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Aetna Medicare Rx Select (PDP) (S5810-276-0)
Tier 1 (250)
Tier 2 (520)
Tier 3 (1062)
Tier 4 (2794)
Tier 5 (713)
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2018 Medicare Part D Plan Formulary Information
Aetna Medicare Rx Select (PDP) (S5810-276-0)
Benefit Details           
The Aetna Medicare Rx Select (PDP) (S5810-276-0)
Formulary Drugs Starting with the Letter M

in CMS PDP Region 2 which includes: CT MA RI VT
Plan Monthly Premium: $17.70 Deductible: $405 Qualifies for LIS: No
Drugs Starting with Letter M

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
M-M-R II VACCINE W/DILUENT 1 DOSE/0.5ML   3 Preferred Brand $47.00N/ANone
Macrobid 25; 75mg/1; mg/1 100 CAPSULE BOTTLE   4 Non-Preferred Drug 39%N/ANone
Macrodantin Nitrofurantion crystals 100mg 100 CAPSULE BOTTLE   4 Non-Preferred Drug 39%N/ANone
Macrodantin Nitrofurantion crystals 25mg 100 CAPSULE BOTTLE   4 Non-Preferred Drug 39%N/ANone
Macrodantin Nitrofurantion crystals 50mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC   4 Non-Preferred Drug 39%N/ANone
MAGNESIUM SULFATE 50% VIAL   4 Non-Preferred Drug 39%N/ANone
MAGNESIUM SULFATE INJECTION 5 GM/10ML   4 Non-Preferred Drug 39%N/ANone
MALATHION 0.5% LOTION   4 Non-Preferred Drug 39%N/ANone
MAPROTILINE 25MG TABLET   4 Non-Preferred Drug 39%N/ANone
MAPROTILINE 50MG TABLET   4 Non-Preferred Drug 39%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MAPROTILINE 75MG TABLET   4 Non-Preferred Drug 39%N/ANone
Marinol 10mg/1 60 CAPSULE BOTTLE   5 Specialty Tier 25%N/AP Q:60
/30Days
MARINOL 2.5MG CAPSULE   4 Non-Preferred Drug 39%N/AP Q:60
/30Days
MARINOL 5MG CAPSULE   5 Specialty Tier 25%N/AP Q:60
/30Days
MARLISSA-28 TABLET   3 Preferred Brand $47.00N/ANone
MARPLAN 10MG TABLET (100 CT)   4 Non-Preferred Drug 39%N/AQ:180
/30Days
MATULANE 50 MG CAPSULE   5 Specialty Tier 25%N/ANone
MATZIM LA 180 MG TABLET   2* Generic $3.00N/ANone
MATZIM LA 240 MG TABLET   2* Generic $3.00N/ANone
MATZIM LA 300 MG TABLET   2* Generic $3.00N/ANone
MATZIM LA 360 MG TABLET   2* Generic $3.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MATZIM LA 420 MG TABLET   2* Generic $3.00N/ANone
MAXALT 10mg/1 18 POUCH per CARTON / 1 TABLET in 1 POUCH   4 Non-Preferred Drug 39%N/AS Q:12
/30Days
MAXALT MLT 10 MG TABLET   4 Non-Preferred Drug 39%N/AS Q:12
/30Days
MAXALT MLT 5 MG TABLET   4 Non-Preferred Drug 39%N/AS Q:12
/30Days
MAXIDEX OPHTHALMIC SUSPENSION 0.1% 5ML BOT   3 Preferred Brand $47.00N/ANone
MAXIPIME 1 GRAM VIAL   4 Non-Preferred Drug 39%N/ANone
MAXIPIME 2 GRAM VIAL   4 Non-Preferred Drug 39%N/ANone
MAXITROL EYE OINTMENT   4 Non-Preferred Drug 39%N/ANone
MAXITROL SUS 0.1% OP   4 Non-Preferred Drug 39%N/ANone
MAXZIDE 37.5 MG-25 MG TABLET   4 Non-Preferred Drug 39%N/ANone
MAXZIDE 50; 75mg 100 TABLET BOTTLE   4 Non-Preferred Drug 39%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MECLIZINE 12.5 MG TABLET   2* Generic $3.00N/ANone
MECLIZINE 25 MG TABLET   2* Generic $3.00N/ANone
MEDROL 16MG TABLET   4 Non-Preferred Drug 39%N/ANone
MEDROL 2 MG TABLET   4 Non-Preferred Drug 39%N/ANone
MEDROL 32MG TABLET   4 Non-Preferred Drug 39%N/ANone
MEDROL 4MG DOSEPAK   4 Non-Preferred Drug 39%N/ANone
MEDROL 4MG DOSEPAK (100 CT)   4 Non-Preferred Drug 39%N/ANone
MEDROL 8MG TABLET   4 Non-Preferred Drug 39%N/ANone
MEDROXYPROGESTERONE 10 MG TABLET [Provera]   2* Generic $3.00N/ANone
MEDROXYPROGESTERONE 150 MG/ML Syringe [Depo-Provera]   4 Non-Preferred Drug 39%N/ANone
MEDROXYPROGESTERONE 150 MG/ML VIAL [Depo-Provera]   4 Non-Preferred Drug 39%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MEDROXYPROGESTERONE 2.5 MG TABLET [Provera]   2* Generic $3.00N/ANone
MEDROXYPROGESTERONE 5 MG TABLET [Provera]   2* Generic $3.00N/ANone
MEFLOQUINE HCL 250 MG TABLET   3 Preferred Brand $47.00N/ANone
MEGACE ES 625 MG/5 ML SUSP Oral Suspension   4 Non-Preferred Drug 39%N/AP
MEGESTROL 20 MG TABLET   3 Preferred Brand $47.00N/AP
MEGESTROL 40 MG TABLET   3 Preferred Brand $47.00N/AP
MEGESTROL 625 MG/5 ML SUSP   4 Non-Preferred Drug 39%N/AP
MEGESTROL ACET 40 MG/ML SUSP   3 Preferred Brand $47.00N/AP
MEKINIST 0.5 MG TABLET   5 Specialty Tier 25%N/AP
MEKINIST 2 MG TABLET   5 Specialty Tier 25%N/AP
MELODETTA 24 FE CHEWABLE TAB [Minastrin]   3 Preferred Brand $47.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MELOXICAM 15 MG TABLET   1* Preferred Generic $0.00N/ANone
MELOXICAM 7.5 MG TABLET   1* Preferred Generic $0.00N/ANone
MELPHALAN 5 MG/ML INJECTABLE SOLUTION   5 Specialty Tier 25%N/AP
MEMANTINE 5-10 MG TITRATION PK [Namenda Titration]   3 Preferred Brand $47.00N/AP Q:98
/365Days
MEMANTINE HCL 10 MG TABLET [Namenda]   3 Preferred Brand $47.00N/AP Q:60
/30Days
MEMANTINE HCL 2 MG/ML SOLUTION [Namenda]   3 Preferred Brand $47.00N/AP Q:360
/30Days
MEMANTINE HCL 5 MG TABLET [Namenda]   3 Preferred Brand $47.00N/AP Q:60
/30Days
MEMANTINE HCL ER 14 MG CAPSULE SPR 24 [Namenda]   4 Non-Preferred Drug 39%N/AP
MEMANTINE HCL ER 21 MG CAPSULE SPR 24 [Namenda]   4 Non-Preferred Drug 39%N/AP
MEMANTINE HCL ER 28 MG CAPSULE SPR 24 [Namenda]   4 Non-Preferred Drug 39%N/AP
MEMANTINE HCL ER 7 MG CAPSULE SPR 24 [Namenda]   4 Non-Preferred Drug 39%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Menactra 4; 4; 4; 4ug/0.5mL; ug/0.5mL; ug/0.5mL; ug/0.5mL 5 VIAL, SINGLE-DOSE in 1 PACKAGE / 0.5 mL   3 Preferred Brand $47.00N/ANone
MENOSTAR 14 MCG/DAY PATCH   4 Non-Preferred Drug 39%N/AP Q:4
/28Days
MENVEO A-C-Y-W-135-DIP VIAL   3 Preferred Brand $47.00N/ANone
MEPERIDINE 100 MG TABLET [Meperitab]   4 Non-Preferred Drug 39%N/AP Q:120
/30Days
MEPERIDINE 100 MG/ML VIAL [Demerol]   4 Non-Preferred Drug 39%N/AP
MEPERIDINE 25 MG/ML VIAL [Demerol]   4 Non-Preferred Drug 39%N/AP
MEPERIDINE 50 MG TABLET [Meperitab]   4 Non-Preferred Drug 39%N/AP Q:120
/30Days
MEPERIDINE 50 MG/5 ML SOLUTION [Demerol]   4 Non-Preferred Drug 39%N/AP Q:3600
/30Days
MEPERIDINE 50 MG/ML VIAL [Demerol]   4 Non-Preferred Drug 39%N/AP
MEPROBAMATE 200 MG TABLET   4 Non-Preferred Drug 39%N/AP
MEPROBAMATE 400 MG TABLET   4 Non-Preferred Drug 39%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MEPRON 750MG/5ML ORAL SUSP   5 Specialty Tier 25%N/AP
MERCAPTOPURINE 50 MG TABLET   4 Non-Preferred Drug 39%N/ANone
MEROPENEM 500MG/VIAL FOR INJECTION   4 Non-Preferred Drug 39%N/ANone
MEROPENEM IV 1 GM VIAL   4 Non-Preferred Drug 39%N/ANone
MESALAMINE 4 GM/60 ML ENEMA   4 Non-Preferred Drug 39%N/ANone
MESALAMINE 800 MG DR TABLET   4 Non-Preferred Drug 39%N/ANone
MESALAMINE DR 1.2 GM TABLET   4 Non-Preferred Drug 39%N/ANone
MESNA 1 GRAM/10 ML VIAL   4 Non-Preferred Drug 39%N/ANone
MESNEX 400MG TABLET   5 Specialty Tier 25%N/ANone
MESTINON 180MG TIMESPAN   4 Non-Preferred Drug 39%N/ANone
MESTINON 60MG/5ML SYRUP   4 Non-Preferred Drug 39%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MESTINON TABLETS 60MG 100 BOT   4 Non-Preferred Drug 39%N/ANone
Metadate er 20 mg tablet   4 Non-Preferred Drug 39%N/AP Q:90
/30Days
METAPROTERENOL 10MG TABLET   4 Non-Preferred Drug 39%N/ANone
METAPROTERENOL 20MG TABLET   4 Non-Preferred Drug 39%N/ANone
Metaproterenol Sulfate 10mg/5mL 473 mL in 1 BOTTLE, PLASTIC   2* Generic $3.00N/ANone
METFORMIN HCL 1,000 MG TABLET   1* Preferred Generic $0.00N/ANone
METFORMIN HCL 500 MG TABLET   1* Preferred Generic $0.00N/ANone
METFORMIN HCL 850 MG TABLET   1* Preferred Generic $0.00N/ANone
METFORMIN HCL ER 500 MG OSM-TB   4 Non-Preferred Drug 39%N/AP
METFORMIN HCL ER 500 MG TABLET   2* Generic $3.00N/ANone
METFORMIN HCL ER 750 MG TABLET   2* Generic $3.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Metformin HCL ER tab 500mg   4 Non-Preferred Drug 39%N/AP Q:150
/30Days
METHADONE 10 MG/5 ML SOLUTION   3 Preferred Brand $47.00N/AQ:3000
/30Days
METHADONE 5 MG/5 ML SOLUTION   3 Preferred Brand $47.00N/AQ:3000
/30Days
METHADONE HCL 10 MG TABLET [Methadose]   4 Non-Preferred Drug 39%N/AQ:180
/30Days
METHADONE HCL 200 MG/20 ML VIAL [Dolophine]   5 Specialty Tier 25%N/ANone
METHADONE HCL 5 MG TABLET [Methadose]   3 Preferred Brand $47.00N/AQ:180
/30Days
Methazolamide 25 MG Oral Tablet   4 Non-Preferred Drug 39%N/ANone
METHAZOLAMIDE 50 MG TABLET   4 Non-Preferred Drug 39%N/ANone
Methenamine Hippurate 1g/1   4 Non-Preferred Drug 39%N/ANone
METHIMAZOLE 10 MG TABLET   2* Generic $3.00N/ANone
METHIMAZOLE 5 MG TABLET   2* Generic $3.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
methotrexate 1 gm vial   2* Generic $3.00N/ANone
METHOTREXATE 2.5MG TABLET   2* Generic $3.00N/ANone
METHOTREXATE 250 MG/10 ML VIAL   2* Generic $3.00N/ANone
METHOTREXATE 250 MG/10 ML VIAL   2* Generic $3.00N/ANone
METHOTREXATE 50 MG/2 ML VIAL   2* Generic $3.00N/ANone
Methoxsalen 10 mg Capsule [8-MOP]   5 Specialty Tier 25%N/ANone
METHSCOPOLAMINE BROMIDE 2.5MG TABLET   4 Non-Preferred Drug 39%N/ANone
METHSCOPOLAMINE BROMIDE 5 MG TAB   4 Non-Preferred Drug 39%N/ANone
METHYCLOTHIAZIDE 5MG TABLET   3 Preferred Brand $47.00N/ANone
METHYLDOPA 250 MG TABLET   4 Non-Preferred Drug 39%N/AP
METHYLDOPA 500 MG TABLET   4 Non-Preferred Drug 39%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METHYLIN 10 MG/5 ML SOLUTION   4 Non-Preferred Drug 39%N/AP Q:900
/30Days
METHYLIN SOLUTION 5MG/5ML 500 ML BOT   4 Non-Preferred Drug 39%N/AP Q:1800
/30Days
METHYLPHENIDATE 10 MG CHEW TABLET [Methylin]   4 Non-Preferred Drug 39%N/AP Q:180
/30Days
METHYLPHENIDATE 10 MG TABLET [Ritalin]   3 Preferred Brand $47.00N/AP Q:90
/30Days
METHYLPHENIDATE 10 MG/5 ML SOLUTION [Methylin]   4 Non-Preferred Drug 39%N/AP Q:900
/30Days
METHYLPHENIDATE 2.5 MG CHEW TABLET [Methylin]   4 Non-Preferred Drug 39%N/AP Q:180
/30Days
METHYLPHENIDATE 20 MG TABLET [Ritalin]   3 Preferred Brand $47.00N/AP Q:90
/30Days
METHYLPHENIDATE 5 MG CHEW TABLET [Methylin]   4 Non-Preferred Drug 39%N/AP Q:180
/30Days
METHYLPHENIDATE 5 MG TABLET [Ritalin]   3 Preferred Brand $47.00N/AP Q:90
/30Days
METHYLPHENIDATE 5 MG/5 ML SOLUTION [Methylin]   4 Non-Preferred Drug 39%N/AP Q:1800
/30Days
METHYLPHENIDATE CD 10 MG CAPSULE CPBP 30-70 [Ritalin LA]   4 Non-Preferred Drug 39%N/AP Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METHYLPHENIDATE CD 20 MG CAPSULE CPBP 30-70 [Ritalin LA]   4 Non-Preferred Drug 39%N/AP Q:30
/30Days
METHYLPHENIDATE CD 30 MG CAPSULE CPBP 30-70 [Ritalin LA]   4 Non-Preferred Drug 39%N/AP Q:30
/30Days
METHYLPHENIDATE CD 40 MG CAPSULE CPBP 30-70 [Ritalin LA]   4 Non-Preferred Drug 39%N/AP Q:30
/30Days
METHYLPHENIDATE CD 50 MG CAPSULE CPBP 30-70 [Metadate CD]   4 Non-Preferred Drug 39%N/AP Q:30
/30Days
METHYLPHENIDATE CD 60 MG CAPSULE CPBP 30-70 [Ritalin LA]   4 Non-Preferred Drug 39%N/AP Q:30
/30Days
METHYLPHENIDATE ER 10 MG TABLET [Methylin]   4 Non-Preferred Drug 39%N/AP Q:90
/30Days
METHYLPHENIDATE ER 18 MG TABLET ER 24 [Concerta]   4 Non-Preferred Drug 39%N/AP Q:30
/30Days
METHYLPHENIDATE ER 20 MG TABLET [Ritalin SR]   4 Non-Preferred Drug 39%N/AP Q:90
/30Days
METHYLPHENIDATE ER 27 MG TABLET ER 24 [Concerta]   4 Non-Preferred Drug 39%N/AP Q:30
/30Days
METHYLPHENIDATE ER 36 MG TABLET ER 24 [Concerta]   4 Non-Preferred Drug 39%N/AP Q:30
/30Days
METHYLPHENIDATE ER 54 MG TABLET ER 24 [Concerta]   4 Non-Preferred Drug 39%N/AP Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METHYLPHENIDATE ER 72 MG TABLET ER 24 [RELEXXII]   4 Non-Preferred Drug 39%N/AP Q:30
/30Days
METHYLPHENIDATE LA 10 MG CAP CPBP 50-50 [Ritalin LA]   4 Non-Preferred Drug 39%N/AP Q:30
/30Days
METHYLPHENIDATE LA 20 MG CAPSULE CPBP 50-50 [Ritalin LA]   4 Non-Preferred Drug 39%N/AP Q:30
/30Days
METHYLPHENIDATE LA 30 MG CAP CPBP 50-50 [Ritalin LA]   4 Non-Preferred Drug 39%N/AP Q:60
/30Days
METHYLPHENIDATE LA 40 MG CAPSULE CPBP 50-50 [Ritalin LA]   4 Non-Preferred Drug 39%N/AP Q:30
/30Days
METHYLPHENIDATE LA 60 MG CAPSULE CPBP 50-50   4 Non-Preferred Drug 39%N/AP Q:30
/30Days
methylprednisolone 125 mg vial   4 Non-Preferred Drug 39%N/ANone
Methylprednisolone 125 mg vial   4 Non-Preferred Drug 39%N/ANone
METHYLPREDNISOLONE 16MG TABLET   2* Generic $3.00N/ANone
METHYLPREDNISOLONE 32MG TABLET   2* Generic $3.00N/ANone
METHYLPREDNISOLONE 4 MG DOSEPK   2* Generic $3.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METHYLPREDNISOLONE 4 MG TABLET   2* Generic $3.00N/ANone
methylprednisolone 40 mg vial   4 Non-Preferred Drug 39%N/ANone
Methylprednisolone 40 mg/ml vl   4 Non-Preferred Drug 39%N/ANone
METHYLPREDNISOLONE 8 MG ORAL TABLET   2* Generic $3.00N/ANone
Methylprednisolone acetate 80 MG per 1 ML Injection   4 Non-Preferred Drug 39%N/ANone
Metipranolol 0.3% eye drops   2* Generic $3.00N/ANone
Metoclopramide 10mg/1   4 Non-Preferred Drug 39%N/ANone
Metoclopramide 10mg/1 500 TABLET BOTTLE   2* Generic $3.00N/ANone
METOCLOPRAMIDE 5 MG TABLET   2* Generic $3.00N/ANone
METOCLOPRAMIDE 5 MG/5 ML SOLN   4 Non-Preferred Drug 39%N/ANone
Metoclopramide 5mg   4 Non-Preferred Drug 39%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Metoclopramide 5mg/mL 25 VIAL in 1 TRAY / 2 mL in 1 VIAL   4 Non-Preferred Drug 39%N/ANone
METOCLOPRAMIDE HCL 10 MG ODT   4 Non-Preferred Drug 39%N/ANone
METOCLOPRAMIDE HCL 5 MG ODT   4 Non-Preferred Drug 39%N/ANone
METOLAZONE 10MG TABLET   3 Preferred Brand $47.00N/ANone
METOLAZONE 2.5MG TABLET   3 Preferred Brand $47.00N/ANone
METOLAZONE 5MG TABLET   3 Preferred Brand $47.00N/ANone
METOPROLOL SUCC ER 100 MG TAB   2* Generic $3.00N/ANone
METOPROLOL SUCC ER 200 MG TAB   2* Generic $3.00N/ANone
METOPROLOL SUCC ER 25 MG TAB   2* Generic $3.00N/ANone
METOPROLOL SUCC ER 50 MG TAB   2* Generic $3.00N/ANone
METOPROLOL TARTRATE 100 MG TAB   1* Preferred Generic $0.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METOPROLOL TARTRATE 25 MG TAB   1* Preferred Generic $0.00N/ANone
Metoprolol Tartrate 5 ML 1 MG/ML Injection   4 Non-Preferred Drug 39%N/ANone
METOPROLOL TARTRATE INJ.USP 5MG/5ML CARPUJECT   4 Non-Preferred Drug 39%N/ANone
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT)   1* Preferred Generic $0.00N/ANone
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET   2* Generic $3.00N/ANone
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET   2* Generic $3.00N/ANone
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET   2* Generic $3.00N/ANone
METROCREAM 0.75% CREAM   4 Non-Preferred Drug 39%N/ANone
METROGEL TOPICAL 1% GEL   4 Non-Preferred Drug 39%N/ANone
METROGEL-VAGINAL 0.75% GEL   4 Non-Preferred Drug 39%N/ANone
METROLOTION TOPICAL 0.75%   4 Non-Preferred Drug 39%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METRONIDAZOLE 0.75% CREAM Cream (g) [Vitazol]   4 Non-Preferred Drug 39%N/ANone
METRONIDAZOLE 0.75% LOTION [MetroLotion]   4 Non-Preferred Drug 39%N/ANone
METRONIDAZOLE 250 MG TABLET [Flagyl]   3 Preferred Brand $47.00N/ANone
METRONIDAZOLE 375 MG CAPSULE [Flagyl]   3 Preferred Brand $47.00N/ANone
METRONIDAZOLE 500 MG Oral Tablet [Flagyl]   4 Non-Preferred Drug 39%N/ANone
METRONIDAZOLE 500 MG TABLET [Flagyl]   3 Preferred Brand $47.00N/ANone
METRONIDAZOLE 500 MG/100 ML PIGGYBACK [Flagyl RTU]   4 Non-Preferred Drug 39%N/ANone
METRONIDAZOLE TOPICAL 0.75% GL Gel [Nydamax]   4 Non-Preferred Drug 39%N/ANone
METRONIDAZOLE TOPICAL 1% GEL [MetroGel]   4 Non-Preferred Drug 39%N/ANone
METRONIDAZOLE VAGINAL 0.75% GL GEL W/APPL [Vandazole]   4 Non-Preferred Drug 39%N/ANone
MEXILETINE 150MG CAPSULE   4 Non-Preferred Drug 39%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MEXILETINE 200MG CAPSULE   4 Non-Preferred Drug 39%N/ANone
MEXILETINE 250MG CAPSULE   4 Non-Preferred Drug 39%N/ANone
MIACALCIN 400 UNIT/2 ML VIAL   5 Specialty Tier 25%N/AP
MIBELAS 24 FE CHEWABLE TABLET   3 Preferred Brand $47.00N/ANone
Micardis 20mg 3 BLISTER PACK per CARTON / 10 TABLET per BLISTER PACK   4 Non-Preferred Drug 39%N/AS Q:30
/30Days
MICARDIS 40MG TABLET   4 Non-Preferred Drug 39%N/AS Q:30
/30Days
MICARDIS 80MG TABLET   4 Non-Preferred Drug 39%N/AS Q:30
/30Days
MICARDIS HCT 40/12.5MG TABLET   4 Non-Preferred Drug 39%N/AS Q:30
/30Days
MICARDIS HCT 80/12.5MG TABLET   4 Non-Preferred Drug 39%N/AS Q:30
/30Days
MICARDIS HCT 80/25MG TABLET   4 Non-Preferred Drug 39%N/AS Q:30
/30Days
MICONAZOLE 3 200MG SUPPOS.   4 Non-Preferred Drug 39%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Microgestin 21 1-20 tablet   3 Preferred Brand $47.00N/ANone
MICROGESTIN 21 1.5-30 TAB   3 Preferred Brand $47.00N/ANone
Microgestin fe 1-20 tablet   3 Preferred Brand $47.00N/ANone
MICROGESTIN FE 1.5-30 TAB   3 Preferred Brand $47.00N/ANone
MICROZIDE 12.5MG CAPSULE   4 Non-Preferred Drug 39%N/ANone
MIDODRINE HCL 10 MG TABLET   3 Preferred Brand $47.00N/ANone
MIDODRINE HCL 2.5 MG TABLET   3 Preferred Brand $47.00N/ANone
MIDODRINE HCL 5 MG TABLET   3 Preferred Brand $47.00N/ANone
MIGLUSTAT 100 MG CAPSULE [Zavesca]   5 Specialty Tier 25%N/AP
MIGRANAL 0.5MG/SPRY AEROSOL SPRAY W/PUMP   4 Non-Preferred Drug 39%N/AQ:8
/28Days
MILI 0.25-0.035 MG TABLET [VyLibra]   3 Preferred Brand $47.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MILLIPRED 10 MG/5 ML SOLUTION   4 Non-Preferred Drug 39%N/ANone
MILLIPRED 5 MG TABLET   4 Non-Preferred Drug 39%N/ANone
MIMVEY 1-0.5 MG TABLET   3 Preferred Brand $47.00N/AP
MIMVEY LO 0.5-0.1 MG TABLET   3 Preferred Brand $47.00N/AP
MINIPRESS 1MG CAPSULE   4 Non-Preferred Drug 39%N/ANone
Minipress 2mg/1 250 CAPSULE BOTTLE   4 Non-Preferred Drug 39%N/ANone
Minipress 5mg/1 250 CAPSULE BOTTLE   4 Non-Preferred Drug 39%N/ANone
MINITRAN 0.1 MG/HR PATCH   3 Preferred Brand $47.00N/ANone
MINITRAN 0.2 MG/HR PATCH   3 Preferred Brand $47.00N/ANone
MINITRAN 0.4 MG/HR PATCH   3 Preferred Brand $47.00N/ANone
MINITRAN 0.6 MG/HR PATCH   3 Preferred Brand $47.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MINIVELLE 0.025 MG PATCH   4 Non-Preferred Drug 39%N/AP Q:8
/28Days
MINIVELLE 0.0375 MG PATCH   4 Non-Preferred Drug 39%N/AP Q:8
/28Days
MINIVELLE 0.05 MG PATCH   4 Non-Preferred Drug 39%N/AP Q:8
/28Days
MINIVELLE 0.075 MG PATCH   4 Non-Preferred Drug 39%N/AP Q:8
/28Days
MINIVELLE 0.1 MG PATCH   4 Non-Preferred Drug 39%N/AP Q:8
/28Days
MINOCIN 100 MG PELLETIZED CAP   4 Non-Preferred Drug 39%N/AS
MINOCIN 50 MG PELLETIZED CAP   4 Non-Preferred Drug 39%N/AS
MINOCYCLINE 100 MG CAPSULE   2* Generic $3.00N/ANone
MINOCYCLINE 50 MG CAPSULE   2* Generic $3.00N/ANone
MINOCYCLINE 75 MG CAPSULE   2* Generic $3.00N/ANone
MINOCYCLINE ER 115 MG TABLET   4 Non-Preferred Drug 39%N/AS
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Minocycline er 45 mg tablet   4 Non-Preferred Drug 39%N/AS
MINOCYCLINE ER 65 MG TABLET   4 Non-Preferred Drug 39%N/AS
MINOCYCLINE HCL 100 MG TABLET   4 Non-Preferred Drug 39%N/AS
MINOCYCLINE HCL 75 MG TABLET   4 Non-Preferred Drug 39%N/AS
MINOCYCLINE HYDROCHLORIDE TABLETS 50MG   4 Non-Preferred Drug 39%N/AS
MINOCYCLINE HYDROCHLORIDE TABLETS ER 135MG   4 Non-Preferred Drug 39%N/AS
MINOCYCLINE HYDROCHLORIDE TABLETS ER 90MG   4 Non-Preferred Drug 39%N/AS
MINOXIDIL 10MG TABLET   2* Generic $3.00N/ANone
MINOXIDIL 2.5MG TABLET   2* Generic $3.00N/ANone
MIRAPEX 0.125MG TABLET   4 Non-Preferred Drug 39%N/AS
MIRAPEX 0.25MG TABLET   4 Non-Preferred Drug 39%N/AS
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MIRAPEX 0.5MG TABLET   4 Non-Preferred Drug 39%N/AS
MIRAPEX 0.75MG TABLET   4 Non-Preferred Drug 39%N/AS
MIRAPEX 1.5MG TABLET   4 Non-Preferred Drug 39%N/AS
MIRAPEX 1MG TABLET   4 Non-Preferred Drug 39%N/AS
MIRAPEX ER 0.375mg/1 1 BOTTLE, PLASTIC per CARTON / 30 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTI   4 Non-Preferred Drug 39%N/AS Q:30
/30Days
MIRAPEX ER 0.75 MG TABLET   4 Non-Preferred Drug 39%N/AS Q:30
/30Days
MIRAPEX ER 1.5 MG TABLET   4 Non-Preferred Drug 39%N/AS Q:30
/30Days
MIRAPEX ER 2.25mg/1 ER 30 TABLET   4 Non-Preferred Drug 39%N/AS Q:30
/30Days
MIRAPEX ER 3 MG TABLET   4 Non-Preferred Drug 39%N/AS Q:30
/30Days
MIRAPEX ER 3.75mg/1 ER 30 TABLET   4 Non-Preferred Drug 39%N/AS Q:30
/30Days
MIRAPEX ER 4.5 MG TABLET   4 Non-Preferred Drug 39%N/AS Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MIRTAZAPINE 15 MG ODT   3 Preferred Brand $47.00N/AQ:30
/30Days
MIRTAZAPINE 15 MG TABLET   2* Generic $3.00N/AQ:30
/30Days
MIRTAZAPINE 30 MG ODT   3 Preferred Brand $47.00N/AQ:30
/30Days
MIRTAZAPINE 30 MG TABLET   2* Generic $3.00N/AQ:30
/30Days
Mirtazapine 45 mg odt   3 Preferred Brand $47.00N/AQ:30
/30Days
MIRTAZAPINE 45 MG TABLET   2* Generic $3.00N/AQ:30
/30Days
MIRTAZAPINE 7.5 MG TABLET   2* Generic $3.00N/ANone
MIRVASO 0.33% GEL PUMP   4 Non-Preferred Drug 39%N/ANone
misoprostol 100 mcg tablet   3 Preferred Brand $47.00N/ANone
misoprostol 200 mcg tablet   3 Preferred Brand $47.00N/ANone
MITIGARE 0.6 MG CAPSULE   4 Non-Preferred Drug 39%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MITOMYCIN 20 MG VIAL   3 Preferred Brand $47.00N/ANone
MITOMYCIN 40 MG VIAL   5 Specialty Tier 25%N/ANone
MITOMYCIN 5 MG VIAL   3 Preferred Brand $47.00N/ANone
MITOXANTRONE INJECTION 2MG 125ML VIAL   3 Preferred Brand $47.00N/ANone
MOBIC 15MG TABLET   4 Non-Preferred Drug 39%N/ANone
MOBIC 7.5MG TABLET   4 Non-Preferred Drug 39%N/ANone
MODAFINIL 100 MG TABLET [Provigil]   3 Preferred Brand $47.00N/AP Q:30
/30Days
MODAFINIL 200 MG TABLET [Provigil]   3 Preferred Brand $47.00N/AP Q:60
/30Days
Moderiba 200 mg tablet   3 Preferred Brand $47.00N/ANone
Moexipril hcl 15 mg tablet   1* Preferred Generic $0.00N/ANone
MOEXIPRIL HCL 7.5 MG TABLET   1* Preferred Generic $0.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-12.5MG TABLET   1* Preferred Generic $0.00N/ANone
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-25MG TABLET   1* Preferred Generic $0.00N/ANone
MOEXIPRIL-HYDROCHLOROTHIAZIDE 7.5-12.5MG TABLET   1* Preferred Generic $0.00N/ANone
MOMETASONE FUROATE 0.1% CREAM   3 Preferred Brand $47.00N/ANone
MOMETASONE FUROATE 0.1% OINT   3 Preferred Brand $47.00N/ANone
MOMETASONE FUROATE 0.1% SOLN   3 Preferred Brand $47.00N/ANone
MOMETASONE FUROATE 50 MCG SPRY   3 Preferred Brand $47.00N/AQ:34
/30Days
MONONESSA TABLETS .250;.035MG; MG 6 X 28 CRTN   3 Preferred Brand $47.00N/ANone
MONTELUKAST SOD 10 MG TABLET [Singulair]   2* Generic $3.00N/AQ:30
/30Days
MONTELUKAST SOD 4 MG GRANULES [Singulair]   3 Preferred Brand $47.00N/AQ:30
/30Days
MONTELUKAST SOD 4 MG TAB CHEW [Singulair]   2* Generic $3.00N/AQ:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MONTELUKAST SOD 5 MG TAB CHEW [Singulair]   2* Generic $3.00N/AQ:30
/30Days
MONUROL 3 GM SACHET   4 Non-Preferred Drug 39%N/ANone
MORGIDOX 50 MG CAPSULE   4 Non-Preferred Drug 39%N/ANone
MORPHINE 10 MG/ML ISECURE SYR   3 Preferred Brand $47.00N/AP
Morphine 2 mg/ml isecure syr   3 Preferred Brand $47.00N/AP
Morphine 4 mg/ml isecure syr   3 Preferred Brand $47.00N/AP
MORPHINE 5 MG/ML SYRINGE   3 Preferred Brand $47.00N/AP
MORPHINE 8 MG/ML ISECURE SYR   3 Preferred Brand $47.00N/AP
MORPHINE SULF 20 MG/5 ML SOLN   3 Preferred Brand $47.00N/AQ:900
/30Days
MORPHINE SULF ER 100 MG TABLET   3 Preferred Brand $47.00N/AQ:60
/30Days
MORPHINE SULF ER 15 MG TABLET   3 Preferred Brand $47.00N/AQ:90
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MORPHINE SULF ER 200 MG TABLET   3 Preferred Brand $47.00N/AQ:60
/30Days
MORPHINE SULF ER 30 MG TABLET   3 Preferred Brand $47.00N/AQ:60
/30Days
MORPHINE SULF ER 60 MG TABLET   3 Preferred Brand $47.00N/AQ:60
/30Days
MORPHINE SULFATE 100 mg/5 ml soln   4 Non-Preferred Drug 39%N/AQ:180
/30Days
MORPHINE SULFATE 10MG/5ML ORAL SOLUTION   3 Preferred Brand $47.00N/AQ:1800
/30Days
MORPHINE SULFATE 15MG TABLETS   3 Preferred Brand $47.00N/AQ:60
/30Days
MORPHINE SULFATE 30MG TABLETS   3 Preferred Brand $47.00N/AQ:180
/30Days
MORPHINE SULFATE ER 10 MG CAP   4 Non-Preferred Drug 39%N/AQ:60
/30Days
MORPHINE SULFATE ER 100 MG CAP   4 Non-Preferred Drug 39%N/AQ:60
/30Days
MORPHINE SULFATE ER 120 MG CAP   4 Non-Preferred Drug 39%N/AQ:30
/30Days
MORPHINE SULFATE ER 20 MG CAP   4 Non-Preferred Drug 39%N/AQ:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MORPHINE SULFATE ER 30 MG CAP   4 Non-Preferred Drug 39%N/AQ:30
/30Days
MORPHINE SULFATE ER 30 MG CAP   4 Non-Preferred Drug 39%N/AQ:60
/30Days
MORPHINE SULFATE ER 45 MG CAP   4 Non-Preferred Drug 39%N/AQ:30
/30Days
MORPHINE SULFATE ER 50 MG CAP   4 Non-Preferred Drug 39%N/AQ:60
/30Days
MORPHINE SULFATE ER 60 MG CAP   4 Non-Preferred Drug 39%N/AQ:30
/30Days
MORPHINE SULFATE ER 60 MG CAP   4 Non-Preferred Drug 39%N/AQ:60
/30Days
MORPHINE SULFATE ER 75 MG CAP   4 Non-Preferred Drug 39%N/AQ:30
/30Days
MORPHINE SULFATE ER 80 MG CAP   4 Non-Preferred Drug 39%N/AQ:60
/30Days
MORPHINE SULFATE ER 90 MG CAP   4 Non-Preferred Drug 39%N/AQ:30
/30Days
MOVANTIK 12.5 MG TABLET   3 Preferred Brand $47.00N/AQ:60
/30Days
MOVANTIK 25 MG TABLET   3 Preferred Brand $47.00N/AQ:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MOVIPREP 7.5-2.691G POWDER IN PACKET   4 Non-Preferred Drug 39%N/ANone
MOXEZA 5.45mg/mL 3 mL in 1 BOTTLE   3 Preferred Brand $47.00N/ANone
MOXIFLOXACIN 0.5% EYE DROPS   3 Preferred Brand $47.00N/ANone
MOXIFLOXACIN 400 MG/250 ML BAG PIGGYBACK [Avelox I.V.]   4 Non-Preferred Drug 39%N/ANone
MOXIFLOXACIN HCL 400 MG TABLET [Avelox]   4 Non-Preferred Drug 39%N/ANone
MOZOBIL 20 MG/ML VIAL   5 Specialty Tier 25%N/AP
MS CONTIN 100 MG TABLET   4 Non-Preferred Drug 39%N/AP Q:60
/30Days
MS CONTIN 15 MG TABLET   4 Non-Preferred Drug 39%N/AP Q:90
/30Days
MS CONTIN 200 MG TABLET   4 Non-Preferred Drug 39%N/AP Q:60
/30Days
MS CONTIN 30 MG TABLET   4 Non-Preferred Drug 39%N/AP Q:60
/30Days
MS CONTIN 60 MG TABLET   4 Non-Preferred Drug 39%N/AP Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Multaq 400mg/1 60 FILM COATED TABLETS in BOTTLE   4 Non-Preferred Drug 39%N/ANone
MUPIROCIN 2% CREAM   4 Non-Preferred Drug 39%N/ANone
MUPIROCIN 2% OINTMENT   2* Generic $3.00N/AQ:30
/30Days
MUSTARGEN 10 MG VIAL   5 Specialty Tier 25%N/AP
MYAMBUTOL 400 MG TABLET   4 Non-Preferred Drug 39%N/ANone
MYCAMINE 100MG/VIAL FOR INJECTION SOLUTION   5 Specialty Tier 25%N/ANone
MYCAMINE 50MG VIAL   5 Specialty Tier 25%N/ANone
MYCOPHENOLATE 200 MG/ML SUSP   5 Specialty Tier 25%N/AP
MYCOPHENOLATE 250 MG CAPSULE   3 Preferred Brand $47.00N/AP
MYCOPHENOLATE 500 MG TABLET [CellCept]   3 Preferred Brand $47.00N/AP
Mycophenolate 500 mg vial   4 Non-Preferred Drug 39%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MYCOPHENOLIC ACID DR 180 MG TB   4 Non-Preferred Drug 39%N/AP
MYCOPHENOLIC ACID DR 360 MG TB   4 Non-Preferred Drug 39%N/AP
MYDAYIS ER 12.5 MG CAPSULE   4 Non-Preferred Drug 39%N/AP Q:30
/30Days
MYDAYIS ER 25 MG CAPSULE   4 Non-Preferred Drug 39%N/AP Q:30
/30Days
MYDAYIS ER 37.5 MG CAPSULE   4 Non-Preferred Drug 39%N/AP Q:30
/30Days
MYDAYIS ER 50 MG CAPSULE   4 Non-Preferred Drug 39%N/AP Q:30
/30Days
MYFORTIC 180MG TABLET   4 Non-Preferred Drug 39%N/AP
MYFORTIC 360MG TABLET   4 Non-Preferred Drug 39%N/AP
Mylotarg 5 mg/5mL 5 mL in 1 VIAL, SINGLE-DOSE   5 Specialty Tier 25%N/AP
MYORISAN 10 MG CAPSULE   4 Non-Preferred Drug 39%N/ANone
MYORISAN 20 MG CAPSULE   4 Non-Preferred Drug 39%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Myorisan 30 mg capsule   4 Non-Preferred Drug 39%N/ANone
MYORISAN 40 MG CAPSULE   4 Non-Preferred Drug 39%N/ANone
MYRBETRIQ ER 25 MG TABLET   4 Non-Preferred Drug 39%N/AQ:60
/30Days
MYRBETRIQ ER 50 MG TABLET   4 Non-Preferred Drug 39%N/AQ:30
/30Days
Mysoline 50mg/1   4 Non-Preferred Drug 39%N/ANone
MYSOLINE ANTICONVULSANT TABLETS 250MG 100 BOT   4 Non-Preferred Drug 39%N/ANone

Chart Legend:

Below are a few notes to help you understand the above 2018 Medicare Part D Aetna Medicare Rx Select (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.