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EnvisionRxPlus (PDP) (S7694-032-0)
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M N O P Q R S T U V W X Y Z 0-9 
2018 Medicare Part D Plan Formulary Information
EnvisionRxPlus (PDP) (S7694-032-0)
Benefit Details           
The EnvisionRxPlus (PDP) (S7694-032-0)
Formulary Drugs Starting with the Letter M
in CMS PDP Region 32 which includes: CA
Plan Monthly Premium: $50.00 Deductible: $405 Qualifies for LIS: No
Drugs Starting with Letter M

Drug Name		 Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order
M-M-R II VACCINE W/DILUENT 1 DOSE/0.5ML   4 Non-Preferred Drug 27%27%None
MAGNESIUM SULFATE 50% VIAL   4 Non-Preferred Drug 27%27%None
MAGNESIUM SULFATE INJECTION 5 GM/10ML   4 Non-Preferred Drug 27%27%None
MALATHION 0.5% LOTION   4 Non-Preferred Drug 27%27%None
MAPROTILINE 25MG TABLET   4 Non-Preferred Drug 27%27%None
MAPROTILINE 50MG TABLET   4 Non-Preferred Drug 27%27%None
MAPROTILINE 75MG TABLET   4 Non-Preferred Drug 27%27%None
MARLISSA-28 TABLET   4 Non-Preferred Drug 27%27%None
MARPLAN 10MG TABLET (100 CT)   4 Non-Preferred Drug 27%27%S Q:180
/30Days
MATULANE 50 MG CAPSULE   5 Specialty Tier 25%N/AP
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
MECLIZINE 12.5 MG TABLET   2 Generic $3.00$4.50None
MECLIZINE 25 MG TABLET   2 Generic $3.00$4.50None
MEDROXYPROGESTERONE 10 MG TABLET [Provera]   2 Generic $3.00$4.50None
MEDROXYPROGESTERONE 150 MG/ML Syringe [Depo-Provera]   4 Non-Preferred Drug 27%27%None
MEDROXYPROGESTERONE 150 MG/ML VIAL [Depo-Provera]   4 Non-Preferred Drug 27%27%None
MEDROXYPROGESTERONE 2.5 MG TABLET [Provera]   2 Generic $3.00$4.50None
MEDROXYPROGESTERONE 5 MG TABLET [Provera]   2 Generic $3.00$4.50None
MEFLOQUINE HCL 250 MG TABLET   4 Non-Preferred Drug 27%27%None
MEGESTROL 20 MG TABLET   2 Generic $3.00$4.50P
MEGESTROL 40 MG TABLET   2 Generic $3.00$4.50P
MEGESTROL 625 MG/5 ML SUSP   4 Non-Preferred Drug 27%27%P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
MEGESTROL ACET 40 MG/ML SUSP   4 Non-Preferred Drug 27%27%P
MEKINIST 0.5 MG TABLET   5 Specialty Tier 25%N/AP Q:120
/30Days
MEKINIST 2 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
MELOXICAM 15 MG TABLET   1 Preferred Generic $1.00$0.00None
MELOXICAM 7.5 MG TABLET   1 Preferred Generic $1.00$0.00None
MELPHALAN 5 MG/ML INJECTABLE SOLUTION   5 Specialty Tier 25%N/AP
MEMANTINE 5-10 MG TITRATION PK [Namenda Titration]   4 Non-Preferred Drug 27%27%None
MEMANTINE HCL 10 MG TABLET [Namenda]   4 Non-Preferred Drug 27%27%None
MEMANTINE HCL 2 MG/ML SOLUTION [Namenda]   4 Non-Preferred Drug 27%27%Q:360
/30Days
MEMANTINE HCL 5 MG TABLET [Namenda]   4 Non-Preferred Drug 27%27%None
MEMANTINE HCL ER 14 MG CAPSULE SPR 24 [Namenda]   3 Preferred Brand 15%15%P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
MEMANTINE HCL ER 21 MG CAPSULE SPR 24 [Namenda]   3 Preferred Brand 15%15%P
MEMANTINE HCL ER 28 MG CAPSULE SPR 24 [Namenda]   3 Preferred Brand 15%15%P
MEMANTINE HCL ER 7 MG CAPSULE SPR 24 [Namenda]   3 Preferred Brand 15%15%P
Menactra 4; 4; 4; 4ug/0.5mL; ug/0.5mL; ug/0.5mL; ug/0.5mL 5 VIAL, SINGLE-DOSE in 1 PACKAGE / 0.5 mL   4 Non-Preferred Drug 27%27%None
MENVEO A-C-Y-W-135-DIP VIAL   4 Non-Preferred Drug 27%27%None
MERCAPTOPURINE 50 MG TABLET   4 Non-Preferred Drug 27%27%None
MEROPENEM 500MG/VIAL FOR INJECTION   4 Non-Preferred Drug 27%27%None
MEROPENEM IV 1 GM VIAL   4 Non-Preferred Drug 27%27%None
MESNA 1 GRAM/10 ML VIAL   4 Non-Preferred Drug 27%27%P
MESNEX 400MG TABLET   5 Specialty Tier 25%N/ANone
Metadate er 20 mg tablet   4 Non-Preferred Drug 27%27%Q:90
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
METAXALONE 800 MG TABLET   4 Non-Preferred Drug 27%27%Q:120
/30Days
METFORMIN HCL 1,000 MG TABLET   1 Preferred Generic $1.00$0.00None
METFORMIN HCL 500 MG TABLET   1 Preferred Generic $1.00$0.00None
METFORMIN HCL 850 MG TABLET   1 Preferred Generic $1.00$0.00None
METFORMIN HCL ER 500 MG TABLET   2 Generic $3.00$4.50None
METFORMIN HCL ER 750 MG TABLET   2 Generic $3.00$4.50None
METHADONE HCL 10 MG TABLET [Methadose]   2 Generic $3.00$4.50Q:240
/30Days
METHADONE HCL 5 MG TABLET [Methadose]   2 Generic $3.00$4.50Q:240
/30Days
Methazolamide 25 MG Oral Tablet   4 Non-Preferred Drug 27%27%None
METHAZOLAMIDE 50 MG TABLET   4 Non-Preferred Drug 27%27%None
Methenamine Hippurate 1g/1   4 Non-Preferred Drug 27%27%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
METHIMAZOLE 10 MG TABLET   2 Generic $3.00$4.50None
METHIMAZOLE 5 MG TABLET   2 Generic $3.00$4.50None
Methocarbamol 100 MG/ML in 10 ML Injection   4 Non-Preferred Drug 27%27%P
METHOCARBAMOL 500 MG TABLET   3 Preferred Brand 15%15%P
METHOCARBAMOL 750 MG TABLET   3 Preferred Brand 15%15%P
methotrexate 1 gm vial   4 Non-Preferred Drug 27%27%P
METHOTREXATE 2.5MG TABLET   2 Generic $3.00$4.50P
METHOTREXATE 250 MG/10 ML VIAL   4 Non-Preferred Drug 27%27%P
METHOTREXATE 250 MG/10 ML VIAL   4 Non-Preferred Drug 27%27%P
METHOTREXATE 50 MG/2 ML VIAL   4 Non-Preferred Drug 27%27%P
METHYCLOTHIAZIDE 5MG TABLET   3 Preferred Brand 15%15%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
METHYLPHENIDATE 10 MG TABLET [Ritalin]   4 Non-Preferred Drug 27%27%Q:90
/30Days
METHYLPHENIDATE 10 MG/5 ML SOLUTION [Methylin]   4 Non-Preferred Drug 27%27%Q:900
/30Days
METHYLPHENIDATE 20 MG TABLET [Ritalin]   4 Non-Preferred Drug 27%27%Q:90
/30Days
METHYLPHENIDATE 5 MG TABLET [Ritalin]   4 Non-Preferred Drug 27%27%Q:90
/30Days
METHYLPHENIDATE 5 MG/5 ML SOLUTION [Methylin]   4 Non-Preferred Drug 27%27%Q:1800
/30Days
METHYLPHENIDATE ER 10 MG TABLET [Methylin]   4 Non-Preferred Drug 27%27%Q:90
/30Days
METHYLPHENIDATE ER 20 MG TABLET [Ritalin SR]   4 Non-Preferred Drug 27%27%Q:90
/30Days
methylprednisolone 125 mg vial   4 Non-Preferred Drug 27%27%None
Methylprednisolone 125 mg vial   4 Non-Preferred Drug 27%27%P
METHYLPREDNISOLONE 16MG TABLET   2 Generic $3.00$4.50None
METHYLPREDNISOLONE 32MG TABLET   2 Generic $3.00$4.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
METHYLPREDNISOLONE 4 MG DOSEPK   4 Non-Preferred Drug 27%27%None
METHYLPREDNISOLONE 4 MG TABLET   2 Generic $3.00$4.50None
methylprednisolone 40 mg vial   4 Non-Preferred Drug 27%27%None
Methylprednisolone 40 mg/ml vl   4 Non-Preferred Drug 27%27%None
METHYLPREDNISOLONE 8 MG ORAL TABLET   2 Generic $3.00$4.50None
Methylprednisolone acetate 80 MG per 1 ML Injection   4 Non-Preferred Drug 27%27%None
Metipranolol 0.3% eye drops   2 Generic $3.00$4.50None
Metoclopramide 10mg/1 500 TABLET BOTTLE   2 Generic $3.00$4.50None
METOCLOPRAMIDE 5 MG TABLET   2 Generic $3.00$4.50None
METOCLOPRAMIDE 5 MG/5 ML SOLN   2 Generic $3.00$4.50None
Metoclopramide 5mg/mL 25 VIAL in 1 TRAY / 2 mL in 1 VIAL   4 Non-Preferred Drug 27%27%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
METOLAZONE 10MG TABLET   3 Preferred Brand 15%15%None
METOLAZONE 2.5MG TABLET   3 Preferred Brand 15%15%None
METOLAZONE 5MG TABLET   3 Preferred Brand 15%15%None
METOPROLOL SUCC ER 100 MG TAB   2 Generic $3.00$4.50None
METOPROLOL SUCC ER 200 MG TAB   2 Generic $3.00$4.50None
METOPROLOL SUCC ER 25 MG TAB   2 Generic $3.00$4.50None
METOPROLOL SUCC ER 50 MG TAB   2 Generic $3.00$4.50None
METOPROLOL TARTRATE 100 MG TAB   1 Preferred Generic $1.00$0.00None
METOPROLOL TARTRATE 25 MG TAB   1 Preferred Generic $1.00$0.00None
Metoprolol Tartrate 5 ML 1 MG/ML Injection   4 Non-Preferred Drug 27%27%None
METOPROLOL TARTRATE INJ.USP 5MG/5ML CARPUJECT   4 Non-Preferred Drug 27%27%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT)   1 Preferred Generic $1.00$0.00None
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET   3 Preferred Brand 15%15%None
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET   3 Preferred Brand 15%15%None
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET   3 Preferred Brand 15%15%None
METRONIDAZOLE 0.75% CREAM Cream (g) [Vitazol]   4 Non-Preferred Drug 27%27%None
METRONIDAZOLE 0.75% LOTION [MetroLotion]   4 Non-Preferred Drug 27%27%None
METRONIDAZOLE 250 MG TABLET [Flagyl]   2 Generic $3.00$4.50None
METRONIDAZOLE 500 MG TABLET [Flagyl]   2 Generic $3.00$4.50None
METRONIDAZOLE 500 MG/100 ML PIGGYBACK [Flagyl RTU]   4 Non-Preferred Drug 27%27%None
METRONIDAZOLE TOPICAL 0.75% GL Gel [Nydamax]   4 Non-Preferred Drug 27%27%None
METRONIDAZOLE TOPICAL 1% GEL [MetroGel]   4 Non-Preferred Drug 27%27%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
METRONIDAZOLE VAGINAL 0.75% GL GEL W/APPL [Vandazole]   4 Non-Preferred Drug 27%27%None
MEXILETINE 150MG CAPSULE   4 Non-Preferred Drug 27%27%None
MEXILETINE 200MG CAPSULE   4 Non-Preferred Drug 27%27%None
MEXILETINE 250MG CAPSULE   4 Non-Preferred Drug 27%27%None
MIACALCIN 400 UNIT/2 ML VIAL   5 Specialty Tier 25%N/AP
Microgestin 21 1-20 tablet   4 Non-Preferred Drug 27%27%None
MICROGESTIN 21 1.5-30 TAB   4 Non-Preferred Drug 27%27%None
Microgestin fe 1-20 tablet   4 Non-Preferred Drug 27%27%None
MICROGESTIN FE 1.5-30 TAB   4 Non-Preferred Drug 27%27%None
MIDODRINE HCL 10 MG TABLET   4 Non-Preferred Drug 27%27%None
MIDODRINE HCL 2.5 MG TABLET   4 Non-Preferred Drug 27%27%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
MIDODRINE HCL 5 MG TABLET   4 Non-Preferred Drug 27%27%None
Migergot suppository   4 Non-Preferred Drug 27%27%Q:20
/28Days
MIGLUSTAT 100 MG CAPSULE [Zavesca]   5 Specialty Tier 25%N/AP
MILI 0.25-0.035 MG TABLET [VyLibra]   4 Non-Preferred Drug 27%27%None
MINOCYCLINE 100 MG CAPSULE   2 Generic $3.00$4.50None
MINOCYCLINE 50 MG CAPSULE   2 Generic $3.00$4.50None
MINOCYCLINE 75 MG CAPSULE   2 Generic $3.00$4.50None
MINOCYCLINE HCL 100 MG TABLET   4 Non-Preferred Drug 27%27%None
MINOCYCLINE HCL 75 MG TABLET   4 Non-Preferred Drug 27%27%None
MINOCYCLINE HYDROCHLORIDE TABLETS 50MG   4 Non-Preferred Drug 27%27%None
MINOXIDIL 10MG TABLET   2 Generic $3.00$4.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
MINOXIDIL 2.5MG TABLET   2 Generic $3.00$4.50None
MIRTAZAPINE 15 MG ODT   4 Non-Preferred Drug 27%27%Q:30
/30Days
MIRTAZAPINE 15 MG TABLET   2 Generic $3.00$4.50None
MIRTAZAPINE 30 MG ODT   4 Non-Preferred Drug 27%27%Q:30
/30Days
MIRTAZAPINE 30 MG TABLET   2 Generic $3.00$4.50None
Mirtazapine 45 mg odt   4 Non-Preferred Drug 27%27%Q:30
/30Days
MIRTAZAPINE 45 MG TABLET   2 Generic $3.00$4.50None
MIRTAZAPINE 7.5 MG TABLET   2 Generic $3.00$4.50Q:45
/30Days
misoprostol 100 mcg tablet   3 Preferred Brand 15%15%None
misoprostol 200 mcg tablet   3 Preferred Brand 15%15%None
MITOMYCIN 20 MG VIAL   4 Non-Preferred Drug 27%27%P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
MITOMYCIN 40 MG VIAL   4 Non-Preferred Drug 27%27%P
MITOMYCIN 5 MG VIAL   4 Non-Preferred Drug 27%27%P
MITOXANTRONE INJECTION 2MG 125ML VIAL   4 Non-Preferred Drug 27%27%None
MODAFINIL 100 MG TABLET [Provigil]   4 Non-Preferred Drug 27%27%P Q:90
/30Days
MODAFINIL 200 MG TABLET [Provigil]   4 Non-Preferred Drug 27%27%P Q:60
/30Days
Moexipril hcl 15 mg tablet   2 Generic $3.00$4.50None
MOEXIPRIL HCL 7.5 MG TABLET   2 Generic $3.00$4.50None
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-12.5MG TABLET   2 Generic $3.00$4.50None
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-25MG TABLET   2 Generic $3.00$4.50None
MOEXIPRIL-HYDROCHLOROTHIAZIDE 7.5-12.5MG TABLET   2 Generic $3.00$4.50None
MOMETASONE FUROATE 0.1% CREAM   2 Generic $3.00$4.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
MOMETASONE FUROATE 0.1% OINT   2 Generic $3.00$4.50None
MONONESSA TABLETS .250;.035MG; MG 6 X 28 CRTN   4 Non-Preferred Drug 27%27%None
MONTELUKAST SOD 10 MG TABLET [Singulair]   1 Preferred Generic $1.00$0.00None
MONTELUKAST SOD 4 MG GRANULES [Singulair]   4 Non-Preferred Drug 27%27%Q:30
/30Days
MONTELUKAST SOD 4 MG TAB CHEW [Singulair]   2 Generic $3.00$4.50Q:30
/30Days
MONTELUKAST SOD 5 MG TAB CHEW [Singulair]   2 Generic $3.00$4.50Q:30
/30Days
MORPHINE SULF 20 MG/5 ML SOLN   4 Non-Preferred Drug 27%27%P Q:900
/30Days
MORPHINE SULF ER 100 MG TABLET   4 Non-Preferred Drug 27%27%Q:90
/30Days
MORPHINE SULF ER 15 MG TABLET   2 Generic $3.00$4.50Q:90
/30Days
MORPHINE SULF ER 200 MG TABLET   4 Non-Preferred Drug 27%27%Q:90
/30Days
MORPHINE SULF ER 30 MG TABLET   4 Non-Preferred Drug 27%27%Q:90
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
MORPHINE SULF ER 60 MG TABLET   4 Non-Preferred Drug 27%27%Q:90
/30Days
MORPHINE SULFATE 100 mg/5 ml soln   4 Non-Preferred Drug 27%27%P Q:300
/30Days
MORPHINE SULFATE 10MG/5ML ORAL SOLUTION   4 Non-Preferred Drug 27%27%P Q:900
/30Days
MORPHINE SULFATE 15MG TABLETS   3 Preferred Brand 15%15%Q:180
/30Days
MORPHINE SULFATE 30MG TABLETS   3 Preferred Brand 15%15%Q:180
/30Days
MOVIPREP 7.5-2.691G POWDER IN PACKET   4 Non-Preferred Drug 27%27%None
MOXEZA 5.45mg/mL 3 mL in 1 BOTTLE   3 Preferred Brand 15%15%None
MOXIFLOXACIN 0.5% EYE DROPS   3 Preferred Brand 15%15%None
MOZOBIL 20 MG/ML VIAL   5 Specialty Tier 25%N/AP Q:8
/30Days
Multaq 400mg/1 60 FILM COATED TABLETS in BOTTLE   3 Preferred Brand 15%15%None
MUPIROCIN 2% OINTMENT   2 Generic $3.00$4.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
MUSTARGEN 10 MG VIAL   4 Non-Preferred Drug 27%27%P
MYCOPHENOLATE 200 MG/ML SUSP   5 Specialty Tier 25%N/AP
MYCOPHENOLATE 250 MG CAPSULE   4 Non-Preferred Drug 27%27%P
MYCOPHENOLATE 500 MG TABLET [CellCept]   4 Non-Preferred Drug 27%27%P
Mycophenolate 500 mg vial   4 Non-Preferred Drug 27%27%P
MYCOPHENOLIC ACID DR 180 MG TB   4 Non-Preferred Drug 27%27%P
MYCOPHENOLIC ACID DR 360 MG TB   4 Non-Preferred Drug 27%27%P
Mylotarg 5 mg/5mL 5 mL in 1 VIAL, SINGLE-DOSE   5 Specialty Tier 25%N/AP
MYRBETRIQ ER 25 MG TABLET   3 Preferred Brand 15%15%None
MYRBETRIQ ER 50 MG TABLET   3 Preferred Brand 15%15%None
MYTESI 125 MG DR TABLET   4 Non-Preferred Drug 27%27%P

Chart Legend:

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