30 /30Days
NEUPRO 8 MG/24 HR PATCH	4	Non-Preferred Brand	$88.00	N/A	Q:30 /30Days
NEVANAC 0.1% DROPTAINER	4	Non-Preferred Brand	$88.00	N/A	Q:3 /30Days
nevirapine 200 mg tablet	4	Non-Preferred Brand	$88.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
nevirapine er 400 mg tablet	4	Non-Preferred Brand	$88.00	N/A	None
NEXAVAR TABLETS 200MG 120 BOT	5	Specialty Tier	33%	N/A	P Q:120 /30Days
NEXIUM 10mg/1 30 GRANULE, DELAYED RELEASE per CARTON	3	Preferred Brand	$37.00	N/A	Q:30 /30Days
NEXIUM 20MG CAPSULE	3	Preferred Brand	$37.00	N/A	Q:30 /30Days
NEXIUM 20MG SUSP FOR RECON DELAYED REL. IN A PACKET	3	Preferred Brand	$37.00	N/A	Q:30 /30Days
NEXIUM 40MG CAPSULE	3	Preferred Brand	$37.00	N/A	Q:30 /30Days
NEXIUM 40MG SUSP FOR RECON DELAYED REL. IN A PACKET	3	Preferred Brand	$37.00	N/A	Q:30 /30Days
NEXIUM DR 2.5 MG PACKET	3	Preferred Brand	$37.00	N/A	Q:30 /30Days
NEXIUM DR 5 MG PACKET	3	Preferred Brand	$37.00	N/A	Q:30 /30Days
NEXIUM IV 20MG VIAL	3	Preferred Brand	$37.00	N/A	None
NEXIUM IV 40MG VIAL	3	Preferred Brand	$37.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NIACIN ER 1,000 MG TABLET	2	Non-Preferred Generic	$11.00	N/A	Q:60 /30Days
NIACIN ER 500 MG TABLET	2	Non-Preferred Generic	$11.00	N/A	Q:30 /30Days
NIACIN ER 750 MG TABLET	2	Non-Preferred Generic	$11.00	N/A	Q:60 /30Days
NIACOR 500MG TABLET	3	Preferred Brand	$37.00	N/A	None
NIASPAN 1000MG TABLET (90 CT)	3	Preferred Brand	$37.00	N/A	Q:60 /30Days
NIASPAN ER 500MG TABLET (90 CT)	3	Preferred Brand	$37.00	N/A	Q:30 /30Days
NIASPAN ER 750MG TABLET (90 CT)	3	Preferred Brand	$37.00	N/A	Q:60 /30Days
NICARDIPINE HYDROCHLORIDE 20MG CAPSULES	2	Non-Preferred Generic	$11.00	N/A	None
NICARDIPINE HYDROCHLORIDE CAPSULES 30MG 500 BOT	2	Non-Preferred Generic	$11.00	N/A	None
NICOTROL NS NASAL SPRAY BOTTLE 10MG 4 X 10MG/ML INHL	3	Preferred Brand	$37.00	N/A	Q:40 /30Days
NIFEDIAC CC 90MG TABLET SA	4	Non-Preferred Brand	$88.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NIFEDICAL XL 30MG TABLET SR OSMOTIC PUSH 24HR	4	Non-Preferred Brand	$88.00	N/A	None
NIFEDICAL XL 60MG TABLET SR OSMOTIC PUSH 24HR	4	Non-Preferred Brand	$88.00	N/A	None
NIFEDIPINE 30MG TABLETS EXTENDED RELEASE	4	Non-Preferred Brand	$88.00	N/A	None
NIFEDIPINE 60MG TABLETS EXTENDED RELEASE	4	Non-Preferred Brand	$88.00	N/A	None
NIFEDIPINE 90MG TABLETS EXTENDED RELEASE	4	Non-Preferred Brand	$88.00	N/A	None
NILANDRON 150 MG TABLET	3	Preferred Brand	$37.00	N/A	None
Nisoldipine 17mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC	4	Non-Preferred Brand	$88.00	N/A	Q:30 /30Days
NISOLDIPINE 20MG TB24	4	Non-Preferred Brand	$88.00	N/A	Q:30 /30Days
Nisoldipine 25.5mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC	4	Non-Preferred Brand	$88.00	N/A	Q:60 /30Days
NISOLDIPINE 30MG TB24	4	Non-Preferred Brand	$88.00	N/A	Q:60 /30Days
Nisoldipine 34mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC	4	Non-Preferred Brand	$88.00	N/A	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NISOLDIPINE 40MG TB24	4	Non-Preferred Brand	$88.00	N/A	Q:30 /30Days
Nisoldipine 8.5mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC	4	Non-Preferred Brand	$88.00	N/A	Q:30 /30Days
NITRO-BID 20mg/g 48 PACKET in 1 BOX / 1 g in 1 PACKET	3	Preferred Brand	$37.00	N/A	None
Nitrofurantoin 25mg/5mL	4	Non-Preferred Brand	$88.00	N/A	P
NITROFURANTOIN MCR 50MG CAP	4	Non-Preferred Brand	$88.00	N/A	P
Nitrofurantoin Monohydrate/Macrocrystals 25; 75mg 100 CAPSULE BOTTLE	4	Non-Preferred Brand	$88.00	N/A	P
NITROGLYCERIN .2MG/HR PATCH	1	Preferred Generic	$3.00	N/A	None
NITROGLYCERIN .4MG/HR PATCH	1	Preferred Generic	$3.00	N/A	None
NITROGLYCERIN .6MG/HR PATCH	1	Preferred Generic	$3.00	N/A	None
Nitroglycerin 5mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 10 mL in 1 VIAL, SINGLE-DOSE	1	Preferred Generic	$3.00	N/A	None
NITROGLYCERIN LINGUAL 0.4 MG	4	Non-Preferred Brand	$88.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NITROGLYCERIN TRANSOERMAL SYSTEM .1MG/HR 30 SYSTEM BOX	1	Preferred Generic	$3.00	N/A	None
NITROMIST AEROSOL	4	Non-Preferred Brand	$88.00	N/A	None
NITROSTAT 0.3MG TABLET SL	3	Preferred Brand	$37.00	N/A	None
NITROSTAT 0.4MG TABLET SL	3	Preferred Brand	$37.00	N/A	None
NITROSTAT 0.6MG TABLET SL	3	Preferred Brand	$37.00	N/A	None
Nizatidine 150mg/1 500 CAPSULE BOTTLE	2	Non-Preferred Generic	$11.00	N/A	None
NIZATIDINE 300 MG CAPSULE (100 CAPS)	2	Non-Preferred Generic	$11.00	N/A	None
NIZATIDINE ORAL SOLUTION 15MG/ML	2	Non-Preferred Generic	$11.00	N/A	None
NORA-BE 0.35MG TABLET	1	Preferred Generic	$3.00	N/A	None
Norethindrone 0.35 mg tablet	1	Preferred Generic	$3.00	N/A	None
NORETHINDRONE 5MG TABLET	1	Preferred Generic	$3.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NORITATE 1% CREAM	4	Non-Preferred Brand	$88.00	N/A	None
NORPACE CR 100MG CAPSULE SA	4	Non-Preferred Brand	$88.00	N/A	None
NORPACE CR 150MG CAPSULE SA	4	Non-Preferred Brand	$88.00	N/A	None
Nortrel (21 Day Regimen) 0.035; 1mg/1; mg/1 3 BLISTER PACK per CARTON / 21 TABLET per BLISTER PACK	4	Non-Preferred Brand	$88.00	N/A	None
Nortrel (28 Day Regimen) 3 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK	4	Non-Preferred Brand	$88.00	N/A	None
NORTREL 1-0.035MG TABLET 28DAY	4	Non-Preferred Brand	$88.00	N/A	None
Nortrel 7/7/7 (28 Day Regimen) 6 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT in 1 BLISTER	4	Non-Preferred Brand	$88.00	N/A	None
NORTRIPTYLINE 10 MG/5 ML SOL	1	Preferred Generic	$3.00	N/A	None
NORTRIPTYLINE HCL 25MG CAP	1	Preferred Generic	$3.00	N/A	None
NORTRIPTYLINE HCL 75MG CAPSULE	1	Preferred Generic	$3.00	N/A	None
Nortriptyline Hydrochloride 10mg/1 100 CAPSULE BOTTLE	1	Preferred Generic	$3.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Nortriptyline Hydrochloride 50mg/1 500 CAPSULE BOTTLE	1	Preferred Generic	$3.00	N/A	None
NORVIR 100 MG TABLET	4	Non-Preferred Brand	$88.00	N/A	None
NORVIR 100mg/1 30 CAPSULE BOTTLE	4	Non-Preferred Brand	$88.00	N/A	None
NORVIR 80MG/ML ORAL SOLUTION	4	Non-Preferred Brand	$88.00	N/A	None
Novolin 100[iU]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL	3	Preferred Brand	$37.00	N/A	None
Novolin 100[USP'U]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL	3	Preferred Brand	$37.00	N/A	None
Novolin R 100[iU]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL	3	Preferred Brand	$37.00	N/A	None
NOVOLOG 100U/ML VIAL	3	Preferred Brand	$37.00	N/A	None
NOVOLOG FLEXPEN SYRINGE	3	Preferred Brand	$37.00	N/A	None
NOVOLOG MIX 70/30 SYRINGE 70-30U/ML	3	Preferred Brand	$37.00	N/A	None
NOVOLOG MIX 70/30 VIAL	3	Preferred Brand	$37.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NOXAFIL 200MG/5ML SUSPENSION ORAL	5	Specialty Tier	33%	N/A	P Q:630 /30Days
NOXAFIL DR 100 MG TABLET	5	Specialty Tier	33%	N/A	P
NUEDEXTA 20; 10mg/1; mg/1	3	Preferred Brand	$37.00	N/A	Q:60 /30Days
NULOJIX 250mg/1 1 VIAL, SINGLE-USE per CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in	5	Specialty Tier	33%	N/A	P
NULYTELY WITH FLAVOR PACKS POWDER FOR SOLUTION 420;1.48;MG;MG;GM; 4 L BOT	3	Preferred Brand	$37.00	N/A	Q:1 /30Days
NUVIGIL 150 MG TABLET	4	Non-Preferred Brand	$88.00	N/A	P Q:30 /30Days
NUVIGIL 250 MG TABLET	4	Non-Preferred Brand	$88.00	N/A	P Q:30 /30Days
NUVIGIL 50 MG TABLET	4	Non-Preferred Brand	$88.00	N/A	P Q:30 /30Days
NYAMYC 100000 U/G POWDER	2	Non-Preferred Generic	$11.00	N/A	None
Nystatin 100000[USP'U]/g	2	Non-Preferred Generic	$11.00	N/A	None
Nystatin 100000[USP'U]/g 1 TUBE per CARTON / 30 g in 1 TUBE	2	Non-Preferred Generic	$11.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Nystatin 100000[USP'U]/g 1 TUBE per CARTON / 30 g in 1 TUBE	2	Non-Preferred Generic	$11.00	N/A	None
Nystatin 100000[USP'U]/mL	2	Non-Preferred Generic	$11.00	N/A	None
NYSTATIN TABLET 500000U (100 CT)	2	Non-Preferred Generic	$11.00	N/A	None
NYSTATIN/TRIAMCINOLONE CRM	2	Non-Preferred Generic	$11.00	N/A	None
NYSTATIN/TRIAMCINOLONE OINT 10000UNT/1MG	2	Non-Preferred Generic	$11.00	N/A	None
NYSTOP 100000U/GM POWDER	2	Non-Preferred Generic	$11.00	N/A	None

Chart Legend:

Below are a few notes to help you understand the above 2014 Medicare Part D First Health Part D Value Plus (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 $310 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 $2850) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2014 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 2014 )

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.