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SilverScript Choice (PDP) (S5601-062-0)
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Tier 2 (1071)
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2015 Medicare Part D Plan Formulary Information
SilverScript Choice (PDP) (S5601-062-0)
Benefit Details           
The SilverScript Choice (PDP) (S5601-062-0)
Formulary Drugs Starting with the Letter N
in CMS PDP Region 31 which includes: ID UT
Plan Monthly Premium: $32.00 Deductible: $0 Qualifies for LIS: Yes
Drugs Starting with Letter N

Drug Name		 Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order
NABUMETONE 500MG TABLET   1 Generic $8.00$20.00None
NABUMETONE 750MG TABLET   1 Generic $8.00$20.00None
NADOLOL 20MG TABLET   3 Non-Preferred Brand 42%42%None
NADOLOL 40MG TABLETS   3 Non-Preferred Brand 42%42%None
Nadolol 80mg/1 90 TABLET BOTTLE   3 Non-Preferred Brand 42%42%None
Nafcillin 1 gm vial   3 Non-Preferred Brand 42%42%None
Nafcillin 10g/100mL   4 Specialty Tier 33%N/ANone
NAGLAZYME 5MG/5ML VIAL   4 Specialty Tier 33%N/AP
naloxone 1 mg/ml syringe   2 Preferred Brand $33.00$82.50None
NALTREXONE HCL 50MG TABLET 100 BLPK   2 Preferred Brand $33.00$82.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NAMENDA 10MG TABLET   3 Non-Preferred Brand 42%42%P
NAMENDA 10MG/5ML SOLUTION   2 Preferred Brand $33.00$82.50P
NAMENDA 5MG TABLET   3 Non-Preferred Brand 42%42%P
NAMENDA XR 14 MG CAPSULE   3 Non-Preferred Brand 42%42%P
NAMENDA XR 21 MG CAPSULE   3 Non-Preferred Brand 42%42%P
NAMENDA XR 28 MG CAPSULE   3 Non-Preferred Brand 42%42%P
NAMENDA XR 7 MG CAPSULE   3 Non-Preferred Brand 42%42%P
NAMENDA XR TITRATION PACK   3 Non-Preferred Brand 42%42%P
NAPROXEN 125 MG/5 ML SUSPEN   2 Preferred Brand $33.00$82.50None
NAPROXEN 250 MG ORAL TABLET   1 Generic $8.00$20.00None
NAPROXEN 375MG TABLET EC   1 Generic $8.00$20.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NAPROXEN 500MG TABLET EC   1 Generic $8.00$20.00None
Naproxen 500mg/1 500 TABLET BOTTLE   1 Generic $8.00$20.00None
NAPROXEN SODIUM 275 MG ORAL TABLET   1 Generic $8.00$20.00None
Naproxen Sodium 550mg/1   1 Generic $8.00$20.00None
NAPROXEN TABLET 375MG (500 CT)   1 Generic $8.00$20.00None
NARATRIPTAN 1MG TABLETS   2 Preferred Brand $33.00$82.50Q:9
/30Days
NARATRIPTAN 2.5MG TABLETS   2 Preferred Brand $33.00$82.50Q:9
/30Days
NASONEX 50ug/1 120 SPRAY, METERED in 1 BOTTLE, PUMP   2 Preferred Brand $33.00$82.50Q:34
/30Days
NATACYN EYE DROPS   3 Non-Preferred Brand 42%42%None
Nateglinide 120mg/1 90 TABLET BOTTLE   1 Generic $8.00$20.00Q:90
/30Days
Nateglinide 60mg/1 90 TABLET BOTTLE   1 Generic $8.00$20.00Q:90
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NEBUPENT 300MG INHAL POWDER   3 Non-Preferred Brand 42%42%P
NECON 0.5/35-28 TABLET   2 Preferred Brand $33.00$82.50None
NECON 1-50-28 TABLET   2 Preferred Brand $33.00$82.50None
NECON 1/35-28 TABLET   2 Preferred Brand $33.00$82.50None
NECON 10/11-28 TABLET   2 Preferred Brand $33.00$82.50None
NECON 7-7-7-28 TABLET   2 Preferred Brand $33.00$82.50None
NEFAZODONE HCL 150MG TABLET (60 CT)   2 Preferred Brand $33.00$82.50None
NEFAZODONE HCL 250MG TABLET   2 Preferred Brand $33.00$82.50None
NEFAZODONE HCL 50MG TABLET   2 Preferred Brand $33.00$82.50None
NEFAZODONE HYDROCHLORIDE TABLETS 100MG 60 BOT   2 Preferred Brand $33.00$82.50None
NEFAZODONE HYDROCHLORIDE TABLETS 200MG 60 BOT   2 Preferred Brand $33.00$82.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NEO/POLYMYXIN/HC EAR TUBEX 10MG/3.5MG/100UNT   1 Generic $8.00$20.00None
Neomycin and Polymyxin B Sulfates and Dexamethasone 1; 3.5; 10000mg/g; mg/g; [USP'U]/g 1 TUBE in 1   1 Generic $8.00$20.00None
NEOMYCIN SULFATE 500MG TABLET   2 Preferred Brand $33.00$82.50None
NEOMYCIN-BACITRACIN-POLY-HC 3.5-10K-1 OINTMENT   2 Preferred Brand $33.00$82.50None
NEOMYCIN-POLYMYXIN-HC 3.5-10K-10 SUSPENSION DROPS   3 Non-Preferred Brand 42%42%None
NEOMYCIN/POLYMY/DEXA EYE DROPS 3.5MG/1ML   1 Generic $8.00$20.00None
NEOMYCIN/POLYMY/GRAM EYE DROPS 0.025MG/ML 1.75MG/M   2 Preferred Brand $33.00$82.50None
NEOMYCIN/POLYMY/HYDRO OTIC SUS   1 Generic $8.00$20.00None
NEORAL 100MG GELATN CAPSULE   2 Preferred Brand $33.00$82.50P
NEORAL 100MG/ML SOLUTION   2 Preferred Brand $33.00$82.50P
NEORAL 25MG GELATIN CAPSULE   2 Preferred Brand $33.00$82.50P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NEPHRAMINE SOLUTION FOR INJECTION   3 Non-Preferred Brand 42%42%P
NEUPOGEN 300 MCG/ML VIAL   4 Specialty Tier 33%N/AP
NEUPOGEN 300MCG/ML VIAL   4 Specialty Tier 33%N/AP
NEUPOGEN 300ug/0.5mL 10 SYRINGE in 1 BOX / 0.5 mL in 1 SYRINGE   4 Specialty Tier 33%N/AP
NEUPOGEN INJECTION 480MCG/0.8ML 10 X 0.8ML SYR   4 Specialty Tier 33%N/AP
NEUPRO 1 MG/24 HR PATCH   3 Non-Preferred Brand 42%42%None
NEUPRO 2 MG/24 HR PATCH   3 Non-Preferred Brand 42%42%None
NEUPRO 3 MG/24 HR PATCH   3 Non-Preferred Brand 42%42%None
NEUPRO 4 MG/24 HR PATCH   3 Non-Preferred Brand 42%42%None
NEUPRO 6 MG/24 HR PATCH   3 Non-Preferred Brand 42%42%None
NEUPRO 8 MG/24 HR PATCH   3 Non-Preferred Brand 42%42%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NEVANAC 0.1% DROPTAINER   3 Non-Preferred Brand 42%42%None
nevirapine 200 mg tablet   2 Preferred Brand $33.00$82.50None
NEVIRAPINE 50 MG/5 ML SUSP   3 Non-Preferred Brand 42%42%None
nevirapine er 400 mg tablet   3 Non-Preferred Brand 42%42%None
NEXAVAR TABLETS 200MG 120 BOT   4 Specialty Tier 33%N/AP
NEXIUM 10mg/1 30 GRANULE, DELAYED RELEASE per CARTON   2 Preferred Brand $33.00$82.50None
NEXIUM 20MG CAPSULE   2 Preferred Brand $33.00$82.50None
NEXIUM 20MG SUSP FOR RECON DELAYED REL. IN A PACKET   2 Preferred Brand $33.00$82.50None
NEXIUM 40MG CAPSULE   2 Preferred Brand $33.00$82.50None
NEXIUM 40MG SUSP FOR RECON DELAYED REL. IN A PACKET   2 Preferred Brand $33.00$82.50None
NEXIUM DR 2.5 MG PACKET   2 Preferred Brand $33.00$82.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NEXIUM DR 5 MG PACKET   2 Preferred Brand $33.00$82.50None
NIACIN ER 1,000 MG TABLET   3 Non-Preferred Brand 42%42%None
NIACIN ER 500 MG TABLET   3 Non-Preferred Brand 42%42%Q:90
/30Days
NIACIN ER 750 MG TABLET   3 Non-Preferred Brand 42%42%None
NIACOR 500MG TABLET   2 Preferred Brand $33.00$82.50None
NICARDIPINE HYDROCHLORIDE 20MG CAPSULES   2 Preferred Brand $33.00$82.50None
NICARDIPINE HYDROCHLORIDE CAPSULES 30MG 500 BOT   2 Preferred Brand $33.00$82.50None
NICOTROL INHALER 10MG 168 X 10MG/CARTRIDGE INHL   3 Non-Preferred Brand 42%42%None
NICOTROL NS NASAL SPRAY BOTTLE 10MG 4 X 10MG/ML INHL   3 Non-Preferred Brand 42%42%None
NIFEDICAL XL 30MG TABLET SR OSMOTIC PUSH 24HR   2 Preferred Brand $33.00$82.50Q:30
/30Days
NIFEDICAL XL 60MG TABLET SR OSMOTIC PUSH 24HR   2 Preferred Brand $33.00$82.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NIFEDIPINE 30MG TABLETS EXTENDED RELEASE   2 Preferred Brand $33.00$82.50Q:30
/30Days
NIFEDIPINE 60MG TABLETS EXTENDED RELEASE   2 Preferred Brand $33.00$82.50None
NIFEDIPINE 90MG TABLETS EXTENDED RELEASE   2 Preferred Brand $33.00$82.50None
Nikki 3 mg-0.02 mg tablet   2 Preferred Brand $33.00$82.50None
NILANDRON 150 MG TABLET   4 Specialty Tier 33%N/ANone
Nimodipine 30mg/1 25 BLISTER PACK in 1 CARTON / 4 CAPSULE in 1 BLISTER PACK   3 Non-Preferred Brand 42%42%None
NIPENT FOR INJECTION 10MG VIALS   4 Specialty Tier 33%N/AP
NITRO-BID 20mg/g 48 PACKET in 1 BOX / 1 g in 1 PACKET   2 Preferred Brand $33.00$82.50None
NITRO-DUR 0.3 MG/HR PATCH   3 Non-Preferred Brand 42%42%None
NITRO-DUR 0.8 MG/HR PATCH   3 Non-Preferred Brand 42%42%None
Nitrofurantoin Macrocrystals 50mg/1 100 CAPSULE in 1 BOTTLE   3 Non-Preferred Brand 42%42%P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Nitrofurantoin mcr 100 mg cap   3 Non-Preferred Brand 42%42%P
Nitrofurantoin Monohydrate/Macrocrystals 25; 75mg 100 CAPSULE BOTTLE   3 Non-Preferred Brand 42%42%P
NITROGLYCERIN .2MG/HR PATCH   2 Preferred Brand $33.00$82.50None
NITROGLYCERIN .4MG/HR PATCH   2 Preferred Brand $33.00$82.50None
NITROGLYCERIN .6MG/HR PATCH   2 Preferred Brand $33.00$82.50None
NITROGLYCERIN TRANSOERMAL SYSTEM .1MG/HR 30 SYSTEM BOX   2 Preferred Brand $33.00$82.50None
Nitrolingual Pumpspray 400ug/1 200 SPRAY, METERED in 1 BOTTLE   3 Non-Preferred Brand 42%42%None
NITROSTAT 0.3MG TABLET SL   2 Preferred Brand $33.00$82.50None
NITROSTAT 0.4MG TABLET SL   2 Preferred Brand $33.00$82.50None
NITROSTAT 0.6MG TABLET SL   2 Preferred Brand $33.00$82.50None
NORA-BE 0.35MG TABLET   2 Preferred Brand $33.00$82.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Norditropin 10mg/1.5mL 1 SYRINGE, PLASTIC per CARTON / 1.5 mL in 1 SYRINGE, PLASTIC   4 Specialty Tier 33%N/AP
Norditropin 15mg/1.5mL 1 SYRINGE, PLASTIC per CARTON / 1.5 mL in 1 SYRINGE, PLASTIC   4 Specialty Tier 33%N/AP
Norditropin 5mg/1.5mL 1 SYRINGE, PLASTIC per CARTON / 1.5 mL in 1 SYRINGE, PLASTIC   4 Specialty Tier 33%N/AP
NORDITROPIN NORDIFLEX 30MG/3ML INJECTION   4 Specialty Tier 33%N/AP
Norethindrone 0.35 mg tablet   2 Preferred Brand $33.00$82.50None
NORETHINDRONE 5MG TABLET   2 Preferred Brand $33.00$82.50None
Norlyroc 0.35 mg tablet   2 Preferred Brand $33.00$82.50None
NORMOSOL -R INJ /D5W   3 Non-Preferred Brand 42%42%None
NORMOSOL-M AND DEXTROSE 5%   3 Non-Preferred Brand 42%42%None
NORMOSOL-R PH 7.4 IV SOLUTION   3 Non-Preferred Brand 42%42%None
NORPACE CR 100MG CAPSULE SA   3 Non-Preferred Brand 42%42%P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NORPACE CR 150MG CAPSULE SA   3 Non-Preferred Brand 42%42%P
Nortrel (21 Day Regimen) 0.035; 1mg/1; mg/1 3 BLISTER PACK per CARTON / 21 TABLET per BLISTER PACK   2 Preferred Brand $33.00$82.50None
Nortrel (28 Day Regimen) 3 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK   2 Preferred Brand $33.00$82.50None
NORTREL 1-0.035MG TABLET 28DAY   2 Preferred Brand $33.00$82.50None
Nortrel 7/7/7 (28 Day Regimen) 6 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT in 1 BLISTER   2 Preferred Brand $33.00$82.50None
NORTRIPTYLINE 10 MG/5 ML SOL   3 Non-Preferred Brand 42%42%None
NORTRIPTYLINE HCL 25MG CAP   1 Generic $8.00$20.00None
NORTRIPTYLINE HCL 75MG CAPSULE   1 Generic $8.00$20.00None
Nortriptyline Hydrochloride 10mg/1 100 CAPSULE BOTTLE   1 Generic $8.00$20.00None
Nortriptyline Hydrochloride 50mg/1 500 CAPSULE BOTTLE   1 Generic $8.00$20.00None
NORVIR 100 MG TABLET   2 Preferred Brand $33.00$82.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NORVIR 100mg/1 30 CAPSULE BOTTLE   2 Preferred Brand $33.00$82.50None
NORVIR 80MG/ML ORAL SOLUTION   2 Preferred Brand $33.00$82.50None
Novolin 100[iU]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL   2 Preferred Brand $33.00$82.50None
Novolin 100[USP'U]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL   2 Preferred Brand $33.00$82.50None
Novolin R 100[iU]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL   2 Preferred Brand $33.00$82.50None
NOVOLOG 100 UNIT/ML CARTRIDGE   2 Preferred Brand $33.00$82.50None
NOVOLOG 100U/ML VIAL   2 Preferred Brand $33.00$82.50None
NOVOLOG FLEXPEN SYRINGE   2 Preferred Brand $33.00$82.50None
NOVOLOG MIX 70/30 SYRINGE 70-30U/ML   2 Preferred Brand $33.00$82.50None
NOVOLOG MIX 70/30 VIAL   2 Preferred Brand $33.00$82.50None
NOXAFIL 200MG/5ML SUSPENSION ORAL   4 Specialty Tier 33%N/ANone
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NOXAFIL DR 100 MG TABLET   4 Specialty Tier 33%N/ANone
NUCYNTA ER 100mg/1 60 TABLET, FILM COATED   2 Preferred Brand $33.00$82.50Q:120
/30Days
NUCYNTA ER 150mg/1 60 TABLET, FILM COATED   2 Preferred Brand $33.00$82.50Q:60
/30Days
NUCYNTA ER 200mg/1 60 TABLET, FILM COATED   2 Preferred Brand $33.00$82.50Q:60
/30Days
NUCYNTA ER 250mg/1 60 TABLET, FILM COATED   2 Preferred Brand $33.00$82.50Q:60
/30Days
NUCYNTA ER 50mg/1 60 TABLET, FILM COATED   2 Preferred Brand $33.00$82.50Q:120
/30Days
NUEDEXTA 20; 10mg/1; mg/1   2 Preferred Brand $33.00$82.50None
NULOJIX 250mg/1 1 VIAL, SINGLE-USE per CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in   4 Specialty Tier 33%N/AP
NULYTELY WITH FLAVOR PACKS POWDER FOR SOLUTION 420;1.48;MG;MG;GM; 4 L BOT   2 Preferred Brand $33.00$82.50None
NUTRILIPID 20 % EMULSION   2 Preferred Brand $33.00$82.50P
NUTRILIPID 20% IV FAT EMULSION   2 Preferred Brand $33.00$82.50P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NUVARING 0.12-0.015 RING VAGINAL   3 Non-Preferred Brand 42%42%None
NUVIGIL 150 MG TABLET   3 Non-Preferred Brand 42%42%P Q:60
/30Days
NUVIGIL 200 MG TABLET   3 Non-Preferred Brand 42%42%P Q:30
/30Days
NUVIGIL 250 MG TABLET   3 Non-Preferred Brand 42%42%P Q:30
/30Days
NUVIGIL 50 MG TABLET   3 Non-Preferred Brand 42%42%P Q:150
/30Days
NYAMYC 100000 U/G POWDER   2 Preferred Brand $33.00$82.50None
Nystatin 100000[USP'U]/g   2 Preferred Brand $33.00$82.50None
Nystatin 100000[USP'U]/g 1 TUBE per CARTON / 30 g in 1 TUBE   2 Preferred Brand $33.00$82.50None
Nystatin 100000[USP'U]/g 1 TUBE per CARTON / 30 g in 1 TUBE   2 Preferred Brand $33.00$82.50None
Nystatin 100000[USP'U]/mL   2 Preferred Brand $33.00$82.50None
NYSTATIN TABLET 500000U (100 CT)   2 Preferred Brand $33.00$82.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
NYSTOP 100000U/GM POWDER   2 Preferred Brand $33.00$82.50None

Chart Legend:

Below are a few notes to help you understand the above 2015 Medicare Part D SilverScript Choice (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 $320 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 $2960) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2016 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 2015 )

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.