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Aetna Medicare Value Plan (PPO) (H5521-088-0)
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2020 Medicare Part D Plan Formulary Information
Aetna Medicare Value Plan (PPO) (H5521-088-0)
Benefit Details           
The Aetna Medicare Value Plan (PPO) (H5521-088-0)
Formulary Drugs Starting with the Letter F

in Allen County, OH: CMS MA Region 12 which includes: OH
Plan Monthly Premium: $0.00 Deductible: $150
Drugs Starting with Letter F

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
FALMINA-28 TABLET   2* Tier 2 $5.00$10.00None
FAMCICLOVIR 125 MG TABLET   2* Tier 2 $5.00$10.00Q:60
/30Days
FAMCICLOVIR 250 MG TABLET   2* Tier 2 $5.00$10.00Q:60
/30Days
FAMCICLOVIR 500 MG TABLET   2* Tier 2 $5.00$10.00Q:21
/30Days
FAMOTIDINE 20 MG TABLET   2* Tier 2 $5.00$10.00None
FAMOTIDINE 40 MG TABLET   2* Tier 2 $5.00$10.00None
FAMOTIDINE 50 MG/5MLFOR ORAL SUSPENSION   3* Tier 3 $47.00$141.00None
FANAPT 1 MG TABLET   4 Tier 4 $100.00$300.00P Q:60
/30Days
FANAPT 10 MG TABLET   4 Tier 4 $100.00$300.00P Q:60
/30Days
FANAPT 12 MG TABLET   4 Tier 4 $100.00$300.00P Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FANAPT 2 MG TABLET   4 Tier 4 $100.00$300.00P Q:60
/30Days
FANAPT 4 MG TABLET   4 Tier 4 $100.00$300.00P Q:60
/30Days
FANAPT 6 MG TABLET   4 Tier 4 $100.00$300.00P Q:60
/30Days
FANAPT 8 MG TABLET   4 Tier 4 $100.00$300.00P Q:60
/30Days
FANAPT TITR TABLETS   4 Tier 4 $100.00$300.00P
FARESTON 60 MG TABLET   5 Tier 5 30%N/AP
FARXIGA 10 MG TABLET   3* Tier 3 $47.00$141.00Q:30
/30Days
FARXIGA 5 MG TABLET   3* Tier 3 $47.00$141.00Q:30
/30Days
FARYDAK 10 MG CAPSULE   5 Tier 5 30%N/AP
FARYDAK 20 MG CAPSULE   5 Tier 5 30%N/AP
FASENRA 30 MG/ML SYRINGE   5 Tier 5 30%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FASENRA PEN 30 MG/ML AUTO INJCT   5 Tier 5 30%N/AP
FAYOSIM TABLET TBDSPK 3MO [Quartette]   2* Tier 2 $5.00$10.00None
FEBUXOSTAT 40 MG TABLET [Uloric]   3* Tier 3 $47.00$141.00S
FEBUXOSTAT 80 MG TABLET [Uloric]   3* Tier 3 $47.00$141.00S
FELBAMATE 400 MG TABLET   4 Tier 4 $100.00$300.00None
FELBAMATE 600 MG TABLET [Felbatol]   4 Tier 4 $100.00$300.00None
FELBAMATE 600 MG/5 ML ORAL SUSPENSION [Felbatol]   4 Tier 4 $100.00$300.00None
FELODIPINE ER 10 MG TABLET   4 Tier 4 $100.00$300.00None
FELODIPINE ER 2.5 MG TABLET ER 24H [Plendil]   4 Tier 4 $100.00$300.00None
FELODIPINE ER 5 MG TABLET   4 Tier 4 $100.00$300.00None
FEMYNOR 28 TABLET [VyLibra]   2* Tier 2 $5.00$10.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FENOFIBRATE 120 MG TABLET [LIPOFEN]   4 Tier 4 $100.00$300.00None
FENOFIBRATE 130 MG CAPSULE [Antara]   3* Tier 3 $47.00$141.00None
FENOFIBRATE 134MG CAPSULE [LIPOFEN]   3* Tier 3 $47.00$141.00None
FENOFIBRATE 145 MG TABLET [Tricor]   3* Tier 3 $47.00$141.00None
FENOFIBRATE 150 MG CAPSULE [LIPOFEN]   3* Tier 3 $47.00$141.00None
FENOFIBRATE 160 MG TABLET [LIPOFEN]   3* Tier 3 $47.00$141.00None
FENOFIBRATE 200 MG CAPSULE [LIPOFEN]   3* Tier 3 $47.00$141.00None
FENOFIBRATE 40 MG TABLET [LIPOFEN]   4 Tier 4 $100.00$300.00None
FENOFIBRATE 43 MG CAPSULE [Antara]   3* Tier 3 $47.00$141.00None
FENOFIBRATE 48 MG TABLET [Tricor]   3* Tier 3 $47.00$141.00None
FENOFIBRATE 50 MG CAPSULE [LIPOFEN]   3* Tier 3 $47.00$141.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FENOFIBRATE 50 MG ORAL CAPSULE [LIPOFEN]   4 Tier 4 $100.00$300.00None
FENOFIBRATE 54 MG 90 TABLET BOTTLE [LIPOFEN]   3* Tier 3 $47.00$141.00None
FENOFIBRATE 67MG CAPSULE [LIPOFEN]   3* Tier 3 $47.00$141.00None
FENOFIBRIC ACID DR 135 MG CAPSULE [TRILIPIX]   4 Tier 4 $100.00$300.00None
FENOFIBRIC ACID DR 45 MG CAPSULE DR [Trilipix]   4 Tier 4 $100.00$300.00None
FENOPROFEN 600 MG TABLET [ProFeno]   4 Tier 4 $100.00$300.00None
FENOPROFEN CALCIUM 400 MG CAPSULE   4 Tier 4 $100.00$300.00None
FENTANYL 100 MCG/HR PATCH TD72 [Duragesic]   4 Tier 4 $100.00$300.00P Q:15
/30Days
FENTANYL 12 MCG/HR PATCH TD72 [Duragesic]   4 Tier 4 $100.00$300.00P Q:15
/30Days
FENTANYL 25 MCG/HR PATCH TD72 [Duragesic]   4 Tier 4 $100.00$300.00P Q:15
/30Days
FENTANYL 37.5 MCG/HR PATCH TD72   4 Tier 4 $100.00$300.00P Q:15
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FENTANYL 50 MCG/HR PATCH TD72 [Duragesic]   4 Tier 4 $100.00$300.00P Q:15
/30Days
FENTANYL 62.5 MCG/HR PATCH TD72   4 Tier 4 $100.00$300.00P Q:15
/30Days
FENTANYL 75 MCG/HR PATCH TD72 [Duragesic]   4 Tier 4 $100.00$300.00P Q:15
/30Days
FENTANYL 87.5 MCG/HR PATCH TD72   4 Tier 4 $100.00$300.00P Q:15
/30Days
FENTANYL CIT OTFC 1,200 MCG LOZENGE HD [Actiq]   5 Tier 5 30%N/AP Q:120
/30Days
FENTANYL CIT OTFC 1,600 MCG LOZENGE HD [Actiq]   5 Tier 5 30%N/AP Q:120
/30Days
FENTANYL CITRATE OTFC 200 MCG LOZENGE HD [Actiq]   5 Tier 5 30%N/AP Q:120
/30Days
FENTANYL CITRATE OTFC 400 MCG LOZENGE HD [Actiq]   5 Tier 5 30%N/AP Q:120
/30Days
FENTANYL CITRATE OTFC 600 MCG LOZENGE HD [Actiq]   5 Tier 5 30%N/AP Q:120
/30Days
FENTANYL CITRATE OTFC 800 MCG LOZENGE HD [Actiq]   5 Tier 5 30%N/AP Q:120
/30Days
FETZIMA 20-40 MG TITRATION PAK   4 Tier 4 $100.00$300.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FETZIMA ER 120 MG CAPSULE   4 Tier 4 $100.00$300.00P Q:30
/30Days
FETZIMA ER 20 MG CAPSULE   4 Tier 4 $100.00$300.00P Q:60
/30Days
FETZIMA ER 40 MG CAPSULE   4 Tier 4 $100.00$300.00P Q:60
/30Days
FETZIMA ER 80 MG CAPSULE   4 Tier 4 $100.00$300.00P Q:30
/30Days
FIASP 100 UNIT/ML FLEXTOUCH INSULIN PEN   3* Tier 3 $47.00$141.00None
FIASP 100 UNIT/ML VIAL   3* Tier 3 $47.00$141.00None
FIASP PENFILL 100 UNIT/ML CART CARTRIDGE   3* Tier 3 $47.00$141.00None
FINACEA 15% FOAM   4 Tier 4 $100.00$300.00Q:50
/30Days
FINACEA 15% GEL   4 Tier 4 $100.00$300.00Q:50
/30Days
FINASTERIDE 5 MG TABLET [Proscar]   1* Tier 1 $0.00$0.00Q:30
/30Days
FIRAZYR 30 MG/3 ML SYRINGE   5 Tier 5 30%N/AP Q:27
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FLAC OTIC OIL 0.01% EAR DROPS [Flac]   4 Tier 4 $100.00$300.00Q:20
/30Days
FLAREX 0.1% EYE DROPS   4 Tier 4 $100.00$300.00None
FLAVOXATE 100 MG TABLET 100   4 Tier 4 $100.00$300.00None
FLEBOGAMMA DIF INJECTION   5 Tier 5 30%N/AP
FLECAINIDE ACETATE 100 MG TABLET [Tambocor]   3* Tier 3 $47.00$141.00None
FLECAINIDE ACETATE 150 MG TABLET [Tambocor]   3* Tier 3 $47.00$141.00None
FLECAINIDE ACETATE 50 MG TABLET [Tambocor]   3* Tier 3 $47.00$141.00None
FLOVENT DISKUS 100ug/1 60 POWDER, METERED in 1 INHALER   3* Tier 3 $47.00$141.00Q:120
/30Days
FLOVENT DISKUS 250ug/1 60 POWDER, METERED in 1 INHALER   3* Tier 3 $47.00$141.00Q:240
/30Days
FLOVENT DISKUS POWDER 50MCG 60 CTR   3* Tier 3 $47.00$141.00Q:120
/30Days
FLOVENT HFA 110ug/1 120 AEROSOL, METERED in 1 INHALER   3* Tier 3 $47.00$141.00Q:24
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FLOVENT HFA 220ug/1 120 AEROSOL, METERED in 1 INHALER   3* Tier 3 $47.00$141.00Q:24
/30Days
FLOVENT HFA 44ug/1 120 AEROSOL, METERED in 1 INHALER   3* Tier 3 $47.00$141.00Q:21
/30Days
FLUCONAZOLE 10 MG/ML ORAL SUSPENSION [Diflucan]   3* Tier 3 $47.00$141.00None
FLUCONAZOLE 100 MG TABLET [Diflucan]   2* Tier 2 $5.00$10.00None
FLUCONAZOLE 150 MG TABLET [Diflucan]   2* Tier 2 $5.00$10.00None
FLUCONAZOLE 200 MG TABLET [Diflucan]   2* Tier 2 $5.00$10.00None
FLUCONAZOLE 40 MG/ML ORAL SUSPENSION [Diflucan]   3* Tier 3 $47.00$141.00None
FLUCONAZOLE 50 MG TABLET [Diflucan]   2* Tier 2 $5.00$10.00None
FLUCONAZOLE-NACL 200 MG/100 ML PIGGYBACK [Diflucan]   4 Tier 4 $100.00$300.00None
FLUCONAZOLE-NACL 400 MG/200 ML PIGGYBACK [Diflucan]   4 Tier 4 $100.00$300.00None
FLUCYTOSINE 250 MG CAPSULE [Ancobon]   5 Tier 5 30%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FLUCYTOSINE 500 MG CAPSULE [Ancobon]   5 Tier 5 30%N/ANone
FLUDROCORTISONE 0.1 MG TABLET   2* Tier 2 $5.00$10.00None
FLUNISOLIDE NASAL SOLUTION 0.025% 25ML INHL   3* Tier 3 $47.00$141.00Q:75
/30Days
FLUOCINOLONE 0.01% CREAM (g)   4 Tier 4 $100.00$300.00Q:60
/30Days
FLUOCINOLONE 0.01% SCALP OIL [Derma-Smoothe/FS]   4 Tier 4 $100.00$300.00Q:118
/30Days
FLUOCINOLONE 0.01% SOLUTION [Synalar]   4 Tier 4 $100.00$300.00Q:90
/30Days
FLUOCINOLONE 0.025% CREAM (g) [Synalar]   4 Tier 4 $100.00$300.00Q:120
/30Days
FLUOCINOLONE 0.025% OINTMENT   4 Tier 4 $100.00$300.00Q:120
/30Days
FLUOCINOLONE OIL 0.01% EAR DROPS [Flac]   4 Tier 4 $100.00$300.00Q:20
/30Days
FLUOCINONIDE 0.05% GEL   4 Tier 4 $100.00$300.00Q:60
/30Days
FLUOCINONIDE 0.05% OINTMENT [Lidex]   4 Tier 4 $100.00$300.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FLUOCINONIDE 0.05% SOLUTION   4 Tier 4 $100.00$300.00Q:60
/30Days
FLUOCINONIDE-E 0.05% CREAM   4 Tier 4 $100.00$300.00Q:120
/30Days
Fluorometholone 0.1% drops   3* Tier 3 $47.00$141.00None
FLUOROPLEX 1% CREAM (G)   5 Tier 5 30%N/AP Q:30
/30Days
FLUOROURACIL 0.5% CREAM   4 Tier 4 $100.00$300.00P Q:30
/30Days
FLUOROURACIL 2% TOPICAL SOLUTION   4 Tier 4 $100.00$300.00Q:10
/30Days
FLUOROURACIL 5% CREAM (g) [Efudex]   4 Tier 4 $100.00$300.00P Q:40
/30Days
FLUOROURACIL 5% TOPICAL SOLUTION   4 Tier 4 $100.00$300.00Q:10
/30Days
Fluoxetine 20mg/5mL 120 mL in 1 BOTTLE, PLASTIC   2* Tier 2 $5.00$10.00None
FLUOXETINE DR 90 MG CAPSULE   4 Tier 4 $100.00$300.00Q:4
/28Days
FLUOXETINE HCL 10 MG CAPSULE [Selfemra]   2* Tier 2 $5.00$10.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FLUOXETINE HCL 10 MG TABLET [Sarafem]   2* Tier 2 $5.00$10.00None
FLUOXETINE HCL 20 MG CAPSULE   2* Tier 2 $5.00$10.00Q:120
/30Days
FLUOXETINE HCL 20 MG TABLET [Sarafem]   2* Tier 2 $5.00$10.00None
FLUOXETINE HCL 40 MG CAPSULE [Prozac]   2* Tier 2 $5.00$10.00Q:60
/30Days
FLUOXETINE HCL 60 MG TABLET   3* Tier 3 $47.00$141.00None
FLUPHENAZINE 1 MG TABLET   2* Tier 2 $5.00$10.00None
FLUPHENAZINE 10 MG TABLET [Prolixin]   2* Tier 2 $5.00$10.00None
FLUPHENAZINE 2.5 MG TABLET   2* Tier 2 $5.00$10.00None
FLUPHENAZINE 2.5 MG/5 ML ELIX   2* Tier 2 $5.00$10.00None
FLUPHENAZINE 2.5MG/ML VIAL   4 Tier 4 $100.00$300.00None
FLUPHENAZINE 5 MG TABLET   2* Tier 2 $5.00$10.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FLUPHENAZINE 5MG/ML CONC   2* Tier 2 $5.00$10.00None
FLUPHENAZINE DEC 125 MG/5 ML VIAL [Prolixin Decanoate]   4 Tier 4 $100.00$300.00None
Flurandrenolide 0.05% Cream [Cordran]   4 Tier 4 $100.00$300.00Q:120
/30Days
FLURBIPROFEN 0.03% EYE DROPS [Ocufen]   2* Tier 2 $5.00$10.00None
Flurbiprofen 100mg/1 100 BOTTLE in 1 BOTTLE / 100 FILM COATED TABLETS in BOTTLE   2* Tier 2 $5.00$10.00None
FLUTAMIDE 125 MG CAPSULE   4 Tier 4 $100.00$300.00None
FLUTICASONE PROP 0.005% OINTMENT [Cutivate]   3* Tier 3 $47.00$141.00None
FLUTICASONE PROP 0.05% LOTION   4 Tier 4 $100.00$300.00Q:120
/30Days
Fluticasone Propionate 0.5mg/g 1 TUBE per CARTON / 30 g in 1 TUBE   3* Tier 3 $47.00$141.00None
FLUTICASONE PROPIONATE 50 MCG SPRAY SUSPENSION   2* Tier 2 $5.00$10.00Q:16
/30Days
FLUVASTATIN ER 80 MG TABLET ER 24H [Lescol XL]   1* Tier 1 $0.00$0.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FLUVASTATIN SODIUM 20 MG CAPSULE [Lescol]   1* Tier 1 $0.00$0.00Q:60
/30Days
FLUVASTATIN SODIUM 40 MG CAPSULE [Lescol]   1* Tier 1 $0.00$0.00Q:60
/30Days
FLUVOXAMINE ER 100 MG CAPSULE   4 Tier 4 $100.00$300.00Q:60
/30Days
FLUVOXAMINE ER 150 MG CAPSULE   4 Tier 4 $100.00$300.00Q:60
/30Days
FLUVOXAMINE MALEATE 100 MG TABLET [Luvox]   3* Tier 3 $47.00$141.00None
FLUVOXAMINE MALEATE 25 MG TABLET [Luvox]   3* Tier 3 $47.00$141.00None
FLUVOXAMINE MALEATE 50 MG TABLET [Luvox]   3* Tier 3 $47.00$141.00None
FONDAPARINUX 10 MG/0.8 ML SYRINGE [Arixtra]   4 Tier 4 $100.00$300.00None
FONDAPARINUX 2.5 MG/0.5 ML SYRINGE [Arixtra]   4 Tier 4 $100.00$300.00None
FONDAPARINUX 5 MG/0.4 ML SYRINGE [Arixtra]   4 Tier 4 $100.00$300.00None
FONDAPARINUX 7.5 MG/0.6 ML SYRINGE [Arixtra]   4 Tier 4 $100.00$300.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Forteo 250ug/mL 1 SYRINGE per CARTON / 2.4 mL in 1 SYRINGE   5 Tier 5 30%N/AP
FOSAMPRENAVIR 700 MG TABLET [Lexiva]   5 Tier 5 30%N/ANone
FOSINOPRIL SODIUM 10 MG TABLET   1* Tier 1 $0.00$0.00None
FOSINOPRIL SODIUM 20 MG TABLET   1* Tier 1 $0.00$0.00None
FOSINOPRIL SODIUM 40 MG TABLET   1* Tier 1 $0.00$0.00None
FOSINOPRIL-HCTZ 10-12.5 MG TABLET [Monopril-HCT]   1* Tier 1 $0.00$0.00None
FOSINOPRIL-HCTZ 20-12.5 MG TABLET [Monopril-HCT]   1* Tier 1 $0.00$0.00None
FRAGMIN 10,000 UNITS SYRINGE   4 Tier 4 $100.00$300.00None
FRAGMIN 12,500 UNITS SYRINGE   4 Tier 4 $100.00$300.00None
FRAGMIN 15,000 UNITS SYRINGE   4 Tier 4 $100.00$300.00None
FRAGMIN 18,000 UNITS SYRINGE   4 Tier 4 $100.00$300.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FRAGMIN 2,500 UNITS SYRINGE   4 Tier 4 $100.00$300.00None
FRAGMIN 5,000 UNITS SYRINGE   4 Tier 4 $100.00$300.00None
FRAGMIN 7,500 UNITS/0.3 ML SYRINGE   4 Tier 4 $100.00$300.00None
FRAGMIN 95,000 UNITS/3.8 ML VIAL   4 Tier 4 $100.00$300.00None
FREAMINE HBC INJECTION   4 Tier 4 $100.00$300.00P
FROVATRIPTAN SUCC 2.5 MG TABLET [Frova]   4 Tier 4 $100.00$300.00Q:12
/30Days
FUROSEMIDE 10 MG/ML SOLUTION   1* Tier 1 $0.00$0.00None
FUROSEMIDE 100 MG/10 ML VIAL   4 Tier 4 $100.00$300.00None
Furosemide 10mg/mL 10 CARTON in 1 CONTAINER / 1 SYRINGE, PLASTIC in 1 CARTON / 4 mL in 1 SYRINGE, P   4 Tier 4 $100.00$300.00None
FUROSEMIDE 20 MG TABLET   1* Tier 1 $0.00$0.00None
FUROSEMIDE 40 MG TABLET [Lasix]   1* Tier 1 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FUROSEMIDE 40MG/5ML TUBEX   1* Tier 1 $0.00$0.00None
FUROSEMIDE 80 MG TABLET   1* Tier 1 $0.00$0.00None
FUZEON 90 MG VIAL   5 Tier 5 30%N/ANone
FYAVOLV 1 MG-5 MCG TABLET   3* Tier 3 $47.00$141.00P
FYCOMPA 0.5 MG/ML ORAL SUSP   5 Tier 5 30%N/AP Q:720
/30Days
FYCOMPA 10 MG TABLET   5 Tier 5 30%N/AP Q:30
/30Days
FYCOMPA 12 MG TABLET   5 Tier 5 30%N/AP Q:30
/30Days
FYCOMPA 2 MG TABLET   4 Tier 4 $100.00$300.00P Q:60
/30Days
FYCOMPA 4 MG TABLET   5 Tier 5 30%N/AP Q:60
/30Days
FYCOMPA 6 MG TABLET   5 Tier 5 30%N/AP Q:60
/30Days
FYCOMPA 8 MG TABLET   5 Tier 5 30%N/AP Q:30
/30Days

Chart Legend:

Below are a few notes to help you understand the above 2020 Medicare Part D Aetna Medicare Value Plan (PPO) 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.