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2017 Medicare Part D Plan Formulary Information
AARP MedicareRx Preferred (PDP) (S5820-001-0) Benefit Details
The AARP MedicareRx Preferred (PDP) (S5820-001-0) Formulary Drugs Starting with the Letter N in CMS PDP Region 01 which includes: ME NH Plan Monthly Premium: $57.50 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
NADOLOL 20MG TABLET	4	Non-Preferred Drug	40%	40%	None
NADOLOL 40MG TABLETS	4	Non-Preferred Drug	40%	40%	None
Nadolol 80mg/1 90 TABLET BOTTLE	4	Non-Preferred Drug	40%	40%	None
NADOLOL-BENDROFLU 40-5 MG TAB	3	Preferred Brand	$35.00	$90.00	Q:30 /30Days
NADOLOL-BENDROFLU 80-5 MG TAB	3	Preferred Brand	$35.00	$90.00	None
Nafcillin 1 gm vial	4	Non-Preferred Drug	40%	40%	None
Nafcillin 10g/100mL	4	Non-Preferred Drug	40%	40%	None
Naftifine HCl 10 MG/ML Topical Cream [Naftin]	4	Non-Preferred Drug	40%	40%	None
Naftifine HCl 20 MG/ML Topical Cream [Naftin]	4	Non-Preferred Drug	40%	40%	None
NAFTIN 2% GEL	4	Non-Preferred Drug	40%	40%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NAFTIN HCL GEL 1% 60GM TUBE	4	Non-Preferred Drug	40%	40%	None
NAGLAZYME 5MG/5ML VIAL	5	Specialty Tier	33%	33%	None
Nalbuphine Hydrochloride 10mg/mL 1 VIAL, MULTI-DOSE per CARTON / 10 mL in 1 VIAL, MULTI-DOSE	4	Non-Preferred Drug	40%	40%	None
Nalbuphine Hydrochloride 20mg/mL 25 VIAL, MULTI-DOSE per CARTON / 10 mL in 1 VIAL, MULTI-DOSE	4	Non-Preferred Drug	40%	40%	None
NALOXONE 0.4 MG/ML VIAL	4	Non-Preferred Drug	40%	40%	None
naloxone 1 mg/ml syringe	4	Non-Preferred Drug	40%	40%	None
NALTREXONE HCL 50MG TABLET 100 BLPK	3	Preferred Brand	$35.00	$90.00	None
NAMENDA XR 14 MG CAPSULE	3	Preferred Brand	$35.00	$90.00	P Q:30 /30Days
NAMENDA XR 21 MG CAPSULE	3	Preferred Brand	$35.00	$90.00	P Q:30 /30Days
NAMENDA XR 28 MG CAPSULE	3	Preferred Brand	$35.00	$90.00	P Q:30 /30Days
NAMENDA XR 7 MG CAPSULE	3	Preferred Brand	$35.00	$90.00	P Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NAMENDA XR TITRATION PACK	3	Preferred Brand	$35.00	$90.00	P Q:30 /30Days
NAMZARIC 14 MG-10 MG CAPSULE	3	Preferred Brand	$35.00	$90.00	P Q:30 /30Days
NAMZARIC 21 MG-10 MG CAPSULE	3	Preferred Brand	$35.00	$90.00	P Q:30 /30Days
NAMZARIC 28 MG-10 MG CAPSULE	3	Preferred Brand	$35.00	$90.00	P Q:30 /30Days
NAMZARIC 7 MG-10 MG CAPSULE	3	Preferred Brand	$35.00	$90.00	P Q:30 /30Days
NAMZARIC TITRATION PACK	3	Preferred Brand	$35.00	$90.00	P Q:28 /28Days
Naproxen 125 mg/5 ml suspen	2	Generic	$8.00	$0.00	None
NAPROXEN 250 MG ORAL TABLET	2	Generic	$8.00	$0.00	None
Naproxen 375 mg tablet	2	Generic	$8.00	$0.00	None
Naproxen 500mg/1 500 TABLET BOTTLE	2	Generic	$8.00	$0.00	None
NAPROXEN DR 375 MG TABLET	2	Generic	$8.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NAPROXEN DR 500 MG TABLET	2	Generic	$8.00	$0.00	None
NARATRIPTAN 2.5MG TABLETS	3	Preferred Brand	$35.00	$90.00	Q:9 /30Days
NARATRIPTAN HCL 1 MG TABLET	3	Preferred Brand	$35.00	$90.00	Q:9 /30Days
NARCAN 4 MG NASAL SPRAY	3	Preferred Brand	$35.00	$90.00	None
NATACYN EYE DROPS	3	Preferred Brand	$35.00	$90.00	None
Nateglinide 120mg/1 90 TABLET BOTTLE	3	Preferred Brand	$35.00	$90.00	Q:90 /30Days
Nateglinide 60mg/1 90 TABLET BOTTLE	3	Preferred Brand	$35.00	$90.00	Q:180 /30Days
NATPARA 100 MCG DOSE CARTRIDGE	5	Specialty Tier	33%	33%	P
NATPARA 25 MCG DOSE CARTRIDGE	5	Specialty Tier	33%	33%	P
NATPARA 50 MCG DOSE CARTRIDGE	5	Specialty Tier	33%	33%	P
NATPARA 75 MCG DOSE CARTRIDGE	5	Specialty Tier	33%	33%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NEBUPENT 300MG INHAL POWDER	4	Non-Preferred Drug	40%	40%	P Q:1 /28Days
Necon 0.5-35-28 tablet	4	Non-Preferred Drug	40%	40%	None
NECON 1-50-28 TABLET	4	Non-Preferred Drug	40%	40%	None
NECON 10/11-28 TABLET	4	Non-Preferred Drug	40%	40%	None
NECON 7-7-7-28 TABLET	4	Non-Preferred Drug	40%	40%	None
NEFAZODONE HCL 150MG TABLET (60 CT)	3	Preferred Brand	$35.00	$90.00	None
NEFAZODONE HCL 250MG TABLET	3	Preferred Brand	$35.00	$90.00	None
NEFAZODONE HCL 50MG TABLET	3	Preferred Brand	$35.00	$90.00	None
NEFAZODONE HYDROCHLORIDE TABLETS 100MG 60 BOT	3	Preferred Brand	$35.00	$90.00	None
NEFAZODONE HYDROCHLORIDE TABLETS 200MG 60 BOT	3	Preferred Brand	$35.00	$90.00	None
NEO/POLYMYXIN/HC EAR TUBEX 10MG/3.5MG/100UNT	3	Preferred Brand	$35.00	$90.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Neomycin and Polymyxin B Sulfates 40; 200000mg/mL; 1/mL 10 AMPULE per CARTON / 1 mL in 1 AMPULE	3	Preferred Brand	$35.00	$90.00	None
Neomycin and Polymyxin B Sulfates and Dexamethasone 1; 3.5; 10000mg/g; mg/g; [USP'U]/g 1 TUBE in 1	2	Generic	$8.00	$0.00	None
NEOMYCIN SULFATE 500MG TABLET	2	Generic	$8.00	$0.00	None
NEOMYCIN-BACITRACIN-POLY-HC 3.5-10K-1 OINTMENT	3	Preferred Brand	$35.00	$90.00	None
NEOMYCIN-POLYMYXIN-HC 3.5-10K-10 SUSPENSION DROPS	4	Non-Preferred Drug	40%	40%	None
NEOMYCIN/POLYMY/DEXA EYE DROPS 3.5MG/1ML	2	Generic	$8.00	$0.00	None
NEOMYCIN/POLYMY/GRAM EYE DROPS 0.025MG/ML 1.75MG/M	3	Preferred Brand	$35.00	$90.00	None
NEOMYCIN/POLYMY/HYDRO OTIC SUS	3	Preferred Brand	$35.00	$90.00	None
NEPHRAMINE SOLUTION FOR INJECTION	4	Non-Preferred Drug	40%	40%	P
NEULASTA 6MG/0.6ML SYRINGE	5	Specialty Tier	33%	33%	P
NEUPRO 1 MG/24 HR PATCH	4	Non-Preferred Drug	40%	40%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NEUPRO 2 MG/24 HR PATCH	4	Non-Preferred Drug	40%	40%	None
NEUPRO 3 MG/24 HR PATCH	4	Non-Preferred Drug	40%	40%	None
NEUPRO 4 MG/24 HR PATCH	4	Non-Preferred Drug	40%	40%	None
NEUPRO 6 MG/24 HR PATCH	4	Non-Preferred Drug	40%	40%	None
NEUPRO 8 MG/24 HR PATCH	4	Non-Preferred Drug	40%	40%	None
NEVANAC 0.1% DROPTAINER	3	Preferred Brand	$35.00	$90.00	None
nevirapine 200 mg tablet	3	Preferred Brand	$35.00	$90.00	Q:90 /30Days
NEVIRAPINE 50 MG/5 ML SUSP	3	Preferred Brand	$35.00	$90.00	Q:1800 /30Days
NEVIRAPINE ER 100 MG TABLET	3	Preferred Brand	$35.00	$90.00	Q:90 /30Days
NEVIRAPINE ER 400 MG TABLET	3	Preferred Brand	$35.00	$90.00	Q:60 /30Days
NEXAVAR TABLETS 200MG 120 BOT	5	Specialty Tier	33%	33%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NEXIUM 10mg/1 30 GRANULE, DELAYED RELEASE per CARTON	3	Preferred Brand	$35.00	$90.00	None
NEXIUM 20MG CAPSULE	3	Preferred Brand	$35.00	$90.00	Q:90 /30Days
NEXIUM 20MG SUSP FOR RECON DELAYED REL. IN A PACKET	3	Preferred Brand	$35.00	$90.00	None
NEXIUM 40MG CAPSULE	3	Preferred Brand	$35.00	$90.00	Q:60 /30Days
NEXIUM 40MG SUSP FOR RECON DELAYED REL. IN A PACKET	3	Preferred Brand	$35.00	$90.00	None
NEXIUM DR 2.5 MG PACKET	3	Preferred Brand	$35.00	$90.00	None
NEXIUM DR 5 MG PACKET	3	Preferred Brand	$35.00	$90.00	None
NIACIN ER 1,000 MG TABLET	4	Non-Preferred Drug	40%	40%	None
NIACIN ER 500 MG TABLET	4	Non-Preferred Drug	40%	40%	None
NIACIN ER 750 MG TABLET	4	Non-Preferred Drug	40%	40%	None
NIACOR 500MG TABLET	2	Generic	$8.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Nicardipine 25 mg/10 ml vial	4	Non-Preferred Drug	40%	40%	None
NICOTROL INHALER 10MG 168 X 10MG/CARTRIDGE INHL	4	Non-Preferred Drug	40%	40%	None
NIFEDIPINE 90MG TABLETS EXTENDED RELEASE	2	Generic	$8.00	$0.00	Q:60 /30Days
NIFEDIPINE ER 30 MG TABLET	2	Generic	$8.00	$0.00	Q:60 /30Days
NIFEDIPINE ER 30 MG TABLET	2	Generic	$8.00	$0.00	Q:60 /30Days
NIFEDIPINE ER 60 MG TABLET	2	Generic	$8.00	$0.00	Q:60 /30Days
NIFEDIPINE ER 60 MG TABLET	2	Generic	$8.00	$0.00	Q:60 /30Days
NIFEDIPINE ER 90 MG TABLET	2	Generic	$8.00	$0.00	Q:60 /30Days
Nikki 3 mg-0.02 mg tablet	4	Non-Preferred Drug	40%	40%	None
NILANDRON 150 MG TABLET	5	Specialty Tier	33%	33%	None
Nilutamide 150 mg tablet [Nilandron]	5	Specialty Tier	33%	33%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Nimodipine 30mg/1 25 BLISTER PACK in 1 CARTON / 4 CAPSULE in 1 BLISTER PACK	5	Specialty Tier	33%	33%	None
NINLARO 2.3 MG CAPSULE	5	Specialty Tier	33%	33%	P Q:3 /28Days
NINLARO 3 MG CAPSULE	5	Specialty Tier	33%	33%	P Q:3 /28Days
NINLARO 4 MG CAPSULE	5	Specialty Tier	33%	33%	P Q:3 /28Days
NIPENT FOR INJECTION 10MG VIALS	5	Specialty Tier	33%	33%	None
NITRO-BID 20mg/g 48 PACKET in 1 BOX / 1 g in 1 PACKET	4	Non-Preferred Drug	40%	40%	None
Nitrofurantoin 25mg/5mL	4	Non-Preferred Drug	40%	40%	None
NITROFURANTOIN MACROCRYSTALLINE 50 mg cap	3	Preferred Brand	$35.00	$90.00	None
Nitrofurantoin mcr 100 mg cap	3	Preferred Brand	$35.00	$90.00	None
NITROFURANTOIN MONO-MCR 100 MG	3	Preferred Brand	$35.00	$90.00	None
NITROGLYCERIN .2MG/HR PATCH	2	Generic	$8.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NITROGLYCERIN .4MG/HR PATCH	2	Generic	$8.00	$0.00	None
NITROGLYCERIN .6MG/HR PATCH	2	Generic	$8.00	$0.00	None
NITROGLYCERIN 0.3 MG TABLET SL	3	Preferred Brand	$35.00	$90.00	None
NITROGLYCERIN 0.4 MG TABLET SL	3	Preferred Brand	$35.00	$90.00	None
NITROGLYCERIN 0.6 MG TABLET SL	3	Preferred Brand	$35.00	$90.00	None
Nitroglycerin 5mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 10 mL in 1 VIAL, SINGLE-DOSE	4	Non-Preferred Drug	40%	40%	None
NITROGLYCERIN LINGUAL 0.4 MG	4	Non-Preferred Drug	40%	40%	None
NITROGLYCERIN TRANSOERMAL SYSTEM .1MG/HR 30 SYSTEM BOX	2	Generic	$8.00	$0.00	None
NITROSTAT 0.3MG TABLET SL	3	Preferred Brand	$35.00	$90.00	None
NITROSTAT 0.4MG TABLET SL	3	Preferred Brand	$35.00	$90.00	None
NITROSTAT 0.6MG TABLET SL	3	Preferred Brand	$35.00	$90.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NORA-BE 0.35MG TABLET	3	Preferred Brand	$35.00	$90.00	None
noret-estr-fe 0.4-0.035(21)-75	4	Non-Preferred Drug	40%	40%	None
Norethin-Estrad-Ferr 0.8-0.025 MG	4	Non-Preferred Drug	40%	40%	None
Norethin-Estrad-Ferr 1-0.02 mg	4	Non-Preferred Drug	40%	40%	None
Norethin-estrad-ferr 1-0.02(24)-75	4	Non-Preferred Drug	40%	40%	None
NORETHIN-ETH ESTRAD 0.5-2.5	3	Preferred Brand	$35.00	$90.00	None
NORETHIN-ETH ESTRAD 1 MG-5 MCG	3	Preferred Brand	$35.00	$90.00	None
norethind-eth estrad 1-0.02 mg	4	Non-Preferred Drug	40%	40%	None
Norethindrone 0.35 mg tablet	3	Preferred Brand	$35.00	$90.00	None
NORETHINDRONE 5MG TABLET	2	Generic	$8.00	$0.00	None
NORG-EE 0.18-0.215-0.25/0.025	4	Non-Preferred Drug	40%	40%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
norg-ee 0.18-0.215-0.25/0.035	4	Non-Preferred Drug	40%	40%	None
Norg-ethin estra 0.25-0.035 mg	4	Non-Preferred Drug	40%	40%	None
Norlyroc 0.35 mg tablet	3	Preferred Brand	$35.00	$90.00	None
NORMOSOL -R INJ /D5W	4	Non-Preferred Drug	40%	40%	None
NORMOSOL-M AND DEXTROSE 5%	4	Non-Preferred Drug	40%	40%	None
NORMOSOL-R PH 7.4 IV SOLUTION	4	Non-Preferred Drug	40%	40%	None
NORTHERA 100 MG CAPSULE	4	Non-Preferred Drug	40%	40%	P Q:90 /30Days
NORTHERA 200 MG CAPSULE	4	Non-Preferred Drug	40%	40%	P Q:180 /30Days
NORTHERA 300 MG CAPSULE	4	Non-Preferred Drug	40%	40%	P Q:180 /30Days
Nortrel (21 Day Regimen) 0.035; 1mg/1; mg/1 3 BLISTER PACK per CARTON / 21 TABLET per BLISTER PACK	4	Non-Preferred Drug	40%	40%	None
Nortrel (28 Day Regimen) 3 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK	4	Non-Preferred Drug	40%	40%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NORTREL 1-0.035MG TABLET 28DAY	4	Non-Preferred Drug	40%	40%	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 Drug	40%	40%	None
NORTRIPTYLINE 10 MG/5 ML SOL	2	Generic	$8.00	$0.00	None
NORTRIPTYLINE HCL 25MG CAP	2	Generic	$8.00	$0.00	None
NORTRIPTYLINE HCL 75 MG CAP	2	Generic	$8.00	$0.00	None
Nortriptyline Hydrochloride 10mg/1 100 CAPSULE BOTTLE	2	Generic	$8.00	$0.00	None
Nortriptyline Hydrochloride 50mg/1 500 CAPSULE BOTTLE	2	Generic	$8.00	$0.00	None
NORVIR 100 MG TABLET	4	Non-Preferred Drug	40%	40%	Q:540 /30Days
NORVIR 100mg/1 30 CAPSULE BOTTLE	4	Non-Preferred Drug	40%	40%	Q:540 /30Days
NORVIR 80MG/ML ORAL SOLUTION	4	Non-Preferred Drug	40%	40%	Q:720 /30Days
novarel 10,000 units vial	4	Non-Preferred Drug	40%	40%	P
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%	33%	Q:600 /30Days
NOXAFIL DR 100 MG TABLET	5	Specialty Tier	33%	33%	P Q:240 /30Days
NUCYNTA ER 100mg/1 60 TABLET, FILM COATED	3	Preferred Brand	$35.00	$90.00	Q:60 /30Days
NUCYNTA ER 150mg/1 60 TABLET, FILM COATED	3	Preferred Brand	$35.00	$90.00	Q:60 /30Days
NUCYNTA ER 200mg/1 60 TABLET, FILM COATED	3	Preferred Brand	$35.00	$90.00	Q:60 /30Days
NUCYNTA ER 250mg/1 60 TABLET, FILM COATED	3	Preferred Brand	$35.00	$90.00	Q:60 /30Days
NUCYNTA ER 50mg/1 60 TABLET, FILM COATED	3	Preferred Brand	$35.00	$90.00	Q:60 /30Days
NUEDEXTA 20; 10mg/1; mg/1	4	Non-Preferred Drug	40%	40%	P
NULOJIX 250mg/1 1 VIAL, SINGLE-USE per CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in	5	Specialty Tier	33%	33%	P
NUPLAZID 17 MG TABLET	5	Specialty Tier	33%	33%	P Q:60 /30Days
NUTRILIPID 20 % EMULSION	4	Non-Preferred Drug	40%	40%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NUTROPIN AQ NUSPIN 10 INJECTOR	5	Specialty Tier	33%	33%	P
NUTROPIN AQ NUSPIN 10MG/2ML SOLUTION	5	Specialty Tier	33%	33%	P
NUTROPIN AQ NUSPIN 20 INJECTOR	5	Specialty Tier	33%	33%	P
NUVARING 0.12-0.015 RING VAGINAL	4	Non-Preferred Drug	40%	40%	None
NYAMYC 100000 U/G POWDER	2	Generic	$8.00	$0.00	None
Nyata 100,000 unit/gm powder	2	Generic	$8.00	$0.00	None
Nystatin 100000[USP'U]/g	2	Generic	$8.00	$0.00	None
Nystatin 100000[USP'U]/g 1 TUBE per CARTON / 30 g in 1 TUBE	2	Generic	$8.00	$0.00	None
Nystatin 100000[USP'U]/g 1 TUBE per CARTON / 30 g in 1 TUBE	2	Generic	$8.00	$0.00	None
Nystatin 100000[USP'U]/mL	2	Generic	$8.00	$0.00	None
NYSTATIN TABLET 500000U (100 CT)	2	Generic	$8.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NYSTOP 100000U/GM POWDER	2	Generic	$8.00	$0.00	None

Chart Legend:

Below are a few notes to help you understand the above 2017 Medicare Part D AARP MedicareRx Preferred (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.