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2019 Medicare Part D Plan Formulary Information
Express Scripts Medicare - Value (PDP) (S5660-108-0) Benefit Details
The Express Scripts Medicare - Value (PDP) (S5660-108-0) Formulary Drugs Starting with the Letter M in CMS PDP Region 6 which includes: PA WV Plan Monthly Premium: $36.20 Deductible: $415 Qualifies for LIS: Yes
Drugs Starting with Letter M Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter M Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
M-M-R II VACCINE W/DILUENT 1 DOSE/0.5ML	3	Preferred Brand	$26.00	$78.00	None
MAFENIDE ACETATE 50 GM POWD PK PACKET	2	Generic	$3.00	$6.00	None
MAGNESIUM SULFATE 50% VIAL	2	Generic	$3.00	$6.00	None
MAGNESIUM SULFATE INJECTION 5 GM/10ML	2	Generic	$3.00	$6.00	None
MALATHION 0.5% LOTION	4	Non-Preferred Drug	35%	N/A	None
MAPROTILINE 25MG TABLET	2	Generic	$3.00	$6.00	None
MAPROTILINE 50MG TABLET	2	Generic	$3.00	$6.00	None
MAPROTILINE 75MG TABLET	2	Generic	$3.00	$6.00	None
MARLISSA-28 TABLET	4	Non-Preferred Drug	35%	N/A	None
MARPLAN 10MG TABLET (100 CT)	3	Preferred Brand	$26.00	$78.00	Q:180 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
MATULANE 50 MG CAPSULE	5	Specialty Tier	25%	N/A	None
MECLIZINE 12.5 MG TABLET	2	Generic	$3.00	$6.00	None
MECLIZINE 25 MG TABLET	2	Generic	$3.00	$6.00	None
MEDROXYPROGESTERONE 10 MG TABLET [Provera]	2	Generic	$3.00	$6.00	None
MEDROXYPROGESTERONE 150 MG/ML Syringe [Depo-Provera]	3	Preferred Brand	$26.00	$78.00	None
MEDROXYPROGESTERONE 150 MG/ML VIAL [Depo-Provera]	3	Preferred Brand	$26.00	$78.00	None
MEDROXYPROGESTERONE 2.5 MG TABLET [Provera]	2	Generic	$3.00	$6.00	None
MEDROXYPROGESTERONE 5 MG TABLET [Provera]	2	Generic	$3.00	$6.00	None
MEFLOQUINE HCL 250 MG TABLET	2	Generic	$3.00	$6.00	None
MEGESTROL 20 MG TABLET	4	Non-Preferred Drug	35%	N/A	P
MEGESTROL 40 MG TABLET	4	Non-Preferred Drug	35%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
MEGESTROL 625 MG/5 ML SUSP	4	Non-Preferred Drug	35%	N/A	P
MEGESTROL ACET 40 MG/ML SUSP	4	Non-Preferred Drug	35%	N/A	P
MEKINIST 0.5 MG TABLET	5	Specialty Tier	25%	N/A	P Q:90 /30Days
MEKINIST 2 MG TABLET	5	Specialty Tier	25%	N/A	P Q:30 /30Days
MEKTOVI 15 MG TABLET	4	Non-Preferred Drug	35%	N/A	P Q:180 /30Days
MELODETTA 24 FE CHEWABLE TAB [Minastrin]	4	Non-Preferred Drug	35%	N/A	None
MELOXICAM 15 MG TABLET	1	Preferred Generic	$1.00	$2.00	Q:30 /30Days
MELOXICAM 7.5 MG TABLET	1	Preferred Generic	$1.00	$2.00	Q:30 /30Days
MEMANTINE 5-10 MG TITRATION PK [Namenda Titration]	3	Preferred Brand	$26.00	$78.00	P Q:98 /28Days
MEMANTINE HCL 10 MG TABLET [Namenda]	3	Preferred Brand	$26.00	$78.00	P Q:60 /30Days
MEMANTINE HCL 2 MG/ML SOLUTION [Namenda]	3	Preferred Brand	$26.00	$78.00	P Q:300 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
MEMANTINE HCL 5 MG TABLET [Namenda]	3	Preferred Brand	$26.00	$78.00	P Q:60 /30Days
MEMANTINE HCL ER 14 MG CAPSULE SPR 24 [Namenda XR]	3	Preferred Brand	$26.00	$78.00	P
MEMANTINE HCL ER 21 MG CAPSULE SPR 24 [Namenda]	3	Preferred Brand	$26.00	$78.00	P
MEMANTINE HCL ER 28 MG CAPSULE SPR 24 [Namenda]	3	Preferred Brand	$26.00	$78.00	P
MEMANTINE HCL ER 7 MG CAPSULE SPR 24 [Namenda XR]	3	Preferred Brand	$26.00	$78.00	P
Menactra 4; 4; 4; 4ug/0.5mL; ug/0.5mL; ug/0.5mL; ug/0.5mL 5 VIAL, SINGLE-DOSE in 1 PACKAGE / 0.5 mL	3	Preferred Brand	$26.00	$78.00	None
MENVEO A-C-Y-W-135-DIP VIAL	3	Preferred Brand	$26.00	$78.00	None
MERCAPTOPURINE 50 MG TABLET	2	Generic	$3.00	$6.00	None
MEROPENEM 500MG/VIAL FOR INJECTION	4	Non-Preferred Drug	35%	N/A	None
MEROPENEM IV 1 GM VIAL	4	Non-Preferred Drug	35%	N/A	None
MESALAMINE 1,000 MG SUPP.RECT [Canasa]	3	Preferred Brand	$26.00	$78.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
MESALAMINE 4 GM/60 ML ENEMA	3	Preferred Brand	$26.00	$78.00	None
MESALAMINE 800 MG DR TABLET DR [Asacol HD]	3	Preferred Brand	$26.00	$78.00	None
MESALAMINE DR 1.2 GM TABLET	3	Preferred Brand	$26.00	$78.00	None
MESALAMINE DR 400 MG CAPSULE (DRTAB) [Delzicol]	3	Preferred Brand	$26.00	$78.00	None
MESNEX 400MG TABLET	5	Specialty Tier	25%	N/A	None
MESTINON 60MG/5ML SYRUP	5	Specialty Tier	25%	N/A	None
METFORMIN HCL 1,000 MG TABLET	1	Preferred Generic	$1.00	$2.00	Q:75 /30Days
METFORMIN HCL 500 MG TABLET	1	Preferred Generic	$1.00	$2.00	Q:150 /30Days
METFORMIN HCL 850 MG TABLET	1	Preferred Generic	$1.00	$2.00	Q:90 /30Days
METFORMIN HCL ER 500 MG TABLET	2	Generic	$3.00	$6.00	Q:120 /30Days
METFORMIN HCL ER 750 MG TABLET ER 24H [Glucophage XR]	2	Generic	$3.00	$6.00	Q:75 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
METHADONE 10 MG/5 ML SOLUTION	4	Non-Preferred Drug	35%	N/A	P Q:600 /30Days
METHADONE 5 MG/5 ML SOLUTION	4	Non-Preferred Drug	35%	N/A	P Q:1200 /30Days
METHADONE HCL 10 MG TABLET [Methadose]	2	Generic	$3.00	$6.00	P Q:120 /30Days
METHADONE HCL 5 MG TABLET [Methadose]	2	Generic	$3.00	$6.00	P Q:240 /30Days
Methazolamide 25 MG Oral Tablet	4	Non-Preferred Drug	35%	N/A	None
METHAZOLAMIDE 50 MG TABLET	4	Non-Preferred Drug	35%	N/A	None
Methenamine Hippurate 1g/1	4	Non-Preferred Drug	35%	N/A	None
METHIMAZOLE 10 MG TABLET [Tapazole]	2	Generic	$3.00	$6.00	None
METHIMAZOLE 5 MG TABLET [Tapazole]	2	Generic	$3.00	$6.00	None
METHOTREXATE 2.5MG TABLET	3	Preferred Brand	$26.00	$78.00	P
METHOTREXATE 250 MG/10 ML VIAL	3	Preferred Brand	$26.00	$78.00	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
METHOTREXATE 50 MG/2 ML VIAL	3	Preferred Brand	$26.00	$78.00	P
Methoxsalen 10 mg Capsule [8-MOP]	5	Specialty Tier	25%	N/A	None
METHYLDOPA 250 MG TABLET	4	Non-Preferred Drug	35%	N/A	None
METHYLDOPA 500 MG TABLET	4	Non-Preferred Drug	35%	N/A	None
METHYLPHENIDATE 10 MG TABLET [Ritalin]	2	Generic	$3.00	$6.00	Q:90 /30Days
METHYLPHENIDATE 10 MG/5 ML SOL Solution [Methylin]	4	Non-Preferred Drug	35%	N/A	Q:900 /30Days
METHYLPHENIDATE 20 MG TABLET [Ritalin]	2	Generic	$3.00	$6.00	Q:90 /30Days
METHYLPHENIDATE 5 MG TABLET [Ritalin]	2	Generic	$3.00	$6.00	Q:90 /30Days
METHYLPHENIDATE 5 MG/5 ML SOLN Solution [Methylin]	4	Non-Preferred Drug	35%	N/A	Q:1800 /30Days
METHYLPHENIDATE CD 10 MG CAPSULE CPBP 30-70 [Ritalin LA]	3	Preferred Brand	$26.00	$78.00	None
METHYLPHENIDATE CD 20 MG CAPSULE CPBP 30-70 [Ritalin LA]	3	Preferred Brand	$26.00	$78.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
METHYLPHENIDATE CD 30 MG CAPSULE CPBP 30-70 [Ritalin LA]	3	Preferred Brand	$26.00	$78.00	None
METHYLPHENIDATE CD 40 MG CAPSULE CPBP 30-70 [Ritalin LA]	3	Preferred Brand	$26.00	$78.00	None
METHYLPHENIDATE CD 50 MG CAPSULE CPBP 30-70 [Metadate CD]	3	Preferred Brand	$26.00	$78.00	None
METHYLPHENIDATE CD 60 MG CAPSULE CPBP 30-70 [Ritalin LA]	3	Preferred Brand	$26.00	$78.00	None
METHYLPHENIDATE LA 10 MG CAP CPBP 50-50 [Ritalin LA]	4	Non-Preferred Drug	35%	N/A	None
METHYLPHENIDATE LA 20 MG CAPSULE CPBP 50-50 [Ritalin LA]	4	Non-Preferred Drug	35%	N/A	None
METHYLPHENIDATE LA 30 MG CAP CPBP 50-50 [Ritalin LA]	4	Non-Preferred Drug	35%	N/A	None
METHYLPHENIDATE LA 40 MG CAPSULE CPBP 50-50 [Ritalin LA]	4	Non-Preferred Drug	35%	N/A	None
METHYLPHENIDATE LA 60 MG CAPSULE CPBP 50-50	4	Non-Preferred Drug	35%	N/A	None
METHYLPREDNISOLONE 16MG TABLET	2	Generic	$3.00	$6.00	P
METHYLPREDNISOLONE 32MG TABLET	2	Generic	$3.00	$6.00	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
METHYLPREDNISOLONE 4 MG DOSEPK	2	Generic	$3.00	$6.00	None
METHYLPREDNISOLONE 4 MG TABLET	2	Generic	$3.00	$6.00	P
METHYLPREDNISOLONE 8 MG ORAL TABLET	2	Generic	$3.00	$6.00	P
METHYLTESTOSTERONE 10 MG CAP	5	Specialty Tier	25%	N/A	None
Metoclopramide 10mg/1 500 TABLET BOTTLE	2	Generic	$3.00	$6.00	None
METOCLOPRAMIDE 5 MG TABLET	2	Generic	$3.00	$6.00	None
METOCLOPRAMIDE 5 MG/5 ML SOLN	2	Generic	$3.00	$6.00	None
METOLAZONE 10MG TABLET	2	Generic	$3.00	$6.00	None
METOLAZONE 2.5MG TABLET	2	Generic	$3.00	$6.00	None
METOLAZONE 5MG TABLET	2	Generic	$3.00	$6.00	None
METOPROLOL SUCC ER 100 MG TAB	2	Generic	$3.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
METOPROLOL SUCC ER 200 MG TAB	2	Generic	$3.00	$6.00	None
METOPROLOL SUCC ER 25 MG TAB	2	Generic	$3.00	$6.00	None
METOPROLOL SUCC ER 50 MG TAB	2	Generic	$3.00	$6.00	None
METOPROLOL TARTRATE 100 MG TAB	1	Preferred Generic	$1.00	$2.00	None
METOPROLOL TARTRATE 25 MG TAB	1	Preferred Generic	$1.00	$2.00	None
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT)	1	Preferred Generic	$1.00	$2.00	None
METRONIDAZOLE 0.75% CREAM Cream (g) [Vitazol]	4	Non-Preferred Drug	35%	N/A	None
METRONIDAZOLE 0.75% LOTION [MetroLotion]	4	Non-Preferred Drug	35%	N/A	None
METRONIDAZOLE 250 MG TABLET [Flagyl]	2	Generic	$3.00	$6.00	None
METRONIDAZOLE 375 MG CAPSULE [Flagyl]	2	Generic	$3.00	$6.00	None
METRONIDAZOLE 500 MG TABLET [Flagyl]	2	Generic	$3.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
METRONIDAZOLE 500 MG/100 ML PIGGYBACK [Flagyl RTU]	2	Generic	$3.00	$6.00	None
METRONIDAZOLE TOPICAL 0.75% GL Gel [Nydamax]	4	Non-Preferred Drug	35%	N/A	None
METRONIDAZOLE TOPICAL 1% GEL [MetroGel]	2	Generic	$3.00	$6.00	None
METRONIDAZOLE VAGINAL 0.75% GL GEL W/APPL [Vandazole]	2	Generic	$3.00	$6.00	None
MEXILETINE 150MG CAPSULE	2	Generic	$3.00	$6.00	None
MEXILETINE 200MG CAPSULE	2	Generic	$3.00	$6.00	None
MEXILETINE 250MG CAPSULE	2	Generic	$3.00	$6.00	None
MIBELAS 24 FE CHEWABLE TABLET	4	Non-Preferred Drug	35%	N/A	None
MICONAZOLE 3 200MG SUPPOS.	4	Non-Preferred Drug	35%	N/A	None
Microgestin 21 1-20 tablet	4	Non-Preferred Drug	35%	N/A	None
MICROGESTIN 21 1.5-30 TAB	4	Non-Preferred Drug	35%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Microgestin fe 1-20 tablet	4	Non-Preferred Drug	35%	N/A	None
MICROGESTIN FE 1.5-30 TAB	4	Non-Preferred Drug	35%	N/A	None
MIDODRINE HCL 10 MG TABLET	4	Non-Preferred Drug	35%	N/A	None
MIDODRINE HCL 2.5 MG TABLET	2	Generic	$3.00	$6.00	None
MIDODRINE HCL 5 MG TABLET	4	Non-Preferred Drug	35%	N/A	None
Migergot suppository	4	Non-Preferred Drug	35%	N/A	None
MILI 0.25-0.035 MG TABLET [VyLibra]	4	Non-Preferred Drug	35%	N/A	None
MINOCYCLINE 100 MG CAPSULE	2	Generic	$3.00	$6.00	None
MINOCYCLINE 50 MG CAPSULE	2	Generic	$3.00	$6.00	None
MINOCYCLINE 75 MG CAPSULE	2	Generic	$3.00	$6.00	None
MINOCYCLINE HCL 100 MG TABLET	4	Non-Preferred Drug	35%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
MINOCYCLINE HCL 75 MG TABLET	4	Non-Preferred Drug	35%	N/A	None
MINOCYCLINE HYDROCHLORIDE TABLETS 50MG	4	Non-Preferred Drug	35%	N/A	None
MINOXIDIL 10MG TABLET	2	Generic	$3.00	$6.00	None
MINOXIDIL 2.5MG TABLET	2	Generic	$3.00	$6.00	None
MIRTAZAPINE 15 MG ODT	2	Generic	$3.00	$6.00	Q:30 /30Days
MIRTAZAPINE 15 MG TABLET [Remeron]	2	Generic	$3.00	$6.00	Q:30 /30Days
MIRTAZAPINE 30 MG ODT	2	Generic	$3.00	$6.00	Q:30 /30Days
MIRTAZAPINE 30 MG TABLET [Remeron]	2	Generic	$3.00	$6.00	Q:30 /30Days
Mirtazapine 45 mg odt	2	Generic	$3.00	$6.00	Q:30 /30Days
MIRTAZAPINE 45 MG TABLET	2	Generic	$3.00	$6.00	Q:30 /30Days
MIRTAZAPINE 7.5 MG TABLET	2	Generic	$3.00	$6.00	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
misoprostol 100 mcg tablet	2	Generic	$3.00	$6.00	None
misoprostol 200 mcg tablet	2	Generic	$3.00	$6.00	None
MODAFINIL 100 MG TABLET [Provigil]	3	Preferred Brand	$26.00	$78.00	P Q:30 /30Days
MODAFINIL 200 MG TABLET [Provigil]	3	Preferred Brand	$26.00	$78.00	P Q:60 /30Days
MOLINDONE HCL 10 MG TABLET	3	Preferred Brand	$26.00	$78.00	None
MOLINDONE HCL 25 MG TABLET	3	Preferred Brand	$26.00	$78.00	None
MOLINDONE HCL 5 MG TABLET	3	Preferred Brand	$26.00	$78.00	None
MONDOXYNE NL 100 MG CAPSULE [Monodox]	4	Non-Preferred Drug	35%	N/A	None
MONDOXYNE NL 75 MG CAPSULE [NutriDox]	4	Non-Preferred Drug	35%	N/A	None
MONONESSA TABLETS .250;.035MG; MG 6 X 28 CRTN	4	Non-Preferred Drug	35%	N/A	None
MONTELUKAST SOD 10 MG TABLET [Singulair]	2	Generic	$3.00	$6.00	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
MONTELUKAST SOD 4 MG GRANULES [Singulair]	3	Preferred Brand	$26.00	$78.00	Q:30 /30Days
MONTELUKAST SOD 4 MG TAB CHEW [Singulair]	2	Generic	$3.00	$6.00	Q:30 /30Days
MONTELUKAST SOD 5 MG TAB CHEW [Singulair]	2	Generic	$3.00	$6.00	Q:30 /30Days
MORGIDOX 50 MG CAPSULE	3	Preferred Brand	$26.00	$78.00	None
MORPHINE 2 MG/ML SYRINGE	4	Non-Preferred Drug	35%	N/A	Q:1000 /30Days
MORPHINE 4 MG/ML SYRINGE	4	Non-Preferred Drug	35%	N/A	Q:500 /30Days
MORPHINE SULF 10 MG/5 ML Solution [MSIR]	4	Non-Preferred Drug	35%	N/A	Q:900 /30Days
MORPHINE SULF 20 MG/5 ML Solution [MSIR]	4	Non-Preferred Drug	35%	N/A	Q:900 /30Days
MORPHINE SULF ER 100 MG TABLET	3	Preferred Brand	$26.00	$78.00	P Q:120 /30Days
MORPHINE SULF ER 15 MG TABLET	3	Preferred Brand	$26.00	$78.00	P Q:120 /30Days
MORPHINE SULF ER 200 MG TABLET	3	Preferred Brand	$26.00	$78.00	P Q:120 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
MORPHINE SULF ER 30 MG TABLET	3	Preferred Brand	$26.00	$78.00	P Q:120 /30Days
MORPHINE SULF ER 60 MG TABLET	3	Preferred Brand	$26.00	$78.00	P Q:120 /30Days
MORPHINE SULFATE 100 mg/5 ml soln	4	Non-Preferred Drug	35%	N/A	Q:900 /30Days
MORPHINE SULFATE 15MG TABLETS	2	Generic	$3.00	$6.00	Q:180 /30Days
MORPHINE SULFATE 30MG TABLETS	2	Generic	$3.00	$6.00	Q:180 /30Days
MOVIPREP 7.5-2.691G POWDER IN PACKET	4	Non-Preferred Drug	35%	N/A	None
MOXIFLOXACIN 0.5% EYE DROPS	3	Preferred Brand	$26.00	$78.00	None
MUPIROCIN 2% OINTMENT	2	Generic	$3.00	$6.00	None
MYALEPT 11.3 MG (5 MG/ML) VIAL	5	Specialty Tier	25%	N/A	P
MYCAMINE 100MG/VIAL FOR INJECTION SOLUTION	5	Specialty Tier	25%	N/A	None
MYCAMINE 50MG VIAL	5	Specialty Tier	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
MYCOPHENOLATE 200 MG/ML SUSP	5	Specialty Tier	25%	N/A	P
MYCOPHENOLATE 250 MG CAPSULE	2	Generic	$3.00	$6.00	P
MYCOPHENOLATE 500 MG TABLET [CellCept]	2	Generic	$3.00	$6.00	P
MYCOPHENOLIC ACID DR 180 MG TB	2	Generic	$3.00	$6.00	P
MYCOPHENOLIC ACID DR 360 MG TB	3	Preferred Brand	$26.00	$78.00	P
MYRBETRIQ ER 25 MG TABLET	4	Non-Preferred Drug	35%	N/A	None
MYRBETRIQ ER 50 MG TABLET	4	Non-Preferred Drug	35%	N/A	None

Chart Legend:

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

Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region). The plan name is followed by the plan type (PDP, HMO, HMO-POS, PPO, PFFS, etc.)
Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.
Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $415 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.
Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
- Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.
- No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.
Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
- Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have five (5) tiers 1=Preferred Generics, 2=Generics, 3=Preferred Brands, 4=Non-preferred Brands, 5=Specialty Drugs. *Some Part D plans exclude one or more drug tiers from the deductible. If the drug tier field above is followed by * (example: 2*), then this drug tier is excluded from the plan’s deductible.
- Tier Description - This is the Medicare Part D plan’s description of this particular drug tier.
Cost Sharing - Copay / Coinsurance - These figures apply to the initial coverage phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
- Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $3820) at a "Preferred" network pharmacy. In most cases, the "Preferred" network pharmacy cost-sharing is lower than the standard (non-preferred) network pharmacy cost-sharing.
- Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
- None - This drug does not fall under any drug utilization management controls.
- P - Prior Authorization -This drug is subject to prior authorization.
- S - Step Therapy -This drug is subject to step therapy.
- Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.

(Chart Source: Centers for Medicare and Medicaid files: CMS Data September 2019 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Part D plan provider.