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Aetna Medicare Rx Select (PDP) (S5810-286-0)
Tier 1 (252)
Tier 2 (494)
Tier 3 (1048)
Tier 4 (1382)
Tier 5 (651)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
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Cick on the first letter of your drug name to browse the formulary:

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2019 Medicare Part D Plan Formulary Information
Aetna Medicare Rx Select (PDP) (S5810-286-0)
Benefit Details           
The Aetna Medicare Rx Select (PDP) (S5810-286-0)
Formulary Drugs Starting with the Letter N

in CMS PDP Region 12 which includes: AL TN
Plan Monthly Premium: $17.10 Deductible: $365 Qualifies for LIS: No
Drugs Starting with Letter N

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
NABUMETONE 500 MG TABLET   2* Generic $2.00$6.00None
NABUMETONE 750 MG TABLET   2* Generic $2.00$6.00None
NADOLOL 20 MG TABLET   4 Non-Preferred Drug 40%40%None
NADOLOL 40MG TABLETS   4 Non-Preferred Drug 40%40%None
NADOLOL 80 MG TABLET   4 Non-Preferred Drug 40%40%None
NADOLOL-BENDROFLU 40-5 MG TAB   3 Preferred Brand $47.00$141.00None
Nafcillin 1 gm vial   4 Non-Preferred Drug 40%40%None
NAFCILLIN 10 GM BULK VIAL   5 Specialty Tier 25%N/ANone
NAFCILLIN 2 GM VIAL   4 Non-Preferred Drug 40%40%None
NAFTIFINE HCL 1% CREAM (g) [Naftin-MP]   4 Non-Preferred Drug 40%40%Q:90
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NAFTIFINE HCL 2% CREAM [Naftin]   4 Non-Preferred Drug 40%40%Q:60
/30Days
NALOXONE 0.4 MG/ML CARPUJECT   3 Preferred Brand $47.00$141.00None
NALOXONE 0.4 MG/ML VIAL   3 Preferred Brand $47.00$141.00None
naloxone 1 mg/ml syringe   3 Preferred Brand $47.00$141.00None
NALTREXONE 50 MG TABLET   3 Preferred Brand $47.00$141.00None
NAMZARIC 14 MG-10 MG CAPSULE   4 Non-Preferred Drug 40%40%None
NAMZARIC 21 MG-10 MG CAPSULE   4 Non-Preferred Drug 40%40%None
NAMZARIC 28 MG-10 MG CAPSULE   4 Non-Preferred Drug 40%40%None
NAMZARIC 7 MG-10 MG CAPSULE   4 Non-Preferred Drug 40%40%None
NAMZARIC TITRATION PACK   4 Non-Preferred Drug 40%40%None
Naproxen 125 mg/5 ml suspen   2* Generic $2.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NAPROXEN 250 MG ORAL TABLET   1* Preferred Generic $0.00$0.00None
NAPROXEN 375 MG TABLET   1* Preferred Generic $0.00$0.00None
NAPROXEN 500 MG TABLET   1* Preferred Generic $0.00$0.00None
NAPROXEN DR 375 MG TABLET   2* Generic $2.00$6.00None
NAPROXEN DR 500 MG TABLET   2* Generic $2.00$6.00None
NAPROXEN SOD ER 375 MG TABLET   4 Non-Preferred Drug 40%40%None
NAPROXEN SOD ER 500 MG TABLET   4 Non-Preferred Drug 40%40%None
NAPROXEN SODIUM 275 MG TAB   2* Generic $2.00$6.00None
NAPROXEN SODIUM 550 MG TAB   2* Generic $2.00$6.00None
NARATRIPTAN HCL 1 MG TABLET   3 Preferred Brand $47.00$141.00Q:9
/30Days
NARATRIPTAN HCL 2.5 MG TABLET   3 Preferred Brand $47.00$141.00Q:9
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NARCAN 4 MG NASAL SPRAY   3 Preferred Brand $47.00$141.00None
NASONEX 50ug/1 120 SPRAY, METERED in 1 BOTTLE, PUMP   4 Non-Preferred Drug 40%40%S Q:34
/30Days
NATACYN EYE DROPS   4 Non-Preferred Drug 40%40%None
NATEGLINIDE 120 MG TABLET   2* Generic $2.00$6.00None
NATEGLINIDE 60 MG TABLET   2* Generic $2.00$6.00None
NATPARA 100 MCG DOSE CARTRIDGE   5 Specialty Tier 25%N/AP
NATPARA 25 MCG DOSE CARTRIDGE   5 Specialty Tier 25%N/AP
NATPARA 50 MCG DOSE CARTRIDGE   5 Specialty Tier 25%N/AP
NATPARA 75 MCG DOSE CARTRIDGE   5 Specialty Tier 25%N/AP
NEBUPENT 300MG INHAL POWDER   4 Non-Preferred Drug 40%40%P
NECON 0.5-35-28 TABLET   3 Preferred Brand $47.00$141.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NEFAZODONE HCL 150MG TABLET (60 CT)   4 Non-Preferred Drug 40%40%None
NEFAZODONE HCL 250MG TABLET   4 Non-Preferred Drug 40%40%None
NEFAZODONE HCL 50MG TABLET   4 Non-Preferred Drug 40%40%None
NEFAZODONE HYDROCHLORIDE TABLETS 100MG 60 BOT   4 Non-Preferred Drug 40%40%None
NEFAZODONE HYDROCHLORIDE TABLETS 200MG 60 BOT   4 Non-Preferred Drug 40%40%None
NEO/POLYMYXIN/HC EAR TUBEX 10MG/3.5MG/100UNT   4 Non-Preferred Drug 40%40%None
NEOMYC-POLYM-DEXAMET EYE OINTM [Poly-Dex]   2* Generic $2.00$6.00None
NEOMYC-POLYM-DEXAMETH EYE DROP   2* Generic $2.00$6.00None
NEOMYCIN SULFATE 500MG TABLET   2* Generic $2.00$6.00None
NEOMYCIN-BACITRACIN-POLY-HC 3.5-10K-1 OINTMENT   4 Non-Preferred Drug 40%40%None
NEOMYCIN-POLYMYXIN-HC 3.5-10K-10 SUSPENSION DROPS   3 Preferred Brand $47.00$141.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NEOMYCIN/POLYMY/GRAM EYE DROPS 0.025MG/ML 1.75MG/M   3 Preferred Brand $47.00$141.00None
NEOMYCIN/POLYMY/HYDRO OTIC SUS   4 Non-Preferred Drug 40%40%None
NEPHRAMINE SOLUTION FOR INJECTION   4 Non-Preferred Drug 40%40%P
NERLYNX 40 MG TABLET   5 Specialty Tier 25%N/AP
Neuac gel   4 Non-Preferred Drug 40%40%None
NEUPOGEN 300 MCG/ML VIAL   5 Specialty Tier 25%N/AP
NEUPOGEN 300MCG/ML VIAL   5 Specialty Tier 25%N/AP
NEUPOGEN 300ug/0.5mL 10 SYRINGE in 1 BOX / 0.5 mL in 1 SYRINGE   5 Specialty Tier 25%N/AP
NEUPOGEN INJECTION 480MCG/0.8ML 10 X 0.8ML SYR   5 Specialty Tier 25%N/AP
NEUPRO 1 MG/24 HR PATCH   4 Non-Preferred Drug 40%40%None
NEUPRO 2 MG/24 HR PATCH   4 Non-Preferred Drug 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NEUPRO 3 MG/24 HR PATCH   4 Non-Preferred Drug 40%40%None
NEUPRO 4 MG/24 HR PATCH   4 Non-Preferred Drug 40%40%None
NEUPRO 6 MG/24 HR PATCH   4 Non-Preferred Drug 40%40%None
NEUPRO 8 MG/24 HR PATCH   4 Non-Preferred Drug 40%40%None
NEVIRAPINE 200 MG TABLET   3 Preferred Brand $47.00$141.00None
NEVIRAPINE 50 MG/5 ML SUSP Oral Suspension [Viramune]   4 Non-Preferred Drug 40%40%None
NEVIRAPINE ER 100 MG TABLET   3 Preferred Brand $47.00$141.00None
NEVIRAPINE ER 400 MG TABLET   3 Preferred Brand $47.00$141.00None
NEXAVAR TABLETS 200MG 120 BOT   5 Specialty Tier 25%N/AP
NIACIN ER 1,000 MG TABLET [Niaspan ER]   4 Non-Preferred Drug 40%40%None
NIACIN ER 500 MG TABLET [Niaspan ER]   4 Non-Preferred Drug 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NIACIN ER 750 MG TABLET [Niaspan ER]   4 Non-Preferred Drug 40%40%None
NIACOR 500 MG TABLET   4 Non-Preferred Drug 40%40%None
Nicardipine hydrochloride 20 MG Oral Capsule   4 Non-Preferred Drug 40%40%None
Nicardipine hydrochloride 30 MG Oral Capsule   4 Non-Preferred Drug 40%40%None
NICOTROL INHALER 10MG 168 X 10MG/CARTRIDGE INHL   4 Non-Preferred Drug 40%40%None
NICOTROL NS NASAL SPRAY BOTTLE 10MG 4 X 10MG/ML INHL   4 Non-Preferred Drug 40%40%None
Nifedipine 10mg/1 100 CAPSULE BOTTLE   4 Non-Preferred Drug 40%40%P
NIFEDIPINE 20MG CAPSULE   4 Non-Preferred Drug 40%40%P
NIFEDIPINE ER 30 MG TABLET   4 Non-Preferred Drug 40%40%None
NIFEDIPINE ER 30 MG TABLET   4 Non-Preferred Drug 40%40%None
NIFEDIPINE ER 60 MG TABLET   4 Non-Preferred Drug 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NIFEDIPINE ER 60 MG TABLET   4 Non-Preferred Drug 40%40%None
NIFEDIPINE ER 90 MG TABLET   4 Non-Preferred Drug 40%40%None
NIFEDIPINE ER 90 MG TABLET   4 Non-Preferred Drug 40%40%None
NIKKI 3 MG-0.02 MG TABLET   3 Preferred Brand $47.00$141.00None
NILUTAMIDE 150 MG TABLET [Nilandron]   5 Specialty Tier 25%N/ANone
NINLARO 2.3 MG CAPSULE   5 Specialty Tier 25%N/AP
NINLARO 3 MG CAPSULE   5 Specialty Tier 25%N/AP
NINLARO 4 MG CAPSULE   5 Specialty Tier 25%N/AP
NISOLDIPINE ER 17 MG TABLET 24H [Sular]   4 Non-Preferred Drug 40%40%None
NISOLDIPINE ER 20 MG TABLET 24H [Sular]   4 Non-Preferred Drug 40%40%None
NISOLDIPINE ER 25.5 MG TABLET 24H [Sular]   4 Non-Preferred Drug 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NISOLDIPINE ER 30 MG TABLET 24H [Sular]   4 Non-Preferred Drug 40%40%None
NISOLDIPINE ER 34 MG TABLET 24H [Sular]   4 Non-Preferred Drug 40%40%None
NISOLDIPINE ER 40 MG TABLET 24H [Sular]   4 Non-Preferred Drug 40%40%None
NISOLDIPINE ER 8.5 MG TABLET 24H [Sular]   4 Non-Preferred Drug 40%40%None
NITRO-BID 2% OINTMENT   3 Preferred Brand $47.00$141.00None
NITRO-DUR 0.3 MG/HR PATCH   4 Non-Preferred Drug 40%40%None
NITRO-DUR 0.8 MG/HR PATCH   4 Non-Preferred Drug 40%40%None
Nitrofurantoin 25mg/5mL   4 Non-Preferred Drug 40%40%None
NITROFURANTOIN MACROCRYSTALLINE 50 mg cap   3 Preferred Brand $47.00$141.00None
NITROFURANTOIN MCR 100 MG CAPSULE [Macrodantin]   3 Preferred Brand $47.00$141.00None
NITROFURANTOIN MCR 25 MG CAP   3 Preferred Brand $47.00$141.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NITROGLYCERIN 0.2 MG/HR PATCH   3 Preferred Brand $47.00$141.00None
NITROGLYCERIN 0.3 MG TABLET SL   3 Preferred Brand $47.00$141.00None
NITROGLYCERIN 0.4 MG TABLET SL   3 Preferred Brand $47.00$141.00None
NITROGLYCERIN 0.4 MG/HR PATCH   3 Preferred Brand $47.00$141.00None
NITROGLYCERIN 0.6 MG TABLET SL   3 Preferred Brand $47.00$141.00None
NITROGLYCERIN 0.6 MG/HR PATCH   3 Preferred Brand $47.00$141.00None
NITROGLYCERIN LINGUAL 0.4 MG   4 Non-Preferred Drug 40%40%None
NITROGLYCERIN TRANSOERMAL SYSTEM .1MG/HR 30 SYSTEM BOX   3 Preferred Brand $47.00$141.00None
NIZATIDINE 15 MG/ML SOLUTION   4 Non-Preferred Drug 40%40%None
NIZATIDINE 150 MG CAPSULE   4 Non-Preferred Drug 40%40%None
NIZATIDINE 300 MG CAPSULE   4 Non-Preferred Drug 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NOLIX 0.05% CREAM   4 Non-Preferred Drug 40%40%Q:120
/30Days
NORA-BE 0.35MG TABLET   3 Preferred Brand $47.00$141.00None
noret-estr-fe 0.4-0.035(21)-75   3 Preferred Brand $47.00$141.00None
NORETH-ESTRAD-FE 1-0.02(24)-75 Chewable TABLET [Minastrin]   3 Preferred Brand $47.00$141.00None
Norethin-Estrad-Ferr 0.8-0.025 MG   3 Preferred Brand $47.00$141.00None
Norethin-Estrad-Ferr 1-0.02 mg   3 Preferred Brand $47.00$141.00None
NORETHIN-ETH ESTRAD 0.5-2.5   3 Preferred Brand $47.00$141.00P
NORETHIN-ETH ESTRAD 1 MG-5 MCG   3 Preferred Brand $47.00$141.00P
NORETHIND-ETH ESTRAD 1-0.02 MG   3 Preferred Brand $47.00$141.00None
NORETHINDRONE 0.35 MG TABLET   3 Preferred Brand $47.00$141.00None
NORETHINDRONE 5MG TABLET   2* Generic $2.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NORG-EE 0.18-0.215-0.25/0.035   3 Preferred Brand $47.00$141.00None
NORG-ETHIN ESTRA 0.18-0.215-0.25/0.025   3 Preferred Brand $47.00$141.00None
NORG-ETHIN ESTRA 0.25-0.035 MG   3 Preferred Brand $47.00$141.00None
NORITATE 1% CREAM   5 Specialty Tier 25%N/AQ:60
/30Days
Norlyroc 0.35 mg tablet   3 Preferred Brand $47.00$141.00None
NORMOSOL -R INJ /D5W   4 Non-Preferred Drug 40%40%None
NORMOSOL-M AND DEXTROSE 5%   4 Non-Preferred Drug 40%40%None
NORMOSOL-R PH 7.4 IV SOLUTION   4 Non-Preferred Drug 40%40%None
NORPACE CR 100 MG CAPSULE   4 Non-Preferred Drug 40%40%None
NORPACE CR 150MG CAPSULE SA   4 Non-Preferred Drug 40%40%None
NORTHERA 100 MG CAPSULE   5 Specialty Tier 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NORTHERA 200 MG CAPSULE   5 Specialty Tier 25%N/AP
NORTHERA 300 MG CAPSULE   5 Specialty Tier 25%N/AP
Nortrel (21 Day Regimen) 0.035; 1mg/1; mg/1 3 BLISTER PACK per CARTON / 21 TABLET per BLISTER PACK   3 Preferred Brand $47.00$141.00None
Nortrel (28 Day Regimen) 3 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK   3 Preferred Brand $47.00$141.00None
NORTREL 1-0.035MG TABLET 28DAY   3 Preferred Brand $47.00$141.00None
Nortrel 7/7/7 (28 Day Regimen) 6 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT in 1 BLISTER   3 Preferred Brand $47.00$141.00None
NORTRIPTYLINE 10 MG/5 ML SOL   2* Generic $2.00$6.00None
NORTRIPTYLINE HCL 25MG CAP   2* Generic $2.00$6.00None
NORTRIPTYLINE HCL 50 MG CAP   2* Generic $2.00$6.00None
NORTRIPTYLINE HCL 75 MG CAP   2* Generic $2.00$6.00None
Nortriptyline Hydrochloride 10mg/1 100 CAPSULE BOTTLE   2* Generic $2.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NORVIR 100 MG POWDER PACKET   4 Non-Preferred Drug 40%40%None
NORVIR 100 MG TABLET   3 Preferred Brand $47.00$141.00None
NORVIR 80MG/ML ORAL SOLUTION   4 Non-Preferred Drug 40%40%None
Novolin 100[iU]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL   3 Preferred Brand $47.00$141.00None
Novolin 100[USP'U]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL   3 Preferred Brand $47.00$141.00None
Novolin R 100[iU]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL   3 Preferred Brand $47.00$141.00None
NOVOLOG 100 UNIT/ML CARTRIDGE   3 Preferred Brand $47.00$141.00None
NOVOLOG 100U/ML VIAL   3 Preferred Brand $47.00$141.00None
NOVOLOG FLEXPEN SYRINGE   3 Preferred Brand $47.00$141.00None
NOVOLOG MIX 70/30 SYRINGE 70-30U/ML   3 Preferred Brand $47.00$141.00None
NOVOLOG MIX 70/30 VIAL   3 Preferred Brand $47.00$141.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NOXAFIL 200MG/5ML SUSPENSION ORAL   5 Specialty Tier 25%N/AQ:630
/30Days
NOXAFIL DR 100 MG TABLET   5 Specialty Tier 25%N/AQ:93
/30Days
NUCYNTA ER 100 MG TABLET   3 Preferred Brand $47.00$141.00P Q:60
/30Days
NUCYNTA ER 150 MG TABLET   3 Preferred Brand $47.00$141.00P Q:90
/30Days
NUCYNTA ER 200 MG TABLET   3 Preferred Brand $47.00$141.00P Q:60
/30Days
NUCYNTA ER 250 MG TABLET   3 Preferred Brand $47.00$141.00P Q:60
/30Days
NUCYNTA ER 50 MG TABLET   3 Preferred Brand $47.00$141.00P Q:60
/30Days
NUEDEXTA 20; 10mg/1; mg/1   4 Non-Preferred Drug 40%40%P Q:60
/30Days
NULYTELY WITH FLAVOR PACKS POWDER FOR SOLUTION 420;1.48;MG;MG;GM; 4 L BOT   3 Preferred Brand $47.00$141.00None
NUPLAZID 10 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
NUPLAZID 34 MG CAPSULE   5 Specialty Tier 25%N/AP Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NUTRILIPID 20 % EMULSION   3 Preferred Brand $47.00$141.00P
NUVARING 0.12-0.015 RING VAGINAL   4 Non-Preferred Drug 40%40%None
NYAMYC 100,000 UNITS/GM POWDER   3 Preferred Brand $47.00$141.00None
NYMALIZE 30 MG/10 ML SOLUTION   5 Specialty Tier 25%N/ANone
NYSTATIN 100,000 UNIT/GM CREAM (g) [Pediaderm AF]   2* Generic $2.00$6.00Q:30
/30Days
NYSTATIN 100,000 UNIT/GM POWD   3 Preferred Brand $47.00$141.00None
NYSTATIN 100,000 UNITS/GM OINT   4 Non-Preferred Drug 40%40%Q:30
/30Days
Nystatin 100000[USP'U]/mL   4 Non-Preferred Drug 40%40%None
NYSTATIN 500,000 UNIT ORAL TAB   4 Non-Preferred Drug 40%40%None
NYSTATIN/TRIAMCINOLONE CRM   4 Non-Preferred Drug 40%40%Q:60
/30Days
NYSTATIN/TRIAMCINOLONE OINT 10000UNT/1MG   4 Non-Preferred Drug 40%40%Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NYSTOP 100,000 UNITS/GM POWDER   3 Preferred Brand $47.00$141.00None

Chart Legend:

Below are a few notes to help you understand the above 2019 Medicare Part D Aetna Medicare Rx Select (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.