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2018 Medicare Part D Plan Formulary Information
Aetna Medicare Rx Select (PDP) (S5810-292-0) Benefit Details
The Aetna Medicare Rx Select (PDP) (S5810-292-0) Formulary Drugs Starting with the Letter B in CMS PDP Region 21 which includes: LA Plan Monthly Premium: $17.70 Deductible: $405 Qualifies for LIS: No
Drugs Starting with Letter B Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter B Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BACiiM 500001/1 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL	4	Non-Preferred Drug	37%	N/A	None
Bacitracin 500 unit/gm Eye Ointment	4	Non-Preferred Drug	37%	N/A	None
BACITRACIN INJ 50000UNT	4	Non-Preferred Drug	37%	N/A	None
BACITRACIN/POLYMYXIN B OINT 500UNT/10000UNT	2*	Generic	$3.00	N/A	None
BACLOFEN 10 MG TABLET	2*	Generic	$3.00	N/A	None
BACLOFEN 20 MG TABLET	2*	Generic	$3.00	N/A	None
BACLOFEN 5 MG TABLET	2*	Generic	$3.00	N/A	None
BACTRIM 400-80 MG TABLET	4	Non-Preferred Drug	37%	N/A	None
BACTRIM DS 800-160 MG TABLET	4	Non-Preferred Drug	37%	N/A	None
BACTROBAN 2% CREAM	4	Non-Preferred Drug	37%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BACTROBAN NASAL 2% OINTMENT	4	Non-Preferred Drug	37%	N/A	None
BALSALAZIDE DISODIUM 750MG CAPSULE (280 CT)	4	Non-Preferred Drug	37%	N/A	None
Balziva 6 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK	3	Preferred Brand	$46.00	N/A	None
Banzel 200mg/1	5	Specialty Tier	25%	N/A	P
Banzel 40mg/mL	5	Specialty Tier	25%	N/A	P
BANZEL TABLET 400MG	5	Specialty Tier	25%	N/A	P
BARACLUDE 0.05mg/mL 1 BOTTLE per CARTON / 210 mL in 1 BOTTLE	5	Specialty Tier	25%	N/A	None
BAVENCIO 200 MG/10 ML VIAL	5	Specialty Tier	25%	N/A	P
BCG VACCINE 50mg/1 1 VIAL per CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL	3	Preferred Brand	$46.00	N/A	None
BECONASE AQ 0.042% SPRAY	4	Non-Preferred Drug	37%	N/A	Q:50 /30Days
BEKYREE 28 DAY TABLET [VIORELE]	3	Preferred Brand	$46.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BELEODAQ 500 MG VIAL	5	Specialty Tier	25%	N/A	P
BENAZEPRIL HCL 10 MG TABLET	1*	Preferred Generic	$0.00	N/A	None
BENAZEPRIL HCL 20 MG TABLET	1*	Preferred Generic	$0.00	N/A	None
BENAZEPRIL HCL 40 MG TABLET	1*	Preferred Generic	$0.00	N/A	None
BENAZEPRIL HCL 5 MG TABLET	1*	Preferred Generic	$0.00	N/A	None
BENAZEPRIL HCL-HCTZ TABLET 10-12.5MG (100 CT)	2*	Generic	$3.00	N/A	None
BENAZEPRIL HCL-HCTZ TABLET 20-12.5MG (100 CT)	2*	Generic	$3.00	N/A	None
BENAZEPRIL HCL-HCTZ TABLET 20-25MG (100 CT)	2*	Generic	$3.00	N/A	None
BENAZEPRIL HCL-HCTZ TABLET 5-6.25MG (100 CT)	2*	Generic	$3.00	N/A	None
BENICAR 20 MG TABLET	4	Non-Preferred Drug	37%	N/A	S Q:30 /30Days
BENICAR 40 MG TABLET	4	Non-Preferred Drug	37%	N/A	S Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BENICAR 5MG TABLET	4	Non-Preferred Drug	37%	N/A	S Q:30 /30Days
BENICAR HCT 20-12.5 MG TABLET	4	Non-Preferred Drug	37%	N/A	S Q:30 /30Days
BENICAR HCT 40-25 MG TABLET	4	Non-Preferred Drug	37%	N/A	S Q:30 /30Days
BENICAR HCT TABLET 12.5-40MG (30 CT)	4	Non-Preferred Drug	37%	N/A	S Q:30 /30Days
BENLYSTA 120mg/1.5mL 1 VIAL per CARTON / 1.5 mL in 1 VIAL	5	Specialty Tier	25%	N/A	P
BENLYSTA 200 MG/ML AUTOINJECT	5	Specialty Tier	25%	N/A	P
BENLYSTA 200 MG/ML SYRINGE	5	Specialty Tier	25%	N/A	P
BENLYSTA 400 MG VIAL	5	Specialty Tier	25%	N/A	P
BENTYL INJECTION 20MG/2ML AMP	4	Non-Preferred Drug	37%	N/A	None
BENZTROPINE 2 MG/2 ML AMPULE [Cogentin]	2*	Generic	$3.00	N/A	P
BENZTROPINE MES 0.5 MG Tablet [Cogentin]	2*	Generic	$3.00	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BENZTROPINE MES 1 MG TABLET [Cogentin]	2*	Generic	$3.00	N/A	P
BENZTROPINE MES 2 MG TABLET [Cogentin]	2*	Generic	$3.00	N/A	P
BEPREVE 1.5% EYE DROPS	3	Preferred Brand	$46.00	N/A	None
BESIVANCE BESIFLOACIN OPTHALMIC SUSPENSION 0.6% 5 ML BOTDR	3	Preferred Brand	$46.00	N/A	None
BETAGAN 0.5% EYE DROPS	4	Non-Preferred Drug	37%	N/A	None
Betamethasone Dipropionate 0.64mg/g / 45 g TUBE	4	Non-Preferred Drug	37%	N/A	None
BETAMETHASONE DP 0.05% LOT	3	Preferred Brand	$46.00	N/A	None
Betamethasone DP 0.05% ointment	4	Non-Preferred Drug	37%	N/A	None
BETAMETHASONE DP AUG 0.05% CRM	3	Preferred Brand	$46.00	N/A	None
BETAMETHASONE DP AUG 0.05% GEL	4	Non-Preferred Drug	37%	N/A	None
BETAMETHASONE DP AUG 0.05% LOT	4	Non-Preferred Drug	37%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BETAMETHASONE DP AUG 0.05% OIN	4	Non-Preferred Drug	37%	N/A	None
BETAMETHASONE VA 0.1% CREAM	3	Preferred Brand	$46.00	N/A	None
BETAMETHASONE VALERATE 0.1% LOTION	3	Preferred Brand	$46.00	N/A	None
BETAMETHASONE VALERATE 0.12% FOAM	4	Non-Preferred Drug	37%	N/A	None
BETAMETHASONE VALERATE OINTMENT USP	3	Preferred Brand	$46.00	N/A	None
BETASERON 0.3 MG KIT	5	Specialty Tier	25%	N/A	P Q:14 /28Days
BETAXOLOL 10 MG TABLET	3	Preferred Brand	$46.00	N/A	None
BETAXOLOL 20 MG TABLET	3	Preferred Brand	$46.00	N/A	None
Betaxolol 5 MG/ML Ophthalmic Solution	3	Preferred Brand	$46.00	N/A	None
BETHANECHOL 10 MG TABLET	3	Preferred Brand	$46.00	N/A	None
BETHANECHOL 25 MG TABLET	3	Preferred Brand	$46.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BETHANECHOL 5 MG TABLET	3	Preferred Brand	$46.00	N/A	None
BETHANECHOL 50 MG TABLET	3	Preferred Brand	$46.00	N/A	None
BETHKIS 300 MG/4 ML AMPULE	5	Specialty Tier	25%	N/A	P Q:224 /56Days
BETIMOL 0.25% EYE DROPS	4	Non-Preferred Drug	37%	N/A	None
BETIMOL 0.5% EYE DROPS	4	Non-Preferred Drug	37%	N/A	None
BETOPTIC S OPHTHALMIC SUSPENSION 0.25% 10 ML BOT	3	Preferred Brand	$46.00	N/A	None
BEVESPI AEROSPHERE INHALER	3	Preferred Brand	$46.00	N/A	Q:11 /30Days
BEXAROTENE 75 MG CAPSULE [Targretin]	5	Specialty Tier	25%	N/A	P
BEXSERO PREFILLED SYRINGE	3	Preferred Brand	$46.00	N/A	None
BICALUTAMIDE 50 MG TABLET	3	Preferred Brand	$46.00	N/A	None
BICILL LA PFS 600MU 1ML PED	4	Non-Preferred Drug	37%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BICILLIN LA PFS 1200MU 2ML	4	Non-Preferred Drug	37%	N/A	None
BICILLIN LA. 600000UNIT/ML 1ML	4	Non-Preferred Drug	37%	N/A	None
BICNU 100 MG VIAL	5	Specialty Tier	25%	N/A	P
BIDIL TABLET	4	Non-Preferred Drug	37%	N/A	None
BIKTARVY 50-200-25 MG TABLET	5	Specialty Tier	25%	N/A	Q:30 /30Days
Biltricide 600mg/1 6 FILM COATED TABLETS in BOTTLE	3	Preferred Brand	$46.00	N/A	None
BINOSTO 70 MG TABLET EFF	4	Non-Preferred Drug	37%	N/A	S Q:4 /28Days
BISOPROLOL FUMARATE 10 MG TAB	2*	Generic	$3.00	N/A	None
BISOPROLOL FUMARATE 5 MG TAB	2*	Generic	$3.00	N/A	None
BISOPROLOL-HCTZ 10-6.25 MG TAB	1*	Preferred Generic	$0.00	N/A	None
BISOPROLOL-HCTZ 2.5-6.25 MG TB	1*	Preferred Generic	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BISOPROLOL-HCTZ 5-6.25 MG TAB	1*	Preferred Generic	$0.00	N/A	None
BIVIGAM LIQUID 10% VIAL	5	Specialty Tier	25%	N/A	P
BLEOMYCIN SULFATE 30 UNIT VIAL	4	Non-Preferred Drug	37%	N/A	P
BLEPH-10 10% EYE DROPS	4	Non-Preferred Drug	37%	N/A	None
BLEPHAMIDE 10-0.2% EYE OINT	4	Non-Preferred Drug	37%	N/A	None
BLEPHAMIDE EYE DROPS	4	Non-Preferred Drug	37%	N/A	None
BLISOVI 24 FE TABLET	3	Preferred Brand	$46.00	N/A	None
BLISOVI FE 1-20 TABLET	3	Preferred Brand	$46.00	N/A	None
BLISOVI FE 1.5-30 TABLET	3	Preferred Brand	$46.00	N/A	None
BONIVA 150 MG TABLET	4	Non-Preferred Drug	37%	N/A	Q:1 /30Days
BONIVA 3mg/3mL SYRINGE	4	Non-Preferred Drug	37%	N/A	Q:3 /90Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BOOSTRIX TDAP VACCINE SYRINGE	3	Preferred Brand	$46.00	N/A	None
BOOSTRIX TDAP VACCINE VIAL	3	Preferred Brand	$46.00	N/A	None
Bortezomib 3.5 Mg Intravenous Solution	5	Specialty Tier	25%	N/A	P
BOSULIF 100 MG TABLET	5	Specialty Tier	25%	N/A	P
BOSULIF 400 MG TABLET	5	Specialty Tier	25%	N/A	P
BOSULIF 500 MG TABLET	5	Specialty Tier	25%	N/A	P
BOTOX 100UNITS VIAL	4	Non-Preferred Drug	37%	N/A	P Q:4 /70Days
BOTOX 200[USP'U]/1 1 VIAL in 1 CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL	4	Non-Preferred Drug	37%	N/A	P Q:2 /70Days
BREO ELLIPTA 100-25 MCG INH	3	Preferred Brand	$46.00	N/A	Q:60 /30Days
BREO ELLIPTA 200-25 MCG INH	3	Preferred Brand	$46.00	N/A	Q:60 /30Days
BRIELLYN TABLET	3	Preferred Brand	$46.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BRILINTA 60 MG TABLET	3	Preferred Brand	$46.00	N/A	None
BRILINTA 90mg/1 60 TABLET BOTTLE	3	Preferred Brand	$46.00	N/A	None
BRIMONIDINE 0.2% EYE DROP	3	Preferred Brand	$46.00	N/A	None
BRIMONIDINE TARTRATE 0.15% DRP	3	Preferred Brand	$46.00	N/A	None
BRIVIACT 10 MG TABLET	5	Specialty Tier	25%	N/A	P
BRIVIACT 10 MG/ML ORAL SOLN	5	Specialty Tier	25%	N/A	P
BRIVIACT 100 MG TABLET	5	Specialty Tier	25%	N/A	P
BRIVIACT 25 MG TABLET	5	Specialty Tier	25%	N/A	P
BRIVIACT 50 MG TABLET	5	Specialty Tier	25%	N/A	P
BRIVIACT 50 MG/5 ML VIAL	4	Non-Preferred Drug	37%	N/A	P
BRIVIACT 75 MG TABLET	5	Specialty Tier	25%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BROMOCRIPTINE 2.5 MG TABLET [Parlodel]	4	Non-Preferred Drug	37%	N/A	None
BROMOCRIPTINE MESYLATE 5MG CAPSULE [Parlodel]	4	Non-Preferred Drug	37%	N/A	None
BROVANA 15MCG/2ML VIAL NEBULIZER	4	Non-Preferred Drug	37%	N/A	P Q:120 /30Days
BUDESONIDE 0.25 MG/2 ML SUSP AMPUL-NEB [Pulmicort]	4	Non-Preferred Drug	37%	N/A	P
BUDESONIDE 0.5 MG/2 ML SUSP AMPUL-NEB [Pulmicort]	4	Non-Preferred Drug	37%	N/A	P
BUDESONIDE 1 MG/2 ML INH SUSP AMPUL-NEB [Pulmicort]	4	Non-Preferred Drug	37%	N/A	P
BUDESONIDE EC 3 MG CAPSULE CAPDR - ER [Entocort EC]	5	Specialty Tier	25%	N/A	None
BUDESONIDE ER 9 MG TABLET DR - ER [UCERIS]	5	Specialty Tier	25%	N/A	None
BUMETANIDE 0.25MG/ML VIAL	4	Non-Preferred Drug	37%	N/A	None
BUMETANIDE 0.5 MG TABLET	3	Preferred Brand	$46.00	N/A	None
BUMETANIDE 1 MG TABLET	3	Preferred Brand	$46.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BUMETANIDE 2 MG TABLET	3	Preferred Brand	$46.00	N/A	None
BUPAP 50 MG-300 MG TABLET	4	Non-Preferred Drug	37%	N/A	P Q:180 /30Days
BUPHENYL 500 MG TABLET	5	Specialty Tier	25%	N/A	P
BUPRENORPHIN-NALOXON 2-0.5 MG SL [Suboxone]	3	Preferred Brand	$46.00	N/A	P Q:90 /30Days
BUPRENORPHIN-NALOXON 8-2 MG SL [Suboxone]	3	Preferred Brand	$46.00	N/A	P Q:90 /30Days
BUPRENORPHINE 10 MCG/HR PATCH [Butrans]	4	Non-Preferred Drug	37%	N/A	S Q:4 /28Days
BUPRENORPHINE 15 MCG/HR PATCH [Butrans]	4	Non-Preferred Drug	37%	N/A	S Q:4 /28Days
BUPRENORPHINE 2 MG TABLET Subligual [Subutex]	3	Preferred Brand	$46.00	N/A	P Q:90 /30Days
BUPRENORPHINE 20 MCG/HR PATCH [Butrans]	4	Non-Preferred Drug	37%	N/A	S Q:4 /28Days
BUPRENORPHINE 5 MCG/HR PATCH [Butrans]	4	Non-Preferred Drug	37%	N/A	S Q:4 /28Days
BUPRENORPHINE 8 MG TABLET Subligual [Subutex]	3	Preferred Brand	$46.00	N/A	P Q:90 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BUPROPION HCL 100 MG TABLET	3	Preferred Brand	$46.00	N/A	Q:180 /30Days
BUPROPION HCL 75 MG TABLET	3	Preferred Brand	$46.00	N/A	Q:180 /30Days
BUPROPION HCL SR 100 MG TABLET	3	Preferred Brand	$46.00	N/A	Q:60 /30Days
BUPROPION HCL SR 150 MG TABLET	3	Preferred Brand	$46.00	N/A	Q:60 /30Days
BUPROPION HCL SR 150 MG TABLET	3	Preferred Brand	$46.00	N/A	Q:60 /30Days
BUPROPION HCL SR 200 MG TABLET	3	Preferred Brand	$46.00	N/A	Q:60 /30Days
BUPROPION HCL XL 150 MG TABLET	3	Preferred Brand	$46.00	N/A	Q:30 /30Days
BUPROPION HCL XL 300 MG TABLET	3	Preferred Brand	$46.00	N/A	Q:30 /30Days
BUSPIRONE HCL 15 MG TABLET	2*	Generic	$3.00	N/A	None
BUSPIRONE HCL 30 MG TABLET	2*	Generic	$3.00	N/A	None
BUSPIRONE HCL 5 MG TABLET	2*	Generic	$3.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BUSPIRONE HCL 7.5 MG TABLET	2*	Generic	$3.00	N/A	None
BUSPIRONE HYDROCHLORIDE 10 MG TABLETS	2*	Generic	$3.00	N/A	None
Busulfan 60 mg/10 ml vial [Busulfex]	5	Specialty Tier	25%	N/A	P
BUSULFEX 6mg/mL	5	Specialty Tier	25%	N/A	P
BUTALB-ACETAMIN-CAFF 50-325-40	4	Non-Preferred Drug	37%	N/A	P Q:180 /30Days
BUTALB-CAFF-ACETAMINOPH-CODEIN	4	Non-Preferred Drug	37%	N/A	P Q:180 /30Days
BUTALBITAL COMP-CODEINE #3 CAP	4	Non-Preferred Drug	37%	N/A	P Q:180 /30Days
BUTALBITAL-ASA-CAFFEINE CAPSULE	4	Non-Preferred Drug	37%	N/A	P Q:180 /30Days
BUTALBITAL/ACETAMINOPHEN/CAFFEINE 50-300-40	4	Non-Preferred Drug	37%	N/A	P Q:180 /30Days
BUTALBITAL/ACETAMINOPHEN/CAFFEINE CP	4	Non-Preferred Drug	37%	N/A	P Q:180 /30Days
BUTORPHANOL 10MG/ML SPRAY	4	Non-Preferred Drug	37%	N/A	Q:5 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BUTORPHANOL 1MG/ML VIAL	4	Non-Preferred Drug	37%	N/A	None
BUTORPHANOL 2MG/ML VIAL	4	Non-Preferred Drug	37%	N/A	None
Butrans 10ug/h	4	Non-Preferred Drug	37%	N/A	S Q:4 /28Days
BUTRANS 15 MCG/HR PATCH	4	Non-Preferred Drug	37%	N/A	S Q:4 /28Days
Butrans 20ug/h	4	Non-Preferred Drug	37%	N/A	S Q:4 /28Days
Butrans 5ug/h	4	Non-Preferred Drug	37%	N/A	S Q:4 /28Days
BUTRANS 7.5 MCG/HR PATCH	4	Non-Preferred Drug	37%	N/A	S Q:4 /28Days
BYDUREON 2 MG PEN INJECT	3	Preferred Brand	$46.00	N/A	Q:4 /28Days
BYDUREON 2 MG VIAL	3	Preferred Brand	$46.00	N/A	Q:4 /28Days
BYDUREON BCISE 2 MG AUTOINJECT	3	Preferred Brand	$46.00	N/A	Q:4 /28Days
BYETTA 10 MCG DOSE PEN INJ	4	Non-Preferred Drug	37%	N/A	Q:2 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BYETTA 5 MCG DOSE PEN INJ	4	Non-Preferred Drug	37%	N/A	Q:1 /30Days
Bystolic 10mg/1 30 TABLET BOTTLE	4	Non-Preferred Drug	37%	N/A	None
Bystolic 2.5mg/1 30 TABLET BOTTLE	4	Non-Preferred Drug	37%	N/A	None
BYSTOLIC 20 MG TABLET	4	Non-Preferred Drug	37%	N/A	None
Bystolic 5mg 30 TABLET BOTTLE	4	Non-Preferred Drug	37%	N/A	None

Chart Legend:

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

Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region). The plan name is followed by the plan type (PDP, HMO, HMO-POS, PPO, PFFS, etc.)
Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.
Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $405 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.
Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
- Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.
- No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.
Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
- Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have five (5) tiers 1=Preferred Generics, 2=Generics, 3=Preferred Brands, 4=Non-preferred Brands, 5=Specialty Drugs. *Some Part D plans exclude one or more drug tiers from the deductible. If the drug tier field above is followed by * (example: 2*), then this drug tier is excluded from the plan’s deductible.
- Tier Description - This is the Medicare Part D plan’s description of this particular drug tier.
Cost Sharing - Copay / Coinsurance - These figures apply to the initial coverage phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
- Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $3750) at a "Preferred" network pharmacy. In most cases, the "Preferred" network network pharmacy cost-sharing is lower than the standard (non-preferred) network pharmacy cost-sharing.
- Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
- None - This drug does not fall under any drug utilization management controls.
- P - Prior Authorization -This drug is subject to prior authorization.
- S - Step Therapy -This drug is subject to step therapy.
- Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.

(Chart Source: Centers for Medicare and Medicaid files: CMS Data September 2018 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Part D plan provider.