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2018 Medicare Part D and Medicare Advantage Plan Formulary Browser
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.
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First Health Part D Value Plus (PDP) (S5768-127-0)
Tier 1 (256)
Tier 2 (514)
Tier 3 (1063)
Tier 4 (2825)
Tier 5 (720)
Requires Prior Authorization:
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Uses Step Therapy:
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Has Quantity Limits:
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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
First Health Part D Value Plus (PDP) (S5768-127-0)
Benefit Details           
The First Health Part D Value Plus (PDP) (S5768-127-0)
Formulary Drugs Starting with the Letter M
in CMS PDP Region 4 which includes: NJ
Plan Monthly Premium: $56.20 Deductible: $0 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 $47.00$141.00None
Macrobid 25; 75mg/1; mg/1 100 CAPSULE BOTTLE   4 Non-Preferred Drug 50%50%None
Macrodantin Nitrofurantion crystals 100mg 100 CAPSULE BOTTLE   4 Non-Preferred Drug 50%50%None
Macrodantin Nitrofurantion crystals 25mg 100 CAPSULE BOTTLE   4 Non-Preferred Drug 50%50%None
Macrodantin Nitrofurantion crystals 50mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC   4 Non-Preferred Drug 50%50%None
MAGNESIUM SULFATE 50% VIAL   4 Non-Preferred Drug 50%50%None
MAGNESIUM SULFATE INJECTION 5 GM/10ML   4 Non-Preferred Drug 50%50%None
MALATHION 0.5% LOTION   4 Non-Preferred Drug 50%50%None
MAPROTILINE 25MG TABLET   4 Non-Preferred Drug 50%50%None
MAPROTILINE 50MG TABLET   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
MAPROTILINE 75MG TABLET   4 Non-Preferred Drug 50%50%None
Marinol 10mg/1 60 CAPSULE BOTTLE   5 Specialty Tier 33%N/AP Q:60
/30Days
MARINOL 2.5MG CAPSULE   4 Non-Preferred Drug 50%50%P Q:60
/30Days
MARINOL 5MG CAPSULE   5 Specialty Tier 33%N/AP Q:60
/30Days
MARLISSA-28 TABLET   3 Preferred Brand $47.00$141.00None
MARPLAN 10MG TABLET (100 CT)   4 Non-Preferred Drug 50%50%Q:180
/30Days
MATULANE 50 MG CAPSULE   5 Specialty Tier 33%N/ANone
MATZIM LA 180 MG TABLET   2 Generic $2.00$6.00None
MATZIM LA 240 MG TABLET   2 Generic $2.00$6.00None
MATZIM LA 300 MG TABLET   2 Generic $2.00$6.00None
MATZIM LA 360 MG TABLET   2 Generic $2.00$6.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
MATZIM LA 420 MG TABLET   2 Generic $2.00$6.00None
MAXALT 10mg/1 18 POUCH per CARTON / 1 TABLET in 1 POUCH   4 Non-Preferred Drug 50%50%S Q:12
/30Days
MAXALT MLT 10 MG TABLET   4 Non-Preferred Drug 50%50%S Q:12
/30Days
MAXALT MLT 5 MG TABLET   4 Non-Preferred Drug 50%50%S Q:12
/30Days
MAXIDEX OPHTHALMIC SUSPENSION 0.1% 5ML BOT   3 Preferred Brand $47.00$141.00None
MAXIPIME 1 GRAM VIAL   4 Non-Preferred Drug 50%50%None
MAXIPIME 2 GRAM VIAL   4 Non-Preferred Drug 50%50%None
MAXITROL EYE OINTMENT   4 Non-Preferred Drug 50%50%None
MAXITROL SUS 0.1% OP   4 Non-Preferred Drug 50%50%None
MAXZIDE 37.5 MG-25 MG TABLET   4 Non-Preferred Drug 50%50%None
MAXZIDE 50; 75mg 100 TABLET BOTTLE   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
MECLIZINE 12.5 MG TABLET   2 Generic $2.00$6.00None
MECLIZINE 25 MG TABLET   2 Generic $2.00$6.00None
MEDROL 16MG TABLET   4 Non-Preferred Drug 50%50%None
MEDROL 2 MG TABLET   4 Non-Preferred Drug 50%50%None
MEDROL 32MG TABLET   4 Non-Preferred Drug 50%50%None
MEDROL 4MG DOSEPAK   4 Non-Preferred Drug 50%50%None
MEDROL 4MG DOSEPAK (100 CT)   4 Non-Preferred Drug 50%50%None
MEDROL 8MG TABLET   4 Non-Preferred Drug 50%50%None
MEDROXYPROGESTERONE 10 MG TABLET [Provera]   2 Generic $2.00$6.00None
MEDROXYPROGESTERONE 150 MG/ML Syringe [Depo-Provera]   4 Non-Preferred Drug 50%50%None
MEDROXYPROGESTERONE 150 MG/ML VIAL [Depo-Provera]   4 Non-Preferred Drug 50%50%None
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 $2.00$6.00None
MEDROXYPROGESTERONE 5 MG TABLET [Provera]   2 Generic $2.00$6.00None
MEFLOQUINE HCL 250 MG TABLET   3 Preferred Brand $47.00$141.00None
MEGACE ES 625 MG/5 ML SUSP Oral Suspension   4 Non-Preferred Drug 50%50%P
MEGESTROL 20 MG TABLET   3 Preferred Brand $47.00$141.00P
MEGESTROL 40 MG TABLET   3 Preferred Brand $47.00$141.00P
MEGESTROL 625 MG/5 ML SUSP   4 Non-Preferred Drug 50%50%P
MEGESTROL ACET 40 MG/ML SUSP   3 Preferred Brand $47.00$141.00P
MEKINIST 0.5 MG TABLET   5 Specialty Tier 33%N/AP
MEKINIST 2 MG TABLET   5 Specialty Tier 33%N/AP
MELODETTA 24 FE CHEWABLE TAB [Minastrin]   3 Preferred Brand $47.00$141.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
MELOXICAM 15 MG TABLET   1 Preferred Generic $1.00$3.00None
MELOXICAM 7.5 MG TABLET   1 Preferred Generic $1.00$3.00None
MELPHALAN 5 MG/ML INJECTABLE SOLUTION   5 Specialty Tier 33%N/AP
MEMANTINE 5-10 MG TITRATION PK [Namenda Titration]   3 Preferred Brand $47.00$141.00P Q:98
/365Days
MEMANTINE HCL 10 MG TABLET [Namenda]   3 Preferred Brand $47.00$141.00P Q:60
/30Days
MEMANTINE HCL 2 MG/ML SOLUTION [Namenda]   3 Preferred Brand $47.00$141.00P Q:360
/30Days
MEMANTINE HCL 5 MG TABLET [Namenda]   3 Preferred Brand $47.00$141.00P Q:60
/30Days
MEMANTINE HCL ER 14 MG CAPSULE SPR 24 [Namenda]   4 Non-Preferred Drug 50%50%P
MEMANTINE HCL ER 21 MG CAPSULE SPR 24 [Namenda]   4 Non-Preferred Drug 50%50%P
MEMANTINE HCL ER 28 MG CAPSULE SPR 24 [Namenda]   4 Non-Preferred Drug 50%50%P
MEMANTINE HCL ER 7 MG CAPSULE SPR 24 [Namenda]   4 Non-Preferred Drug 50%50%P
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 $47.00$141.00None
MENOSTAR 14 MCG/DAY PATCH   4 Non-Preferred Drug 50%50%P Q:4
/28Days
MENVEO A-C-Y-W-135-DIP VIAL   3 Preferred Brand $47.00$141.00None
MEPERIDINE 100 MG TABLET [Meperitab]   4 Non-Preferred Drug 50%50%P Q:120
/30Days
MEPERIDINE 100 MG/ML VIAL [Demerol]   4 Non-Preferred Drug 50%50%P
MEPERIDINE 25 MG/ML VIAL [Demerol]   4 Non-Preferred Drug 50%50%P
MEPERIDINE 50 MG TABLET [Meperitab]   4 Non-Preferred Drug 50%50%P Q:120
/30Days
MEPERIDINE 50 MG/5 ML SOLUTION [Demerol]   4 Non-Preferred Drug 50%50%P Q:3600
/30Days
MEPERIDINE 50 MG/ML VIAL [Demerol]   4 Non-Preferred Drug 50%50%P
MEPROBAMATE 200 MG TABLET   4 Non-Preferred Drug 50%50%P
MEPROBAMATE 400 MG TABLET   4 Non-Preferred Drug 50%50%P
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 33%N/AP
MERCAPTOPURINE 50 MG TABLET   4 Non-Preferred Drug 50%50%None
MEROPENEM 500MG/VIAL FOR INJECTION   4 Non-Preferred Drug 50%50%None
MEROPENEM IV 1 GM VIAL   4 Non-Preferred Drug 50%50%None
MESALAMINE 4 GM/60 ML ENEMA   4 Non-Preferred Drug 50%50%None
MESALAMINE 800 MG DR TABLET   4 Non-Preferred Drug 50%50%None
MESALAMINE DR 1.2 GM TABLET   4 Non-Preferred Drug 50%50%None
MESNA 1 GRAM/10 ML VIAL   4 Non-Preferred Drug 50%50%None
MESNEX 400MG TABLET   5 Specialty Tier 33%N/ANone
MESTINON 180MG TIMESPAN   4 Non-Preferred Drug 50%50%None
MESTINON 60MG/5ML SYRUP   4 Non-Preferred Drug 50%50%None
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 50%50%None
Metadate er 20 mg tablet   4 Non-Preferred Drug 50%50%P Q:90
/30Days
METAPROTERENOL 10MG TABLET   4 Non-Preferred Drug 50%50%None
METAPROTERENOL 20MG TABLET   4 Non-Preferred Drug 50%50%None
Metaproterenol Sulfate 10mg/5mL 473 mL in 1 BOTTLE, PLASTIC   2 Generic $2.00$6.00None
METFORMIN HCL 1,000 MG TABLET   1 Preferred Generic $1.00$3.00None
METFORMIN HCL 500 MG TABLET   1 Preferred Generic $1.00$3.00None
METFORMIN HCL 850 MG TABLET   1 Preferred Generic $1.00$3.00None
METFORMIN HCL ER 500 MG OSM-TB   4 Non-Preferred Drug 50%50%P
METFORMIN HCL ER 500 MG TABLET   2 Generic $2.00$6.00None
METFORMIN HCL ER 750 MG TABLET   2 Generic $2.00$6.00None
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 50%50%P Q:150
/30Days
METHADONE 10 MG/5 ML SOLUTION   3 Preferred Brand $47.00$141.00Q:3000
/30Days
METHADONE 5 MG/5 ML SOLUTION   3 Preferred Brand $47.00$141.00Q:3000
/30Days
METHADONE HCL 10 MG TABLET [Methadose]   4 Non-Preferred Drug 50%50%Q:180
/30Days
METHADONE HCL 200 MG/20 ML VIAL [Dolophine]   5 Specialty Tier 33%N/ANone
METHADONE HCL 5 MG TABLET [Methadose]   3 Preferred Brand $47.00$141.00Q:180
/30Days
Methazolamide 25 MG Oral Tablet   4 Non-Preferred Drug 50%50%None
METHAZOLAMIDE 50 MG TABLET   4 Non-Preferred Drug 50%50%None
Methenamine Hippurate 1g/1   4 Non-Preferred Drug 50%50%None
METHIMAZOLE 10 MG TABLET   2 Generic $2.00$6.00None
METHIMAZOLE 5 MG TABLET   2 Generic $2.00$6.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
methotrexate 1 gm vial   2 Generic $2.00$6.00None
METHOTREXATE 2.5MG TABLET   2 Generic $2.00$6.00None
METHOTREXATE 250 MG/10 ML VIAL   2 Generic $2.00$6.00None
METHOTREXATE 250 MG/10 ML VIAL   2 Generic $2.00$6.00None
METHOTREXATE 50 MG/2 ML VIAL   2 Generic $2.00$6.00None
Methoxsalen 10 mg Capsule [8-MOP]   5 Specialty Tier 33%N/ANone
METHSCOPOLAMINE BROMIDE 2.5MG TABLET   4 Non-Preferred Drug 50%50%None
METHSCOPOLAMINE BROMIDE 5 MG TAB   4 Non-Preferred Drug 50%50%None
METHYCLOTHIAZIDE 5MG TABLET   3 Preferred Brand $47.00$141.00None
METHYLDOPA 250 MG TABLET   4 Non-Preferred Drug 50%50%P
METHYLDOPA 500 MG TABLET   4 Non-Preferred Drug 50%50%P
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 50%50%P Q:900
/30Days
METHYLIN SOLUTION 5MG/5ML 500 ML BOT   4 Non-Preferred Drug 50%50%P Q:1800
/30Days
METHYLPHENIDATE 10 MG CHEW TABLET [Methylin]   4 Non-Preferred Drug 50%50%P Q:180
/30Days
METHYLPHENIDATE 10 MG TABLET [Ritalin]   3 Preferred Brand $47.00$141.00P Q:90
/30Days
METHYLPHENIDATE 10 MG/5 ML SOLUTION [Methylin]   4 Non-Preferred Drug 50%50%P Q:900
/30Days
METHYLPHENIDATE 2.5 MG CHEW TABLET [Methylin]   4 Non-Preferred Drug 50%50%P Q:180
/30Days
METHYLPHENIDATE 20 MG TABLET [Ritalin]   3 Preferred Brand $47.00$141.00P Q:90
/30Days
METHYLPHENIDATE 5 MG CHEW TABLET [Methylin]   4 Non-Preferred Drug 50%50%P Q:180
/30Days
METHYLPHENIDATE 5 MG TABLET [Ritalin]   3 Preferred Brand $47.00$141.00P Q:90
/30Days
METHYLPHENIDATE 5 MG/5 ML SOLUTION [Methylin]   4 Non-Preferred Drug 50%50%P Q:1800
/30Days
METHYLPHENIDATE CD 10 MG CAPSULE CPBP 30-70 [Ritalin LA]   4 Non-Preferred Drug 50%50%P 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 50%50%P Q:30
/30Days
METHYLPHENIDATE CD 30 MG CAPSULE CPBP 30-70 [Ritalin LA]   4 Non-Preferred Drug 50%50%P Q:30
/30Days
METHYLPHENIDATE CD 40 MG CAPSULE CPBP 30-70 [Ritalin LA]   4 Non-Preferred Drug 50%50%P Q:30
/30Days
METHYLPHENIDATE CD 50 MG CAPSULE CPBP 30-70 [Metadate CD]   4 Non-Preferred Drug 50%50%P Q:30
/30Days
METHYLPHENIDATE CD 60 MG CAPSULE CPBP 30-70 [Ritalin LA]   4 Non-Preferred Drug 50%50%P Q:30
/30Days
METHYLPHENIDATE ER 10 MG TABLET [Methylin]   4 Non-Preferred Drug 50%50%P Q:90
/30Days
METHYLPHENIDATE ER 18 MG TABLET ER 24 [Concerta]   4 Non-Preferred Drug 50%50%P Q:30
/30Days
METHYLPHENIDATE ER 20 MG TABLET [Ritalin SR]   4 Non-Preferred Drug 50%50%P Q:90
/30Days
METHYLPHENIDATE ER 27 MG TABLET ER 24 [Concerta]   4 Non-Preferred Drug 50%50%P Q:30
/30Days
METHYLPHENIDATE ER 36 MG TABLET ER 24 [Concerta]   4 Non-Preferred Drug 50%50%P Q:30
/30Days
METHYLPHENIDATE ER 54 MG TABLET ER 24 [Concerta]   4 Non-Preferred Drug 50%50%P 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 50%50%P Q:30
/30Days
METHYLPHENIDATE LA 10 MG CAP CPBP 50-50 [Ritalin LA]   4 Non-Preferred Drug 50%50%P Q:30
/30Days
METHYLPHENIDATE LA 20 MG CAPSULE CPBP 50-50 [Ritalin LA]   4 Non-Preferred Drug 50%50%P Q:30
/30Days
METHYLPHENIDATE LA 30 MG CAP CPBP 50-50 [Ritalin LA]   4 Non-Preferred Drug 50%50%P Q:60
/30Days
METHYLPHENIDATE LA 40 MG CAPSULE CPBP 50-50 [Ritalin LA]   4 Non-Preferred Drug 50%50%P Q:30
/30Days
METHYLPHENIDATE LA 60 MG CAPSULE CPBP 50-50   4 Non-Preferred Drug 50%50%P Q:30
/30Days
methylprednisolone 125 mg vial   4 Non-Preferred Drug 50%50%None
Methylprednisolone 125 mg vial   4 Non-Preferred Drug 50%50%None
METHYLPREDNISOLONE 16MG TABLET   2 Generic $2.00$6.00None
METHYLPREDNISOLONE 32MG TABLET   2 Generic $2.00$6.00None
METHYLPREDNISOLONE 4 MG DOSEPK   2 Generic $2.00$6.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
METHYLPREDNISOLONE 4 MG TABLET   2 Generic $2.00$6.00None
methylprednisolone 40 mg vial   4 Non-Preferred Drug 50%50%None
Methylprednisolone 40 mg/ml vl   4 Non-Preferred Drug 50%50%None
METHYLPREDNISOLONE 8 MG ORAL TABLET   2 Generic $2.00$6.00None
Methylprednisolone acetate 80 MG per 1 ML Injection   4 Non-Preferred Drug 50%50%None
Metipranolol 0.3% eye drops   2 Generic $2.00$6.00None
Metoclopramide 10mg/1   4 Non-Preferred Drug 50%50%None
Metoclopramide 10mg/1 500 TABLET BOTTLE   2 Generic $2.00$6.00None
METOCLOPRAMIDE 5 MG TABLET   2 Generic $2.00$6.00None
METOCLOPRAMIDE 5 MG/5 ML SOLN   4 Non-Preferred Drug 50%50%None
Metoclopramide 5mg   4 Non-Preferred Drug 50%50%None
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 50%50%None
METOCLOPRAMIDE HCL 10 MG ODT   4 Non-Preferred Drug 50%50%None
METOCLOPRAMIDE HCL 5 MG ODT   4 Non-Preferred Drug 50%50%None
METOLAZONE 10MG TABLET   3 Preferred Brand $47.00$141.00None
METOLAZONE 2.5MG TABLET   3 Preferred Brand $47.00$141.00None
METOLAZONE 5MG TABLET   3 Preferred Brand $47.00$141.00None
METOPROLOL SUCC ER 100 MG TAB   2 Generic $2.00$6.00None
METOPROLOL SUCC ER 200 MG TAB   2 Generic $2.00$6.00None
METOPROLOL SUCC ER 25 MG TAB   2 Generic $2.00$6.00None
METOPROLOL SUCC ER 50 MG TAB   2 Generic $2.00$6.00None
METOPROLOL TARTRATE 100 MG TAB   1 Preferred Generic $1.00$3.00None
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 $1.00$3.00None
Metoprolol Tartrate 5 ML 1 MG/ML Injection   4 Non-Preferred Drug 50%50%None
METOPROLOL TARTRATE INJ.USP 5MG/5ML CARPUJECT   4 Non-Preferred Drug 50%50%None
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT)   1 Preferred Generic $1.00$3.00None
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET   2 Generic $2.00$6.00None
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET   2 Generic $2.00$6.00None
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET   2 Generic $2.00$6.00None
METROCREAM 0.75% CREAM   4 Non-Preferred Drug 50%50%None
METROGEL TOPICAL 1% GEL   4 Non-Preferred Drug 50%50%None
METROGEL-VAGINAL 0.75% GEL   4 Non-Preferred Drug 50%50%None
METROLOTION TOPICAL 0.75%   4 Non-Preferred Drug 50%50%None
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 50%50%None
METRONIDAZOLE 0.75% LOTION [MetroLotion]   4 Non-Preferred Drug 50%50%None
METRONIDAZOLE 250 MG TABLET [Flagyl]   3 Preferred Brand $47.00$141.00None
METRONIDAZOLE 375 MG CAPSULE [Flagyl]   3 Preferred Brand $47.00$141.00None
METRONIDAZOLE 500 MG Oral Tablet [Flagyl]   4 Non-Preferred Drug 50%50%None
METRONIDAZOLE 500 MG TABLET [Flagyl]   3 Preferred Brand $47.00$141.00None
METRONIDAZOLE 500 MG/100 ML PIGGYBACK [Flagyl RTU]   4 Non-Preferred Drug 50%50%None
METRONIDAZOLE TOPICAL 0.75% GL Gel [Nydamax]   4 Non-Preferred Drug 50%50%None
METRONIDAZOLE TOPICAL 1% GEL [MetroGel]   4 Non-Preferred Drug 50%50%None
METRONIDAZOLE VAGINAL 0.75% GL GEL W/APPL [Vandazole]   4 Non-Preferred Drug 50%50%None
MEXILETINE 150MG CAPSULE   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
MEXILETINE 200MG CAPSULE   4 Non-Preferred Drug 50%50%None
MEXILETINE 250MG CAPSULE   4 Non-Preferred Drug 50%50%None
MIACALCIN 400 UNIT/2 ML VIAL   5 Specialty Tier 33%N/AP
MIBELAS 24 FE CHEWABLE TABLET   3 Preferred Brand $47.00$141.00None
Micardis 20mg 3 BLISTER PACK per CARTON / 10 TABLET per BLISTER PACK   4 Non-Preferred Drug 50%50%S Q:30
/30Days
MICARDIS 40MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
MICARDIS 80MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
MICARDIS HCT 40/12.5MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
MICARDIS HCT 80/12.5MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
MICARDIS HCT 80/25MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
MICONAZOLE 3 200MG SUPPOS.   4 Non-Preferred Drug 50%50%None
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 $47.00$141.00None
MICROGESTIN 21 1.5-30 TAB   3 Preferred Brand $47.00$141.00None
Microgestin fe 1-20 tablet   3 Preferred Brand $47.00$141.00None
MICROGESTIN FE 1.5-30 TAB   3 Preferred Brand $47.00$141.00None
MICROZIDE 12.5MG CAPSULE   4 Non-Preferred Drug 50%50%None
MIDODRINE HCL 10 MG TABLET   3 Preferred Brand $47.00$141.00None
MIDODRINE HCL 2.5 MG TABLET   3 Preferred Brand $47.00$141.00None
MIDODRINE HCL 5 MG TABLET   3 Preferred Brand $47.00$141.00None
MIGLUSTAT 100 MG CAPSULE [Zavesca]   5 Specialty Tier 33%N/AP
MIGRANAL 0.5MG/SPRY AEROSOL SPRAY W/PUMP   4 Non-Preferred Drug 50%50%Q:8
/28Days
MILI 0.25-0.035 MG TABLET [VyLibra]   3 Preferred Brand $47.00$141.00None
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 50%50%None
MILLIPRED 5 MG TABLET   4 Non-Preferred Drug 50%50%None
MIMVEY 1-0.5 MG TABLET   3 Preferred Brand $47.00$141.00P
MIMVEY LO 0.5-0.1 MG TABLET   3 Preferred Brand $47.00$141.00P
MINIPRESS 1MG CAPSULE   4 Non-Preferred Drug 50%50%None
Minipress 2mg/1 250 CAPSULE BOTTLE   4 Non-Preferred Drug 50%50%None
Minipress 5mg/1 250 CAPSULE BOTTLE   4 Non-Preferred Drug 50%50%None
MINITRAN 0.1 MG/HR PATCH   3 Preferred Brand $47.00$141.00None
MINITRAN 0.2 MG/HR PATCH   3 Preferred Brand $47.00$141.00None
MINITRAN 0.4 MG/HR PATCH   3 Preferred Brand $47.00$141.00None
MINITRAN 0.6 MG/HR PATCH   3 Preferred Brand $47.00$141.00None
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 50%50%P Q:8
/28Days
MINIVELLE 0.0375 MG PATCH   4 Non-Preferred Drug 50%50%P Q:8
/28Days
MINIVELLE 0.05 MG PATCH   4 Non-Preferred Drug 50%50%P Q:8
/28Days
MINIVELLE 0.075 MG PATCH   4 Non-Preferred Drug 50%50%P Q:8
/28Days
MINIVELLE 0.1 MG PATCH   4 Non-Preferred Drug 50%50%P Q:8
/28Days
MINOCIN 100 MG PELLETIZED CAP   4 Non-Preferred Drug 50%50%S
MINOCIN 50 MG PELLETIZED CAP   4 Non-Preferred Drug 50%50%S
MINOCYCLINE 100 MG CAPSULE   2 Generic $2.00$6.00None
MINOCYCLINE 50 MG CAPSULE   2 Generic $2.00$6.00None
MINOCYCLINE 75 MG CAPSULE   2 Generic $2.00$6.00None
MINOCYCLINE ER 115 MG TABLET   4 Non-Preferred Drug 50%50%S
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 50%50%S
MINOCYCLINE ER 65 MG TABLET   4 Non-Preferred Drug 50%50%S
MINOCYCLINE HCL 100 MG TABLET   4 Non-Preferred Drug 50%50%S
MINOCYCLINE HCL 75 MG TABLET   4 Non-Preferred Drug 50%50%S
MINOCYCLINE HYDROCHLORIDE TABLETS 50MG   4 Non-Preferred Drug 50%50%S
MINOCYCLINE HYDROCHLORIDE TABLETS ER 135MG   4 Non-Preferred Drug 50%50%S
MINOCYCLINE HYDROCHLORIDE TABLETS ER 90MG   4 Non-Preferred Drug 50%50%S
MINOXIDIL 10MG TABLET   2 Generic $2.00$6.00None
MINOXIDIL 2.5MG TABLET   2 Generic $2.00$6.00None
MIRAPEX 0.125MG TABLET   4 Non-Preferred Drug 50%50%S
MIRAPEX 0.25MG TABLET   4 Non-Preferred Drug 50%50%S
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 50%50%S
MIRAPEX 0.75MG TABLET   4 Non-Preferred Drug 50%50%S
MIRAPEX 1.5MG TABLET   4 Non-Preferred Drug 50%50%S
MIRAPEX 1MG TABLET   4 Non-Preferred Drug 50%50%S
MIRAPEX ER 0.375mg/1 1 BOTTLE, PLASTIC per CARTON / 30 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTI   4 Non-Preferred Drug 50%50%S Q:30
/30Days
MIRAPEX ER 0.75 MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
MIRAPEX ER 1.5 MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
MIRAPEX ER 2.25mg/1 ER 30 TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
MIRAPEX ER 3 MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
MIRAPEX ER 3.75mg/1 ER 30 TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
MIRAPEX ER 4.5 MG TABLET   4 Non-Preferred Drug 50%50%S 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 $47.00$141.00Q:30
/30Days
MIRTAZAPINE 15 MG TABLET   2 Generic $2.00$6.00Q:30
/30Days
MIRTAZAPINE 30 MG ODT   3 Preferred Brand $47.00$141.00Q:30
/30Days
MIRTAZAPINE 30 MG TABLET   2 Generic $2.00$6.00Q:30
/30Days
Mirtazapine 45 mg odt   3 Preferred Brand $47.00$141.00Q:30
/30Days
MIRTAZAPINE 45 MG TABLET   2 Generic $2.00$6.00Q:30
/30Days
MIRTAZAPINE 7.5 MG TABLET   2 Generic $2.00$6.00None
MIRVASO 0.33% GEL PUMP   4 Non-Preferred Drug 50%50%None
misoprostol 100 mcg tablet   3 Preferred Brand $47.00$141.00None
misoprostol 200 mcg tablet   3 Preferred Brand $47.00$141.00None
MITIGARE 0.6 MG CAPSULE   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
MITOMYCIN 20 MG VIAL   3 Preferred Brand $47.00$141.00None
MITOMYCIN 40 MG VIAL   5 Specialty Tier 33%N/ANone
MITOMYCIN 5 MG VIAL   3 Preferred Brand $47.00$141.00None
MITOXANTRONE INJECTION 2MG 125ML VIAL   3 Preferred Brand $47.00$141.00None
MOBIC 15MG TABLET   4 Non-Preferred Drug 50%50%None
MOBIC 7.5MG TABLET   4 Non-Preferred Drug 50%50%None
MODAFINIL 100 MG TABLET [Provigil]   3 Preferred Brand $47.00$141.00P Q:30
/30Days
MODAFINIL 200 MG TABLET [Provigil]   3 Preferred Brand $47.00$141.00P Q:60
/30Days
Moderiba 200 mg tablet   3 Preferred Brand $47.00$141.00None
Moexipril hcl 15 mg tablet   1 Preferred Generic $1.00$3.00None
MOEXIPRIL HCL 7.5 MG TABLET   1 Preferred Generic $1.00$3.00None
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 $1.00$3.00None
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-25MG TABLET   1 Preferred Generic $1.00$3.00None
MOEXIPRIL-HYDROCHLOROTHIAZIDE 7.5-12.5MG TABLET   1 Preferred Generic $1.00$3.00None
MOMETASONE FUROATE 0.1% CREAM   3 Preferred Brand $47.00$141.00None
MOMETASONE FUROATE 0.1% OINT   3 Preferred Brand $47.00$141.00None
MOMETASONE FUROATE 0.1% SOLN   3 Preferred Brand $47.00$141.00None
MOMETASONE FUROATE 50 MCG SPRY   3 Preferred Brand $47.00$141.00Q:34
/30Days
MONONESSA TABLETS .250;.035MG; MG 6 X 28 CRTN   3 Preferred Brand $47.00$141.00None
MONTELUKAST SOD 10 MG TABLET [Singulair]   2 Generic $2.00$6.00Q:30
/30Days
MONTELUKAST SOD 4 MG GRANULES [Singulair]   3 Preferred Brand $47.00$141.00Q:30
/30Days
MONTELUKAST SOD 4 MG TAB CHEW [Singulair]   2 Generic $2.00$6.00Q: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 $2.00$6.00Q:30
/30Days
MONUROL 3 GM SACHET   4 Non-Preferred Drug 50%50%None
MORGIDOX 50 MG CAPSULE   4 Non-Preferred Drug 50%50%None
MORPHINE 10 MG/ML ISECURE SYR   3 Preferred Brand $47.00$141.00P
Morphine 2 mg/ml isecure syr   3 Preferred Brand $47.00$141.00P
Morphine 4 mg/ml isecure syr   3 Preferred Brand $47.00$141.00P
MORPHINE 5 MG/ML SYRINGE   3 Preferred Brand $47.00$141.00P
MORPHINE 8 MG/ML ISECURE SYR   3 Preferred Brand $47.00$141.00P
MORPHINE SULF 20 MG/5 ML SOLN   3 Preferred Brand $47.00$141.00Q:900
/30Days
MORPHINE SULF ER 100 MG TABLET   3 Preferred Brand $47.00$141.00Q:60
/30Days
MORPHINE SULF ER 15 MG TABLET   3 Preferred Brand $47.00$141.00Q: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 $47.00$141.00Q:60
/30Days
MORPHINE SULF ER 30 MG TABLET   3 Preferred Brand $47.00$141.00Q:60
/30Days
MORPHINE SULF ER 60 MG TABLET   3 Preferred Brand $47.00$141.00Q:60
/30Days
MORPHINE SULFATE 100 mg/5 ml soln   4 Non-Preferred Drug 50%50%Q:180
/30Days
MORPHINE SULFATE 10MG/5ML ORAL SOLUTION   3 Preferred Brand $47.00$141.00Q:1800
/30Days
MORPHINE SULFATE 15MG TABLETS   3 Preferred Brand $47.00$141.00Q:60
/30Days
MORPHINE SULFATE 30MG TABLETS   3 Preferred Brand $47.00$141.00Q:180
/30Days
MORPHINE SULFATE ER 10 MG CAP   4 Non-Preferred Drug 50%50%Q:60
/30Days
MORPHINE SULFATE ER 100 MG CAP   4 Non-Preferred Drug 50%50%Q:60
/30Days
MORPHINE SULFATE ER 120 MG CAP   4 Non-Preferred Drug 50%50%Q:30
/30Days
MORPHINE SULFATE ER 20 MG CAP   4 Non-Preferred Drug 50%50%Q: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 50%50%Q:30
/30Days
MORPHINE SULFATE ER 30 MG CAP   4 Non-Preferred Drug 50%50%Q:60
/30Days
MORPHINE SULFATE ER 45 MG CAP   4 Non-Preferred Drug 50%50%Q:30
/30Days
MORPHINE SULFATE ER 50 MG CAP   4 Non-Preferred Drug 50%50%Q:60
/30Days
MORPHINE SULFATE ER 60 MG CAP   4 Non-Preferred Drug 50%50%Q:30
/30Days
MORPHINE SULFATE ER 60 MG CAP   4 Non-Preferred Drug 50%50%Q:60
/30Days
MORPHINE SULFATE ER 75 MG CAP   4 Non-Preferred Drug 50%50%Q:30
/30Days
MORPHINE SULFATE ER 80 MG CAP   4 Non-Preferred Drug 50%50%Q:60
/30Days
MORPHINE SULFATE ER 90 MG CAP   4 Non-Preferred Drug 50%50%Q:30
/30Days
MOVANTIK 12.5 MG TABLET   3 Preferred Brand $47.00$141.00Q:60
/30Days
MOVANTIK 25 MG TABLET   3 Preferred Brand $47.00$141.00Q: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 50%50%None
MOXEZA 5.45mg/mL 3 mL in 1 BOTTLE   3 Preferred Brand $47.00$141.00None
MOXIFLOXACIN 0.5% EYE DROPS   3 Preferred Brand $47.00$141.00None
MOXIFLOXACIN 400 MG/250 ML BAG PIGGYBACK [Avelox I.V.]   4 Non-Preferred Drug 50%50%None
MOXIFLOXACIN HCL 400 MG TABLET [Avelox]   4 Non-Preferred Drug 50%50%None
MOZOBIL 20 MG/ML VIAL   5 Specialty Tier 33%N/AP
MS CONTIN 100 MG TABLET   4 Non-Preferred Drug 50%50%P Q:60
/30Days
MS CONTIN 15 MG TABLET   4 Non-Preferred Drug 50%50%P Q:90
/30Days
MS CONTIN 200 MG TABLET   4 Non-Preferred Drug 50%50%P Q:60
/30Days
MS CONTIN 30 MG TABLET   4 Non-Preferred Drug 50%50%P Q:60
/30Days
MS CONTIN 60 MG TABLET   4 Non-Preferred Drug 50%50%P 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 50%50%None
MUPIROCIN 2% CREAM   4 Non-Preferred Drug 50%50%None
MUPIROCIN 2% OINTMENT   2 Generic $2.00$6.00Q:30
/30Days
MUSTARGEN 10 MG VIAL   5 Specialty Tier 33%N/AP
MYAMBUTOL 400 MG TABLET   4 Non-Preferred Drug 50%50%None
MYCAMINE 100MG/VIAL FOR INJECTION SOLUTION   5 Specialty Tier 33%N/ANone
MYCAMINE 50MG VIAL   5 Specialty Tier 33%N/ANone
MYCOPHENOLATE 200 MG/ML SUSP   5 Specialty Tier 33%N/AP
MYCOPHENOLATE 250 MG CAPSULE   3 Preferred Brand $47.00$141.00P
MYCOPHENOLATE 500 MG TABLET [CellCept]   3 Preferred Brand $47.00$141.00P
Mycophenolate 500 mg vial   4 Non-Preferred Drug 50%50%P
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 50%50%P
MYCOPHENOLIC ACID DR 360 MG TB   4 Non-Preferred Drug 50%50%P
MYDAYIS ER 12.5 MG CAPSULE   4 Non-Preferred Drug 50%50%P Q:30
/30Days
MYDAYIS ER 25 MG CAPSULE   4 Non-Preferred Drug 50%50%P Q:30
/30Days
MYDAYIS ER 37.5 MG CAPSULE   4 Non-Preferred Drug 50%50%P Q:30
/30Days
MYDAYIS ER 50 MG CAPSULE   4 Non-Preferred Drug 50%50%P Q:30
/30Days
MYFORTIC 180MG TABLET   4 Non-Preferred Drug 50%50%P
MYFORTIC 360MG TABLET   4 Non-Preferred Drug 50%50%P
Mylotarg 5 mg/5mL 5 mL in 1 VIAL, SINGLE-DOSE   5 Specialty Tier 33%N/AP
MYORISAN 10 MG CAPSULE   4 Non-Preferred Drug 50%50%None
MYORISAN 20 MG CAPSULE   4 Non-Preferred Drug 50%50%None
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 50%50%None
MYORISAN 40 MG CAPSULE   4 Non-Preferred Drug 50%50%None
MYRBETRIQ ER 25 MG TABLET   4 Non-Preferred Drug 50%50%Q:60
/30Days
MYRBETRIQ ER 50 MG TABLET   4 Non-Preferred Drug 50%50%Q:30
/30Days
Mysoline 50mg/1   4 Non-Preferred Drug 50%50%None
MYSOLINE ANTICONVULSANT TABLETS 250MG 100 BOT   4 Non-Preferred Drug 50%50%None

Chart Legend:

Below are a few notes to help you understand the above 2018 Medicare Part D First Health Part D Value Plus (PDP) Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region). 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.





 
 


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  • Q1Medicare®, Q1Rx®, and Q1Group® are registered Service Marks of Q1Group LLC and may not be used in any advertising, publicity, or for commercial purposes without the express authorization of Q1Group.
  • 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 PDPCompare.com and MACompare.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.
    Statement required by Medicare:
    "We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options."
  • 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.
.