Q1GROUP LLC | Q1Medicare.com - a non-government resource for the Medicare community
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

Select your search style and criteria below or use this example to get started

Search by:
State & Plan   ZIP & Plan   PlanID   FormularyID

Search Criteria
PDP     MAPD
Scroll down to see formulary results.

Express Scripts Medicare - Choice (PDP) (S5660-176-0)
Tier 1 (247)
Tier 2 (1376)
Tier 3 (616)
Tier 4 (657)
Tier 5 (468)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
Yes No Show either
Cick on the first letter of your drug name to browse the formulary:

A B C D E F G H I J K L 
M N O P Q R S T U V W X Y Z 0-9 
2019 Medicare Part D Plan Formulary Information
Express Scripts Medicare - Choice (PDP) (S5660-176-0)
Benefit Details           
The Express Scripts Medicare - Choice (PDP) (S5660-176-0)
Formulary Drugs Starting with the Letter F

in CMS PDP Region 6 which includes: PA WV
Plan Monthly Premium: $100.00 Deductible: $350 Qualifies for LIS: No
Drugs Starting with Letter F

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
FALMINA-28 TABLET   2* Generic $7.00$4.00None
FAMCICLOVIR 125 MG TABLET   2* Generic $7.00$4.00Q:60
/30Days
FAMCICLOVIR 250 MG TABLET   2* Generic $7.00$4.00Q:60
/30Days
FAMCICLOVIR 500 MG TABLET   2* Generic $7.00$4.00Q:21
/30Days
FAMOTIDINE 20 MG TABLET   2* Generic $7.00$4.00None
FAMOTIDINE 40 MG TABLET   2* Generic $7.00$4.00None
FAMOTIDINE 50 MG/5MLFOR ORAL SUSPENSION   2* Generic $7.00$4.00None
FANAPT 1 MG TABLET   4 Non-Preferred Drug 48%N/AP Q:60
/30Days
FANAPT 10 MG TABLET   4 Non-Preferred Drug 48%N/AP Q:60
/30Days
FANAPT 12 MG TABLET   4 Non-Preferred Drug 48%N/AP Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FANAPT 2 MG TABLET   4 Non-Preferred Drug 48%N/AP Q:60
/30Days
FANAPT 4 MG TABLET   4 Non-Preferred Drug 48%N/AP Q:60
/30Days
FANAPT 6 MG TABLET   4 Non-Preferred Drug 48%N/AP Q:60
/30Days
FANAPT 8 MG TABLET   4 Non-Preferred Drug 48%N/AP Q:60
/30Days
FANAPT TITR TABLETS   4 Non-Preferred Drug 48%N/AP Q:8
/28Days
FARESTON 60 MG TABLET   5 Specialty Tier 26%N/ANone
FARXIGA 10 MG TABLET   4 Non-Preferred Drug 48%N/AQ:30
/30Days
FARXIGA 5 MG TABLET   4 Non-Preferred Drug 48%N/AQ:60
/30Days
FARYDAK 10 MG CAPSULE   5 Specialty Tier 26%N/AP Q:12
/21Days
FARYDAK 15 MG CAPSULE   5 Specialty Tier 26%N/AP Q:6
/21Days
FARYDAK 20 MG CAPSULE   5 Specialty Tier 26%N/AP Q:6
/21Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FASENRA 30 MG/ML SYRINGE   5 Specialty Tier 26%N/AP
FAYOSIM TABLET TBDSPK 3MO [Quartette]   2* Generic $7.00$4.00None
FAZACLO 150 MG ODT TAB RAPDIS   4 Non-Preferred Drug 48%N/ANone
FAZACLO 200 MG ODT TAB RAPDIS   4 Non-Preferred Drug 48%N/ANone
FELBAMATE 400 MG TABLET   4 Non-Preferred Drug 48%N/ANone
FELBAMATE 600 MG TABLET   4 Non-Preferred Drug 48%N/ANone
FELBAMATE 600 MG/5 ML SUSP   4 Non-Preferred Drug 48%N/ANone
FELODIPINE ER 10 MG TABLET   4 Non-Preferred Drug 48%N/ANone
FELODIPINE ER 2.5 MG TABLET   4 Non-Preferred Drug 48%N/ANone
FELODIPINE ER 5 MG TABLET   4 Non-Preferred Drug 48%N/ANone
Femynor 28 tablet   2* Generic $7.00$4.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FENOFIBRATE 134MG CAPSULE [LIPOFEN]   2* Generic $7.00$4.00Q:30
/30Days
FENOFIBRATE 145 MG TABLET [LIPOFEN]   2* Generic $7.00$4.00Q:30
/30Days
FENOFIBRATE 160 MG TABLET [LIPOFEN]   2* Generic $7.00$4.00Q:30
/30Days
FENOFIBRATE 200 MG CAPSULE [LIPOFEN]   2* Generic $7.00$4.00Q:30
/30Days
FENOFIBRATE 48 MG TABLET [Tricor]   2* Generic $7.00$4.00Q:60
/30Days
FENOFIBRATE 50 MG ORAL CAPSULE [LIPOFEN]   4 Non-Preferred Drug 48%N/ANone
FENOFIBRATE 54 MG 90 TABLET BOTTLE [LIPOFEN]   2* Generic $7.00$4.00Q:60
/30Days
FENOFIBRATE 67MG CAPSULE [LIPOFEN]   2* Generic $7.00$4.00Q:60
/30Days
FENOFIBRIC ACID DR 135 MG CAP [TRILIPIX]   2* Generic $7.00$4.00None
FENOFIBRIC ACID DR 45 MG CAPSULE DR [Trilipix]   2* Generic $7.00$4.00None
FENTANYL 100 MCG/HR PATCH TD72 [Duragesic]   2* Generic $7.00$4.00P Q:10
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FENTANYL 12 MCG/HR PATCH TD72 [Duragesic]   2* Generic $7.00$4.00P Q:10
/30Days
FENTANYL 25 MCG/HR PATCH TD72 [Duragesic]   2* Generic $7.00$4.00P Q:10
/30Days
FENTANYL 50 MCG/HR PATCH TD72 [Duragesic]   2* Generic $7.00$4.00P Q:10
/30Days
FENTANYL 75 MCG/HR PATCH TD72 [Duragesic]   2* Generic $7.00$4.00P Q:10
/30Days
FENTANYL CITRATE OTFC 1,200 MCG [Actiq]   5 Specialty Tier 26%N/AP Q:120
/30Days
FENTANYL CITRATE OTFC 1,600 MCG [Actiq]   5 Specialty Tier 26%N/AP Q:120
/30Days
FENTANYL CITRATE OTFC 200 MCG [Actiq]   5 Specialty Tier 26%N/AP Q:120
/30Days
FENTANYL CITRATE OTFC 400 MCG [Actiq]   5 Specialty Tier 26%N/AP Q:120
/30Days
FENTANYL CITRATE OTFC 600 MCG [Actiq]   5 Specialty Tier 26%N/AP Q:120
/30Days
FENTANYL CITRATE OTFC 800 MCG [Actiq]   5 Specialty Tier 26%N/AP Q:120
/30Days
FERRIPROX 500 MG TABLET   5 Specialty Tier 26%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FETZIMA 20-40 MG TITRATION PAK   4 Non-Preferred Drug 48%N/AS Q:28
/28Days
FETZIMA ER 120 MG CAPSULE   4 Non-Preferred Drug 48%N/AS Q:30
/30Days
FETZIMA ER 20 MG CAPSULE   4 Non-Preferred Drug 48%N/AS Q:30
/30Days
FETZIMA ER 40 MG CAPSULE   4 Non-Preferred Drug 48%N/AS Q:30
/30Days
FETZIMA ER 80 MG CAPSULE   4 Non-Preferred Drug 48%N/AS Q:30
/30Days
FINASTERIDE 5 MG TABLET   2* Generic $7.00$4.00Q:30
/30Days
FIRAZYR 30 MG/3 ML SYRINGE   5 Specialty Tier 26%N/AP Q:270
/30Days
FIRDAPSE 10 MG TABLET   5 Specialty Tier 26%N/AP
FIRMAGON 2 X 120 MG KIT   4 Non-Preferred Drug 48%N/AP
FIRMAGON 80 MG KIT   4 Non-Preferred Drug 48%N/AP
FLAC OTIC OIL 0.01% EAR DROPS [Flac]   4 Non-Preferred Drug 48%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FLAVOXATE 100 MG TAB 100   2* Generic $7.00$4.00None
FLECAINIDE ACETATE 100 MG TAB   2* Generic $7.00$4.00None
FLECAINIDE ACETATE 150 MG TAB   2* Generic $7.00$4.00None
FLECAINIDE ACETATE 50 MG TAB   2* Generic $7.00$4.00None
FLOVENT DISKUS 100ug/1 60 POWDER, METERED in 1 INHALER   3 Preferred Brand $42.00$126.00Q:60
/30Days
FLOVENT DISKUS 250ug/1 60 POWDER, METERED in 1 INHALER   3 Preferred Brand $42.00$126.00Q:240
/30Days
FLOVENT DISKUS POWDER 50MCG 60 CTR   3 Preferred Brand $42.00$126.00Q:60
/30Days
FLOVENT HFA 110ug/1 120 AEROSOL, METERED in 1 INHALER   3 Preferred Brand $42.00$126.00Q:12
/30Days
FLOVENT HFA 220ug/1 120 AEROSOL, METERED in 1 INHALER   3 Preferred Brand $42.00$126.00Q:24
/30Days
FLOVENT HFA 44ug/1 120 AEROSOL, METERED in 1 INHALER   3 Preferred Brand $42.00$126.00Q:11
/30Days
FLUCONAZOLE 10 MG/ML SUSP   2* Generic $7.00$4.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FLUCONAZOLE 100 MG TABLET   2* Generic $7.00$4.00None
FLUCONAZOLE 150 MG TABLET   2* Generic $7.00$4.00None
FLUCONAZOLE 200 MG TABLET   2* Generic $7.00$4.00None
FLUCONAZOLE 40 MG/ML SUSP   2* Generic $7.00$4.00None
Fluconazole 50mg/1 30 TABLET BOTTLE   2* Generic $7.00$4.00None
FLUCONAZOLE-NACL 200 MG/100 ML   2* Generic $7.00$4.00None
FLUCONAZOLE-NACL 400 MG/200 ML   2* Generic $7.00$4.00None
FLUCYTOSINE 250 MG CAPSULE [Ancobon]   5 Specialty Tier 26%N/ANone
FLUCYTOSINE 500 MG CAPSULE [Ancobon]   5 Specialty Tier 26%N/ANone
FLUDROCORTISONE 0.1 MG TABLET   2* Generic $7.00$4.00None
FLUNISOLIDE NASAL SOLUTION 0.025% 25ML INHL   2* Generic $7.00$4.00Q:50
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Fluocinolone 0.01% cream   4 Non-Preferred Drug 48%N/ANone
FLUOCINOLONE 0.01% SCALP OIL   4 Non-Preferred Drug 48%N/ANone
FLUOCINOLONE 0.01% SOLUTION   4 Non-Preferred Drug 48%N/ANone
FLUOCINOLONE 0.025% CREAM (g) [Synalar]   4 Non-Preferred Drug 48%N/ANone
FLUOCINOLONE 0.025% OINTMENT   4 Non-Preferred Drug 48%N/ANone
FLUOCINOLONE OIL 0.01% EAR DRP   4 Non-Preferred Drug 48%N/ANone
FLUOCINONIDE 0.05% GEL   2* Generic $7.00$4.00Q:120
/30Days
FLUOCINONIDE 0.05% OINTMENT   2* Generic $7.00$4.00Q:120
/30Days
FLUOCINONIDE 0.05% SOLUTION   2* Generic $7.00$4.00Q:120
/30Days
FLUOCINONIDE 0.1% CREAM   4 Non-Preferred Drug 48%N/AQ:120
/30Days
FLUOCINONIDE-E 0.05% CREAM   2* Generic $7.00$4.00Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Fluorometholone 0.1% drops   2* Generic $7.00$4.00None
FLUOROURACIL 2% TOPICAL SOLN   3 Preferred Brand $42.00$126.00None
FLUOROURACIL 5% TOP SOLUTION   3 Preferred Brand $42.00$126.00None
FLUOROURACIL CREA 5%   3 Preferred Brand $42.00$126.00None
Fluoxetine 10mg/1 30 FILM COATED TABLETS in BOTTLE   2* Generic $7.00$4.00Q:30
/30Days
Fluoxetine 20mg/5mL 120 mL in 1 BOTTLE, PLASTIC   2* Generic $7.00$4.00None
FLUOXETINE CAPSULES 10MG (100 CT)   1* Preferred Generic $2.00$0.00Q:30
/30Days
FLUOXETINE HCL 20 MG CAPSULE   1* Preferred Generic $2.00$0.00None
FLUOXETINE HCL 20 MG TABLET   2* Generic $7.00$4.00None
FLUOXETINE HCL 40 MG CAPSULE   1* Preferred Generic $2.00$0.00Q:60
/30Days
FLUOXETINE HCL 60 MG TABLET   2* Generic $7.00$4.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FLUPHENAZINE 1 MG TABLET   2* Generic $7.00$4.00None
FLUPHENAZINE 10 MG TABLET   2* Generic $7.00$4.00None
FLUPHENAZINE 2.5 MG TABLET   2* Generic $7.00$4.00None
FLUPHENAZINE 2.5 MG/5 ML ELIX   2* Generic $7.00$4.00None
FLUPHENAZINE 2.5MG/ML VIAL   2* Generic $7.00$4.00None
FLUPHENAZINE 5 MG TABLET   2* Generic $7.00$4.00None
FLUPHENAZINE 5MG/ML CONC   2* Generic $7.00$4.00None
FLUPHENAZINE DEC 125 MG/5 ML   2* Generic $7.00$4.00None
FLURBIPROFEN 0.03% EYE DROPS [Ocufen]   2* Generic $7.00$4.00None
Flurbiprofen 100mg/1 100 BOTTLE in 1 BOTTLE / 100 FILM COATED TABLETS in BOTTLE   2* Generic $7.00$4.00None
FLURBIPROFEN 50MG TABLET   2* Generic $7.00$4.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FLUTAMIDE 125 MG CAPSULE   2* Generic $7.00$4.00None
Fluticasone Propionate 0.05mg/g 1 TUBE per CARTON / 30 g in 1 TUBE   2* Generic $7.00$4.00None
Fluticasone Propionate 0.5mg/g 1 TUBE per CARTON / 30 g in 1 TUBE   2* Generic $7.00$4.00None
FLUTICASONE PROPIONATE 50MCG SPRAY SUSPENSION   2* Generic $7.00$4.00Q:16
/30Days
FLUVASTATIN SODIUM 20 MG CAP [Lescol]   2* Generic $7.00$4.00Q:30
/30Days
FLUVASTATIN SODIUM 40 MG CAPSULE [Lescol]   2* Generic $7.00$4.00Q:60
/30Days
FLUVOXAMINE ER 100 MG CAPSULE   4 Non-Preferred Drug 48%N/AQ:60
/30Days
FLUVOXAMINE ER 150 MG CAPSULE   4 Non-Preferred Drug 48%N/AQ:60
/30Days
FLUVOXAMINE MALEATE 100MG TABLET   4 Non-Preferred Drug 48%N/AQ:90
/30Days
Fluvoxamine Maleate 25mg/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 FILM COATED TABLETS in   4 Non-Preferred Drug 48%N/AQ:30
/30Days
Fluvoxamine maleate 50mg/1 100 FILM COATED TABLETS in BOTTLE   4 Non-Preferred Drug 48%N/AQ:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Fondaparinux Sodium 10mg/0.8mL 2 SYRINGES per CARTON / 0.8 mL in 1 SYRINGE [Arixtra]   5 Specialty Tier 26%N/ANone
Fondaparinux Sodium 2.5mg/0.5mL 2 SYRINGES per CARTON / 0.5 mL in 1 SYRINGE [Arixtra]   3 Preferred Brand $42.00$126.00None
Fondaparinux Sodium 5mg/4mL 2 SYRINGES per CARTON / 0.4 mL in 1 SYRINGE [Arixtra]   5 Specialty Tier 26%N/ANone
Fondaparinux Sodium 7.5mg/0.6mL 2 SYRINGES per CARTON / 0.6 mL in 1 SYRINGE [Arixtra]   5 Specialty Tier 26%N/ANone
FORFIVO XL 450 MG TABLET   4 Non-Preferred Drug 48%N/AQ:30
/30Days
FOSAMPRENAVIR 700 MG TABLET [Lexiva]   5 Specialty Tier 26%N/AQ:120
/30Days
FOSINOPRIL SODIUM 10 MG TAB   1* Preferred Generic $2.00$0.00None
FOSINOPRIL SODIUM 20 MG TAB   1* Preferred Generic $2.00$0.00None
FOSINOPRIL SODIUM 40 MG TAB   1* Preferred Generic $2.00$0.00None
FOSINOPRIL-HCTZ 10-12.5 MG TAB   2* Generic $7.00$4.00None
FOSINOPRIL-HCTZ 20-12.5 MG TAB   2* Generic $7.00$4.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FRAGMIN 2,500 UNITS SYRINGE   4 Non-Preferred Drug 48%N/ANone
FRAGMIN 5,000 UNITS SYRINGE   4 Non-Preferred Drug 48%N/ANone
FRAGMIN 95,000 UNITS/3.8 ML VL   4 Non-Preferred Drug 48%N/ANone
FREAMINE HBC INJECTION   3 Preferred Brand $42.00$126.00P
FUROSEMIDE 10 MG/ML SOLUTION   2* Generic $7.00$4.00None
Furosemide 10 ML 10 MG/ML Injection   2* Generic $7.00$4.00None
Furosemide 10mg/mL 10 CARTON in 1 CONTAINER / 1 SYRINGE, PLASTIC in 1 CARTON / 4 mL in 1 SYRINGE, P   2* Generic $7.00$4.00None
FUROSEMIDE 20 MG TABLET   1* Preferred Generic $2.00$0.00None
FUROSEMIDE 40 MG TABLET   1* Preferred Generic $2.00$0.00None
FUROSEMIDE 40MG/5ML TUBEX   2* Generic $7.00$4.00None
FUROSEMIDE 80 MG TABLET   1* Preferred Generic $2.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FUZEON 90 MG VIAL   4 Non-Preferred Drug 48%N/AQ:60
/30Days
FYCOMPA 0.5 MG/ML ORAL SUSP   4 Non-Preferred Drug 48%N/AP Q:720
/30Days
FYCOMPA 10 MG TABLET   4 Non-Preferred Drug 48%N/AP Q:30
/30Days
FYCOMPA 12 MG TABLET   4 Non-Preferred Drug 48%N/AP Q:30
/30Days
FYCOMPA 2 MG TABLET   4 Non-Preferred Drug 48%N/AP Q:180
/30Days
FYCOMPA 4 MG TABLET   4 Non-Preferred Drug 48%N/AP Q:90
/30Days
FYCOMPA 6 MG TABLET   4 Non-Preferred Drug 48%N/AP Q:60
/30Days
FYCOMPA 8 MG TABLET   4 Non-Preferred Drug 48%N/AP Q:30
/30Days

Chart Legend:

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