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Aetna Medicare Assure (HMO D-SNP) (H5337-001-0)
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2020 Medicare Part D Plan Formulary Information
Aetna Medicare Assure (HMO D-SNP) (H5337-001-0)
Benefit Details           
The Aetna Medicare Assure (HMO D-SNP) (H5337-001-0)
Formulary Drugs Starting with the Letter S

in Belmont County, OH: CMS MA Region 12 which includes: OH
Plan Monthly Premium: $18.80 Deductible: $275
Drugs Starting with Letter S

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
SANCUSO TRANSDERMAL SYSTEM 3.1MG/24HRS 1 PATCH CRTN   5 Tier 5 28%N/AQ:4
/28Days
SANDIMMUNE 100MG/ML TUBEX   3 Tier 3 $47.00$141.00P
SANTYL OINTMENT   4 Tier 4 $100.00$300.00None
SAPHRIS 10 MG TABLET SL BLACK CHERRY   4 Tier 4 $100.00$300.00Q:60
/30Days
SAPHRIS 2.5 MG TABLET SL BLACK CHERRY   4 Tier 4 $100.00$300.00Q:60
/30Days
SAPHRIS 5 MG TABLET SL BLACK CHERRY   4 Tier 4 $100.00$300.00Q:60
/30Days
SCOPOLAMINE 1 MG/3 DAY PATCH TD 3 [Transderm Scop]   4 Tier 4 $100.00$300.00P Q:10
/30Days
SECUADO 3.8 MG/24 HR PATCH   5 Tier 5 28%N/AP Q:30
/30Days
SECUADO 5.7 MG/24 HR PATCH   5 Tier 5 28%N/AP Q:30
/30Days
SECUADO 7.6 MG/24 HR PATCH   5 Tier 5 28%N/AP Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SELEGILINE HCL 5 MG TABLET   2* Tier 2 $0.00$0.00None
SELEGILINE HCL 5MG CAPSULE   2* Tier 2 $0.00$0.00None
SELENIUM SULFIDE 2.5mg/100mL 118 mL in 1 BOTTLE   2* Tier 2 $0.00$0.00None
SELZENTRY 150mg/1 60 FILM COATED TABLETS in BOTTLE   5 Tier 5 28%N/ANone
SELZENTRY 20 MG/ML ORAL SOLN   5 Tier 5 28%N/ANone
SELZENTRY 25 MG TABLET   4 Tier 4 $100.00$300.00None
SELZENTRY 300mg/1 60 FILM COATED TABLETS in BOTTLE   5 Tier 5 28%N/ANone
SELZENTRY 75 MG TABLET   5 Tier 5 28%N/ANone
SENSIPAR 30MG TABLET   5 Tier 5 28%N/AP Q:120
/30Days
SENSIPAR 60MG TABLET   5 Tier 5 28%N/AP Q:60
/30Days
SENSIPAR 90MG TABLET   5 Tier 5 28%N/AP Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SEREVENT DIS AER 50MCG   3 Tier 3 $47.00$141.00Q:60
/30Days
SERTRALINE 20 MG/ML ORAL CONC   3 Tier 3 $47.00$141.00Q:300
/30Days
SERTRALINE HCL 100 MG TABLET   1* Tier 1 $0.00$0.00Q:60
/30Days
SERTRALINE HCL 25 MG TABLET   1* Tier 1 $0.00$0.00Q:30
/30Days
SERTRALINE HCL 50 MG TABLET   1* Tier 1 $0.00$0.00Q:60
/30Days
SETLAKIN 0.15 MG-0.03 MG TAB   2* Tier 2 $0.00$0.00None
SEVELAMER 0.8 GM POWDER PACKET [RENVELA]   3 Tier 3 $47.00$141.00None
SEVELAMER 2.4 GM POWDER PACKET POWD PACK [Renvela]   3 Tier 3 $47.00$141.00None
SEVELAMER CARBONATE 800 MG TABLET [RENVELA]   4 Tier 4 $100.00$300.00None
SHAROBEL 0.35 MG TABLET   3 Tier 3 $47.00$141.00None
SHINGRIX VIAL KIT   3 Tier 3 $47.00$141.00Q:2
/999Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Signifor .3 mg/mL   5 Tier 5 28%N/AP
Signifor .6 mg/mL   5 Tier 5 28%N/AP
Signifor .9 mg/mL   5 Tier 5 28%N/AP
SILDENAFIL 20 MG TABLET [Revatio]   3 Tier 3 $47.00$141.00P Q:90
/30Days
SILENOR 3 MG TABLET   3 Tier 3 $47.00$141.00Q:30
/30Days
SILENOR 6 MG TABLET   3 Tier 3 $47.00$141.00Q:30
/30Days
SILODOSIN 4 MG CAPSULE [Rapaflo]   4 Tier 4 $100.00$300.00Q:30
/30Days
SILODOSIN 8 MG CAPSULE [Rapaflo]   4 Tier 4 $100.00$300.00Q:30
/30Days
SILVER SULFADIAZINE 1% CREAM   3 Tier 3 $47.00$141.00None
SIMBRINZA 1%-0.2% EYE DROPS   3 Tier 3 $47.00$141.00None
SIMVASTATIN 10 MG TABLET   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
SIMVASTATIN 20 MG TABLET   1* Tier 1 $0.00$0.00Q:30
/30Days
SIMVASTATIN 40 MG TABLET   1* Tier 1 $0.00$0.00Q:30
/30Days
SIMVASTATIN 5 MG TABLET [Zocor]   1* Tier 1 $0.00$0.00Q:30
/30Days
SIMVASTATIN 80 MG TABLET   1* Tier 1 $0.00$0.00Q:30
/30Days
Sirolimus 0.5 MG Tablet [Rapamune]   4 Tier 4 $100.00$300.00P
SIROLIMUS 1 MG TABLET [Rapamune]   4 Tier 4 $100.00$300.00P
SIROLIMUS 1 MG/ML SOLUTION [Rapamune]   5 Tier 5 28%N/AP
SIROLIMUS 2 MG TABLET [Rapamune]   4 Tier 4 $100.00$300.00P
SIRTURO 100 MG TABLET   5 Tier 5 28%N/AP
SIVEXTRO 200 MG TABLET   5 Tier 5 28%N/ANone
SIVEXTRO 200 MG VIAL   5 Tier 5 28%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SKYRIZI 150 MG DOSE KIT-2 SYRINGEKIT   5 Tier 5 28%N/AP Q:7
/365Days
SLYND 4 MG TABLET   3 Tier 3 $47.00$141.00None
SODIUM CHLORIDE 0.45% Sodium Chloride Injection, USP   4 Tier 4 $100.00$300.00None
SODIUM CHLORIDE 0.9% IRRIG.   3 Tier 3 $47.00$141.00None
SODIUM CHLORIDE 0.9% IV SOLN   4 Tier 4 $100.00$300.00None
SODIUM CHLORIDE 3% IV SOLUTION   4 Tier 4 $100.00$300.00None
SODIUM CHLORIDE INJECTION USP 5%   4 Tier 4 $100.00$300.00None
SODIUM PHENYLBUTYRATE 500MG TB [Buphenyl]   5 Tier 5 28%N/AP
SODIUM PHENYLBUTYRATE POWDER [Buphenyl]   5 Tier 5 28%N/AP
SODIUM POLYSTYREN SULF 15 G/60 ML ORAL SUSPENSION [SPS]   3 Tier 3 $47.00$141.00None
SODIUM POLYSTYRENE SULF POWDER   3 Tier 3 $47.00$141.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SOLIFENACIN 10 MG TABLET [VESIcare]   4 Tier 4 $100.00$300.00S Q:30
/30Days
SOLIFENACIN 5 MG TABLET [VESIcare]   4 Tier 4 $100.00$300.00S Q:30
/30Days
SOLIQUA 100 UNIT-33 MCG/ML PEN   3 Tier 3 $47.00$141.00Q:30
/30Days
SOLTAMOX 20 MG/10 ML SOLN Solution   5 Tier 5 28%N/ANone
SOMATULINE DEPOT 120 MG/0.5 ML SYRINGE   5 Tier 5 28%N/AP
SOMATULINE DEPOT 60 MG/0.2 ML SYRINGE   5 Tier 5 28%N/AP
SOMATULINE DEPOT 90 MG/0.3 ML SYRINGE   5 Tier 5 28%N/AP
SOMAVERT 10 MG VIAL   5 Tier 5 28%N/AP
SOMAVERT 15 MG VIAL   5 Tier 5 28%N/AP
SOMAVERT 20 MG VIAL   5 Tier 5 28%N/AP
SOMAVERT 25 MG VIAL   5 Tier 5 28%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SOMAVERT 30 MG VIAL   5 Tier 5 28%N/AP
SORINE SOLTALOL HCL TABLETS 240MG 100 BOXUD   2* Tier 2 $0.00$0.00None
SORINE SOTALOL HCL TABLETS 120MG 100 BOXUD   2* Tier 2 $0.00$0.00None
SORINE SOTALOL HCL TABLETS 160MG 100 BOXUD   2* Tier 2 $0.00$0.00None
SORINE SOTALOL HCL TABLETS 80MG 100 BOXUD   2* Tier 2 $0.00$0.00None
SOTALOL 120 MG TABLET [Sorine]   2* Tier 2 $0.00$0.00None
SOTALOL 160 MG TABLET [Sorine]   2* Tier 2 $0.00$0.00None
SOTALOL 240 MG TABLET [Sorine]   2* Tier 2 $0.00$0.00None
SOTALOL 80 MG TABLET [Sorine]   2* Tier 2 $0.00$0.00None
SOTALOL AF 120 MG TABLET   2* Tier 2 $0.00$0.00None
SOTALOL AF 160 MG TABLET [Sorine]   2* Tier 2 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SOTALOL AF 80 MG TABLET [Sorine]   2* Tier 2 $0.00$0.00None
SPIRONOLACTONE 100 MG TABLET [Aldactone]   1* Tier 1 $0.00$0.00None
SPIRONOLACTONE 25 MG TABLET [Aldactone]   1* Tier 1 $0.00$0.00None
SPIRONOLACTONE 50 MG TABLET [Aldactone]   1* Tier 1 $0.00$0.00None
SPIRONOLACTONE-HCTZ 25-25 TABLET [Aldactazide]   3 Tier 3 $47.00$141.00None
SPRINTEC 0.25-0.035 TABLET   2* Tier 2 $0.00$0.00None
SPRITAM 1,000 MG TABLET   4 Tier 4 $100.00$300.00None
SPRITAM 250 MG TABLET   4 Tier 4 $100.00$300.00None
SPRITAM 500 MG TABLET   4 Tier 4 $100.00$300.00None
SPRITAM 750 MG TABLET   4 Tier 4 $100.00$300.00None
SPRYCEL 100mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE   5 Tier 5 28%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SPRYCEL 140mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE   5 Tier 5 28%N/AP
SPRYCEL 20MG TABLET   5 Tier 5 28%N/AP
SPRYCEL 50MG TABLET   5 Tier 5 28%N/AP
SPRYCEL 70MG TABLET   5 Tier 5 28%N/AP
SPRYCEL 80mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE   5 Tier 5 28%N/AP
SPS 15 GM/60 ML SUSPENSION   3 Tier 3 $47.00$141.00None
SRONYX 0.10-0.02 MG TABLET   2* Tier 2 $0.00$0.00None
SSD 1% CREAM   3 Tier 3 $47.00$141.00None
STALEVO 100 TABLET   5 Tier 5 28%N/AS
STALEVO 125/200 MG/MG TABLETS   5 Tier 5 28%N/AS
STALEVO 150 TABLET   5 Tier 5 28%N/AS
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
STALEVO 18.75/75 MG/MG TABLETS   5 Tier 5 28%N/AS
STALEVO 200 50-200-200 TABLET   5 Tier 5 28%N/AS
STALEVO 50 TABLET   4 Tier 4 $100.00$300.00S
STAVUDINE 15 MG CAPSULE [Zerit]   3 Tier 3 $47.00$141.00None
STAVUDINE 20 MG CAPSULE [Zerit]   3 Tier 3 $47.00$141.00None
STAVUDINE 30 MG CAPSULE [Zerit]   3 Tier 3 $47.00$141.00None
STAVUDINE 40 MG CAPSULE [Zerit]   3 Tier 3 $47.00$141.00None
STELARA 45 MG/0.5 ML SYRINGE   5 Tier 5 28%N/AP Q:1
/28Days
STELARA 45 MG/0.5 ML VIAL   5 Tier 5 28%N/AP Q:1
/28Days
STELARA 90 MG/ML SYRINGE   5 Tier 5 28%N/AP Q:1
/28Days
Stimate 1.5mg/mL 1 BOTTLE, SPRAY per CARTON / 2.5 mL in 1 BOTTLE, SPRAY   5 Tier 5 28%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
STIVARGA 40 MG TABLET   5 Tier 5 28%N/AP
STREPTOMYCIN FOR INJECTION 1GM/VIL   4 Tier 4 $100.00$300.00None
STRIBILD TABLET   5 Tier 5 28%N/ANone
SUCRALFATE 1 GM/10 ML ORAL SUSPENSION [Carafate]   4 Tier 4 $100.00$300.00None
SUCRALFATE 1GM TABLET   2* Tier 2 $0.00$0.00None
SULF-PRED 10-0.23% EYE DROPS   2* Tier 2 $0.00$0.00None
SULFACETAMIDE 10% EYE DROPS [Sulf-10]   3 Tier 3 $47.00$141.00None
SULFACETAMIDE 10% EYE OINTMENT   4 Tier 4 $100.00$300.00None
SULFACETAMIDE SOD 10% TOP SUSP   3 Tier 3 $47.00$141.00None
Sulfadiazine 500mg/1 100 TABLET BOTTLE   4 Tier 4 $100.00$300.00None
SULFAMETHOXAZOLE-TMP DS TABLET [Septra DS]   1* Tier 1 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SULFAMETHOXAZOLE-TMP SS TABLET [Septra]   1* Tier 1 $0.00$0.00None
SULFAMETHOXAZOLE-TMP SUSP Oral Suspension [Sultrex Pediatric]   4 Tier 4 $100.00$300.00None
SULFAMYLON 8.5% CREAM   4 Tier 4 $100.00$300.00None
SULFASALAZINE 500 MG TABLET   3 Tier 3 $47.00$141.00None
SULFASALAZINE DR 500 MG TABLET [Sulfazine EC]   3 Tier 3 $47.00$141.00None
SULINDAC 150 MG TABLET   2* Tier 2 $0.00$0.00None
SULINDAC 200 MG TABLET   2* Tier 2 $0.00$0.00None
Sumatriptan 20 MG/ACTUAT Nasal Spray   2* Tier 2 $0.00$0.00Q:12
/30Days
SUMATRIPTAN 4 MG/0.5 ML CART   4 Tier 4 $100.00$300.00Q:4
/30Days
Sumatriptan 4 mg/0.5 ml inject   4 Tier 4 $100.00$300.00Q:4
/30Days
Sumatriptan 5 MG/ACTUAT Nasal Spray   2* Tier 2 $0.00$0.00Q:12
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SUMATRIPTAN 6 MG/0.5 ML INJECT   4 Tier 4 $100.00$300.00Q:4
/30Days
SUMATRIPTAN 6 MG/0.5 ML INJECT   4 Tier 4 $100.00$300.00Q:4
/30Days
SUMATRIPTAN 6 MG/0.5 ML SYRNG Syringe [Sumavel DosePro System]   4 Tier 4 $100.00$300.00Q:4
/30Days
Sumatriptan 6 mg/0.5 ml vial   4 Tier 4 $100.00$300.00Q:4
/30Days
SUMATRIPTAN SUCC 100 MG TABLET   2* Tier 2 $0.00$0.00Q:9
/30Days
SUMATRIPTAN SUCC 25 MG TABLET [Imitrex]   2* Tier 2 $0.00$0.00Q:9
/30Days
SUMATRIPTAN SUCC 50 MG TABLET [Migraine Pack]   2* Tier 2 $0.00$0.00Q:9
/30Days
SUMATRIPTAN-NAPROXEN 85-500 MG Tablet [Treximet]   4 Tier 4 $100.00$300.00Q:9
/30Days
SUPRAX 100 MG TABLET CHEWABLE   4 Tier 4 $100.00$300.00None
SUPRAX 200 MG TABLET CHEWABLE   4 Tier 4 $100.00$300.00None
SUPRAX 400 MG CAPSULE   3 Tier 3 $47.00$141.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SUPRAX 500 MG/5 ML SUSPENSION   3 Tier 3 $47.00$141.00None
SUPREP BOWEL PREP KIT SOLN RECON   4 Tier 4 $100.00$300.00None
SUSTIVA 200MG CAPSULE   5 Tier 5 28%N/ANone
SUSTIVA 50MG CAPSULE   4 Tier 4 $100.00$300.00None
SUSTIVA 600MG TABLET   5 Tier 5 28%N/ANone
SUTENT 12.5MG CAPSULE   5 Tier 5 28%N/AP Q:30
/30Days
SUTENT 25mg/1 28 CAPSULE BOTTLE   5 Tier 5 28%N/AP Q:30
/30Days
SUTENT 37.5 MG CAPSULE   5 Tier 5 28%N/AP Q:30
/30Days
SUTENT 50MG CAPSULE   5 Tier 5 28%N/AP Q:30
/30Days
SYEDA 28 TABLET [Zarah]   2* Tier 2 $0.00$0.00None
SYLATRON 200 MCG KIT   5 Tier 5 28%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SYLATRON 300 MCG KIT   5 Tier 5 28%N/AP
SYMBICORT 160-4.5MCG HFA AEROSOL WITH ADAPTER   3 Tier 3 $47.00$141.00Q:10
/30Days
SYMBICORT 80; 4.5ug/1; ug/1 1 POUCH in 1 CARTON / 1 CANISTER in 1 POUCH / 120 AEROSOL in 1 CANISTER   3 Tier 3 $47.00$141.00Q:10
/30Days
SYMDEKO 100/150 MG-150 MG TABS   5 Tier 5 28%N/AP
SYMDEKO 50/75 MG-75 MG TABLET SEQ   5 Tier 5 28%N/AP
SYMFI 600-300-300 MG TABLET   5 Tier 5 28%N/ANone
SYMFI LO 400-300-300 MG TABLET   5 Tier 5 28%N/ANone
SYMLINPEN 120 PEN INJECTOR   5 Tier 5 28%N/AP Q:11
/30Days
SYMLINPEN 60 PEN INJECTOR   5 Tier 5 28%N/AP Q:12
/30Days
SYMPAZAN 10 MG FILM   5 Tier 5 28%N/AP
SYMPAZAN 20 MG FILM   5 Tier 5 28%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SYMPAZAN 5 MG FILM   4 Tier 4 $100.00$300.00P
SYMTUZA 800-150-200-10 MG TABLET   5 Tier 5 28%N/ANone
SYNAREL 2MG/ML NASAL SPRAY   5 Tier 5 28%N/ANone
SYNJARDY 12.5-1,000 MG TABLET   3 Tier 3 $47.00$141.00Q:60
/30Days
SYNJARDY 12.5-500 MG TABLET   3 Tier 3 $47.00$141.00Q:60
/30Days
SYNJARDY 5-1,000 MG TABLET   3 Tier 3 $47.00$141.00Q:60
/30Days
SYNJARDY XR 10-1,000 MG TABLET BP 24H   3 Tier 3 $47.00$141.00Q:60
/30Days
SYNJARDY XR 12.5-1,000 MG TABLET BP 24H   3 Tier 3 $47.00$141.00Q:60
/30Days
SYNJARDY XR 25-1,000 MG TABLET BP 24H   3 Tier 3 $47.00$141.00Q:30
/30Days
SYNJARDY XR 5-1,000 MG TABLET BP 24H   3 Tier 3 $47.00$141.00Q:60
/30Days
SYNRIBO 3.5 MG/ML VIAL   5 Tier 5 28%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SYNTHROID 100 MCG TABLET   4 Tier 4 $100.00$300.00None
SYNTHROID 112 MCG TABLET   4 Tier 4 $100.00$300.00None
SYNTHROID 125 MCG TABLET   4 Tier 4 $100.00$300.00None
Synthroid 137ug/1 90 TABLET BOTTLE   4 Tier 4 $100.00$300.00None
SYNTHROID 150 MCG TABLET   4 Tier 4 $100.00$300.00None
SYNTHROID 175 MCG TABLET   4 Tier 4 $100.00$300.00None
SYNTHROID 200 MCG TABLET   4 Tier 4 $100.00$300.00None
SYNTHROID 25 MCG TABLET   4 Tier 4 $100.00$300.00None
SYNTHROID 300 MCG TABLET   4 Tier 4 $100.00$300.00None
SYNTHROID 50 MCG TABLET   4 Tier 4 $100.00$300.00None
SYNTHROID 75 MCG TABLET   4 Tier 4 $100.00$300.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SYNTHROID 88 MCG TABLET   4 Tier 4 $100.00$300.00None

Chart Legend:

Below are a few notes to help you understand the above 2020 Medicare Part D Aetna Medicare Assure (HMO D-SNP) 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.