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2017 Medicare Part D Plan Formulary Information
First Health Part D Premier Plus (PDP) (S5768-164-0) Benefit Details
The First Health Part D Premier Plus (PDP) (S5768-164-0) Formulary Drugs Starting with the Letter E in CMS PDP Region 5 which includes: DC DE MD Plan Monthly Premium: $125.70 Deductible: $0 Qualifies for LIS: No
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 Drug	50%	50%	None
ECONAZOLE NITRATE 1% CREAM 85GM TUBE	4	Non-Preferred Drug	50%	50%	None
EDARBI 40 MG TABLET	3	Preferred Brand	$34.00	$102.00	Q:30 /30Days
EDARBI 80 MG TABLET	3	Preferred Brand	$34.00	$102.00	Q:30 /30Days
EDARBYCLOR 40-12.5 MG TABLET	3	Preferred Brand	$34.00	$102.00	Q:30 /30Days
EDARBYCLOR 40-25 MG TABLET	3	Preferred Brand	$34.00	$102.00	Q:30 /30Days
EDURANT 27.5mg/1	5	Specialty Tier	33%	N/A	Q:30 /30Days
EFFIENT 10 MG TABLET	3	Preferred Brand	$34.00	$102.00	Q:30 /30Days
EFFIENT 5 MG TABLET	3	Preferred Brand	$34.00	$102.00	Q:30 /30Days
EGRIFTA 2 MG VIAL	5	Specialty Tier	33%	N/A	P Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ELESTRIN 0.06% GEL	4	Non-Preferred Drug	50%	50%	None
ELIDEL 1% CREAM	4	Non-Preferred Drug	50%	50%	S Q:60 /30Days
ELIQUIS 2.5 MG TABLET	4	Non-Preferred Drug	50%	50%	Q:60 /30Days
ELIQUIS 5 MG TABLET	4	Non-Preferred Drug	50%	50%	Q:74 /30Days
Elitek 3 KIT per CARTON / 1 KIT in 1 KIT	5	Specialty Tier	33%	N/A	P
ELITEK 7.5 MG VIAL	5	Specialty Tier	33%	N/A	P
ELMIRON 100mg GELATIN COATED 100 CAPSULE BOTTLE	4	Non-Preferred Drug	50%	50%	None
EMBEDA ER 100-4 MG CAPSULE	4	Non-Preferred Drug	50%	50%	S Q:60 /30Days
EMBEDA ER 20-0.8 MG CAPSULE	4	Non-Preferred Drug	50%	50%	S Q:60 /30Days
EMBEDA ER 30-1.2 MG CAPSULE	4	Non-Preferred Drug	50%	50%	S Q:60 /30Days
EMBEDA ER 50-2 MG CAPSULE	4	Non-Preferred Drug	50%	50%	S Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
EMBEDA ER 60-2.4 MG CAPSULE	4	Non-Preferred Drug	50%	50%	S Q:60 /30Days
EMBEDA ER 80-3.2 MG CAPSULE	4	Non-Preferred Drug	50%	50%	S Q:60 /30Days
EMCYT 140MG CAPSULE	4	Non-Preferred Drug	50%	50%	None
EMEND 40MG CAPSULE	4	Non-Preferred Drug	50%	50%	P Q:1 /30Days
EMEND CAPSULES 125MG 6 BLPK	4	Non-Preferred Drug	50%	50%	P Q:6 /30Days
EMEND CAPSULES 80MG 2 BLPK	4	Non-Preferred Drug	50%	50%	P Q:6 /30Days
EMEND TRIFOLD PACK	4	Non-Preferred Drug	50%	50%	P Q:6 /30Days
Emoquette 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK	2	Generic	$2.00	$6.00	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	5	Specialty Tier	33%	N/A	S Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H	5	Specialty Tier	33%	N/A	S Q:30 /30Days
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H	5	Specialty Tier	33%	N/A	S Q:30 /30Days
EMTRIVA 10MG/ML SOLUTION	4	Non-Preferred Drug	50%	50%	None
EMTRIVA 200MG CAPSULE	4	Non-Preferred Drug	50%	50%	None
ENABLEX 15 MG TABLET	4	Non-Preferred Drug	50%	50%	S Q:30 /30Days
Enablex 7.5mg EXTENDED RELEASE 90 TABLET BOTTLE	4	Non-Preferred Drug	50%	50%	S Q:30 /30Days
ENALAPRIL MALEATE 10MG TABLET (100 CT)	2	Generic	$2.00	$6.00	None
ENALAPRIL MALEATE 2.5 MG TAB	2	Generic	$2.00	$6.00	None
Enalapril Maleate 20mg/1 100 TABLET BOTTLE, PLASTIC	2	Generic	$2.00	$6.00	None
ENALAPRIL MALEATE 5 MG TABLET	2	Generic	$2.00	$6.00	None
Enalapril Maleate and Hydrochlorothiazide 10; 25mg/1; mg/1 100 TABLET BOTTLE, PLASTIC	1	Preferred Generic	$1.00	$3.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ENALAPRIL MALEATE-HCTZ 5-12.5MG TABLET	1	Preferred Generic	$1.00	$3.00	None
ENBREL 25 MG/0.5 ML SYRINGE	5	Specialty Tier	33%	N/A	P Q:4 /28Days
ENBREL 25MG KIT	5	Specialty Tier	33%	N/A	P Q:8 /28Days
ENBREL 50 MG/ML SURECLICK SYR	5	Specialty Tier	33%	N/A	P Q:8 /28Days
ENBREL 50mg/mL	5	Specialty Tier	33%	N/A	P Q:8 /28Days
ENDOCET 10MG-325MG TABLET	3	Preferred Brand	$34.00	$102.00	Q:180 /30Days
ENDOCET 5/325 TABLET	3	Preferred Brand	$34.00	$102.00	Q:180 /30Days
ENDOCET 7.5-325MG TABLET	3	Preferred Brand	$34.00	$102.00	Q:180 /30Days
ENGERIX B INJECTION	3	Preferred Brand	$34.00	$102.00	P
ENGERIX-B 10MCG 10 X 0.5ML VIALSD	3	Preferred Brand	$34.00	$102.00	P
ENGERIX-B 20 MCG/ML SYRN	3	Preferred Brand	$34.00	$102.00	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ENOXAPARIN 100 MG/ML SYRINGE	4	Non-Preferred Drug	50%	50%	None
ENOXAPARIN 120 MG/0.8 ML SYRINGE	4	Non-Preferred Drug	50%	50%	None
ENOXAPARIN 150 MG/ML SYRINGE	4	Non-Preferred Drug	50%	50%	None
ENOXAPARIN 30 MG/0.3 ML SYRINGE	4	Non-Preferred Drug	50%	50%	None
ENOXAPARIN 300 MG/3 ML vial	4	Non-Preferred Drug	50%	50%	None
ENOXAPARIN 40 MG/0.4 ML SYRINGE	4	Non-Preferred Drug	50%	50%	None
ENOXAPARIN 60 MG/0.6 ML SYRINGE	4	Non-Preferred Drug	50%	50%	None
ENOXAPARIN 80 MG/0.8 ML SYRINGE	4	Non-Preferred Drug	50%	50%	None
ENTACAPONE 200 MG TABLET [Comtan Entacapone]	4	Non-Preferred Drug	50%	50%	None
ENTECAVIR 0.5 MG TABLET [Baraclude]	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
ENTECAVIR 1 MG TABLET [Baraclude]	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ENTRESTO 24 MG-26 MG TABLET	3	Preferred Brand	$34.00	$102.00	P Q:60 /30Days
ENTRESTO 49 MG-51 MG TABLET	3	Preferred Brand	$34.00	$102.00	P Q:60 /30Days
ENTRESTO 97 MG-103 MG TABLET	3	Preferred Brand	$34.00	$102.00	P Q:60 /30Days
ENULOSE 10 GM/15 ML SOLUTION	2	Generic	$2.00	$6.00	None
ENVARSUS XR 0.75 MG TABLET	4	Non-Preferred Drug	50%	50%	P
ENVARSUS XR 1 MG TABLET	4	Non-Preferred Drug	50%	50%	P
ENVARSUS XR 4 MG TABLET	4	Non-Preferred Drug	50%	50%	P
EPCLUSA 400 MG-100 MG TABLET	5	Specialty Tier	33%	N/A	P Q:28 /28Days
EPINASTINE HCL 0.05% EYE DROPS	3	Preferred Brand	$34.00	$102.00	None
EPINEPHRINE 0.15 MG AUTO-INJCT	3	Preferred Brand	$34.00	$102.00	Q:2 /30Days
EPINEPHRINE 0.3 MG AUTO-INJECT	3	Preferred Brand	$34.00	$102.00	Q:2 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
EPINEPHRINE 0.3 MG AUTO-INJECT	3	Preferred Brand	$34.00	$102.00	Q:2 /30Days
EPIPEN 0.3MG AUTO-INJECTOR	3	Preferred Brand	$34.00	$102.00	Q:2 /30Days
EPIPEN JR 0.15MG AUTO-INJCT	3	Preferred Brand	$34.00	$102.00	Q:2 /30Days
Epirubicin 200 mg/100 ml vial	3	Preferred Brand	$34.00	$102.00	None
EPITOL 200MG TABLET	4	Non-Preferred Drug	50%	50%	None
EPIVIR 10 MG/ML ORAL SOLUTION	4	Non-Preferred Drug	50%	50%	None
EPIVIR HBV 25MG/5ML TUBEX	4	Non-Preferred Drug	50%	50%	None
Eplerenone 25mg/1 90 TABLET BOTTLE	4	Non-Preferred Drug	50%	50%	None
Eplerenone 50mg/1 90 TABLET BOTTLE	4	Non-Preferred Drug	50%	50%	None
EPROSARTAN MESYLATE 600 MG TABLET	2	Generic	$2.00	$6.00	Q:30 /30Days
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 Drug	50%	50%	None
EQUETRO CAPSULES 300MG 120 BOT	4	Non-Preferred Drug	50%	50%	None
EQUETRO EXTENDED RELEASE CAPSULES 100MG 120 BOT	4	Non-Preferred Drug	50%	50%	None
ERAXIS 100mg/30mL 30 mL in 1 VIAL, SINGLE-USE	5	Specialty Tier	33%	N/A	P
ERAXIS(WATER DIL) 50 MG VIAL	5	Specialty Tier	33%	N/A	P
ERBITUX 100MG/50ML VIAL	5	Specialty Tier	33%	N/A	P
ERGOLOID MESYLATES TABLETS 1MG 100 BOT	2	Generic	$2.00	$6.00	P
Ergotamine-caffeine 1-100mg tb	4	Non-Preferred Drug	50%	50%	Q:40 /28Days
ERIVEDGE 150 MG CAPSULE	5	Specialty Tier	33%	N/A	P Q:30 /30Days
Errin 0.35 mg tablet	2	Generic	$2.00	$6.00	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	4	Non-Preferred Drug	50%	50%	None
ERY-TAB 500mg/1 100 TABLET, DELAYED RELEASE in 1 BOTTLE	3	Preferred Brand	$34.00	$102.00	None
ERY-TAB TAB 250MG EC	3	Preferred Brand	$34.00	$102.00	None
ERY-TAB TAB 333MG EC	3	Preferred Brand	$34.00	$102.00	None
ERYPED 200 MG/5 ML SUSPENSION	4	Non-Preferred Drug	50%	50%	None
ERYPED 400 MG/5 ML SUSPENSION	4	Non-Preferred Drug	50%	50%	None
ERYTHROCIN 500MG ADDVNT VL	4	Non-Preferred Drug	50%	50%	None
ERYTHROCIN TAB 250MG	4	Non-Preferred Drug	50%	50%	None
Erythromycin 2% solution	2	Generic	$2.00	$6.00	None
Erythromycin 20mg/g 1 TUBE per CARTON / 60 g in 1 TUBE	2	Generic	$2.00	$6.00	None
ERYTHROMYCIN 500 MG FILMTAB	2	Generic	$2.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ERYTHROMYCIN EC 250 MG CAP	2	Generic	$2.00	$6.00	None
ERYTHROMYCIN ES 400 MG TAB	2	Generic	$2.00	$6.00	None
Erythromycin Ethylsuccinate 40 MG/ML Oral Suspension	4	Non-Preferred Drug	50%	50%	None
ERYTHROMYCIN OPHTHALMIC OINTMENT 0.5% 1 G BOX OF 50 TUBE	2	Generic	$2.00	$6.00	None
ERYTHROMYCIN TAB 250MG BS	2	Generic	$2.00	$6.00	None
ERYTHROMYCIN-BENZOYL PEROXIDE 3-5% GEL	2	Generic	$2.00	$6.00	None
ESBRIET 267 MG CAPSULE	5	Specialty Tier	33%	N/A	P Q:270 /30Days
ESBRIET 267 MG TABLET	5	Specialty Tier	33%	N/A	P Q:270 /30Days
ESBRIET 801 MG TABLET	5	Specialty Tier	33%	N/A	P Q:90 /30Days
ESCITALOPRAM 10 MG TABLET [Lexapro]	3	Preferred Brand	$34.00	$102.00	Q:45 /30Days
ESCITALOPRAM 20 MG TABLET [Lexapro]	3	Preferred Brand	$34.00	$102.00	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ESCITALOPRAM 5 MG TABLET [Lexapro]	3	Preferred Brand	$34.00	$102.00	Q:45 /30Days
ESCITALOPRAM OXALATE 5 MG/5 ML [Lexapro]	3	Preferred Brand	$34.00	$102.00	Q:600 /30Days
ESOMEPRAZOLE DR 49.3 MG CAPSULE [Nexium]	3	Preferred Brand	$34.00	$102.00	Q:30 /30Days
ESOMEPRAZOLE MAG DR 20 MG CAPSULE [Nexium]	3	Preferred Brand	$34.00	$102.00	Q:30 /30Days
ESOMEPRAZOLE SODIUM 20 MG VIAL [Nexium]	3	Preferred Brand	$34.00	$102.00	None
ESOMEPRAZOLE SODIUM 40 MG VIAL [Nexium]	3	Preferred Brand	$34.00	$102.00	None
ESTRACE VAG CREAM 0.1MG/GM	4	Non-Preferred Drug	50%	50%	None
Estradiol / Norethindrone Acetate 0.5; 0.1mg/1; mg/1 1 BLISTER PACK per CARTON / 28 TABLET, FILM C	2	Generic	$2.00	$6.00	P
Estradiol 0.025 mg patch	3	Preferred Brand	$34.00	$102.00	P Q:8 /28Days
Estradiol 0.0375 mg patch	3	Preferred Brand	$34.00	$102.00	P Q:8 /28Days
Estradiol 0.05 mg patch	3	Preferred Brand	$34.00	$102.00	P Q:8 /28Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Estradiol 0.075 mg patch	3	Preferred Brand	$34.00	$102.00	P Q:8 /28Days
Estradiol 0.1 mg patch	3	Preferred Brand	$34.00	$102.00	P Q:8 /28Days
ESTRADIOL 0.5MG TABLET	2	Generic	$2.00	$6.00	P
ESTRADIOL 2MG TABLET	2	Generic	$2.00	$6.00	P
ESTRADIOL TABLET 1MG (500 CT)	2	Generic	$2.00	$6.00	P
ESTRADIOL TDS 0.025 MG/DAY	3	Preferred Brand	$34.00	$102.00	P Q:4 /28Days
ESTRADIOL TDS 0.0375 MG/DAY	3	Preferred Brand	$34.00	$102.00	P Q:4 /28Days
ESTRADIOL TDS 0.05 MG/DAY	3	Preferred Brand	$34.00	$102.00	P Q:4 /28Days
ESTRADIOL TDS 0.06 MG/DAY	3	Preferred Brand	$34.00	$102.00	P Q:4 /28Days
ESTRADIOL TDS 0.075 MG/DAY	3	Preferred Brand	$34.00	$102.00	P Q:4 /28Days
ESTRADIOL TDS 0.1 MG/DAY	3	Preferred Brand	$34.00	$102.00	P Q:4 /28Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ESTRADIOL-NORETH 1.0-0.5MG TABLET	2	Generic	$2.00	$6.00	P
ESTRING 2MG VAGINAL RING	4	Non-Preferred Drug	50%	50%	Q:1 /90Days
ETHAMBUTOL HCL 400 MG TABLET	3	Preferred Brand	$34.00	$102.00	None
Ethambutol Hydrochloride 100mg/1	3	Preferred Brand	$34.00	$102.00	None
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6	2	Generic	$2.00	$6.00	None
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TAB 21	2	Generic	$2.00	$6.00	None
ETHOSUXIMIDE 250 MG CAPSULE	4	Non-Preferred Drug	50%	50%	None
ETHOSUXIMIDE 250MG/5ML SYRP	4	Non-Preferred Drug	50%	50%	None
ethynodiol-eth estra 1mg-50mcg [ZOVIA]	2	Generic	$2.00	$6.00	None
ETIDRONATE DISODIUM 400MG TABLET (60 CT)	2	Generic	$2.00	$6.00	None
ETIDRONATE DISODIUM TABLETS 200MG 60 BOT	2	Generic	$2.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ETODOLAC 200MG CAPSULE	3	Preferred Brand	$34.00	$102.00	None
Etodolac 300 mg capsule	3	Preferred Brand	$34.00	$102.00	None
ETODOLAC 400 MG TABLET	3	Preferred Brand	$34.00	$102.00	None
ETODOLAC 400MG TABLET SR 24HR	4	Non-Preferred Drug	50%	50%	None
ETODOLAC 500 MG TABLET	3	Preferred Brand	$34.00	$102.00	None
ETODOLAC 500MG TABLET SR 24HR	4	Non-Preferred Drug	50%	50%	None
ETODOLAC 600MG TABLET SR 24HR	4	Non-Preferred Drug	50%	50%	None
Etoposide 500 mg/25 ml vial	3	Preferred Brand	$34.00	$102.00	None
EVAMIST 1.53 MG/SPRAY	4	Non-Preferred Drug	50%	50%	Q:16 /30Days
EVISTA 60 MG TABLET	4	Non-Preferred Drug	50%	50%	None
EVOTAZ 300 MG-150 MG TABLET	5	Specialty Tier	33%	N/A	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Exelderm 10mg/g 60 g in 1 TUBE	4	Non-Preferred Drug	50%	50%	None
Exelderm 10mg/mL 30 mL in 1 BOTTLE, PLASTIC	4	Non-Preferred Drug	50%	50%	None
Exemestane 25mg/1 30 FILM COATED TABLETS in BOTTLE	4	Non-Preferred Drug	50%	50%	None
EXFORGE 10MG-160MG TABLET	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
EXFORGE 10MG-320MG TABLET	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
EXFORGE 5MG-160MG TABLET	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
EXFORGE 5MG-320MG TABLET	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
EXFORGE HCT 10-160-12.5 MG TAB	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
EXFORGE HCT 10-160-25 MG TAB	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
EXFORGE HCT 10-320-25 MG TAB	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
EXFORGE HCT 5-160-12.5 MG TAB	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
EXFORGE HCT 5-160-25 MG TAB	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
EXJADE 125MG TABLET	5	Specialty Tier	33%	N/A	P
EXJADE 250MG TABLET	5	Specialty Tier	33%	N/A	P
EXJADE 500MG TABLET	5	Specialty Tier	33%	N/A	P
Ezetimibe 10 mg tablet [Zetia]	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
Ezetimibe-Simvastatin 10-10 MG [Vytorin]	4	Non-Preferred Drug	50%	50%	S Q:30 /30Days
Ezetimibe-Simvastatin 10-20 MG [Vytorin]	4	Non-Preferred Drug	50%	50%	S Q:30 /30Days
Ezetimibe-Simvastatin 10-40 MG [Vytorin]	4	Non-Preferred Drug	50%	50%	S Q:30 /30Days
Ezetimibe-Simvastatin 10-80 MG [Vytorin]	4	Non-Preferred Drug	50%	50%	S Q:30 /30Days

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.