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Express Scripts Medicare - Value (PDP) (S5660-114-0)
Tier 1 (104)
Tier 2 (808)
Tier 3 (706)
Tier 4 (949)
Tier 5 (455)
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2019 Medicare Part D Plan Formulary Information
Express Scripts Medicare - Value (PDP) (S5660-114-0)
Benefit Details           
The Express Scripts Medicare - Value (PDP) (S5660-114-0)
Formulary Drugs Starting with the Letter M

in CMS PDP Region 12 which includes: AL TN
Plan Monthly Premium: $30.20 Deductible: $415 Qualifies for LIS: Yes
Drugs Starting with Letter M

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
M-M-R II VACCINE W/DILUENT 1 DOSE/0.5ML   3 Preferred Brand $25.00$75.00None
MAFENIDE ACETATE 50 GM POWD PK PACKET   2 Generic $3.00$6.00None
MAGNESIUM SULFATE 50% VIAL   2 Generic $3.00$6.00None
MAGNESIUM SULFATE INJECTION 5 GM/10ML   2 Generic $3.00$6.00None
MALATHION 0.5% LOTION   4 Non-Preferred Drug 41%N/ANone
MAPROTILINE 25MG TABLET   2 Generic $3.00$6.00None
MAPROTILINE 50MG TABLET   2 Generic $3.00$6.00None
MAPROTILINE 75MG TABLET   2 Generic $3.00$6.00None
MARLISSA-28 TABLET   4 Non-Preferred Drug 41%N/ANone
MARPLAN 10MG TABLET (100 CT)   3 Preferred Brand $25.00$75.00Q:180
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MATULANE 50 MG CAPSULE   5 Specialty Tier 25%N/ANone
MECLIZINE 12.5 MG TABLET   2 Generic $3.00$6.00None
MECLIZINE 25 MG TABLET   2 Generic $3.00$6.00None
MEDROXYPROGESTERONE 10 MG TABLET [Provera]   2 Generic $3.00$6.00None
MEDROXYPROGESTERONE 150 MG/ML Syringe [Depo-Provera]   3 Preferred Brand $25.00$75.00None
MEDROXYPROGESTERONE 150 MG/ML VIAL [Depo-Provera]   3 Preferred Brand $25.00$75.00None
MEDROXYPROGESTERONE 2.5 MG TABLET [Provera]   2 Generic $3.00$6.00None
MEDROXYPROGESTERONE 5 MG TABLET [Provera]   2 Generic $3.00$6.00None
MEFLOQUINE HCL 250 MG TABLET   2 Generic $3.00$6.00None
MEGESTROL 20 MG TABLET   4 Non-Preferred Drug 41%N/AP
MEGESTROL 40 MG TABLET   4 Non-Preferred Drug 41%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MEGESTROL 625 MG/5 ML SUSP   4 Non-Preferred Drug 41%N/AP
MEGESTROL ACET 40 MG/ML SUSP   4 Non-Preferred Drug 41%N/AP
MEKINIST 0.5 MG TABLET   5 Specialty Tier 25%N/AP Q:90
/30Days
MEKINIST 2 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
MEKTOVI 15 MG TABLET   4 Non-Preferred Drug 41%N/AP Q:180
/30Days
MELODETTA 24 FE CHEWABLE TAB [Minastrin]   4 Non-Preferred Drug 41%N/ANone
MELOXICAM 15 MG TABLET   1 Preferred Generic $1.00$2.00Q:30
/30Days
MELOXICAM 7.5 MG TABLET   1 Preferred Generic $1.00$2.00Q:30
/30Days
MEMANTINE 5-10 MG TITRATION PK [Namenda Titration]   3 Preferred Brand $25.00$75.00P Q:98
/28Days
MEMANTINE HCL 10 MG TABLET [Namenda]   3 Preferred Brand $25.00$75.00P Q:60
/30Days
MEMANTINE HCL 2 MG/ML SOLUTION [Namenda]   3 Preferred Brand $25.00$75.00P Q:300
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MEMANTINE HCL 5 MG TABLET [Namenda]   3 Preferred Brand $25.00$75.00P Q:60
/30Days
MEMANTINE HCL ER 14 MG CAPSULE SPR 24 [Namenda XR]   3 Preferred Brand $25.00$75.00P
MEMANTINE HCL ER 21 MG CAPSULE SPR 24 [Namenda]   3 Preferred Brand $25.00$75.00P
MEMANTINE HCL ER 28 MG CAPSULE SPR 24 [Namenda]   3 Preferred Brand $25.00$75.00P
MEMANTINE HCL ER 7 MG CAPSULE SPR 24 [Namenda XR]   3 Preferred Brand $25.00$75.00P
Menactra 4; 4; 4; 4ug/0.5mL; ug/0.5mL; ug/0.5mL; ug/0.5mL 5 VIAL, SINGLE-DOSE in 1 PACKAGE / 0.5 mL   3 Preferred Brand $25.00$75.00None
MENVEO A-C-Y-W-135-DIP VIAL   3 Preferred Brand $25.00$75.00None
MERCAPTOPURINE 50 MG TABLET   2 Generic $3.00$6.00None
MEROPENEM 500MG/VIAL FOR INJECTION   4 Non-Preferred Drug 41%N/ANone
MEROPENEM IV 1 GM VIAL   4 Non-Preferred Drug 41%N/ANone
MESALAMINE 1,000 MG SUPP.RECT [Canasa]   3 Preferred Brand $25.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MESALAMINE 4 GM/60 ML ENEMA   3 Preferred Brand $25.00$75.00None
MESALAMINE 800 MG DR TABLET DR [Asacol HD]   3 Preferred Brand $25.00$75.00None
MESALAMINE DR 1.2 GM TABLET   3 Preferred Brand $25.00$75.00None
MESALAMINE DR 400 MG CAPSULE (DRTAB) [Delzicol]   3 Preferred Brand $25.00$75.00None
MESNEX 400MG TABLET   5 Specialty Tier 25%N/ANone
MESTINON 60MG/5ML SYRUP   5 Specialty Tier 25%N/ANone
METFORMIN HCL 1,000 MG TABLET   1 Preferred Generic $1.00$2.00Q:75
/30Days
METFORMIN HCL 500 MG TABLET   1 Preferred Generic $1.00$2.00Q:150
/30Days
METFORMIN HCL 850 MG TABLET   1 Preferred Generic $1.00$2.00Q:90
/30Days
METFORMIN HCL ER 500 MG TABLET   2 Generic $3.00$6.00Q:120
/30Days
METFORMIN HCL ER 750 MG TABLET ER 24H [Glucophage XR]   2 Generic $3.00$6.00Q:75
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METHADONE 10 MG/5 ML SOLUTION   4 Non-Preferred Drug 41%N/AP Q:600
/30Days
METHADONE 5 MG/5 ML SOLUTION   4 Non-Preferred Drug 41%N/AP Q:1200
/30Days
METHADONE HCL 10 MG TABLET [Methadose]   2 Generic $3.00$6.00P Q:120
/30Days
METHADONE HCL 5 MG TABLET [Methadose]   2 Generic $3.00$6.00P Q:240
/30Days
Methazolamide 25 MG Oral Tablet   4 Non-Preferred Drug 41%N/ANone
METHAZOLAMIDE 50 MG TABLET   4 Non-Preferred Drug 41%N/ANone
Methenamine Hippurate 1g/1   4 Non-Preferred Drug 41%N/ANone
METHIMAZOLE 10 MG TABLET [Tapazole]   2 Generic $3.00$6.00None
METHIMAZOLE 5 MG TABLET [Tapazole]   2 Generic $3.00$6.00None
METHOTREXATE 2.5MG TABLET   3 Preferred Brand $25.00$75.00P
METHOTREXATE 250 MG/10 ML VIAL   3 Preferred Brand $25.00$75.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METHOTREXATE 50 MG/2 ML VIAL   3 Preferred Brand $25.00$75.00P
Methoxsalen 10 mg Capsule [8-MOP]   5 Specialty Tier 25%N/ANone
METHYLDOPA 250 MG TABLET   4 Non-Preferred Drug 41%N/ANone
METHYLDOPA 500 MG TABLET   4 Non-Preferred Drug 41%N/ANone
METHYLPHENIDATE 10 MG TABLET [Ritalin]   2 Generic $3.00$6.00Q:90
/30Days
METHYLPHENIDATE 10 MG/5 ML SOL Solution [Methylin]   4 Non-Preferred Drug 41%N/AQ:900
/30Days
METHYLPHENIDATE 20 MG TABLET [Ritalin]   2 Generic $3.00$6.00Q:90
/30Days
METHYLPHENIDATE 5 MG TABLET [Ritalin]   2 Generic $3.00$6.00Q:90
/30Days
METHYLPHENIDATE 5 MG/5 ML SOLN Solution [Methylin]   4 Non-Preferred Drug 41%N/AQ:1800
/30Days
METHYLPHENIDATE CD 10 MG CAPSULE CPBP 30-70 [Ritalin LA]   3 Preferred Brand $25.00$75.00None
METHYLPHENIDATE CD 20 MG CAPSULE CPBP 30-70 [Ritalin LA]   3 Preferred Brand $25.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METHYLPHENIDATE CD 30 MG CAPSULE CPBP 30-70 [Ritalin LA]   3 Preferred Brand $25.00$75.00None
METHYLPHENIDATE CD 40 MG CAPSULE CPBP 30-70 [Ritalin LA]   3 Preferred Brand $25.00$75.00None
METHYLPHENIDATE CD 50 MG CAPSULE CPBP 30-70 [Metadate CD]   3 Preferred Brand $25.00$75.00None
METHYLPHENIDATE CD 60 MG CAPSULE CPBP 30-70 [Ritalin LA]   3 Preferred Brand $25.00$75.00None
METHYLPHENIDATE LA 10 MG CAP CPBP 50-50 [Ritalin LA]   4 Non-Preferred Drug 41%N/ANone
METHYLPHENIDATE LA 20 MG CAPSULE CPBP 50-50 [Ritalin LA]   4 Non-Preferred Drug 41%N/ANone
METHYLPHENIDATE LA 30 MG CAP CPBP 50-50 [Ritalin LA]   4 Non-Preferred Drug 41%N/ANone
METHYLPHENIDATE LA 40 MG CAPSULE CPBP 50-50 [Ritalin LA]   4 Non-Preferred Drug 41%N/ANone
METHYLPHENIDATE LA 60 MG CAPSULE CPBP 50-50   4 Non-Preferred Drug 41%N/ANone
METHYLPREDNISOLONE 16MG TABLET   2 Generic $3.00$6.00P
METHYLPREDNISOLONE 32MG TABLET   2 Generic $3.00$6.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METHYLPREDNISOLONE 4 MG DOSEPK   2 Generic $3.00$6.00None
METHYLPREDNISOLONE 4 MG TABLET   2 Generic $3.00$6.00P
METHYLPREDNISOLONE 8 MG ORAL TABLET   2 Generic $3.00$6.00P
METHYLTESTOSTERONE 10 MG CAP   5 Specialty Tier 25%N/ANone
Metoclopramide 10mg/1 500 TABLET BOTTLE   2 Generic $3.00$6.00None
METOCLOPRAMIDE 5 MG TABLET   2 Generic $3.00$6.00None
METOCLOPRAMIDE 5 MG/5 ML SOLN   2 Generic $3.00$6.00None
METOLAZONE 10MG TABLET   2 Generic $3.00$6.00None
METOLAZONE 2.5MG TABLET   2 Generic $3.00$6.00None
METOLAZONE 5MG TABLET   2 Generic $3.00$6.00None
METOPROLOL SUCC ER 100 MG TAB   2 Generic $3.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METOPROLOL SUCC ER 200 MG TAB   2 Generic $3.00$6.00None
METOPROLOL SUCC ER 25 MG TAB   2 Generic $3.00$6.00None
METOPROLOL SUCC ER 50 MG TAB   2 Generic $3.00$6.00None
METOPROLOL TARTRATE 100 MG TAB   1 Preferred Generic $1.00$2.00None
METOPROLOL TARTRATE 25 MG TAB   1 Preferred Generic $1.00$2.00None
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT)   1 Preferred Generic $1.00$2.00None
METRONIDAZOLE 0.75% CREAM Cream (g) [Vitazol]   4 Non-Preferred Drug 41%N/ANone
METRONIDAZOLE 0.75% LOTION [MetroLotion]   4 Non-Preferred Drug 41%N/ANone
METRONIDAZOLE 250 MG TABLET [Flagyl]   2 Generic $3.00$6.00None
METRONIDAZOLE 375 MG CAPSULE [Flagyl]   2 Generic $3.00$6.00None
METRONIDAZOLE 500 MG TABLET [Flagyl]   2 Generic $3.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METRONIDAZOLE 500 MG/100 ML PIGGYBACK [Flagyl RTU]   2 Generic $3.00$6.00None
METRONIDAZOLE TOPICAL 0.75% GL Gel [Nydamax]   4 Non-Preferred Drug 41%N/ANone
METRONIDAZOLE TOPICAL 1% GEL [MetroGel]   2 Generic $3.00$6.00None
METRONIDAZOLE VAGINAL 0.75% GL GEL W/APPL [Vandazole]   2 Generic $3.00$6.00None
MEXILETINE 150MG CAPSULE   2 Generic $3.00$6.00None
MEXILETINE 200MG CAPSULE   2 Generic $3.00$6.00None
MEXILETINE 250MG CAPSULE   2 Generic $3.00$6.00None
MIBELAS 24 FE CHEWABLE TABLET   4 Non-Preferred Drug 41%N/ANone
MICONAZOLE 3 200MG SUPPOS.   4 Non-Preferred Drug 41%N/ANone
Microgestin 21 1-20 tablet   4 Non-Preferred Drug 41%N/ANone
MICROGESTIN 21 1.5-30 TAB   4 Non-Preferred Drug 41%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Microgestin fe 1-20 tablet   4 Non-Preferred Drug 41%N/ANone
MICROGESTIN FE 1.5-30 TAB   4 Non-Preferred Drug 41%N/ANone
MIDODRINE HCL 10 MG TABLET   4 Non-Preferred Drug 41%N/ANone
MIDODRINE HCL 2.5 MG TABLET   2 Generic $3.00$6.00None
MIDODRINE HCL 5 MG TABLET   4 Non-Preferred Drug 41%N/ANone
Migergot suppository   4 Non-Preferred Drug 41%N/ANone
MILI 0.25-0.035 MG TABLET [VyLibra]   4 Non-Preferred Drug 41%N/ANone
MINOCYCLINE 100 MG CAPSULE   2 Generic $3.00$6.00None
MINOCYCLINE 50 MG CAPSULE   2 Generic $3.00$6.00None
MINOCYCLINE 75 MG CAPSULE   2 Generic $3.00$6.00None
MINOCYCLINE HCL 100 MG TABLET   4 Non-Preferred Drug 41%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MINOCYCLINE HCL 75 MG TABLET   4 Non-Preferred Drug 41%N/ANone
MINOCYCLINE HYDROCHLORIDE TABLETS 50MG   4 Non-Preferred Drug 41%N/ANone
MINOXIDIL 10MG TABLET   2 Generic $3.00$6.00None
MINOXIDIL 2.5MG TABLET   2 Generic $3.00$6.00None
MIRTAZAPINE 15 MG ODT   2 Generic $3.00$6.00Q:30
/30Days
MIRTAZAPINE 15 MG TABLET [Remeron]   2 Generic $3.00$6.00Q:30
/30Days
MIRTAZAPINE 30 MG ODT   2 Generic $3.00$6.00Q:30
/30Days
MIRTAZAPINE 30 MG TABLET [Remeron]   2 Generic $3.00$6.00Q:30
/30Days
Mirtazapine 45 mg odt   2 Generic $3.00$6.00Q:30
/30Days
MIRTAZAPINE 45 MG TABLET   2 Generic $3.00$6.00Q:30
/30Days
MIRTAZAPINE 7.5 MG TABLET   2 Generic $3.00$6.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
misoprostol 100 mcg tablet   2 Generic $3.00$6.00None
misoprostol 200 mcg tablet   2 Generic $3.00$6.00None
MODAFINIL 100 MG TABLET [Provigil]   3 Preferred Brand $25.00$75.00P Q:30
/30Days
MODAFINIL 200 MG TABLET [Provigil]   3 Preferred Brand $25.00$75.00P Q:60
/30Days
MOLINDONE HCL 10 MG TABLET   3 Preferred Brand $25.00$75.00None
MOLINDONE HCL 25 MG TABLET   3 Preferred Brand $25.00$75.00None
MOLINDONE HCL 5 MG TABLET   3 Preferred Brand $25.00$75.00None
MONDOXYNE NL 100 MG CAPSULE [Monodox]   4 Non-Preferred Drug 41%N/ANone
MONDOXYNE NL 75 MG CAPSULE [NutriDox]   4 Non-Preferred Drug 41%N/ANone
MONONESSA TABLETS .250;.035MG; MG 6 X 28 CRTN   4 Non-Preferred Drug 41%N/ANone
MONTELUKAST SOD 10 MG TABLET [Singulair]   2 Generic $3.00$6.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MONTELUKAST SOD 4 MG GRANULES [Singulair]   3 Preferred Brand $25.00$75.00Q:30
/30Days
MONTELUKAST SOD 4 MG TAB CHEW [Singulair]   2 Generic $3.00$6.00Q:30
/30Days
MONTELUKAST SOD 5 MG TAB CHEW [Singulair]   2 Generic $3.00$6.00Q:30
/30Days
MORGIDOX 50 MG CAPSULE   3 Preferred Brand $25.00$75.00None
MORPHINE 2 MG/ML SYRINGE   4 Non-Preferred Drug 41%N/AQ:1000
/30Days
MORPHINE 4 MG/ML SYRINGE   4 Non-Preferred Drug 41%N/AQ:500
/30Days
MORPHINE SULF 10 MG/5 ML Solution [MSIR]   4 Non-Preferred Drug 41%N/AQ:900
/30Days
MORPHINE SULF 20 MG/5 ML Solution [MSIR]   4 Non-Preferred Drug 41%N/AQ:900
/30Days
MORPHINE SULF ER 100 MG TABLET   3 Preferred Brand $25.00$75.00P Q:120
/30Days
MORPHINE SULF ER 15 MG TABLET   3 Preferred Brand $25.00$75.00P Q:120
/30Days
MORPHINE SULF ER 200 MG TABLET   3 Preferred Brand $25.00$75.00P Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MORPHINE SULF ER 30 MG TABLET   3 Preferred Brand $25.00$75.00P Q:120
/30Days
MORPHINE SULF ER 60 MG TABLET   3 Preferred Brand $25.00$75.00P Q:120
/30Days
MORPHINE SULFATE 100 mg/5 ml soln   4 Non-Preferred Drug 41%N/AQ:900
/30Days
MORPHINE SULFATE 15MG TABLETS   2 Generic $3.00$6.00Q:180
/30Days
MORPHINE SULFATE 30MG TABLETS   2 Generic $3.00$6.00Q:180
/30Days
MOVIPREP 7.5-2.691G POWDER IN PACKET   4 Non-Preferred Drug 41%N/ANone
MOXIFLOXACIN 0.5% EYE DROPS   3 Preferred Brand $25.00$75.00None
MUPIROCIN 2% OINTMENT   2 Generic $3.00$6.00None
MYALEPT 11.3 MG (5 MG/ML) VIAL   5 Specialty Tier 25%N/AP
MYCAMINE 100MG/VIAL FOR INJECTION SOLUTION   5 Specialty Tier 25%N/ANone
MYCAMINE 50MG VIAL   5 Specialty Tier 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MYCOPHENOLATE 200 MG/ML SUSP   5 Specialty Tier 25%N/AP
MYCOPHENOLATE 250 MG CAPSULE   2 Generic $3.00$6.00P
MYCOPHENOLATE 500 MG TABLET [CellCept]   2 Generic $3.00$6.00P
MYCOPHENOLIC ACID DR 180 MG TB   2 Generic $3.00$6.00P
MYCOPHENOLIC ACID DR 360 MG TB   3 Preferred Brand $25.00$75.00P
MYRBETRIQ ER 25 MG TABLET   4 Non-Preferred Drug 41%N/ANone
MYRBETRIQ ER 50 MG TABLET   4 Non-Preferred Drug 41%N/ANone

Chart Legend:

Below are a few notes to help you understand the above 2019 Medicare Part D Express Scripts Medicare - Value (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.