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AvMed Medicare Circle (HMO) (H1016-023-0)
Tier 1 (298)
Tier 2 (484)
Tier 3 (954)
Tier 4 (796)
Tier 5 (615)
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2019 Medicare Part D Plan Formulary Information
AvMed Medicare Circle (HMO) (H1016-023-0)
Benefit Details           
The AvMed Medicare Circle (HMO) (H1016-023-0)
Formulary Drugs Starting with the Letter M

in Miami-Dade County, FL: CMS MA Region 9 which includes: FL
Plan Monthly Premium: $0.00 Deductible: $0
Drugs Starting with Letter M

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
M-M-R II VACCINE W/DILUENT 1 DOSE/0.5ML   3 Preferred Brand $30.00$75.00None
MAGNESIUM SULFATE 50% VIAL   3 Preferred Brand $30.00$75.00None
MAGNESIUM SULFATE INJECTION 5 GM/10ML   3 Preferred Brand $30.00$75.00None
MALATHION 0.5% LOTION   4 Non-Preferred Drug $65.00$162.50None
MAPROTILINE 25MG TABLET   4 Non-Preferred Drug $65.00$162.50None
MAPROTILINE 50MG TABLET   4 Non-Preferred Drug $65.00$162.50None
MAPROTILINE 75MG TABLET   4 Non-Preferred Drug $65.00$162.50None
MARLISSA-28 TABLET   2 Generic $0.00$0.00None
MARPLAN 10MG TABLET (100 CT)   4 Non-Preferred Drug $65.00$162.50Q:180
/30Days
MATULANE 50 MG CAPSULE   5 Specialty Tier 33%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MAVYRET 100-40 MG TABLET   5 Specialty Tier 33%N/AP
MECLIZINE 12.5 MG TABLET   2 Generic $0.00$0.00None
MECLIZINE 25 MG TABLET   2 Generic $0.00$0.00None
MEDROXYPROGESTERONE 10 MG TABLET [Provera]   1 Preferred Generic $0.00$0.00None
MEDROXYPROGESTERONE 150 MG/ML Syringe [Depo-Provera]   2 Generic $0.00$0.00None
MEDROXYPROGESTERONE 150 MG/ML VIAL [Depo-Provera]   2 Generic $0.00$0.00None
MEDROXYPROGESTERONE 2.5 MG TABLET [Provera]   1 Preferred Generic $0.00$0.00None
MEDROXYPROGESTERONE 5 MG TABLET [Provera]   1 Preferred Generic $0.00$0.00None
MEFLOQUINE HCL 250 MG TABLET   3 Preferred Brand $30.00$75.00None
MEGESTROL 20 MG TABLET   3 Preferred Brand $30.00$75.00None
MEGESTROL 40 MG TABLET   3 Preferred Brand $30.00$75.00None
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 $65.00$162.50P
MEGESTROL ACET 40 MG/ML SUSP   4 Non-Preferred Drug $65.00$162.50None
MEKINIST 0.5 MG TABLET   5 Specialty Tier 33%N/AP
MEKINIST 2 MG TABLET   5 Specialty Tier 33%N/AP
MEKTOVI 15 MG TABLET   5 Specialty Tier 33%N/AP
MELOXICAM 15 MG TABLET   1 Preferred Generic $0.00$0.00None
MELOXICAM 7.5 MG TABLET   1 Preferred Generic $0.00$0.00None
MEMANTINE HCL 10 MG TABLET [Namenda]   3 Preferred Brand $30.00$75.00P
MEMANTINE HCL 2 MG/ML SOLUTION [Namenda]   4 Non-Preferred Drug $65.00$162.50P
MEMANTINE HCL 5 MG TABLET [Namenda]   3 Preferred Brand $30.00$75.00P
MEMANTINE HCL ER 14 MG CAPSULE SPR 24 [Namenda XR]   4 Non-Preferred Drug $65.00$162.50P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MEMANTINE HCL ER 21 MG CAPSULE SPR 24 [Namenda]   4 Non-Preferred Drug $65.00$162.50P
MEMANTINE HCL ER 28 MG CAPSULE SPR 24 [Namenda]   4 Non-Preferred Drug $65.00$162.50P
MEMANTINE HCL ER 7 MG CAPSULE SPR 24 [Namenda XR]   4 Non-Preferred Drug $65.00$162.50P
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 $30.00$75.00None
MENVEO A-C-Y-W-135-DIP VIAL   3 Preferred Brand $30.00$75.00None
MERCAPTOPURINE 50 MG TABLET   4 Non-Preferred Drug $65.00$162.50None
MEROPENEM 500MG/VIAL FOR INJECTION   4 Non-Preferred Drug $65.00$162.50None
MEROPENEM IV 1 GM VIAL   4 Non-Preferred Drug $65.00$162.50None
MESALAMINE 1,000 MG SUPP.RECT [Canasa]   4 Non-Preferred Drug $65.00$162.50None
MESALAMINE 4 GM/60 ML ENEMA   4 Non-Preferred Drug $65.00$162.50None
MESALAMINE 800 MG DR TABLET DR [Asacol HD]   4 Non-Preferred Drug $65.00$162.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MESALAMINE DR 400 MG CAPSULE (DRTAB) [Delzicol]   4 Non-Preferred Drug $65.00$162.50None
MESNEX 400MG TABLET   5 Specialty Tier 33%N/ANone
Metadate er 20 mg tablet   4 Non-Preferred Drug $65.00$162.50Q:90
/30Days
METFORMIN HCL 1,000 MG TABLET   1 Preferred Generic $0.00$0.00Q:75
/30Days
METFORMIN HCL 500 MG TABLET   1 Preferred Generic $0.00$0.00Q:150
/30Days
METFORMIN HCL 850 MG TABLET   1 Preferred Generic $0.00$0.00Q:90
/30Days
METFORMIN HCL ER 500 MG TABLET   1 Preferred Generic $0.00$0.00Q:120
/30Days
METFORMIN HCL ER 750 MG TABLET ER 24H [Glucophage XR]   1 Preferred Generic $0.00$0.00Q:60
/30Days
METHADONE 10 MG/5 ML SOLUTION   3 Preferred Brand $30.00$75.00P Q:450
/30Days
METHADONE 5 MG/5 ML SOLUTION   3 Preferred Brand $30.00$75.00P Q:450
/30Days
METHADONE HCL 10 MG TABLET [Methadose]   3 Preferred Brand $30.00$75.00P Q:90
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METHADONE HCL 5 MG TABLET [Methadose]   3 Preferred Brand $30.00$75.00P Q:90
/30Days
Methazolamide 25 MG Oral Tablet   4 Non-Preferred Drug $65.00$162.50None
METHAZOLAMIDE 50 MG TABLET   4 Non-Preferred Drug $65.00$162.50None
Methenamine Hippurate 1g/1   3 Preferred Brand $30.00$75.00None
METHIMAZOLE 10 MG TABLET [Tapazole]   2 Generic $0.00$0.00None
METHIMAZOLE 5 MG TABLET [Tapazole]   2 Generic $0.00$0.00None
METHOTREXATE 2.5MG TABLET   3 Preferred Brand $30.00$75.00None
METHOTREXATE 250 MG/10 ML VIAL   2 Generic $0.00$0.00P
METHOTREXATE 50 MG/2 ML VIAL   2 Generic $0.00$0.00P
METHYLPHENIDATE 10 MG TABLET [Ritalin]   3 Preferred Brand $30.00$75.00Q:180
/30Days
METHYLPHENIDATE 10 MG/5 ML SOL Solution [Methylin]   4 Non-Preferred Drug $65.00$162.50Q:900
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METHYLPHENIDATE 20 MG TABLET [Ritalin]   3 Preferred Brand $30.00$75.00Q:90
/30Days
METHYLPHENIDATE 5 MG TABLET [Ritalin]   3 Preferred Brand $30.00$75.00Q:180
/30Days
METHYLPHENIDATE 5 MG/5 ML SOLN Solution [Methylin]   4 Non-Preferred Drug $65.00$162.50Q:1800
/30Days
METHYLPHENIDATE ER 10 MG TABLET [Methylin]   4 Non-Preferred Drug $65.00$162.50Q:90
/30Days
METHYLPHENIDATE ER 20 MG TABLET [Ritalin SR]   4 Non-Preferred Drug $65.00$162.50Q:90
/30Days
METHYLPREDNISOLONE 16MG TABLET   3 Preferred Brand $30.00$75.00P
METHYLPREDNISOLONE 32MG TABLET   3 Preferred Brand $30.00$75.00P
METHYLPREDNISOLONE 4 MG DOSEPK   2 Generic $0.00$0.00None
METHYLPREDNISOLONE 4 MG TABLET   3 Preferred Brand $30.00$75.00P
METHYLPREDNISOLONE 8 MG ORAL TABLET   3 Preferred Brand $30.00$75.00P
Metoclopramide 10mg/1 500 TABLET BOTTLE   1 Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METOCLOPRAMIDE 5 MG TABLET   1 Preferred Generic $0.00$0.00None
METOCLOPRAMIDE 5 MG/5 ML SOLN   2 Generic $0.00$0.00None
METOLAZONE 10MG TABLET   3 Preferred Brand $30.00$75.00None
METOLAZONE 2.5MG TABLET   3 Preferred Brand $30.00$75.00None
METOLAZONE 5MG TABLET   3 Preferred Brand $30.00$75.00None
METOPROLOL SUCC ER 100 MG TAB   2 Generic $0.00$0.00None
METOPROLOL SUCC ER 200 MG TAB   2 Generic $0.00$0.00None
METOPROLOL SUCC ER 25 MG TAB   2 Generic $0.00$0.00None
METOPROLOL SUCC ER 50 MG TAB   2 Generic $0.00$0.00None
METOPROLOL TARTRATE 100 MG TAB   1 Preferred Generic $0.00$0.00None
METOPROLOL TARTRATE 25 MG TAB   1 Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT)   1 Preferred Generic $0.00$0.00None
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET   3 Preferred Brand $30.00$75.00None
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET   3 Preferred Brand $30.00$75.00None
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET   3 Preferred Brand $30.00$75.00None
METRONIDAZOLE 0.75% CREAM Cream (g) [Vitazol]   4 Non-Preferred Drug $65.00$162.50None
METRONIDAZOLE 0.75% LOTION [MetroLotion]   4 Non-Preferred Drug $65.00$162.50None
METRONIDAZOLE 250 MG TABLET [Flagyl]   2 Generic $0.00$0.00None
METRONIDAZOLE 500 MG TABLET [Flagyl]   2 Generic $0.00$0.00None
METRONIDAZOLE 500 MG/100 ML PIGGYBACK [Flagyl RTU]   2 Generic $0.00$0.00None
METRONIDAZOLE TOPICAL 0.75% GL Gel [Nydamax]   4 Non-Preferred Drug $65.00$162.50None
METRONIDAZOLE VAGINAL 0.75% GL GEL W/APPL [Vandazole]   4 Non-Preferred Drug $65.00$162.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MEXILETINE 150MG CAPSULE   4 Non-Preferred Drug $65.00$162.50None
MEXILETINE 200MG CAPSULE   4 Non-Preferred Drug $65.00$162.50None
MEXILETINE 250MG CAPSULE   4 Non-Preferred Drug $65.00$162.50None
Microgestin 21 1-20 tablet   2 Generic $0.00$0.00None
MICROGESTIN 21 1.5-30 TAB   2 Generic $0.00$0.00None
Microgestin fe 1-20 tablet   2 Generic $0.00$0.00None
MICROGESTIN FE 1.5-30 TAB   2 Generic $0.00$0.00None
MIDODRINE HCL 10 MG TABLET   3 Preferred Brand $30.00$75.00None
MIDODRINE HCL 2.5 MG TABLET   3 Preferred Brand $30.00$75.00None
MIDODRINE HCL 5 MG TABLET   3 Preferred Brand $30.00$75.00None
MIGLUSTAT 100 MG CAPSULE [Zavesca]   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MILI 0.25-0.035 MG TABLET [VyLibra]   2 Generic $0.00$0.00None
MINITRAN 0.1 MG/HR PATCH   3 Preferred Brand $30.00$75.00None
MINITRAN 0.2 MG/HR PATCH   3 Preferred Brand $30.00$75.00None
MINITRAN 0.4 MG/HR PATCH   3 Preferred Brand $30.00$75.00None
MINITRAN 0.6 MG/HR PATCH   3 Preferred Brand $30.00$75.00None
MINOCYCLINE 100 MG CAPSULE   3 Preferred Brand $30.00$75.00None
MINOCYCLINE 50 MG CAPSULE   3 Preferred Brand $30.00$75.00None
MINOCYCLINE 75 MG CAPSULE   3 Preferred Brand $30.00$75.00None
MINOXIDIL 10MG TABLET   2 Generic $0.00$0.00None
MINOXIDIL 2.5MG TABLET   2 Generic $0.00$0.00None
MIRTAZAPINE 15 MG ODT   3 Preferred Brand $30.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MIRTAZAPINE 15 MG TABLET [Remeron]   2 Generic $0.00$0.00None
MIRTAZAPINE 30 MG ODT   3 Preferred Brand $30.00$75.00None
MIRTAZAPINE 30 MG TABLET [Remeron]   2 Generic $0.00$0.00None
Mirtazapine 45 mg odt   3 Preferred Brand $30.00$75.00None
MIRTAZAPINE 45 MG TABLET   2 Generic $0.00$0.00None
MIRTAZAPINE 7.5 MG TABLET   2 Generic $0.00$0.00None
misoprostol 100 mcg tablet   3 Preferred Brand $30.00$75.00None
misoprostol 200 mcg tablet   3 Preferred Brand $30.00$75.00None
MITIGARE 0.6 MG CAPSULE   3 Preferred Brand $30.00$75.00Q:60
/30Days
Moexipril hcl 15 mg tablet   1 Preferred Generic $0.00$0.00None
MOEXIPRIL HCL 7.5 MG TABLET   1 Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MOLINDONE HCL 10 MG TABLET   4 Non-Preferred Drug $65.00$162.50None
MOLINDONE HCL 25 MG TABLET   4 Non-Preferred Drug $65.00$162.50None
MOLINDONE HCL 5 MG TABLET   4 Non-Preferred Drug $65.00$162.50None
MOMETASONE FUROATE 0.1% CREAM (g) [Elocon]   2 Generic $0.00$0.00None
MOMETASONE FUROATE 0.1% OINT   3 Preferred Brand $30.00$75.00None
MOMETASONE FUROATE 0.1% SOLUTION   3 Preferred Brand $30.00$75.00None
MONDOXYNE NL 100 MG CAPSULE [Monodox]   2 Generic $0.00$0.00None
MONONESSA TABLETS .250;.035MG; MG 6 X 28 CRTN   2 Generic $0.00$0.00None
MONTELUKAST SOD 10 MG TABLET [Singulair]   2 Generic $0.00$0.00None
MONTELUKAST SOD 4 MG GRANULES [Singulair]   4 Non-Preferred Drug $65.00$162.50None
MONTELUKAST SOD 4 MG TAB CHEW [Singulair]   2 Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MONTELUKAST SOD 5 MG TAB CHEW [Singulair]   2 Generic $0.00$0.00None
MORGIDOX 50 MG CAPSULE   3 Preferred Brand $30.00$75.00None
MORPHINE 10 MG/ML SYRINGE [Infumorph]   4 Non-Preferred Drug $65.00$162.50P
MORPHINE 2 MG/ML SYRINGE   4 Non-Preferred Drug $65.00$162.50P
MORPHINE 4 MG/ML SYRINGE   4 Non-Preferred Drug $65.00$162.50P
MORPHINE 5 MG/ML SYRINGE   4 Non-Preferred Drug $65.00$162.50P
MORPHINE 8 MG/ML SYRINGE [Duramorph]   4 Non-Preferred Drug $65.00$162.50P
MORPHINE SULF 10 MG/5 ML Solution [MSIR]   3 Preferred Brand $30.00$75.00Q:900
/30Days
MORPHINE SULF 20 MG/5 ML Solution [MSIR]   3 Preferred Brand $30.00$75.00Q:750
/30Days
MORPHINE SULF ER 100 MG TABLET   3 Preferred Brand $30.00$75.00P Q:90
/30Days
MORPHINE SULF ER 15 MG TABLET   3 Preferred Brand $30.00$75.00P Q:90
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MORPHINE SULF ER 200 MG TABLET   3 Preferred Brand $30.00$75.00P Q:60
/30Days
MORPHINE SULF ER 30 MG TABLET   3 Preferred Brand $30.00$75.00P Q:90
/30Days
MORPHINE SULF ER 60 MG TABLET   3 Preferred Brand $30.00$75.00P Q:90
/30Days
MORPHINE SULFATE 100 mg/5 ml soln   3 Preferred Brand $30.00$75.00Q:180
/30Days
MORPHINE SULFATE 15MG TABLETS   3 Preferred Brand $30.00$75.00Q:180
/30Days
MORPHINE SULFATE 30MG TABLETS   3 Preferred Brand $30.00$75.00Q:90
/30Days
MOVANTIK 12.5 MG TABLET   3 Preferred Brand $30.00$75.00Q:60
/30Days
MOVANTIK 25 MG TABLET   3 Preferred Brand $30.00$75.00Q:30
/30Days
MOVIPREP 7.5-2.691G POWDER IN PACKET   4 Non-Preferred Drug $65.00$162.50None
MOXEZA 5.45mg/mL 3 mL in 1 BOTTLE   3 Preferred Brand $30.00$75.00None
MOXIFLOXACIN 0.5% EYE DROPS   3 Preferred Brand $30.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Multaq 400mg/1 60 FILM COATED TABLETS in BOTTLE   4 Non-Preferred Drug $65.00$162.50None
MUPIROCIN 2% OINTMENT   2 Generic $0.00$0.00None
MYCAMINE 100MG/VIAL FOR INJECTION SOLUTION   5 Specialty Tier 33%N/ANone
MYCAMINE 50MG VIAL   5 Specialty Tier 33%N/ANone
MYCOPHENOLATE 200 MG/ML SUSP   5 Specialty Tier 33%N/AP
MYCOPHENOLATE 250 MG CAPSULE   3 Preferred Brand $30.00$75.00P
MYCOPHENOLATE 500 MG TABLET [CellCept]   3 Preferred Brand $30.00$75.00P
MYCOPHENOLIC ACID DR 180 MG TB   4 Non-Preferred Drug $65.00$162.50P
MYCOPHENOLIC ACID DR 360 MG TB   4 Non-Preferred Drug $65.00$162.50P
MYORISAN 10 MG CAPSULE   4 Non-Preferred Drug $65.00$162.50P
MYORISAN 20 MG CAPSULE   4 Non-Preferred Drug $65.00$162.50P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Myorisan 30 mg capsule   4 Non-Preferred Drug $65.00$162.50P
MYORISAN 40 MG CAPSULE   4 Non-Preferred Drug $65.00$162.50P
MYRBETRIQ ER 25 MG TABLET   4 Non-Preferred Drug $65.00$162.50Q:60
/30Days
MYRBETRIQ ER 50 MG TABLET   4 Non-Preferred Drug $65.00$162.50Q:30
/30Days

Chart Legend:

Below are a few notes to help you understand the above 2019 Medicare Part D AvMed Medicare Circle (HMO) 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.