Powered by Q1Group LLC
Education and Decision Support Tools for the Medicare Community


2019 Medicare Part D and Medicare Advantage Plan Formulary Browser

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.

HealthSun MediMax (HMO) (H5431-006-0)
Tier 1 (715)
Tier 2 (1510)
Tier 3 (304)
Tier 4 (433)
Tier 5 (565)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
Yes No Show either
  *required
 
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 
2019 Medicare Part D Plan Formulary Information
HealthSun MediMax (HMO) (H5431-006-0)
Benefit Details           
The HealthSun MediMax (HMO) (H5431-006-0)
Formulary Drugs Starting with the Letter C

in Broward County, FL: CMS MA Region 9 which includes: FL
Plan Monthly Premium: $30.30 Deductible: $415
Drugs Starting with Letter C

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
CABERGOLINE 0.5 MG TABLET   2 Generic 25%25%None
CABLIVI 11 MG KIT   5 Specialty Tier 25%N/AP
CABOMETYX 20 MG TABLET   5 Specialty Tier 25%N/AP
CABOMETYX 40 MG TABLET   5 Specialty Tier 25%N/AP
CABOMETYX 60 MG TABLET   5 Specialty Tier 25%N/AP
CALCIPOTRIENE 0.005% CREAM   2 Generic 25%25%None
CALCIPOTRIENE 0.005% SOLUTION   2 Generic 25%25%None
Calcipotriene 50ug/g 60 g per CARTON   2 Generic 25%25%None
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY   2 Generic 25%25%P Q:8
/30Days
CALCITRIOL 0.25 MCG CAPSULE [Rocaltrol]   1 Preferred Generic 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CALCITRIOL 0.5 MCG CAPSULE [Rocaltrol]   1 Preferred Generic 25%25%P
CALCITRIOL 1MCG/ML SOLUTION ORAL   2 Generic 25%25%P
CALCIUM ACETATE 667 MG TABLET [PhosLo]   2 Generic 25%25%None
CALCIUM ACETATE CAPSULE 667 MG   2 Generic 25%25%None
CALQUENCE 100 MG CAPSULE   5 Specialty Tier 25%N/AP
CAMILA 0.35 MG TABLET   3 Preferred Brand 25%N/ANone
CANDESARTAN CILEXETIL 16 MG TABLET [Atacand]   2 Generic 25%25%None
CANDESARTAN CILEXETIL 32 MG TABLET [Atacand]   2 Generic 25%25%None
CANDESARTAN CILEXETIL 4 MG TABLET [Atacand]   2 Generic 25%25%None
CANDESARTAN CILEXETIL 8 MG TABLET [Atacand]   2 Generic 25%25%None
candesartan-hctz 16-12.5 mg tablet   2 Generic 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
candesartan-hctz 32-12.5 mg tablet   2 Generic 25%25%None
CANDESARTAN-HCTZ 32-25 MG TAB   2 Generic 25%25%None
CAPRELSA 100 MG TABLET   5 Specialty Tier 25%N/AP
CAPRELSA 300 MG TABLET   5 Specialty Tier 25%N/AP
CAPTOPRIL 100MG TABLET   1 Preferred Generic 25%25%None
CAPTOPRIL 12.5MG TABLET   1 Preferred Generic 25%25%None
CAPTOPRIL 25 MG TABLET   1 Preferred Generic 25%25%None
CAPTOPRIL 50MG TABLET   1 Preferred Generic 25%25%None
Captopril and Hydrochlorothiazide 25; 15mg 100 TABLET BOTTLE   2 Generic 25%25%None
Captopril and Hydrochlorothiazide 25; 25mg 100 TABLET BOTTLE   2 Generic 25%25%None
Captopril and Hydrochlorothiazide 50; 15mg 100 TABLET BOTTLE   2 Generic 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Captopril and Hydrochlorothiazide 50; 25mg 100 TABLET BOTTLE   2 Generic 25%25%None
CARAFATE SUS 1GM/10ML   4 Non-Preferred Brand 25%N/ANone
CARBAGLU 200 MG DISPER TABLET   5 Specialty Tier 25%N/ANone
CARBAMAZEPINE 100 MG TAB CHEW   1 Preferred Generic 25%25%None
CARBAMAZEPINE 100 MG/5 ML SUSP   2 Generic 25%25%None
CARBAMAZEPINE 200 MG TABLET   1 Preferred Generic 25%25%None
CARBAMAZEPINE ER 100 MG CAP CPMP 12HR [Carbatrol]   2 Generic 25%25%None
CARBAMAZEPINE ER 100 MG TABLET   2 Generic 25%25%None
CARBAMAZEPINE ER 200 MG CAP CPMP 12HR [Carbatrol]   2 Generic 25%25%None
CARBAMAZEPINE ER 300 MG CAP CPMP 12HR [Carbatrol]   2 Generic 25%25%None
CARBAMAZEPINE XR 200 MG TABLET   2 Generic 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARBAMAZEPINE XR 400 MG TABLET   2 Generic 25%25%None
Carbidopa 25mg Tab 100 [Lodosyn]   2 Generic 25%25%None
CARBIDOPA AND LEVEDOPA ORALLY DISINTEGRATING TABLETS 10;100MG;MG 100 BOT   2 Generic 25%25%None
CARBIDOPA AND LEVODOPA ODT 25;100MG;MG 100 BOT   2 Generic 25%25%None
CARBIDOPA AND LEVODOPA ODT 25;250MG;MG 100 BOT   2 Generic 25%25%None
CARBIDOPA-LEVO ER 25-100 TAB   2 Generic 25%25%None
CARBIDOPA-LEVO ER 50-200 TAB   2 Generic 25%25%None
CARBIDOPA-LEVODOPA 10-100 TAB   1 Preferred Generic 25%25%None
CARBIDOPA-LEVODOPA 25-100 TAB   2 Generic 25%25%None
CARBIDOPA-LEVODOPA 25-250 TAB   2 Generic 25%25%None
CARBIDOPA-LEVODOPA-ENTA 150 MG   2 Generic 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARBIDOPA-LEVODOPA-ENTA 75 MG   2 Generic 25%25%None
CARBIDOPA-LEVODOPA-ENTACAPONE 100 MG [Stalevo]   2 Generic 25%25%None
CARBIDOPA-LEVODOPA-ENTACAPONE 125 MG [Stalevo]   2 Generic 25%25%None
CARBIDOPA-LEVODOPA-ENTACAPONE 200 MG [Stalevo]   2 Generic 25%25%None
CARBIDOPA-LEVODOPA-ENTACAPONE 50 MG [Stalevo]   2 Generic 25%25%None
CARBINOXAMINE 4 MG/5 ML LIQUID   2 Generic 25%25%P
CARISOPRODOL 250 MG TABLET   2 Generic 25%25%P
CARISOPRODOL 350 MG TABLET   2 Generic 25%25%P
CARISOPRODOL-ASPIRIN 200-325 MG   2 Generic 25%25%P
CARISOPRODOL-ASPIRIN-CODEIN TB   2 Generic 25%25%P
CARTEOLOL HCL 1% EYE DROPS   1 Preferred Generic 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARTIA XT 120MG CAPSULE SA   3 Preferred Brand 25%N/ANone
CARTIA XT 180MG CAPSULE SA   3 Preferred Brand 25%N/ANone
CARTIA XT 240MG CAPSULE SA   3 Preferred Brand 25%N/ANone
CARTIA XT 300 MG CAPSULE   3 Preferred Brand 25%N/ANone
CARVEDILOL 12.5 MG TABLET   1 Preferred Generic 25%25%None
CARVEDILOL 25 MG TABLET   1 Preferred Generic 25%25%None
CARVEDILOL 3.125 MG TABLET   1 Preferred Generic 25%25%None
CARVEDILOL 6.25 MG TABLET   1 Preferred Generic 25%25%None
CARVEDILOL ER 10 MG CAPSULE   2 Generic 25%25%None
CARVEDILOL ER 20 MG CAPSULE   2 Generic 25%25%None
CARVEDILOL ER 40 MG CAPSULE   2 Generic 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARVEDILOL ER 80 MG CAPSULE   2 Generic 25%25%None
CASPOFUNGIN ACETATE 50 MG VIAL   5 Specialty Tier 25%N/AP
CASPOFUNGIN ACETATE 70 MG VIAL   5 Specialty Tier 25%N/AP
CAYSTON KIT 75 MG/VIAL   5 Specialty Tier 25%N/ANone
CEFACLOR 250 MG CAPSULES   2 Generic 25%25%None
CEFACLOR 500 MG CAPSULES   2 Generic 25%25%None
CEFACLOR ER 500MG TABLET SR 12HR   2 Generic 25%25%None
CEFADROXIL 1 GM TABLET   2 Generic 25%25%None
CEFADROXIL 250 MG/5 ML SUSP   2 Generic 25%25%None
CEFADROXIL 500 MG CAPSULE   2 Generic 25%25%None
CEFADROXIL 500 MG/5 ML SUSP   2 Generic 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFAZOLIN 1 GM VIAL 25/Box   2 Generic 25%25%P
Cefazolin 10g/1 10 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 PACKAGE   2 Generic 25%25%P
CEFAZOLIN 500 MG VIAL   2 Generic 25%25%P
CEFDINIR 125 MG/5 ML SUSP   2 Generic 25%25%None
CEFDINIR 250 MG/5 ML SUSP   2 Generic 25%25%None
CEFDINIR 300 MG CAPSULE   2 Generic 25%25%None
CEFEPIME HCL 1 GM VIAL [Maxipime]   2 Generic 25%25%P
CEFEPIME HCL 2 GRAM VIAL [Maxipime]   2 Generic 25%25%P
CEFIXIME 100 MG/5 ML SUSP [Suprax]   2 Generic 25%25%None
CEFIXIME 200 MG/5 ML SUSP [Suprax]   2 Generic 25%25%None
CEFOXITIN 1 GM VIAL   2 Generic 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFOXITIN 10 GM VIAL   2 Generic 25%25%P
CEFOXITIN 2 GM VIAL   2 Generic 25%25%P
CEFPODOXIME 100 MG TABLET   2 Generic 25%25%None
CEFPODOXIME 100 MG/5 ML SUSP   2 Generic 25%25%None
CEFPODOXIME 200 MG TABLET   2 Generic 25%25%None
CEFPODOXIME 50 MG/5 ML SUSP   2 Generic 25%25%None
CEFPROZIL 125 MG/5 ML SUSP   2 Generic 25%25%None
CEFPROZIL 250 MG TABLET   2 Generic 25%25%None
CEFPROZIL 250 MG/5 ML SUSP   2 Generic 25%25%None
CEFPROZIL 500 MG TABLET   2 Generic 25%25%None
CEFTAZIDIME 1 GM VIAL   2 Generic 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFTAZIDIME FOR INJECTION 2GM/VIAL 10 X 2 CRTN   2 Generic 25%25%None
CEFTAZIDIME FOR INJECTION 6GM/VIAL 6 X 6 CRTN   2 Generic 25%25%None
CEFTRIAXONE 1 GM VIAL   2 Generic 25%25%P
CEFTRIAXONE 10 GM VIAL   2 Generic 25%25%P
CEFTRIAXONE 2 GM VIAL   2 Generic 25%25%P
CEFTRIAXONE 250 MG VIAL   2 Generic 25%25%P
CEFTRIAXONE 500 MG VIAL   2 Generic 25%25%P
CEFUROXIME 1.5 GM/VIAL FOR INJECTION   2 Generic 25%25%P
CEFUROXIME 750 MG FOR INJECTION   2 Generic 25%25%P
Cefuroxime 95 MG/ML Injectable Solution   2 Generic 25%25%P
CEFUROXIME AXETIL 250 MG TAB   2 Generic 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFUROXIME AXETIL 500 MG TAB   2 Generic 25%25%None
CELECOXIB 100 MG CAPSULE [Celebrex]   2 Generic 25%25%None
CELECOXIB 200 MG CAPSULE [Celebrex]   2 Generic 25%25%None
CELECOXIB 400 MG CAPSULE [Celebrex]   2 Generic 25%25%None
CELECOXIB 50 MG CAPSULE [Celebrex]   2 Generic 25%25%None
CELONTIN 300 MG KAPSEAL   4 Non-Preferred Brand 25%N/AS
CEPHALEXIN 125 MG/5 ML SUSP   2 Generic 25%25%None
CEPHALEXIN 250 MG CAPSULE   1 Preferred Generic 25%25%None
CEPHALEXIN 250 MG TABLET   2 Generic 25%25%None
CEPHALEXIN 250 MG/5 ML SUSP   2 Generic 25%25%None
CEPHALEXIN 500 MG CAPSULE   1 Preferred Generic 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEPHALEXIN 500 MG TABLET   2 Generic 25%25%None
CETIRIZINE HCL 1 MG/ML SOLN   1 Preferred Generic 25%25%None
CEVIMELINE HCL 30 MG CAPSULE [Evoxac]   2 Generic 25%25%None
CHANTIX 0.5 MG TABLET   3 Preferred Brand 25%N/AQ:11
/30Days
CHANTIX 1 MG CONT MONTH BOX   3 Preferred Brand 25%N/AQ:56
/28Days
CHANTIX 1 MG TABLET   3 Preferred Brand 25%N/AQ:180
/90Days
CHANTIX STARTING MONTH BOX   3 Preferred Brand 25%N/AQ:53
/28Days
CHLORDIAZEPO-AMITRIPTYL 5-12.5   2 Generic 25%25%None
CHLORDIAZEPOXIDE 10 MG CAPSULE   2 Generic 25%25%None
CHLORDIAZEPOXIDE 25 MG CAPSULE   2 Generic 25%25%None
CHLORDIAZEPOXIDE 5 MG CAPSULE   2 Generic 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CHLORHEXIDINE GLUCONATE 0.12% RINSE   1 Preferred Generic 25%25%None
CHLOROQUINE PH 250 MG TABLET   2 Generic 25%25%None
CHLOROQUINE PH 500 MG TABLET   2 Generic 25%25%None
CHLOROTHIAZIDE 250 MG TABLET   1 Preferred Generic 25%25%None
Chlorothiazide 500mg 100 TABLET BOTTLE   1 Preferred Generic 25%25%None
CHLORPROMAZINE 10 MG TABLET   2 Generic 25%25%P
CHLORPROMAZINE 100 MG TABLET   2 Generic 25%25%P
CHLORPROMAZINE 200 MG TABLET   2 Generic 25%25%P
CHLORPROMAZINE 25 MG TABLET   2 Generic 25%25%P
CHLORPROMAZINE 50 MG TABLET   2 Generic 25%25%P
CHLORTHALIDONE 25 MG TABLET (100 CT)   1 Preferred Generic 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CHLORTHALIDONE 50 MG TABLET   1 Preferred Generic 25%25%None
CHLORZOXAZONE 375 MG TABLET [Lorzone]   2 Generic 25%25%P
CHLORZOXAZONE 500 MG TABLET   2 Generic 25%25%P
CHLORZOXAZONE 750 MG TABLET [Lorzone]   2 Generic 25%25%P
CHOLESTYRAMINE LIGHT POWDER   2 Generic 25%25%None
CHOLESTYRAMINE PACKET   2 Generic 25%25%None
CICLOPIROX 0.77% CREAM   1 Preferred Generic 25%25%None
CICLOPIROX 0.77% GEL   2 Generic 25%25%None
CICLOPIROX 0.77% TOPICAL SUSP   1 Preferred Generic 25%25%None
CICLOPIROX 1% SHAMPOO   2 Generic 25%25%None
CICLOPIROX 8% SOLUTION   2 Generic 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Cilastatin 250 MG / Imipenem 250 MG Injection   2 Generic 25%25%P
CILOSTAZOL 100 MG TABLET   2 Generic 25%25%None
CILOSTAZOL 50 MG TABLET   2 Generic 25%25%None
CIMDUO 300-300 MG TABLET   5 Specialty Tier 25%N/ANone
Cimetidine 200mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC   2 Generic 25%25%None
Cimetidine 300 MG Oral Tablet   2 Generic 25%25%None
Cimetidine 400mg/1 100 FILM COATED TABLETS in BOTTLE   2 Generic 25%25%None
Cimetidine 800mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC   2 Generic 25%25%None
Cimetidine Hydrochloride Oral Solution 300mg/5mL 237 mL in 1 BOTTLE   2 Generic 25%25%None
Cimzia 2 KIT per CARTON / 1 KIT in 1 KIT   5 Specialty Tier 25%N/AS
CIMZIA 200 MG/ML SYRINGE KIT   5 Specialty Tier 25%N/AS
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CINACALCET HCL 30 MG TABLET [Sensipar]   2 Generic 25%25%P
CINACALCET HCL 60 MG TABLET [Sensipar]   5 Specialty Tier 25%N/AP
CINACALCET HCL 90 MG TABLET [Sensipar]   5 Specialty Tier 25%N/AP
Cinryze 500[iU]/5mL 1 VIAL per CARTON / 5 mL in 1 VIAL   5 Specialty Tier 25%N/AP
CIPRODEX OTIC SUSPENSION   4 Non-Preferred Brand 25%N/ANone
CIPROFLOXACIN 0.2% OTIC SOLN DROPERETTE [Cetraxal]   2 Generic 25%25%None
CIPROFLOXACIN 0.3% EYE DROP [Ciloxan]   1 Preferred Generic 25%25%None
CIPROFLOXACIN 250 MG TABLET (100 CT) [Cipro]   1 Preferred Generic 25%25%None
CIPROFLOXACIN 500 MG/5 ML SUSP MC REC [Cipro]   2 Generic 25%25%None
CIPROFLOXACIN HCL 100 MG Tablet [Cipro]   2 Generic 25%25%None
CIPROFLOXACIN HCL 500 MG Tablet [Cipro]   1 Preferred Generic 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CIPROFLOXACIN HCL 750 MG Tablet [Cipro]   2 Generic 25%25%None
CIPROFLOXACIN-D5W 200 MG/100 ML PIGGYBACK [Cipro]   2 Generic 25%25%P
CITALOPRAM HBR 10 MG TABLET   1 Preferred Generic 25%25%None
CITALOPRAM HBR 10 MG/5 ML SOLN   2 Generic 25%25%None
CITALOPRAM HBR 20 MG TABLET   1 Preferred Generic 25%25%None
CITALOPRAM HBR 40 MG TABLET   1 Preferred Generic 25%25%None
CLARAVIS 10 MG CAPSULE   4 Non-Preferred Brand 25%N/ANone
CLARAVIS 20 MG CAPSULE   4 Non-Preferred Brand 25%N/ANone
Claravis 30mg 3 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK   4 Non-Preferred Brand 25%N/ANone
CLARAVIS 40 MG CAPSULE   4 Non-Preferred Brand 25%N/ANone
CLARITHROMYCIN 125 MG/5ML FOR ORAL SUSPENSION   2 Generic 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLARITHROMYCIN 250 MG TABLET   2 Generic 25%25%None
CLARITHROMYCIN 250 MG/5MLFOR ORAL SUSPENSION   2 Generic 25%25%None
CLARITHROMYCIN 500 MG TABLET   2 Generic 25%25%None
CLARITHROMYCIN ER 500 MG TAB   2 Generic 25%25%None
Clemastine fum 2.68 mg tab   2 Generic 25%25%P
CLENPIQ 10-3.5/160   4 Non-Preferred Brand 25%N/ANone
CLIMARA PRO DIS WEEKLY 4.40MG/1.39MG   4 Non-Preferred Brand 25%N/AP
CLINDAMYCIN 75 MG/5 ML SOLN   2 Generic 25%25%None
CLINDAMYCIN HCL 150 MG CAPSULE   1 Preferred Generic 25%25%None
CLINDAMYCIN HCL 300 MG CAPSULE   1 Preferred Generic 25%25%None
CLINDAMYCIN HCL 75 MG 200 CAPSULE BOTTLE   1 Preferred Generic 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLINDAMYCIN PH 1% SOLUTION   2 Generic 25%25%None
CLINDAMYCIN PH 600 MG/4 ML VL   2 Generic 25%25%P
CLINDAMYCIN PHOSP 1% LOTION   2 Generic 25%25%None
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE   2 Generic 25%25%None
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX   2 Generic 25%25%None
CLINDAMYCIN PHOSPHATE VAGINAL CREAM   2 Generic 25%25%None
Clindamycin-d5w 300 mg/50 ml   2 Generic 25%25%None
Clindamycin-d5w 600 mg/50 ml   2 Generic 25%25%None
Clindamycin-d5w 900 mg/50 ml   2 Generic 25%25%None
CLINIMIX 4.25%-25% SOLUTION IV SOLN   4 Non-Preferred Brand 25%N/AP
CLINIMIX 5/20 SOLUTION   4 Non-Preferred Brand 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLINIMIX 5/25 SULFITE FREE INJECTIONS 1035MG-420MEQ 1000ML BAG   4 Non-Preferred Brand 25%N/AP
CLINIMIX 5%-15% SOLUTION   4 Non-Preferred Brand 25%N/AP
CLINIMIX E 2.75/5 SOLUTION   4 Non-Preferred Brand 25%N/AP
CLINIMIX E 4.25/5 SOLUTION   4 Non-Preferred Brand 25%N/AP
CLINIMIX E 5/20 SOLUTION   4 Non-Preferred Brand 25%N/AP
CLINIMIX E 5%/15% INJECTION 2000ML BAG   4 Non-Preferred Brand 25%N/AP
CLINISOL 15% SOLUTION   4 Non-Preferred Brand 25%N/AP
CLOBAZAM 10 MG TABLET [ONFI]   2 Generic 25%25%None
CLOBAZAM 2.5 MG/ML Oral Suspension [ONFI]   2 Generic 25%25%None
CLOBAZAM 20 MG TABLET [ONFI]   2 Generic 25%25%None
CLOBETASOL 0.05% CREAM (g) [Temovate]   2 Generic 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLOBETASOL 0.05% OINTMENT   2 Generic 25%25%None
CLOBETASOL 0.05% SOLUTION   2 Generic 25%25%None
CLOBETASOL 0.05% TOPICAL LOTN   2 Generic 25%25%None
CLOBETASOL EMOLLIENT 0.05% CREAM (g) [Temovate E]   2 Generic 25%25%None
Clobetasol Propionate 0.5 MG/ML Medicated Shampoo   2 Generic 25%25%None
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE   2 Generic 25%25%None
CLOMIPRAMINE 25 MG CAPSULE   2 Generic 25%25%None
CLOMIPRAMINE 50 MG CAPSULE   2 Generic 25%25%None
CLOMIPRAMINE 75 MG CAPSULE   2 Generic 25%25%None
CLONAZEPAM 0.125 MG DIS TAB RAPDIS [Klonopin]   2 Generic 25%25%None
CLONAZEPAM 0.25 MG ODT TAB RAPDIS [Klonopin]   2 Generic 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLONAZEPAM 0.5 MG DIS TABLET RAPDIS [Klonopin]   2 Generic 25%25%None
CLONAZEPAM 0.5 MG TABLET [Klonopin]   1 Preferred Generic 25%25%None
CLONAZEPAM 1 MG DIS TABLET RAPDIS [Klonopin]   2 Generic 25%25%None
CLONAZEPAM 1 MG TABLET [Klonopin]   1 Preferred Generic 25%25%None
CLONAZEPAM 2 MG ODT TAB RAPDIS [Klonopin]   2 Generic 25%25%None
CLONAZEPAM 2 MG TABLET [Klonopin]   1 Preferred Generic 25%25%None
Clonidine 0.1mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH   2 Generic 25%25%Q:5
/30Days
Clonidine 0.2mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH   2 Generic 25%25%Q:5
/30Days
Clonidine 0.3mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH   2 Generic 25%25%Q:5
/30Days
CLONIDINE HCL 0.1 MG TABLET   1 Preferred Generic 25%25%None
CLONIDINE HCL 0.2 MG TABLET   1 Preferred Generic 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLONIDINE HCL 0.3 MG TABLET   1 Preferred Generic 25%25%None
CLONIDINE HCL ER 0.1 MG TABLET   2 Generic 25%25%None
CLOPIDOGREL 75 MG TABLET [Plavix]   2 Generic 25%25%None
CLORAZEPATE 15 MG TABLET   2 Generic 25%25%None
CLORAZEPATE 3.75 MG TABLET   2 Generic 25%25%None
CLORAZEPATE 7.5 MG TABLET   2 Generic 25%25%None
CLOTRIMAZOLE 1% CREAM   1 Preferred Generic 25%25%None
CLOTRIMAZOLE 1% SOLUTION   1 Preferred Generic 25%25%None
CLOTRIMAZOLE 10 MG TROCHE   1 Preferred Generic 25%25%None
CLOTRIMAZOLE-BETAMETHASONE LOT   2 Generic 25%25%None
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE 0.64; 10mg/g; mg/g 45 g in 1 TUBE   2 Generic 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLOZAPINE 100 MG TABLET [Clozaril]   2 Generic 25%25%None
CLOZAPINE 200 MG TABLET   2 Generic 25%25%None
CLOZAPINE 25 MG TABLET [Clozaril]   2 Generic 25%25%None
CLOZAPINE 50 MG TABLET   2 Generic 25%25%None
CLOZAPINE ODT 100 MG TABLET RAPDIS [Fazaclo]   2 Generic 25%25%None
CLOZAPINE ODT 12.5 MG TABLET RAPDIS [Fazaclo]   2 Generic 25%25%None
CLOZAPINE ODT 150 MG TABLET RAPDIS [Fazaclo]   2 Generic 25%25%None
CLOZAPINE ODT 200 MG TABLET RAPDIS [Fazaclo]   2 Generic 25%25%None
CLOZAPINE ODT 25 MG TABLET RAPDIS [Fazaclo]   2 Generic 25%25%None
COARTEM 20MG-120MG   4 Non-Preferred Brand 25%N/ANone
COLCHICINE 0.6 MG CAPSULE [Mitigare]   2 Generic 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COLCHICINE 0.6 MG TABLET [Colcrys]   2 Generic 25%25%None
COLESEVELAM 625 MG TABLET [WelChol]   2 Generic 25%25%None
COLESEVELAM HCL 3.75 G PACKET POWD PACK [WelChol]   2 Generic 25%25%None
COLESTIPOL HCL 1G TABLET   2 Generic 25%25%None
COLESTIPOL HCL GRANULES PACKET   2 Generic 25%25%None
COLISTIMETHATE 150 MG VIAL [Coly-Mycin M]   2 Generic 25%25%P
COMBIGAN 0.2%-0.5% DROPS   4 Non-Preferred Brand 25%N/ANone
COMBIVENT RESPIMAT INHAL SPRAY   4 Non-Preferred Brand 25%N/AQ:4
/30Days
COMETRIQ 100 MG DAILY-DOSE PK   5 Specialty Tier 25%N/AP
COMETRIQ 140 MG DAILY-DOSE PK   5 Specialty Tier 25%N/AP
COMETRIQ 60 MG DAILY-DOSE PACK   5 Specialty Tier 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COMPLERA 200; 27.5; 300mg/1; mg/1; mg/1   5 Specialty Tier 25%N/ANone
CONDYLOX 0.5% GEL   4 Non-Preferred Brand 25%N/ANone
COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN   5 Specialty Tier 25%N/AP
COPAXONE 40 MG/ML SYRINGE   5 Specialty Tier 25%N/AP
COPIKTRA 15 MG CAPSULE   5 Specialty Tier 25%N/AP
COPIKTRA 25 MG CAPSULE   5 Specialty Tier 25%N/AP
CORLANOR 5 MG TABLET   4 Non-Preferred Brand 25%N/ANone
CORLANOR 7.5 MG TABLET   4 Non-Preferred Brand 25%N/ANone
COSENTYX 300 MG DOSE-2 PENS   5 Specialty Tier 25%N/AS
COTELLIC 20 MG TABLET   5 Specialty Tier 25%N/AP
Creon 256.11mg/1 1 BOTTLE per CARTON / 70 CAPSULE, DELAYED RELEASE in 1 BOTTLE   3 Preferred Brand 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CREON DELAYED RELEASE CAPSULES 12000MG 100 BOT   3 Preferred Brand 25%N/ANone
CREON DELAYED RELEASE CAPSULES 24000MG 100 BOT   3 Preferred Brand 25%N/ANone
CREON DELAYED RELEASE CAPSULES 6000MG 100 BOT   3 Preferred Brand 25%N/ANone
CREON DR 36,000 UNITS CAPSULE   3 Preferred Brand 25%N/ANone
CRIXIVAN 200MG CAPSULE   4 Non-Preferred Brand 25%N/ANone
CRIXIVAN 400mg, 180 CAPSULE BOTTLE   4 Non-Preferred Brand 25%N/ANone
CROMOLYN 20 MG/2 ML NEB SOLN   2 Generic 25%25%P
CROMOLYN SODIUM 100 MG/5 ML   2 Generic 25%25%None
CROMOLYN SODIUM 4% 40MG 10ML BOT   1 Preferred Generic 25%25%None
CUPRIMINE 250 MG CAPSULE   5 Specialty Tier 25%N/ANone
CYCLOBENZAPRINE 10 MG TABLET   2 Generic 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CYCLOBENZAPRINE 5 MG TABLET   2 Generic 25%25%P
CYCLOBENZAPRINE 7.5 MG TABLET   2 Generic 25%25%P
CYCLOPHOSPHAMIDE 25 MG CAPSULE   2 Generic 25%25%P
CYCLOPHOSPHAMIDE 50 MG CAPSULE   2 Generic 25%25%P
CYCLOSET 0.8MG TABLETS   4 Non-Preferred Brand 25%N/ANone
CYCLOSPORINE 100MG CAPSULE   2 Generic 25%25%P
CYCLOSPORINE 25MG CAPSULE   1 Preferred Generic 25%25%P
CYCLOSPORINE MODIFIED 100 MG   2 Generic 25%25%P
CYCLOSPORINE MODIFIED 25 MG   1 Preferred Generic 25%25%P
CYCLOSPORINE MODIFIED 50 MG   2 Generic 25%25%P
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT   2 Generic 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CYPROHEPTADINE 4 MG TABLET   1 Preferred Generic 25%25%P
CYPROHEPTADINE HYDROCHLORIDE SOLUTION USP SYRUP 2MG 473 ML BOTGL   1 Preferred Generic 25%25%P
CYRED EQ 28 DAY TABLET [Solia]   1 Preferred Generic 25%25%None
CYSTADANE 1 GRAM/1.7 ML POWDER   4 Non-Preferred Brand 25%N/ANone
CYSTAGON 150MG CAPSULE   4 Non-Preferred Brand 25%N/ANone
CYSTAGON 50MG CAPSULE   4 Non-Preferred Brand 25%N/ANone
CYSTARAN 0.44% EYE DROPS   5 Specialty Tier 25%N/ANone

Chart Legend:

Below are a few notes to help you understand the above 2019 Medicare Part D HealthSun MediMax (HMO) 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 $415 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 $3820) at a "Preferred" network pharmacy. In most cases, the "Preferred" 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 2019 )

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.








Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.