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EnvisionRxPlus (PDP) (S7694-012-0)
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2019 Medicare Part D Plan Formulary Information
EnvisionRxPlus (PDP) (S7694-012-0)
Benefit Details           
The EnvisionRxPlus (PDP) (S7694-012-0)
Formulary Drugs Starting with the Letter D
in CMS PDP Region 12 which includes: AL TN
Plan Monthly Premium: $50.40 Deductible: $415 Qualifies for LIS: No
Drugs Starting with Letter D

Drug Name		 Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order
D-AMPHETAMINE ER 10 MG CAPSULE   4 Non-Preferred Drug 33%33%Q:180
/30Days
D-AMPHETAMINE ER 15 MG CAPSULE   4 Non-Preferred Drug 33%33%Q:120
/30Days
D-AMPHETAMINE ER 5 MG CAPSULE   4 Non-Preferred Drug 33%33%Q:360
/30Days
D5%-1/2NS-KCL 10 MEQ/L IV SOL IV SOLN   4 Non-Preferred Drug 33%33%None
D5%-1/2NS-KCL 40 MEQ/L IV SOL IV SOLN   4 Non-Preferred Drug 33%33%None
DALFAMPRIDINE ER 10 MG TABLET ER 12H [Ampyra]   5 Specialty Tier 25%N/AP Q:60
/30Days
DALIRESP 250 MCG TABLET   3 Preferred Brand 15%15%Q:30
/30Days
DALIRESP 500 MCG TABLET   3 Preferred Brand 15%15%Q:30
/30Days
DANAZOL 100 MG CAPSULE   4 Non-Preferred Drug 33%33%None
DANAZOL 50MG CAPSULE   4 Non-Preferred Drug 33%33%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DANAZOL CAPSULES USP 200MG (100 CT)   4 Non-Preferred Drug 33%33%None
DAPSONE 25 MG TABLET   3 Preferred Brand 15%15%None
DAPSONE TABLETS 100MG 30 BLPK   3 Preferred Brand 15%15%None
DAPTACEL VACCINE 15;5;5;3; LF/.5ML   3 Preferred Brand 15%15%None
DAPTOMYCIN 350 MG VIAL [Cubicin RF]   4 Non-Preferred Drug 33%33%None
DAPTOMYCIN 500 MG VIAL [Cubicin]   4 Non-Preferred Drug 33%33%None
DARIFENACIN ER 15 MG TABLET [Enablex]   4 Non-Preferred Drug 33%33%None
DARIFENACIN ER 7.5 MG TABLET [Enablex]   4 Non-Preferred Drug 33%33%None
DAURISMO 100 MG TABLET   5 Specialty Tier 25%N/AP
DAURISMO 25 MG TABLET   5 Specialty Tier 25%N/AP
DEBLITANE 0.35 MG TABLET   4 Non-Preferred Drug 33%33%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DEFERASIROX 125 MG TABLET DISPER [Exjade]   5 Specialty Tier 25%N/AP
DEFERASIROX 250 MG TABLET DISPER [Exjade]   5 Specialty Tier 25%N/AP
DEFERASIROX 500 MG TABLET DISPER [Exjade]   5 Specialty Tier 25%N/AP
DELSTRIGO 100-300-300 MG TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
Delyla-28 tablet   4 Non-Preferred Drug 33%33%None
DEMSER CAPSULES 250MG (100 CT)   5 Specialty Tier 25%N/ANone
DEPEN 250MG TITRATAB   5 Specialty Tier 25%N/ANone
DEPO-PROVERA 400MG/ML VIAL   4 Non-Preferred Drug 33%33%P
DESCOVY 200-25 MG TABLET   5 Specialty Tier 25%N/ANone
DESIPRAMINE 10 MG TABLET [Norpramin]   4 Non-Preferred Drug 33%33%None
DESIPRAMINE 100 MG TABLET [Norpramin]   4 Non-Preferred Drug 33%33%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DESIPRAMINE 150 MG TABLET [Norpramin]   4 Non-Preferred Drug 33%33%None
DESIPRAMINE 25 MG TABLET [Norpramin]   4 Non-Preferred Drug 33%33%None
DESIPRAMINE 50 MG TABLET [Norpramin]   4 Non-Preferred Drug 33%33%None
DESIPRAMINE 75 MG TABLET [Norpramin]   4 Non-Preferred Drug 33%33%None
DESLORATADINE 5 MG TABLET   2 Generic $3.00$4.50None
DESMOPRESSIN ACETATE 0.1 MG TB   3 Preferred Brand 15%15%None
DESMOPRESSIN ACETATE 0.2 MG TB   3 Preferred Brand 15%15%None
DESMOPRESSIN ACETATE NASAL SOLUTION 0.1% 5 ML BOTSPR   4 Non-Preferred Drug 33%33%None
DESOGESTR-ETH ESTRA 0.15-0.03MG   4 Non-Preferred Drug 33%33%None
DESOGESTR-ETH ESTRAD   4 Non-Preferred Drug 33%33%None
Desonide 0.0005 MG/MG Topical Ointment   4 Non-Preferred Drug 33%33%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DESONIDE 0.05% CREAM   4 Non-Preferred Drug 33%33%None
DESONIDE 0.05% LOTION   4 Non-Preferred Drug 33%33%None
DESOXIMETASONE 0.25% CREAM   4 Non-Preferred Drug 33%33%None
DESOXIMETASONE 0.25% OINTMENT   4 Non-Preferred Drug 33%33%None
Desoximetasone 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE   4 Non-Preferred Drug 33%33%None
Desoximetasone 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE   4 Non-Preferred Drug 33%33%None
DESVENLAFAXINE ER 100 MG TAB   4 Non-Preferred Drug 33%33%Q:120
/30Days
DESVENLAFAXINE ER 50 MG TAB   4 Non-Preferred Drug 33%33%Q:30
/30Days
Desvenlafaxine Succinate ER 100 mg [Pristiq]   4 Non-Preferred Drug 33%33%Q:120
/30Days
Desvenlafaxine Succinate ER 25 mg tb [Pristiq]   4 Non-Preferred Drug 33%33%Q:30
/30Days
Desvenlafaxine Succinate ER 50 mg tb [Pristiq]   4 Non-Preferred Drug 33%33%Q:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DEXAMETHASONE 0.1% EYE DROP   4 Non-Preferred Drug 33%33%None
DEXAMETHASONE 0.5MG TABLET   2 Generic $3.00$4.50None
DEXAMETHASONE 0.5MG/0.5ML DROP   4 Non-Preferred Drug 33%33%None
DEXAMETHASONE 0.5MG/5ML ELX   4 Non-Preferred Drug 33%33%None
DEXAMETHASONE 0.75MG TABLET   2 Generic $3.00$4.50None
DEXAMETHASONE 1.5MG TABLET   2 Generic $3.00$4.50None
DEXAMETHASONE 1MG TABLET   2 Generic $3.00$4.50None
DEXAMETHASONE 2MG TABLET   2 Generic $3.00$4.50None
DEXAMETHASONE 4MG TABLET   2 Generic $3.00$4.50None
DEXAMETHASONE 6MG TABLET   2 Generic $3.00$4.50None
DEXILANT CAPSULES DELAYED RELEASE 30 MG   3 Preferred Brand 15%15%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DEXILANT DR 60 MG CAPSULE   3 Preferred Brand 15%15%None
DEXMETHYLPHENIDATE HCL 10MG TABLET   3 Preferred Brand 15%15%Q:60
/30Days
DEXMETHYLPHENIDATE HCL 2.5MG TABLET   3 Preferred Brand 15%15%Q:90
/30Days
DEXMETHYLPHENIDATE HCL 5MG TABLET   3 Preferred Brand 15%15%Q:120
/30Days
DEXTROAMP-AMPHETAMIN 20 MG TAB   4 Non-Preferred Drug 33%33%Q:90
/30Days
DEXTROAMP-AMPHETAMIN 30 MG TAB   4 Non-Preferred Drug 33%33%Q:60
/30Days
DEXTROAMPHETAMINE 10 MG TAB   4 Non-Preferred Drug 33%33%Q:180
/30Days
DEXTROAMPHETAMINE 5 MG TAB   4 Non-Preferred Drug 33%33%Q:150
/30Days
DEXTROAMPHETAMINE SACCHARATE AND SULFATE AMPHETAMINE ASPARTATE 10MG TABLET (100 CT)   4 Non-Preferred Drug 33%33%Q:90
/30Days
DEXTROSE 10%-1/4NS IV TUBEX   4 Non-Preferred Drug 33%33%None
Dextrose 10%-water iv solution   4 Non-Preferred Drug 33%33%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DEXTROSE 2.5%-1/2NS IV SOLUTION   4 Non-Preferred Drug 33%33%None
DEXTROSE 5%-0.45% NACL IV SOLN   4 Non-Preferred Drug 33%33%None
DEXTROSE 5%-0.9% NACL IV SOLN   4 Non-Preferred Drug 33%33%None
DEXTROSE 5%-1/4NS IV SOLUTION   4 Non-Preferred Drug 33%33%None
DEXTROSE 5%-WATER IV SOLN   4 Non-Preferred Drug 33%33%None
DEXTROSE IN SODIUM CHLORIDE INJECTION   4 Non-Preferred Drug 33%33%None
DEXTROSE IN SODIUM CHLORIDE INJECTION 1000ML X 12 CASE   4 Non-Preferred Drug 33%33%None
DEXTROSE IN SODIUM CHLORIDE INJECTION 500ML X 24 BAG   4 Non-Preferred Drug 33%33%None
DIASTAT 2.5 MG PEDI SYSTEM   4 Non-Preferred Drug 33%33%None
DIASTAT ACUDIAL 12.5-15-20 MG   4 Non-Preferred Drug 33%33%None
DIASTAT ACUDIAL 5-7.5-10 MG KT   4 Non-Preferred Drug 33%33%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DIAZEPAM 10 MG TABLET [Valium]   2 Generic $3.00$4.50Q:120
/30Days
DIAZEPAM 2 MG TABLET [Valium]   2 Generic $3.00$4.50Q:600
/30Days
DIAZEPAM 5 MG TABLET [Valium]   2 Generic $3.00$4.50Q:240
/30Days
DIAZEPAM 5 MG/5 ML SOLUTION   4 Non-Preferred Drug 33%33%Q:1200
/30Days
DIAZEPAM 5 MG/ML ORAL CONC   4 Non-Preferred Drug 33%33%Q:240
/30Days
DICLOFENAC 0.1% EYE DROPS [Voltaren]   2 Generic $3.00$4.50None
DICLOFENAC POT 50 MG TABLET   4 Non-Preferred Drug 33%33%None
DICLOFENAC SOD EC 25 MG TAB   4 Non-Preferred Drug 33%33%None
DICLOFENAC SOD EC 50 MG TAB   2 Generic $3.00$4.50None
DICLOFENAC SOD EC 75 MG TAB   2 Generic $3.00$4.50None
DICLOFENAC SOD ER 100 MG TABLET ER 24H [Voltaren-XR]   4 Non-Preferred Drug 33%33%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Diclofenac sodium 1.5% soln   4 Non-Preferred Drug 33%33%None
Diclofenac Sodium 1% gel   4 Non-Preferred Drug 33%33%None
DICLOXACILLIN 250MG CAPSULE   4 Non-Preferred Drug 33%33%None
DICLOXACILLIN SODIUM 500MG CAP   4 Non-Preferred Drug 33%33%None
DICYCLOMINE 10 MG CAPSULE   1 Preferred Generic $1.00$0.00None
DICYCLOMINE 20 MG TABLET   1 Preferred Generic $1.00$0.00None
DICYCLOMINE HCL 10MG/5ML SYRUP   4 Non-Preferred Drug 33%33%None
DIDANOSINE DR 200 MG CAPSULE DR [Videx EC]   4 Non-Preferred Drug 33%33%Q:60
/30Days
DIDANOSINE DR 250 MG CAPSULE [Videx EC]   4 Non-Preferred Drug 33%33%Q:30
/30Days
DIDANOSINE DR 400 MG CAPSULE [Videx EC]   4 Non-Preferred Drug 33%33%Q:30
/30Days
DIFLUNISAL 500 MG TABLET   4 Non-Preferred Drug 33%33%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DIGITEK 125 MCG TABLET   2 Generic $3.00$4.50None
DIGITEK 250 MCG TABLET   3 Preferred Brand 15%15%None
DIGOX 125 MCG TABLET   2 Generic $3.00$4.50None
DIGOX 250 MCG TABLET   3 Preferred Brand 15%15%None
DIGOXIN 0.05 MG/ML SOLUTION [Lanoxin]   4 Non-Preferred Drug 33%33%None
DIGOXIN 125 MCG TABLET [Lanoxin]   2 Generic $3.00$4.50None
DIGOXIN 250 MCG TABLET [Lanoxin]   3 Preferred Brand 15%15%None
DIHYDROERGOTAMINE 4 MG/ML SPRAY   5 Specialty Tier 25%N/AQ:8
/30Days
DILANTIN CAPSULES 30 MG ER   4 Non-Preferred Drug 33%33%None
DILT XR 120 MG CAPSULE   3 Preferred Brand 15%15%None
DILT XR 180 MG CAPSULE   3 Preferred Brand 15%15%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DILT XR 240 MG CAPSULE   3 Preferred Brand 15%15%None
DILTIAZEM 120 MG TABLET [Cardizem]   2 Generic $3.00$4.50None
DILTIAZEM 12HR ER 120 MG CAPSULE [Tiazac]   4 Non-Preferred Drug 33%33%None
DILTIAZEM 12HR ER 60 MG CAPSULE [Cardizem SR]   4 Non-Preferred Drug 33%33%None
DILTIAZEM 12HR ER 90 MG CAPSULE [Cardizem SR]   4 Non-Preferred Drug 33%33%None
DILTIAZEM 24HR ER 120 MG CAPSULE [Tiazac]   3 Preferred Brand 15%15%None
DILTIAZEM 24HR ER 180 MG CAPSULE [Tiazac]   3 Preferred Brand 15%15%None
DILTIAZEM 24HR ER 240 MG CAPSULE [Tiazac]   3 Preferred Brand 15%15%None
DILTIAZEM 24HR ER 300 MG CAPSULE [Tiazac]   3 Preferred Brand 15%15%None
DILTIAZEM 24HR ER 360 MG CAP [Tiazac]   3 Preferred Brand 15%15%None
DILTIAZEM 24HR ER 420 MG CAP [Tiazac]   3 Preferred Brand 15%15%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DILTIAZEM 30 MG TABLET [Cardizem]   2 Generic $3.00$4.50None
DILTIAZEM 60 MG TABLET [Cardizem]   2 Generic $3.00$4.50None
DILTIAZEM 90 MG TABLET [Cardizem]   2 Generic $3.00$4.50None
Diph-Tetanus Tox-Acell Pert adsorbed and IPV vaccine 0.5 ML Prefilled Syringe [Kinrix]   3 Preferred Brand 15%15%None
Diph-Tetanus Tox-Acell Pert-Hepatitis B-Polio IPV Vac 0.5 ML Prefilled Syringe [Pediarix]   3 Preferred Brand 15%15%None
Diphenoxylate Hydrochloride and Atropine Sulfate 0.025; 2.5mg 100 TABLET BOTTLE   3 Preferred Brand 15%15%None
DIPHENOXYLATE/ATROPINE LIQ   4 Non-Preferred Drug 33%33%None
Diphtheria Toxoid Vaccine 25 UNT/ML / Tetanus Toxoid Vaccine 5 UNT per 0.5 ML Injectable Suspension   3 Preferred Brand 15%15%P
Diphtheria toxoid vaccine, inact 4 UNT/ML / tetanus toxoid vaccine, inact 4 UNT/ML Inj Sus   3 Preferred Brand 15%15%P
DISULFIRAM 250 MG TABLET   4 Non-Preferred Drug 33%33%None
DISULFIRAM 500 MG TABLET   4 Non-Preferred Drug 33%33%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DIVALPROEX DR 125 MG CAP SPRNK   4 Non-Preferred Drug 33%33%None
DIVALPROEX SOD DR 125 MG TAB   3 Preferred Brand 15%15%None
DIVALPROEX SOD DR 250 MG TAB   3 Preferred Brand 15%15%None
DIVALPROEX SOD DR 500 MG TAB   3 Preferred Brand 15%15%None
DIVALPROEX SOD ER 500 MG TAB   4 Non-Preferred Drug 33%33%None
DIVALPROEX SODIUM ER TABLETS 250MG 100 BOT   4 Non-Preferred Drug 33%33%None
DOFETILIDE 125 MCG CAPSULE [Tikosyn]   4 Non-Preferred Drug 33%33%None
DOFETILIDE 250 MCG CAPSULE [Tikosyn]   4 Non-Preferred Drug 33%33%None
DOFETILIDE 500 MCG CAPSULE [Tikosyn]   4 Non-Preferred Drug 33%33%None
DONEPEZIL HCL 10 MG TABLET   2 Generic $3.00$4.50None
DONEPEZIL HCL 23 MG TABLET   4 Non-Preferred Drug 33%33%Q:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DONEPEZIL HCL 5 MG TABLET   2 Generic $3.00$4.50None
DONEPEZIL HCL ODT 10 MG TABLET   4 Non-Preferred Drug 33%33%Q:60
/30Days
DONEPEZIL HCL ODT 5 MG TABLET   4 Non-Preferred Drug 33%33%Q:30
/30Days
DORIPENEM 500 MG VIAL [Doribax]   4 Non-Preferred Drug 33%33%None
DORZOLAMIDE HCL OPHTHALMIC 2% 10 ML BOTDR   2 Generic $3.00$4.50None
Dorzolamide Hydrochloride and Timolol Maleate 20; 5mg/mL; mg/mL 1 BOTTLE, DROPPER in 1 BOX / 10 mL   4 Non-Preferred Drug 33%33%None
DORZOLAMIDE-TIMOLOL 2%-0.5% DROPERETTE [Cosopt PF]   4 Non-Preferred Drug 33%33%None
DOVATO 50-300 MG TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
DOXAZOSIN MESYLATE 1 MG TAB   2 Generic $3.00$4.50None
DOXAZOSIN MESYLATE 2 MG TAB   2 Generic $3.00$4.50None
DOXAZOSIN MESYLATE 4 MG TAB   2 Generic $3.00$4.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DOXAZOSIN MESYLATE 8 MG TAB   2 Generic $3.00$4.50None
DOXEPIN 10 MG/ML ORAL CONC   4 Non-Preferred Drug 33%33%None
DOXEPIN 10MG CAPSULE   4 Non-Preferred Drug 33%33%None
DOXEPIN 50 MG CAPSULE   4 Non-Preferred Drug 33%33%None
DOXEPIN 75MG CAPSULE   4 Non-Preferred Drug 33%33%None
DOXEPIN HCL 25MG CAPSULE (100 CT)   4 Non-Preferred Drug 33%33%None
Doxepin Hydrochloride 150mg/1 100 CAPSULE BOTTLE   4 Non-Preferred Drug 33%33%None
DOXEPIN HYDROCHLORIDE CAPSULES 100MG 100 BOT   4 Non-Preferred Drug 33%33%None
DOXY 100 VIAL   4 Non-Preferred Drug 33%33%None
DOXYCYCLINE HYCLATE 100 MG CAP   3 Preferred Brand 15%15%None
DOXYCYCLINE HYCLATE 100 MG TAB   3 Preferred Brand 15%15%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DOXYCYCLINE HYCLATE 20MG TABLET (100 CT)   3 Preferred Brand 15%15%None
DOXYCYCLINE HYCLATE 50 MG CAP   3 Preferred Brand 15%15%None
DOXYCYCLINE MONO 100 MG CAP   2 Generic $3.00$4.50None
DOXYCYCLINE MONO 100 MG TABLET   4 Non-Preferred Drug 33%33%None
DOXYCYCLINE MONO 50 MG CAP   2 Generic $3.00$4.50None
DOXYCYCLINE MONO 50 MG TABLET   4 Non-Preferred Drug 33%33%None
DRONABINOL 10 MG CAPSULE [Marinol]   4 Non-Preferred Drug 33%33%P Q:60
/30Days
DRONABINOL 2.5 MG CAPSULE [Marinol]   4 Non-Preferred Drug 33%33%P Q:60
/30Days
DRONABINOL 5 MG CAPSULE [Marinol]   4 Non-Preferred Drug 33%33%P Q:60
/30Days
DROSPIRENONE-EE 3-0.03 MG TAB   4 Non-Preferred Drug 33%33%None
DROXIA 200MG CAPSULE   3 Preferred Brand 15%15%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
DROXIA 300MG CAPSULE   3 Preferred Brand 15%15%None
DROXIA 400MG CAPSULE   3 Preferred Brand 15%15%None
DUAVEE 0.45-20 MG TABLET   4 Non-Preferred Drug 33%33%None
DULOXETINE HCL DR 20 MG CAPSULE DR [Cymbalta]   4 Non-Preferred Drug 33%33%Q:60
/30Days
DULOXETINE HCL DR 30 MG CAPSULE DR [Cymbalta]   4 Non-Preferred Drug 33%33%Q:60
/30Days
DULOXETINE HCL DR 40 MG CAPSULE DR [Irenka]   4 Non-Preferred Drug 33%33%Q:60
/30Days
DULOXETINE HCL DR 60 MG CAPSULE DR [Cymbalta]   4 Non-Preferred Drug 33%33%Q:60
/30Days
DUREZOL 0.05% EYE DROPS   3 Preferred Brand 15%15%None
DUTASTERIDE 0.5 MG CAPSULE   2 Generic $3.00$4.50None
DUTASTERIDE-TAMSULOSIN 0.5-0.4 [Jalyn]   4 Non-Preferred Drug 33%33%None

Chart Legend:

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