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Humana Walmart Rx Plan (PDP) (S5884-158-0)
Tier 1 (192)
Tier 2 (620)
Tier 3 (687)
Tier 4 (1095)
Tier 5 (587)
Requires Prior Authorization:
Yes No Show either
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
Humana Walmart Rx Plan (PDP) (S5884-158-0)
Benefit Details           
The Humana Walmart Rx Plan (PDP) (S5884-158-0)
Formulary Drugs Starting with the Letter M

in CMS PDP Region 12 which includes: AL TN
Plan Monthly Premium: $28.80 Deductible: $415 Qualifies for LIS: No
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   4 Non-Preferred Drug 35%35%None
MALATHION 0.5% LOTION   4 Non-Preferred Drug 35%35%None
MAPROTILINE 25MG TABLET   4 Non-Preferred Drug 35%35%None
MAPROTILINE 50MG TABLET   4 Non-Preferred Drug 35%35%None
MAPROTILINE 75MG TABLET   4 Non-Preferred Drug 35%35%None
MARLISSA-28 TABLET   4 Non-Preferred Drug 35%35%None
MARPLAN 10MG TABLET (100 CT)   4 Non-Preferred Drug 35%35%None
MATULANE 50 MG CAPSULE   5 Specialty Tier 25%N/ANone
MAVYRET 100-40 MG TABLET   5 Specialty Tier 25%N/AP Q:84
/28Days
MECLIZINE 12.5 MG TABLET   3 Preferred Brand 20%17%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MECLIZINE 25 MG TABLET   3 Preferred Brand 20%17%None
MEDROXYPROGESTERONE 10 MG TABLET [Provera]   1* Preferred Generic $1.00$0.00None
MEDROXYPROGESTERONE 150 MG/ML Syringe [Depo-Provera]   2* Generic $4.00$8.00Q:1
/90Days
MEDROXYPROGESTERONE 150 MG/ML VIAL [Depo-Provera]   2* Generic $4.00$8.00Q:1
/90Days
MEDROXYPROGESTERONE 2.5 MG TABLET [Provera]   1* Preferred Generic $1.00$0.00None
MEDROXYPROGESTERONE 5 MG TABLET [Provera]   1* Preferred Generic $1.00$0.00None
MEFLOQUINE HCL 250 MG TABLET   2* Generic $4.00$8.00None
MEGESTROL 20 MG TABLET   1* Preferred Generic $1.00$0.00None
MEGESTROL 40 MG TABLET   2* Generic $4.00$8.00None
MEGESTROL ACET 40 MG/ML SUSP   4 Non-Preferred Drug 35%35%None
MEKINIST 0.5 MG TABLET   5 Specialty Tier 25%N/AP Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MEKINIST 2 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
MEKTOVI 15 MG TABLET   5 Specialty Tier 25%N/AP Q:180
/30Days
MELOXICAM 15 MG TABLET   1* Preferred Generic $1.00$0.00Q:30
/30Days
MELOXICAM 7.5 MG TABLET   1* Preferred Generic $1.00$0.00Q:60
/30Days
MEMANTINE 5-10 MG TITRATION PK [Namenda Titration]   2* Generic $4.00$8.00P Q:98
/30Days
MEMANTINE HCL 10 MG TABLET [Namenda]   2* Generic $4.00$8.00P Q:60
/30Days
MEMANTINE HCL 2 MG/ML SOLUTION [Namenda]   4 Non-Preferred Drug 35%35%P Q:360
/30Days
MEMANTINE HCL 5 MG TABLET [Namenda]   2* Generic $4.00$8.00P Q:60
/30Days
MEMANTINE HCL ER 14 MG CAPSULE SPR 24 [Namenda XR]   3 Preferred Brand 20%17%P Q:30
/30Days
MEMANTINE HCL ER 21 MG CAPSULE SPR 24 [Namenda]   3 Preferred Brand 20%17%P Q:30
/30Days
MEMANTINE HCL ER 28 MG CAPSULE SPR 24 [Namenda]   3 Preferred Brand 20%17%P Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MEMANTINE HCL ER 7 MG CAPSULE SPR 24 [Namenda XR]   3 Preferred Brand 20%17%P Q:30
/30Days
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   4 Non-Preferred Drug 35%35%None
MENEST 0.3MG TABLET   4 Non-Preferred Drug 35%35%None
MENEST 0.625MG TABLET   4 Non-Preferred Drug 35%35%None
MENEST 1.25MG TABLET   4 Non-Preferred Drug 35%35%None
MENVEO A-C-Y-W-135-DIP VIAL   4 Non-Preferred Drug 35%35%None
MEPERIDINE 100 MG TABLET [Meperitab]   3 Preferred Brand 20%17%Q:360
/30Days
MEPERIDINE 50 MG TABLET [Meperitab]   3 Preferred Brand 20%17%Q:480
/30Days
MEPERIDINE 50 MG/5 ML SOLUTION [Demerol]   3 Preferred Brand 20%17%Q:720
/30Days
MERCAPTOPURINE 50 MG TABLET   3 Preferred Brand 20%17%None
MEROPENEM 500MG/VIAL FOR INJECTION   4 Non-Preferred Drug 35%35%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MEROPENEM IV 1 GM VIAL   4 Non-Preferred Drug 35%35%None
MESALAMINE 4 GM/60 ML ENEMA   4 Non-Preferred Drug 35%35%Q:1800
/30Days
MESNEX 400MG TABLET   5 Specialty Tier 25%N/ANone
METAPROTERENOL 10MG TABLET   4 Non-Preferred Drug 35%35%None
METAPROTERENOL 20MG TABLET   4 Non-Preferred Drug 35%35%None
Metaproterenol Sulfate 10mg/5mL 473 mL in 1 BOTTLE, PLASTIC   4 Non-Preferred Drug 35%35%None
METFORMIN HCL 1,000 MG TABLET   1* Preferred Generic $1.00$0.00None
METFORMIN HCL 500 MG TABLET   1* Preferred Generic $1.00$0.00None
METFORMIN HCL 850 MG TABLET   1* Preferred Generic $1.00$0.00None
METFORMIN HCL ER 500 MG TABLET   1* Preferred Generic $1.00$0.00Q:120
/30Days
METFORMIN HCL ER 750 MG TABLET ER 24H [Glucophage XR]   2* Generic $4.00$8.00Q:60
/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%35%Q:1800
/30Days
METHADONE 5 MG/5 ML SOLUTION   4 Non-Preferred Drug 35%35%Q:3600
/30Days
METHADONE HCL 10 MG TABLET [Methadose]   4 Non-Preferred Drug 35%35%Q:240
/30Days
METHADONE HCL 5 MG TABLET [Methadose]   4 Non-Preferred Drug 35%35%Q:480
/30Days
Methazolamide 25 MG Oral Tablet   4 Non-Preferred Drug 35%35%None
METHAZOLAMIDE 50 MG TABLET   4 Non-Preferred Drug 35%35%None
Methenamine Hippurate 1g/1   4 Non-Preferred Drug 35%35%None
METHIMAZOLE 10 MG TABLET [Tapazole]   2* Generic $4.00$8.00None
METHIMAZOLE 5 MG TABLET [Tapazole]   2* Generic $4.00$8.00None
METHITEST 10MG TABLET   5 Specialty Tier 25%N/ANone
METHOCARBAMOL 500 MG TABLET   4 Non-Preferred Drug 35%35%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METHOCARBAMOL 750 MG TABLET   4 Non-Preferred Drug 35%35%None
METHOTREXATE 2.5MG TABLET   3 Preferred Brand 20%17%P
METHOTREXATE 250 MG/10 ML VIAL   2* Generic $4.00$8.00None
METHOTREXATE 50 MG/2 ML VIAL   2* Generic $4.00$8.00None
Methoxsalen 10 mg Capsule [8-MOP]   5 Specialty Tier 25%N/ANone
METHYLDOPA 250 MG TABLET   1* Preferred Generic $1.00$0.00None
METHYLDOPA 500 MG TABLET   3 Preferred Brand 20%17%None
METHYLDOPA-HCTZ 250-25 MG TABLETt [Aldoril]   3 Preferred Brand 20%17%None
METHYLDOPA/HCTZ 250-15 TABLET   3 Preferred Brand 20%17%None
METHYLPHENIDATE 10 MG TABLET [Ritalin]   4 Non-Preferred Drug 35%35%Q:90
/30Days
METHYLPHENIDATE 10 MG/5 ML SOL Solution [Methylin]   4 Non-Preferred Drug 35%35%Q:900
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METHYLPHENIDATE 20 MG TABLET [Ritalin]   4 Non-Preferred Drug 35%35%Q:90
/30Days
METHYLPHENIDATE 5 MG TABLET [Ritalin]   4 Non-Preferred Drug 35%35%Q:90
/30Days
METHYLPHENIDATE 5 MG/5 ML SOLN Solution [Methylin]   4 Non-Preferred Drug 35%35%Q:1800
/30Days
METHYLPHENIDATE ER 10 MG TABLET [Methylin]   4 Non-Preferred Drug 35%35%Q:180
/30Days
METHYLPHENIDATE ER 20 MG TABLET [Ritalin SR]   4 Non-Preferred Drug 35%35%Q:90
/30Days
METHYLPREDNISOLONE 16MG TABLET   2* Generic $4.00$8.00P
METHYLPREDNISOLONE 32MG TABLET   2* Generic $4.00$8.00P
METHYLPREDNISOLONE 4 MG DOSEPK   2* Generic $4.00$8.00None
METHYLPREDNISOLONE 4 MG TABLET   2* Generic $4.00$8.00P
METHYLPREDNISOLONE 8 MG ORAL TABLET   2* Generic $4.00$8.00P
METHYLTESTOSTERONE 10 MG CAP   5 Specialty Tier 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Metoclopramide 10mg/1 500 TABLET BOTTLE   1* Preferred Generic $1.00$0.00None
METOCLOPRAMIDE 5 MG TABLET   2* Generic $4.00$8.00None
METOCLOPRAMIDE 5 MG/5 ML SOLN   1* Preferred Generic $1.00$0.00None
METOPROLOL SUCC ER 100 MG TAB   2* Generic $4.00$8.00Q:60
/30Days
METOPROLOL SUCC ER 200 MG TAB   2* Generic $4.00$8.00Q:60
/30Days
METOPROLOL SUCC ER 25 MG TAB   2* Generic $4.00$8.00Q:60
/30Days
METOPROLOL SUCC ER 50 MG TAB   2* Generic $4.00$8.00Q:60
/30Days
METOPROLOL TARTRATE 100 MG TAB   1* Preferred Generic $1.00$0.00None
METOPROLOL TARTRATE 25 MG TAB   1* Preferred Generic $1.00$0.00None
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT)   1* Preferred Generic $1.00$0.00None
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET   3 Preferred Brand 20%17%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET   3 Preferred Brand 20%17%None
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET   3 Preferred Brand 20%17%None
METRONIDAZOLE 0.75% CREAM Cream (g) [Vitazol]   4 Non-Preferred Drug 35%35%None
METRONIDAZOLE 0.75% LOTION [MetroLotion]   4 Non-Preferred Drug 35%35%None
METRONIDAZOLE 250 MG TABLET [Flagyl]   2* Generic $4.00$8.00None
METRONIDAZOLE 500 MG TABLET [Flagyl]   2* Generic $4.00$8.00None
METRONIDAZOLE 500 MG/100 ML PIGGYBACK [Flagyl RTU]   4 Non-Preferred Drug 35%35%None
METRONIDAZOLE TOPICAL 0.75% GL Gel [Nydamax]   4 Non-Preferred Drug 35%35%None
METRONIDAZOLE TOPICAL 1% GEL [MetroGel]   4 Non-Preferred Drug 35%35%None
METRONIDAZOLE VAGINAL 0.75% GL GEL W/APPL [Vandazole]   4 Non-Preferred Drug 35%35%None
MICONAZOLE 3 200MG SUPPOS.   3 Preferred Brand 20%17%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Microgestin 21 1-20 tablet   4 Non-Preferred Drug 35%35%None
MICROGESTIN 21 1.5-30 TAB   4 Non-Preferred Drug 35%35%None
Microgestin fe 1-20 tablet   4 Non-Preferred Drug 35%35%None
MICROGESTIN FE 1.5-30 TAB   4 Non-Preferred Drug 35%35%None
MIDODRINE HCL 10 MG TABLET   4 Non-Preferred Drug 35%35%None
MIDODRINE HCL 2.5 MG TABLET   4 Non-Preferred Drug 35%35%None
MIDODRINE HCL 5 MG TABLET   4 Non-Preferred Drug 35%35%None
MILI 0.25-0.035 MG TABLET [VyLibra]   4 Non-Preferred Drug 35%35%None
MIMVEY 1-0.5 MG TABLET   4 Non-Preferred Drug 35%35%None
MINOCYCLINE 100 MG CAPSULE   2* Generic $4.00$8.00None
MINOCYCLINE 50 MG CAPSULE   2* Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MINOCYCLINE 75 MG CAPSULE   2* Generic $4.00$8.00None
MINOXIDIL 10MG TABLET   2* Generic $4.00$8.00None
MINOXIDIL 2.5MG TABLET   2* Generic $4.00$8.00None
MIRTAZAPINE 15 MG ODT   4 Non-Preferred Drug 35%35%Q:30
/30Days
MIRTAZAPINE 15 MG TABLET [Remeron]   2* Generic $4.00$8.00Q:30
/30Days
MIRTAZAPINE 30 MG ODT   4 Non-Preferred Drug 35%35%Q:30
/30Days
MIRTAZAPINE 30 MG TABLET [Remeron]   2* Generic $4.00$8.00Q:30
/30Days
Mirtazapine 45 mg odt   4 Non-Preferred Drug 35%35%Q:30
/30Days
MIRTAZAPINE 45 MG TABLET   2* Generic $4.00$8.00Q:30
/30Days
MIRTAZAPINE 7.5 MG TABLET   2* Generic $4.00$8.00None
misoprostol 100 mcg tablet   3 Preferred Brand 20%17%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
misoprostol 200 mcg tablet   3 Preferred Brand 20%17%None
MODAFINIL 100 MG TABLET [Provigil]   4 Non-Preferred Drug 35%35%P Q:60
/30Days
MODAFINIL 200 MG TABLET [Provigil]   4 Non-Preferred Drug 35%35%P Q:60
/30Days
Moexipril hcl 15 mg tablet   2* Generic $4.00$8.00None
MOEXIPRIL HCL 7.5 MG TABLET   2* Generic $4.00$8.00None
MOLINDONE HCL 10 MG TABLET   4 Non-Preferred Drug 35%35%P Q:240
/30Days
MOLINDONE HCL 25 MG TABLET   4 Non-Preferred Drug 35%35%P Q:270
/30Days
MOLINDONE HCL 5 MG TABLET   4 Non-Preferred Drug 35%35%P Q:360
/30Days
MOMETASONE FUROATE 0.1% CREAM (g) [Elocon]   2* Generic $4.00$8.00None
MOMETASONE FUROATE 0.1% OINT   2* Generic $4.00$8.00None
MOMETASONE FUROATE 0.1% SOLUTION   2* Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MONTELUKAST SOD 10 MG TABLET [Singulair]   2* Generic $4.00$8.00Q:30
/30Days
MONTELUKAST SOD 4 MG GRANULES [Singulair]   4 Non-Preferred Drug 35%35%Q:30
/30Days
MONTELUKAST SOD 4 MG TAB CHEW [Singulair]   2* Generic $4.00$8.00Q:30
/30Days
MONTELUKAST SOD 5 MG TAB CHEW [Singulair]   2* Generic $4.00$8.00Q:30
/30Days
MORPHINE SULF 10 MG/5 ML Solution [MSIR]   3 Preferred Brand 20%17%Q:2700
/30Days
MORPHINE SULF 20 MG/5 ML Solution [MSIR]   3 Preferred Brand 20%17%Q:1350
/30Days
MORPHINE SULF ER 100 MG TABLET   3 Preferred Brand 20%17%Q:180
/30Days
MORPHINE SULF ER 15 MG TABLET   3 Preferred Brand 20%17%Q:120
/30Days
MORPHINE SULF ER 200 MG TABLET   3 Preferred Brand 20%17%Q:90
/30Days
MORPHINE SULF ER 30 MG TABLET   3 Preferred Brand 20%17%Q:120
/30Days
MORPHINE SULF ER 60 MG TABLET   3 Preferred Brand 20%17%Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MORPHINE SULFATE 100 mg/5 ml soln   3 Preferred Brand 20%17%Q:540
/30Days
MORPHINE SULFATE 15MG TABLETS   3 Preferred Brand 20%17%Q:180
/30Days
MORPHINE SULFATE 30MG TABLETS   3 Preferred Brand 20%17%Q:180
/30Days
MOVANTIK 12.5 MG TABLET   3 Preferred Brand 20%17%Q:30
/30Days
MOVANTIK 25 MG TABLET   3 Preferred Brand 20%17%Q:30
/30Days
MOXIFLOXACIN 0.5% EYE DROPS   3 Preferred Brand 20%17%None
Multaq 400mg/1 60 FILM COATED TABLETS in BOTTLE   3 Preferred Brand 20%17%Q:60
/30Days
MUPIROCIN 2% OINTMENT   2* Generic $4.00$8.00None
MYALEPT 11.3 MG (5 MG/ML) VIAL   5 Specialty Tier 25%N/AP Q:30
/30Days
MYCOPHENOLATE 200 MG/ML SUSP   4 Non-Preferred Drug 35%35%P
MYCOPHENOLATE 250 MG CAPSULE   3 Preferred Brand 20%17%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
MYCOPHENOLATE 500 MG TABLET [CellCept]   3 Preferred Brand 20%17%P
MYCOPHENOLIC ACID DR 180 MG TB   4 Non-Preferred Drug 35%35%P
MYCOPHENOLIC ACID DR 360 MG TB   4 Non-Preferred Drug 35%35%P
MYFORTIC 180MG TABLET   4 Non-Preferred Drug 35%35%P
MYFORTIC 360MG TABLET   4 Non-Preferred Drug 35%35%P
MYORISAN 10 MG CAPSULE   4 Non-Preferred Drug 35%35%Q:60
/30Days
MYORISAN 20 MG CAPSULE   4 Non-Preferred Drug 35%35%Q:60
/30Days
Myorisan 30 mg capsule   4 Non-Preferred Drug 35%35%Q:60
/30Days
MYORISAN 40 MG CAPSULE   4 Non-Preferred Drug 35%35%Q:120
/30Days
MYRBETRIQ ER 25 MG TABLET   3 Preferred Brand 20%17%Q:30
/30Days
MYRBETRIQ ER 50 MG TABLET   3 Preferred Brand 20%17%Q:30
/30Days

Chart Legend:

Below are a few notes to help you understand the above 2019 Medicare Part D Humana Walmart Rx Plan (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.