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Horizon Medicare Blue Rx Standard (PDP) (S5993-001-0)
Tier 1 (76)
Tier 2 (615)
Tier 3 (786)
Tier 4 (574)
Tier 5 (657)
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Uses Step Therapy:
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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
Horizon Medicare Blue Rx Standard (PDP) (S5993-001-0)
Benefits & Contact Info           
The Horizon Medicare Blue Rx Standard (PDP) (S5993-001-0)
Formulary Drugs Starting with the Letter A

in CMS PDP Region 4 which includes: NJ
Plan Monthly Premium: $49.90 Deductible: $415 Qualifies for LIS: No
Drugs Starting with Letter A

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
ABACAVIR 20 MG/ML SOLUTION   4 Non-Preferred Drug 25%25%Q:960
/30Days
ABACAVIR 300 MG TABLET   4 Non-Preferred Drug 25%25%Q:60
/30Days
Abacavir Sulfate-Lamivudine-Zidovudine tablets [Trizivir]   5 Specialty Tier 25%N/AQ:60
/30Days
ABACAVIR-LAMIVUDINE 600-300 MG   4 Non-Preferred Drug 25%25%Q:30
/30Days
ABIRATERONE ACETATE 250 MG TABLET [ZYTIGA]   5 Specialty Tier 25%N/AP Q:120
/30Days
Acamprosate Calcium DR 333 MG tablets [Campral]   4 Non-Preferred Drug 25%25%None
ACARBOSE 100 MG TABLET   2 Generic $8.00$12.00Q:90
/30Days
ACARBOSE 25 MG TABLET   2 Generic $8.00$12.00Q:360
/30Days
ACARBOSE 50 MG TABLET   2 Generic $8.00$12.00Q:180
/30Days
ACETAMINOP-CODEINE 120-12 MG/5   3 Preferred Brand $32.00$96.00Q:2700
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Acetaminophen 325 MG / Hydrocodone Bitartrate 5 MG Oral Tablet [Lorcet]   3 Preferred Brand $32.00$96.00Q:360
/30Days
ACETAMINOPHEN-COD #2 TABLET   3 Preferred Brand $32.00$96.00Q:360
/30Days
ACETAMINOPHEN-COD #3 TABLET   3 Preferred Brand $32.00$96.00Q:360
/30Days
ACETAMINOPHEN-COD #4 TABLET   3 Preferred Brand $32.00$96.00Q:180
/30Days
ACETAZOLAMIDE 125MG TABLET   3 Preferred Brand $32.00$96.00None
ACETAZOLAMIDE 250MG TABLET (100 CT)   3 Preferred Brand $32.00$96.00None
ACETAZOLAMIDE ER 500 MG CAP   4 Non-Preferred Drug 25%25%None
ACETYLCYSTEINE 10% VIAL   4 Non-Preferred Drug 25%25%P
Acetylcysteine 200 MG/ML Inhalant Solution   4 Non-Preferred Drug 25%25%P
ACITRETIN 10 MG CAPSULE [Soriatane]   4 Non-Preferred Drug 25%25%None
ACITRETIN 17.5 MG CAPSULE [Soriatane]   4 Non-Preferred Drug 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACITRETIN 25 MG CAPSULE [Soriatane]   4 Non-Preferred Drug 25%25%None
ACTHIB VACCINE WITH DILUENT   3 Preferred Brand $32.00$96.00None
ACTIMMUNE 100 MCG/0.5 ML VIAL   5 Specialty Tier 25%N/AP
ACYCLOVIR 200 MG CAPSULE   2 Generic $8.00$12.00None
ACYCLOVIR 200 MG/5 ML SUSP   4 Non-Preferred Drug 25%25%None
ACYCLOVIR 400 MG TABLET   2 Generic $8.00$12.00None
ACYCLOVIR 800 MG TABLET   2 Generic $8.00$12.00None
Acyclovir sodium 500 mg vial   4 Non-Preferred Drug 25%25%P
ADACEL TDAP SYRINGE   3 Preferred Brand $32.00$96.00None
ADACEL VIAL 2UNT/5UNT   3 Preferred Brand $32.00$96.00None
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA]   5 Specialty Tier 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADCIRCA TABLETS 20MG 60 BOTTLE   5 Specialty Tier 25%N/AP Q:60
/30Days
ADEFOVIR DIPIVOXIL 10 MG TAB [Hepsera]   5 Specialty Tier 25%N/ANone
ADEMPAS 0.5 MG TABLET   5 Specialty Tier 25%N/AP Q:90
/30Days
ADEMPAS 1 MG TABLET   5 Specialty Tier 25%N/AP Q:90
/30Days
ADEMPAS 1.5 MG TABLET   5 Specialty Tier 25%N/AP Q:90
/30Days
ADEMPAS 2 MG TABLET   5 Specialty Tier 25%N/AP Q:90
/30Days
ADEMPAS 2.5 MG TABLET   5 Specialty Tier 25%N/AP Q:90
/30Days
ADVAIR DISKUS MIS 100/50   3 Preferred Brand $32.00$96.00Q:60
/30Days
ADVAIR DISKUS MIS 250/50   3 Preferred Brand $32.00$96.00Q:60
/30Days
ADVAIR DISKUS MIS 500/50   3 Preferred Brand $32.00$96.00Q:60
/30Days
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER   3 Preferred Brand $32.00$96.00Q:12
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL   3 Preferred Brand $32.00$96.00Q:12
/30Days
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL   3 Preferred Brand $32.00$96.00Q:12
/30Days
Afinitor 7.5mg/1 28 BLISTER PACK per CARTON / 1 TABLET per BLISTER PACK   5 Specialty Tier 25%N/AP Q:30
/30Days
AFINITOR DISPERZ 2 MG TABLET   5 Specialty Tier 25%N/AP Q:60
/30Days
AFINITOR DISPERZ 3 MG TABLET   5 Specialty Tier 25%N/AP Q:90
/30Days
AFINITOR DISPERZ 5 MG TABLET   5 Specialty Tier 25%N/AP Q:60
/30Days
AFINITOR TABLETS 10 MG   5 Specialty Tier 25%N/AP Q:30
/30Days
AFINITOR TABLETS 2.5 MG   5 Specialty Tier 25%N/AP Q:30
/30Days
AFINITOR TABLETS 5 MG   5 Specialty Tier 25%N/AP Q:30
/30Days
AIMOVIG 140 MG/ML AUTOINJECTOR   3 Preferred Brand $32.00$96.00P Q:1
/30Days
AIMOVIG 70 MG/ML AUTOINJECTOR   3 Preferred Brand $32.00$96.00P Q:2
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Ala-cort 2.5% cream   2 Generic $8.00$12.00None
ALBENDAZOLE 200 MG TABLET [Albenza]   5 Specialty Tier 25%N/ANone
ALBENZA 200 MG TABLET   5 Specialty Tier 25%N/ANone
ALBUTEROL SUL 2.5 MG/3 ML SOLN   2 Generic $8.00$12.00P
ALBUTEROL SULFATE 0.75mg/3mL 30 POUCH per CARTON / 1 VIAL, SINGLE-DOSE in 1 POUCH / 3 mL in 1 VIAL   3 Preferred Brand $32.00$96.00P
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER   3 Preferred Brand $32.00$96.00P
ALBUTEROL SULFATE 2 MG TAB   4 Non-Preferred Drug 25%25%None
ALBUTEROL SULFATE 4 MG TAB   4 Non-Preferred Drug 25%25%None
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   3 Preferred Brand $32.00$96.00P
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT   2 Generic $8.00$12.00None
ALECENSA 150 MG CAPSULE   5 Specialty Tier 25%N/AP Q:240
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALENDRONATE SODIUM 10 MG TAB   2 Generic $8.00$12.00Q:120
/30Days
ALENDRONATE SODIUM 35 MG TABLET [Fosamax]   1 Preferred Generic $1.00$1.50Q:4
/28Days
ALENDRONATE SODIUM 5 MG TABLET   2 Generic $8.00$12.00Q:30
/30Days
ALENDRONATE SODIUM 70 MG TABLET [Fosamax]   1 Preferred Generic $1.00$1.50Q:4
/28Days
ALFUZOSIN HCL ER 10 MG TABLET   2 Generic $8.00$12.00Q:30
/30Days
ALINIA 100 MG/5 ML SUSPENSION   5 Specialty Tier 25%N/ANone
ALINIA 500 MG TABLET   5 Specialty Tier 25%N/ANone
ALISKIREN 150 MG TABLET [Tekturna]   3 Preferred Brand $32.00$96.00Q:30
/30Days
ALISKIREN 300 MG TABLET [Tekturna]   3 Preferred Brand $32.00$96.00Q:30
/30Days
ALLOPURINOL 100 MG TABLET   2 Generic $8.00$12.00None
ALLOPURINOL 300 MG TABLET   2 Generic $8.00$12.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALOSETRON HCL 0.5 MG TABLET [Lotronex]   5 Specialty Tier 25%N/ANone
ALOSETRON HCL 1 MG TABLET [Lotronex]   5 Specialty Tier 25%N/ANone
ALPRAZOLAM 0.25 MG TABLET   3 Preferred Brand $32.00$96.00Q:120
/30Days
ALPRAZOLAM 0.5 MG TABLET   3 Preferred Brand $32.00$96.00Q:120
/30Days
ALPRAZOLAM 1 MG TABLET   3 Preferred Brand $32.00$96.00Q:120
/30Days
ALPRAZOLAM 2 MG TABLET   3 Preferred Brand $32.00$96.00Q:150
/30Days
ALTAVERA-28 TABLET [Portia]   3 Preferred Brand $32.00$96.00None
ALUNBRIG 180 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
ALUNBRIG 30 MG TABLET   5 Specialty Tier 25%N/AP Q:120
/30Days
ALUNBRIG 90 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
ALUNBRIG 90 MG-180 MG TABLET PACK   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
ALYACEN 1-35-28 TABLET   3 Preferred Brand $32.00$96.00None
ALYQ 20 MG TABLET   5 Specialty Tier 25%N/AP Q:60
/30Days
Amabelz 1 MG/0.5 MG 28 TABLET/BLISTER PACK 3 PER CARTON   4 Non-Preferred Drug 25%25%None
AMANTADINE 100 MG CAPSULE   3 Preferred Brand $32.00$96.00None
AMANTADINE 50 MG/5 ML SOLUTION   2 Generic $8.00$12.00None
AMBISOME 50MG VIAL   5 Specialty Tier 25%N/AP
AMBRISENTAN 10 MG TABLET [LETAIRIS]   5 Specialty Tier 25%N/AP Q:30
/30Days
AMBRISENTAN 5 MG TABLET [LETAIRIS]   5 Specialty Tier 25%N/AP Q:30
/30Days
AMETHIA LO TABLET   2 Generic $8.00$12.00None
AMIKACIN SULF 500 MG/2 ML VIAL   4 Non-Preferred Drug 25%25%None
AMILORIDE HCL 5 MG TABLET [Midamor]   2 Generic $8.00$12.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMIODARONE HCL 200 MG TABLET   2 Generic $8.00$12.00None
AMIODARONE HCL 400 MG TABLET   4 Non-Preferred Drug 25%25%None
AMITIZA 8MCG CAPSULE   3 Preferred Brand $32.00$96.00P
AMITIZA CAPSULES 24MCG 60 CAP BOT   3 Preferred Brand $32.00$96.00P
AMITRIPTYLINE HCL 10 MG TAB   4 Non-Preferred Drug 25%25%P
AMITRIPTYLINE HCL 100 MG TAB   4 Non-Preferred Drug 25%25%P
AMITRIPTYLINE HCL 150 MG TAB   4 Non-Preferred Drug 25%25%P
AMITRIPTYLINE HCL 25 MG TAB   4 Non-Preferred Drug 25%25%P
AMITRIPTYLINE HCL 50 MG TAB   4 Non-Preferred Drug 25%25%P
AMITRIPTYLINE HCL 75 MG TAB   4 Non-Preferred Drug 25%25%P
AMLOD-VALSA-HCTZ 10-160-12.5MG [Exforge HCT]   3 Preferred Brand $32.00$96.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLOD-VALSA-HCTZ 10-160-25 MG [Exforge HCT]   3 Preferred Brand $32.00$96.00Q:30
/30Days
AMLOD-VALSA-HCTZ 10-320-25 MG [Exforge HCT]   3 Preferred Brand $32.00$96.00Q:30
/30Days
AMLOD-VALSA-HCTZ 5-160-12.5 MG [Exforge HCT]   3 Preferred Brand $32.00$96.00Q:30
/30Days
AMLOD-VALSA-HCTZ 5-160-25 MG [Exforge HCT]   3 Preferred Brand $32.00$96.00Q:30
/30Days
AMLODIPINE BESYLATE 10 MG TABLET [Norvasc]   2 Generic $8.00$12.00None
AMLODIPINE BESYLATE 2.5 MG TAB   2 Generic $8.00$12.00None
AMLODIPINE BESYLATE 5 MG TABLET [Norvasc]   2 Generic $8.00$12.00None
AMLODIPINE-VALSARTAN 10-160 MG   2 Generic $8.00$12.00Q:30
/30Days
AMLODIPINE-VALSARTAN 10-320 MG   2 Generic $8.00$12.00Q:30
/30Days
AMLODIPINE-VALSARTAN 5-160 MG   2 Generic $8.00$12.00Q:30
/30Days
AMLODIPINE-VALSARTAN 5-320 MG   2 Generic $8.00$12.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMMONIUM LACTATE 12% CREAM   2 Generic $8.00$12.00None
AMMONIUM LACTATE 12% LOTION   3 Preferred Brand $32.00$96.00None
AMNESTEEM 10 MG CAPSULE   3 Preferred Brand $32.00$96.00None
AMNESTEEM 20 MG CAPSULE   4 Non-Preferred Drug 25%25%None
AMNESTEEM 40 MG CAPSULE   4 Non-Preferred Drug 25%25%None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE [Augmentin]   3 Preferred Brand $32.00$96.00None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET [Augmentin]   4 Non-Preferred Drug 25%25%None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE [Augmentin]   4 Non-Preferred Drug 25%25%None
AMOX-CLAV 500-125 MG TABLET [Augmentin]   2 Generic $8.00$12.00None
AMOX-CLAV 875-125 MG TABLET [Augmentin]   2 Generic $8.00$12.00None
AMOXAPINE 100MG TABLET   4 Non-Preferred Drug 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXAPINE 150MG TABLET   4 Non-Preferred Drug 25%25%P
AMOXAPINE 25MG TABLET   4 Non-Preferred Drug 25%25%P
AMOXAPINE 50MG TABLET   4 Non-Preferred Drug 25%25%P
AMOXICILLIN 125 MG/5 ML SUSP   1 Preferred Generic $1.00$1.50None
AMOXICILLIN 200 MG/5 ML SUSP   2 Generic $8.00$12.00None
AMOXICILLIN 250 MG CAPSULE   1 Preferred Generic $1.00$1.50None
AMOXICILLIN 250 MG/5 ML SUSP   2 Generic $8.00$12.00None
AMOXICILLIN 400 MG/5 ML SUSP   2 Generic $8.00$12.00None
AMOXICILLIN 500 MG CAPSULE   1 Preferred Generic $1.00$1.50None
AMOXICILLIN 500 MG TABLET   2 Generic $8.00$12.00None
AMOXICILLIN 875 MG TABLET   1 Preferred Generic $1.00$1.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
amphotericin b 50mg/10mL 10 mL in 1 VIAL   4 Non-Preferred Drug 25%25%P
Ampicillin 1000 MG Injection   3 Preferred Brand $32.00$96.00None
Ampicillin 2000 MG / Sulbactam 1000 MG Injection   4 Non-Preferred Drug 25%25%None
AMPICILLIN CAPSULES 500MG 100 BOT   2 Generic $8.00$12.00None
AMPYRA ER 10 MG TABLET   5 Specialty Tier 25%N/AP
ANADROL-50 TABLET   5 Specialty Tier 25%N/AP
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE   3 Preferred Brand $32.00$96.00None
Anagrelide Hydrochloride 1mg/1 100 CAPSULE BOTTLE   4 Non-Preferred Drug 25%25%None
ANASTROZOLE 1 MG TABLET   2 Generic $8.00$12.00None
ANDRODERM 2 MG/24HR PATCH   3 Preferred Brand $32.00$96.00P Q:30
/30Days
ANDRODERM 4 MG/24HR PATCH   3 Preferred Brand $32.00$96.00P Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANDROGEL 1.62% (1.25G) GEL PCKT   3 Preferred Brand $32.00$96.00P Q:38
/30Days
ANDROGEL 1.62% (2.5G) GEL PCKT   3 Preferred Brand $32.00$96.00P Q:150
/30Days
Androgel 16.2mg/g 1 BOTTLE, PUMP per CARTON / 88 g in 1 BOTTLE, PUMP   3 Preferred Brand $32.00$96.00P Q:150
/30Days
ANORO ELLIPTA 62.5-25 MCG INH   3 Preferred Brand $32.00$96.00Q:60
/30Days
APOKYN 30 MG/3 ML CARTRIDGE   5 Specialty Tier 25%N/AP Q:60
/30Days
APREPITANT 125 MG CAPSULE [Emend]   3 Preferred Brand $32.00$96.00P
APREPITANT 125-80-80 MG PACK [Emend]   4 Non-Preferred Drug 25%25%P
APREPITANT 40 MG CAPSULE [Emend]   4 Non-Preferred Drug 25%25%P
APREPITANT 80 MG CAPSULE [Emend]   4 Non-Preferred Drug 25%25%P
APRI 0.15-0.03 TABLET   3 Preferred Brand $32.00$96.00None
APRISO CP24   4 Non-Preferred Drug 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
APTIOM 200 MG TABLET   5 Specialty Tier 25%N/ANone
APTIOM 400 MG TABLET   5 Specialty Tier 25%N/ANone
APTIOM 600 MG TABLET   5 Specialty Tier 25%N/ANone
APTIOM 800 MG TABLET   5 Specialty Tier 25%N/ANone
APTIVUS 250MG CAPSULE   5 Specialty Tier 25%N/AQ:120
/30Days
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT   5 Specialty Tier 25%N/AQ:380
/30Days
ARANELLE 7-9-5 TABLET   3 Preferred Brand $32.00$96.00None
ARCALYST INJECTION 220MG/VIAL   5 Specialty Tier 25%N/AP
ARIPIPRAZOLE 1 MG/ML SOLUTION [Abilify]   4 Non-Preferred Drug 25%25%P Q:750
/30Days
ARIPIPRAZOLE 10 MG TABLET [Abilify]   3 Preferred Brand $32.00$96.00P Q:30
/30Days
ARIPIPRAZOLE 15 MG TABLET [Abilify]   3 Preferred Brand $32.00$96.00P Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARIPIPRAZOLE 2 MG TABLET [Abilify]   3 Preferred Brand $32.00$96.00P Q:45
/30Days
ARIPIPRAZOLE 20 MG TABLET [Abilify]   3 Preferred Brand $32.00$96.00P Q:30
/30Days
ARIPIPRAZOLE 30 MG TABLET [Abilify]   3 Preferred Brand $32.00$96.00P Q:30
/30Days
ARIPIPRAZOLE 5 MG TABLET [Abilify]   3 Preferred Brand $32.00$96.00P Q:45
/30Days
ARIPIPRAZOLE ODT 10 MG TABLET RAPDIS [Abilify Discmelt]   5 Specialty Tier 25%N/AP Q:60
/30Days
ARIPIPRAZOLE ODT 15 MG TABLET RAPDIS [Abilify Discmelt]   5 Specialty Tier 25%N/AP Q:60
/30Days
ARISTADA ER 1064 MG/3.9 ML SYR   5 Specialty Tier 25%N/AP Q:4
/56Days
ARISTADA ER 441 MG/1.6 ML SYRN   5 Specialty Tier 25%N/AP Q:2
/28Days
ARISTADA ER 662 MG/2.4 ML SYRN   5 Specialty Tier 25%N/AP Q:2
/28Days
ARISTADA ER 882 MG/3.2 ML SYRN   5 Specialty Tier 25%N/AP Q:3
/28Days
ARISTADA INITIO ER 675 MG/2.4 SUSER SYR   5 Specialty Tier 25%N/AP Q:2
/42Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Armodafinil 150 MG TABLET [NUVIGIL]   3 Preferred Brand $32.00$96.00P Q:30
/30Days
Armodafinil 200 MG Oral Tablet [NUVIGIL]   4 Non-Preferred Drug 25%25%P Q:30
/30Days
Armodafinil 250 MG TABLET [NUVIGIL]   3 Preferred Brand $32.00$96.00P Q:30
/30Days
Armodafinil 50 MG TABLET [NUVIGIL]   3 Preferred Brand $32.00$96.00P Q:30
/30Days
ARNUITY ELLIPTA 100 MCG INH   3 Preferred Brand $32.00$96.00Q:30
/30Days
ARNUITY ELLIPTA 200 MCG INH   3 Preferred Brand $32.00$96.00Q:30
/30Days
ARNUITY ELLIPTA 50 MCG INH BLST W/DEV   3 Preferred Brand $32.00$96.00Q:30
/30Days
ASMANEX HFA 100 MCG INHALER   3 Preferred Brand $32.00$96.00Q:13
/30Days
ASMANEX HFA 200 MCG INHALER   3 Preferred Brand $32.00$96.00Q:13
/30Days
ASMANEX TWISTHALER 110 MCG #30   3 Preferred Brand $32.00$96.00Q:1
/30Days
ASMANEX TWISTHALER 220 MCG #30   3 Preferred Brand $32.00$96.00Q:1
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ASMANEX TWISTHALER 220MCG #120   3 Preferred Brand $32.00$96.00Q:1
/30Days
ASMANEX TWISTHALER 220MCG #60   3 Preferred Brand $32.00$96.00Q:1
/30Days
Aspirin-Diphenhydramine ER 25-200 MG   4 Non-Preferred Drug 25%25%None
ATAZANAVIR SULFATE 150 MG CAP [Reyataz]   5 Specialty Tier 25%N/AQ:30
/30Days
ATAZANAVIR SULFATE 200 MG CAP [Reyataz]   5 Specialty Tier 25%N/AQ:60
/30Days
ATAZANAVIR SULFATE 300 MG CAP [Reyataz]   5 Specialty Tier 25%N/AQ:30
/30Days
ATENOLOL 100 MG TABLET   2 Generic $8.00$12.00None
ATENOLOL 25 MG TABLET   2 Generic $8.00$12.00None
ATENOLOL 50 MG TABLET   2 Generic $8.00$12.00None
ATOMOXETINE HCL 10 MG CAPSULE [Strattera]   4 Non-Preferred Drug 25%25%Q:60
/30Days
ATOMOXETINE HCL 100 MG CAPSULE [Strattera]   4 Non-Preferred Drug 25%25%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATOMOXETINE HCL 18 MG CAPSULE [Strattera]   4 Non-Preferred Drug 25%25%Q:60
/30Days
ATOMOXETINE HCL 25 MG CAPSULE [Strattera]   4 Non-Preferred Drug 25%25%Q:60
/30Days
ATOMOXETINE HCL 40 MG CAPSULE [Strattera]   4 Non-Preferred Drug 25%25%Q:60
/30Days
ATOMOXETINE HCL 60 MG CAPSULE [Strattera]   4 Non-Preferred Drug 25%25%Q:30
/30Days
ATOMOXETINE HCL 80 MG CAPSULE [Strattera]   4 Non-Preferred Drug 25%25%Q:30
/30Days
ATORVASTATIN 10 MG TABLET [Lipitor]   2 Generic $8.00$12.00Q:45
/30Days
ATORVASTATIN 20 MG TABLET [Lipitor]   2 Generic $8.00$12.00Q:45
/30Days
ATORVASTATIN 40 MG TABLET [Lipitor]   2 Generic $8.00$12.00Q:45
/30Days
ATORVASTATIN 80 MG TABLET [Lipitor]   2 Generic $8.00$12.00Q:30
/30Days
ATOVAQUONE 750 MG/5 ML SUSP [Mepron]   5 Specialty Tier 25%N/ANone
Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone]   4 Non-Preferred Drug 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATOVAQUONE-PROGUANIL 62.5-25 [Malarone]   3 Preferred Brand $32.00$96.00None
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC   5 Specialty Tier 25%N/AQ:30
/30Days
ATROVENT HFA AER 17MCG   4 Non-Preferred Drug 25%25%Q:26
/30Days
AUBAGIO 14 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
AUBAGIO 7 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
AUBRA-28 TABLET   3 Preferred Brand $32.00$96.00None
AVIANE 0.1-0.02 TABLET   3 Preferred Brand $32.00$96.00None
Avita 0.25mg/g 45 g in 1 TUBE   4 Non-Preferred Drug 25%25%None
AVONEX ADMIN PACK 30 MCG VL   5 Specialty Tier 25%N/AP Q:4
/28Days
AVONEX PEN 30 MCG/0.5 ML KIT   5 Specialty Tier 25%N/AP Q:1
/28Days
AVONEX PREFILLED SYR 30 MCG KT   5 Specialty Tier 25%N/AP Q:1
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZATHIOPRINE 50 MG TABLET   2 Generic $8.00$12.00P
AZELAIC ACID 15% GEL [Finacea]   3 Preferred Brand $32.00$96.00None
AZELASTINE 0.15% NASAL SPRAY   3 Preferred Brand $32.00$96.00Q:60
/30Days
AZELASTINE 137 MCG NASAL SPRAY   2 Generic $8.00$12.00Q:60
/30Days
AZELASTINE HCL 0.05% DROPS   3 Preferred Brand $32.00$96.00None
AZITHROMYCIN 100 MG/5 ML SUSP   4 Non-Preferred Drug 25%25%None
AZITHROMYCIN 200 MG/5 ML SUSP   4 Non-Preferred Drug 25%25%None
AZITHROMYCIN 250 MG TABLET   2 Generic $8.00$12.00None
AZITHROMYCIN 250 MG TABLET   2 Generic $8.00$12.00None
AZITHROMYCIN 500 MG TABLET   2 Generic $8.00$12.00None
AZITHROMYCIN 500 MG TABLET [Zithromax Tri-Pak]   2 Generic $8.00$12.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZITHROMYCIN 600 MG TABLET   2 Generic $8.00$12.00None
AZITHROMYCIN I.V. 500 MG VIAL   4 Non-Preferred Drug 25%25%None
AZTREONAM FOR INJECTION   4 Non-Preferred Drug 25%25%None

Chart Legend:

Below are a few notes to help you understand the above 2019 Medicare Part D Horizon Medicare Blue Rx Standard (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 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 wit 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 which tier the drug is in. 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.






 
 

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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.