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Peoples Health Choices Value (HMO) (H1961-018-0)
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2020 Medicare Part D Plan Formulary Information
Peoples Health Choices Value (HMO) (H1961-018-0)
Benefit Details           
The Peoples Health Choices Value (HMO) (H1961-018-0)
Formulary Drugs Starting with the Letter E

in Acadia Parish, LA: CMS MA Region 16 which includes: LA
Plan Monthly Premium: $0.00 Deductible: $300
Drugs Starting with Letter E

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
E.E.S. 200 MG/5 ML GRANULES   4 Tier 4 $100.00$300.00None
ECONAZOLE NITRATE 1% CREAM (g) [Spectazole]   4 Tier 4 $100.00$300.00Q:90
/30Days
EDARBI 40 MG TABLET   4 Tier 4 $100.00$300.00Q:30
/30Days
EDARBI 80 MG TABLET   4 Tier 4 $100.00$300.00Q:30
/30Days
EDARBYCLOR 40-12.5 MG TABLET   4 Tier 4 $100.00$300.00Q:30
/30Days
EDARBYCLOR 40-25 MG TABLET   4 Tier 4 $100.00$300.00Q:30
/30Days
EDURANT 27.5mg/1   5 Tier 5 27%27%Q:30
/30Days
EFAVIRENZ 200 MG CAPSULE [Sustiva]   4 Tier 4 $100.00$300.00Q:90
/30Days
EFAVIRENZ 50 MG CAPSULE [Sustiva]   4 Tier 4 $100.00$300.00Q:90
/30Days
EFAVIRENZ 600 MG TABLET [Sustiva]   5 Tier 5 27%27%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
EGRIFTA 2 MG VIAL   5 Tier 5 27%27%P
ELESTRIN 0.06% GEL MD PUMP   4 Tier 4 $100.00$300.00None
ELIQUIS 2.5 MG TABLET   3* Tier 3 $45.00$135.00Q:60
/30Days
ELIQUIS 5 MG STARTER PACK   3* Tier 3 $45.00$135.00Q:74
/30Days
ELIQUIS 5 MG TABLET   3* Tier 3 $45.00$135.00Q:60
/30Days
ELMIRON 100mg GELATIN COATED 100 CAPSULE BOTTLE   5 Tier 5 27%27%None
ELURYNG VAGINAL RING [NuvaRing]   4 Tier 4 $100.00$300.00None
EMCYT 140MG CAPSULE   5 Tier 5 27%27%None
EMGALITY 120 MG/ML PEN INJCTR   4 Tier 4 $100.00$300.00P Q:2
/30Days
EMGALITY 120 MG/ML SYRINGE   4 Tier 4 $100.00$300.00P Q:2
/30Days
EMGALITY 300 MG (100 MG X3SYR) SYRINGE   4 Tier 4 $100.00$300.00P Q:3
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
EMOQUETTE 28 DAY TABLET [Solia]   4 Tier 4 $100.00$300.00None
Empagliflozin 5 MG / Metformin hydrochloride 500 MG Oral Tablet [Synjardy]   3* Tier 3 $45.00$135.00Q:60
/30Days
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H   5 Tier 5 27%27%Q:30
/30Days
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H   5 Tier 5 27%27%Q:30
/30Days
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H   5 Tier 5 27%27%Q:30
/30Days
EMTRIVA 10MG/ML SOLUTION   4 Tier 4 $100.00$300.00Q:850
/30Days
EMTRIVA 200MG CAPSULE   4 Tier 4 $100.00$300.00Q:30
/30Days
ENALAPRIL MALEATE 10 MG TABLET   1* Tier 1 $0.00$0.00Q:60
/30Days
ENALAPRIL MALEATE 2.5 MG TABLET   1* Tier 1 $0.00$0.00Q:60
/30Days
ENALAPRIL MALEATE 20 MG TABLET   1* Tier 1 $0.00$0.00Q:60
/30Days
ENALAPRIL MALEATE 5 MG TABLET   1* Tier 1 $0.00$0.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ENALAPRIL-HCTZ 10-25 MG TABLET [Vaseretic]   1* Tier 1 $0.00$0.00Q:60
/30Days
ENALAPRIL-HCTZ 5-12.5 MG TABLET [Vaseretic]   1* Tier 1 $0.00$0.00Q:30
/30Days
ENBREL 25 MG/0.5 ML SYRINGE   5 Tier 5 27%27%P
ENBREL 25MG KIT   5 Tier 5 27%27%P
ENBREL 50 MG/ML MINI CARTRIDGE   5 Tier 5 27%27%P
ENBREL 50 MG/ML SURECLICK SYR   5 Tier 5 27%27%P
ENBREL 50 MG/ML SYRINGE   5 Tier 5 27%27%P
ENDOCET 10MG-325MG TABLET   3* Tier 3 $45.00$135.00Q:360
/30Days
ENDOCET 5/325 TABLET   3* Tier 3 $45.00$135.00Q:360
/30Days
ENDOCET 7.5-325MG TABLET   3* Tier 3 $45.00$135.00Q:360
/30Days
ENGERIX B INJECTION   3* Tier 3 $45.00$135.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ENGERIX-B 20 MCG/ML SYRINGE   3* Tier 3 $45.00$135.00P
ENOXAPARIN 100 MG/ML SYRINGE [Lovenox]   4 Tier 4 $100.00$300.00Q:60
/30Days
ENOXAPARIN 120 MG/0.8 ML SYRINGE [Lovenox]   4 Tier 4 $100.00$300.00Q:48
/30Days
ENOXAPARIN 150 MG/ML SYRINGE [Lovenox]   4 Tier 4 $100.00$300.00Q:60
/30Days
ENOXAPARIN 30 MG/0.3 ML SYRINGE [Lovenox]   4 Tier 4 $100.00$300.00Q:18
/30Days
ENOXAPARIN 40 MG/0.4 ML SYRINGE [Lovenox]   4 Tier 4 $100.00$300.00Q:24
/30Days
ENOXAPARIN 60 MG/0.6 ML SYRINGE [Lovenox]   4 Tier 4 $100.00$300.00Q:36
/30Days
ENOXAPARIN 80 MG/0.8 ML SYRINGE [Lovenox]   4 Tier 4 $100.00$300.00Q:48
/30Days
ENSKYCE 28 TABLET [Solia]   4 Tier 4 $100.00$300.00None
ENTACAPONE 200 MG TABLET [Comtan Entacapone]   4 Tier 4 $100.00$300.00None
ENTECAVIR 0.5 MG TABLET [Baraclude]   4 Tier 4 $100.00$300.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ENTECAVIR 1 MG TABLET [Baraclude]   4 Tier 4 $100.00$300.00None
ENTRESTO 24 MG-26 MG TABLET   3* Tier 3 $45.00$135.00Q:60
/30Days
ENTRESTO 49 MG-51 MG TABLET   3* Tier 3 $45.00$135.00Q:60
/30Days
ENTRESTO 97 MG-103 MG TABLET   3* Tier 3 $45.00$135.00Q:60
/30Days
ENULOSE 10 GM/15 ML SOLUTION   2* Tier 2 $10.00$0.00None
ENVARSUS XR 0.75 MG TABLET   4 Tier 4 $100.00$300.00P
ENVARSUS XR 1 MG TABLET   4 Tier 4 $100.00$300.00P
ENVARSUS XR 4 MG TABLET ER 24H   4 Tier 4 $100.00$300.00P
EPCLUSA 400 MG-100 MG TABLET   5 Tier 5 27%27%P Q:28
/28Days
EPIDIOLEX 100 MG/ML SOLUTION   5 Tier 5 27%27%P
EPINASTINE HCL 0.05% EYE DROPS   3* Tier 3 $45.00$135.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
EPINEPHRINE 0.15 MG AUTO-INJECT   3* Tier 3 $45.00$135.00Q:4
/30Days
EPINEPHRINE 0.15 MG AUTO-INJECT [Twinject]   3* Tier 3 $45.00$135.00Q:4
/30Days
EPINEPHRINE 0.3 MG AUTO-INJECT   3* Tier 3 $45.00$135.00Q:4
/30Days
EPINEPHRINE 0.3 MG AUTO-INJECT [Twinject]   3* Tier 3 $45.00$135.00Q:4
/30Days
EPIPEN 0.3MG AUTO-INJECTOR   3* Tier 3 $45.00$135.00Q:4
/30Days
EPIPEN JR 0.15MG AUTO-INJCT   3* Tier 3 $45.00$135.00Q:4
/30Days
EPITOL 200MG TABLET   3* Tier 3 $45.00$135.00None
EPIVIR HBV 25MG/5ML TUBEX   4 Tier 4 $100.00$300.00None
EPLERENONE 25 MG TABLET [Inspra]   3* Tier 3 $45.00$135.00None
EPLERENONE 50 MG TABLET [Inspra]   3* Tier 3 $45.00$135.00None
ERAXIS 100mg/30mL 30 mL in 1 VIAL, SINGLE-USE   5 Tier 5 27%27%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ERAXIS(WATER DIL) 50 MG VIAL   4 Tier 4 $100.00$300.00None
Ergotamine-caffeine 1-100mg tablet   3* Tier 3 $45.00$135.00None
ERIVEDGE 150 MG CAPSULE   5 Tier 5 27%27%P Q:30
/30Days
ERLEADA 60 MG TABLET   5 Tier 5 27%27%P Q:120
/30Days
ERLOTINIB HCL 100 MG TABLET [Tarceva]   5 Tier 5 27%27%P Q:30
/30Days
ERLOTINIB HCL 150 MG TABLET [Tarceva]   5 Tier 5 27%27%P Q:30
/30Days
ERLOTINIB HCL 25 MG TABLET [Tarceva]   5 Tier 5 27%27%P Q:90
/30Days
ERRIN 0.35 MG TABLET [Sharobel 28-Day]   3* Tier 3 $45.00$135.00None
ERTAPENEM 1 GRAM VIAL [Invanz]   4 Tier 4 $100.00$300.00None
ERY 2% PADS 2% 60 PADS JAR   3* Tier 3 $45.00$135.00None
ERYTHROCIN 500MG ADDVNT VL   4 Tier 4 $100.00$300.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ERYTHROMYCIN 0.5% EYE OINTMENT [Romycin]   2* Tier 2 $10.00$0.00None
ERYTHROMYCIN 2% GEL [Erygel]   4 Tier 4 $100.00$300.00None
ERYTHROMYCIN 2% SOLUTION   2* Tier 2 $10.00$0.00None
ERYTHROMYCIN 200 MG/5 ML ORAL SUSPENSION [EryPed]   4 Tier 4 $100.00$300.00None
ERYTHROMYCIN 500 MG FILMTAB   4 Tier 4 $100.00$300.00None
ERYTHROMYCIN DR 250 MG CAPSULE DR [ERYC]   4 Tier 4 $100.00$300.00None
ERYTHROMYCIN DR 250 MG TABLET DR [Ery-Tab]   4 Tier 4 $100.00$300.00None
ERYTHROMYCIN DR 333 MG TABLET DR [Ery-Tab]   4 Tier 4 $100.00$300.00None
ERYTHROMYCIN DR 500 MG TABLET DR [Ery-Tab]   4 Tier 4 $100.00$300.00None
ERYTHROMYCIN ES 400 MG TABLET   4 Tier 4 $100.00$300.00None
ERYTHROMYCIN TABLET 250MG BS   4 Tier 4 $100.00$300.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ERYTHROMYCIN-BENZOYL GEL   4 Tier 4 $100.00$300.00None
ESBRIET 267 MG CAPSULE   5 Tier 5 27%27%P Q:270
/30Days
ESBRIET 267 MG TABLET   5 Tier 5 27%27%P Q:270
/30Days
ESBRIET 801 MG TABLET   5 Tier 5 27%27%P Q:90
/30Days
ESCITALOPRAM 10 MG TABLET [Lexapro]   1* Tier 1 $0.00$0.00None
ESCITALOPRAM 20 MG TABLET [Lexapro]   1* Tier 1 $0.00$0.00None
ESCITALOPRAM 5 MG TABLET [Lexapro]   1* Tier 1 $0.00$0.00None
ESCITALOPRAM OXALATE 5 MG/5 ML [Lexapro]   2* Tier 2 $10.00$0.00None
ESOMEPRAZOLE MAG DR 20 MG CAPSULE [Nexium]   3* Tier 3 $45.00$135.00Q:90
/30Days
ESOMEPRAZOLE MAG DR 40 MG CAPSULE [Nexium]   3* Tier 3 $45.00$135.00Q:60
/30Days
ESTARYLLA 0.25-0.035 MG TABLET [VyLibra]   4 Tier 4 $100.00$300.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ESTRADIOL 0.01% CREAM   4 Tier 4 $100.00$300.00None
ESTRADIOL 0.5 MG TABLET   3* Tier 3 $45.00$135.00None
ESTRADIOL 1 MG TABLET   3* Tier 3 $45.00$135.00None
ESTRADIOL 10 MCG VAGINAL INSRT   4 Tier 4 $100.00$300.00Q:30
/30Days
ESTRADIOL 2MG TABLET   3* Tier 3 $45.00$135.00None
ESTRADIOL TDS 0.025 MG/DAY   3* Tier 3 $45.00$135.00Q:4
/28Days
ESTRADIOL TDS 0.0375 MG/DAY   3* Tier 3 $45.00$135.00Q:4
/28Days
ESTRADIOL TDS 0.05 MG/DAY   3* Tier 3 $45.00$135.00Q:4
/28Days
ESTRADIOL TDS 0.06 MG/DAY   3* Tier 3 $45.00$135.00Q:4
/28Days
ESTRADIOL TDS 0.075 MG/DAY   3* Tier 3 $45.00$135.00Q:4
/28Days
ESTRADIOL TDS 0.1 MG/DAY   3* Tier 3 $45.00$135.00Q:4
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ESTRADIOL VALERATE 20mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE   4 Tier 4 $100.00$300.00None
ESTRADIOL VALERATE 40mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE   4 Tier 4 $100.00$300.00None
ESTRING 2MG VAGINAL RING   4 Tier 4 $100.00$300.00None
ETHACRYNIC ACID 25 MG TABLET [Edecrin]   4 Tier 4 $100.00$300.00None
ETHAMBUTOL HCL 400 MG TABLET   3* Tier 3 $45.00$135.00None
Ethambutol Hydrochloride 100mg/1   3* Tier 3 $45.00$135.00None
Ethinyl Estradiol 0.0025 MG / norethindrone acetate 0.5 MG Oral Tablet [Fyavolv]   4 Tier 4 $100.00$300.00None
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6   4 Tier 4 $100.00$300.00None
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TABLET 21   4 Tier 4 $100.00$300.00None
ETHOSUXIMIDE 250 MG CAPSULE [Zarontin]   3* Tier 3 $45.00$135.00None
ETHOSUXIMIDE 250 MG/5 ML SOLN   3* Tier 3 $45.00$135.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ETHYNODIOL-ETH ESTRA 1MG-35MCG [ZOVIA]   4 Tier 4 $100.00$300.00None
ETHYNODIOL-ETH ESTRA 1MG-50MCG [ZOVIA]   4 Tier 4 $100.00$300.00None
ETODOLAC 200 MG CAPSULE [Lodine]   3* Tier 3 $45.00$135.00None
ETODOLAC 300 MG CAPSULE [Lodine]   3* Tier 3 $45.00$135.00None
ETODOLAC 400 MG TABLET [Lodine]   3* Tier 3 $45.00$135.00None
ETODOLAC 500 MG TABLET [Lodine]   3* Tier 3 $45.00$135.00None
ETODOLAC ER 400 MG TABLET [Lodine]   4 Tier 4 $100.00$300.00None
ETODOLAC ER 500 MG TABLET ER 24H [Lodine XL]   4 Tier 4 $100.00$300.00None
ETODOLAC ER 600 MG TABLET ER 24H [Lodine XL]   4 Tier 4 $100.00$300.00None
ETONOGESTREL-EE VAGINAL RING [NuvaRing]   4 Tier 4 $100.00$300.00None
EUTHYROX 100 MCG TABLET   3* Tier 3 $45.00$135.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
EUTHYROX 112 MCG TABLET   3* Tier 3 $45.00$135.00None
EUTHYROX 125 MCG TABLET   3* Tier 3 $45.00$135.00None
EUTHYROX 137 MCG TABLET   3* Tier 3 $45.00$135.00None
EUTHYROX 150 MCG TABLET   3* Tier 3 $45.00$135.00None
EUTHYROX 175 MCG TABLET   3* Tier 3 $45.00$135.00None
EUTHYROX 200 MCG TABLET   3* Tier 3 $45.00$135.00None
EUTHYROX 25 MCG TABLET   3* Tier 3 $45.00$135.00None
EUTHYROX 50 MCG TABLET   3* Tier 3 $45.00$135.00None
EUTHYROX 75 MCG TABLET   3* Tier 3 $45.00$135.00None
EUTHYROX 88 MCG TABLET   3* Tier 3 $45.00$135.00None
EVEROLIMUS 0.25 MG TABLET [Zortress]   5 Tier 5 27%27%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
EVEROLIMUS 0.5 MG TABLET [Zortress]   5 Tier 5 27%27%P
EVEROLIMUS 0.75 MG TABLET [Zortress]   5 Tier 5 27%27%P
EVEROLIMUS 2.5 MG TABLET [Afinitor]   5 Tier 5 27%27%P
EVEROLIMUS 5 MG TABLET [Afinitor]   5 Tier 5 27%27%P
EVEROLIMUS 7.5 MG TABLET [Afinitor]   5 Tier 5 27%27%P
EVOTAZ 300 MG-150 MG TABLET   5 Tier 5 27%27%Q:30
/30Days
EXEMESTANE 25 MG TABLET [Aromasin]   4 Tier 4 $100.00$300.00None
EZETIMIBE 10 MG TABLET [Zetia]   2* Tier 2 $10.00$0.00Q:30
/30Days
EZETIMIBE-SIMVASTATIN 10-10 MG TABLET [Vytorin]   3* Tier 3 $45.00$135.00Q:30
/30Days
EZETIMIBE-SIMVASTATIN 10-20 MG TABLET [Vytorin]   3* Tier 3 $45.00$135.00Q:30
/30Days
EZETIMIBE-SIMVASTATIN 10-40 MG TABLET [Vytorin]   3* Tier 3 $45.00$135.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
EZETIMIBE-SIMVASTATIN 10-80 MG TABLET [Vytorin]   3* Tier 3 $45.00$135.00Q:30
/30Days

Chart Legend:

Below are a few notes to help you understand the above 2020 Medicare Part D Peoples Health Choices Value (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.