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2017 Medicare Part D and Medicare Advantage Plan Formulary Browser

This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.
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First Health Part D Premier Plus (PDP) (S5768-167-0)
Tier 1 (283)
Tier 2 (974)
Tier 3 (855)
Tier 4 (1334)
Tier 5 (488)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
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Has Quantity Limits:
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Cick on the first letter of your drug name to browse the formulary:

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M N O P Q R S T U V W X Y Z 0-9 
2017 Medicare Part D Plan Formulary Information
First Health Part D Premier Plus (PDP) (S5768-167-0)
Benefit Details           
The First Health Part D Premier Plus (PDP) (S5768-167-0)
Formulary Drugs Starting with the Letter S

in CMS PDP Region 8 which includes: NC
Plan Monthly Premium: $95.50 Deductible: $0 Qualifies for LIS: No
Drugs Starting with Letter S

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
SANDIMMUNE 100MG/ML TUBEX   4 Non-Preferred Drug 50%50%P
SANTYL OINTMENT   3 Preferred Brand $34.00$102.00None
SAPHRIS 10 MG TAB SL BLK CHERY   4 Non-Preferred Drug 50%50%Q:60
/30Days
SAPHRIS 2.5 MG TAB SL BLK CHRY   4 Non-Preferred Drug 50%50%Q:60
/30Days
SAPHRIS 5 MG TAB SL BLK CHERRY   4 Non-Preferred Drug 50%50%Q:60
/30Days
SAVAYSA 15 MG TABLET   4 Non-Preferred Drug 50%50%Q:30
/30Days
SAVAYSA 30 MG TABLET   4 Non-Preferred Drug 50%50%Q:30
/30Days
SAVAYSA 60 MG TABLET   4 Non-Preferred Drug 50%50%Q:30
/30Days
SAVELLA TABLETS 100MG 60 COUNT BOT   4 Non-Preferred Drug 50%50%P Q:60
/30Days
SAVELLA TABLETS 12.5MG 60 COUNT BOT   4 Non-Preferred Drug 50%50%P Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SAVELLA TABLETS 25MG 60 COUNT BOT   4 Non-Preferred Drug 50%50%P Q:60
/30Days
SAVELLA TABLETS TITRATION PACK KIT 12.5;25;50MG;MG;MG 55 COUNT PKGCOM   4 Non-Preferred Drug 50%50%P Q:110
/365Days
SAVELLA TALBETS 50MG 60 COUNT BOT   4 Non-Preferred Drug 50%50%P Q:60
/30Days
SELEGILINE HCL 5 MG TABLET   2 Generic $2.00$6.00None
SELEGILINE HCL 5MG CAPSULE   2 Generic $2.00$6.00None
SELENIUM SULFIDE 2.5mg/100mL 118 mL in 1 BOTTLE   2 Generic $2.00$6.00None
SELZENTRY 150mg/1 60 FILM COATED TABLETS in BOTTLE   5 Specialty Tier 33%N/AQ:60
/30Days
SELZENTRY 25 MG TABLET   4 Non-Preferred Drug 50%50%Q:240
/30Days
SELZENTRY 300mg/1 60 FILM COATED TABLETS in BOTTLE   5 Specialty Tier 33%N/AQ:120
/30Days
SELZENTRY 75 MG TABLET   5 Specialty Tier 33%N/AQ:60
/30Days
SENSIPAR 30MG TABLET   3 Preferred Brand $34.00$102.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SENSIPAR 60MG TABLET   5 Specialty Tier 33%N/AQ:60
/30Days
SENSIPAR 90MG TABLET   5 Specialty Tier 33%N/AQ:120
/30Days
SEREVENT DIS AER 50MCG   4 Non-Preferred Drug 50%50%Q:60
/30Days
SEROQUEL TABLETS EXTENDED RELEASE 150MG 100 CRTN   3 Preferred Brand $34.00$102.00Q:30
/30Days
SEROQUEL TABLETS EXTENDED RELEASE 200MG 100 X 200 MG CRTN   3 Preferred Brand $34.00$102.00Q:30
/30Days
SEROQUEL TABLETS EXTENDED RELEASE 400MG 100 X 400 MG CRTN   3 Preferred Brand $34.00$102.00Q:60
/30Days
SEROQUEL TABLETS EXTENDED RELEASE 50MG 100 TABS CRTN   3 Preferred Brand $34.00$102.00Q:180
/30Days
SEROQUEL XR 300MG TABLET 60X300MG BOT   3 Preferred Brand $34.00$102.00Q:60
/30Days
SERTRALINE 20 MG/ML ORAL CONC   3 Preferred Brand $34.00$102.00None
SERTRALINE HCL 100 MG TABLET   1 Preferred Generic $1.00$3.00None
SERTRALINE HCL 25 MG TABLET   1 Preferred Generic $1.00$3.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Sertraline hcl 50 mg tablet   1 Preferred Generic $1.00$3.00None
SETLAKIN 0.15 MG-0.03 MG TAB   2 Generic $2.00$6.00None
SEVELAMER CARBONATE 26.7 MG/ML ORAL SUSPENSION [RENVELA]   3 Preferred Brand $34.00$102.00None
Sevelamer Carbonate 26.7 MG/ML Oral Suspension [RENVELA]   3 Preferred Brand $34.00$102.00None
SEVELAMER CARBONATE 40 MG/ML ORAL SUSPENSION [RENVELA]   3 Preferred Brand $34.00$102.00None
Sevelamer Carbonate 40 MG/ML Oral Suspension [RENVELA]   3 Preferred Brand $34.00$102.00None
SHAROBEL 0.35 MG TABLET   2 Generic $2.00$6.00None
Signifor .3 mg/mL   5 Specialty Tier 33%N/AP Q:60
/30Days
Signifor .6 mg/mL   5 Specialty Tier 33%N/AP Q:60
/30Days
Signifor .9 mg/mL   5 Specialty Tier 33%N/AP Q:60
/30Days
SILDENAFIL 20 MG TABLET   3 Preferred Brand $34.00$102.00P Q:90
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SILENOR 3 MG TABLET   4 Non-Preferred Drug 50%50%Q:30
/30Days
SILENOR 6 MG TABLET   4 Non-Preferred Drug 50%50%Q:30
/30Days
SILVER SULFADIAZINE 1% CRM   2 Generic $2.00$6.00None
SIMBRINZA 1%-0.2% EYE DROPS   4 Non-Preferred Drug 50%50%None
SIMULECT 20MG VIAL   5 Specialty Tier 33%N/AP
SIMVASTATIN 10 MG TABLET   1 Preferred Generic $1.00$3.00None
SIMVASTATIN 20 MG TABLET   1 Preferred Generic $1.00$3.00None
SIMVASTATIN 40MG TABLET (500 CT)   1 Preferred Generic $1.00$3.00None
SIMVASTATIN 5 MG TABLET   1 Preferred Generic $1.00$3.00None
SIMVASTATIN 80MG TABLET (1000 CT)   1 Preferred Generic $1.00$3.00Q:30
/30Days
Sirolimus 0.5 MG Tablet [Rapamune]   4 Non-Preferred Drug 50%50%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SIROLIMUS 1 MG TABLET [Rapamune]   4 Non-Preferred Drug 50%50%P
SIROLIMUS 2 MG TABLET [Rapamune]   4 Non-Preferred Drug 50%50%P
SIRTURO 100 MG TABLET   5 Specialty Tier 33%N/AP Q:188
/365Days
SIVEXTRO 200 MG TABLET   5 Specialty Tier 33%N/ANone
SIVEXTRO 200 MG VIAL   5 Specialty Tier 33%N/ANone
SODIUM CHLORIDE 0.45% TUBEX   2 Generic $2.00$6.00None
Sodium Chloride 3g/100mL   2 Generic $2.00$6.00None
Sodium Chloride 900mg/100mL 9 BOTTLE, PLASTIC in 1 CASE / 1500 mL in 1 BOTTLE, PLASTIC   1 Preferred Generic $1.00$3.00None
Sodium Chloride 9g/1000mL 4 BAG in 1 PACKAGE / 100 mL in 1 BAG   2 Generic $2.00$6.00None
SODIUM CHLORIDE INJECTION USP 5%   2 Generic $2.00$6.00None
SODIUM CL 2.5 MEQ/ML VIAL   2 Generic $2.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SODIUM PHENYLBUTYRATE POWDER   5 Specialty Tier 33%N/AP
sodium polystyrene sulf pwd   3 Preferred Brand $34.00$102.00None
SOLTAMOX 10 MG/5 ML SOLN   4 Non-Preferred Drug 50%50%P
SOMATULINE DEPOT 120 MG/0.5 ML   5 Specialty Tier 33%N/AP Q:1
/28Days
SOMATULINE DEPOT 60 MG/0.2 ML   5 Specialty Tier 33%N/AP
SOMATULINE DEPOT 90 MG/0.3 ML   5 Specialty Tier 33%N/AP
SOMAVERT 10 MG VIAL   5 Specialty Tier 33%N/AP
SOMAVERT 15 MG VIAL   5 Specialty Tier 33%N/AP
SOMAVERT 20 MG VIAL   5 Specialty Tier 33%N/AP
SOMAVERT 25 MG VIAL   5 Specialty Tier 33%N/AP
SOMAVERT 30 MG VIAL   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SORINE SOLTALOL HCL TABLETS 240MG 100 BOXUD   1 Preferred Generic $1.00$3.00None
SORINE SOTALOL HCL TABLETS 120MG 100 BOXUD   1 Preferred Generic $1.00$3.00None
SORINE SOTALOL HCL TABLETS 160MG 100 BOXUD   1 Preferred Generic $1.00$3.00None
SORINE SOTALOL HCL TABLETS 80MG 100 BOXUD   1 Preferred Generic $1.00$3.00None
SOTALOL HCL TABLET 240MG   1 Preferred Generic $1.00$3.00None
Sotalol Hydrochloride 120mg/1 100 TABLET BOTTLE, PLASTIC   1 Preferred Generic $1.00$3.00None
sotalol hydrochloride 160mg/1 100 TABLET BOTTLE   1 Preferred Generic $1.00$3.00None
Sotalol Hydrochloride 80mg/1 100 TABLET BOTTLE, PLASTIC   1 Preferred Generic $1.00$3.00None
SOVALDI 400 MG TABLET   5 Specialty Tier 33%N/AP Q:28
/28Days
SPIRIVA 18MCG CP-HANDIHALER 90 (9 X 10) BLPK   3 Preferred Brand $34.00$102.00Q:30
/30Days
SPIRIVA RESPIMAT 1.25 MCG INH   3 Preferred Brand $34.00$102.00Q:4
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SPIRIVA RESPIMAT INHAL SPRAY   3 Preferred Brand $34.00$102.00Q:4
/30Days
SPIRONOLACTONE 100MG TABLET   1 Preferred Generic $1.00$3.00None
SPIRONOLACTONE 25MG TABLET (100 CT)   1 Preferred Generic $1.00$3.00None
SPIRONOLACTONE 50MG TABLET (100 CT)   1 Preferred Generic $1.00$3.00None
SPIRONOLACTONE/HCTZ TABLET 25-25MG (500 CT)   3 Preferred Brand $34.00$102.00None
SPORANOX 10MG/ML SOLUTION   5 Specialty Tier 33%N/AP
SPRINTEC 0.25-0.035 TABLET   2 Generic $2.00$6.00None
SPRITAM 1,000 MG TABLET   4 Non-Preferred Drug 50%50%P Q:60
/30Days
SPRITAM 250 MG TABLET   4 Non-Preferred Drug 50%50%P Q:60
/30Days
SPRITAM 500 MG TABLET   4 Non-Preferred Drug 50%50%P Q:60
/30Days
SPRITAM 750 MG TABLET   4 Non-Preferred Drug 50%50%P Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SPRYCEL 100mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE   5 Specialty Tier 33%N/AP Q:30
/30Days
SPRYCEL 140mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE   5 Specialty Tier 33%N/AP Q:30
/30Days
SPRYCEL 20MG TABLET   5 Specialty Tier 33%N/AP Q:60
/30Days
SPRYCEL 50MG TABLET   5 Specialty Tier 33%N/AP Q:60
/30Days
SPRYCEL 70MG TABLET   5 Specialty Tier 33%N/AP Q:60
/30Days
SPRYCEL 80mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE   5 Specialty Tier 33%N/AP Q:60
/30Days
SPS 15 GM/60 ML SUSPENSION   3 Preferred Brand $34.00$102.00None
SRONYX 0.10-0.02 MG TABLET   2 Generic $2.00$6.00None
SSD Cream 10g/1000g 85 g in 1 TUBE   2 Generic $2.00$6.00None
STALEVO 100 TABLET   4 Non-Preferred Drug 50%50%S
STALEVO 150 TABLET   4 Non-Preferred Drug 50%50%S
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
STALEVO 200 50-200-200 TABLET   4 Non-Preferred Drug 50%50%S
STAVUDINE CAPSULES 15MG 60 BOT   3 Preferred Brand $34.00$102.00None
STAVUDINE CAPSULES 20MG 60 BOT   3 Preferred Brand $34.00$102.00None
STAVUDINE CAPSULES 30MG 60 BOT   3 Preferred Brand $34.00$102.00None
STAVUDINE CAPSULES 40MG 60 BOT   3 Preferred Brand $34.00$102.00None
STERILE WATER FOR IRRIGATION   2 Generic $2.00$6.00None
STIOLTO RESPIMAT INHAL SPRAY   3 Preferred Brand $34.00$102.00Q:4
/30Days
STIVARGA 40 MG TABLET   5 Specialty Tier 33%N/AP Q:120
/30Days
STRATTERA 100MG CAPSULE   4 Non-Preferred Drug 50%50%Q:30
/30Days
STRATTERA 10MG CAPSULE   4 Non-Preferred Drug 50%50%Q:60
/30Days
STRATTERA 18MG CAPSULE   4 Non-Preferred Drug 50%50%Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
STRATTERA 25MG CAPSULE   4 Non-Preferred Drug 50%50%Q:60
/30Days
STRATTERA 40MG CAPSULE   4 Non-Preferred Drug 50%50%Q:60
/30Days
STRATTERA 60MG CAPSULE   4 Non-Preferred Drug 50%50%Q:60
/30Days
STRATTERA 80MG CAPSULE   4 Non-Preferred Drug 50%50%Q:30
/30Days
STREPTOMYCIN FOR INJECTION 1GM/VIL   2 Generic $2.00$6.00None
STRIBILD TABLET   5 Specialty Tier 33%N/AQ:30
/30Days
STRIVERDI RESPIMAT INHAL SPRAY   3 Preferred Brand $34.00$102.00Q:4
/30Days
SUBOXONE 12 MG-3 MG SL FILM   4 Non-Preferred Drug 50%50%P Q:60
/30Days
Suboxone 2; 0.5mg/1; mg/1 30 POUCH per CARTON / 1 FILM, SOLUBLE in 1 POUCH   4 Non-Preferred Drug 50%50%P Q:90
/30Days
SUBOXONE 4 MG-1 MG SL FILM   4 Non-Preferred Drug 50%50%P Q:90
/30Days
Suboxone 8; 2mg/1; mg/1 30 POUCH per CARTON / 1 FILM, SOLUBLE in 1 POUCH   4 Non-Preferred Drug 50%50%P Q:90
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SUCRALFATE 1GM TABLET   2 Generic $2.00$6.00None
SULF-PRED 10-0.23% EYE DROPS   2 Generic $2.00$6.00None
SULFACETAMIDE 10% EYE OINTMENT   2 Generic $2.00$6.00None
Sulfacetamide Sodium 100mg/mL 118 mL in 1 BOTTLE   2 Generic $2.00$6.00None
SULFACETAMIDE SODIUM OPHTHALMIC SOLUTION USP 10% 15 ML BOT   3 Preferred Brand $34.00$102.00None
Sulfadiazine 500mg/1 100 TABLET BOTTLE   2 Generic $2.00$6.00None
Sulfamethoxazole and Trimethoprim 200; 40mg/5mL; mg/5mL   3 Preferred Brand $34.00$102.00None
Sulfamethoxazole and Trimethoprim 800; 160mg/1; mg/1 100 TABLET BOTTLE   1 Preferred Generic $1.00$3.00None
SULFAMETHOXAZOLE W/TMP VIAL 80MG-16ML 10 X 10ML VIAL   1 Preferred Generic $1.00$3.00None
SULFAMETHOXAZOLE-TMP SS TABLET   1 Preferred Generic $1.00$3.00None
SULFAMYLON CREAM 85GM 4 OZ TUBE   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SULFASALAZINE 500MG TABLET   3 Preferred Brand $34.00$102.00None
SULFASALAZINE DR 500 MG TAB   3 Preferred Brand $34.00$102.00None
SULINDAC 150MG TABLET (100 CT)   2 Generic $2.00$6.00None
SULINDAC 200MG TABLET   2 Generic $2.00$6.00None
Sumatriptan 20 MG/ACTUAT Nasal Spray   2 Generic $2.00$6.00Q:12
/30Days
SUMATRIPTAN 4 MG/0.5 ML CART   4 Non-Preferred Drug 50%50%Q:4
/30Days
Sumatriptan 4 mg/0.5 ml inject   4 Non-Preferred Drug 50%50%Q:4
/30Days
Sumatriptan 5 MG/ACTUAT Nasal Spray   2 Generic $2.00$6.00Q:12
/30Days
SUMATRIPTAN 6 MG/0.5 ML INJECT   4 Non-Preferred Drug 50%50%Q:4
/30Days
SUMATRIPTAN 6 MG/0.5 ML REFILL   4 Non-Preferred Drug 50%50%Q:4
/30Days
SUMATRIPTAN 6 MG/0.5 ML SYRNG   2 Generic $2.00$6.00Q:4
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Sumatriptan 6 mg/0.5 ml vial   4 Non-Preferred Drug 50%50%Q:4
/30Days
Sumatriptan Succinate 25mg/1 9 BLISTER PACK per CARTON / 9 TABLET per BLISTER PACK   2 Generic $2.00$6.00Q:9
/30Days
Sumatriptan Succinate 50 MG TABLET   2 Generic $2.00$6.00Q:9
/30Days
SUMATRIPTAN SUCCINATE TABLETS 100MG 9 BOXUD   2 Generic $2.00$6.00Q:9
/30Days
SUMAVEL DOSEPRO 4 MG/0.5 ML   5 Specialty Tier 33%N/AQ:4
/30Days
SUMAVEL DOSEPRO 6 MG/0.5 ML   5 Specialty Tier 33%N/AQ:4
/30Days
SUPRAX 100 MG TABLET CHEWABLE   4 Non-Preferred Drug 50%50%None
SUPRAX 200 MG TABLET CHEWABLE   4 Non-Preferred Drug 50%50%None
SUPRAX 400 MG CAPSULE   4 Non-Preferred Drug 50%50%None
SUPRAX 500 MG/5 ML SUSPENSION   4 Non-Preferred Drug 50%50%None
SUPREP bowel prep 1.6; 3.13; 17.5g/mL; g/mL; g/mL 2 BOTTLE, PLASTIC per CARTON / 177.4 mL in 1 BOT   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SUSTIVA 200MG CAPSULE   4 Non-Preferred Drug 50%50%None
SUSTIVA 50MG CAPSULE   4 Non-Preferred Drug 50%50%None
SUSTIVA 600MG TABLET   4 Non-Preferred Drug 50%50%None
SUTENT 12.5MG CAPSULE   5 Specialty Tier 33%N/AP Q:90
/30Days
SUTENT 25mg/1 28 CAPSULE BOTTLE   5 Specialty Tier 33%N/AP Q:30
/30Days
SUTENT 37.5 MG CAPSULE   5 Specialty Tier 33%N/AP Q:30
/30Days
SUTENT 50MG CAPSULE   5 Specialty Tier 33%N/AP Q:30
/30Days
SYLATRON 200 MCG KIT   5 Specialty Tier 33%N/AP
SYLATRON 300 MCG KIT   5 Specialty Tier 33%N/AP
SYLATRON 600 MCG KIT   5 Specialty Tier 33%N/AP
SYLVANT 100 MG VIAL   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SYMBICORT 160-4.5MCG HFA AEROSOL WITH ADAPTER   4 Non-Preferred Drug 50%50%S Q:10
/30Days
SYMBICORT 80; 4.5ug/1; ug/1 1 POUCH in 1 CARTON / 1 CANISTER in 1 POUCH / 120 AEROSOL in 1 CANISTER   4 Non-Preferred Drug 50%50%S Q:10
/30Days
SYMLINPEN 120 PEN INJECTOR   4 Non-Preferred Drug 50%50%Q:11
/30Days
SYMLINPEN 60 PEN INJECTOR   4 Non-Preferred Drug 50%50%Q:6
/30Days
SYNAGIS 50MG/0.5ML VIAL   5 Specialty Tier 33%N/AP
SYNAREL 2MG/ML NASAL SPRAY   5 Specialty Tier 33%N/ANone
SYNERCID 500MG VIAL   5 Specialty Tier 33%N/ANone
SYNJARDY 12.5-1,000 MG TABLET   4 Non-Preferred Drug 50%50%Q:60
/30Days
SYNJARDY 12.5-500 MG TABLET   4 Non-Preferred Drug 50%50%Q:60
/30Days
SYNJARDY 5-1,000 MG TABLET   4 Non-Preferred Drug 50%50%Q:60
/30Days
SYNJARDY 5-500 MG TABLET   4 Non-Preferred Drug 50%50%Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SYNRIBO 3.5 MG/ML VIAL   5 Specialty Tier 33%N/AP
SYNTHROID 100MCG TABLET   3 Preferred Brand $34.00$102.00None
SYNTHROID 112 MCG TABLET   3 Preferred Brand $34.00$102.00None
SYNTHROID 125MCG TABLET   3 Preferred Brand $34.00$102.00None
Synthroid 137ug/1 90 TABLET BOTTLE   3 Preferred Brand $34.00$102.00None
SYNTHROID 150MCG TABLET   3 Preferred Brand $34.00$102.00None
SYNTHROID 175MCG TABLET   3 Preferred Brand $34.00$102.00None
SYNTHROID 200MCG TABLET   3 Preferred Brand $34.00$102.00None
SYNTHROID 25MCG TABLET   3 Preferred Brand $34.00$102.00None
SYNTHROID 300MCG TABLET   3 Preferred Brand $34.00$102.00None
SYNTHROID 50MCG TABLET   3 Preferred Brand $34.00$102.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SYNTHROID 75MCG TABLET   3 Preferred Brand $34.00$102.00None
SYNTHROID 88 MCG TABLET   3 Preferred Brand $34.00$102.00None
SYPRINE 250 MG CAPSULE   5 Specialty Tier 33%N/ANone

Chart Legend:

Below are a few notes to help you understand the above 2017 Medicare Part D First Health Part D Premier 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 $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 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 $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 September 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.







Tips & Disclaimers
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  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDPCompare.com and MACompare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
    Statement required by Medicare:
    "We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options."
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.