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 V
in CMS PDP Region 01 which includes: ME NH
Plan Monthly Premium: $96.80 Deductible: $0 Qualifies for LIS: No
Drugs Starting with Letter V

Drug Name		 Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order
VAGIFEM 10 MCG VAGINAL TAB   4 Non-Preferred Drug 42%42%None
VALACYCLOVIR HCL 1 GRAM TABLET   3 Preferred Brand $35.00$105.00None
VALACYCLOVIR HCL 500 MG TABLET   3 Preferred Brand $35.00$105.00None
VALCHLOR 0.016% GEL   5 Specialty Tier 33%N/AP
VALCYTE 450MG TABLET   5 Specialty Tier 33%N/ANone
VALCYTE FOR ORAL SOLUTION 50MG/ML   5 Specialty Tier 33%N/ANone
VALGANCICLOVIR 450 MG TABLET [Valcyte]   5 Specialty Tier 33%N/ANone
VALGANCICLOVIR HCL 50 MG/ML [Valcyte]   5 Specialty Tier 33%N/ANone
VALIUM 10 MG TABLET   4 Non-Preferred Drug 42%42%Q:120
/30Days
Valium 2mg/1 100 TABLET BOTTLE, PLASTIC   4 Non-Preferred Drug 42%42%Q:120
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
VALPROATE SOD 500 MG/5 ML VIAL [Depacon]   3 Preferred Brand $35.00$105.00None
VALPROIC ACID 250 MG CAPSULE [Depakene]   2 Generic $2.00$6.00None
VALPROIC ACID 500 MG/10 ML Solution [Depakene]   2 Generic $2.00$6.00None
VALSARTAN 160 MG TABLET [Diovan]   2 Generic $2.00$6.00Q:60
/30Days
VALSARTAN 320 MG TABLET [Diovan]   2 Generic $2.00$6.00Q:30
/30Days
VALSARTAN 40 MG TABLET [Diovan]   2 Generic $2.00$6.00Q:60
/30Days
VALSARTAN 80 MG TABLET [Diovan]   2 Generic $2.00$6.00Q:60
/30Days
VALSARTAN-HCTZ 160-12.5 MG TAB [Diovan HCT]   2 Generic $2.00$6.00Q:30
/30Days
VALSARTAN-HCTZ 160-25 MG TAB [Diovan HCT]   2 Generic $2.00$6.00Q:30
/30Days
VALSARTAN-HCTZ 320-12.5 MG TAB [Diovan HCT]   2 Generic $2.00$6.00Q:30
/30Days
VALSARTAN-HCTZ 320-25 MG TAB [Diovan HCT]   2 Generic $2.00$6.00Q:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
VALSARTAN-HCTZ 80-12.5 MG Tablet [Diovan HCT]   2 Generic $2.00$6.00Q:30
/30Days
VALTREX 1 GM CAPLET   4 Non-Preferred Drug 42%42%None
VALTREX 500 MG CAPLET   4 Non-Preferred Drug 42%42%None
VANCOCIN HCL 125 MG CAPSULE   4 Non-Preferred Drug 42%42%Q:120
/30Days
VANCOCIN HCL 250 MG CAPSULE   5 Specialty Tier 33%N/ANone
VANCOMYCIN 500 MG VIAL   4 Non-Preferred Drug 42%42%None
VANCOMYCIN HCL 125 MG CAPSULE   4 Non-Preferred Drug 42%42%Q:120
/30Days
VANCOMYCIN HCL 250 MG CAPSULE   5 Specialty Tier 33%N/ANone
VANCOMYCIN HCL INJECTION 10 X 1GM VIAL (STERILE )   4 Non-Preferred Drug 42%42%None
VANCOMYCIN HYDROCHLORIDE 100MG/ML 1 VIAL, PHARMACY BULK PACKAGE in 1 CASE / 95 mL in 1 VIAL, PHARMA   4 Non-Preferred Drug 42%42%None
VANDAZOLE 0.75% GEL WITH APPLICATOR   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
VANOS 0.1% CREAM   4 Non-Preferred Drug 42%42%Q:120
/30Days
VAQTA 25 UNITS/0.5 ML SYRINGE   3 Preferred Brand $35.00$105.00None
VAQTA 50 UNITS/ML SYRINGE   3 Preferred Brand $35.00$105.00None
Vaqta Hepatitis A Vaccine Adult 50 Unit / mL Injection Single Dose Vial 1 mL   3 Preferred Brand $35.00$105.00None
Vaqta Hepatitis A Vaccine Pediatric / Adolescent 25 Unit / 0.5 mL Injection Single Dose Vial 0.5 mL   3 Preferred Brand $35.00$105.00None
VARIVAX VACCINE W/DILUENT   3 Preferred Brand $35.00$105.00None
VASCEPA 0.5 GM CAPSULE   4 Non-Preferred Drug 42%42%None
VASCEPA 1 GM CAPSULE   4 Non-Preferred Drug 42%42%None
VASOTEC 20 MG TABLET   4 Non-Preferred Drug 42%42%None
VASOTEC 5 MG TABLET   4 Non-Preferred Drug 42%42%None
VECTIBIX 100 MG/5 ML VIAL   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
VECTICAL OINTMENT 3MCG/GM 100 GM TUBE   4 Non-Preferred Drug 42%42%None
VELCADE 3.5MG VIAL   5 Specialty Tier 33%N/AP
VELIVET 28 DAY TABLET [Velivet]   3 Preferred Brand $35.00$105.00None
VENCLEXTA 10 MG TABLET   4 Non-Preferred Drug 42%42%P
VENCLEXTA 100 MG TABLET   5 Specialty Tier 33%N/AP
VENCLEXTA 50 MG TABLET   4 Non-Preferred Drug 42%42%P
VENCLEXTA STARTING PACK   5 Specialty Tier 33%N/AP
VENLAFAXINE HCL 100 MG TABLET [Effexor]   3 Preferred Brand $35.00$105.00None
VENLAFAXINE HCL 25 MG TABLET [Effexor]   3 Preferred Brand $35.00$105.00None
VENLAFAXINE HCL 37.5 MG TABLET [Effexor]   3 Preferred Brand $35.00$105.00None
VENLAFAXINE HCL 50 MG TABLET [Effexor]   3 Preferred Brand $35.00$105.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
VENLAFAXINE HCL 75 MG TABLET [Effexor]   3 Preferred Brand $35.00$105.00None
VENLAFAXINE HCL ER 150 MG CAPSULE 24H [Effexor XR]   3 Preferred Brand $35.00$105.00Q:60
/30Days
VENLAFAXINE HCL ER 150 MG TABLET 24 [Venlafaxine]   3 Preferred Brand $35.00$105.00Q:60
/30Days
VENLAFAXINE HCL ER 37.5 MG CAPSULE 24H [Effexor XR]   3 Preferred Brand $35.00$105.00Q:30
/30Days
VENLAFAXINE HCL ER 37.5 MG TAB ER 24 [Venlafaxine]   3 Preferred Brand $35.00$105.00Q:30
/30Days
VENLAFAXINE HCL ER 75 MG CAPSULE 24H [Effexor XR]   3 Preferred Brand $35.00$105.00Q:30
/30Days
VENLAFAXINE HCL ER 75 MG TABLET 24 [Venlafaxine]   3 Preferred Brand $35.00$105.00Q:30
/30Days
Ventavis 0.01mg/mL   5 Specialty Tier 33%N/AP
Ventavis 0.02mg/mL   5 Specialty Tier 33%N/AP
VENTOLIN HFA 90MCG INHALER   3 Preferred Brand $35.00$105.00Q:36
/30Days
VERAPAMIL 120 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
VERAPAMIL 120MG CAP PELLET   2 Generic $2.00$6.00None
VERAPAMIL 180MG CAP PELLET   2 Generic $2.00$6.00None
VERAPAMIL 2.5 MG/ML VIAL [Isoptin]   4 Non-Preferred Drug 42%42%None
VERAPAMIL 240MG CAP PELLET   2 Generic $2.00$6.00None
VERAPAMIL 40MG TABLET   1 Preferred Generic $1.00$3.00None
VERAPAMIL 80 MG TABLET   1 Preferred Generic $1.00$3.00None
VERAPAMIL ER 100MG CAPSULE 24HR SR PELLETS   2 Generic $2.00$6.00None
VERAPAMIL ER 120 MG TABLET   2 Generic $2.00$6.00None
VERAPAMIL ER 180 MG TABLET   2 Generic $2.00$6.00None
VERAPAMIL ER 200MG CAPSULE 24HR SR PELLETS (100 CT)   2 Generic $2.00$6.00None
VERAPAMIL ER 240 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
VERAPAMIL ER 300MG CAPSULE 24HR SR PELLETS   2 Generic $2.00$6.00None
VERAPAMIL HCL 360MG CAPSULES SUSTAINED RELEASE   3 Preferred Brand $35.00$105.00None
VERELAN 120 MG CAP PELLET   4 Non-Preferred Drug 42%42%None
VERELAN 180 MG CAP PELLET   4 Non-Preferred Drug 42%42%None
VERELAN 240 MG CAP PELLET   4 Non-Preferred Drug 42%42%None
VERELAN 360 MG CAP PELLET   4 Non-Preferred Drug 42%42%None
VERELAN PM 100 MG CAP PELLET   4 Non-Preferred Drug 42%42%None
VERELAN PM 200 MG CAP PELLET   4 Non-Preferred Drug 42%42%None
VERELAN PM 300 MG CAP PELLET   4 Non-Preferred Drug 42%42%None
VERIPRED 20 20 MG/5 ML SOLN   4 Non-Preferred Drug 42%42%None
VERSACLOZ 50 MG/ML SUSPENSION   5 Specialty Tier 33%N/AP Q:600
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
VERZENIO 100 MG TABLET   5 Specialty Tier 33%N/AP Q:60
/30Days
VERZENIO 150 MG TABLET   5 Specialty Tier 33%N/AP Q:60
/30Days
VERZENIO 200 MG TABLET   5 Specialty Tier 33%N/AP Q:60
/30Days
VERZENIO 50 MG TABLET   5 Specialty Tier 33%N/AP Q:60
/30Days
VESICARE 10 MG TABLET   4 Non-Preferred Drug 42%42%Q:30
/30Days
VESICARE 5 MG TABLET   4 Non-Preferred Drug 42%42%Q:30
/30Days
VESTURA 3 MG-0.02 MG TABLET   3 Preferred Brand $35.00$105.00None
VIBRAMYCIN 100MG CAPSULE   4 Non-Preferred Drug 42%42%S
VIBRAMYCIN 25MG/5ML SUSP   4 Non-Preferred Drug 42%42%S
VICODIN 5-300 MG TABLET   4 Non-Preferred Drug 42%42%Q:180
/30Days
VICODIN ES 7.5-300 MG TABLET   4 Non-Preferred Drug 42%42%Q:180
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
VICODIN HP 10-300 MG TABLET   4 Non-Preferred Drug 42%42%Q:180
/30Days
VICTOZA 3-PAK 18 MG/3 ML PEN   3 Preferred Brand $35.00$105.00Q:9
/30Days
VIDEX 4 GM PEDIATRIC SOLN   4 Non-Preferred Drug 42%42%None
VIDEX EC 125MG CAPSULE SA   4 Non-Preferred Drug 42%42%None
VIDEX EC 200MG CAPSULE SA   4 Non-Preferred Drug 42%42%None
VIDEX EC 250MG CAPSULE SA   4 Non-Preferred Drug 42%42%None
VIDEX EC 400MG CAPSULE SA   4 Non-Preferred Drug 42%42%None
VIENVA-28 TABLET   3 Preferred Brand $35.00$105.00None
VIGABATRIN 50 MG/ML ORAL SOLUTION [SABRIL]   5 Specialty Tier 33%N/AP Q:180
/30Days
VIGABATRIN 500 MG ORAL TABLET [SABRIL]   5 Specialty Tier 33%N/AP Q:180
/30Days
VIGABATRIN 500 MG POWDER PACKET [SABRIL]   5 Specialty Tier 33%N/AP Q:180
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
VIGAMOX 0.5% EYE DROPS   3 Preferred Brand $35.00$105.00None
VIIBRYD 10-20 MG STARTER PACK   4 Non-Preferred Drug 42%42%None
VIIBRYD 10mg/1 30 FILM COATED TABLETS in BOTTLE   4 Non-Preferred Drug 42%42%Q:30
/30Days
VIIBRYD 20mg/1 30 FILM COATED TABLETS in BOTTLE   4 Non-Preferred Drug 42%42%Q:30
/30Days
VIIBRYD 40mg/1 30 FILM COATED TABLETS in BOTTLE   4 Non-Preferred Drug 42%42%Q:30
/30Days
VIMOVO 375-20 MG TABLET   4 Non-Preferred Drug 42%42%None
VIMOVO 500-20 MG TABLET   4 Non-Preferred Drug 42%42%None
VIMPAT 10 MG/ML SOLUTION   4 Non-Preferred Drug 42%42%Q:1200
/30Days
Vimpat 100mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC   4 Non-Preferred Drug 42%42%Q:60
/30Days
Vimpat 10mg/mL 10 VIAL, GLASS per CARTON / 20 mL in 1 VIAL, GLASS   4 Non-Preferred Drug 42%42%None
Vimpat 150mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC   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
Vimpat 200mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC   4 Non-Preferred Drug 42%42%Q:60
/30Days
Vimpat 50mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC   4 Non-Preferred Drug 42%42%Q:180
/30Days
VINBLASTINE 1 MG/ML VIAL   4 Non-Preferred Drug 42%42%P
VINCRISTINE 1MG/ML VIAL   4 Non-Preferred Drug 42%42%P
VINCRISTINE 1MG/ML VIAL   4 Non-Preferred Drug 42%42%P
VINORELBINE 50 MG/5 ML VIAL   3 Preferred Brand $35.00$105.00None
VIRACEPT 250MG TABLET   5 Specialty Tier 33%N/ANone
VIRACEPT 625MG TABLET   5 Specialty Tier 33%N/ANone
VIRAMUNE 200MG TABLET   4 Non-Preferred Drug 42%42%None
Viramune 400mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE   4 Non-Preferred Drug 42%42%None
VIRAMUNE 50MG/5ML SUSP   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
VIRAMUNE XR 100 MG TABLET   4 Non-Preferred Drug 42%42%None
VIREAD 150 MG TABLET   5 Specialty Tier 33%N/ANone
VIREAD 200 MG TABLET   5 Specialty Tier 33%N/ANone
VIREAD 250 MG TABLET   5 Specialty Tier 33%N/ANone
VIREAD 300MG TABLET   5 Specialty Tier 33%N/ANone
VIREAD POWDER   5 Specialty Tier 33%N/ANone
VIROPTIC 1% EYE DROPS   4 Non-Preferred Drug 42%42%None
VISTARIL 25MG CAPSULE   4 Non-Preferred Drug 42%42%P
VISTARIL 50MG CAPSULE   4 Non-Preferred Drug 42%42%P
VIVELLE-DOT 0.025 MG PATCH   4 Non-Preferred Drug 42%42%P Q:8
/28Days
VIVELLE-DOT 0.0375MG PATCH 8 POUCH CRTN (1 X 8 POUCH CRTN)   4 Non-Preferred Drug 42%42%P Q:8
/28Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
VIVELLE-DOT 0.05MG PATCH 8 POUCH CRTN (1X8 POUCH CRTN)   4 Non-Preferred Drug 42%42%P Q:8
/28Days
VIVELLE-DOT 0.075 MG PATCH   4 Non-Preferred Drug 42%42%P Q:8
/28Days
VIVELLE-DOT 0.1 MG PATCH   4 Non-Preferred Drug 42%42%P Q:8
/28Days
VIVLODEX 10 MG CAPSULE   4 Non-Preferred Drug 42%42%S
VIVLODEX 5 MG CAPSULE   4 Non-Preferred Drug 42%42%S
VOGELXO 12.5 MG/1.25 GRAM PUMP   4 Non-Preferred Drug 42%42%P Q:300
/30Days
VOGELXO 50 MG/5 GRAM GEL PACKT   4 Non-Preferred Drug 42%42%P Q:300
/30Days
VOLTAREN 1% GEL   4 Non-Preferred Drug 42%42%S Q:1000
/30Days
VORICONAZOLE 200 MG TABLET   4 Non-Preferred Drug 42%42%None
VORICONAZOLE 200 MG VIAL   4 Non-Preferred Drug 42%42%None
Voriconazole 40 MG/ML Oral Suspension   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
VORICONAZOLE 50 MG TABLET   4 Non-Preferred Drug 42%42%None
VOTRIENT 200 MG TABLET   5 Specialty Tier 33%N/AP
VRAYLAR 1.5 MG CAP   5 Specialty Tier 33%N/AP Q:120
/30Days
VRAYLAR 1.5 MG-3 MG PACK   4 Non-Preferred Drug 42%42%P
VRAYLAR 3 MG CAP   5 Specialty Tier 33%N/AP Q:60
/30Days
VRAYLAR 4.5 MG CAP   5 Specialty Tier 33%N/AP Q:30
/30Days
VRAYLAR 6 MG CAP   5 Specialty Tier 33%N/AP Q:30
/30Days
Vyfemla 28 tablet   3 Preferred Brand $35.00$105.00None
VYLIBRA 28 TABLET   3 Preferred Brand $35.00$105.00None
VYTORIN 10-10 MG TABLET   4 Non-Preferred Drug 42%42%S Q:30
/30Days
VYTORIN 10-20 MG TABLET   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
VYTORIN 10-40 MG TABLET   4 Non-Preferred Drug 42%42%S Q:30
/30Days
VYTORIN 10-80 MG TABLET   4 Non-Preferred Drug 42%42%S Q:30
/30Days
VYVANSE 10 MG CAPSULE   4 Non-Preferred Drug 42%42%P Q:30
/30Days
VYVANSE 10 MG CHEWABLE TABLET   4 Non-Preferred Drug 42%42%P Q:30
/30Days
VYVANSE 20 MG CHEWABLE TABLET   4 Non-Preferred Drug 42%42%P Q:30
/30Days
VYVANSE 30 MG CHEWABLE TABLET   4 Non-Preferred Drug 42%42%P Q:30
/30Days
VYVANSE 30MG CAPSULE   4 Non-Preferred Drug 42%42%P Q:30
/30Days
VYVANSE 40 MG CHEWABLE TABLET   4 Non-Preferred Drug 42%42%P Q:30
/30Days
VYVANSE 40MG CAPSULE 100 EA   4 Non-Preferred Drug 42%42%P Q:30
/30Days
VYVANSE 50 MG CHEWABLE TABLET   4 Non-Preferred Drug 42%42%P Q:30
/30Days
VYVANSE 50MG CAPSULE   4 Non-Preferred Drug 42%42%P Q:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
VYVANSE 60 MG CHEWABLE TABLET   4 Non-Preferred Drug 42%42%P Q:30
/30Days
VYVANSE 70MG CAPSULE   4 Non-Preferred Drug 42%42%P Q:30
/30Days
VYVANSE CAPSULES 20MG 100 BOT   4 Non-Preferred Drug 42%42%P Q:30
/30Days
VYVANSE CAPSULES 60MG 100 BOT   4 Non-Preferred Drug 42%42%P Q:30
/30Days
VYXEOS 44 MG-100 MG 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.