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2020 Medicare Part D and Medicare Advantage Plan Formulary Browser

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SOLIS SPF 001 (HMO) (H0982-001-0)
Tier 1 (716)
Tier 2 (1780)
Tier 3 (465)
Tier 4 (1475)
Tier 5 (618)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
Yes No Show either
  *required
 
Cick on the first letter of your drug name to browse the formulary:

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M N O P Q R S T U V W X Y Z 0-9 
2020 Medicare Part D Plan Formulary Information
SOLIS SPF 001 (HMO) (H0982-001-0)
Benefits & Contact Info           
The SOLIS SPF 001 (HMO) (H0982-001-0)
Formulary Drugs Starting with the Letter T

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

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
TABLOID 40 MG TABLET   3 Tier 3 $0.00N/ANone
TABRECTA 150 MG TABLET   5 Tier 5 33%N/AP Q:120
/30Days
TABRECTA 200 MG TABLET   5 Tier 5 33%N/AP Q:120
/30Days
TACLONEX OINTMENT   4 Tier 4 $35.00N/AQ:420
/30Days
TACLONEX SCALP SUSPENSION   4 Tier 4 $35.00N/AQ:420
/30Days
Tacrolimus 0.03% ointment   2 Tier 2 $0.00$0.00Q:100
/30Days
Tacrolimus 0.1% ointment   2 Tier 2 $0.00$0.00Q:100
/30Days
TACROLIMUS 0.5 MG CAPSULE   1 Tier 1 $0.00$0.00P
TACROLIMUS 1 MG CAPSULE   1 Tier 1 $0.00$0.00P
TACROLIMUS 5 MG CAPSULE   1 Tier 1 $0.00$0.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TADALAFIL 20 MG TABLET [ALYQ]   1 Tier 1 $0.00$0.00P
TAFINLAR 50 MG CAPSULE   5 Tier 5 33%N/AP Q:120
/30Days
TAFINLAR 75 MG CAPSULE   5 Tier 5 33%N/AP Q:120
/30Days
TAGRISSO 40 MG TABLET   5 Tier 5 33%N/AP
TAGRISSO 80 MG TABLET   5 Tier 5 33%N/AP
TAKHZYRO 300 MG/2 ML VIAL   5 Tier 5 33%N/AP Q:4
/28Days
TALZENNA 0.25 MG CAPSULE   5 Tier 5 33%N/AP Q:90
/30Days
TALZENNA 1 MG CAPSULE   5 Tier 5 33%N/AP Q:30
/30Days
TAMIFLU 30 MG 1 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK   4 Tier 4 $35.00N/AQ:84
/180Days
TAMIFLU 45 MG 1 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK   4 Tier 4 $35.00N/AQ:42
/180Days
TAMIFLU 6 MG/ML SUSPENSION   4 Tier 4 $35.00N/AQ:540
/180Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TAMIFLU 75 MG CAPSULE UD   4 Tier 4 $35.00N/AQ:42
/180Days
TAMOXIFEN 10 MG TABLET [Nolvadex]   1 Tier 1 $0.00$0.00None
TAMOXIFEN 20 MG TABLET [Nolvadex]   1 Tier 1 $0.00$0.00None
TAMSULOSIN HCL 0.4 MG CAPSULE   1 Tier 1 $0.00$0.00None
TAPAZOLE 10MG TABLET   4 Tier 4 $35.00N/ANone
TAPAZOLE 5MG TABLET   4 Tier 4 $35.00N/ANone
TARCEVA 100MG TABLET   5 Tier 5 33%N/AP
TARCEVA 150MG TABLET   5 Tier 5 33%N/AP
TARCEVA 25MG TABLET   5 Tier 5 33%N/AP
TARGRETIN 1% GEL   5 Tier 5 33%N/AP
TARGRETIN 75 MG CAPSULE   5 Tier 5 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TARINA 24 FE 1 MG-20 MCG TABLET   2 Tier 2 $0.00$0.00None
Tarina Fe 1-20 tablet   2 Tier 2 $0.00$0.00None
Tarka 2; 240mg/1; mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE   4 Tier 4 $35.00N/ANone
TARKA 2/180MG TABLET SA   4 Tier 4 $35.00N/ANone
Tarka 4; 240mg/1; mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE   4 Tier 4 $35.00N/ANone
Tasigna 150mg/1 4 BLISTER PACK per CARTON / 28 CAPSULE per BLISTER PACK   5 Tier 5 33%N/AP
TASIGNA 200 MG CAPSULE   5 Tier 5 33%N/AP
TASIGNA 50 MG CAPSULE   5 Tier 5 33%N/AP
TASMAR 100MG TABLET   4 Tier 4 $35.00N/ANone
TAVALISSE 100 MG TABLET   5 Tier 5 33%N/AP Q:60
/30Days
TAVALISSE 150 MG TABLET   5 Tier 5 33%N/AP Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TAZAROTENE 0.1% CREAM [Tazorac]   2 Tier 2 $0.00$0.00None
TAZICEF 1GM VIAL   2 Tier 2 $0.00$0.00None
TAZICEF 2 GRAM VIAL   2 Tier 2 $0.00$0.00None
TAZICEF 6 GRAM VIAL   2 Tier 2 $0.00$0.00None
TAZORAC 0.05% CREAM (G)   4 Tier 4 $35.00N/ANone
TAZORAC 0.05% GEL   4 Tier 4 $35.00N/ANone
TAZORAC 0.1% CREAM   4 Tier 4 $35.00N/ANone
TAZORAC 0.1% GEL   4 Tier 4 $35.00N/ANone
TAZTIA XT 120 MG CAPSULE SA 24H [Tiazac]   2 Tier 2 $0.00$0.00None
TAZTIA XT 180 MG CAPSULE   2 Tier 2 $0.00$0.00None
TAZTIA XT 240 MG CAPSULE SA 24H [Tiazac]   2 Tier 2 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TAZTIA XT 300 MG CAPSULE   2 Tier 2 $0.00$0.00None
TAZTIA XT 360 MG CAPSULE SA 24H [Tiazac]   2 Tier 2 $0.00$0.00None
TAZVERIK 200 MG TABLET   5 Tier 5 33%N/AP Q:240
/30Days
TDVAX VIAL   3 Tier 3 $0.00N/AP
TECFIDERA DR 120 MG CAPSULE   5 Tier 5 33%N/ANone
TECFIDERA DR 240 MG CAPSULE   5 Tier 5 33%N/ANone
TECFIDERA STARTER PACK   5 Tier 5 33%N/ANone
Teflaro 400mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE   5 Tier 5 33%N/ANone
Teflaro 600mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE   5 Tier 5 33%N/ANone
TEGRETOL SUSPENSION 100MG/5ML 450 ML BOT   4 Tier 4 $35.00N/ANone
TEGRETOL TABLETS 200MG 100 BOT   4 Tier 4 $35.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TEGRETOL XR TABLETS 100MG 100 BOT   4 Tier 4 $35.00N/ANone
TEGRETOL XR TABLETS 200MG 100 BOT   4 Tier 4 $35.00N/ANone
TEGRETOL XR TABLETS 400MG 100 BOT   4 Tier 4 $35.00N/ANone
TEGSEDI 284 MG/1.5 ML SYRINGE   5 Tier 5 33%N/AP Q:6
/28Days
TEKTURNA 150 MG TABLET   4 Tier 4 $35.00N/ANone
TEKTURNA 300 MG TABLET   4 Tier 4 $35.00N/ANone
TEKTURNA HCT 300-25 MG TABLET   4 Tier 4 $35.00N/ANone
TELMISARTAN 20 MG TABLET [Micardis]   2 Tier 2 $0.00$0.00None
TELMISARTAN 40 MG TABLET [Micardis]   2 Tier 2 $0.00$0.00None
TELMISARTAN 80 MG TABLET [Micardis]   2 Tier 2 $0.00$0.00None
Telmisartan-Amlodipine 40-10 MG [Micardis]   2 Tier 2 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Telmisartan-Amlodipine 40-5 MG [Micardis]   2 Tier 2 $0.00$0.00None
Telmisartan-Amlodipine 80-10 MG [Micardis]   2 Tier 2 $0.00$0.00None
Telmisartan-Amlodipine 80-5 MG [Micardis]   2 Tier 2 $0.00$0.00None
TELMISARTAN-HCTZ 40-12.5 MG TABLET [Micardis HCT]   2 Tier 2 $0.00$0.00None
TELMISARTAN-HCTZ 80-12.5 MG TABLET [Micardis HCT]   2 Tier 2 $0.00$0.00None
TELMISARTAN-HCTZ 80-25 MG TABLET [Micardis HCT]   2 Tier 2 $0.00$0.00None
TEMAZEPAM 15 MG CAPSULE [Restoril]   1 Tier 1 $0.00$0.00None
TEMAZEPAM 22.5 MG CAPSULE   2 Tier 2 $0.00$0.00None
TEMAZEPAM 30 MG CAPSULE   1 Tier 1 $0.00$0.00None
Temazepam 7.5mg/1 100 CAPSULE BOTTLE, PLASTIC   2 Tier 2 $0.00$0.00None
TENIVAC SYRINGE   3 Tier 3 $0.00N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TENOFOVIR DISOP FUM 300 MG TABLET [Viread]   2 Tier 2 $0.00$0.00None
TENORETIC 100 TABLET   4 Tier 4 $35.00N/ANone
TENORETIC 50 TABLET   4 Tier 4 $35.00N/ANone
TENORMIN 100 MG TABLET   4 Tier 4 $35.00N/ANone
TENORMIN 25 MG TABLET   4 Tier 4 $35.00N/ANone
TENORMIN 50 MG TABLET   4 Tier 4 $35.00N/ANone
TERAZOSIN 1 MG CAPSULE   1 Tier 1 $0.00$0.00None
TERAZOSIN 10 MG CAPSULE [Hytrin]   1 Tier 1 $0.00$0.00None
TERAZOSIN 2 MG CAPSULE   1 Tier 1 $0.00$0.00None
TERAZOSIN 5 MG CAPSULE [Hytrin]   1 Tier 1 $0.00$0.00None
TERBINAFINE HCL 250 MG TABLET [Terbinex]   1 Tier 1 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TERBUTALINE SULFATE 2.5 MG TAB   2 Tier 2 $0.00$0.00None
TERBUTALINE SULFATE 5MG TABLET   2 Tier 2 $0.00$0.00None
TERCONAZOLE 0.4% CREAM WITH APPLICATOR   2 Tier 2 $0.00$0.00None
TERCONAZOLE 0.8% CREAM   2 Tier 2 $0.00$0.00None
TERCONAZOLE 80MG SUPPOSITORY VAGINAL   2 Tier 2 $0.00$0.00None
TESTIM 1%(50MG) GEL   4 Tier 4 $35.00N/AP Q:300
/30Days
TESTOSTERON CYP 2,000 MG/10 ML VIAL [Virilon]   2 Tier 2 $0.00$0.00None
TESTOSTERON ENAN 1,000 MG/5 ML VIAL [Delatestryl]   2 Tier 2 $0.00$0.00None
TESTOSTERONE 1.62% (2.5 G) PKT GEL PACKET [AndroGel]   2 Tier 2 $0.00$0.00P Q:150
/30Days
TESTOSTERONE 1.62% GEL PUMP GEL MD PMP [AndroGel]   2 Tier 2 $0.00$0.00P Q:150
/30Days
TESTOSTERONE 1.62%(1.25 G) GEL PACKET [AndroGel]   2 Tier 2 $0.00$0.00P Q:75
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TESTOSTERONE 12.5 MG/1.25 GRAM GEL MD PMP [Vogelxo]   2 Tier 2 $0.00$0.00P Q:300
/30Days
TESTOSTERONE 25 MG/2.5 GM GEL PACKET [Vogelxo]   2 Tier 2 $0.00$0.00P Q:300
/30Days
TESTOSTERONE 50 MG/5 GRAM GEL PACKET [Vogelxo]   2 Tier 2 $0.00$0.00P Q:300
/30Days
Testosterone cyp 100 mg/ml   2 Tier 2 $0.00$0.00None
TESTOSTERONE CYP 200 MG/ML   2 Tier 2 $0.00$0.00None
TETRABENAZINE 12.5 MG TABLET [XENAZINE]   5 Tier 5 33%N/AP
TETRABENAZINE 25 MG TABLET [XENAZINE]   5 Tier 5 33%N/AP
TETRACYCLINE 250 MG CAPSULE   4 Tier 4 $35.00N/ANone
TETRACYCLINE 500 MG CAPSULE   4 Tier 4 $35.00N/ANone
THALOMID 100 MG CAPSULE   5 Tier 5 33%N/AP
THALOMID 150 MG CAPSULE   5 Tier 5 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
THALOMID 200 MG CAPSULE   5 Tier 5 33%N/AP
THALOMID 50 MG CAPSULE   5 Tier 5 33%N/AP
THEO-24 ER 100 MG CAPSULE   4 Tier 4 $35.00N/ANone
THEO-24 ER 200 MG CAPSULE   4 Tier 4 $35.00N/ANone
THEO-24 ER 300 MG CAPSULE   4 Tier 4 $35.00N/ANone
THEO-24 ER 400 MG CAPSULE   4 Tier 4 $35.00N/ANone
THEOPHYLLINE 80 MG/15 ML SOLN   2 Tier 2 $0.00$0.00None
THEOPHYLLINE ER 300 MG TAB   1 Tier 1 $0.00$0.00None
THEOPHYLLINE ER 400 MG TABLET   1 Tier 1 $0.00$0.00None
THEOPHYLLINE ER 600 MG TABLET   1 Tier 1 $0.00$0.00None
THIOLA 100 MG TABLET   4 Tier 4 $35.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
THIOLA EC 100 MG TABLET DR   4 Tier 4 $35.00N/ANone
THIOLA EC 300 MG TABLET DR   4 Tier 4 $35.00N/ANone
THIORIDAZINE 10 MG TABLET   2 Tier 2 $0.00$0.00None
THIORIDAZINE 100MG TABLET   2 Tier 2 $0.00$0.00None
THIORIDAZINE 25 MG TABLET   2 Tier 2 $0.00$0.00None
THIORIDAZINE 50 MG TABLET   2 Tier 2 $0.00$0.00None
THIOTHIXENE 1 MG CAPSULE   2 Tier 2 $0.00$0.00None
THIOTHIXENE 10MG CAPSULE   2 Tier 2 $0.00$0.00None
THIOTHIXENE 2MG CAPSULE   2 Tier 2 $0.00$0.00None
THIOTHIXENE 5MG CAPSULE   2 Tier 2 $0.00$0.00None
TIADYLT ER 120 MG CAPSULE SA 24H [Tiazac]   2 Tier 2 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TIADYLT ER 180 MG CAPSULE SA 24H [Tiazac]   2 Tier 2 $0.00$0.00None
TIADYLT ER 240 MG CAPSULE SA 24H [Tiazac]   2 Tier 2 $0.00$0.00None
TIADYLT ER 300 MG CAPSULE SA 24H [Tiazac]   2 Tier 2 $0.00$0.00None
TIADYLT ER 360 MG CAPSULE SA 24H [Tiazac]   2 Tier 2 $0.00$0.00None
TIADYLT ER 420 MG CAPSULE SA 24H [Tiazac]   2 Tier 2 $0.00$0.00None
TIAGABINE HCL 12 MG TABLET [Gabitril]   2 Tier 2 $0.00$0.00None
TIAGABINE HCL 16 MG TABLET [Gabitril]   2 Tier 2 $0.00$0.00None
TIAGABINE HCL 2 MG TABLET [Gabitril]   2 Tier 2 $0.00$0.00None
TIAGABINE HCL 4 MG TABLET [Gabitril]   2 Tier 2 $0.00$0.00None
TIAZAC ER 120 MG CAPSULE   4 Tier 4 $35.00N/ANone
TIAZAC ER 180 MG CAPSULE   4 Tier 4 $35.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TIAZAC ER 240 MG CAPSULE   4 Tier 4 $35.00N/ANone
TIAZAC ER 300 MG CAPSULE SA 24H   4 Tier 4 $35.00N/ANone
TIAZAC ER 360 MG CAPSULE SA 24H   4 Tier 4 $35.00N/ANone
TIAZAC ER 420 MG CAPSULE SA 24H   4 Tier 4 $35.00N/ANone
TIBSOVO 250 MG TABLET   5 Tier 5 33%N/AP Q:60
/30Days
TIGAN 300MG CAPSULE   4 Tier 4 $35.00N/ANone
TIGECYCLINE 50 MG VIAL [Tygacil]   5 Tier 5 33%N/ANone
TIKOSYN .125MG CAPSULE   4 Tier 4 $35.00N/ANone
TIKOSYN .250MG CAPSULE   4 Tier 4 $35.00N/ANone
TIKOSYN .5MG CAPSULE   4 Tier 4 $35.00N/ANone
TIMOLOL 0.25% EYE DROPS   1 Tier 1 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TIMOLOL 0.25% GFS GEL-SOLUTION   3 Tier 3 $0.00N/ANone
TIMOLOL 0.5% EYE DROPS   2 Tier 2 $0.00$0.00None
TIMOLOL 0.5% EYE DROPS   1 Tier 1 $0.00$0.00None
TIMOLOL 0.5% GFS GEL-SOLUTION   3 Tier 3 $0.00N/ANone
TIMOLOL MALEATE 10MG TABLET   2 Tier 2 $0.00$0.00None
TIMOLOL MALEATE 20MG TABLET   2 Tier 2 $0.00$0.00None
TIMOLOL MALEATE 5MG TABLET   2 Tier 2 $0.00$0.00None
TIMOPTIC 0.25% OCUDOSE DROP   4 Tier 4 $35.00N/ANone
TIMOPTIC 0.5% OCUDOSE DROP   4 Tier 4 $35.00N/ANone
TIMOPTIC-XE 0.25% EYE GEL-SOLUTION SOL-GEL   3 Tier 3 $0.00N/ANone
TIMOPTIC-XE 0.5% GEL-SOLUTION SOL-GEL   3 Tier 3 $0.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TINIDAZOLE 250 MG TABLET   2 Tier 2 $0.00$0.00None
TINIDAZOLE 500 MG TABLET   2 Tier 2 $0.00$0.00None
TIVICAY 10 MG TABLET   4 Tier 4 $35.00N/ANone
TIVICAY 25 MG TABLET   4 Tier 4 $35.00N/ANone
TIVICAY 50 MG TABLET   5 Tier 5 33%N/ANone
TIZANIDINE HCL 2 MG CAPSULE   2 Tier 2 $0.00$0.00None
TIZANIDINE HCL 2 MG TABLET   2 Tier 2 $0.00$0.00None
TIZANIDINE HCL 4 MG CAPSULE   2 Tier 2 $0.00$0.00None
TIZANIDINE HCL 4 MG TABLET   2 Tier 2 $0.00$0.00None
TIZANIDINE HCL 6 MG CAPSULE   2 Tier 2 $0.00$0.00None
TOBI PODHALER 28 MG INHALE CAP   5 Tier 5 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TOBRADEX EYE OINTMENT   3 Tier 3 $0.00N/ANone
TOBRADEX ST 0.5; 3mg/mL; mg/mL 5 mL in 1 BOTTLE   4 Tier 4 $35.00N/ANone
TOBRADEX SUSPENSION OPHTHALMIC 0.1%/0.3% 5ML BOT   4 Tier 4 $35.00N/ANone
TOBRAMYCIN 0.3% EYE DROPS [Tobrex]   2 Tier 2 $0.00$0.00None
TOBRAMYCIN 10 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate]   2 Tier 2 $0.00$0.00None
TOBRAMYCIN 300 MG/5 ML AMPULE [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate]   5 Tier 5 33%N/AP
TOBRAMYCIN 40 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate]   2 Tier 2 $0.00$0.00None
TOBRAMYCIN-DEXAMETH OPTH SUSP   2 Tier 2 $0.00$0.00None
TOBREX 0.3% EYE DROPS   4 Tier 4 $35.00N/ANone
TOBREX 0.3% EYE OINTMENT   4 Tier 4 $35.00N/ANone
TOLAK 4% CREAM   4 Tier 4 $35.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TOLCAPONE 100 MG TABLET [Tasmar]   2 Tier 2 $0.00$0.00None
TOLMETIN SODIUM 400 MG CAP   4 Tier 4 $35.00N/ANone
TOLMETIN SODIUM 600MG TABLET   4 Tier 4 $35.00N/ANone
TOLTERODINE TART ER 2 MG CAPSULE ER 24H [Detrol LA]   2 Tier 2 $0.00$0.00None
TOLTERODINE TART ER 4 MG CAPSULE ER 24H [Detrol LA]   2 Tier 2 $0.00$0.00None
TOLTERODINE TARTRATE 1 MG TABLET [Detrol LA]   2 Tier 2 $0.00$0.00None
TOLTERODINE TARTRATE 2 MG TABLET [Detrol]   2 Tier 2 $0.00$0.00None
TOPAMAX 15 MG SPRINKLE CAP   4 Tier 4 $35.00N/ANone
TOPAMAX 25 MG SPRINKLE CAP   4 Tier 4 $35.00N/ANone
TOPAMAX TABLETS 100MG 60 BOT   4 Tier 4 $35.00N/ANone
TOPAMAX TABLETS 200MG 60 BOT   4 Tier 4 $35.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TOPAMAX TABLETS 25MG 60 BOT   4 Tier 4 $35.00N/ANone
TOPAMAX TABLETS 50MG 60 BOT   4 Tier 4 $35.00N/ANone
Topicort 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE   4 Tier 4 $35.00N/AP
Topicort 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE   4 Tier 4 $35.00N/ANone
Topicort 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE   4 Tier 4 $35.00N/AP
Topicort 2.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE   4 Tier 4 $35.00N/AP
Topicort 2.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE   4 Tier 4 $35.00N/ANone
TOPIRAMATE 100 MG TABLET   1 Tier 1 $0.00$0.00None
TOPIRAMATE 15 MG SPRINKLE CAP   2 Tier 2 $0.00$0.00None
TOPIRAMATE 200 MG TABLET [Topiragen]   1 Tier 1 $0.00$0.00None
TOPIRAMATE 25 MG TABLET   1 Tier 1 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Topiramate 25mg/1   2 Tier 2 $0.00$0.00None
TOPIRAMATE 50 MG TABLET [Topiragen]   1 Tier 1 $0.00$0.00None
TOPIRAMATE ER 100 MG CAPSULE   4 Tier 4 $35.00N/AP
TOPIRAMATE ER 150 MG CAPSULE   4 Tier 4 $35.00N/AP
TOPIRAMATE ER 200 MG CAPSULE   4 Tier 4 $35.00N/AP
TOPIRAMATE ER 25 MG CAPSULE   4 Tier 4 $35.00N/AP
TOPIRAMATE ER 50 MG CAPSULE   4 Tier 4 $35.00N/AP
TOPROL XL 100 MG TABLET ER 24H   4 Tier 4 $35.00N/ANone
TOPROL XL 200 MG TABLET ER 24H   4 Tier 4 $35.00N/ANone
TOPROL XL 25 MG TABLET ER 24H   4 Tier 4 $35.00N/ANone
TOPROL XL 50 MG TABLET ER 24H   4 Tier 4 $35.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TOREMIFENE CITRATE 60 MG TABLET [Fareston]   2 Tier 2 $0.00$0.00None
TORSEMIDE 10 MG TABLET   1 Tier 1 $0.00$0.00None
TORSEMIDE 100 MG TABLET   1 Tier 1 $0.00$0.00None
TORSEMIDE 20 MG TABLET   1 Tier 1 $0.00$0.00None
TORSEMIDE 5 MG TABLET [Demadex]   1 Tier 1 $0.00$0.00None
TOUJEO MAX SOLOSTAR 300UNIT/ML INSULN PEN   3 Tier 3 $0.00N/ANone
TOUJEO SOLOSTAR 300 UNITS/ML   3 Tier 3 $0.00N/ANone
TOVET EMOLLIENT 0.05% FOAM [Olux-E]   2 Tier 2 $0.00$0.00P
TPN ELECTROLYTES16.5/25.4 VIAL   2 Tier 2 $0.00$0.00P
TRACLEER 125MG TABLET   5 Tier 5 33%N/AP Q:60
/30Days
TRACLEER 32 MG TABLET FOR SUSP   5 Tier 5 33%N/AP Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRACLEER 62.5MG TABLET   5 Tier 5 33%N/AP Q:60
/30Days
TRADJENTA 5 MG TABLET   3 Tier 3 $0.00N/AQ:30
/30Days
TRAMADOL ER 100 MG TABLET   2 Tier 2 $0.00$0.00Q:60
/30Days
TRAMADOL ER 200 MG TABLET   2 Tier 2 $0.00$0.00Q:60
/30Days
TRAMADOL ER 300 MG TABLET TBMP 24HR [Ultram ER]   2 Tier 2 $0.00$0.00Q:60
/30Days
TRAMADOL HCL 50 MG TABLET   2 Tier 2 $0.00$0.00Q:240
/30Days
TRAMADOL HCL ER 100 MG TABLET   2 Tier 2 $0.00$0.00Q:60
/30Days
TRAMADOL HCL ER 200 MG TABLET   2 Tier 2 $0.00$0.00Q:60
/30Days
TRAMADOL HCL ER 300 MG Tablet ER 24H [Ultram ER]   2 Tier 2 $0.00$0.00Q:60
/30Days
TRAMADOL-ACETAMINOPHN 37.5-325   2 Tier 2 $0.00$0.00Q:360
/30Days
TRANDOLAPRIL 1 MG TABLET   1 Tier 1 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRANDOLAPRIL 2 MG TABLET   1 Tier 1 $0.00$0.00None
TRANDOLAPRIL 4 MG TABLET   1 Tier 1 $0.00$0.00None
TRANDOLAPRIL-VERAPAMIL ER 1-240 MG   2 Tier 2 $0.00$0.00None
TRANDOLAPRIL-VERAPAMIL ER 2-180 MG   2 Tier 2 $0.00$0.00None
TRANDOLAPRIL-VERAPAMIL ER 2-240 MG   2 Tier 2 $0.00$0.00None
TRANDOLAPRIL-VERAPAMIL ER 4-240 MG   2 Tier 2 $0.00$0.00None
TRANEXAMIC ACID 650 MG TABLET [Lysteda]   2 Tier 2 $0.00$0.00None
TRANSDERM-SCOP 1.5 MG/3 DAY   4 Tier 4 $35.00N/ANone
TRANXENE T-TAB 7.5 MG   4 Tier 4 $35.00N/ANone
TRANYLCYPROMINE SULF 10 MG TABLET [Parnate]   2 Tier 2 $0.00$0.00None
TRAVASOL 10% SOLUTION VIAFLEX   4 Tier 4 $35.00N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRAVATAN Z 0.04MG DROPS 2.5ML BOT   3 Tier 3 $0.00N/AQ:5
/30Days
TRAVOPROST 0.004% EYE DROPS [Travatan]   2 Tier 2 $0.00$0.00Q:5
/30Days
TRAZODONE 100 MG TABLET   1 Tier 1 $0.00$0.00None
TRAZODONE 150 MG TABLET [Desyrel]   1 Tier 1 $0.00$0.00None
TRAZODONE 300 MG TABLET [Desyrel]   2 Tier 2 $0.00$0.00None
TRAZODONE 50 MG TABLET   1 Tier 1 $0.00$0.00None
TRECATOR 250MG TABLET   4 Tier 4 $35.00N/ANone
TRELEGY ELLIPTA 100-62.5-25   3 Tier 3 $0.00N/AQ:60
/30Days
TRELSTAR 11.25 MG SYRINGE   5 Tier 5 33%N/ANone
TRELSTAR 3.75 MG SYRINGE   5 Tier 5 33%N/ANone
TRESIBA 100 UNIT/ML VIAL   3 Tier 3 $0.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRESIBA FLEXTOUCH 100 UNITS/ML   3 Tier 3 $0.00N/ANone
TRESIBA FLEXTOUCH 200 UNITS/ML   3 Tier 3 $0.00N/ANone
Tretinoin 0.0004 MG/MG Topical Gel   2 Tier 2 $0.00$0.00P
Tretinoin 0.001 MG/MG Topical Gel   2 Tier 2 $0.00$0.00P
TRETINOIN 0.01% GEL [Tretin-X]   2 Tier 2 $0.00$0.00P
TRETINOIN 0.025% CREAM   2 Tier 2 $0.00$0.00P
TRETINOIN 0.025% GEL [Tretin-X]   2 Tier 2 $0.00$0.00P
TRETINOIN 0.05% CREAM   2 Tier 2 $0.00$0.00P
TRETINOIN 0.05% GEL [Atralin]   2 Tier 2 $0.00$0.00P
TRETINOIN 0.1% CREAM   2 Tier 2 $0.00$0.00P
Tretinoin 0.25 MG/ML Topical Cream [Retin-A]   4 Tier 4 $35.00N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Tretinoin 0.5 MG/ML Topical Cream [Retin-A]   4 Tier 4 $35.00N/AP
TRETINOIN 10MG CAPSULE   1 Tier 1 $0.00$0.00None
TREXALL 10MG TABLET   3 Tier 3 $0.00N/ANone
TREXALL 15MG TABLET   3 Tier 3 $0.00N/ANone
TREXALL 5MG TABLET   3 Tier 3 $0.00N/ANone
TREXALL 7.5MG TABLET   3 Tier 3 $0.00N/ANone
TRI-ESTARYLLA TABLET [Trinessa]   2 Tier 2 $0.00$0.00None
TRI-LEGEST FE 5-7-9-7 TABLET   2 Tier 2 $0.00$0.00None
TRI-LO-ESTARYLLA TABLET [Trinessa Lo]   2 Tier 2 $0.00$0.00None
TRI-LO-SPRINTEC TABLET   2 Tier 2 $0.00$0.00None
TRI-MILI 28 TABLET [Trinessa]   2 Tier 2 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRI-PREVIFEM TABLET [Trinessa]   2 Tier 2 $0.00$0.00None
TRI-SPRINTEC 7DAYSX3 28 TABLET   2 Tier 2 $0.00$0.00None
TRI-VYLIBRA 28 TABLET [Trinessa]   2 Tier 2 $0.00$0.00None
TRI-VYLIBRA LO TABLET [Trinessa Lo]   2 Tier 2 $0.00$0.00None
TRIAMCINOLONE 0.025% CREAM   2 Tier 2 $0.00$0.00None
TRIAMCINOLONE 0.025% LOTION   2 Tier 2 $0.00$0.00None
TRIAMCINOLONE 0.025% OINT   2 Tier 2 $0.00$0.00None
TRIAMCINOLONE 0.1% CREAM (g) [Triderm]   2 Tier 2 $0.00$0.00None
TRIAMCINOLONE 0.1% LOTION [Kenalog]   2 Tier 2 $0.00$0.00None
TRIAMCINOLONE 0.1% OINTMENT [Triderm]   2 Tier 2 $0.00$0.00None
TRIAMCINOLONE 0.1% PASTE (G) [Oralone]   2 Tier 2 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Triamcinolone 0.147 MG/G Spray   2 Tier 2 $0.00$0.00None
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE   2 Tier 2 $0.00$0.00None
Triamcinolone Acetonide 1 MG/ML Topical Cream [Triderm]   2 Tier 2 $0.00$0.00None
Triamcinolone Acetonide 5mg/g 1 TUBE per CARTON / 15 g in 1 TUBE   2 Tier 2 $0.00$0.00None
TRIAMTERENE 100 MG CAPSULE [Dyrenium]   2 Tier 2 $0.00$0.00None
TRIAMTERENE 50 MG CAPSULE [Dyrenium]   2 Tier 2 $0.00$0.00None
TRIAMTERENE-HCTZ 37.5-25 MG CAPSULE [Dyazide]   1 Tier 1 $0.00$0.00None
TRIAMTERENE-HCTZ 37.5-25 MG TB   1 Tier 1 $0.00$0.00None
TRIAMTERENE-HCTZ 75-50 MG TAB   1 Tier 1 $0.00$0.00None
TRIAZOLAM 0.125 MG TABLET [Halcion]   2 Tier 2 $0.00$0.00None
TRIAZOLAM 0.25 MG TABLET [Halcion]   2 Tier 2 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRICOR 145 MG TABLET   4 Tier 4 $35.00N/ANone
TRICOR 48 MG TABLET   4 Tier 4 $35.00N/ANone
TRIDESILON 0.05% CREAM   4 Tier 4 $35.00N/AP
TRIENTINE HCL 250 MG CAPSULE [Syprine]   2 Tier 2 $0.00$0.00P
TRIFLUOPERAZINE 1 MG TABLET   2 Tier 2 $0.00$0.00None
TRIFLUOPERAZINE HCL 2MG TABLET   2 Tier 2 $0.00$0.00None
TRIFLUOPERAZINE HCL 5MG TABLET   2 Tier 2 $0.00$0.00None
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT)   2 Tier 2 $0.00$0.00None
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT   2 Tier 2 $0.00$0.00None
TRIGLIDE 160 MG TABLET   4 Tier 4 $35.00N/ANone
TRIHEXYPHENIDYL 2 MG TABLET   1 Tier 1 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRIHEXYPHENIDYL 5 MG TABLET [Artane]   1 Tier 1 $0.00$0.00None
Trihexyphenidyl Hydrochloride 2mg/5mL 473 mL in 1 BOTTLE   2 Tier 2 $0.00$0.00None
TRIJARDY XR 10-5-1,000 MG TABLET BP 24H   3 Tier 3 $0.00N/AQ:30
/30Days
TRIJARDY XR 12.5-2.5-1,000 MG TAB BP 24H   3 Tier 3 $0.00N/AQ:60
/30Days
TRIJARDY XR 25-5-1,000 MG TABLET BP 24H   3 Tier 3 $0.00N/AQ:30
/30Days
TRIJARDY XR 5-2.5-1,000 MG TABLET BP 24H   3 Tier 3 $0.00N/AQ:60
/30Days
TRIKAFTA 100/50/75 MG-150 MG TABLET SEQ   5 Tier 5 33%N/AP Q:90
/30Days
TRILEPTAL 150MG TABLET   4 Tier 4 $35.00N/ANone
TRILEPTAL 300MG TABLET   4 Tier 4 $35.00N/ANone
TRILEPTAL 300MG/5ML SUSP   4 Tier 4 $35.00N/ANone
TRILEPTAL 600MG TABLET   4 Tier 4 $35.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRILIPIX DR 135 MG CAPSULE   4 Tier 4 $35.00N/ANone
TRILIPIX DR 45 MG CAPSULE   4 Tier 4 $35.00N/ANone
TRILYTE WITH FLAVOR PACKETS   1 Tier 1 $0.00$0.00None
TRIMETHOBENZAMIDE 300 MG CAP   2 Tier 2 $0.00$0.00None
TRIMETHOPRIM 100 MG TABLET   1 Tier 1 $0.00$0.00None
TRIMIPRAMINE MALEATE 100 MG CP   2 Tier 2 $0.00$0.00P
TRIMIPRAMINE MALEATE 25 MG CAP   2 Tier 2 $0.00$0.00P
TRIMIPRAMINE MALEATE 50 MG CAP   2 Tier 2 $0.00$0.00P
TRINTELLIX 10 MG TABLET   3 Tier 3 $0.00N/AS Q:30
/30Days
TRINTELLIX 20 MG TABLET   3 Tier 3 $0.00N/AS Q:30
/30Days
TRINTELLIX 5 MG TABLET   3 Tier 3 $0.00N/AS Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Triptorelin 11.3 MG/ML Injectable Suspension [Trelstar]   5 Tier 5 33%N/ANone
TRIUMEQ TABLET   5 Tier 5 33%N/ANone
TRIVORA-28 TABLET [Trivora]   2 Tier 2 $0.00$0.00None
TRIZIVIR 300; 150; 300mg/1; mg/1; mg/1 60 FILM COATED TABLETS in BOTTLE   4 Tier 4 $35.00N/ANone
TROKENDI XR 100 MG CAPSULE ER 24H   4 Tier 4 $35.00N/AP
TROKENDI XR 200 MG CAPSULE ER 24H   4 Tier 4 $35.00N/AP
TROKENDI XR 25 MG CAPSULE ER 24H   4 Tier 4 $35.00N/AP
TROKENDI XR 50 MG CAPSULE   4 Tier 4 $35.00N/AP
TROPHAMINE INJECTION SOLUTION   4 Tier 4 $35.00N/AP
TROSPIUM CHLORIDE 20 MG TABLET   2 Tier 2 $0.00$0.00None
TROSPIUM CHLORIDE ER 60 MG CAP   2 Tier 2 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRULICITY 0.75 MG/0.5 ML PEN   3 Tier 3 $0.00N/AQ:2
/28Days
TRULICITY 1.5 MG/0.5 ML PEN   3 Tier 3 $0.00N/AQ:2
/28Days
TRUMENBA 120 MCG/0.5 ML VACCIN Syringe   3 Tier 3 $0.00N/ANone
TRUSOPT PLUS 2% EYE DROPS 10ML BOT   4 Tier 4 $35.00N/ANone
TRUVADA 100 MG-150 MG TABLET   5 Tier 5 33%N/ANone
TRUVADA 133 MG-200 MG TABLET   5 Tier 5 33%N/ANone
TRUVADA 167 MG-250 MG TABLET   5 Tier 5 33%N/ANone
TRUVADA 200/300MG TABLET   5 Tier 5 33%N/ANone
TUKYSA 150 MG TABLET   5 Tier 5 33%N/AP Q:120
/30Days
TUKYSA 50 MG TABLET   5 Tier 5 33%N/AP Q:120
/30Days
TURALIO 200 MG CAPSULE   5 Tier 5 33%N/AP Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TWINRIX VACCINE SYRINGE   3 Tier 3 $0.00N/ANone
Twynsta 10; 40mg/1; mg/1 3 BLISTER PACK per CARTON / 10 TABLET, MULTILAYER per BLISTER PACK   4 Tier 4 $35.00N/ANone
Twynsta 5; 40mg/1; mg/1 3 BLISTER PACK per CARTON / 10 TABLET, MULTILAYER per BLISTER PACK   4 Tier 4 $35.00N/ANone
Twynsta 5; 80mg/1; mg/1 3 BLISTER PACK per CARTON / 10 TABLET, MULTILAYER per BLISTER PACK   4 Tier 4 $35.00N/ANone
TWYNSTA 80-10 MG TABLET   4 Tier 4 $35.00N/ANone
TYBOST 150 MG TABLET   3 Tier 3 $0.00N/ANone
TYDEMY TABLET   2 Tier 2 $0.00$0.00None
Tygacil 50mg/5mL 10 VIAL, SINGLE-USE per CARTON / 50 mL in 1 VIAL, SINGLE-USE   5 Tier 5 33%N/ANone
TYKERB 250 MG TABLET   5 Tier 5 33%N/AP
TYMLOS 80 MCG DOSE PEN INJECTR   5 Tier 5 33%N/ANone
TYPHIM VI 25 MCG/0.5 ML SYRINGE   3 Tier 3 $0.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TYPHIM VI 25MCG/0.5ML VIAL   3 Tier 3 $0.00N/ANone

Chart Legend:

Below are a few notes to help you understand the above 2020 Medicare Part D SOLIS SPF 001 (HMO) Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug or Medicare Advantage 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 $435 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.
    • Tier Number* - Some Part D drug plans exclude one or more drug tiers from the plan’s 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 - This is what you will pay for formulary drugs in 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 initial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $4020) 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 2020 )

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 Medicare plan provider.








Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.