Powered by Q1Group LLC
Education and Decision Support Tools for the Medicare Community


2018 Medicare Part D and Medicare Advantage Plan Formulary Browser

Select your search style and criteria below or use this example to get started

Search by:
State & Plan   ZIP & Plan   PlanID   FormularyID

Search Criteria
PDP     MAPD
Scroll down to see formulary results.

Anthem Blue MedicareRx Premier (PDP) (S5596-003-0)
Tier 1 (211)
Tier 2 (839)
Tier 3 (751)
Tier 4 (1301)
Tier 5 (592)
Tier 6 (59)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
Yes No Show either
  *required
 
Cick on the first letter of your drug name to browse the formulary:

A B C D E F G H I J K L 
M N O P Q R S T U V W X Y Z 0-9 
2018 Medicare Part D Plan Formulary Information
Anthem Blue MedicareRx Premier (PDP) (S5596-003-0)
Benefit Details           
The Anthem Blue MedicareRx Premier (PDP) (S5596-003-0)
Formulary Drugs Starting with the Letter C

in CMS PDP Region 01 which includes: ME NH
Plan Monthly Premium: $148.80 Deductible: $0 Qualifies for LIS: No
Drugs Starting with Letter C

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
CABERGOLINE 0.5 MG TABLET   3 Preferred Brand $28.00N/ANone
CABOMETYX 20 MG TABLET   5 Specialty Tier 33%N/AP Q:90
/30Days
CABOMETYX 40 MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
CABOMETYX 60 MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
CALAN 120MG TABLET   3 Preferred Brand $28.00N/ANone
CALAN SR 120MG CAPLET SA   3 Preferred Brand $28.00N/ANone
CALCIPOTRIENE 0.005% CREAM   4 Non-Preferred Drug 35%N/AQ:120
/30Days
CALCIPOTRIENE 0.005% SOLUTION   3 Preferred Brand $28.00N/AQ:60
/30Days
Calcipotriene 50ug/g 60 g per CARTON   4 Non-Preferred Drug 35%N/AQ:120
/30Days
Calcipotriene-Betamethasone Dipropionate Ointment [Taclonex]   4 Non-Preferred Drug 35%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY   3 Preferred Brand $28.00N/AQ:4
/30Days
CALCITRIOL 0.25 MCG CAPSULE [Rocaltrol]   2 Generic $3.00N/ANone
CALCITRIOL 0.5 MCG CAPSULE [Rocaltrol]   2 Generic $3.00N/ANone
Calcitriol 1 MCG per 1 ML Injection   4 Non-Preferred Drug 35%N/ANone
CALCITRIOL 1MCG/ML SOLUTION ORAL   2 Generic $3.00N/AP
CALCITRIOL 3 MCG/G OINTMENT   4 Non-Preferred Drug 35%N/ANone
CALCIUM ACETATE CAPSULE 667 MG   2 Generic $3.00N/ANone
Calcium Chloride 0.002 MEQ/ML / Potassium Chloride 0.004 MEQ/ML / Sodium Chloride 0.147 MEQ/ML Injec   4 Non-Preferred Drug 35%N/ANone
CALQUENCE 100 MG CAPSULE   5 Specialty Tier 33%N/AP
CAMILA 0.35 MG TABLET   3 Preferred Brand $28.00N/ANone
CANASA 1,000 MG SUPPOSITORY   4 Non-Preferred Drug 35%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CANCIDAS IV 50MG VIAL   5 Specialty Tier 33%N/AP
CANCIDAS IV 70MG VIAL   5 Specialty Tier 33%N/AP
CANDESARTAN CILEXETIL 16 MG TABLET [Atacand]   2 Generic $3.00N/ANone
CANDESARTAN CILEXETIL 32 MG TABLET [Atacand]   2 Generic $3.00N/ANone
CANDESARTAN CILEXETIL 4 MG TABLET [Atacand]   2 Generic $3.00N/ANone
CANDESARTAN CILEXETIL 8 MG TABLET [Atacand]   2 Generic $3.00N/ANone
candesartan-hctz 16-12.5 mg tablet   2 Generic $3.00N/ANone
candesartan-hctz 32-12.5 mg tablet   2 Generic $3.00N/ANone
CANDESARTAN-HCTZ 32-25 MG TAB   2 Generic $3.00N/ANone
CAPASTAT SULFATE 1g/1 1 INJECTION, POWDER, FOR SOLUTION per CARTON   4 Non-Preferred Drug 35%N/ANone
CAPEX SHA 0.01%   4 Non-Preferred Drug 35%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CAPRELSA 100 MG TABLET   5 Specialty Tier 33%N/AP Q:90
/30Days
CAPRELSA 300 MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
CAPTOPRIL 100MG TABLET   2 Generic $3.00N/ANone
CAPTOPRIL 12.5MG TABLET   2 Generic $3.00N/ANone
CAPTOPRIL 25 MG TABLET   2 Generic $3.00N/ANone
CAPTOPRIL 50MG TABLET   2 Generic $3.00N/ANone
Captopril and Hydrochlorothiazide 25; 15mg 100 TABLET BOTTLE   2 Generic $3.00N/ANone
Captopril and Hydrochlorothiazide 25; 25mg 100 TABLET BOTTLE   2 Generic $3.00N/ANone
Captopril and Hydrochlorothiazide 50; 15mg 100 TABLET BOTTLE   2 Generic $3.00N/ANone
Captopril and Hydrochlorothiazide 50; 25mg 100 TABLET BOTTLE   2 Generic $3.00N/ANone
CARAFATE SUS 1GM/10ML   3 Preferred Brand $28.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARBAGLU 200 MG DISPER TABLET   5 Specialty Tier 33%N/AP
CARBAMAZEPINE 100 MG TAB CHEW   4 Non-Preferred Drug 35%N/ANone
CARBAMAZEPINE 100 MG/5 ML SUSP   4 Non-Preferred Drug 35%N/ANone
CARBAMAZEPINE 200 MG TABLET   4 Non-Preferred Drug 35%N/ANone
CARBAMAZEPINE ER 100 MG CAP CPMP 12HR [Carbatrol]   4 Non-Preferred Drug 35%N/ANone
CARBAMAZEPINE ER 100 MG TABLET   4 Non-Preferred Drug 35%N/ANone
CARBAMAZEPINE ER 200 MG CAP CPMP 12HR [Carbatrol]   4 Non-Preferred Drug 35%N/ANone
CARBAMAZEPINE ER 300 MG CAP CPMP 12HR [Carbatrol]   4 Non-Preferred Drug 35%N/ANone
CARBAMAZEPINE XR 200 MG TABLET   4 Non-Preferred Drug 35%N/ANone
CARBAMAZEPINE XR 400 MG TABLET   4 Non-Preferred Drug 35%N/ANone
Carbatrol 100mg/1 120 CAPSULE, ER in BOTTLE   4 Non-Preferred Drug 35%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARBATROL 200MG CAPSULE SA   4 Non-Preferred Drug 35%N/ANone
CARBATROL 300MG CAPSULE SA   4 Non-Preferred Drug 35%N/ANone
CARBIDOPA AND LEVEDOPA ORALLY DISINTEGRATING TABLETS 10;100MG;MG 100 BOT   4 Non-Preferred Drug 35%N/ANone
CARBIDOPA AND LEVODOPA ODT 25;100MG;MG 100 BOT   4 Non-Preferred Drug 35%N/ANone
CARBIDOPA AND LEVODOPA ODT 25;250MG;MG 100 BOT   4 Non-Preferred Drug 35%N/ANone
CARBIDOPA-LEVO ER 25-100 TAB   2 Generic $3.00N/ANone
CARBIDOPA-LEVO ER 50-200 TAB   2 Generic $3.00N/ANone
CARBIDOPA-LEVODOPA 10-100 TAB   2 Generic $3.00N/ANone
CARBIDOPA-LEVODOPA 25-100 TAB   2 Generic $3.00N/ANone
CARBIDOPA-LEVODOPA 25-250 TAB   2 Generic $3.00N/ANone
Carboplatin 10 MG/ML Injectable Solution   4 Non-Preferred Drug 35%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARDIZEM LA 120 MG TABLET   4 Non-Preferred Drug 35%N/ANone
CARDIZEM LA 180 MG TABLET   4 Non-Preferred Drug 35%N/ANone
CARDIZEM LA 240 MG TABLET ER 24H   4 Non-Preferred Drug 35%N/ANone
CARDIZEM LA 420 MG TABLET   3 Preferred Brand $28.00N/ANone
CARDURA XL 4MG TABLET   4 Non-Preferred Drug 35%N/ANone
CARDURA XL 8MG TABLET   4 Non-Preferred Drug 35%N/ANone
CARISOPRODOL 350 MG TABLET   2 Generic $3.00N/AP
CARTEOLOL HCL 1% EYE DROPS   1 Preferred Generic $1.00N/ANone
CARTIA XT 120MG CAPSULE SA   2 Generic $3.00N/ANone
CARTIA XT 180MG CAPSULE SA   2 Generic $3.00N/ANone
CARTIA XT 240MG CAPSULE SA   2 Generic $3.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARTIA XT 300 MG CAPSULE   2 Generic $3.00N/ANone
CARVEDILOL 12.5 MG TABLET   1 Preferred Generic $1.00N/ANone
CARVEDILOL 25 MG TABLET   1 Preferred Generic $1.00N/ANone
CARVEDILOL 3.125 MG TABLET   1 Preferred Generic $1.00N/ANone
CARVEDILOL 6.25 MG TABLET   1 Preferred Generic $1.00N/ANone
CARVEDILOL ER 10 MG CAPSULE   4 Non-Preferred Drug 35%N/ANone
CARVEDILOL ER 20 MG CAPSULE   4 Non-Preferred Drug 35%N/ANone
CARVEDILOL ER 40 MG CAPSULE   4 Non-Preferred Drug 35%N/ANone
CARVEDILOL ER 80 MG CAPSULE   4 Non-Preferred Drug 35%N/ANone
CAYSTON KIT 75 MG/VIAL   5 Specialty Tier 33%N/AP
CAZIANT 28 DAY TABLET   4 Non-Preferred Drug 35%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFACLOR 125 MG/5 ML SUSP Oral Suspension [Ceclor]   2 Generic $3.00N/ANone
CEFACLOR 250 MG CAPSULES   2 Generic $3.00N/ANone
CEFACLOR 250 MG/5 ML SUSPEN Oral Suspension [Ceclor]   3 Preferred Brand $28.00N/ANone
CEFACLOR 375 MG/5 ML SUSPEN Oral Suspension [Ceclor]   2 Generic $3.00N/ANone
CEFACLOR 500 MG CAPSULES   2 Generic $3.00N/ANone
CEFACLOR ER 500MG TABLET SR 12HR   2 Generic $3.00N/ANone
CEFADROXIL 1 GM TABLET   3 Preferred Brand $28.00N/ANone
CEFADROXIL 250 MG/5 ML SUSP   2 Generic $3.00N/ANone
CEFADROXIL 500 MG CAPSULE   2 Generic $3.00N/ANone
CEFADROXIL 500 MG/5 ML SUSP   2 Generic $3.00N/ANone
CEFAZOLIN 1 GM VIAL 25/Box   4 Non-Preferred Drug 35%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Cefazolin 10g/1 10 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 PACKAGE   4 Non-Preferred Drug 35%N/ANone
CEFAZOLIN 500 MG VIAL   4 Non-Preferred Drug 35%N/ANone
CEFDINIR 125 MG/5 ML SUSP   3 Preferred Brand $28.00N/ANone
CEFDINIR 250 MG/5 ML SUSP   3 Preferred Brand $28.00N/ANone
CEFDINIR 300 MG CAPSULE   2 Generic $3.00N/ANone
CEFEPIME HCL 1 GM VIAL   4 Non-Preferred Drug 35%N/ANone
CEFEPIME HCL 2 GRAM VIAL   4 Non-Preferred Drug 35%N/ANone
CEFIXIME 100 MG/5 ML SUSP [Suprax]   4 Non-Preferred Drug 35%N/ANone
CEFIXIME 200 MG/5 ML SUSP [Suprax]   4 Non-Preferred Drug 35%N/ANone
Cefotaxime 500 MG Injection   4 Non-Preferred Drug 35%N/ANone
Cefotaxime sodium 1 gm vial   4 Non-Preferred Drug 35%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Cefotaxime sodium 2 gm vial   4 Non-Preferred Drug 35%N/ANone
CEFOTETAN 1GM VIAL 1EA x 10   4 Non-Preferred Drug 35%N/ANone
CEFOTETAN 2GM VIAL 1EA x 10   4 Non-Preferred Drug 35%N/ANone
CEFOXITIN 1 GM VIAL   4 Non-Preferred Drug 35%N/ANone
CEFOXITIN 10 GM VIAL   4 Non-Preferred Drug 35%N/ANone
CEFOXITIN 2 GM VIAL   4 Non-Preferred Drug 35%N/ANone
CEFPODOXIME 100 MG TABLET   2 Generic $3.00N/ANone
CEFPODOXIME 100 MG/5 ML SUSP   2 Generic $3.00N/ANone
CEFPODOXIME 200 MG TABLET   2 Generic $3.00N/ANone
CEFPODOXIME 50 MG/5 ML SUSP   4 Non-Preferred Drug 35%N/ANone
CEFPROZIL 125 MG/5 ML SUSP   4 Non-Preferred Drug 35%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFPROZIL 250 MG TABLET   2 Generic $3.00N/ANone
CEFPROZIL 250 MG/5 ML SUSP   2 Generic $3.00N/ANone
CEFPROZIL 500 MG TABLET   2 Generic $3.00N/ANone
CEFTAZIDIME 1 GM VIAL   4 Non-Preferred Drug 35%N/ANone
CEFTAZIDIME FOR INJECTION 2GM/VIAL 10 X 2 CRTN   4 Non-Preferred Drug 35%N/ANone
CEFTAZIDIME FOR INJECTION 6GM/VIAL 6 X 6 CRTN   4 Non-Preferred Drug 35%N/ANone
CEFTRIAXONE 1 GM VIAL   4 Non-Preferred Drug 35%N/ANone
CEFTRIAXONE 10 GM VIAL   4 Non-Preferred Drug 35%N/ANone
CEFTRIAXONE 2 GM VIAL   4 Non-Preferred Drug 35%N/ANone
CEFTRIAXONE 250 MG VIAL   4 Non-Preferred Drug 35%N/ANone
CEFTRIAXONE 500 MG VIAL   4 Non-Preferred Drug 35%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFUROXIME 1.5 GM/VIAL FOR INJECTION   4 Non-Preferred Drug 35%N/ANone
CEFUROXIME 750 MG FOR INJECTION   4 Non-Preferred Drug 35%N/ANone
Cefuroxime 95 MG/ML Injectable Solution   4 Non-Preferred Drug 35%N/ANone
CEFUROXIME AXETIL 250 MG TAB   2 Generic $3.00N/ANone
CEFUROXIME AXETIL 500 MG TAB   2 Generic $3.00N/ANone
CELECOXIB 100 MG CAPSULE [Celebrex]   4 Non-Preferred Drug 35%N/AP
CELECOXIB 200 MG CAPSULE [Celebrex]   4 Non-Preferred Drug 35%N/AP
CELECOXIB 400 MG CAPSULE [Celebrex]   4 Non-Preferred Drug 35%N/AP
CELECOXIB 50 MG CAPSULE [Celebrex]   4 Non-Preferred Drug 35%N/AP
CELLCEPT IV INJ 500 MG   4 Non-Preferred Drug 35%N/AP
CELONTIN 300 MG KAPSEAL   4 Non-Preferred Drug 35%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEPHALEXIN 125 MG/5 ML SUSP   2 Generic $3.00N/ANone
CEPHALEXIN 250 MG CAPSULE   1 Preferred Generic $1.00N/ANone
CEPHALEXIN 250 MG TABLET   2 Generic $3.00N/ANone
CEPHALEXIN 250 MG/5 ML SUSP   2 Generic $3.00N/ANone
CEPHALEXIN 500 MG CAPSULE   1 Preferred Generic $1.00N/ANone
CEPHALEXIN 500 MG TABLET   2 Generic $3.00N/ANone
CEPHALEXIN 750 MG CAPSULE   2 Generic $3.00N/ANone
CEREZYME 400 UNITS VIAL   5 Specialty Tier 33%N/AP
CETIRIZINE HCL 1 MG/ML SOLN   2 Generic $3.00N/ANone
CEVIMELINE HCL 30 MG CAPSULE [Evoxac]   3 Preferred Brand $28.00N/ANone
CHANTIX 0.5 MG TABLET   4 Non-Preferred Drug 35%N/AP Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CHANTIX 1 MG CONT MONTH BOX   4 Non-Preferred Drug 35%N/AP Q:56
/28Days
CHANTIX 1 MG TABLET   4 Non-Preferred Drug 35%N/AP Q:60
/30Days
CHANTIX STARTING MONTH BOX   4 Non-Preferred Drug 35%N/AP Q:106
/365Days
CHEMET 100 MG CAPSULE   4 Non-Preferred Drug 35%N/ANone
CHLORAMPHEN NA SUCC 1GM VL   4 Non-Preferred Drug 35%N/ANone
CHLORHEXIDINE GLUCONATE 0.12% RINSE   1 Preferred Generic $1.00N/ANone
CHLOROQUINE PH 250 MG TABLET   2 Generic $3.00N/ANone
CHLOROQUINE PH 500 MG TABLET   2 Generic $3.00N/ANone
CHLOROTHIAZIDE 250 MG TABLET   2 Generic $3.00N/ANone
Chlorothiazide 500 MG Injection   4 Non-Preferred Drug 35%N/ANone
Chlorothiazide 500mg 100 TABLET BOTTLE   2 Generic $3.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CHLORPROMAZINE 10 MG TABLET   3 Preferred Brand $28.00N/AP
CHLORPROMAZINE 100 MG TABLET   4 Non-Preferred Drug 35%N/AP
CHLORPROMAZINE 200 MG TABLET   4 Non-Preferred Drug 35%N/AP
CHLORPROMAZINE 25 MG TABLET   3 Preferred Brand $28.00N/AP
CHLORPROMAZINE 25 MG/ML AMP   4 Non-Preferred Drug 35%N/AP
CHLORPROMAZINE 50 MG TABLET   3 Preferred Brand $28.00N/AP
CHLORTHALIDONE 25 MG TABLET (100 CT)   2 Generic $3.00N/ANone
CHLORTHALIDONE 50 MG TABLET   2 Generic $3.00N/ANone
CHOLESTYRAMINE LIGHT POWDER   2 Generic $3.00N/ANone
CHOLESTYRAMINE PACKET   2 Generic $3.00N/ANone
CICLOPIROX 0.77% CREAM   2 Generic $3.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CICLOPIROX 0.77% GEL   3 Preferred Brand $28.00N/ANone
CICLOPIROX 0.77% TOPICAL SUSP   2 Generic $3.00N/ANone
CICLOPIROX 1% SHAMPOO   3 Preferred Brand $28.00N/ANone
CICLOPIROX 8% SOLUTION   2 Generic $3.00N/ANone
Cilastatin 250 MG / Imipenem 250 MG Injection   3 Preferred Brand $28.00N/ANone
Cilastatin 500 MG / Imipenem 500 MG Injection   4 Non-Preferred Drug 35%N/ANone
CILOSTAZOL 100 MG TABLET   2 Generic $3.00N/ANone
CILOSTAZOL 50 MG TABLET   2 Generic $3.00N/ANone
Cimetidine 200mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC   3 Preferred Brand $28.00N/ANone
Cimetidine 300 MG Oral Tablet   3 Preferred Brand $28.00N/ANone
Cimetidine 400mg/1 100 FILM COATED TABLETS in BOTTLE   3 Preferred Brand $28.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CIPRO HC OTIC SUSPENSION   4 Non-Preferred Drug 35%N/ANone
CIPRODEX OTIC SUSPENSION   3 Preferred Brand $28.00N/ANone
CIPROFLOXACIN 0.3% EYE DROP [Ciloxan]   1 Preferred Generic $1.00N/ANone
CIPROFLOXACIN 250 MG TABLET (100 CT) [Cipro]   1 Preferred Generic $1.00N/ANone
CIPROFLOXACIN 250 MG/5 ML SUSP MC REC [Cipro]   3 Preferred Brand $28.00N/ANone
CIPROFLOXACIN 500 MG/5 ML SUSP MC REC [Cipro]   4 Non-Preferred Drug 35%N/ANone
CIPROFLOXACIN ER 1,000 MG TAB TBMP 24HR [Cipro XR]   2 Generic $3.00N/ANone
CIPROFLOXACIN ER 500 MG TABLET TBMP 24HR [Proquin XR]   2 Generic $3.00N/ANone
CIPROFLOXACIN HCL 100 MG Tablet [Cipro]   3 Preferred Brand $28.00N/ANone
CIPROFLOXACIN HCL 500 MG Tablet [Cipro]   1 Preferred Generic $1.00N/ANone
CIPROFLOXACIN HCL 750 MG Tablet [Cipro]   1 Preferred Generic $1.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CIPROFLOXACIN-D5W 200 MG/100 ML PIGGYBACK [Cipro]   4 Non-Preferred Drug 35%N/ANone
CISPLATIN 50MG/50ML MDV   4 Non-Preferred Drug 35%N/AP
CITALOPRAM HBR 10 MG TABLET   1 Preferred Generic $1.00N/AQ:120
/30Days
CITALOPRAM HBR 10 MG/5 ML SOLN   2 Generic $3.00N/AQ:600
/30Days
CITALOPRAM HBR 20 MG TABLET   1 Preferred Generic $1.00N/AQ:60
/30Days
CITALOPRAM HBR 40 MG TABLET   1 Preferred Generic $1.00N/AQ:30
/30Days
Cladribine 1 MG/ML in 10 ML Injection   5 Specialty Tier 33%N/AP
CLARAVIS 10 MG CAPSULE   4 Non-Preferred Drug 35%N/ANone
CLARAVIS 20 MG CAPSULE   4 Non-Preferred Drug 35%N/ANone
Claravis 30mg 3 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK   4 Non-Preferred Drug 35%N/ANone
CLARAVIS 40 MG CAPSULE   4 Non-Preferred Drug 35%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLARITHROMYCIN 125 MG/5ML FOR ORAL SUSPENSION   3 Preferred Brand $28.00N/ANone
CLARITHROMYCIN 250 MG TABLET   3 Preferred Brand $28.00N/ANone
CLARITHROMYCIN 250 MG/5MLFOR ORAL SUSPENSION   3 Preferred Brand $28.00N/ANone
CLARITHROMYCIN 500 MG TABLET   3 Preferred Brand $28.00N/ANone
CLARITHROMYCIN ER 500 MG TAB   3 Preferred Brand $28.00N/ANone
Clemastine fum 2.68 mg tab   3 Preferred Brand $28.00N/AP
CLEOCIN 100 MG VAGINAL OVULE   4 Non-Preferred Drug 35%N/ANone
CLEOCIN HCL 75 MG CAPSULE   4 Non-Preferred Drug 35%N/ANone
CLIND PH-BENZOYL PEROX 1.2-5% [Benzaclin]   3 Preferred Brand $28.00N/ANone
CLINDAGEL 1% GEL   4 Non-Preferred Drug 35%N/ANone
Clindamycin 150 MG/ML 2ml   4 Non-Preferred Drug 35%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLINDAMYCIN HCL 150 MG CAPSULE   1 Preferred Generic $1.00N/ANone
CLINDAMYCIN HCL 300 MG CAPSULE   1 Preferred Generic $1.00N/ANone
CLINDAMYCIN HCL 75 MG 200 CAPSULE BOTTLE   2 Generic $3.00N/ANone
CLINDAMYCIN PH 1% SOLUTION   2 Generic $3.00N/ANone
CLINDAMYCIN PH 600 MG/4 ML VL   4 Non-Preferred Drug 35%N/ANone
CLINDAMYCIN PHOSP 1% LOTION   2 Generic $3.00N/ANone
CLINDAMYCIN PHOSPHATE 1% FOAM   4 Non-Preferred Drug 35%N/ANone
Clindamycin Phosphate and Benzoyl Peroxide 1 KIT   3 Preferred Brand $28.00N/ANone
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE   2 Generic $3.00N/ANone
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX   2 Generic $3.00N/ANone
CLINDAMYCIN PHOSPHATE VAGINAL CREAM   4 Non-Preferred Drug 35%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Clindamycin-d5w 300 mg/50 ml   4 Non-Preferred Drug 35%N/ANone
Clindamycin-d5w 600 mg/50 ml   4 Non-Preferred Drug 35%N/ANone
Clindamycin-d5w 900 mg/50 ml   4 Non-Preferred Drug 35%N/ANone
CLINDAMYCIN-TRETINOIN 1.2%-0.025% [Veltin, Ziana]   4 Non-Preferred Drug 35%N/ANone
CLINIMIX 2.75%/5% INJECTION 1000ML BAG   4 Non-Preferred Drug 35%N/AP
CLINIMIX 4.25%-25% SOLUTION   4 Non-Preferred Drug 35%N/AP
CLINIMIX 5/20 SOLUTION   4 Non-Preferred Drug 35%N/AP
CLINIMIX 5/25 SULFITE FREE INJECTIONS 1035MG-420MEQ 1000ML BAG   4 Non-Preferred Drug 35%N/AP
CLINIMIX 5%-15% SOLUTION   4 Non-Preferred Drug 35%N/AP
CLINIMIX E 2.75/10 SOLUTION   4 Non-Preferred Drug 35%N/AP
CLINIMIX E 2.75/5 SOLUTION   4 Non-Preferred Drug 35%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLINIMIX E 4.25/5 SOLUTION   4 Non-Preferred Drug 35%N/AP
CLINIMIX E 4.25%-25% SOLUTION   4 Non-Preferred Drug 35%N/AP
CLINIMIX E 5/20 SOLUTION   4 Non-Preferred Drug 35%N/AP
CLINIMIX E 5/25 SOLUTION   4 Non-Preferred Drug 35%N/AP
CLINIMIX E 5%/15% INJECTION 2000ML BAG   4 Non-Preferred Drug 35%N/AP
CLOBETASOL 0.05% OINTMENT   3 Preferred Brand $28.00N/AQ:120
/30Days
CLOBETASOL 0.05% SOLUTION   2 Generic $3.00N/ANone
CLOBETASOL 0.05% TOPICAL LOTN   4 Non-Preferred Drug 35%N/ANone
CLOBETASOL EMOLLIENT 0.05% CRM   2 Generic $3.00N/AQ:120
/30Days
CLOBETASOL PROP 0.05% SPRAY   4 Non-Preferred Drug 35%N/ANone
Clobetasol Propionate 0.5 MG/ML Medicated Shampoo   3 Preferred Brand $28.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Clobetasol Propionate 0.5mg/g 1 CAN per CARTON / 100 g in 1 CAN   3 Preferred Brand $28.00N/AQ:100
/30Days
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE   2 Generic $3.00N/ANone
CLODERM 0.1% CREAM   4 Non-Preferred Drug 35%N/ANone
CLOFARABINE 20 MG/20 ML VIAL [Clolar]   5 Specialty Tier 33%N/ANone
CLOLAR 20 MG/20 ML VIAL   5 Specialty Tier 33%N/AP
CLOMIPRAMINE 25 MG CAPSULE   4 Non-Preferred Drug 35%N/AP
CLOMIPRAMINE 50 MG CAPSULE   4 Non-Preferred Drug 35%N/AP
CLOMIPRAMINE 75 MG CAPSULE   4 Non-Preferred Drug 35%N/AP
CLONAZEPAM 0.125 MG DIS TAB RAPDIS [Klonopin]   3 Preferred Brand $28.00N/AQ:4800
/30Days
CLONAZEPAM 0.25 MG ODT TAB RAPDIS [Klonopin]   3 Preferred Brand $28.00N/AQ:2400
/30Days
CLONAZEPAM 0.5 MG DIS TABLET RAPDIS [Klonopin]   3 Preferred Brand $28.00N/AQ:1200
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLONAZEPAM 0.5 MG TABLET [Klonopin]   2 Generic $3.00N/AQ:1200
/30Days
CLONAZEPAM 1 MG DIS TABLET RAPDIS [Klonopin]   3 Preferred Brand $28.00N/AQ:600
/30Days
CLONAZEPAM 1 MG TABLET [Klonopin]   2 Generic $3.00N/AQ:600
/30Days
CLONAZEPAM 2 MG ODT TAB RAPDIS [Klonopin]   3 Preferred Brand $28.00N/AQ:300
/30Days
CLONAZEPAM 2 MG TABLET [Klonopin]   2 Generic $3.00N/AQ:300
/30Days
Clonidine 0.1mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH   3 Preferred Brand $28.00N/AQ:4
/28Days
Clonidine 0.2mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH   3 Preferred Brand $28.00N/AQ:4
/28Days
Clonidine 0.3mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH   3 Preferred Brand $28.00N/AQ:4
/28Days
CLONIDINE HCL 0.1 MG TABLET   1 Preferred Generic $1.00N/ANone
CLONIDINE HCL 0.2 MG TABLET   1 Preferred Generic $1.00N/ANone
CLONIDINE HCL 0.3 MG TABLET   1 Preferred Generic $1.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLONIDINE HCL ER 0.1 MG TABLET   4 Non-Preferred Drug 35%N/ANone
CLOPIDOGREL 75 MG TABLET [Plavix]   2 Generic $3.00N/AQ:30
/30Days
CLORAZEPATE 15 MG TABLET   3 Preferred Brand $28.00N/ANone
CLORAZEPATE 3.75 MG TABLET   3 Preferred Brand $28.00N/ANone
CLORAZEPATE 7.5 MG TABLET   3 Preferred Brand $28.00N/ANone
CLOTRIMAZOLE 1% CREAM   2 Generic $3.00N/ANone
CLOTRIMAZOLE 1% SOLUTION   2 Generic $3.00N/ANone
CLOTRIMAZOLE 10 MG TROCHE   2 Generic $3.00N/ANone
CLOTRIMAZOLE-BETAMETHASONE LOT   3 Preferred Brand $28.00N/ANone
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE 0.64; 10mg/g; mg/g 45 g in 1 TUBE   2 Generic $3.00N/ANone
CLOZAPINE 100 MG TABLET [Clozaril]   2 Generic $3.00N/AQ:270
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLOZAPINE 200 MG TABLET   3 Preferred Brand $28.00N/AQ:120
/30Days
CLOZAPINE 25 MG TABLET [Clozaril]   2 Generic $3.00N/AQ:1080
/30Days
CLOZAPINE 50 MG TABLET   2 Generic $3.00N/AQ:540
/30Days
CLOZAPINE ODT 100 MG TABLET RAPDIS [Fazaclo]   4 Non-Preferred Drug 35%N/AQ:270
/30Days
CLOZAPINE ODT 12.5 MG TABLET RAPDIS [Fazaclo]   4 Non-Preferred Drug 35%N/AQ:2160
/30Days
CLOZAPINE ODT 150 MG TABLET RAPDIS [Fazaclo]   4 Non-Preferred Drug 35%N/AQ:180
/30Days
CLOZAPINE ODT 200 MG TABLET RAPDIS [Fazaclo]   4 Non-Preferred Drug 35%N/AQ:120
/30Days
CLOZAPINE ODT 25 MG TABLET RAPDIS [Fazaclo]   4 Non-Preferred Drug 35%N/AQ:1080
/30Days
COARTEM 20MG-120MG   4 Non-Preferred Drug 35%N/ANone
CODEINE SULFATE 15 mg tablet   3 Preferred Brand $28.00N/AQ:360
/30Days
CODEINE SULFATE 30 mg tablet   3 Preferred Brand $28.00N/AQ:360
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CODEINE SULFATE 60 mg tablet   3 Preferred Brand $28.00N/AQ:180
/30Days
COLCRYS 0.6 MG TABLET   3 Preferred Brand $28.00N/ANone
COLESEVELAM 625 MG TABLET [WelChol]   4 Non-Preferred Drug 35%N/ANone
COLESTIPOL HCL 1G TABLET   2 Generic $3.00N/ANone
COLESTIPOL HCL GRANULES PACKET   2 Generic $3.00N/ANone
COLISTIMETHATE 150 MG VIAL   4 Non-Preferred Drug 35%N/ANone
COLOCORT 100MG ENEMA   3 Preferred Brand $28.00N/ANone
COLY-MYCIN S OTIC SUSP DROP   4 Non-Preferred Drug 35%N/ANone
COMBIGAN 0.2%-0.5% DROPS   3 Preferred Brand $28.00N/ANone
COMBIVENT RESPIMAT INHAL SPRAY   4 Non-Preferred Drug 35%N/AQ:8
/30Days
COMETRIQ 100 MG DAILY-DOSE PK   5 Specialty Tier 33%N/AP Q:56
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COMETRIQ 140 MG DAILY-DOSE PK   5 Specialty Tier 33%N/AP Q:112
/28Days
COMETRIQ 60 MG DAILY-DOSE PACK   5 Specialty Tier 33%N/AP Q:84
/28Days
COMPLERA 200; 27.5; 300mg/1; mg/1; mg/1   5 Specialty Tier 33%N/AQ:30
/30Days
COMPRO 25MG SUPPOSITORY   2 Generic $3.00N/ANone
CONDYLOX 0.5% GEL   4 Non-Preferred Drug 35%N/ANone
CONSTULOSE 10 GM/15 ML SOLN   2 Generic $3.00N/ANone
COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN   5 Specialty Tier 33%N/AP Q:30
/30Days
COPAXONE 40 MG/ML SYRINGE   5 Specialty Tier 33%N/AP Q:12
/28Days
CORDRAN 4 MCG/SQ CM TAPE LARGE   4 Non-Preferred Drug 35%N/ANone
COREG CR 10MG CAPSULE MULTIPHASIC RELEASE 24 HR   4 Non-Preferred Drug 35%N/ANone
COREG CR 20MG CAPSULE MULTIPHASIC RELEASE 24 HR   4 Non-Preferred Drug 35%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COREG CR 40MG CAPSULE MULTIPHASIC RELEASE 24 HR   4 Non-Preferred Drug 35%N/ANone
COREG CR 80MG CAPSULE MULTIPHASIC RELEASE 24 HR   4 Non-Preferred Drug 35%N/ANone
CORLANOR 5 MG TABLET   4 Non-Preferred Drug 35%N/AP Q:60
/30Days
CORLANOR 7.5 MG TABLET   4 Non-Preferred Drug 35%N/AP Q:60
/30Days
Cortisone 25 MG Tablet   3 Preferred Brand $28.00N/ANone
CORTISPORIN CRE 0.5%   4 Non-Preferred Drug 35%N/ANone
CORTISPORIN OINTMENT   4 Non-Preferred Drug 35%N/ANone
COSMEGEN 0.5 MG VIAL   5 Specialty Tier 33%N/AP
COTELLIC 20 MG TABLET   5 Specialty Tier 33%N/AP Q:90
/30Days
COUMADIN 1 MG TABLET   4 Non-Preferred Drug 35%N/ANone
COUMADIN 10MG TABLET   4 Non-Preferred Drug 35%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COUMADIN 2.5 MG TABLET   4 Non-Preferred Drug 35%N/ANone
COUMADIN 2MG TABLET   4 Non-Preferred Drug 35%N/ANone
COUMADIN 3mg/1 1 BOTTLE per CARTON / 100 TABLET BOTTLE   4 Non-Preferred Drug 35%N/ANone
COUMADIN 4mg/1 1 BOTTLE in 1 CARTON / 100 TABLET BOTTLE   4 Non-Preferred Drug 35%N/ANone
COUMADIN 5MG TABLET   4 Non-Preferred Drug 35%N/ANone
COUMADIN 6MG TABLET   4 Non-Preferred Drug 35%N/ANone
COUMADIN 7.5MG TABLET   4 Non-Preferred Drug 35%N/ANone
COZAAR 100 MG TABLET   4 Non-Preferred Drug 35%N/ANone
COZAAR 25 MG TABLET   4 Non-Preferred Drug 35%N/ANone
COZAAR 50 MG TABLET   4 Non-Preferred Drug 35%N/ANone
Creon 256.11mg/1 1 BOTTLE per CARTON / 70 CAPSULE, DELAYED RELEASE in 1 BOTTLE   3 Preferred Brand $28.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CREON DELAYED RELEASE CAPSULES 12000MG 100 BOT   3 Preferred Brand $28.00N/ANone
CREON DELAYED RELEASE CAPSULES 24000MG 100 BOT   3 Preferred Brand $28.00N/ANone
CREON DELAYED RELEASE CAPSULES 6000MG 100 BOT   3 Preferred Brand $28.00N/ANone
CREON DR 36,000 UNITS CAPSULE   3 Preferred Brand $28.00N/ANone
CRINONE 4% GEL   4 Non-Preferred Drug 35%N/AP
CRINONE 8% GEL   4 Non-Preferred Drug 35%N/AP
CRIXIVAN 200MG CAPSULE   4 Non-Preferred Drug 35%N/AQ:360
/30Days
CRIXIVAN 400mg, 180 CAPSULE BOTTLE   4 Non-Preferred Drug 35%N/AQ:180
/30Days
CROMOLYN 20 MG/2 ML NEB SOLN   3 Preferred Brand $28.00N/AP Q:240
/30Days
CROMOLYN SODIUM 100 MG/5 ML   4 Non-Preferred Drug 35%N/ANone
CROMOLYN SODIUM 4% 40MG 10ML BOT   1 Preferred Generic $1.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Cyclafem 1/35 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK   3 Preferred Brand $28.00N/ANone
CYCLAFEM 7-7-7-28 TABLET   3 Preferred Brand $28.00N/ANone
CYCLOBENZAPRINE 10 MG TABLET   4 Non-Preferred Drug 35%N/AP
CYCLOBENZAPRINE 5 MG TABLET   4 Non-Preferred Drug 35%N/AP
CYCLOBENZAPRINE 7.5 MG TABLET   4 Non-Preferred Drug 35%N/AP
CYCLOPHOSPHAMIDE 25 MG CAPSULE   4 Non-Preferred Drug 35%N/AP
CYCLOPHOSPHAMIDE 50 MG CAPSULE   4 Non-Preferred Drug 35%N/AP
CYCLOSET 0.8MG TABLETS   4 Non-Preferred Drug 35%N/AS Q:180
/30Days
CYCLOSPORINE 100MG CAPSULE   4 Non-Preferred Drug 35%N/AP
CYCLOSPORINE 25MG CAPSULE   4 Non-Preferred Drug 35%N/AP
Cyclosporine 50 mg/ml vial   4 Non-Preferred Drug 35%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CYCLOSPORINE MODIFIED 100 MG   4 Non-Preferred Drug 35%N/AP
CYCLOSPORINE MODIFIED 25 MG   3 Preferred Brand $28.00N/AP
CYCLOSPORINE MODIFIED 50 MG   3 Preferred Brand $28.00N/AP
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT   4 Non-Preferred Drug 35%N/AP
CYPROHEPTADINE 4 MG TABLET   3 Preferred Brand $28.00N/AP
CYRAMZA 100 MG/10 ML VIAL   5 Specialty Tier 33%N/AP
CYRAMZA 500 MG/50 ML VIAL   5 Specialty Tier 33%N/AP
CYSTADANE 1 GRAM/1.7 ML POWDER   5 Specialty Tier 33%N/ANone
CYSTAGON 150MG CAPSULE   4 Non-Preferred Drug 35%N/ANone
CYSTAGON 50MG CAPSULE   4 Non-Preferred Drug 35%N/ANone
CYSTARAN 0.44% EYE DROPS   5 Specialty Tier 33%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CYTARABINE 20MG/ML VIAL   4 Non-Preferred Drug 35%N/AP
CYTARABINE SOLUTION INJECTION 100MG 20ML VIALSD   4 Non-Preferred Drug 35%N/AP
CYTOMEL 25MCG TABLET   3 Preferred Brand $28.00N/ANone
CYTOMEL 50MCG TABLET   3 Preferred Brand $28.00N/ANone
CYTOMEL 5MCG TABLET   3 Preferred Brand $28.00N/ANone

Chart Legend:

Below are a few notes to help you understand the above 2018 Medicare Part D Anthem Blue MedicareRx Premier (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). The plan name is followed by the plan type (PDP, HMO, HMO-POS, PPO, PFFS, etc.)

  • 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 $405 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 five (5) tiers 1=Preferred Generics, 2=Generics, 3=Preferred Brands, 4=Non-preferred Brands, 5=Specialty Drugs. *Some Part D plans exclude one or more drug tiers from the deductible. If the drug tier field above is followed by * (example: 2*), then this drug tier is excluded from the plan’s deductible.
    • Tier 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 $3750) at a "Preferred" network pharmacy. In most cases, the "Preferred" network network pharmacy cost-sharing is lower than the standard (non-preferred) network pharmacy cost-sharing.
    • 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 2018 )

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
  • 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 PDP-Compare.com and MA-Compare.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.
  • 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.