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2017 Medicare Part D Plan Formulary Information
SilverScript Choice (PDP) (S5601-010-0) Benefit Details
The SilverScript Choice (PDP) (S5601-010-0) Formulary Drugs Starting with the Letter N in CMS PDP Region 5 which includes: DC DE MD Plan Monthly Premium: $33.90 Deductible: $0 Qualifies for LIS: Yes
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
Nabumetone 500 mg tablet	2	Generic	$19.00	$47.50	None
Nabumetone 750 mg tablet	2	Generic	$19.00	$47.50	None
Nafcillin 1 gm vial	4	Non-Preferred Drug	50%	50%	None
Nafcillin 10g/100mL	4	Non-Preferred Drug	50%	50%	None
NAGLAZYME 5MG/5ML VIAL	5	Specialty Tier	33%	N/A	P
Nalbuphine Hydrochloride 10mg/mL 1 VIAL, MULTI-DOSE per CARTON / 10 mL in 1 VIAL, MULTI-DOSE	4	Non-Preferred Drug	50%	50%	None
Nalbuphine Hydrochloride 20mg/mL 25 VIAL, MULTI-DOSE per CARTON / 10 mL in 1 VIAL, MULTI-DOSE	4	Non-Preferred Drug	50%	50%	None
NALOXONE 0.4 MG/ML VIAL	3	Preferred Brand	$47.00	$117.50	None
naloxone 1 mg/ml syringe	3	Preferred Brand	$47.00	$117.50	None
NALTREXONE HCL 50MG TABLET 100 BLPK	3	Preferred Brand	$47.00	$117.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NAMENDA XR 14 MG CAPSULE	4	Non-Preferred Drug	50%	50%	P
NAMENDA XR 21 MG CAPSULE	4	Non-Preferred Drug	50%	50%	P
NAMENDA XR 28 MG CAPSULE	4	Non-Preferred Drug	50%	50%	P
NAMENDA XR 7 MG CAPSULE	4	Non-Preferred Drug	50%	50%	P
NAMENDA XR TITRATION PACK	4	Non-Preferred Drug	50%	50%	P
NAMZARIC 14 MG-10 MG CAPSULE	4	Non-Preferred Drug	50%	50%	None
NAMZARIC 21 MG-10 MG CAPSULE	4	Non-Preferred Drug	50%	50%	None
NAMZARIC 28 MG-10 MG CAPSULE	4	Non-Preferred Drug	50%	50%	None
NAMZARIC 7 MG-10 MG CAPSULE	4	Non-Preferred Drug	50%	50%	None
NAMZARIC TITRATION PACK	4	Non-Preferred Drug	50%	50%	None
Naproxen 125 mg/5 ml suspen	3	Preferred Brand	$47.00	$117.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NAPROXEN 250 MG ORAL TABLET	1	Preferred Generic	$3.00	$7.50	None
Naproxen 375 mg tablet	1	Preferred Generic	$3.00	$7.50	None
Naproxen 500mg/1 500 TABLET BOTTLE	1	Preferred Generic	$3.00	$7.50	None
NAPROXEN DR 375 MG TABLET	2	Generic	$19.00	$47.50	None
NAPROXEN DR 500 MG TABLET	2	Generic	$19.00	$47.50	None
NAPROXEN SODIUM 275 MG ORAL TABLET	4	Non-Preferred Drug	50%	50%	None
NAPROXEN SODIUM 550 MG	4	Non-Preferred Drug	50%	50%	None
NARATRIPTAN 2.5MG TABLETS	3	Preferred Brand	$47.00	$117.50	None
NARATRIPTAN HCL 1 MG TABLET	3	Preferred Brand	$47.00	$117.50	None
NASONEX 50ug/1 120 SPRAY, METERED in 1 BOTTLE, PUMP	3	Preferred Brand	$47.00	$117.50	Q:34 /30Days
NATACYN EYE DROPS	4	Non-Preferred Drug	50%	50%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Nateglinide 120mg/1 90 TABLET BOTTLE	2	Generic	$19.00	$47.50	Q:90 /30Days
Nateglinide 60mg/1 90 TABLET BOTTLE	2	Generic	$19.00	$47.50	Q:90 /30Days
NATPARA 100 MCG DOSE CARTRIDGE	5	Specialty Tier	33%	N/A	P
NATPARA 25 MCG DOSE CARTRIDGE	5	Specialty Tier	33%	N/A	P
NATPARA 50 MCG DOSE CARTRIDGE	5	Specialty Tier	33%	N/A	P
NATPARA 75 MCG DOSE CARTRIDGE	5	Specialty Tier	33%	N/A	P
NEBUPENT 300MG INHAL POWDER	4	Non-Preferred Drug	50%	50%	P
Necon 0.5-35-28 tablet	3	Preferred Brand	$47.00	$117.50	None
NECON 1-50-28 TABLET	3	Preferred Brand	$47.00	$117.50	None
NECON 10/11-28 TABLET	3	Preferred Brand	$47.00	$117.50	None
NECON 7-7-7-28 TABLET	3	Preferred Brand	$47.00	$117.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NEFAZODONE HCL 150MG TABLET (60 CT)	4	Non-Preferred Drug	50%	50%	None
NEFAZODONE HCL 250MG TABLET	4	Non-Preferred Drug	50%	50%	None
NEFAZODONE HCL 50MG TABLET	4	Non-Preferred Drug	50%	50%	None
NEFAZODONE HYDROCHLORIDE TABLETS 100MG 60 BOT	4	Non-Preferred Drug	50%	50%	None
NEFAZODONE HYDROCHLORIDE TABLETS 200MG 60 BOT	4	Non-Preferred Drug	50%	50%	None
NEO/POLYMYXIN/HC EAR TUBEX 10MG/3.5MG/100UNT	3	Preferred Brand	$47.00	$117.50	None
Neomycin and Polymyxin B Sulfates and Dexamethasone 1; 3.5; 10000mg/g; mg/g; [USP'U]/g 1 TUBE in 1	2	Generic	$19.00	$47.50	None
NEOMYCIN SULFATE 500MG TABLET	3	Preferred Brand	$47.00	$117.50	None
NEOMYCIN-BACITRACIN-POLY-HC 3.5-10K-1 OINTMENT	3	Preferred Brand	$47.00	$117.50	None
NEOMYCIN-POLYMYXIN-HC 3.5-10K-10 SUSPENSION DROPS	4	Non-Preferred Drug	50%	50%	None
NEOMYCIN/POLYMY/DEXA EYE DROPS 3.5MG/1ML	2	Generic	$19.00	$47.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NEOMYCIN/POLYMY/GRAM EYE DROPS 0.025MG/ML 1.75MG/M	3	Preferred Brand	$47.00	$117.50	None
NEOMYCIN/POLYMY/HYDRO OTIC SUS	3	Preferred Brand	$47.00	$117.50	None
NEORAL 100MG GELATN CAPSULE	3	Preferred Brand	$47.00	$117.50	P
NEORAL 100MG/ML SOLUTION	3	Preferred Brand	$47.00	$117.50	P
NEORAL 25MG GELATIN CAPSULE	3	Preferred Brand	$47.00	$117.50	P
NEPHRAMINE SOLUTION FOR INJECTION	4	Non-Preferred Drug	50%	50%	P
NEUPOGEN 300 MCG/ML VIAL	5	Specialty Tier	33%	N/A	P
NEUPOGEN 300MCG/ML VIAL	5	Specialty Tier	33%	N/A	P
NEUPOGEN 300ug/0.5mL 10 SYRINGE in 1 BOX / 0.5 mL in 1 SYRINGE	5	Specialty Tier	33%	N/A	P
NEUPOGEN INJECTION 480MCG/0.8ML 10 X 0.8ML SYR	5	Specialty Tier	33%	N/A	P
NEUPRO 1 MG/24 HR PATCH	4	Non-Preferred Drug	50%	50%	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	50%	50%	None
NEUPRO 3 MG/24 HR PATCH	4	Non-Preferred Drug	50%	50%	None
NEUPRO 4 MG/24 HR PATCH	4	Non-Preferred Drug	50%	50%	None
NEUPRO 6 MG/24 HR PATCH	4	Non-Preferred Drug	50%	50%	None
NEUPRO 8 MG/24 HR PATCH	4	Non-Preferred Drug	50%	50%	None
nevirapine 200 mg tablet	3	Preferred Brand	$47.00	$117.50	None
NEVIRAPINE 50 MG/5 ML SUSP	4	Non-Preferred Drug	50%	50%	None
NEVIRAPINE ER 100 MG TABLET	4	Non-Preferred Drug	50%	50%	None
NEVIRAPINE ER 400 MG TABLET	4	Non-Preferred Drug	50%	50%	None
NEXAVAR TABLETS 200MG 120 BOT	5	Specialty Tier	33%	N/A	P
NEXIUM 10mg/1 30 GRANULE, DELAYED RELEASE per CARTON	3	Preferred Brand	$47.00	$117.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NEXIUM 20MG CAPSULE	3	Preferred Brand	$47.00	$117.50	None
NEXIUM 20MG SUSP FOR RECON DELAYED REL. IN A PACKET	3	Preferred Brand	$47.00	$117.50	None
NEXIUM 40MG CAPSULE	3	Preferred Brand	$47.00	$117.50	None
NEXIUM 40MG SUSP FOR RECON DELAYED REL. IN A PACKET	3	Preferred Brand	$47.00	$117.50	None
NEXIUM DR 2.5 MG PACKET	3	Preferred Brand	$47.00	$117.50	None
NEXIUM DR 5 MG PACKET	3	Preferred Brand	$47.00	$117.50	None
NIACIN ER 1,000 MG TABLET	4	Non-Preferred Drug	50%	50%	None
NIACIN ER 500 MG TABLET	4	Non-Preferred Drug	50%	50%	None
NIACIN ER 750 MG TABLET	4	Non-Preferred Drug	50%	50%	None
NIACOR 500MG TABLET	3	Preferred Brand	$47.00	$117.50	None
NICARDIPINE HYDROCHLORIDE 20MG CAPSULES	4	Non-Preferred Drug	50%	50%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NICARDIPINE HYDROCHLORIDE CAPSULES 30MG 500 BOT	4	Non-Preferred Drug	50%	50%	None
NICOTROL INHALER 10MG 168 X 10MG/CARTRIDGE INHL	4	Non-Preferred Drug	50%	50%	None
NICOTROL NS NASAL SPRAY BOTTLE 10MG 4 X 10MG/ML INHL	4	Non-Preferred Drug	50%	50%	None
NIFEDIPINE 90MG TABLETS EXTENDED RELEASE	3	Preferred Brand	$47.00	$117.50	None
NIFEDIPINE ER 30 MG TABLET	3	Preferred Brand	$47.00	$117.50	None
NIFEDIPINE ER 30 MG TABLET	3	Preferred Brand	$47.00	$117.50	None
NIFEDIPINE ER 60 MG TABLET	3	Preferred Brand	$47.00	$117.50	None
NIFEDIPINE ER 60 MG TABLET	3	Preferred Brand	$47.00	$117.50	None
NIFEDIPINE ER 90 MG TABLET	3	Preferred Brand	$47.00	$117.50	None
Nikki 3 mg-0.02 mg tablet	3	Preferred Brand	$47.00	$117.50	None
Nilutamide 150 mg tablet [Nilandron]	5	Specialty Tier	33%	N/A	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%	N/A	None
NINLARO 2.3 MG CAPSULE	5	Specialty Tier	33%	N/A	P
NINLARO 3 MG CAPSULE	5	Specialty Tier	33%	N/A	P
NINLARO 4 MG CAPSULE	5	Specialty Tier	33%	N/A	P
NIPENT FOR INJECTION 10MG VIALS	5	Specialty Tier	33%	N/A	P
NITRO-BID 20mg/g 48 PACKET in 1 BOX / 1 g in 1 PACKET	3	Preferred Brand	$47.00	$117.50	None
NITRO-DUR 0.3 MG/HR PATCH	4	Non-Preferred Drug	50%	50%	None
NITRO-DUR 0.8 MG/HR PATCH	4	Non-Preferred Drug	50%	50%	None
NITROFURANTOIN MACROCRYSTALLINE 50 mg cap	4	Non-Preferred Drug	50%	50%	P
Nitrofurantoin mcr 100 mg cap	4	Non-Preferred Drug	50%	50%	P
NITROFURANTOIN MONO-MCR 100 MG	4	Non-Preferred Drug	50%	50%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NITROGLYCERIN .2MG/HR PATCH	3	Preferred Brand	$47.00	$117.50	None
NITROGLYCERIN .4MG/HR PATCH	3	Preferred Brand	$47.00	$117.50	None
NITROGLYCERIN .6MG/HR PATCH	3	Preferred Brand	$47.00	$117.50	None
NITROGLYCERIN 0.3 MG TABLET SL	3	Preferred Brand	$47.00	$117.50	None
NITROGLYCERIN 0.4 MG TABLET SL	3	Preferred Brand	$47.00	$117.50	None
NITROGLYCERIN 0.6 MG TABLET SL	3	Preferred Brand	$47.00	$117.50	None
NITROGLYCERIN TRANSOERMAL SYSTEM .1MG/HR 30 SYSTEM BOX	3	Preferred Brand	$47.00	$117.50	None
NORA-BE 0.35MG TABLET	3	Preferred Brand	$47.00	$117.50	None
Norditropin 10mg/1.5mL 1 SYRINGE, PLASTIC per CARTON / 1.5 mL in 1 SYRINGE, PLASTIC	5	Specialty Tier	33%	N/A	P
Norditropin 15mg/1.5mL 1 SYRINGE, PLASTIC per CARTON / 1.5 mL in 1 SYRINGE, PLASTIC	5	Specialty Tier	33%	N/A	P
Norditropin 5mg/1.5mL 1 SYRINGE, PLASTIC per CARTON / 1.5 mL in 1 SYRINGE, PLASTIC	5	Specialty Tier	33%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NORDITROPIN FLEXPRO 30 MG/3 ML	5	Specialty Tier	33%	N/A	P
NORETHIN-ETH ESTRAD 1 MG-5 MCG	4	Non-Preferred Drug	50%	50%	None
norethind-eth estrad 1-0.02 mg	3	Preferred Brand	$47.00	$117.50	None
Norethindrone 0.35 mg tablet	3	Preferred Brand	$47.00	$117.50	None
NORETHINDRONE 5MG TABLET	3	Preferred Brand	$47.00	$117.50	None
NORG-EE 0.18-0.215-0.25/0.025	3	Preferred Brand	$47.00	$117.50	None
norg-ee 0.18-0.215-0.25/0.035	3	Preferred Brand	$47.00	$117.50	None
Norg-ethin estra 0.25-0.035 mg	3	Preferred Brand	$47.00	$117.50	None
Norlyroc 0.35 mg tablet	3	Preferred Brand	$47.00	$117.50	None
NORMOSOL -R INJ /D5W	4	Non-Preferred Drug	50%	50%	None
NORMOSOL-M AND DEXTROSE 5%	4	Non-Preferred Drug	50%	50%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NORMOSOL-R PH 7.4 IV SOLUTION	4	Non-Preferred Drug	50%	50%	None
NORPACE CR 100MG CAPSULE SA	4	Non-Preferred Drug	50%	50%	None
NORPACE CR 150MG CAPSULE SA	4	Non-Preferred Drug	50%	50%	None
NORTHERA 100 MG CAPSULE	5	Specialty Tier	33%	N/A	P
NORTHERA 200 MG CAPSULE	5	Specialty Tier	33%	N/A	P
NORTHERA 300 MG CAPSULE	5	Specialty Tier	33%	N/A	P
Nortrel (21 Day Regimen) 0.035; 1mg/1; mg/1 3 BLISTER PACK per CARTON / 21 TABLET per BLISTER PACK	3	Preferred Brand	$47.00	$117.50	None
Nortrel (28 Day Regimen) 3 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK	3	Preferred Brand	$47.00	$117.50	None
NORTREL 1-0.035MG TABLET 28DAY	3	Preferred Brand	$47.00	$117.50	None
Nortrel 7/7/7 (28 Day Regimen) 6 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT in 1 BLISTER	3	Preferred Brand	$47.00	$117.50	None
NORTRIPTYLINE 10 MG/5 ML SOL	4	Non-Preferred Drug	50%	50%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NORTRIPTYLINE HCL 25MG CAP	2	Generic	$19.00	$47.50	None
NORTRIPTYLINE HCL 75 MG CAP	2	Generic	$19.00	$47.50	None
Nortriptyline Hydrochloride 10mg/1 100 CAPSULE BOTTLE	2	Generic	$19.00	$47.50	None
Nortriptyline Hydrochloride 50mg/1 500 CAPSULE BOTTLE	2	Generic	$19.00	$47.50	None
NORVIR 100 MG TABLET	3	Preferred Brand	$47.00	$117.50	None
NORVIR 100mg/1 30 CAPSULE BOTTLE	3	Preferred Brand	$47.00	$117.50	None
NORVIR 80MG/ML ORAL SOLUTION	3	Preferred Brand	$47.00	$117.50	None
Novolin 100[iU]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL	3	Preferred Brand	$47.00	$117.50	None
Novolin 100[USP'U]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL	3	Preferred Brand	$47.00	$117.50	None
Novolin R 100[iU]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL	3	Preferred Brand	$47.00	$117.50	None
NOVOLOG 100 UNIT/ML CARTRIDGE	3	Preferred Brand	$47.00	$117.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NOVOLOG 100U/ML VIAL	3	Preferred Brand	$47.00	$117.50	None
NOVOLOG FLEXPEN SYRINGE	3	Preferred Brand	$47.00	$117.50	None
NOVOLOG MIX 70/30 SYRINGE 70-30U/ML	3	Preferred Brand	$47.00	$117.50	None
NOVOLOG MIX 70/30 VIAL	3	Preferred Brand	$47.00	$117.50	None
NOXAFIL 200MG/5ML SUSPENSION ORAL	5	Specialty Tier	33%	N/A	None
NOXAFIL DR 100 MG TABLET	5	Specialty Tier	33%	N/A	None
NUCYNTA ER 100mg/1 60 TABLET, FILM COATED	3	Preferred Brand	$47.00	$117.50	Q:120 /30Days
NUCYNTA ER 150mg/1 60 TABLET, FILM COATED	3	Preferred Brand	$47.00	$117.50	Q:60 /30Days
NUCYNTA ER 200mg/1 60 TABLET, FILM COATED	3	Preferred Brand	$47.00	$117.50	Q:60 /30Days
NUCYNTA ER 250mg/1 60 TABLET, FILM COATED	3	Preferred Brand	$47.00	$117.50	Q:60 /30Days
NUCYNTA ER 50mg/1 60 TABLET, FILM COATED	3	Preferred Brand	$47.00	$117.50	Q:120 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
NUEDEXTA 20; 10mg/1; mg/1	4	Non-Preferred Drug	50%	50%	P
NULOJIX 250mg/1 1 VIAL, SINGLE-USE per CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in	5	Specialty Tier	33%	N/A	P
NULYTELY WITH FLAVOR PACKS POWDER FOR SOLUTION 420;1.48;MG;MG;GM; 4 L BOT	3	Preferred Brand	$47.00	$117.50	None
NUPLAZID 17 MG TABLET	5	Specialty Tier	33%	N/A	P Q:60 /30Days
NUTRILIPID 20 % EMULSION	4	Non-Preferred Drug	50%	50%	P
NUVARING 0.12-0.015 RING VAGINAL	4	Non-Preferred Drug	50%	50%	None
NYAMYC 100000 U/G POWDER	3	Preferred Brand	$47.00	$117.50	None
Nyata 100,000 unit/gm powder	3	Preferred Brand	$47.00	$117.50	None
Nystatin 100000[USP'U]/g	3	Preferred Brand	$47.00	$117.50	None
Nystatin 100000[USP'U]/g 1 TUBE per CARTON / 30 g in 1 TUBE	3	Preferred Brand	$47.00	$117.50	None
Nystatin 100000[USP'U]/g 1 TUBE per CARTON / 30 g in 1 TUBE	3	Preferred Brand	$47.00	$117.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Nystatin 100000[USP'U]/mL	3	Preferred Brand	$47.00	$117.50	None
NYSTATIN TABLET 500000U (100 CT)	3	Preferred Brand	$47.00	$117.50	None
NYSTOP 100000U/GM POWDER	3	Preferred Brand	$47.00	$117.50	None

Chart Legend:

Below are a few notes to help you understand the above 2017 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 $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.