Q1GROUP LLC | Q1Medicare.com - a non-government resource for the Medicare community
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

Select your search style and criteria below or use this example to get started

Search by:
State & Plan   ZIP & Plan   PlanID   FormularyID

Search Criteria
PDP     MAPD
Scroll down to see formulary results.

First Health Part D Premier Plus (PDP) (S5768-185-0)
Tier 1 (256)
Tier 2 (514)
Tier 3 (1063)
Tier 4 (2826)
Tier 5 (717)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
Yes No Show either
Cick on the first letter of your drug name to browse the formulary:

A B C D E F G H I J K L 
M N O P Q R S T U V W X Y Z 0-9 
2018 Medicare Part D Plan Formulary Information
First Health Part D Premier Plus (PDP) (S5768-185-0)
Benefit Details           
The First Health Part D Premier Plus (PDP) (S5768-185-0)
Formulary Drugs Starting with the Letter T
in CMS PDP Region 01 which includes: ME NH
Plan Monthly Premium: $96.80 Deductible: $0 Qualifies for LIS: No
Drugs Starting with Letter T

Drug Name		 Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order
TABLOID 40 MG TABLET   4 Non-Preferred Drug 42%42%None
TACLONEX OINTMENT   4 Non-Preferred Drug 42%42%S Q:400
/28Days
TACLONEX SCALP SUSPENSION   4 Non-Preferred Drug 42%42%S
Tacrolimus 0.03% ointment   4 Non-Preferred Drug 42%42%Q:60
/30Days
Tacrolimus 0.1% ointment   4 Non-Preferred Drug 42%42%Q:60
/30Days
TACROLIMUS 0.5 MG CAPSULE   4 Non-Preferred Drug 42%42%P
TACROLIMUS 1 MG CAPSULE   4 Non-Preferred Drug 42%42%P
TACROLIMUS 5 MG CAPSULE   4 Non-Preferred Drug 42%42%P
TAFINLAR 50 MG CAPSULE   5 Specialty Tier 33%N/AP
TAFINLAR 75 MG CAPSULE   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
TAGRISSO 40 MG TABLET   5 Specialty Tier 33%N/AP
TAGRISSO 80 MG TABLET   5 Specialty Tier 33%N/AP
TAMIFLU 30 MG 1 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK   3 Preferred Brand $35.00$105.00None
TAMIFLU 45 MG 1 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK   3 Preferred Brand $35.00$105.00None
TAMIFLU 6 MG/ML SUSPENSION   3 Preferred Brand $35.00$105.00None
TAMIFLU 75 MG CAPSULE UD   3 Preferred Brand $35.00$105.00None
TAMOXIFEN 10 MG TABLET   2 Generic $2.00$6.00None
TAMOXIFEN CITRATE 20MG TABLET (30 CT)   2 Generic $2.00$6.00None
TAMSULOSIN HCL 0.4 MG CAPSULE   2 Generic $2.00$6.00Q:60
/30Days
TAPAZOLE 10MG TABLET   4 Non-Preferred Drug 42%42%None
TAPAZOLE 5MG TABLET   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
TARCEVA 100MG TABLET   5 Specialty Tier 33%N/AP
TARCEVA 150MG TABLET   5 Specialty Tier 33%N/AP
TARCEVA 25MG TABLET   5 Specialty Tier 33%N/AP
TARGRETIN 1% GEL   5 Specialty Tier 33%N/AP
Tarina Fe 1-20 tablet   3 Preferred Brand $35.00$105.00None
Tarka 2; 240mg/1; mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE   4 Non-Preferred Drug 42%42%None
TARKA 2/180MG TABLET SA   4 Non-Preferred Drug 42%42%None
Tarka 4; 240mg/1; mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE   4 Non-Preferred Drug 42%42%None
Tasigna 150mg/1 4 BLISTER PACK per CARTON / 28 CAPSULE per BLISTER PACK   5 Specialty Tier 33%N/AP
TASIGNA 200 MG CAPSULE   5 Specialty Tier 33%N/AP
TASIGNA 50 MG CAPSULE   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
TAXOTERE 80mg/4mL 1 VIAL, GLASS per CARTON / 4 mL in 1 VIAL, GLASS   5 Specialty Tier 33%N/AP
TAZAROTENE 0.1% CREAM [Tazorac]   4 Non-Preferred Drug 42%42%None
TAZICEF 1GM VIAL   4 Non-Preferred Drug 42%42%None
TAZICEF 2 GRAM VIAL   4 Non-Preferred Drug 42%42%None
TAZICEF 6 GRAM VIAL   4 Non-Preferred Drug 42%42%None
TAZORAC 0.05% CREAM   4 Non-Preferred Drug 42%42%P
TAZORAC 0.05% GEL   4 Non-Preferred Drug 42%42%P
TAZORAC 0.1% CREAM   4 Non-Preferred Drug 42%42%P
TAZORAC 0.1% GEL   4 Non-Preferred Drug 42%42%P
TAZTIA DILTIAZEM HYDROCHLORIDE 120MG ER CAPSULES   2 Generic $2.00$6.00None
TAZTIA XT 180 MG CAPSULE   2 Generic $2.00$6.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
TAZTIA XT 240MG CAPSULE SA   2 Generic $2.00$6.00None
TAZTIA XT 300 MG CAPSULE   2 Generic $2.00$6.00None
TAZTIA XT 360MG CAPSULE SA   2 Generic $2.00$6.00None
TECENTRIQ 1,200 MG/20 ML VIAL   5 Specialty Tier 33%N/AP
Teflaro 400mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE   5 Specialty Tier 33%N/ANone
Teflaro 600mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE   5 Specialty Tier 33%N/ANone
TEGRETOL SUSPENSION 100MG/5ML 450 ML BOT   4 Non-Preferred Drug 42%42%S
TEGRETOL TABLETS 200MG 100 BOT   4 Non-Preferred Drug 42%42%S
TEGRETOL XR TABLETS 100MG 100 BOT   4 Non-Preferred Drug 42%42%S
TEGRETOL XR TABLETS 200MG 100 BOT   4 Non-Preferred Drug 42%42%S
TEGRETOL XR TABLETS 400MG 100 BOT   4 Non-Preferred Drug 42%42%S
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
TEKTURNA 150 MG TABLET   4 Non-Preferred Drug 42%42%Q:30
/30Days
TEKTURNA 300 MG TABLET   4 Non-Preferred Drug 42%42%Q:30
/30Days
TEKTURNA HCT 300-25 MG TABLET   4 Non-Preferred Drug 42%42%Q:30
/30Days
Telmisartan 20 MG Tablet [Micardis]   2 Generic $2.00$6.00Q:30
/30Days
Telmisartan 40 MG Tablet [Micardis]   2 Generic $2.00$6.00Q:30
/30Days
Telmisartan 80 MG Tablet [Micardis]   2 Generic $2.00$6.00Q:30
/30Days
Telmisartan-Amlodipine 40-10 MG [Micardis]   1 Preferred Generic $1.00$3.00Q:30
/30Days
Telmisartan-Amlodipine 40-5 MG [Micardis]   1 Preferred Generic $1.00$3.00Q:30
/30Days
Telmisartan-Amlodipine 80-10 MG [Micardis]   1 Preferred Generic $1.00$3.00Q:30
/30Days
Telmisartan-Amlodipine 80-5 MG [Micardis]   1 Preferred Generic $1.00$3.00Q:30
/30Days
TELMISARTAN-HCTZ 40-12.5 MG TB [Micardis]   3 Preferred Brand $35.00$105.00Q:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
TELMISARTAN-HCTZ 80-12.5 MG TAB [Micardis HCT]   3 Preferred Brand $35.00$105.00Q:30
/30Days
TELMISARTAN-HCTZ 80-25 MG TAB [Micardis HCT]   3 Preferred Brand $35.00$105.00Q:30
/30Days
TEMAZEPAM 15 MG CAPSULE   4 Non-Preferred Drug 42%42%Q:30
/30Days
TEMAZEPAM 22.5 MG CAPSULE   4 Non-Preferred Drug 42%42%Q:30
/30Days
TEMAZEPAM 30 MG CAPSULE   4 Non-Preferred Drug 42%42%Q:30
/30Days
Temazepam 7.5mg/1 100 CAPSULE BOTTLE, PLASTIC   4 Non-Preferred Drug 42%42%Q:30
/30Days
TENIVAC SYRINGE   3 Preferred Brand $35.00$105.00P
TENOFOVIR DISOP FUM 300 MG TB [Viread]   5 Specialty Tier 33%N/ANone
TENORMIN 100 MG TABLET   4 Non-Preferred Drug 42%42%None
TENORMIN 25 MG TABLET   4 Non-Preferred Drug 42%42%None
TENORMIN 50 MG TABLET   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
TERAZOSIN 1 MG CAPSULE   1 Preferred Generic $1.00$3.00None
TERAZOSIN 10 MG CAPSULE [Hytrin]   1 Preferred Generic $1.00$3.00None
TERAZOSIN 2 MG CAPSULE   1 Preferred Generic $1.00$3.00None
TERAZOSIN 5 MG CAPSULE [Hytrin]   1 Preferred Generic $1.00$3.00None
TERBINAFINE HCL 250 MG TABLET   2 Generic $2.00$6.00None
TERBUTALINE SULF 1MG/ML VL   4 Non-Preferred Drug 42%42%None
TERBUTALINE SULFATE 2.5 MG TAB   4 Non-Preferred Drug 42%42%None
TERBUTALINE SULFATE 5MG TABLET   4 Non-Preferred Drug 42%42%None
TERCONAZOLE 0.4% CREAM WITH APPLICATOR   3 Preferred Brand $35.00$105.00None
TERCONAZOLE 0.8% CREAM   3 Preferred Brand $35.00$105.00None
TERCONAZOLE 80MG SUPPOSITORY VAGINAL   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
TESTIM 1%(50MG) GEL   4 Non-Preferred Drug 42%42%P Q:300
/30Days
TESTOSTERONE 10 MG GEL PUMP   4 Non-Preferred Drug 42%42%P Q:120
/30Days
TESTOSTERONE 12.5 MG/1.25 GRAM   4 Non-Preferred Drug 42%42%P Q:300
/30Days
Testosterone 2500 MG 0.01 MG/MG Topical Gel   4 Non-Preferred Drug 42%42%P Q:300
/30Days
TESTOSTERONE 30 MG/1.5 ML PUMP   3 Preferred Brand $35.00$105.00P Q:440
/30Days
Testosterone 5000 MG 0.01 MG/MG Topical Gel   4 Non-Preferred Drug 42%42%P Q:300
/30Days
Testosterone cyp 100 mg/ml   4 Non-Preferred Drug 42%42%None
TESTOSTERONE CYP 200 MG/ML   4 Non-Preferred Drug 42%42%None
Testosterone cypionate 200 MG/ML Injectable Solution [Depo-testosterone]   4 Non-Preferred Drug 42%42%P
TESTOSTERONE ENANTHATE 200MG/ML INJECTION   4 Non-Preferred Drug 42%42%None
TETRABENAZINE 12.5 MG TABLET [XENAZINE]   5 Specialty Tier 33%N/AP Q:90
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
TETRABENAZINE 25 MG TABLET [XENAZINE]   5 Specialty Tier 33%N/AP Q:120
/30Days
TETRACYCLINE 250 MG CAPSULE   4 Non-Preferred Drug 42%42%None
TETRACYCLINE 500 MG CAPSULE   4 Non-Preferred Drug 42%42%None
THALOMID 100 MG CAPSULE   5 Specialty Tier 33%N/AP
THALOMID 150 MG CAPSULE   5 Specialty Tier 33%N/AP
THALOMID 200 MG CAPSULE   5 Specialty Tier 33%N/AP
THALOMID 50 MG CAPSULE   5 Specialty Tier 33%N/AP
THEO-24 ER 100 MG CAPSULE   4 Non-Preferred Drug 42%42%None
THEO-24 ER 200 MG CAPSULE   4 Non-Preferred Drug 42%42%None
THEO-24 ER 300 MG CAPSULE   4 Non-Preferred Drug 42%42%None
THEO-24 ER 400 MG CAPSULE   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
THEOPHYLLINE 80 MG/15 ML SOLN   3 Preferred Brand $35.00$105.00None
THEOPHYLLINE ER 100 MG TABLET   3 Preferred Brand $35.00$105.00None
THEOPHYLLINE ER 200 MG TABLET   3 Preferred Brand $35.00$105.00None
THEOPHYLLINE ER 300 MG TAB   3 Preferred Brand $35.00$105.00None
THEOPHYLLINE ER 400 MG TABLET   3 Preferred Brand $35.00$105.00None
THEOPHYLLINE ER 600 MG TABLET   3 Preferred Brand $35.00$105.00None
THIORIDAZINE 10 MG TABLET   3 Preferred Brand $35.00$105.00P
THIORIDAZINE 100MG TABLET   3 Preferred Brand $35.00$105.00P
THIORIDAZINE 25 MG TABLET   3 Preferred Brand $35.00$105.00P
THIORIDAZINE 50 MG TABLET   3 Preferred Brand $35.00$105.00P
THIOTEPA 15 MG VIAL   5 Specialty Tier 33%N/ANone
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
THIOTHIXENE 1 MG CAPSULE   4 Non-Preferred Drug 42%42%None
THIOTHIXENE 10MG CAPSULE   4 Non-Preferred Drug 42%42%None
THIOTHIXENE 2MG CAPSULE   4 Non-Preferred Drug 42%42%None
THIOTHIXENE 5MG CAPSULE   4 Non-Preferred Drug 42%42%None
THYMOGLOBULIN 25MG VIAL   5 Specialty Tier 33%N/AP
TIAGABINE HCL 12 MG TABLET [Gabitril]   4 Non-Preferred Drug 42%42%None
TIAGABINE HCL 16 MG TABLET [Gabitril]   4 Non-Preferred Drug 42%42%None
tiagabine hcl 2 mg tablet [Gabitril]   4 Non-Preferred Drug 42%42%None
tiagabine hcl 4 mg tablet [Gabitril]   4 Non-Preferred Drug 42%42%None
TIAZAC ER 120 MG CAPSULE   4 Non-Preferred Drug 42%42%None
TIAZAC ER 180 MG CAPSULE   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
TIAZAC ER 240 MG CAPSULE   4 Non-Preferred Drug 42%42%None
TIAZAC ER 300 MG CAPSULE CAP SA 24H   4 Non-Preferred Drug 42%42%None
TIAZAC ER 360 MG CAPSULE   4 Non-Preferred Drug 42%42%None
TIAZAC ER 420 MG CAPSULE CAP SA 24H   4 Non-Preferred Drug 42%42%None
TIGAN 100 MG/ML VIAL   4 Non-Preferred Drug 42%42%P
TIGAN 300MG CAPSULE   4 Non-Preferred Drug 42%42%P
TIGECYCLINE 50 MG VIAL [Tygacil]   5 Specialty Tier 33%N/ANone
TIKOSYN .125MG CAPSULE   4 Non-Preferred Drug 42%42%S
TIKOSYN .250MG CAPSULE   4 Non-Preferred Drug 42%42%S
TIKOSYN .5MG CAPSULE   4 Non-Preferred Drug 42%42%S
TIMOLOL 0.25% EYE DROPS   1 Preferred Generic $1.00$3.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
TIMOLOL 0.25% GFS GEL-SOLUTION   4 Non-Preferred Drug 42%42%None
TIMOLOL 0.5% EYE DROPS   3 Preferred Brand $35.00$105.00None
TIMOLOL 0.5% EYE DROPS   1 Preferred Generic $1.00$3.00None
TIMOLOL 0.5% GFS GEL-SOLUTION   4 Non-Preferred Drug 42%42%None
TIMOLOL MALEATE 10MG TABLET   1 Preferred Generic $1.00$3.00None
TIMOLOL MALEATE 20MG TABLET   1 Preferred Generic $1.00$3.00None
TIMOLOL MALEATE 5MG TABLET   1 Preferred Generic $1.00$3.00None
TIMOPTIC 0.25% OCUDOSE DROP   4 Non-Preferred Drug 42%42%None
TIMOPTIC 0.5% OCUDOSE DROP   4 Non-Preferred Drug 42%42%None
TIMOPTIC-XE 0.25% EYE GEL-SOLN SOL-GEL   4 Non-Preferred Drug 42%42%None
TINIDAZOLE 250 MG TABLET   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
TINIDAZOLE 500 MG TABLET   4 Non-Preferred Drug 42%42%None
Tirosint 100ug/1 4 BLISTER PACK per CARTON / 7 CAPSULE per BLISTER PACK   4 Non-Preferred Drug 42%42%None
Tirosint 112ug/1 4 BLISTER PACK per CARTON / 7 CAPSULE per BLISTER PACK   4 Non-Preferred Drug 42%42%None
Tirosint 125ug/1 4 BLISTER PACK per CARTON / 7 CAPSULE per BLISTER PACK   4 Non-Preferred Drug 42%42%None
Tirosint 137ug/1 4 BLISTER PACK per CARTON / 7 CAPSULE per BLISTER PACK   4 Non-Preferred Drug 42%42%None
Tirosint 13ug/1 4 BLISTER PACK per CARTON / 7 CAPSULE per BLISTER PACK   4 Non-Preferred Drug 42%42%None
Tirosint 150ug/1 4 BLISTER PACK per CARTON / 7 CAPSULE per BLISTER PACK   4 Non-Preferred Drug 42%42%None
Tirosint 25ug/1 4 BLISTER PACK per CARTON / 7 CAPSULE per BLISTER PACK   4 Non-Preferred Drug 42%42%None
Tirosint 50ug/1 4 BLISTER PACK per CARTON / 7 CAPSULE per BLISTER PACK   4 Non-Preferred Drug 42%42%None
Tirosint 75ug/1 4 BLISTER PACK per CARTON / 7 CAPSULE per BLISTER PACK   4 Non-Preferred Drug 42%42%None
Tirosint 88ug/1 4 BLISTER PACK per CARTON / 7 CAPSULE per BLISTER PACK   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
TIVICAY 10 MG TABLET   3 Preferred Brand $35.00$105.00None
TIVICAY 25 MG TABLET   5 Specialty Tier 33%N/ANone
TIVICAY 50 MG TABLET   5 Specialty Tier 33%N/ANone
TIVORBEX 20 MG CAPSULE   4 Non-Preferred Drug 42%42%P
TIVORBEX 40 MG CAPSULE   4 Non-Preferred Drug 42%42%P
TIZANIDINE HCL 2 MG CAPSULE   4 Non-Preferred Drug 42%42%None
TIZANIDINE HCL 2 MG TABLET   2 Generic $2.00$6.00None
TIZANIDINE HCL 4 MG CAPSULE   4 Non-Preferred Drug 42%42%None
TIZANIDINE HCL 4 MG TABLET   2 Generic $2.00$6.00None
TIZANIDINE HCL 6 MG CAPSULE   4 Non-Preferred Drug 42%42%None
TOBI 300mg/5mL 56 AMPULE per CARTON / 5 mL in 1 AMPULE   5 Specialty Tier 33%N/AP Q:280
/56Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
TOBI PODHALER 28 MG INHALE CAP   5 Specialty Tier 33%N/AP Q:224
/42Days
TOBRADEX EYE OINTMENT   3 Preferred Brand $35.00$105.00None
TOBRADEX ST 0.5; 3mg/mL; mg/mL 5 mL in 1 BOTTLE   3 Preferred Brand $35.00$105.00None
TOBRADEX SUSPENSION OPHTHALMIC 0.1%/0.3% 5ML BOT   4 Non-Preferred Drug 42%42%None
TOBRAMYCIN 0.3% EYE DROPS [Tobrex]   2 Generic $2.00$6.00None
TOBRAMYCIN 10 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate]   4 Non-Preferred Drug 42%42%None
TOBRAMYCIN 300 MG/5 ML AMPULE [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate]   3 Preferred Brand $35.00$105.00P Q:280
/56Days
TOBRAMYCIN 40 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate]   4 Non-Preferred Drug 42%42%None
TOBRAMYCIN-DEXAMETH OPTH SUSP   4 Non-Preferred Drug 42%42%None
TOBREX 0.3% EYE DROPS   4 Non-Preferred Drug 42%42%None
TOBREX 0.3% EYE OINTMENT   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
TOFRANIL 50MG TABLET (30 CT)   4 Non-Preferred Drug 42%42%P
TOFRANIL TABLETS 10MG 30 BOT   4 Non-Preferred Drug 42%42%P
TOFRANIL TABLETS 25MG 30 BOT   4 Non-Preferred Drug 42%42%P
TOLAK 4% CREAM   4 Non-Preferred Drug 42%42%None
TOLAZAMIDE TABLETS 250MG 100 BOT   3 Preferred Brand $35.00$105.00None
TOLAZAMIDE TABLETS 500MG 100 BOT   3 Preferred Brand $35.00$105.00None
TOLBUTAMIDE 500 MG TABLET   2 Generic $2.00$6.00None
TOLTERODINE TARTRATE 1 MG TAB [Detrol LA]   4 Non-Preferred Drug 42%42%Q:60
/30Days
TOLTERODINE TARTRATE 2 MG TAB [Detrol LA]   4 Non-Preferred Drug 42%42%Q:60
/30Days
Tolterodine Tartrate ER 2 MG CAPSULE [Detrol LA]   4 Non-Preferred Drug 42%42%Q:30
/30Days
TOPAMAX 15 MG SPRINKLE CAP   4 Non-Preferred Drug 42%42%S
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
TOPAMAX 25 MG SPRINKLE CAP   4 Non-Preferred Drug 42%42%S
TOPAMAX TABLETS 100MG 60 BOT   4 Non-Preferred Drug 42%42%S
TOPAMAX TABLETS 200MG 60 BOT   4 Non-Preferred Drug 42%42%S
TOPAMAX TABLETS 25MG 60 BOT   4 Non-Preferred Drug 42%42%S
TOPAMAX TABLETS 50MG 60 BOT   4 Non-Preferred Drug 42%42%S
TOPICORT 0.25% SPRAY   4 Non-Preferred Drug 42%42%None
Topicort 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE   4 Non-Preferred Drug 42%42%None
Topicort 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE   4 Non-Preferred Drug 42%42%None
Topicort 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE   4 Non-Preferred Drug 42%42%None
Topicort 2.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE   4 Non-Preferred Drug 42%42%None
Topicort 2.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
TOPIRAMATE 100 MG TABLET   2 Generic $2.00$6.00None
TOPIRAMATE 15 MG SPRINKLE CAP   2 Generic $2.00$6.00None
TOPIRAMATE 200 MG TABLET   2 Generic $2.00$6.00None
TOPIRAMATE 25 MG TABLET   2 Generic $2.00$6.00None
Topiramate 25mg/1   2 Generic $2.00$6.00None
TOPIRAMATE 50 MG TABLET   2 Generic $2.00$6.00None
TOPIRAMATE ER 100 MG CAPSULE   4 Non-Preferred Drug 42%42%None
TOPIRAMATE ER 150 MG CAPSULE   4 Non-Preferred Drug 42%42%None
TOPIRAMATE ER 200 MG CAPSULE   4 Non-Preferred Drug 42%42%None
TOPIRAMATE ER 25 MG CAPSULE   4 Non-Preferred Drug 42%42%None
TOPIRAMATE ER 50 MG CAPSULE   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
TOPOSAR INJECTION 20MG/ML 50ML VIAL MD CRTN   3 Preferred Brand $35.00$105.00None
Topotecan 4 MG Injection   5 Specialty Tier 33%N/ANone
TOPROL XL 100 MG TABLET ER 24H   4 Non-Preferred Drug 42%42%S
TOPROL XL 200 MG TABLET ER 24H   4 Non-Preferred Drug 42%42%S
TOPROL XL 25 MG TABLET ER 24H   4 Non-Preferred Drug 42%42%S
TOPROL XL 50 MG TABLET ER 24H   4 Non-Preferred Drug 42%42%S
Torisel 1 KIT per CARTON   5 Specialty Tier 33%N/ANone
TORSEMIDE 10 MG TABLET   2 Generic $2.00$6.00None
TORSEMIDE 100 MG TABLET   2 Generic $2.00$6.00None
TORSEMIDE 20 MG TABLET   2 Generic $2.00$6.00None
TORSEMIDE 5 MG TABLET   2 Generic $2.00$6.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
TOUJEO MAX SOLOSTAR 300UNIT/ML INSULN PEN   3 Preferred Brand $35.00$105.00None
TOUJEO SOLOSTAR 300 UNITS/ML   3 Preferred Brand $35.00$105.00None
TOVIAZ TABLETS 4MG EXTENDED RELEASE   3 Preferred Brand $35.00$105.00Q:30
/30Days
TOVIAZ TABLETS 8MG EXTENDED RELEASE   3 Preferred Brand $35.00$105.00Q:30
/30Days
TPN ELECTROLYTES16.5/25.4 VIAL   4 Non-Preferred Drug 42%42%P
TRACLEER 125MG TABLET   5 Specialty Tier 33%N/AP Q:60
/30Days
TRACLEER 32 MG TABLET FOR SUSP   5 Specialty Tier 33%N/AP Q:120
/30Days
TRACLEER 62.5MG TABLET   5 Specialty Tier 33%N/AP Q:120
/30Days
TRADJENTA 5 MG TABLET   3 Preferred Brand $35.00$105.00Q:30
/30Days
TRAMADOL ER 100 MG TABLET   4 Non-Preferred Drug 42%42%Q:30
/30Days
TRAMADOL ER 200 MG TABLET   4 Non-Preferred Drug 42%42%Q:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
TRAMADOL ER 300 MG TABLET   4 Non-Preferred Drug 42%42%Q:30
/30Days
TRAMADOL ER 300 MG TABLET   4 Non-Preferred Drug 42%42%Q:30
/30Days
TRAMADOL HCL 50 MG TABLET   2 Generic $2.00$6.00Q:240
/30Days
TRAMADOL HCL ER 100 MG CAPSULE   4 Non-Preferred Drug 42%42%Q:30
/30Days
TRAMADOL HCL ER 100 MG TABLET   4 Non-Preferred Drug 42%42%Q:30
/30Days
TRAMADOL HCL ER 200 MG CAPSULE   4 Non-Preferred Drug 42%42%Q:30
/30Days
TRAMADOL HCL ER 200 MG TABLET   4 Non-Preferred Drug 42%42%Q:30
/30Days
TRAMADOL HCL ER 300 MG CAPSULE   4 Non-Preferred Drug 42%42%Q:30
/30Days
TRAMADOL-ACETAMINOPHN 37.5-325   4 Non-Preferred Drug 42%42%Q:240
/30Days
TRANDOLAPRIL 1 MG TABLET   1 Preferred Generic $1.00$3.00None
TRANDOLAPRIL 2 MG TABLET   1 Preferred Generic $1.00$3.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
TRANDOLAPRIL 4 MG TABLET   1 Preferred Generic $1.00$3.00None
TRANDOLAPRIL-VERAPAMIL ER 1-240 MG   1 Preferred Generic $1.00$3.00None
TRANDOLAPRIL-VERAPAMIL ER 2-180 MG   1 Preferred Generic $1.00$3.00None
TRANDOLAPRIL-VERAPAMIL ER 2-240 MG   1 Preferred Generic $1.00$3.00None
TRANDOLAPRIL-VERAPAMIL ER 4-240 MG   1 Preferred Generic $1.00$3.00None
TRANEXAMIC ACID 1,000 MG/10 ML   4 Non-Preferred Drug 42%42%None
tranexamic acid 650 mg tablet   4 Non-Preferred Drug 42%42%Q:30
/30Days
TRANSDERM-SCOP 1.5 MG/3 DAY   4 Non-Preferred Drug 42%42%P Q:10
/30Days
TRANXENE T-TAB 7.5 MG   4 Non-Preferred Drug 42%42%None
TRANYLCYPROMINE SULFATE 10MG TABLET   4 Non-Preferred Drug 42%42%None
TRAVASOL 10% SOLUTION VIAFLEX   4 Non-Preferred Drug 42%42%P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
TRAVATAN Z 0.04MG DROPS 2.5ML BOT   3 Preferred Brand $35.00$105.00None
TRAZODONE 100 MG TABLET   2 Generic $2.00$6.00None
TRAZODONE 300 MG TABLET   2 Generic $2.00$6.00None
TRAZODONE 50 MG TABLET   2 Generic $2.00$6.00None
TRAZODONE HCL TABLET USP 150MG (100 CT)   2 Generic $2.00$6.00None
TREANDA 25 MG VIAL   5 Specialty Tier 33%N/AP
TREANDA FOR INJECTION 100MG/VIAL   5 Specialty Tier 33%N/AP
TRECATOR 250MG TABLET   4 Non-Preferred Drug 42%42%None
TRELSTAR 11.25 MG SYRINGE   5 Specialty Tier 33%N/AP
TRELSTAR 3.75 MG SYRINGE   5 Specialty Tier 33%N/AP
TRESIBA FLEXTOUCH 100 UNITS/ML   3 Preferred Brand $35.00$105.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
TRESIBA FLEXTOUCH 200 UNITS/ML   3 Preferred Brand $35.00$105.00None
Tretinoin 0.0004 MG/MG Topical Gel   4 Non-Preferred Drug 42%42%P
Tretinoin 0.0005 MG/MG Topical Gel   4 Non-Preferred Drug 42%42%P
Tretinoin 0.001 MG/MG Topical Gel   4 Non-Preferred Drug 42%42%P
TRETINOIN 0.01% GEL   4 Non-Preferred Drug 42%42%P
TRETINOIN 0.025% CREAM   4 Non-Preferred Drug 42%42%P
TRETINOIN 0.025% GEL   4 Non-Preferred Drug 42%42%P
TRETINOIN 0.05% CREAM   4 Non-Preferred Drug 42%42%P
TRETINOIN 0.1% CREAM   4 Non-Preferred Drug 42%42%P
Tretinoin 0.25 MG/ML Topical Cream [Retin-A]   4 Non-Preferred Drug 42%42%P
Tretinoin 0.5 MG/ML Topical Cream [Retin-A]   4 Non-Preferred Drug 42%42%P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Tretinoin 1 MG/ML Topical Cream [Retin-A]   4 Non-Preferred Drug 42%42%P
TRETINOIN 10MG CAPSULE   5 Specialty Tier 33%N/ANone
TREXALL 10MG TABLET   4 Non-Preferred Drug 42%42%P
TREXALL 15MG TABLET   4 Non-Preferred Drug 42%42%P
TREXALL 5MG TABLET   4 Non-Preferred Drug 42%42%P
TREXALL 7.5MG TABLET   4 Non-Preferred Drug 42%42%P
TREXIMET 85-500 MG TABLET   4 Non-Preferred Drug 42%42%S Q:9
/30Days
TRI PREVIFEM TABLETS   3 Preferred Brand $35.00$105.00None
TRI-LEGEST FE 5-7-9-7 TABLET   3 Preferred Brand $35.00$105.00None
TRI-LO-ESTARYLLA TABLET [Trinessa Lo]   3 Preferred Brand $35.00$105.00None
TRI-LO-SPRINTEC TABLET   3 Preferred Brand $35.00$105.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
TRI-MILI 28 TABLET [Trinessa]   3 Preferred Brand $35.00$105.00None
TRI-SPRINTEC 7DAYSX3 28 TABLET   3 Preferred Brand $35.00$105.00None
TRI-VYLIBRA 28 TABLET [Trinessa]   3 Preferred Brand $35.00$105.00None
TRIAMCINOLONE 0.025% CREAM   2 Generic $2.00$6.00None
TRIAMCINOLONE 0.025% LOTION   3 Preferred Brand $35.00$105.00None
TRIAMCINOLONE 0.025% OINT   2 Generic $2.00$6.00None
TRIAMCINOLONE 0.1% CREAM   2 Generic $2.00$6.00None
TRIAMCINOLONE 0.1% LOTION [Kenalog]   3 Preferred Brand $35.00$105.00None
TRIAMCINOLONE 0.1% OINTMENT   2 Generic $2.00$6.00None
TRIAMCINOLONE 0.1% PASTE   4 Non-Preferred Drug 42%42%None
Triamcinolone 0.147 MG/G Spray   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
TRIAMCINOLONE 200 MG/5 ML VIAL [Triesence]   4 Non-Preferred Drug 42%42%None
Triamcinolone 55 mcg nasal spr   4 Non-Preferred Drug 42%42%None
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE   2 Generic $2.00$6.00None
Triamcinolone Acetonide 1 MG/ML Topical Cream [Triderm]   4 Non-Preferred Drug 42%42%None
Triamcinolone Acetonide 5mg/g 1 TUBE per CARTON / 15 g in 1 TUBE   2 Generic $2.00$6.00None
TRIAMTERENE-HCTZ 37.5-25 MG CP   1 Preferred Generic $1.00$3.00None
TRIAMTERENE-HCTZ 37.5-25 MG TB   1 Preferred Generic $1.00$3.00None
TRIAMTERENE-HCTZ 75-50 MG TAB   1 Preferred Generic $1.00$3.00None
Trianex 0.05% Ointment   4 Non-Preferred Drug 42%42%None
TRIAZOLAM 0.125 MG TABLET   4 Non-Preferred Drug 42%42%Q:60
/30Days
TRIAZOLAM 0.25 MG TABLET   4 Non-Preferred Drug 42%42%Q:60
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
TRIBENZOR 20/5/12.5MG TABLETS   4 Non-Preferred Drug 42%42%S Q:30
/30Days
TRIBENZOR 40/10/12.5MG TABLETS   4 Non-Preferred Drug 42%42%S Q:30
/30Days
TRIBENZOR 40/10/25MG TABLETS   4 Non-Preferred Drug 42%42%S Q:30
/30Days
Tribenzor 5; 12.5; 40mg/1; mg/1; mg/1   4 Non-Preferred Drug 42%42%S Q:30
/30Days
Tribenzor 5; 25; 40mg/1; mg/1; mg/1   4 Non-Preferred Drug 42%42%S Q:30
/30Days
TRICOR 145 MG TABLET   4 Non-Preferred Drug 42%42%None
TRICOR 48 MG TABLET   4 Non-Preferred Drug 42%42%None
TRIENTINE HCL 250 MG CAPSULE [Syprine]   5 Specialty Tier 33%N/ANone
TRIFLUOPERAZINE 1MG TABLET   4 Non-Preferred Drug 42%42%None
TRIFLUOPERAZINE HCL 2MG TABLET   4 Non-Preferred Drug 42%42%None
TRIFLUOPERAZINE HCL 5MG TABLET   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT)   4 Non-Preferred Drug 42%42%None
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT   3 Preferred Brand $35.00$105.00None
TRIGLIDE 160 MG TABLET   4 Non-Preferred Drug 42%42%None
TRIHEXYPHENIDYL 2 MG TABLET   2 Generic $2.00$6.00P
TRIHEXYPHENIDYL 5 MG TABLET   2 Generic $2.00$6.00P
Trihexyphenidyl Hydrochloride 2mg/5mL 473 mL in 1 BOTTLE   2 Generic $2.00$6.00P
TRILEPTAL 150MG TABLET   4 Non-Preferred Drug 42%42%S
TRILEPTAL 300MG TABLET   4 Non-Preferred Drug 42%42%S
TRILEPTAL 300MG/5ML SUSP   4 Non-Preferred Drug 42%42%S
TRILEPTAL 600MG TABLET   4 Non-Preferred Drug 42%42%S
TRILIPIX DR 135 MG CAPSULE   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
TRILIPIX DR 45 MG CAPSULE   4 Non-Preferred Drug 42%42%None
TRILYTE WITH FLAVOR PACKETS   2 Generic $2.00$6.00None
TRIMETHOBENZAMIDE 300 MG CAP   4 Non-Preferred Drug 42%42%P
TRIMETHOPRIM 100 MG TABLET   1 Preferred Generic $1.00$3.00None
TRIMIPRAMINE MALEATE 100 MG CP   4 Non-Preferred Drug 42%42%P
TRIMIPRAMINE MALEATE 25 MG CAP   4 Non-Preferred Drug 42%42%P
TRIMIPRAMINE MALEATE 50 MG CAP   4 Non-Preferred Drug 42%42%P
TRINESSA TABLET   3 Preferred Brand $35.00$105.00None
TRINTELLIX 10 MG TABLET   4 Non-Preferred Drug 42%42%S Q:60
/30Days
TRINTELLIX 20 MG TABLET   4 Non-Preferred Drug 42%42%S Q:30
/30Days
TRINTELLIX 5 MG TABLET   4 Non-Preferred Drug 42%42%S Q:120
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Triostat 10ug/mL 6 VIAL in 1 CARTON / 1 mL in 1 VIAL   5 Specialty Tier 33%N/ANone
Triptorelin 11.3 MG/ML Injectable Suspension [Trelstar]   5 Specialty Tier 33%N/AP
TRISENOX 12 MG/6 ML VIAL   5 Specialty Tier 33%N/AP
TRIUMEQ TABLET   5 Specialty Tier 33%N/ANone
Trivora-28 tablet   3 Preferred Brand $35.00$105.00None
TROKENDI XR 100 MG CAPSULE ER 24H   4 Non-Preferred Drug 42%42%None
TROKENDI XR 200 MG CAPSULE   4 Non-Preferred Drug 42%42%None
TROKENDI XR 25 MG CAPSULE   4 Non-Preferred Drug 42%42%None
TROKENDI XR 50 MG CAPSULE   4 Non-Preferred Drug 42%42%None
TROPHAMINE INJECTION SOLUTION   4 Non-Preferred Drug 42%42%P
TROSPIUM CHLORIDE 20 MG TABLET   2 Generic $2.00$6.00Q:60
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
TROSPIUM CHLORIDE ER 60 MG CAP   2 Generic $2.00$6.00Q:30
/30Days
TRULICITY 0.75 MG/0.5 ML PEN   4 Non-Preferred Drug 42%42%Q:4
/28Days
TRULICITY 1.5 MG/0.5 ML PEN   4 Non-Preferred Drug 42%42%Q:4
/28Days
TRUMENBA 120 MCG/0.5 ML VACCIN Syringe   3 Preferred Brand $35.00$105.00None
TRUSOPT PLUS 2% EYE DROPS 10ML BOT   4 Non-Preferred Drug 42%42%None
TRUVADA 100 MG-150 MG TABLET   5 Specialty Tier 33%N/AQ:60
/30Days
TRUVADA 133 MG-200 MG TABLET   5 Specialty Tier 33%N/AQ:30
/30Days
TRUVADA 167 MG-250 MG TABLET   5 Specialty Tier 33%N/AQ:30
/30Days
TRUVADA 200/300MG TABLET   5 Specialty Tier 33%N/AQ:30
/30Days
TWINRIX VACCINE SYRINGE   3 Preferred Brand $35.00$105.00None
Twynsta 10; 40mg/1; mg/1 3 BLISTER PACK per CARTON / 10 TABLET, MULTILAYER per BLISTER PACK   4 Non-Preferred Drug 42%42%S Q:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Twynsta 10; 80mg/1; mg/1 3 BLISTER PACK per CARTON / 10 TABLET, MULTILAYER per BLISTER PACK   4 Non-Preferred Drug 42%42%S Q:30
/30Days
Twynsta 5; 40mg/1; mg/1 3 BLISTER PACK per CARTON / 10 TABLET, MULTILAYER per BLISTER PACK   4 Non-Preferred Drug 42%42%S Q:30
/30Days
Twynsta 5; 80mg/1; mg/1 3 BLISTER PACK per CARTON / 10 TABLET, MULTILAYER per BLISTER PACK   4 Non-Preferred Drug 42%42%S Q:30
/30Days
TYBOST 150 MG TABLET   3 Preferred Brand $35.00$105.00None
TYDEMY TABLET   3 Preferred Brand $35.00$105.00None
Tygacil 50mg/5mL 10 VIAL, SINGLE-USE per CARTON / 50 mL in 1 VIAL, SINGLE-USE   5 Specialty Tier 33%N/ANone
TYKERB 250 MG TABLET   5 Specialty Tier 33%N/AP
TYLENOL WITH CODEINE #3 TABLET   4 Non-Preferred Drug 42%42%Q:180
/30Days
TYPHIM VI 25 MCG/0.5 ML SYRINGE   3 Preferred Brand $35.00$105.00None
TYPHIM VI 25MCG/0.5ML VIAL   3 Preferred Brand $35.00$105.00None
TYSABRI 300 MG/15 ML VIAL   5 Specialty Tier 33%N/AP

Chart Legend:

Below are a few notes to help you understand the above 2018 Medicare Part D First Health Part D Premier Plus (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.