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Prescription Blue Option A (PDP) (S5584-001-0)
Tier 1 (276)
Tier 2 (1426)
Tier 3 (307)
Tier 4 (1105)
Tier 5 (694)
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2018 Medicare Part D Plan Formulary Information
Prescription Blue Option A (PDP) (S5584-001-0)
Benefit Details           
The Prescription Blue Option A (PDP) (S5584-001-0)
Formulary Drugs Starting with the Letter A

in CMS PDP Region 13 which includes: MI
Plan Monthly Premium: $73.10 Deductible: $360 Qualifies for LIS: No
Drugs Starting with Letter A

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
ABACAVIR 20 MG/ML SOLUTION   2 Generic $11.00$33.00None
ABACAVIR 300 MG TABLET   4 Non-Preferred Drug 50%50%None
Abacavir Sulfate-Lamivudine-Zidovudine tablets [Trizivir]   5 Specialty Tier 25%N/ANone
ABACAVIR-LAMIVUDINE 600-300 MG   5 Specialty Tier 25%N/ANone
ABELCET INJECTION SUSPENSION 5MG/ML   5 Specialty Tier 25%N/AP
ABILIFY MAINTENA ER 300 MG SYR   5 Specialty Tier 25%N/AS
ABILIFY MAINTENA ER 300 MG VL   5 Specialty Tier 25%N/AS
ABILIFY MAINTENA ER 400 MG SUSER VIAL   5 Specialty Tier 25%N/AS
ABILIFY MAINTENA ER 400 MG SYR   5 Specialty Tier 25%N/AS
ABRAXANE 100MG VIAL   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ABSTRAL 100 MCG TAB SUBLINGUAL   5 Specialty Tier 25%N/AP Q:124
/31Days
ABSTRAL 200 MCG TAB SUBLINGUAL   5 Specialty Tier 25%N/AP Q:124
/31Days
ABSTRAL 300 MCG TAB SUBLINGUAL   5 Specialty Tier 25%N/AP Q:124
/31Days
ABSTRAL 400 MCG TAB SUBLINGUAL   5 Specialty Tier 25%N/AP Q:124
/31Days
ABSTRAL 600 MCG TAB SUBLINGUAL   5 Specialty Tier 25%N/AP Q:124
/31Days
ABSTRAL 800 MCG TAB SUBLINGUAL   5 Specialty Tier 25%N/AP Q:124
/31Days
Acamprosate Calcium DR 333 MG tablets [Campral]   2 Generic $11.00$33.00None
ACARBOSE 100 MG TABLET   2 Generic $11.00$33.00None
ACARBOSE 25 MG TABLET   2 Generic $11.00$33.00None
ACARBOSE 50 MG TABLET   2 Generic $11.00$33.00None
ACEBUTOLOL 200 MG CAPSULE   2 Generic $11.00$33.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACEBUTOLOL 400 MG CAPSULE   2 Generic $11.00$33.00None
ACETAMINOP-CODEINE 120-12 MG/5   2 Generic $11.00$33.00Q:5167
/31Days
Acetaminophen 325 MG / Hydrocodone Bitartrate 5 MG Oral Tablet [Lorcet]   2 Generic $11.00$33.00Q:1080
/90Days
ACETAMINOPHEN-COD #2 TABLET   2 Generic $11.00$33.00Q:1080
/90Days
ACETAMINOPHEN-COD #3 TABLET   2 Generic $11.00$33.00Q:1080
/90Days
ACETAMINOPHEN-COD #4 TABLET   2 Generic $11.00$33.00Q:540
/90Days
ACETAZOLAMIDE 125MG TABLET   2 Generic $11.00$33.00None
ACETAZOLAMIDE 250MG TABLET (100 CT)   2 Generic $11.00$33.00None
Acetazolamide 500mg/5mL 1 VIAL in 1 CARTON / 5 mL in 1 VIAL   4 Non-Preferred Drug 50%50%None
ACETAZOLAMIDE ER 500 MG CAP   2 Generic $11.00$33.00None
ACETIC ACID 2% EAR SOLUTION   2 Generic $11.00$33.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETYLCYSTEINE 10% VIAL   2 Generic $11.00$33.00P
Acetylcysteine 200 MG/ML Inhalant Solution   2 Generic $11.00$33.00P
ACITRETIN 10 MG CAPSULE [Soriatane]   4 Non-Preferred Drug 50%50%None
ACITRETIN 17.5 MG CAPSULE [Soriatane]   4 Non-Preferred Drug 50%50%None
ACITRETIN 25 MG CAPSULE [Soriatane]   4 Non-Preferred Drug 50%50%None
ACTEMRA 162 MG/0.9 ML SYRINGE   5 Specialty Tier 25%N/AP
ACTHIB VACCINE WITH DILUENT   3 Preferred Brand $42.00$126.00None
ACTIMMUNE 100 MCG/0.5 ML VIAL   5 Specialty Tier 25%N/ANone
ACUVAIL 0.45% OPHTH SOLUTION #30X0.4 EA   4 Non-Preferred Drug 50%50%None
ACYCLOVIR 200 MG CAPSULE   2 Generic $11.00$33.00None
ACYCLOVIR 200 MG/5 ML SUSP   2 Generic $11.00$33.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACYCLOVIR 400 MG TABLET   2 Generic $11.00$33.00None
Acyclovir 5% Ointment   4 Non-Preferred Drug 50%50%None
ACYCLOVIR 800 MG TABLET   2 Generic $11.00$33.00None
Acyclovir sodium 500 mg vial   4 Non-Preferred Drug 50%50%P
ADACEL TDAP SYRINGE   3 Preferred Brand $42.00$126.00None
ADACEL VIAL 2UNT/5UNT   3 Preferred Brand $42.00$126.00None
ADAGEN 250U/ML VIAL   5 Specialty Tier 25%N/ANone
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA]   5 Specialty Tier 25%N/AQ:6
/28Days
ADAPALENE 0.1% CREAM   4 Non-Preferred Drug 50%50%None
Adapalene 0.3% gel   4 Non-Preferred Drug 50%50%None
ADCIRCA TABLETS 20MG 60 BOTTLE   5 Specialty Tier 25%N/AP Q:62
/31Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADEFOVIR DIPIVOXIL 10 MG TAB [Hepsera]   5 Specialty Tier 25%N/ANone
ADEMPAS 0.5 MG TABLET   5 Specialty Tier 25%N/AP
ADEMPAS 1 MG TABLET   5 Specialty Tier 25%N/AP
ADEMPAS 1.5 MG TABLET   5 Specialty Tier 25%N/AP
ADEMPAS 2 MG TABLET   5 Specialty Tier 25%N/AP
ADEMPAS 2.5 MG TABLET   5 Specialty Tier 25%N/AP
Adrenalin 1 mg/ml vial   4 Non-Preferred Drug 50%50%None
Adriamycin 20 mg/10 ml vial   4 Non-Preferred Drug 50%50%P
ADRUCIL 50mg/mL 10 VIAL in 1 TRAY / 10 mL in 1 VIAL   4 Non-Preferred Drug 50%50%P
ADVAIR DISKUS MIS 100/50   3 Preferred Brand $42.00$126.00Q:180
/90Days
ADVAIR DISKUS MIS 250/50   3 Preferred Brand $42.00$126.00Q:180
/90Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADVAIR DISKUS MIS 500/50   3 Preferred Brand $42.00$126.00Q:180
/90Days
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER   3 Preferred Brand $42.00$126.00Q:36
/90Days
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL   3 Preferred Brand $42.00$126.00Q:36
/90Days
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL   3 Preferred Brand $42.00$126.00Q:36
/90Days
AFEDITAB CR 30MG TABLET SA   2 Generic $11.00$33.00Q:90
/90Days
AFEDITAB CR 60MG TABLET SA   2 Generic $11.00$33.00Q:90
/90Days
Afinitor 7.5mg/1 28 BLISTER PACK per CARTON / 1 TABLET per BLISTER PACK   5 Specialty Tier 25%N/AP
AFINITOR DISPERZ 2 MG TABLET   5 Specialty Tier 25%N/AP
AFINITOR DISPERZ 3 MG TABLET   5 Specialty Tier 25%N/AP
AFINITOR DISPERZ 5 MG TABLET   5 Specialty Tier 25%N/AP
AFINITOR TABLETS 10 MG   5 Specialty Tier 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AFINITOR TABLETS 2.5 MG   5 Specialty Tier 25%N/AP
AFINITOR TABLETS 5 MG   5 Specialty Tier 25%N/AP
Ala-cort 2.5% cream   2 Generic $11.00$33.00None
ALBENZA 200 MG TABLET   4 Non-Preferred Drug 50%50%None
ALBUTEROL SUL 2.5 MG/3 ML SOLN   1* Preferred Generic $2.00$6.00P
ALBUTEROL SULFATE 0.75mg/3mL 30 POUCH per CARTON / 1 VIAL, SINGLE-DOSE in 1 POUCH / 3 mL in 1 VIAL   1* Preferred Generic $2.00$6.00P
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER   1* Preferred Generic $2.00$6.00P
ALBUTEROL SULFATE 2 MG TAB   4 Non-Preferred Drug 50%50%None
ALBUTEROL SULFATE 4 MG TAB   4 Non-Preferred Drug 50%50%None
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   1* Preferred Generic $2.00$6.00P
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT   1* Preferred Generic $2.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALCLOMETASONE DIPR 0.05% OINT   2 Generic $11.00$33.00None
ALCLOMETASONE DIPRO 0.05% CRM   2 Generic $11.00$33.00None
ALDURAZYME 2.9MG/5ML VIAL   5 Specialty Tier 25%N/ANone
ALECENSA 150 MG CAPSULE   5 Specialty Tier 25%N/AP
ALENDRONATE SODIUM 10 MG TAB   2 Generic $11.00$33.00Q:90
/90Days
ALENDRONATE SODIUM 35 MG TAB   2 Generic $11.00$33.00Q:12
/84Days
ALENDRONATE SODIUM 40 MG TABLET   2 Generic $11.00$33.00Q:90
/90Days
ALENDRONATE SODIUM 5 MG TABLET   2 Generic $11.00$33.00Q:90
/90Days
ALENDRONATE SODIUM 70 MG TAB   2 Generic $11.00$33.00Q:12
/84Days
ALENDRONATE SODIUM 70 MG/75 ML   2 Generic $11.00$33.00None
ALFUZOSIN HCL ER 10 MG TABLET   2 Generic $11.00$33.00Q:90
/90Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALIMTA 100 MG VIAL   4 Non-Preferred Drug 50%50%None
ALIMTA 500 MG VIAL   4 Non-Preferred Drug 50%50%None
ALINIA 100 MG/5 ML SUSPENSION   3 Preferred Brand $42.00$126.00None
ALINIA 500 MG TABLET   3 Preferred Brand $42.00$126.00None
ALIQOPA 60 MG VIAL   5 Specialty Tier 25%N/AP
Aliskiren 150 MG / Hydrochlorothiazide 12.5 MG Oral Tablet [Tekturna HCT]   4 Non-Preferred Drug 50%50%Q:90
/90Days
Aliskiren 150 MG / Hydrochlorothiazide 25 MG Oral Tablet [Tekturna HCT]   4 Non-Preferred Drug 50%50%Q:90
/90Days
Aliskiren 300 MG / Hydrochlorothiazide 12.5 MG Oral Tablet [Tekturna HCT]   4 Non-Preferred Drug 50%50%Q:90
/90Days
ALLOPURINOL 100 MG TABLET   1* Preferred Generic $2.00$6.00None
ALLOPURINOL 300 MG TABLET   1* Preferred Generic $2.00$6.00None
Allopurinol sodium 500 mg vial   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALMOTRIPTAN MALATE 12.5 MG TAB [Axert]   4 Non-Preferred Drug 50%50%S Q:36
/90Days
ALMOTRIPTAN MALATE 6.25 MG TAB [Axert]   4 Non-Preferred Drug 50%50%S Q:36
/90Days
ALOPRIM SOLUTION FOR INJECTION 500MG/VIAL 30 ML VIALGL   4 Non-Preferred Drug 50%50%None
ALOSETRON HCL 0.5 MG TABLET [Lotronex]   4 Non-Preferred Drug 50%50%P
ALOSETRON HCL 1 MG TABLET [Lotronex]   4 Non-Preferred Drug 50%50%P
ALPHAGAN P 0.1% DROPS   3 Preferred Brand $42.00$126.00None
ALPRAZOLAM 0.25 MG TABLET   2 Generic $11.00$33.00None
ALPRAZOLAM 0.5 MG TABLET   2 Generic $11.00$33.00None
ALPRAZOLAM 1 MG TABLET   2 Generic $11.00$33.00None
Alprazolam 1mg/mL 1 BOTTLE in 1 CONTAINER / 30 mL in 1 BOTTLE   2 Generic $11.00$33.00None
ALPRAZOLAM 2 MG TABLET   2 Generic $11.00$33.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALUNBRIG 180 MG TABLET   5 Specialty Tier 25%N/AP
ALUNBRIG 30 MG TABLET   5 Specialty Tier 25%N/AP
ALUNBRIG 90 MG TABLET   5 Specialty Tier 25%N/AP
ALVESCO 160MCG/ACT AERS   3 Preferred Brand $42.00$126.00Q:37
/90Days
ALVESCO 80MCG/ACT AERS   3 Preferred Brand $42.00$126.00Q:37
/90Days
Amabelz 0.5 MG/0.1 MG 28 TABLET/BLISTER PACK 3 PER CARTON   2 Generic $11.00$33.00None
Amabelz 1 MG/0.5 MG 28 TABLET/BLISTER PACK 3 PER CARTON   2 Generic $11.00$33.00None
AMANTADINE 100 MG CAPSULE   2 Generic $11.00$33.00None
AMANTADINE 100 MG TABLET   2 Generic $11.00$33.00None
AMANTADINE 50 MG/5 ML SOLUTION   2 Generic $11.00$33.00None
AMBISOME 50MG VIAL   5 Specialty Tier 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMCINONIDE 0.1% CREAM   4 Non-Preferred Drug 50%50%None
AMCINONIDE 0.1% LOTION   4 Non-Preferred Drug 50%50%None
AMCINONIDE 0.1% OINTMENT 60GM TUBE   4 Non-Preferred Drug 50%50%None
AMETHIA 0.15-0.03-0.01 MG TABLET   4 Non-Preferred Drug 50%50%Q:91
/91Days
AMETHIA LO TABLET   2 Generic $11.00$33.00Q:91
/91Days
AMIKACIN SULF 500 MG/2 ML VIAL   4 Non-Preferred Drug 50%50%None
AMILORIDE HCL 5 MG TABLET   2 Generic $11.00$33.00None
AMILORIDE HCL-HCTZ 5-50 MG TABLET   2 Generic $11.00$33.00None
Amino Acids 15% Solution   4 Non-Preferred Drug 50%50%P
Amino acids 4.25% in dextrose 10% Injectable Solution [Clinimix 4.25/10]   4 Non-Preferred Drug 50%50%P
Amino acids 4.25% in dextrose 20% Injectable Solution [Clinimix 4.25/20]   4 Non-Preferred Drug 50%50%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Amino acids 4.25% in dextrose 5% Injectable Solution [Clinimix 4.25/5]   4 Non-Preferred Drug 50%50%P
Amino acids 4.25% with electrolytes in dextrose 10% Injectable Solution [Clinimix E 4.25/10]   4 Non-Preferred Drug 50%50%P
Aminophylline 25 MG/ML 10 ML Injection   4 Non-Preferred Drug 50%50%None
AMINOSYN 7%-ELECTROLYTE SOL   4 Non-Preferred Drug 50%50%P
AMINOSYN HBC INJECTION SULFITE FREE 7%   4 Non-Preferred Drug 50%50%P
AMINOSYN II 10% SOL 6X2000 ML   4 Non-Preferred Drug 50%50%P
AMINOSYN II 15% IV SOLUTION   4 Non-Preferred Drug 50%50%P
AMINOSYN II 8.5% ELECTROLYT   4 Non-Preferred Drug 50%50%P
AMINOSYN II 8.5% ELECTROLYT   4 Non-Preferred Drug 50%50%P
AMINOSYN PF INJECTION   4 Non-Preferred Drug 50%50%P
AMINOSYN-PF 7% IV SOLUTION   4 Non-Preferred Drug 50%50%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN-RF 5.2% IV SOLUTION   4 Non-Preferred Drug 50%50%P
AMIODARONE HCL 100 MG TABLET   2 Generic $11.00$33.00None
AMIODARONE HCL 200 MG TABLET   2 Generic $11.00$33.00None
AMIODARONE HCL 400 MG TABLET   2 Generic $11.00$33.00None
AMIODARONE HCL 50 MG/ML in 3 ML Injection   4 Non-Preferred Drug 50%50%None
AMITIZA 8MCG CAPSULE   4 Non-Preferred Drug 50%50%P Q:180
/90Days
AMITIZA CAPSULES 24MCG 60 CAP BOT   4 Non-Preferred Drug 50%50%P Q:180
/90Days
AMITRIPTYLINE HCL 10 MG TAB   2 Generic $11.00$33.00None
AMITRIPTYLINE HCL 100 MG TAB   2 Generic $11.00$33.00None
AMITRIPTYLINE HCL 150 MG TAB   2 Generic $11.00$33.00None
AMITRIPTYLINE HCL 25 MG TAB   2 Generic $11.00$33.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITRIPTYLINE HCL 50 MG TAB   2 Generic $11.00$33.00None
AMITRIPTYLINE HCL 75 MG TAB   2 Generic $11.00$33.00None
AMLOD-VALSA-HCTZ 10-160-12.5MG [Exforge HCT]   2 Generic $11.00$33.00None
AMLOD-VALSA-HCTZ 10-160-25 MG [Exforge HCT]   2 Generic $11.00$33.00None
AMLOD-VALSA-HCTZ 10-320-25 MG [Exforge HCT]   2 Generic $11.00$33.00None
AMLOD-VALSA-HCTZ 5-160-12.5 MG [Exforge HCT]   2 Generic $11.00$33.00None
AMLOD-VALSA-HCTZ 5-160-25 MG [Exforge HCT]   2 Generic $11.00$33.00None
AMLODIPINE BESYLATE 10 MG TAB   1* Preferred Generic $2.00$6.00None
AMLODIPINE BESYLATE 2.5 MG TAB   1* Preferred Generic $2.00$6.00None
AMLODIPINE BESYLATE 5 MG TAB   1* Preferred Generic $2.00$6.00None
AMLODIPINE-ATORVAST 10-20 MG [Caduet]   2 Generic $11.00$33.00Q:90
/90Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE-ATORVAST 10-40 MG [Caduet]   2 Generic $11.00$33.00Q:90
/90Days
Amlodipine-Atorvastatin 10-10 mg [Caduet]   2 Generic $11.00$33.00Q:90
/90Days
Amlodipine-Atorvastatin 10-80 mg [Caduet]   2 Generic $11.00$33.00Q:90
/90Days
Amlodipine-Atorvastatin 2.5-10 mg [Caduet]   2 Generic $11.00$33.00Q:90
/90Days
Amlodipine-Atorvastatin 2.5-20 mg [Caduet]   2 Generic $11.00$33.00Q:90
/90Days
Amlodipine-Atorvastatin 2.5-40 mg [Caduet]   2 Generic $11.00$33.00Q:90
/90Days
Amlodipine-Atorvastatin 5-10 mg [Caduet]   2 Generic $11.00$33.00Q:90
/90Days
Amlodipine-Atorvastatin 5-20 mg [Caduet]   2 Generic $11.00$33.00Q:90
/90Days
Amlodipine-Atorvastatin 5-40 mg [Caduet]   2 Generic $11.00$33.00Q:90
/90Days
Amlodipine-Atorvastatin 5-80 mg [Caduet]   2 Generic $11.00$33.00Q:90
/90Days
AMLODIPINE-BENAZEPRIL 10-20 MG Capsule [Lotrel]   2 Generic $11.00$33.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE-BENAZEPRIL 10-40 MG Capsule [Lotrel]   2 Generic $11.00$33.00None
AMLODIPINE-BENAZEPRIL 2.5-10 Capsule [Lotrel]   2 Generic $11.00$33.00None
AMLODIPINE-BENAZEPRIL 5-10 MG Capsule [Lotrel]   2 Generic $11.00$33.00None
AMLODIPINE-BENAZEPRIL 5-20 MG Capsule [Lotrel]   2 Generic $11.00$33.00None
AMLODIPINE-BENAZEPRIL 5-40 MG Capsule [Lotrel]   2 Generic $11.00$33.00None
AMLODIPINE-OLMESARTAN 10-20 MG [Azor]   2 Generic $11.00$33.00Q:90
/90Days
AMLODIPINE-OLMESARTAN 10-40 MG [Azor]   2 Generic $11.00$33.00Q:90
/90Days
AMLODIPINE-OLMESARTAN 5-20 MG [Azor]   2 Generic $11.00$33.00Q:90
/90Days
AMLODIPINE-OLMESARTAN 5-40 MG [Azor]   2 Generic $11.00$33.00Q:90
/90Days
AMLODIPINE-VALSARTAN 10-160 MG   2 Generic $11.00$33.00None
AMLODIPINE-VALSARTAN 10-320 MG   2 Generic $11.00$33.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE-VALSARTAN 5-160 MG   2 Generic $11.00$33.00None
AMLODIPINE-VALSARTAN 5-320 MG   2 Generic $11.00$33.00None
AMMONIUM LACTATE 12% CREAM   2 Generic $11.00$33.00None
AMMONIUM LACTATE 12% LOTION   2 Generic $11.00$33.00None
AMNESTEEM 10 MG CAPSULE   4 Non-Preferred Drug 50%50%None
AMNESTEEM 20 MG CAPSULE   4 Non-Preferred Drug 50%50%None
AMNESTEEM 40 MG CAPSULE   4 Non-Preferred Drug 50%50%None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE [Augmentin]   2 Generic $11.00$33.00None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET [Augmentin]   2 Generic $11.00$33.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE [Augmentin]   2 Generic $11.00$33.00None
AMOX-CLAV 200-28.5 MG/5 ML SUS   2 Generic $11.00$33.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOX-CLAV 250-62.5 MG/5 ML SUS   2 Generic $11.00$33.00None
AMOX-CLAV 400-57 MG/5 ML SUSP   2 Generic $11.00$33.00None
AMOX-CLAV 500-125 MG TABLET [Augmentin]   2 Generic $11.00$33.00None
AMOX-CLAV 600-42.9 MG/5 ML SUS   2 Generic $11.00$33.00None
AMOX-CLAV 875-125 MG TABLET [Augmentin]   2 Generic $11.00$33.00None
AMOX-CLAV ER 1,000-62.5 MG TABLET [Augmentin]   4 Non-Preferred Drug 50%50%None
AMOXAPINE 100MG TABLET   2 Generic $11.00$33.00None
AMOXAPINE 150MG TABLET   2 Generic $11.00$33.00None
AMOXAPINE 25MG TABLET   2 Generic $11.00$33.00None
AMOXAPINE 50MG TABLET   2 Generic $11.00$33.00None
AMOXICILLIN 125 MG/5 ML SUSP   2 Generic $11.00$33.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN 125MG TABLET CHEW   2 Generic $11.00$33.00None
AMOXICILLIN 200 MG/5 ML SUSP   2 Generic $11.00$33.00None
AMOXICILLIN 250 MG CAPSULE   1* Preferred Generic $2.00$6.00None
AMOXICILLIN 250 MG TAB CHEW   2 Generic $11.00$33.00None
AMOXICILLIN 250 MG/5 ML SUSP   2 Generic $11.00$33.00None
AMOXICILLIN 400 MG/5 ML SUSP   2 Generic $11.00$33.00None
AMOXICILLIN 500 MG CAPSULE   1* Preferred Generic $2.00$6.00None
AMOXICILLIN 500 MG TABLET   1* Preferred Generic $2.00$6.00None
AMOXICILLIN 875 MG TABLET   1* Preferred Generic $2.00$6.00None
AMPHETAMINE SALT COMBO 12.5MG TABLET   2 Generic $11.00$33.00Q:270
/90Days
AMPHETAMINE SALT COMBO 15MG TABLET   2 Generic $11.00$33.00Q:270
/90Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPHETAMINE SALT COMBO 7.5MG TABLET   2 Generic $11.00$33.00Q:270
/90Days
AMPHETAMINE SALTS 5 MG TAB   2 Generic $11.00$33.00Q:270
/90Days
amphotericin b 50mg/10mL 10 mL in 1 VIAL   4 Non-Preferred Drug 50%50%P
AMPICILLIN 10 GM VIAL   4 Non-Preferred Drug 50%50%None
Ampicillin 1000 MG / Sulbactam 500 MG Injection   4 Non-Preferred Drug 50%50%None
Ampicillin 1000 MG Injection   4 Non-Preferred Drug 50%50%None
Ampicillin 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS   4 Non-Preferred Drug 50%50%None
Ampicillin 2000 MG / Sulbactam 1000 MG Injection   4 Non-Preferred Drug 50%50%None
AMPICILLIN CAPSULES 500MG 100 BOT   2 Generic $11.00$33.00None
AMPICILLIN-SULBACTAM 15 GM VL   4 Non-Preferred Drug 50%50%None
AMPYRA ER 10 MG TABLET   5 Specialty Tier 25%N/AP Q:62
/31Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANADROL-50 TABLET   4 Non-Preferred Drug 50%50%P
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE   2 Generic $11.00$33.00None
Anagrelide Hydrochloride 1mg/1 100 CAPSULE BOTTLE   2 Generic $11.00$33.00None
ANASTROZOLE 1 MG TABLET   2 Generic $11.00$33.00None
ANDRODERM 2 MG/24HR PATCH   3 Preferred Brand $42.00$126.00P Q:90
/90Days
ANDRODERM 4 MG/24HR PATCH   3 Preferred Brand $42.00$126.00P Q:90
/90Days
ANDROGEL 1.62% (1.25G) GEL PCKT   3 Preferred Brand $42.00$126.00P Q:225
/90Days
ANDROGEL 1.62% (2.5G) GEL PCKT   3 Preferred Brand $42.00$126.00P Q:450
/90Days
ANDROGEL 1% (50MG) GEL PACKET   3 Preferred Brand $42.00$126.00P Q:900
/90Days
Androgel 16.2mg/g 1 BOTTLE, PUMP per CARTON / 88 g in 1 BOTTLE, PUMP   3 Preferred Brand $42.00$126.00P Q:450
/90Days
ANORO ELLIPTA 62.5-25 MCG INH   3 Preferred Brand $42.00$126.00Q:180
/90Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Antineoplastic Agent Etoposide 20 mg / mL Intravenous Injection Multiple Dose Vial 5 mL   2 Generic $11.00$33.00None
ANZEMET 100 MG TABLET   4 Non-Preferred Drug 50%50%P
ANZEMET 50 MG TABLET   4 Non-Preferred Drug 50%50%P
APEXICON E 0.05% CREAM   4 Non-Preferred Drug 50%50%None
APOKYN 30 MG/3 ML CARTRIDGE   5 Specialty Tier 25%N/ANone
Apraclonidine 5 MG/ML Ophthalmic Solution   2 Generic $11.00$33.00None
APREPITANT 125 MG CAPSULE [Emend]   2 Generic $11.00$33.00P
APREPITANT 125-80-80 MG PACK [Emend]   2 Generic $11.00$33.00P
APREPITANT 40 MG CAPSULE [Emend]   2 Generic $11.00$33.00P
APREPITANT 80 MG CAPSULE [Emend]   2 Generic $11.00$33.00P
APTIOM 200 MG 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
APTIOM 400 MG TABLET   4 Non-Preferred Drug 50%50%None
APTIOM 600 MG TABLET   4 Non-Preferred Drug 50%50%None
APTIOM 800 MG TABLET   4 Non-Preferred Drug 50%50%None
APTIVUS 250MG CAPSULE   5 Specialty Tier 25%N/ANone
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT   5 Specialty Tier 25%N/ANone
ARANESP 10 MCG/0.4 ML SYRINGE   4 Non-Preferred Drug 50%50%P
ARANESP 100ug/0.5mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.5 mL in 1 SYRINGE   5 Specialty Tier 25%N/AP
ARANESP 100ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE   5 Specialty Tier 25%N/AP
ARANESP 200MCG/0.4ML SYRINGE   5 Specialty Tier 25%N/AP
ARANESP 200MCG/ML VIAL   5 Specialty Tier 25%N/AP
ARANESP 25ug/0.42mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.42 mL in 1 SYRING   4 Non-Preferred Drug 50%50%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP 25ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE   4 Non-Preferred Drug 50%50%P
ARANESP 300MCG/ML VIAL   5 Specialty Tier 25%N/AP
ARANESP 500MCG/1ML SYRINGE   5 Specialty Tier 25%N/AP
ARANESP 60MCG/ML VIAL   5 Specialty Tier 25%N/AP
ARANESP 60ug/0.3mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.3 mL in 1 SYRINGE   5 Specialty Tier 25%N/AP
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR   5 Specialty Tier 25%N/AP
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR   5 Specialty Tier 25%N/AP
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR   4 Non-Preferred Drug 50%50%P
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD   4 Non-Preferred Drug 50%50%P
ARCALYST INJECTION 220MG/VIAL   5 Specialty Tier 25%N/AP
ARIPIPRAZOLE 1 MG/ML SOLUTION [Abilify]   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARIPIPRAZOLE 10 MG TABLET [Abilify]   4 Non-Preferred Drug 50%50%None
ARIPIPRAZOLE 15 MG TABLET [Abilify]   4 Non-Preferred Drug 50%50%None
ARIPIPRAZOLE 2 MG TABLET [Abilify]   4 Non-Preferred Drug 50%50%None
ARIPIPRAZOLE 20 MG TABLET [Abilify]   4 Non-Preferred Drug 50%50%None
ARIPIPRAZOLE 30 MG TABLET [Abilify]   4 Non-Preferred Drug 50%50%None
ARIPIPRAZOLE 5 MG TABLET [Abilify]   4 Non-Preferred Drug 50%50%None
ARIPIPRAZOLE ODT 10 MG TABLET [Abilify]   2 Generic $11.00$33.00None
ARIPIPRAZOLE ODT 15 MG TABLET [Abilify]   2 Generic $11.00$33.00None
ARISTADA ER 1064 MG/3.9 ML SYR   5 Specialty Tier 25%N/AS
ARISTADA ER 441 MG/1.6 ML SYRN   5 Specialty Tier 25%N/AS
ARISTADA ER 662 MG/2.4 ML SYRN   5 Specialty Tier 25%N/AS
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARISTADA ER 882 MG/3.2 ML SYRN   5 Specialty Tier 25%N/AS
Armodafinil 150 MG TABLET [NUVIGIL]   4 Non-Preferred Drug 50%50%P Q:90
/90Days
Armodafinil 200 MG Oral Tablet [NUVIGIL]   4 Non-Preferred Drug 50%50%P Q:90
/90Days
Armodafinil 250 MG TABLET [NUVIGIL]   4 Non-Preferred Drug 50%50%P Q:90
/90Days
Armodafinil 50 MG TABLET [NUVIGIL]   4 Non-Preferred Drug 50%50%P Q:90
/90Days
ARRANON 250 MG VIAL   4 Non-Preferred Drug 50%50%None
ASACOL HD DR 800 MG TABLET   3 Preferred Brand $42.00$126.00None
ASHLYNA 0.15-0.03-0.01 MG TAB   4 Non-Preferred Drug 50%50%Q:91
/91Days
ASMANEX HFA 100 MCG INHALER   3 Preferred Brand $42.00$126.00Q:39
/90Days
ASMANEX HFA 200 MCG INHALER   3 Preferred Brand $42.00$126.00Q:39
/90Days
ASMANEX TWISTHALER 110 MCG #30   3 Preferred Brand $42.00$126.00Q:3
/90Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ASMANEX TWISTHALER 220 MCG #30   3 Preferred Brand $42.00$126.00Q:3
/90Days
ASMANEX TWISTHALER 220MCG #120   3 Preferred Brand $42.00$126.00Q:3
/90Days
ASMANEX TWISTHALER 220MCG #60   3 Preferred Brand $42.00$126.00Q:3
/90Days
Aspirin-Diphenhydramine ER 25-200 MG   4 Non-Preferred Drug 50%50%None
ASTAGRAF XL 0.5 MG CAPSULE   4 Non-Preferred Drug 50%50%P
ASTAGRAF XL 1 MG CAPSULE   4 Non-Preferred Drug 50%50%P
ASTAGRAF XL 5 MG CAPSULE   5 Specialty Tier 25%N/AP
ATAZANAVIR SULFATE 150 MG CAP [Reyataz]   4 Non-Preferred Drug 50%50%None
ATAZANAVIR SULFATE 200 MG CAP [Reyataz]   4 Non-Preferred Drug 50%50%None
ATAZANAVIR SULFATE 300 MG CAP [Reyataz]   5 Specialty Tier 25%N/ANone
ATENOLOL 100 MG TABLET   1* Preferred Generic $2.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATENOLOL 25 MG TABLET   1* Preferred Generic $2.00$6.00None
ATENOLOL 50 MG TABLET   1* Preferred Generic $2.00$6.00None
ATENOLOL-CHLORTHALIDONE 100-25   2 Generic $11.00$33.00None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   2 Generic $11.00$33.00None
ATOMOXETINE HCL 10 MG CAPSULE [Strattera]   4 Non-Preferred Drug 50%50%S Q:180
/90Days
ATOMOXETINE HCL 100 MG CAPSULE [Strattera]   4 Non-Preferred Drug 50%50%S Q:90
/90Days
ATOMOXETINE HCL 18 MG CAPSULE [Strattera]   4 Non-Preferred Drug 50%50%S Q:180
/90Days
ATOMOXETINE HCL 25 MG CAPSULE [Strattera]   4 Non-Preferred Drug 50%50%S Q:180
/90Days
ATOMOXETINE HCL 40 MG CAPSULE [Strattera]   4 Non-Preferred Drug 50%50%S Q:180
/90Days
ATOMOXETINE HCL 60 MG CAPSULE [Strattera]   4 Non-Preferred Drug 50%50%S Q:180
/90Days
ATOMOXETINE HCL 80 MG CAPSULE [Strattera]   4 Non-Preferred Drug 50%50%S Q:90
/90Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATORVASTATIN 10 MG TABLET [Lipitor]   1* Preferred Generic $2.00$6.00None
ATORVASTATIN 20 MG TABLET [Lipitor]   1* Preferred Generic $2.00$6.00None
ATORVASTATIN 40 MG TABLET [Lipitor]   1* Preferred Generic $2.00$6.00None
ATORVASTATIN 80 MG TABLET [Lipitor]   1* Preferred Generic $2.00$6.00Q:90
/90Days
ATOVAQUONE 750 MG/5 ML SUSP [Mepron]   5 Specialty Tier 25%N/ANone
Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone]   2 Generic $11.00$33.00None
ATOVAQUONE-PROGUANIL 62.5-25 [Malarone]   2 Generic $11.00$33.00None
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC   5 Specialty Tier 25%N/ANone
ATROPINE 1% EYE DROPS   2 Generic $11.00$33.00None
ATROVENT HFA AER 17MCG   3 Preferred Brand $42.00$126.00None
AUBAGIO 14 MG TABLET   5 Specialty Tier 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AUBAGIO 7 MG TABLET   5 Specialty Tier 25%N/AP
AUVI-Q 0.1 MG AUTO-INJECTOR   3 Preferred Brand $42.00$126.00None
AUVI-Q 0.15 MG AUTO-INJECTOR   3 Preferred Brand $42.00$126.00None
AUVI-Q 0.3 MG AUTO-INJECTOR   3 Preferred Brand $42.00$126.00None
AVASTIN 100MG/4ML VIAL   5 Specialty Tier 25%N/ANone
AVASTIN 400 MG/16 ML VIAL   5 Specialty Tier 25%N/ANone
AVC 15% CREAM   4 Non-Preferred Drug 50%50%None
AVITA 0.025% CREAM   4 Non-Preferred Drug 50%50%None
AVONEX ADMIN PACK 30 MCG VL   5 Specialty Tier 25%N/AP
AVONEX PEN 30 MCG/0.5 ML KIT   5 Specialty Tier 25%N/AP
AVONEX PREFILLED SYR 30 MCG KT   5 Specialty Tier 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Azacitidine 100 mg vial [Vidaza]   5 Specialty Tier 25%N/ANone
AZASITE 1% EYE DROPS   4 Non-Preferred Drug 50%50%None
AZATHIOPRINE 50 MG TABLET   2 Generic $11.00$33.00P
AZATHIOPRINE SODIUM 100 MG VIAL   4 Non-Preferred Drug 50%50%P
AZELASTINE 0.15% NASAL SPRAY   2 Generic $11.00$33.00None
AZELASTINE 137 MCG NASAL SPRAY   2 Generic $11.00$33.00None
AZELASTINE HCL 0.05% DROPS   2 Generic $11.00$33.00None
AZITHROMYCIN 1 GM PWD PACKET   2 Generic $11.00$33.00None
AZITHROMYCIN 100 MG/5 ML SUSP   2 Generic $11.00$33.00None
AZITHROMYCIN 200 MG/5 ML SUSP   2 Generic $11.00$33.00None
AZITHROMYCIN 250 MG TABLET   2 Generic $11.00$33.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZITHROMYCIN 250 MG TABLET   2 Generic $11.00$33.00None
AZITHROMYCIN 500 MG TABLET   2 Generic $11.00$33.00None
Azithromycin 500mg/1 30 FILM COATED TABLETS in BOTTLE   2 Generic $11.00$33.00None
AZITHROMYCIN 600 MG TABLET   2 Generic $11.00$33.00None
AZITHROMYCIN I.V. 500 MG VIAL   4 Non-Preferred Drug 50%50%None
AZOPT 1% EYE DROPS   3 Preferred Brand $42.00$126.00None
Aztreonam 2000 MG Injection [Azactam]   4 Non-Preferred Drug 50%50%None
AZTREONAM FOR INJECTION   4 Non-Preferred Drug 50%50%None

Chart Legend:

Below are a few notes to help you understand the above 2018 Medicare Part D Prescription Blue Option A (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.