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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)
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2020 Medicare Part D Plan Formulary Information
SOLIS SPF 001 (HMO) (H0982-001-0)
Benefit Details           
The SOLIS SPF 001 (HMO) (H0982-001-0)
Formulary Drugs Starting with the Letter R

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

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
RABAVERT RABIES VACCINE VIAL   3 Tier 3 $0.00N/AP
RABEPRAZOLE SOD DR 20 MG TABLET DR [AcipHex]   2 Tier 2 $0.00$0.00None
RALOXIFENE HCL 60 MG TABLET [Evista]   2 Tier 2 $0.00$0.00None
RAMELTEON 8 MG TABLET [Rozerem]   2 Tier 2 $0.00$0.00Q:30
/30Days
RAMIPRIL 1.25 MG CAPSULE   1 Tier 1 $0.00$0.00None
RAMIPRIL 10 MG CAPSULE   1 Tier 1 $0.00$0.00None
RAMIPRIL 2.5 MG CAPSULE [Altace]   1 Tier 1 $0.00$0.00None
RAMIPRIL 5 MG CAPSULE   1 Tier 1 $0.00$0.00None
RANOLAZINE ER 1,000 MG TABLET 12H [Ranexa]   2 Tier 2 $0.00$0.00None
RANOLAZINE ER 500 MG TABLET 12H [Ranexa]   2 Tier 2 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
RAPAFLO 4 MG CAPSULE   4 Tier 4 $35.00N/ANone
RAPAFLO 8 MG CAPSULE   4 Tier 4 $35.00N/ANone
RAPAMUNE 0.5MG TABLETS   4 Tier 4 $35.00N/AP
RAPAMUNE 1MG TABLET   4 Tier 4 $35.00N/AP
RAPAMUNE 1MG/ML ORAL TUBEX   4 Tier 4 $35.00N/AP
RAPAMUNE 2MG TABLET   4 Tier 4 $35.00N/AP
RASAGILINE MESYLATE 0.5 MG TABLET [Azilect]   2 Tier 2 $0.00$0.00None
RASAGILINE MESYLATE 1 MG TABLET [Azilect]   2 Tier 2 $0.00$0.00None
RAVICTI 1.1 GRAM/ML LIQUID   5 Tier 5 33%N/AP
RAZADYNE ER 16MG CAPSULE   4 Tier 4 $35.00N/ANone
RAZADYNE ER 24MG CAPSULE   4 Tier 4 $35.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
RAZADYNE ER 8MG CAPSULE   4 Tier 4 $35.00N/ANone
REBIF 22ug/0.5mL 12 SYRINGE, GLASS per CARTON / 0.5 mL in 1 SYRINGE, GLASS   5 Tier 5 33%N/ANone
REBIF 44ug/0.5mL 12 SYRINGE, GLASS per CARTON / 0.5 mL in 1 SYRINGE, GLASS   5 Tier 5 33%N/ANone
REBIF REBIDOSE 22 MCG/0.5 ML   5 Tier 5 33%N/ANone
REBIF REBIDOSE 44 MCG/0.5 ML   5 Tier 5 33%N/ANone
REBIF REBIDOSE TITRATION PACK   5 Tier 5 33%N/ANone
REBIF TITRTN SOL PACK 8.8MCG/22 VIAL   5 Tier 5 33%N/ANone
RECLIPSEN 28 DAY TABLET [Solia]   2 Tier 2 $0.00$0.00None
RECOMBIVAX HB 10 MCG/ML SYR   3 Tier 3 $0.00N/AP
RECOMBIVAX HB 10 MCG/ML VIAL   3 Tier 3 $0.00N/AP
RECOMBIVAX HB 40MCG/ML VIAL   3 Tier 3 $0.00N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
RECTIV 0.4% OINTMENT   4 Tier 4 $35.00N/AQ:30
/30Days
REGLAN 10 MG TABLET   4 Tier 4 $35.00N/ANone
REGLAN 5 MG TABLET   4 Tier 4 $35.00N/ANone
REGRANEX 0.01% GEL   5 Tier 5 33%N/AQ:30
/15Days
RELENZA 5MG DISKHALER   3 Tier 3 $0.00N/AQ:120
/30Days
RELISTOR 12 MG/0.6 ML SYRINGE   4 Tier 4 $35.00N/AP
RELISTOR 12 MG/0.6 ML VIAL   4 Tier 4 $35.00N/AP
RELISTOR 8 MG/0.4 ML SYRINGE   4 Tier 4 $35.00N/AP
REMERON 15MG TABLET   4 Tier 4 $35.00N/ANone
REMERON 30MG TABLET   4 Tier 4 $35.00N/ANone
REMERON SLTABLET 15MG TABLET 30 BLPK CRTN   4 Tier 4 $35.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
REMERON SLTABLET 30MG TABLET 30 TABLET S CRTN   4 Tier 4 $35.00N/ANone
REMERON SLTABLET 45MG TABLET   4 Tier 4 $35.00N/ANone
RENAGEL 800MG TABLET   4 Tier 4 $35.00N/ANone
RENVELA 800MG TABLET   4 Tier 4 $35.00N/ANone
REPAGLINIDE 0.5 MG TABLET [Prandin]   2 Tier 2 $0.00$0.00None
REPAGLINIDE 1 MG TABLET [Prandin]   2 Tier 2 $0.00$0.00None
REPAGLINIDE 2 MG TABLET [Prandin]   2 Tier 2 $0.00$0.00None
REPATHA 140 MG/ML SURECLICK PEN INJCTR   3 Tier 3 $0.00N/AP Q:2
/28Days
REPATHA 140 MG/ML SYRINGE   3 Tier 3 $0.00N/AP Q:2
/28Days
REPATHA 420 MG/3.5ML PUSHTRONX WEAR INJCT   3 Tier 3 $0.00N/AP Q:4
/28Days
RESTASIS 0.05% EYE EMULSION   3 Tier 3 $0.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
RESTORIL 15mg/1 100 CAPSULE BOTTLE   4 Tier 4 $35.00N/ANone
RESTORIL 22.5mg/1 30 CAPSULE BOTTLE   4 Tier 4 $35.00N/ANone
RESTORIL 30mg/1 100 CAPSULE BOTTLE   4 Tier 4 $35.00N/ANone
RESTORIL 7.5 MG CAPSULE   4 Tier 4 $35.00N/ANone
RETACRIT 10,000 UNIT/ML VIAL   3 Tier 3 $0.00N/AP
RETACRIT 2,000 UNIT/ML VIAL   3 Tier 3 $0.00N/AP
RETACRIT 3,000 UNIT/ML VIAL   3 Tier 3 $0.00N/AP
RETACRIT 4,000 UNIT/ML VIAL   3 Tier 3 $0.00N/AP
RETACRIT 40,000 UNIT/ML VIAL   3 Tier 3 $0.00N/AP
RETEVMO 40 MG CAPSULE   5 Tier 5 33%N/AP Q:180
/30Days
RETEVMO 80 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
RETIN-A 0.01% GEL   4 Tier 4 $35.00N/AP
RETIN-A 0.025% GEL   4 Tier 4 $35.00N/AP
RETIN-A 0.1% CREAM (g)   4 Tier 4 $35.00N/AP
RETIN-A MICRO 0.04% GEL   4 Tier 4 $35.00N/AP
RETIN-A MICRO 0.1% GEL   4 Tier 4 $35.00N/AP
RETROVIR 100mg/1 100 CAPSULE BOTTLE   4 Tier 4 $35.00N/ANone
RETROVIR 50mg/5mL 240 mL in 1 BOTTLE   4 Tier 4 $35.00N/ANone
REVATIO 20MG TABLET   5 Tier 5 33%N/AP
REVLIMID 10 MG CAPSULE   5 Tier 5 33%N/AP Q:30
/30Days
REVLIMID 15MG CAPSULE 21 BOT   5 Tier 5 33%N/AP Q:30
/30Days
REVLIMID 2.5 MG CAPSULE   5 Tier 5 33%N/AP Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
REVLIMID 20 MG CAPSULE   5 Tier 5 33%N/AP Q:30
/30Days
REVLIMID 25 MG CAPSULE   5 Tier 5 33%N/AP Q:30
/30Days
REVLIMID 5 MG CAPSULE   5 Tier 5 33%N/AP Q:30
/30Days
REXULTI 0.25 MG TABLET   4 Tier 4 $35.00N/AP Q:30
/30Days
REXULTI 0.5 MG TABLET   4 Tier 4 $35.00N/AP Q:30
/30Days
REXULTI 1 MG TABLET   4 Tier 4 $35.00N/AP Q:30
/30Days
REXULTI 2 MG TABLET   4 Tier 4 $35.00N/AP Q:30
/30Days
REXULTI 3 MG TABLET   4 Tier 4 $35.00N/AP Q:30
/30Days
REXULTI 4 MG TABLET   4 Tier 4 $35.00N/AP Q:30
/30Days
REYATAZ 150MG CAPSULE   5 Tier 5 33%N/ANone
REYATAZ 200MG CAPSULE   5 Tier 5 33%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
REYATAZ 300MG CAPSULE   5 Tier 5 33%N/ANone
REYATAZ 50 MG POWDER PACKET   5 Tier 5 33%N/ANone
RIBAVIRIN 200 MG CAPSULE   1 Tier 1 $0.00$0.00None
RIBAVIRIN 200MG TABLET 168 BOT   1 Tier 1 $0.00$0.00None
RIDAURA 3 MG CAPSULE   3 Tier 3 $0.00N/ANone
RIFABUTIN 150 MG CAPSULE [Mycobutin]   2 Tier 2 $0.00$0.00None
RIFADIN 150MG CAPSULE   4 Tier 4 $35.00N/ANone
RIFAMPIN 150 MG CAPSULE   2 Tier 2 $0.00$0.00None
RIFAMPIN 300 MG CAPSULE   2 Tier 2 $0.00$0.00None
RIFAMPIN IV 600 MG VIAL [Rifadin]   2 Tier 2 $0.00$0.00None
RILUTEK 50 MG TABLET   5 Tier 5 33%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
RILUZOLE 50 MG TABLET [Rilutek]   2 Tier 2 $0.00$0.00None
Rimantadine 100mg/1 100 TABLET BOTTLE   2 Tier 2 $0.00$0.00None
RINVOQ ER 15 MG TABLET ER 24H   5 Tier 5 33%N/AP
RIOMET 500MG/5ML SOLUTION ORAL   4 Tier 4 $35.00N/ANone
RIOMET ER 500 MG/5 ML SUSP ER REC   4 Tier 4 $35.00N/ANone
RISEDRONATE SODIUM 150 MG TABLET [Actonel]   2 Tier 2 $0.00$0.00None
RISEDRONATE SODIUM 30 MG TABLET [Actonel]   2 Tier 2 $0.00$0.00None
RISEDRONATE SODIUM 35 MG TABLET [Actonel]   2 Tier 2 $0.00$0.00None
RISEDRONATE SODIUM 35 MG TABLET [Actonel]   2 Tier 2 $0.00$0.00None
RISEDRONATE SODIUM 35 MG TABLET [Actonel]   2 Tier 2 $0.00$0.00None
RISEDRONATE SODIUM 5 MG TABLET [Actonel]   2 Tier 2 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
RISPERDAL 0.5 MG TABLET   4 Tier 4 $35.00N/ANone
RISPERDAL 1 MG TABLET   4 Tier 4 $35.00N/ANone
RISPERDAL 1MG/ML SOLUTION   4 Tier 4 $35.00N/ANone
RISPERDAL 2 MG TABLET   4 Tier 4 $35.00N/ANone
RISPERDAL 3 MG TABLET   4 Tier 4 $35.00N/ANone
RISPERDAL 4 MG TABLET   4 Tier 4 $35.00N/ANone
RISPERDAL CONSTA 25MG SYR   4 Tier 4 $35.00N/ANone
RISPERDAL CONSTA 37.5MG SYR   4 Tier 4 $35.00N/ANone
RISPERDAL CONSTA 50MG SYR   4 Tier 4 $35.00N/ANone
RISPERDAL CONSTA FOR INJECTION 12.5MG/VIAL   4 Tier 4 $35.00N/ANone
RISPERIDONE 0.25 MG TABLET [Risperdal]   1 Tier 1 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
RISPERIDONE 0.5 MG ODT   2 Tier 2 $0.00$0.00None
RISPERIDONE 0.5 MG TABLET   1 Tier 1 $0.00$0.00None
RISPERIDONE 1 MG ODT TABLET RAPDIS [Risperdal M-Tab]   2 Tier 2 $0.00$0.00None
RISPERIDONE 1 MG TABLET   1 Tier 1 $0.00$0.00None
RISPERIDONE 1 MG/ML SOLUTION   2 Tier 2 $0.00$0.00None
RISPERIDONE 2 MG ODT   2 Tier 2 $0.00$0.00None
RISPERIDONE 2 MG TABLET   1 Tier 1 $0.00$0.00None
RISPERIDONE 3 MG ODT   2 Tier 2 $0.00$0.00None
RISPERIDONE 3 MG TABLET   1 Tier 1 $0.00$0.00None
RISPERIDONE 4 MG ODT   2 Tier 2 $0.00$0.00None
RISPERIDONE 4 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
RISPERIDONE TABLET 0.25MG 4 IN 1 BLPK   2 Tier 2 $0.00$0.00None
RITALIN 10MG TABLET   4 Tier 4 $35.00N/ANone
RITALIN 20MG TABLET   4 Tier 4 $35.00N/ANone
RITALIN 5MG TABLET   4 Tier 4 $35.00N/ANone
RITALIN LA 10MG CAPSULE   4 Tier 4 $35.00N/ANone
RITALIN LA 20MG CAPSULE   4 Tier 4 $35.00N/ANone
RITALIN LA 30MG CAPSULE   4 Tier 4 $35.00N/ANone
RITALIN LA 40MG CAPSULE   4 Tier 4 $35.00N/ANone
RITONAVIR 100 MG TABLET [Norvir]   2 Tier 2 $0.00$0.00None
RIVASTIGMINE 1.5 MG CAPSULE [Exelon]   2 Tier 2 $0.00$0.00None
RIVASTIGMINE 13.3 MG/24HR PTCH   2 Tier 2 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
RIVASTIGMINE 3 MG CAPSULE [Exelon]   2 Tier 2 $0.00$0.00None
RIVASTIGMINE 4.5 MG CAPSULE [Exelon]   2 Tier 2 $0.00$0.00None
RIVASTIGMINE 4.6 MG/24HR PATCH   2 Tier 2 $0.00$0.00None
RIVASTIGMINE 6 MG CAPSULE [Exelon]   2 Tier 2 $0.00$0.00None
RIVASTIGMINE 9.5 MG/24HR PATCH   2 Tier 2 $0.00$0.00None
RIVELSA TABLET TBDSPK 3MO   2 Tier 2 $0.00$0.00None
RIZATRIPTAN 10 MG ODT [Maxalt-MLT]   2 Tier 2 $0.00$0.00Q:36
/60Days
RIZATRIPTAN 10 MG TABLET [Maxalt]   2 Tier 2 $0.00$0.00Q:36
/60Days
RIZATRIPTAN 5 MG ODT [Maxalt-MLT]   2 Tier 2 $0.00$0.00Q:36
/60Days
RIZATRIPTAN 5 MG TABLET [Maxalt]   2 Tier 2 $0.00$0.00Q:36
/60Days
Rocaltrol 0.25ug GELATIN COATED 100 CAPSULE BOTTLE   4 Tier 4 $35.00N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Rocaltrol 0.5ug GELATIN COATED 100 CAPSULE BOTTLE   4 Tier 4 $35.00N/AP
Rocaltrol 1ug/mL 15 mL in 1 BOTTLE   4 Tier 4 $35.00N/AP
ROPINIROLE HCL 0.25 MG TABLET   1 Tier 1 $0.00$0.00None
ROPINIROLE HCL 0.5 MG TABLET   1 Tier 1 $0.00$0.00None
ROPINIROLE HCL 1 MG TABLET [Requip]   1 Tier 1 $0.00$0.00None
ROPINIROLE HCL 2 MG TABLET [Requip]   1 Tier 1 $0.00$0.00None
ROPINIROLE HCL 3 MG TABLET   1 Tier 1 $0.00$0.00None
ROPINIROLE HCL 4 MG TABLET   1 Tier 1 $0.00$0.00None
ROPINIROLE HCL 5 MG TABLET   1 Tier 1 $0.00$0.00None
ROPINIROLE HCL ER 12 MG TABLET ER 24H [Requip XL]   2 Tier 2 $0.00$0.00None
ROPINIROLE HCL ER 2 MG TABLET ER 24H [Requip XL]   2 Tier 2 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ROPINIROLE HCL ER 4 MG TABLET   2 Tier 2 $0.00$0.00None
ROPINIROLE HCL ER 6 MG TABLET ER 24H [Requip XL]   2 Tier 2 $0.00$0.00None
ROPINIROLE HCL ER 8 MG TABLET   2 Tier 2 $0.00$0.00None
ROSUVASTATIN CALCIUM 10 MG TABLET [Crestor]   1 Tier 1 $0.00$0.00None
ROSUVASTATIN CALCIUM 20 MG TABLET [Crestor]   1 Tier 1 $0.00$0.00None
ROSUVASTATIN CALCIUM 40 MG TABLET [Crestor]   1 Tier 1 $0.00$0.00None
ROSUVASTATIN CALCIUM 5 MG TABLET [Crestor]   1 Tier 1 $0.00$0.00None
ROTARIX VACCINE SUSPENSION   3 Tier 3 $0.00N/ANone
ROTATEQ VACCINE SOLUTION   3 Tier 3 $0.00N/ANone
Roweepra 1,000 mg tablet   2 Tier 2 $0.00$0.00None
ROWEEPRA 500 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
Roweepra 750 mg tablet   2 Tier 2 $0.00$0.00None
ROWEEPRA XR 500 MG TABLET ER 24H   1 Tier 1 $0.00$0.00None
ROWEEPRA XR 750 MG TABLET ER 24H   1 Tier 1 $0.00$0.00None
ROXICODONE 15 MG TABLET   4 Tier 4 $35.00N/AQ:180
/30Days
ROXICODONE 30 MG TABLET   4 Tier 4 $35.00N/AQ:180
/30Days
ROXICODONE 5 MG TABLET   4 Tier 4 $35.00N/AQ:360
/30Days
ROZLYTREK 100 MG CAPSULE   5 Tier 5 33%N/AP Q:30
/30Days
ROZLYTREK 200 MG CAPSULE   5 Tier 5 33%N/AP Q:90
/30Days
RUBRACA 200 MG TABLET   5 Tier 5 33%N/AP Q:120
/30Days
RUBRACA 250 MG TABLET   5 Tier 5 33%N/AP Q:120
/30Days
RUBRACA 300 MG TABLET   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
RUCONEST 2,100 UNIT VIAL   5 Tier 5 33%N/AP
RUZURGI 10 MG TABLET   5 Tier 5 33%N/AP
RYBELSUS 14 MG TABLET   3 Tier 3 $0.00N/AQ:30
/30Days
RYBELSUS 3 MG TABLET   3 Tier 3 $0.00N/AQ:30
/30Days
RYBELSUS 7 MG TABLET   3 Tier 3 $0.00N/AQ:30
/30Days
RYDAPT 25 MG CAPSULE   5 Tier 5 33%N/AP
RYTHMOL SR 225mg/1 60 CAPSULE, EXTENDED RELEASE in 1 BOTTLE   4 Tier 4 $35.00N/ANone
RYTHMOL SR 325mg/1 60 CAPSULE, EXTENDED RELEASE in 1 BOTTLE   4 Tier 4 $35.00N/ANone
RYTHMOL SR 425mg/1 60 CAPSULE, EXTENDED RELEASE in 1 BOTTLE   4 Tier 4 $35.00N/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.