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BlueRx Essential (PDP) (S1030-006-0)
Tier 1 (76)
Tier 2 (615)
Tier 3 (786)
Tier 4 (574)
Tier 5 (657)
Requires Prior Authorization:
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Uses Step Therapy:
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M N O P Q R S T U V W X Y Z 0-9 
2019 Medicare Part D Plan Formulary Information
BlueRx Essential (PDP) (S1030-006-0)
Benefit Details           
The BlueRx Essential (PDP) (S1030-006-0)
Formulary Drugs Starting with the Letter L

in CMS PDP Region 12 which includes: AL TN
Plan Monthly Premium: $34.40 Deductible: $415 Qualifies for LIS: No
Drugs Starting with Letter L

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
LABETALOL HCL 100 MG TABLET   2 Generic $4.00$8.00None
LABETALOL HCL 200 MG TABLET   2 Generic $4.00$8.00None
LABETALOL HCL 300 MG TABLET   2 Generic $4.00$8.00None
LACRISERT 5 MG INS   4 Non-Preferred Drug 50%50%None
LACTULOSE 10 GM/15 ML SOLUTION [Constulose]   2 Generic $4.00$8.00None
Lamivudine 10 mg/ml oral soln   4 Non-Preferred Drug 50%50%Q:960
/30Days
LAMIVUDINE 150 MG TABLET   3 Preferred Brand $47.00$94.00Q:60
/30Days
LAMIVUDINE 300 MG TABLET   4 Non-Preferred Drug 50%50%Q:30
/30Days
Lamivudine hbv 100 mg tablet   4 Non-Preferred Drug 50%50%None
LAMIVUDINE-ZIDOVUDINE TABLET   4 Non-Preferred Drug 50%50%Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LAMOTRIGINE 150MG TABLET (60 CT)   2 Generic $4.00$8.00None
LAMOTRIGINE 200MG TABLET (60 CT)   2 Generic $4.00$8.00None
LAMOTRIGINE 25 MG DISPER TAB CHW DSP [Lamictal CD]   3 Preferred Brand $47.00$94.00None
LAMOTRIGINE 25 MG TABLET [Subvenite]   2 Generic $4.00$8.00None
LAMOTRIGINE 5 MG DISPER TABLET CHW DSP [Lamictal CD]   2 Generic $4.00$8.00None
LAMOTRIGINE TABLET 100MG (100 CT)   2 Generic $4.00$8.00None
LANTHANUM CARB 1,000 MG TAB CHEW [Fosrenol]   5 Specialty Tier 25%25%None
LANTHANUM CARB 500 MG TAB CHEW [Fosrenol]   5 Specialty Tier 25%25%None
LANTHANUM CARB 750 MG TAB CHEW [Fosrenol]   5 Specialty Tier 25%25%None
LANTUS 100U/ML VIAL   3 Preferred Brand $47.00$94.00Q:60
/30Days
LANTUS SOLOSTAR INJECTION   3 Preferred Brand $47.00$94.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LARIN 1.5 MG-30 MCG TABLET   3 Preferred Brand $47.00$94.00None
LARIN 21 1-20 TABLET   3 Preferred Brand $47.00$94.00None
LARIN FE 1-20 TABLET   3 Preferred Brand $47.00$94.00None
LARIN FE 1.5-30 TABLET   3 Preferred Brand $47.00$94.00None
Larissia-28 tablet   3 Preferred Brand $47.00$94.00None
LATANOPROST 0.005% EYE DROPS   2 Generic $4.00$8.00None
LATUDA 120 MG TABLET   5 Specialty Tier 25%25%P Q:30
/30Days
LATUDA 20 MG TABLET   5 Specialty Tier 25%25%P Q:30
/30Days
LATUDA 40 MG TABLET   5 Specialty Tier 25%25%P Q:30
/30Days
LATUDA 60 MG TABLET   5 Specialty Tier 25%25%P Q:30
/30Days
LATUDA 80 MG TABLET   5 Specialty Tier 25%25%P Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LAZANDA 100 MCG NASAL SPRAY   5 Specialty Tier 25%25%P Q:30
/30Days
LAZANDA 300 MCG NASAL SPRAY   5 Specialty Tier 25%25%P Q:30
/30Days
LAZANDA 400 MCG NASAL SPRAY   5 Specialty Tier 25%25%P Q:30
/30Days
LEENA 28 TABLET [Tri-Norinyl]   3 Preferred Brand $47.00$94.00None
LEFLUNOMIDE 10 MG TABLET   4 Non-Preferred Drug 50%50%None
LEFLUNOMIDE 20 MG TABLET   4 Non-Preferred Drug 50%50%None
LENVIMA 10 MG DAILY DOSE   5 Specialty Tier 25%25%P Q:30
/30Days
LENVIMA 12 MG DAILY DOSE Capsule   5 Specialty Tier 25%25%P Q:90
/30Days
LENVIMA 14 MG DAILY DOSE   5 Specialty Tier 25%25%P Q:60
/30Days
LENVIMA 18 MG DAILY DOSE   5 Specialty Tier 25%25%P Q:90
/30Days
LENVIMA 20 MG DAILY DOSE   5 Specialty Tier 25%25%P Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LENVIMA 24 MG DAILY DOSE   5 Specialty Tier 25%25%P Q:90
/30Days
LENVIMA 4 MG CAPSULE   5 Specialty Tier 25%25%P Q:30
/30Days
LENVIMA 8 MG DAILY DOSE   5 Specialty Tier 25%25%P Q:60
/30Days
Lessina 3 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK   3 Preferred Brand $47.00$94.00None
LETAIRIS 10 MG TABLET   5 Specialty Tier 25%25%P Q:30
/30Days
LETAIRIS 5 MG TABLET   5 Specialty Tier 25%25%P Q:30
/30Days
LETROZOLE 2.5 MG TABLET   2 Generic $4.00$8.00None
LEUCOVORIN CALCIUM 10MG TABLET   4 Non-Preferred Drug 50%50%None
Leucovorin Calcium 15mg/1 24 TABLET BOTTLE   4 Non-Preferred Drug 50%50%None
LEUCOVORIN CALCIUM 25MG TABLET   4 Non-Preferred Drug 50%50%None
LEUCOVORIN CALCIUM 5 MG TAB   2 Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEUKERAN 2 MG TABLET   5 Specialty Tier 25%25%None
LEUKINE 250 MCG VIAL   5 Specialty Tier 25%25%None
LEUPROLIDE 2WK 14 MG/2.8 ML KT   5 Specialty Tier 25%25%None
LEVETIRACETAM 1,000 MG TABLET   2 Generic $4.00$8.00None
LEVETIRACETAM 100 MG/ML SOLN   3 Preferred Brand $47.00$94.00None
LEVETIRACETAM 250 MG TABLET   2 Generic $4.00$8.00None
LEVETIRACETAM 500 MG TABLET   2 Generic $4.00$8.00None
LEVETIRACETAM 750 MG TABLET   2 Generic $4.00$8.00None
LEVO-T 100 MCG TABLET   2 Generic $4.00$8.00None
LEVO-T 112 MCG TABLET   2 Generic $4.00$8.00None
LEVO-T 125 MCG TABLET   2 Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEVO-T 137 MCG TABLET   2 Generic $4.00$8.00None
LEVO-T 150 MCG TABLET   2 Generic $4.00$8.00None
LEVO-T 175 MCG TABLET   2 Generic $4.00$8.00None
LEVO-T 200 MCG TABLET   2 Generic $4.00$8.00None
LEVO-T 25 MCG TABLET   2 Generic $4.00$8.00None
LEVO-T 300 MCG TABLET   2 Generic $4.00$8.00None
LEVO-T 50 MCG TABLET   2 Generic $4.00$8.00None
LEVO-T 75 MCG TABLET   2 Generic $4.00$8.00None
LEVO-T 88 MCG TABLET   2 Generic $4.00$8.00None
LEVOCARNITINE 1 G/10 ML SOLN   4 Non-Preferred Drug 50%50%None
LEVOCARNITINE 330 MG TABLET   3 Preferred Brand $47.00$94.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEVOCETIRIZINE 5 MG TABLET   2 Generic $4.00$8.00None
LEVOFLOXACIN 25 MG/ML SOLUTION [LEVAQUIN]   4 Non-Preferred Drug 50%50%None
LEVOFLOXACIN 250 MG TABLET [LEVAQUIN]   1 Preferred Generic $1.00$2.00None
LEVOFLOXACIN 500 MG TABLET [LEVAQUIN]   1 Preferred Generic $1.00$2.00None
LEVOFLOXACIN 500 MG/20 ML VIAL [Levaquin]   4 Non-Preferred Drug 50%50%None
Levofloxacin 5mg/mL 24 POUCH per CARTON / 1 BAG in 1 POUCH / 100 mL in 1 BAG [LEVAQUIN]   4 Non-Preferred Drug 50%50%None
LEVOFLOXACIN 750 MG TABLET [LEVAQUIN]   2 Generic $4.00$8.00None
LEVOFLOXACIN 750 MG/150 ML-D5W [LEVAQUIN]   4 Non-Preferred Drug 50%50%None
LEVONEST-28 TABLET   3 Preferred Brand $47.00$94.00None
LEVONO-E ESTRAD 0.10-0.02-0.01   2 Generic $4.00$8.00None
LEVONOR-ETH ESTRAD 0.1-0.02 MG   3 Preferred Brand $47.00$94.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEVONOR-ETH ESTRAD 0.15-0.03   3 Preferred Brand $47.00$94.00None
LEVONOR-ETH ESTRAD 0.15-0.03   3 Preferred Brand $47.00$94.00None
LEVONOR-ETH ESTRAD TRIPHASIC   3 Preferred Brand $47.00$94.00None
Levora-28 tablet   3 Preferred Brand $47.00$94.00None
LEVOTHYROXINE 100 MCG TABLET   2 Generic $4.00$8.00None
LEVOTHYROXINE 112 MCG TABLET   2 Generic $4.00$8.00None
LEVOTHYROXINE 125 MCG TABLET   2 Generic $4.00$8.00None
LEVOTHYROXINE 137 MCG TABLET   2 Generic $4.00$8.00None
LEVOTHYROXINE 150 MCG TABLET   2 Generic $4.00$8.00None
LEVOTHYROXINE 175 MCG TABLET   2 Generic $4.00$8.00None
LEVOTHYROXINE 200 MCG TABLET   2 Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEVOTHYROXINE 25 MCG TABLET   2 Generic $4.00$8.00None
LEVOTHYROXINE 300 MCG TABLET   2 Generic $4.00$8.00None
LEVOTHYROXINE 50 MCG TABLET   2 Generic $4.00$8.00None
LEVOTHYROXINE 75 MCG TABLET   2 Generic $4.00$8.00None
LEVOTHYROXINE 88 MCG TABLET   2 Generic $4.00$8.00None
LEVOXYL 100 MCG TABLET   2 Generic $4.00$8.00None
LEVOXYL 112 MCG TABLET   2 Generic $4.00$8.00None
LEVOXYL 125 MCG TABLET   2 Generic $4.00$8.00None
LEVOXYL 137 MCG TABLET   2 Generic $4.00$8.00None
LEVOXYL 150 MCG TABLET   2 Generic $4.00$8.00None
LEVOXYL 175 MCG TABLET   2 Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEVOXYL 200 MCG TABLET   2 Generic $4.00$8.00None
LEVOXYL 25 MCG TABLET   2 Generic $4.00$8.00None
LEVOXYL 50 MCG TABLET   2 Generic $4.00$8.00None
LEVOXYL 75 MCG TABLET   2 Generic $4.00$8.00None
LEVOXYL 88 MCG TABLET   2 Generic $4.00$8.00None
LEXIVA 50mg/mL 225 mL in 1 BOTTLE   4 Non-Preferred Drug 50%50%Q:1800
/30Days
LIDOCAINE 2% VISCOUS SOLN   2 Generic $4.00$8.00None
Lidocaine 5% patch   4 Non-Preferred Drug 50%50%P Q:90
/30Days
LIDOCAINE HCL 2% JELLY 30ML TUBE   3 Preferred Brand $47.00$94.00P Q:150
/30Days
LIDOCAINE HCL IV 4% SOLUTION   3 Preferred Brand $47.00$94.00P Q:150
/30Days
LIDOCAINE-PRILOCAINE CREAM   4 Non-Preferred Drug 50%50%P Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Linezolid 20 MG/ML Oral Suspension [Zyvox]   5 Specialty Tier 25%25%P
LINEZOLID 600 MG TABLET [Zyvox]   4 Non-Preferred Drug 50%50%P
LINEZOLID 600 MG/300 ML IV SOL [Zyvox]   5 Specialty Tier 25%25%None
LINZESS 145 MCG CAPSULE   3 Preferred Brand $47.00$94.00P
LINZESS 290 MCG CAPSULE   3 Preferred Brand $47.00$94.00P
LINZESS 72 MCG CAPSULE   3 Preferred Brand $47.00$94.00P
LIOTHYRONINE SOD 25 MCG TAB   2 Generic $4.00$8.00None
LIOTHYRONINE SOD 5 MCG TAB   2 Generic $4.00$8.00None
LIOTHYRONINE SOD 50 MCG TABLET [Cytomel]   2 Generic $4.00$8.00None
LISINOPRIL 10 MG TABLET   2 Generic $4.00$8.00None
LISINOPRIL 2.5 MG TABLET   1 Preferred Generic $1.00$2.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LISINOPRIL 20 MG TABLET   2 Generic $4.00$8.00None
LISINOPRIL 30 MG TABLET   2 Generic $4.00$8.00None
LISINOPRIL 40 MG TABLET   2 Generic $4.00$8.00None
LISINOPRIL 5 MG TABLET   2 Generic $4.00$8.00None
LISINOPRIL-HCTZ 10-12.5 MG TAB   2 Generic $4.00$8.00None
LISINOPRIL-HCTZ 20-12.5 MG TAB   1 Preferred Generic $1.00$2.00None
LISINOPRIL-HCTZ 20-25 MG TAB   1 Preferred Generic $1.00$2.00None
LITHIUM CARBONATE 150 MG CAP   3 Preferred Brand $47.00$94.00None
LITHIUM CARBONATE 300 MG Capsule [Eskalith]   2 Generic $4.00$8.00None
Lithium Carbonate 300 mg tab   2 Generic $4.00$8.00None
Lithium Carbonate 450mg/1   2 Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LITHIUM CARBONATE 600 MG CAP   3 Preferred Brand $47.00$94.00None
LITHIUM CARBONATE ER 300 MG TB   2 Generic $4.00$8.00None
LITHIUM CIT 8MEQ/5ML SYRUP   3 Preferred Brand $47.00$94.00None
LONSURF 15 MG-6.14 MG TABLET   5 Specialty Tier 25%25%P Q:100
/28Days
LONSURF 20 MG-8.19 MG TABLET   5 Specialty Tier 25%25%P Q:80
/28Days
LOPERAMIDE HCL 2MG CAPSULE   2 Generic $4.00$8.00None
LOPINAVIR-RITONAVIR 80-20MG/ML Solution [Kaletra]   5 Specialty Tier 25%25%Q:480
/30Days
LOPREEZA 1 MG-0.5 MG TABLET [Mimvey]   4 Non-Preferred Drug 50%50%None
LORAZEPAM 0.5 MG TABLET   2 Generic $4.00$8.00P Q:120
/30Days
LORAZEPAM 1 MG TABLET   2 Generic $4.00$8.00P Q:120
/30Days
LORAZEPAM 2 MG TABLET   1 Preferred Generic $1.00$2.00P Q:150
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LORBRENA 100 MG TABLET   5 Specialty Tier 25%25%P Q:30
/30Days
LORBRENA 25 MG TABLET   5 Specialty Tier 25%25%P Q:90
/30Days
LORCET HD 10-325 MG TABLET   3 Preferred Brand $47.00$94.00Q:180
/30Days
Lorcet plus 7.5-325 mg tablet   3 Preferred Brand $47.00$94.00Q:180
/30Days
LORYNA 3 MG-0.02 MG TABLET [Yaz]   3 Preferred Brand $47.00$94.00None
LOSARTAN POTASSIUM 100 MG TAB   1 Preferred Generic $1.00$2.00Q:30
/30Days
LOSARTAN POTASSIUM 25 MG TAB   1 Preferred Generic $1.00$2.00Q:60
/30Days
LOSARTAN POTASSIUM 50 MG TAB   1 Preferred Generic $1.00$2.00Q:60
/30Days
LOSARTAN-HCTZ 100-12.5 MG TAB   1 Preferred Generic $1.00$2.00Q:30
/30Days
LOSARTAN-HCTZ 100-25 MG TAB   1 Preferred Generic $1.00$2.00Q:30
/30Days
LOSARTAN-HCTZ 50-12.5 MG TAB   1 Preferred Generic $1.00$2.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LOVASTATIN 10 MG TABLET   1 Preferred Generic $1.00$2.00Q:60
/30Days
LOVASTATIN 20 MG TABLET   1 Preferred Generic $1.00$2.00Q:60
/30Days
LOVASTATIN 40 MG TABLET   1 Preferred Generic $1.00$2.00Q:60
/30Days
LOW-OGESTREL-28 TABLET   3 Preferred Brand $47.00$94.00None
LOXAPINE 10 MG CAPSULE   3 Preferred Brand $47.00$94.00P
LOXAPINE 25MG CAPSULE (100 CT)   3 Preferred Brand $47.00$94.00P
LOXAPINE CAPSULES 50MG 100 BOT   3 Preferred Brand $47.00$94.00P
LOXAPINE CAPSULES 5MG 100 BOT   3 Preferred Brand $47.00$94.00P
LUPRON DEPOT 11.25 MG 3MO KIT   5 Specialty Tier 25%25%None
LUPRON DEPOT 22.5 MG 3MO KIT SYRINGEKIT   5 Specialty Tier 25%25%None
LUPRON DEPOT 3.75 MG KIT   5 Specialty Tier 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LUPRON DEPOT 45 MG 6MO KIT   5 Specialty Tier 25%25%None
LUPRON DEPOT 7.5 MG KIT   5 Specialty Tier 25%25%None
LUPRON DEPOT-4 MONTH KIT   5 Specialty Tier 25%25%None
LUTERA-28 TABLET   3 Preferred Brand $47.00$94.00None
LYNPARZA 100 MG TABLET   5 Specialty Tier 25%25%P Q:120
/30Days
LYNPARZA 150 MG TABLET   5 Specialty Tier 25%25%P Q:120
/30Days
LYRICA 100MG CAPSULE   3 Preferred Brand $47.00$94.00Q:90
/30Days
LYRICA 150MG CAPSULE   3 Preferred Brand $47.00$94.00Q:90
/30Days
LYRICA 20 MG/ML ORAL SOLUTION   3 Preferred Brand $47.00$94.00Q:900
/30Days
LYRICA 200MG CAPSULE   3 Preferred Brand $47.00$94.00Q:90
/30Days
LYRICA 225MG CAPSULE   3 Preferred Brand $47.00$94.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LYRICA 25MG CAPSULE   3 Preferred Brand $47.00$94.00Q:90
/30Days
LYRICA 300MG CAPSULE   3 Preferred Brand $47.00$94.00Q:60
/30Days
LYRICA 50MG CAPSULE   3 Preferred Brand $47.00$94.00Q:90
/30Days
LYRICA 75MG CAPSULE   3 Preferred Brand $47.00$94.00Q:90
/30Days
LYSODREN 500MG TABLET   5 Specialty Tier 25%25%None
LYZA 0.35 MG TABLET   2 Generic $4.00$8.00None

Chart Legend:

Below are a few notes to help you understand the above 2019 Medicare Part D BlueRx Essential (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 $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.