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2017 Medicare Part D Plan Formulary Information
AAA1 Vantage PREMIUM (HMO-POS) (H5576-018-2) Benefit Details
The AAA1 Vantage PREMIUM (HMO-POS) (H5576-018-2) Formulary Drugs Starting with the Letter E in Iberia Parish, LA: CMS MA Region 16 which includes: LA Plan Monthly Premium: $151.00 Deductible: $0
Drugs Starting with Letter E Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter E Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
E.E.S. GRAN SUS 200/5ML	4	Non-Preferred Brand	$100.00	$300.00	None
ECONAZOLE NITRATE 1% CREAM 85GM TUBE	2	Generic	$10.00	$30.00	None
EDARBI 40 MG TABLET	4	Non-Preferred Brand	$100.00	$300.00	None
EDARBI 80 MG TABLET	4	Non-Preferred Brand	$100.00	$300.00	None
EDARBYCLOR 40-12.5 MG TABLET	4	Non-Preferred Brand	$100.00	$300.00	None
EDARBYCLOR 40-25 MG TABLET	4	Non-Preferred Brand	$100.00	$300.00	None
EDECRIN 25 MG TABLET	3	Preferred Brand	$47.00	$141.00	None
EDURANT 27.5mg/1	5	Specialty Tier	33%	N/A	None
EFFIENT 10 MG TABLET	3	Preferred Brand	$47.00	$141.00	None
EFFIENT 5 MG TABLET	3	Preferred Brand	$47.00	$141.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ELAPRASE 6mg/3mL 1 VIAL, GLASS in 1 BOX / 3 mL in 1 VIAL, GLASS	5	Specialty Tier	33%	N/A	None
ELIDEL 1% CREAM	3	Preferred Brand	$47.00	$141.00	None
ELIGARD 22.5 MG SYRINGE	4	Non-Preferred Brand	$100.00	$300.00	None
ELIGARD 30 MG SYRINGE KIT	4	Non-Preferred Brand	$100.00	$300.00	None
ELIGARD 45 MG SYRINGE KIT	4	Non-Preferred Brand	$100.00	$300.00	None
ELIGARD 7.5 MG SYRINGE KIT	4	Non-Preferred Brand	$100.00	$300.00	None
ELIQUIS 2.5 MG TABLET	3	Preferred Brand	$47.00	$141.00	None
ELIQUIS 5 MG TABLET	3	Preferred Brand	$47.00	$141.00	None
Elitek 3 KIT per CARTON / 1 KIT in 1 KIT	5	Specialty Tier	33%	N/A	None
ELITEK 7.5 MG VIAL	5	Specialty Tier	33%	N/A	None
ELMIRON 100mg GELATIN COATED 100 CAPSULE BOTTLE	3	Preferred Brand	$47.00	$141.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
EMADINE 0.05% EYE DROPS	4	Non-Preferred Brand	$100.00	$300.00	None
EMBEDA ER 100-4 MG CAPSULE	4	Non-Preferred Brand	$100.00	$300.00	Q:60 /30Days
EMBEDA ER 20-0.8 MG CAPSULE	4	Non-Preferred Brand	$100.00	$300.00	Q:60 /30Days
EMBEDA ER 30-1.2 MG CAPSULE	4	Non-Preferred Brand	$100.00	$300.00	Q:60 /30Days
EMBEDA ER 50-2 MG CAPSULE	4	Non-Preferred Brand	$100.00	$300.00	Q:60 /30Days
EMBEDA ER 60-2.4 MG CAPSULE	4	Non-Preferred Brand	$100.00	$300.00	Q:60 /30Days
EMBEDA ER 80-3.2 MG CAPSULE	4	Non-Preferred Brand	$100.00	$300.00	Q:60 /30Days
EMCYT 140MG CAPSULE	3	Preferred Brand	$47.00	$141.00	None
EMEND 40MG CAPSULE	3	Preferred Brand	$47.00	$141.00	P Q:3 /2Days
EMEND CAPSULES 125MG 6 BLPK	3	Preferred Brand	$47.00	$141.00	P Q:3 /2Days
EMEND CAPSULES 80MG 2 BLPK	3	Preferred Brand	$47.00	$141.00	P Q:3 /2Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
EMEND TRIFOLD PACK	3	Preferred Brand	$47.00	$141.00	P Q:3 /2Days
Emoquette 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK	2	Generic	$10.00	$30.00	None
EMPLICITI 300 MG VIAL	5	Specialty Tier	33%	N/A	P
EMPLICITI 400 MG VIAL	5	Specialty Tier	33%	N/A	P
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H	4	Non-Preferred Brand	$100.00	$300.00	None
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H	4	Non-Preferred Brand	$100.00	$300.00	None
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H	4	Non-Preferred Brand	$100.00	$300.00	None
EMTRIVA 10MG/ML SOLUTION	3	Preferred Brand	$47.00	$141.00	None
EMTRIVA 200MG CAPSULE	3	Preferred Brand	$47.00	$141.00	None
EMVERM 100 MG TABLET CHEW	5	Specialty Tier	33%	N/A	None
ENALAPRIL MALEATE 10MG TABLET (100 CT)	1	Preferred Generic	$4.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ENALAPRIL MALEATE 2.5 MG TAB	1	Preferred Generic	$4.00	$0.00	None
Enalapril Maleate 20mg/1 100 TABLET BOTTLE, PLASTIC	1	Preferred Generic	$4.00	$0.00	None
ENALAPRIL MALEATE 5 MG TABLET	1	Preferred Generic	$4.00	$0.00	None
Enalapril Maleate and Hydrochlorothiazide 10; 25mg/1; mg/1 100 TABLET BOTTLE, PLASTIC	1	Preferred Generic	$4.00	$0.00	None
ENALAPRIL MALEATE-HCTZ 5-12.5MG TABLET	1	Preferred Generic	$4.00	$0.00	None
ENBREL 25 MG/0.5 ML SYRINGE	5	Specialty Tier	33%	N/A	P
ENBREL 25MG KIT	5	Specialty Tier	33%	N/A	P
ENBREL 50 MG/ML SURECLICK SYR	5	Specialty Tier	33%	N/A	P
ENBREL 50mg/mL	5	Specialty Tier	33%	N/A	P
ENDOCET 10MG-325MG TABLET	2	Generic	$10.00	$30.00	Q:360 /30Days
ENDOCET 5/325 TABLET	2	Generic	$10.00	$30.00	Q:360 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ENDOCET 7.5-325MG TABLET	2	Generic	$10.00	$30.00	Q:360 /30Days
ENGERIX B INJECTION	3	Preferred Brand	$47.00	$141.00	P
ENGERIX-B 10MCG 10 X 0.5ML VIALSD	3	Preferred Brand	$47.00	$141.00	P
ENGERIX-B 20 MCG/ML SYRN	3	Preferred Brand	$47.00	$141.00	P
ENOXAPARIN 100 MG/ML SYRINGE	2	Generic	$10.00	$30.00	Q:34 /17Days
ENOXAPARIN 120 MG/0.8 ML SYRINGE	2	Generic	$10.00	$30.00	Q:28 /17Days
ENOXAPARIN 150 MG/ML SYRINGE	2	Generic	$10.00	$30.00	Q:34 /17Days
ENOXAPARIN 30 MG/0.3 ML SYRINGE	2	Generic	$10.00	$30.00	Q:11 /17Days
ENOXAPARIN 300 MG/3 ML vial	2	Generic	$10.00	$30.00	Q:51 /17Days
ENOXAPARIN 40 MG/0.4 ML SYRINGE	2	Generic	$10.00	$30.00	Q:14 /17Days
ENOXAPARIN 60 MG/0.6 ML SYRINGE	2	Generic	$10.00	$30.00	Q:21 /17Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ENOXAPARIN 80 MG/0.8 ML SYRINGE	2	Generic	$10.00	$30.00	Q:28 /17Days
ENTACAPONE 200 MG TABLET [Comtan Entacapone]	2	Generic	$10.00	$30.00	None
ENTECAVIR 0.5 MG TABLET [Baraclude]	2	Generic	$10.00	$30.00	None
ENTECAVIR 1 MG TABLET [Baraclude]	2	Generic	$10.00	$30.00	None
ENTRESTO 24 MG-26 MG TABLET	3	Preferred Brand	$47.00	$141.00	P Q:60 /30Days
ENTRESTO 49 MG-51 MG TABLET	3	Preferred Brand	$47.00	$141.00	P Q:60 /30Days
ENTRESTO 97 MG-103 MG TABLET	3	Preferred Brand	$47.00	$141.00	P Q:60 /30Days
ENULOSE 10 GM/15 ML SOLUTION	2	Generic	$10.00	$30.00	None
ENVARSUS XR 0.75 MG TABLET	4	Non-Preferred Brand	$100.00	$300.00	P
ENVARSUS XR 1 MG TABLET	4	Non-Preferred Brand	$100.00	$300.00	P
ENVARSUS XR 4 MG TABLET	4	Non-Preferred Brand	$100.00	$300.00	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
EPCLUSA 400 MG-100 MG TABLET	5	Specialty Tier	33%	N/A	P Q:30 /30Days
EPIDUO FORTE 0.3-2.5% GEL PUMP	4	Non-Preferred Brand	$100.00	$300.00	P
EPIDUO GEL	4	Non-Preferred Brand	$100.00	$300.00	P
EPINASTINE HCL 0.05% EYE DROPS	2	Generic	$10.00	$30.00	None
EPINEPHRINE 0.15 MG AUTO-INJCT	3	Preferred Brand	$47.00	$141.00	Q:2 /15Days
EPINEPHRINE 0.15 MG AUTO-INJECT	4	Non-Preferred Brand	$100.00	$300.00	S Q:2 /15Days
EPINEPHRINE 0.3 MG AUTO-INJECT	3	Preferred Brand	$47.00	$141.00	Q:2 /15Days
EPINEPHRINE 0.3 MG AUTO-INJECT	4	Non-Preferred Brand	$100.00	$300.00	S Q:2 /15Days
EPIPEN 0.3MG AUTO-INJECTOR	3	Preferred Brand	$47.00	$141.00	Q:2 /15Days
EPIPEN JR 0.15MG AUTO-INJCT	3	Preferred Brand	$47.00	$141.00	Q:2 /15Days
Epirubicin 200 mg/100 ml vial	2	Generic	$10.00	$30.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
EPITOL 200MG TABLET	2	Generic	$10.00	$30.00	None
EPIVIR HBV 25MG/5ML TUBEX	3	Preferred Brand	$47.00	$141.00	None
Eplerenone 25mg/1 90 TABLET BOTTLE	2	Generic	$10.00	$30.00	None
Eplerenone 50mg/1 90 TABLET BOTTLE	2	Generic	$10.00	$30.00	None
EPOGEN 10000U/ML VIAL MDV	3	Preferred Brand	$47.00	$141.00	P
EPOGEN 2000[iU]/mL 10 VIAL in 1 PACKAGE / 1 mL in 1 VIAL	3	Preferred Brand	$47.00	$141.00	P
EPOGEN 3000U/ML VIAL SDV	3	Preferred Brand	$47.00	$141.00	P
EPOGEN 4000U/ML VIAL SDV	3	Preferred Brand	$47.00	$141.00	P
EPOGEN INJECTION 20000U 10 X 1ML CRTN	3	Preferred Brand	$47.00	$141.00	P
EPROSARTAN MESYLATE 600 MG TABLET	2	Generic	$10.00	$30.00	None
EPZICOM 600MG/300MG TABLETS	5	Specialty Tier	33%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
EQUETRO CAPSULES 200MG 120 BOT	4	Non-Preferred Brand	$100.00	$300.00	None
EQUETRO CAPSULES 300MG 120 BOT	4	Non-Preferred Brand	$100.00	$300.00	None
EQUETRO EXTENDED RELEASE CAPSULES 100MG 120 BOT	4	Non-Preferred Brand	$100.00	$300.00	None
ERAXIS 100mg/30mL 30 mL in 1 VIAL, SINGLE-USE	3	Preferred Brand	$47.00	$141.00	None
ERAXIS(WATER DIL) 50 MG VIAL	3	Preferred Brand	$47.00	$141.00	None
ERBITUX 100MG/50ML VIAL	5	Specialty Tier	33%	N/A	None
ERGOLOID MESYLATES TABLETS 1MG 100 BOT	2	Generic	$10.00	$30.00	None
ERIVEDGE 150 MG CAPSULE	5	Specialty Tier	33%	N/A	P
Errin 0.35 mg tablet	2	Generic	$10.00	$30.00	None
ERTACZO 2% CREAM	4	Non-Preferred Brand	$100.00	$300.00	None
ERWINAZE 10,000 UNITS VIAL	5	Specialty Tier	33%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ERY 2% PADS 2% 60 PADS JAR	2	Generic	$10.00	$30.00	None
ERY-TAB 500mg/1 100 TABLET, DELAYED RELEASE in 1 BOTTLE	3	Preferred Brand	$47.00	$141.00	None
ERY-TAB TAB 250MG EC	3	Preferred Brand	$47.00	$141.00	None
ERY-TAB TAB 333MG EC	3	Preferred Brand	$47.00	$141.00	None
ERYPED 200 MG/5 ML SUSPENSION	4	Non-Preferred Brand	$100.00	$300.00	None
ERYPED 400 MG/5 ML SUSPENSION	4	Non-Preferred Brand	$100.00	$300.00	None
ERYTHROCIN 500MG ADDVNT VL	4	Non-Preferred Brand	$100.00	$300.00	None
Erythromycin 2% solution	2	Generic	$10.00	$30.00	None
Erythromycin 20mg/g 1 TUBE per CARTON / 60 g in 1 TUBE	2	Generic	$10.00	$30.00	None
ERYTHROMYCIN 500 MG FILMTAB	3	Preferred Brand	$47.00	$141.00	None
Erythromycin Ethylsuccinate 40 MG/ML Oral Suspension	2	Generic	$10.00	$30.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ERYTHROMYCIN OPHTHALMIC OINTMENT 0.5% 1 G BOX OF 50 TUBE	2	Generic	$10.00	$30.00	None
ERYTHROMYCIN TAB 250MG BS	3	Preferred Brand	$47.00	$141.00	None
ERYTHROMYCIN-BENZOYL PEROXIDE 3-5% GEL	2	Generic	$10.00	$30.00	None
ESBRIET 267 MG CAPSULE	5	Specialty Tier	33%	N/A	P
ESBRIET 267 MG TABLET	5	Specialty Tier	33%	N/A	P
ESBRIET 801 MG TABLET	5	Specialty Tier	33%	N/A	P
ESCITALOPRAM 10 MG TABLET [Lexapro]	1	Preferred Generic	$4.00	$0.00	None
ESCITALOPRAM 20 MG TABLET [Lexapro]	1	Preferred Generic	$4.00	$0.00	None
ESCITALOPRAM 5 MG TABLET [Lexapro]	1	Preferred Generic	$4.00	$0.00	None
ESCITALOPRAM OXALATE 5 MG/5 ML [Lexapro]	2	Generic	$10.00	$30.00	None
ESOMEPRAZOLE SODIUM 20 MG VIAL [Nexium]	2	Generic	$10.00	$30.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ESOMEPRAZOLE SODIUM 40 MG VIAL [Nexium]	2	Generic	$10.00	$30.00	None
ESTRACE VAG CREAM 0.1MG/GM	4	Non-Preferred Brand	$100.00	$300.00	None
Estradiol / Norethindrone Acetate 0.5; 0.1mg/1; mg/1 1 BLISTER PACK per CARTON / 28 TABLET, FILM C	2	Generic	$10.00	$30.00	None
Estradiol 0.025 mg patch	2	Generic	$10.00	$30.00	None
Estradiol 0.0375 mg patch	2	Generic	$10.00	$30.00	None
Estradiol 0.05 mg patch	2	Generic	$10.00	$30.00	None
Estradiol 0.075 mg patch	2	Generic	$10.00	$30.00	None
Estradiol 0.1 mg patch	2	Generic	$10.00	$30.00	None
ESTRADIOL 0.5MG TABLET	1	Preferred Generic	$4.00	$0.00	None
ESTRADIOL 2MG TABLET	1	Preferred Generic	$4.00	$0.00	None
ESTRADIOL TABLET 1MG (500 CT)	1	Preferred Generic	$4.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ESTRADIOL TDS 0.025 MG/DAY	2	Generic	$10.00	$30.00	None
ESTRADIOL TDS 0.0375 MG/DAY	2	Generic	$10.00	$30.00	None
ESTRADIOL TDS 0.05 MG/DAY	2	Generic	$10.00	$30.00	None
ESTRADIOL TDS 0.06 MG/DAY	2	Generic	$10.00	$30.00	None
ESTRADIOL TDS 0.075 MG/DAY	2	Generic	$10.00	$30.00	None
ESTRADIOL TDS 0.1 MG/DAY	2	Generic	$10.00	$30.00	None
ESTRADIOL VALERATE 20mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE	2	Generic	$10.00	$30.00	None
ESTRADIOL VALERATE 40mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE	2	Generic	$10.00	$30.00	None
ESTRADIOL-NORETH 1.0-0.5MG TABLET	2	Generic	$10.00	$30.00	None
ESTRING 2MG VAGINAL RING	4	Non-Preferred Brand	$100.00	$300.00	None
ESTROPIPATE 0.625(0.75 MG) TABLET	2	Generic	$10.00	$30.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ESTROPIPATE 1.25(1.5 MG) TABLET	2	Generic	$10.00	$30.00	None
ESTROPIPATE 2.5(3 MG) TABLET	2	Generic	$10.00	$30.00	None
ESZOPICLONE 1 MG TABLET [Lunesta]	2	Generic	$10.00	$30.00	Q:30 /30Days
ESZOPICLONE 2 MG TABLET [Lunesta]	2	Generic	$10.00	$30.00	Q:30 /30Days
ESZOPICLONE 3 MG TABLET [Lunesta]	2	Generic	$10.00	$30.00	Q:30 /30Days
Ethacrynic Acid 25 MG Oral Tablet [Edecrin]	2	Generic	$10.00	$30.00	None
ETHAMBUTOL HCL 400 MG TABLET	2	Generic	$10.00	$30.00	None
Ethambutol Hydrochloride 100mg/1	2	Generic	$10.00	$30.00	None
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6	2	Generic	$10.00	$30.00	None
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TAB 21	2	Generic	$10.00	$30.00	None
ETHOSUXIMIDE 250 MG CAPSULE	2	Generic	$10.00	$30.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ETHOSUXIMIDE 250MG/5ML SYRP	2	Generic	$10.00	$30.00	None
ethynodiol-eth estra 1mg-50mcg [ZOVIA]	2	Generic	$10.00	$30.00	None
ETIDRONATE DISODIUM 400MG TABLET (60 CT)	2	Generic	$10.00	$30.00	None
ETIDRONATE DISODIUM TABLETS 200MG 60 BOT	2	Generic	$10.00	$30.00	None
ETODOLAC 200MG CAPSULE	2	Generic	$10.00	$30.00	None
Etodolac 300 mg capsule	2	Generic	$10.00	$30.00	None
ETODOLAC 400 MG TABLET	2	Generic	$10.00	$30.00	None
ETODOLAC 400MG TABLET SR 24HR	2	Generic	$10.00	$30.00	None
ETODOLAC 500 MG TABLET	2	Generic	$10.00	$30.00	None
ETODOLAC 500MG TABLET SR 24HR	2	Generic	$10.00	$30.00	None
ETODOLAC 600MG TABLET SR 24HR	2	Generic	$10.00	$30.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ETOPOPHOS 100MG VIAL	4	Non-Preferred Brand	$100.00	$300.00	None
Etoposide 500 mg/25 ml vial	2	Generic	$10.00	$30.00	None
Eurax Lotion and Cream 100mg/g 454 g in 1 BOTTLE	4	Non-Preferred Brand	$100.00	$300.00	None
Eurax Lotion and Cream 100mg/g 60 g in 1 TUBE	4	Non-Preferred Brand	$100.00	$300.00	None
EVAMIST 1.53 MG/SPRAY	4	Non-Preferred Brand	$100.00	$300.00	None
EVOTAZ 300 MG-150 MG TABLET	5	Specialty Tier	33%	N/A	None
EXALGO ER 32 MG TABLET	4	Non-Preferred Brand	$100.00	$300.00	Q:60 /30Days
Exelderm 10mg/g 60 g in 1 TUBE	4	Non-Preferred Brand	$100.00	$300.00	None
Exelderm 10mg/mL 30 mL in 1 BOTTLE, PLASTIC	4	Non-Preferred Brand	$100.00	$300.00	None
Exemestane 25mg/1 30 FILM COATED TABLETS in BOTTLE	2	Generic	$10.00	$30.00	None
EXJADE 125MG TABLET	5	Specialty Tier	33%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
EXJADE 250MG TABLET	5	Specialty Tier	33%	N/A	None
EXJADE 500MG TABLET	5	Specialty Tier	33%	N/A	None
EXONDYS 51 100 MG/2 ML VIAL	5	Specialty Tier	33%	N/A	P
EXONDYS 51 500 MG/10 ML VIAL	5	Specialty Tier	33%	N/A	P
EXTAVIA 15 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK	5	Specialty Tier	33%	N/A	S
Ezetimibe 10 mg tablet [Zetia]	1	Preferred Generic	$4.00	$0.00	None
Ezetimibe-Simvastatin 10-10 MG [Vytorin]	1	Preferred Generic	$4.00	$0.00	Q:30 /30Days
Ezetimibe-Simvastatin 10-20 MG [Vytorin]	1	Preferred Generic	$4.00	$0.00	Q:30 /30Days
Ezetimibe-Simvastatin 10-40 MG [Vytorin]	1	Preferred Generic	$4.00	$0.00	Q:30 /30Days
Ezetimibe-Simvastatin 10-80 MG [Vytorin]	1	Preferred Generic	$4.00	$0.00	Q:30 /30Days

Chart Legend:

Below are a few notes to help you understand the above 2017 Medicare Part D AAA1 Vantage PREMIUM (HMO-POS) 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.