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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:
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Uses Step Therapy:
Yes No Show either
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  *required
 
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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 N

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

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
NABUMETONE 500 MG TABLET   2 Generic $3.00N/ANone
NABUMETONE 750 MG TABLET   2 Generic $3.00N/ANone
NADOLOL 20 MG TABLET   3 Preferred Brand $28.00N/ANone
NADOLOL 40MG TABLETS   3 Preferred Brand $28.00N/ANone
NADOLOL 80 MG TABLET   3 Preferred Brand $28.00N/ANone
NADOLOL-BENDROFLU 40-5 MG TAB   3 Preferred Brand $28.00N/ANone
NADOLOL-BENDROFLU 80-5 MG TAB   3 Preferred Brand $28.00N/ANone
Nafcillin 1 gm vial   4 Non-Preferred Drug 35%N/ANone
NAFCILLIN 10 GM BULK VIAL   5 Specialty Tier 33%N/ANone
NAFTIFINE HCL 1% CREAM (g) [Naftin-MP]   4 Non-Preferred Drug 35%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NAFTIFINE HCL 2% CREAM [Naftin]   4 Non-Preferred Drug 35%N/ANone
NAFTIN 1% GEL   4 Non-Preferred Drug 35%N/ANone
NAFTIN 2% CREAM   4 Non-Preferred Drug 35%N/ANone
NAFTIN 2% GEL   4 Non-Preferred Drug 35%N/ANone
NAGLAZYME 5MG/5ML VIAL   5 Specialty Tier 33%N/AP
Nalbuphine Hydrochloride 10mg/mL 1 VIAL, MULTI-DOSE per CARTON / 10 mL in 1 VIAL, MULTI-DOSE   3 Preferred Brand $28.00N/AQ:180
/30Days
Nalbuphine Hydrochloride 20mg/mL 25 VIAL, MULTI-DOSE per CARTON / 10 mL in 1 VIAL, MULTI-DOSE   4 Non-Preferred Drug 35%N/AQ:90
/30Days
NALOXONE 0.4 MG/ML CARPUJECT   4 Non-Preferred Drug 35%N/ANone
NALOXONE 0.4 MG/ML VIAL   4 Non-Preferred Drug 35%N/ANone
naloxone 1 mg/ml syringe   3 Preferred Brand $28.00N/ANone
NALTREXONE 50 MG TABLET   2 Generic $3.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NAMENDA XR 14 MG CAPSULE   3 Preferred Brand $28.00N/AP Q:30
/30Days
NAMENDA XR 21 MG CAPSULE   3 Preferred Brand $28.00N/AP Q:30
/30Days
NAMENDA XR 28 MG CAPSULE   3 Preferred Brand $28.00N/AP Q:30
/30Days
NAMENDA XR 7 MG CAPSULE   3 Preferred Brand $28.00N/AP Q:30
/30Days
NAMENDA XR TITRATION PACK   3 Preferred Brand $28.00N/AP Q:56
/365Days
NAMZARIC 14 MG-10 MG CAPSULE   3 Preferred Brand $28.00N/AP
NAMZARIC 21 MG-10 MG CAPSULE   3 Preferred Brand $28.00N/AP
NAMZARIC 28 MG-10 MG CAPSULE   3 Preferred Brand $28.00N/AP
NAMZARIC 7 MG-10 MG CAPSULE   3 Preferred Brand $28.00N/AP
NAMZARIC TITRATION PACK   3 Preferred Brand $28.00N/AP
Naproxen 125 mg/5 ml suspen   2 Generic $3.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NAPROXEN 250 MG ORAL TABLET   1 Preferred Generic $1.00N/ANone
NAPROXEN 375 MG TABLET   1 Preferred Generic $1.00N/ANone
NAPROXEN 500 MG TABLET   1 Preferred Generic $1.00N/ANone
NAPROXEN DR 375 MG TABLET   2 Generic $3.00N/ANone
NAPROXEN DR 500 MG TABLET   2 Generic $3.00N/ANone
NAPROXEN SODIUM 275 MG TAB   4 Non-Preferred Drug 35%N/ANone
NAPROXEN SODIUM 550 MG TAB   4 Non-Preferred Drug 35%N/ANone
NARATRIPTAN HCL 1 MG TABLET   3 Preferred Brand $28.00N/AQ:9
/30Days
NARATRIPTAN HCL 2.5 MG TABLET   3 Preferred Brand $28.00N/AQ:9
/30Days
NARCAN 4 MG NASAL SPRAY   3 Preferred Brand $28.00N/ANone
NASONEX 50ug/1 120 SPRAY, METERED in 1 BOTTLE, PUMP   4 Non-Preferred Drug 35%N/AS
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NATACYN EYE DROPS   4 Non-Preferred Drug 35%N/ANone
NATEGLINIDE 120 MG TABLET   2 Generic $3.00N/AQ:90
/30Days
NATEGLINIDE 60 MG TABLET   2 Generic $3.00N/AQ:180
/30Days
NATPARA 100 MCG DOSE CARTRIDGE   5 Specialty Tier 33%N/AP Q:2
/28Days
NATPARA 25 MCG DOSE CARTRIDGE   5 Specialty Tier 33%N/AP Q:2
/28Days
NATPARA 50 MCG DOSE CARTRIDGE   5 Specialty Tier 33%N/AP Q:2
/28Days
NATPARA 75 MCG DOSE CARTRIDGE   5 Specialty Tier 33%N/AP Q:2
/28Days
NEBUPENT 300MG INHAL POWDER   3 Preferred Brand $28.00N/AP
NECON 0.5-35-28 TABLET   3 Preferred Brand $28.00N/ANone
NECON 7-7-7-28 TABLET   3 Preferred Brand $28.00N/ANone
NEFAZODONE HCL 150MG TABLET (60 CT)   4 Non-Preferred Drug 35%N/AQ:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NEFAZODONE HCL 250MG TABLET   4 Non-Preferred Drug 35%N/AQ:72
/30Days
NEFAZODONE HCL 50MG TABLET   4 Non-Preferred Drug 35%N/AQ:360
/30Days
NEFAZODONE HYDROCHLORIDE TABLETS 100MG 60 BOT   4 Non-Preferred Drug 35%N/AQ:180
/30Days
NEFAZODONE HYDROCHLORIDE TABLETS 200MG 60 BOT   4 Non-Preferred Drug 35%N/AQ:90
/30Days
NEO/POLYMYXIN/HC EAR TUBEX 10MG/3.5MG/100UNT   2 Generic $3.00N/ANone
NEOMYC-POLYM-DEXAMET EYE OINTM [Poly-Dex]   2 Generic $3.00N/ANone
NEOMYC-POLYM-DEXAMETH EYE DROP   2 Generic $3.00N/ANone
NEOMYCIN SULFATE 500MG TABLET   2 Generic $3.00N/ANone
NEOMYCIN-BACITRACIN-POLY-HC 3.5-10K-1 OINTMENT   3 Preferred Brand $28.00N/ANone
NEOMYCIN-POLYMYXIN-HC 3.5-10K-10 SUSPENSION DROPS   4 Non-Preferred Drug 35%N/ANone
NEOMYCIN/POLY AMP 10X1 ML   2 Generic $3.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NEOMYCIN/POLYMY/GRAM EYE DROPS 0.025MG/ML 1.75MG/M   2 Generic $3.00N/ANone
NEOMYCIN/POLYMY/HYDRO OTIC SUS   2 Generic $3.00N/ANone
NEPHRAMINE SOLUTION FOR INJECTION   4 Non-Preferred Drug 35%N/AP
NERLYNX 40 MG TABLET   5 Specialty Tier 33%N/AP Q:180
/30Days
NEULASTA 6MG/0.6ML SYRINGE   5 Specialty Tier 33%N/AP Q:1
/28Days
NEUPOGEN 300 MCG/ML VIAL   5 Specialty Tier 33%N/AP
NEUPOGEN 300MCG/ML VIAL   5 Specialty Tier 33%N/AP
NEUPOGEN 300ug/0.5mL 10 SYRINGE in 1 BOX / 0.5 mL in 1 SYRINGE   5 Specialty Tier 33%N/AP
NEUPOGEN INJECTION 480MCG/0.8ML 10 X 0.8ML SYR   5 Specialty Tier 33%N/AP
NEUPRO 1 MG/24 HR PATCH   4 Non-Preferred Drug 35%N/AP Q:30
/30Days
NEUPRO 2 MG/24 HR PATCH   4 Non-Preferred Drug 35%N/AP Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NEUPRO 3 MG/24 HR PATCH   4 Non-Preferred Drug 35%N/AP Q:30
/30Days
NEUPRO 4 MG/24 HR PATCH   4 Non-Preferred Drug 35%N/AP Q:30
/30Days
NEUPRO 6 MG/24 HR PATCH   4 Non-Preferred Drug 35%N/AP Q:30
/30Days
NEUPRO 8 MG/24 HR PATCH   4 Non-Preferred Drug 35%N/AP Q:30
/30Days
NEVANAC 0.1% DROPTAINER   3 Preferred Brand $28.00N/ANone
NEVIRAPINE 200 MG TABLET   3 Preferred Brand $28.00N/AQ:60
/30Days
NEVIRAPINE ER 100 MG TABLET   4 Non-Preferred Drug 35%N/ANone
NEVIRAPINE ER 400 MG TABLET   4 Non-Preferred Drug 35%N/AQ:30
/30Days
NEXAVAR TABLETS 200MG 120 BOT   5 Specialty Tier 33%N/AP Q:120
/30Days
NIACIN ER 1,000 MG TABLET [Niaspan ER]   3 Preferred Brand $28.00N/ANone
NIACIN ER 500 MG TABLET [Niaspan ER]   3 Preferred Brand $28.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NIACIN ER 750 MG TABLET [Niaspan ER]   3 Preferred Brand $28.00N/ANone
NIACOR 500 MG TABLET   3 Preferred Brand $28.00N/ANone
NICARDIPINE 25 MG/10 ML VIAL   4 Non-Preferred Drug 35%N/ANone
Nicardipine hydrochloride 20 MG Oral Capsule   2 Generic $3.00N/ANone
Nicardipine hydrochloride 30 MG Oral Capsule   2 Generic $3.00N/ANone
NICOTROL INHALER 10MG 168 X 10MG/CARTRIDGE INHL   4 Non-Preferred Drug 35%N/ANone
NICOTROL NS NASAL SPRAY BOTTLE 10MG 4 X 10MG/ML INHL   4 Non-Preferred Drug 35%N/AQ:120
/30Days
NIFEDIPINE ER 30 MG TABLET   2 Generic $3.00N/ANone
NIFEDIPINE ER 30 MG TABLET   2 Generic $3.00N/ANone
NIFEDIPINE ER 60 MG TABLET   2 Generic $3.00N/ANone
NIFEDIPINE ER 60 MG TABLET   2 Generic $3.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NIFEDIPINE ER 90 MG TABLET   2 Generic $3.00N/ANone
NIFEDIPINE ER 90 MG TABLET   2 Generic $3.00N/ANone
NILUTAMIDE 150 MG TABLET [Nilandron]   5 Specialty Tier 33%N/AQ:30
/30Days
NIMODIPINE 30 MG CAPSULE   4 Non-Preferred Drug 35%N/ANone
NINLARO 2.3 MG CAPSULE   5 Specialty Tier 33%N/AP Q:3
/28Days
NINLARO 3 MG CAPSULE   5 Specialty Tier 33%N/AP Q:3
/28Days
NINLARO 4 MG CAPSULE   5 Specialty Tier 33%N/AP Q:3
/28Days
NIPENT FOR INJECTION 10MG VIALS   5 Specialty Tier 33%N/AP
NITRO-BID 2% OINTMENT   2 Generic $3.00N/ANone
NITROFURANTOIN MACROCRYSTALLINE 50 mg cap   4 Non-Preferred Drug 35%N/AP
Nitrofurantoin mcr 100 mg cap   4 Non-Preferred Drug 35%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NITROFURANTOIN MONO-MCR 100 MG   4 Non-Preferred Drug 35%N/AP
NITROGLYCERIN 0.2 MG/HR PATCH   2 Generic $3.00N/ANone
NITROGLYCERIN 0.3 MG TABLET SL   3 Preferred Brand $28.00N/ANone
NITROGLYCERIN 0.4 MG TABLET SL   2 Generic $3.00N/ANone
NITROGLYCERIN 0.4 MG/HR PATCH   2 Generic $3.00N/ANone
NITROGLYCERIN 0.6 MG TABLET SL   3 Preferred Brand $28.00N/ANone
NITROGLYCERIN 0.6 MG/HR PATCH   2 Generic $3.00N/ANone
Nitroglycerin 5mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 10 mL in 1 VIAL, SINGLE-DOSE   4 Non-Preferred Drug 35%N/AP
NITROGLYCERIN TRANSOERMAL SYSTEM .1MG/HR 30 SYSTEM BOX   2 Generic $3.00N/ANone
NIZATIDINE 150 MG CAPSULE   2 Generic $3.00N/ANone
NIZATIDINE 300 MG CAPSULE   2 Generic $3.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NORA-BE 0.35MG TABLET   3 Preferred Brand $28.00N/ANone
Norditropin 10mg/1.5mL 1 SYRINGE, PLASTIC per CARTON / 1.5 mL in 1 SYRINGE, PLASTIC   5 Specialty Tier 33%N/AP
Norditropin 15mg/1.5mL 1 SYRINGE, PLASTIC per CARTON / 1.5 mL in 1 SYRINGE, PLASTIC   5 Specialty Tier 33%N/AP
Norditropin 5mg/1.5mL 1 SYRINGE, PLASTIC per CARTON / 1.5 mL in 1 SYRINGE, PLASTIC   5 Specialty Tier 33%N/AP
NORDITROPIN FLEXPRO 30 MG/3 ML   5 Specialty Tier 33%N/AP
NORETHINDRONE 0.35 MG TABLET   3 Preferred Brand $28.00N/ANone
NORETHINDRONE 5MG TABLET   2 Generic $3.00N/ANone
NORG-EE 0.18-0.215-0.25/0.035   4 Non-Preferred Drug 35%N/ANone
NORG-ETHIN ESTRA 0.25-0.035 MG   4 Non-Preferred Drug 35%N/ANone
NORMOSOL -R INJ /D5W   4 Non-Preferred Drug 35%N/ANone
NORMOSOL-M AND DEXTROSE 5%   4 Non-Preferred Drug 35%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NORMOSOL-R PH 7.4 IV SOLUTION   4 Non-Preferred Drug 35%N/ANone
NORPACE 100MG CAPSULE   4 Non-Preferred Drug 35%N/AP
NORPACE 150MG CAPSULE   3 Preferred Brand $28.00N/AP
NORTHERA 100 MG CAPSULE   5 Specialty Tier 33%N/AP Q:540
/30Days
NORTHERA 200 MG CAPSULE   5 Specialty Tier 33%N/AP Q:270
/30Days
NORTHERA 300 MG CAPSULE   5 Specialty Tier 33%N/AP Q:180
/30Days
Nortrel (21 Day Regimen) 0.035; 1mg/1; mg/1 3 BLISTER PACK per CARTON / 21 TABLET per BLISTER PACK   3 Preferred Brand $28.00N/ANone
Nortrel (28 Day Regimen) 3 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK   3 Preferred Brand $28.00N/ANone
NORTREL 1-0.035MG TABLET 28DAY   3 Preferred Brand $28.00N/ANone
Nortrel 7/7/7 (28 Day Regimen) 6 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT in 1 BLISTER   3 Preferred Brand $28.00N/ANone
NORTRIPTYLINE 10 MG/5 ML SOL   4 Non-Preferred Drug 35%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NORTRIPTYLINE HCL 25MG CAP   1 Preferred Generic $1.00N/ANone
NORTRIPTYLINE HCL 50 MG CAP   2 Generic $3.00N/ANone
NORTRIPTYLINE HCL 75 MG CAP   2 Generic $3.00N/ANone
Nortriptyline Hydrochloride 10mg/1 100 CAPSULE BOTTLE   1 Preferred Generic $1.00N/ANone
NORVASC 10MG TABLET   4 Non-Preferred Drug 35%N/ANone
NORVASC 2.5MG TABLET   3 Preferred Brand $28.00N/ANone
NORVASC 5 MG TABLET   3 Preferred Brand $28.00N/ANone
NORVIR 100 MG POWDER PACKET   4 Non-Preferred Drug 35%N/AQ:360
/30Days
NORVIR 100 MG TABLET   4 Non-Preferred Drug 35%N/AQ:360
/30Days
NORVIR 100mg/1 30 CAPSULE BOTTLE   4 Non-Preferred Drug 35%N/AQ:360
/30Days
NORVIR 80MG/ML ORAL SOLUTION   4 Non-Preferred Drug 35%N/AQ:480
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NOXAFIL 200MG/5ML SUSPENSION ORAL   5 Specialty Tier 33%N/AP
NUEDEXTA 20; 10mg/1; mg/1   3 Preferred Brand $28.00N/AQ:60
/30Days
NULOJIX 250mg/1 1 VIAL, SINGLE-USE per CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in   5 Specialty Tier 33%N/AP
NULYTELY WITH FLAVOR PACKS POWDER FOR SOLUTION 420;1.48;MG;MG;GM; 4 L BOT   4 Non-Preferred Drug 35%N/ANone
NUPLAZID 17 MG TABLET   5 Specialty Tier 33%N/AP Q:60
/30Days
NUVARING 0.12-0.015 RING VAGINAL   4 Non-Preferred Drug 35%N/ANone
NYAMYC 100,000 UNITS/GM POWDER   2 Generic $3.00N/ANone
NYSTATIN 100,000 UNIT/GM CREAM   2 Generic $3.00N/ANone
NYSTATIN 100,000 UNIT/GM POWD   2 Generic $3.00N/ANone
NYSTATIN 100,000 UNITS/GM OINT   2 Generic $3.00N/ANone
Nystatin 100000[USP'U]/mL   2 Generic $3.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NYSTATIN 500,000 UNIT ORAL TAB   2 Generic $3.00N/ANone
NYSTATIN/TRIAMCINOLONE CRM   3 Preferred Brand $28.00N/ANone
NYSTATIN/TRIAMCINOLONE OINT 10000UNT/1MG   3 Preferred Brand $28.00N/ANone
NYSTOP 100,000 UNITS/GM POWDER   2 Generic $3.00N/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.