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2018 Medicare Part D Plan Formulary Information
Asuris Medicare Script Basic (PDP) (S5609-001-0) Benefit Details
The Asuris Medicare Script Basic (PDP) (S5609-001-0) Formulary Drugs Starting with the Letter E in CMS PDP Region 30 which includes: OR WA Plan Monthly Premium: $100.00 Deductible: $210 Qualifies for LIS: No
Drugs Starting with Letter E Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter E Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
E.E.S. 200 MG/5 ML GRANULES	4	Non-Preferred Drug	45%	N/A	None
ECONAZOLE NITRATE 1% CREAM 85GM TUBE	4	Non-Preferred Drug	45%	N/A	None
EDURANT 27.5mg/1	5	Specialty Tier	28%	N/A	None
EFAVIRENZ 200 MG CAPSULE [Sustiva]	4	Non-Preferred Drug	45%	N/A	None
EFAVIRENZ 50 MG CAPSULE [Sustiva]	4	Non-Preferred Drug	45%	N/A	None
EFAVIRENZ 600 MG TABLET [Sustiva]	5	Specialty Tier	28%	N/A	None
ELAPRASE 6mg/3mL 1 VIAL, GLASS in 1 BOX / 3 mL in 1 VIAL, GLASS	5	Specialty Tier	28%	N/A	None
ELELYSO 200 UNITS VIAL	5	Specialty Tier	28%	N/A	P
ELETRIPTAN HBR 20 MG TABLET [Relpax]	4	Non-Preferred Drug	45%	N/A	Q:12 /30Days
ELETRIPTAN HBR 40 MG TABLET [Relpax]	4	Non-Preferred Drug	45%	N/A	Q:12 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ELIDEL 1% CREAM	4	Non-Preferred Drug	45%	N/A	None
ELIGARD 22.5 MG SYRINGE	4	Non-Preferred Drug	45%	N/A	None
ELIGARD 30 MG SYRINGE KIT	4	Non-Preferred Drug	45%	N/A	None
ELIGARD 45 MG SYRINGE KIT	4	Non-Preferred Drug	45%	N/A	None
ELIGARD 7.5 MG SYRINGE KIT	4	Non-Preferred Drug	45%	N/A	None
ELIQUIS 2.5 MG TABLET	3	Preferred Brand	$47.00	N/A	None
ELIQUIS 5 MG STARTER PACK	3	Preferred Brand	$47.00	N/A	None
ELIQUIS 5 MG TABLET	3	Preferred Brand	$47.00	N/A	None
Elitek 3 KIT per CARTON / 1 KIT in 1 KIT	5	Specialty Tier	28%	N/A	None
ELITEK 7.5 MG VIAL	5	Specialty Tier	28%	N/A	None
ELMIRON 100mg GELATIN COATED 100 CAPSULE BOTTLE	3	Preferred Brand	$47.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
EMCYT 140MG CAPSULE	5	Specialty Tier	28%	N/A	None
EMFLAZA 18 MG TABLET	5	Specialty Tier	28%	N/A	P
EMFLAZA 22.75 MG/ML ORAL SUSP	5	Specialty Tier	28%	N/A	P
EMFLAZA 30 MG TABLET	5	Specialty Tier	28%	N/A	P
EMFLAZA 36 MG TABLET	5	Specialty Tier	28%	N/A	P
EMFLAZA 6 MG TABLET	5	Specialty Tier	28%	N/A	P
Emoquette 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK	2	Generic	$15.00	N/A	None
Empagliflozin 5 MG / Metformin hydrochloride 500 MG Oral Tablet [Synjardy]	3	Preferred Brand	$47.00	N/A	P Q:60 /30Days
EMPLICITI 300 MG VIAL	5	Specialty Tier	28%	N/A	P
EMPLICITI 400 MG VIAL	5	Specialty Tier	28%	N/A	P
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H	5	Specialty Tier	28%	N/A	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H	5	Specialty Tier	28%	N/A	Q:30 /30Days
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H	5	Specialty Tier	28%	N/A	Q:30 /30Days
EMTRIVA 10MG/ML SOLUTION	3	Preferred Brand	$47.00	N/A	None
EMTRIVA 200MG CAPSULE	3	Preferred Brand	$47.00	N/A	None
ENALAPRIL MALEATE 10 MG TAB	6*	Select Care Drugs	$0.00	N/A	None
ENALAPRIL MALEATE 2.5 MG TAB	6*	Select Care Drugs	$0.00	N/A	None
ENALAPRIL MALEATE 20 MG TAB	6*	Select Care Drugs	$0.00	N/A	None
ENALAPRIL MALEATE 5 MG TABLET	6*	Select Care Drugs	$0.00	N/A	None
Enalapril Maleate and Hydrochlorothiazide 10; 25mg/1; mg/1 100 TABLET BOTTLE, PLASTIC	6*	Select Care Drugs	$0.00	N/A	None
ENALAPRIL-HCTZ 5-12.5 MG TAB	6*	Select Care Drugs	$0.00	N/A	None
ENBREL 25 MG/0.5 ML SYRINGE	5	Specialty Tier	28%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ENBREL 25MG KIT	5	Specialty Tier	28%	N/A	P
ENBREL 50 MG/ML SURECLICK SYR	5	Specialty Tier	28%	N/A	P
ENBREL 50mg/mL	5	Specialty Tier	28%	N/A	P
ENDOCET 10MG-325MG TABLET	3	Preferred Brand	$47.00	N/A	Q:360 /30Days
ENDOCET 5/325 TABLET	3	Preferred Brand	$47.00	N/A	Q:360 /30Days
ENDOCET 7.5-325MG TABLET	3	Preferred Brand	$47.00	N/A	Q:360 /30Days
ENGERIX B INJECTION	3	Preferred Brand	$47.00	N/A	P
ENGERIX-B 20 MCG/ML SYRN	3	Preferred Brand	$47.00	N/A	P
ENOXAPARIN 100 MG/ML SYRINGE	4	Non-Preferred Drug	45%	N/A	None
ENOXAPARIN 120 MG/0.8 ML SYRINGE	4	Non-Preferred Drug	45%	N/A	None
ENOXAPARIN 150 MG/ML SYRINGE	4	Non-Preferred Drug	45%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ENOXAPARIN 30 MG/0.3 ML SYR	4	Non-Preferred Drug	45%	N/A	None
ENOXAPARIN 300 MG/3 ML VIAL	4	Non-Preferred Drug	45%	N/A	None
ENOXAPARIN 40 MG/0.4 ML SYR	4	Non-Preferred Drug	45%	N/A	None
ENOXAPARIN 60 MG/0.6 ML SYRINGE	4	Non-Preferred Drug	45%	N/A	None
ENOXAPARIN 80 MG/0.8 ML SYRINGE	4	Non-Preferred Drug	45%	N/A	None
ENSKYCE 28 TABLET	2	Generic	$15.00	N/A	None
ENSTILAR 0.005%-0.064% FOAM	5	Specialty Tier	28%	N/A	None
ENTACAPONE 200 MG TABLET [Comtan Entacapone]	4	Non-Preferred Drug	45%	N/A	None
ENTECAVIR 0.5 MG TABLET [Baraclude]	5	Specialty Tier	28%	N/A	Q:30 /30Days
ENTECAVIR 1 MG TABLET [Baraclude]	5	Specialty Tier	28%	N/A	Q:30 /30Days
ENTRESTO 24 MG-26 MG TABLET	4	Non-Preferred Drug	45%	N/A	P Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ENTRESTO 49 MG-51 MG TABLET	4	Non-Preferred Drug	45%	N/A	P Q:60 /30Days
ENTRESTO 97 MG-103 MG TABLET	4	Non-Preferred Drug	45%	N/A	P Q:60 /30Days
ENULOSE 10 GM/15 ML SOLUTION	1	Preferred Generic	$5.00	N/A	None
ENVARSUS XR 0.75 MG TABLET	4	Non-Preferred Drug	45%	N/A	P
ENVARSUS XR 1 MG TABLET	4	Non-Preferred Drug	45%	N/A	P
ENVARSUS XR 4 MG TABLET	4	Non-Preferred Drug	45%	N/A	P
EPCLUSA 400 MG-100 MG TABLET	5	Specialty Tier	28%	N/A	P
EPINASTINE HCL 0.05% EYE DROPS	2	Generic	$15.00	N/A	None
EPINEPHRINE 0.15 MG AUTO-INJCT	3	Preferred Brand	$47.00	N/A	None
EPINEPHRINE 0.3 MG AUTO-INJECT	3	Preferred Brand	$47.00	N/A	None
EPIPEN 0.3MG AUTO-INJECTOR	3	Preferred Brand	$47.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
EPIPEN JR 0.15MG AUTO-INJCT	3	Preferred Brand	$47.00	N/A	None
Epirubicin HCl 200 MG per 100 ML Injection	1	Preferred Generic	$5.00	N/A	None
EPITOL 200MG TABLET	1	Preferred Generic	$5.00	N/A	None
EPIVIR HBV 25MG/5ML TUBEX	3	Preferred Brand	$47.00	N/A	None
Eplerenone 25mg/1 90 TABLET BOTTLE	4	Non-Preferred Drug	45%	N/A	None
Eplerenone 50mg/1 90 TABLET BOTTLE	4	Non-Preferred Drug	45%	N/A	None
EPOGEN 10000U/ML VIAL MDV	3	Preferred Brand	$47.00	N/A	P
EPOGEN 2000[iU]/mL 10 VIAL in 1 PACKAGE / 1 mL in 1 VIAL	3	Preferred Brand	$47.00	N/A	P
EPOGEN 3000U/ML VIAL SDV	3	Preferred Brand	$47.00	N/A	P
EPOGEN 4000U/ML VIAL SDV	3	Preferred Brand	$47.00	N/A	P
EPOGEN INJECTION 20000U 10 X 1ML CRTN	5	Specialty Tier	28%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
EPROSARTAN MESYLATE 600 MG TABLET	2	Generic	$15.00	N/A	None
EPZICOM 600MG/300MG TABLETS	5	Specialty Tier	28%	N/A	None
EQUETRO CAPSULES 200MG 120 BOT	4	Non-Preferred Drug	45%	N/A	None
EQUETRO CAPSULES 300MG 120 BOT	4	Non-Preferred Drug	45%	N/A	None
EQUETRO EXTENDED RELEASE CAPSULES 100MG 120 BOT	4	Non-Preferred Drug	45%	N/A	None
ERAXIS 100mg/30mL 30 mL in 1 VIAL, SINGLE-USE	5	Specialty Tier	28%	N/A	None
ERAXIS(WATER DIL) 50 MG VIAL	5	Specialty Tier	28%	N/A	None
ERBITUX 100MG/50ML VIAL	5	Specialty Tier	28%	N/A	P
ERGOLOID MESYLATES TABLETS 1MG 100 BOT	3	Preferred Brand	$47.00	N/A	P
ERIVEDGE 150 MG CAPSULE	5	Specialty Tier	28%	N/A	P Q:30 /30Days
ERLEADA 60 MG TABLET	5	Specialty Tier	28%	N/A	P Q:120 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Errin 0.35 mg tablet	2	Generic	$15.00	N/A	None
ERWINAZE 10,000 UNITS VIAL	5	Specialty Tier	28%	N/A	None
ERY 2% PADS 2% 60 PADS JAR	2	Generic	$15.00	N/A	None
ERYPED 200 MG/5 ML SUSPENSION	4	Non-Preferred Drug	45%	N/A	None
ERYPED 400 MG/5 ML SUSPENSION	4	Non-Preferred Drug	45%	N/A	None
ERYTHROCIN 500MG ADDVNT VL	3	Preferred Brand	$47.00	N/A	None
ERYTHROCIN TAB 250MG	2	Generic	$15.00	N/A	None
ERYTHROMYCIN 0.5% EYE OINTMENT	2	Generic	$15.00	N/A	None
ERYTHROMYCIN 2% GEL	1	Preferred Generic	$5.00	N/A	None
ERYTHROMYCIN 2% SOLUTION	1	Preferred Generic	$5.00	N/A	None
ERYTHROMYCIN 500 MG FILMTAB	4	Non-Preferred Drug	45%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ERYTHROMYCIN EC 250 MG CAP	4	Non-Preferred Drug	45%	N/A	None
ERYTHROMYCIN ES 400 MG TAB	2	Generic	$15.00	N/A	None
Erythromycin Ethylsuccinate 40 MG/ML Oral Suspension	2	Generic	$15.00	N/A	None
ERYTHROMYCIN TAB 250MG BS	4	Non-Preferred Drug	45%	N/A	None
ERYTHROMYCIN-BENZOYL GEL	1	Preferred Generic	$5.00	N/A	None
ESBRIET 267 MG CAPSULE	5	Specialty Tier	28%	N/A	P
ESBRIET 267 MG TABLET	5	Specialty Tier	28%	N/A	P
ESBRIET 801 MG TABLET	5	Specialty Tier	28%	N/A	P
ESCITALOPRAM 10 MG TABLET [Lexapro]	1	Preferred Generic	$5.00	N/A	None
ESCITALOPRAM 20 MG TABLET [Lexapro]	1	Preferred Generic	$5.00	N/A	None
ESCITALOPRAM 5 MG TABLET [Lexapro]	1	Preferred Generic	$5.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ESCITALOPRAM OXALATE 5 MG/5 ML [Lexapro]	1	Preferred Generic	$5.00	N/A	None
ESOMEPRAZOLE SODIUM 20 MG VIAL [Nexium]	4	Non-Preferred Drug	45%	N/A	None
ESOMEPRAZOLE SODIUM 40 MG VIAL [Nexium]	4	Non-Preferred Drug	45%	N/A	None
ESTARYLLA 0.25-0.035 MG TABLET [VyLibra]	2	Generic	$15.00	N/A	None
ESTRACE VAG CREAM 0.1MG/GM	4	Non-Preferred Drug	45%	N/A	None
Estradiol / Norethindrone Acetate 0.5; 0.1mg/1; mg/1 1 BLISTER PACK per CARTON / 28 TABLET, FILM C	4	Non-Preferred Drug	45%	N/A	P
ESTRADIOL 0.01% CREAM	4	Non-Preferred Drug	45%	N/A	None
Estradiol 0.025 mg patch	3	Preferred Brand	$47.00	N/A	P
Estradiol 0.0375 mg patch	3	Preferred Brand	$47.00	N/A	P
Estradiol 0.05 mg patch	3	Preferred Brand	$47.00	N/A	P
Estradiol 0.075 mg patch	3	Preferred Brand	$47.00	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Estradiol 0.1 mg patch	3	Preferred Brand	$47.00	N/A	P
ESTRADIOL 0.5 MG TABLET	3	Preferred Brand	$47.00	N/A	P
ESTRADIOL 1 MG TABLET	3	Preferred Brand	$47.00	N/A	P
ESTRADIOL 10 MCG VAGINAL INSRT	2	Generic	$15.00	N/A	None
ESTRADIOL 2MG TABLET	3	Preferred Brand	$47.00	N/A	P
ESTRADIOL TDS 0.025 MG/DAY	3	Preferred Brand	$47.00	N/A	P
ESTRADIOL TDS 0.0375 MG/DAY	3	Preferred Brand	$47.00	N/A	P
ESTRADIOL TDS 0.05 MG/DAY	3	Preferred Brand	$47.00	N/A	P
ESTRADIOL TDS 0.06 MG/DAY	3	Preferred Brand	$47.00	N/A	P
ESTRADIOL TDS 0.075 MG/DAY	3	Preferred Brand	$47.00	N/A	P
ESTRADIOL TDS 0.1 MG/DAY	3	Preferred Brand	$47.00	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ESTRADIOL VALERATE 20mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE	2	Generic	$15.00	N/A	None
ESTRADIOL VALERATE 40mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE	2	Generic	$15.00	N/A	None
ESTRADIOL-NORETH 1.0-0.5MG TABLET	4	Non-Preferred Drug	45%	N/A	P
ESTRING 2MG VAGINAL RING	4	Non-Preferred Drug	45%	N/A	Q:1 /30Days
ESTROPIPATE 0.625(0.75 MG) TABLET	3	Preferred Brand	$47.00	N/A	P
ESTROPIPATE 1.25(1.5 MG) TABLET	3	Preferred Brand	$47.00	N/A	P
ETHAMBUTOL HCL 400 MG TABLET	2	Generic	$15.00	N/A	None
Ethambutol Hydrochloride 100mg/1	2	Generic	$15.00	N/A	None
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6	2	Generic	$15.00	N/A	None
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TAB 21	2	Generic	$15.00	N/A	None
ETHOSUXIMIDE 250 MG CAPSULE	2	Generic	$15.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ETHOSUXIMIDE 250 MG/5 ML SOLN	4	Non-Preferred Drug	45%	N/A	None
ETHYNODIOL-ETH ESTRA 1MG-35MCG [ZOVIA]	2	Generic	$15.00	N/A	None
ethynodiol-eth estra 1mg-50mcg [ZOVIA]	2	Generic	$15.00	N/A	None
ETIDRONATE DISODIUM 400MG TABLET (60 CT)	2	Generic	$15.00	N/A	None
ETIDRONATE DISODIUM TABLETS 200MG 60 BOT	2	Generic	$15.00	N/A	None
ETODOLAC 200 MG CAPSULE [LODINE]	2	Generic	$15.00	N/A	None
ETODOLAC 300 MG CAPSULE [LODINE]	2	Generic	$15.00	N/A	None
ETODOLAC 400 MG TABLET [LODINE]	2	Generic	$15.00	N/A	None
ETODOLAC 500 MG TABLET [LODINE]	2	Generic	$15.00	N/A	None
ETODOLAC ER 400 MG TABLET [LODINE]	4	Non-Preferred Drug	45%	N/A	None
ETODOLAC ER 500 MG TABLET [LODINE]	4	Non-Preferred Drug	45%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ETODOLAC ER 600 MG TABLET [LODINE]	4	Non-Preferred Drug	45%	N/A	None
ETOPOPHOS 100MG VIAL	5	Specialty Tier	28%	N/A	None
EURAX 10% LOTION	4	Non-Preferred Drug	45%	N/A	None
Eurax Lotion and Cream 100mg/g 60 g in 1 TUBE	4	Non-Preferred Drug	45%	N/A	None
EVOTAZ 300 MG-150 MG TABLET	5	Specialty Tier	28%	N/A	Q:30 /30Days
EXEMESTANE 25 MG TABLET	4	Non-Preferred Drug	45%	N/A	None
EXJADE 125MG TABLET	5	Specialty Tier	28%	N/A	None
EXJADE 250MG TABLET	5	Specialty Tier	28%	N/A	None
EXJADE 500MG TABLET	5	Specialty Tier	28%	N/A	None
EXTAVIA 15 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK	5	Specialty Tier	28%	N/A	P Q:15 /30Days
Ezetimibe 10 MG Oral Tablet [Zetia]	4	Non-Preferred Drug	45%	N/A	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Ezetimibe-Simvastatin 10-10 MG [Vytorin]	2	Generic	$15.00	N/A	None
Ezetimibe-Simvastatin 10-20 MG [Vytorin]	2	Generic	$15.00	N/A	None
Ezetimibe-Simvastatin 10-40 MG [Vytorin]	2	Generic	$15.00	N/A	None
Ezetimibe-Simvastatin 10-80 MG [Vytorin]	2	Generic	$15.00	N/A	None

Chart Legend:

Below are a few notes to help you understand the above 2018 Medicare Part D Asuris Medicare Script Basic (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.