Powered by Q1Group LLC
Education and Decision Support Tools for the Medicare Community
  • Menu ☰
  • Home
  • Contact
  • MAPD
  • PDP
  • 2020
  • 2021
  • FAQs
  • Articles
  • Search
  • Contact
  • 2020
  • 2021
  • FAQs
  • Articles
  • Latest Medicare News
  • Search


2021 Medicare Part D and Medicare Advantage Plan Formulary Browser

Select your search style and criteria below or use this example to get started

Search by:
State & Plan   ZIP & Plan   PlanID   FormularyID

Search Criteria
PDP     MAPD
Scroll down to see formulary results.

Anthem MediBlue Rx Enhanced (PDP) (S5596-080-0)
Tier 1 (185)
Tier 2 (602)
Tier 3 (788)
Tier 4 (1090)
Tier 5 (457)
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:

A B C D E F G H I J K L 
M N O P Q R S T U V W X Y Z 0-9 
2021 Medicare Part D Plan Formulary Information
Anthem MediBlue Rx Enhanced (PDP) (S5596-080-0)
Benefits & Contact Info           
The Anthem MediBlue Rx Enhanced (PDP) (S5596-080-0)
Formulary Drugs Starting with the Letter A

in CMS PDP Region 16 which includes: WI
Plan Monthly Premium: $24.60 Deductible: $290 Qualifies for LIS: No
Drugs Starting with Letter A

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
ABACAVIR 20 MG/ML SOLUTION [Ziagen]   4 Non-Preferred Drug 37%37%Q:960
/30Days
ABACAVIR 300 MG TABLET [Ziagen]   4 Non-Preferred Drug 37%37%Q:60
/30Days
Abacavir Sulfate-Lamivudine-Zidovudine tablets [Trizivir]   5 Specialty Tier 26%N/AQ:60
/30Days
ABACAVIR-LAMIVUDINE 600-300 MG TABLET [Epzicom]   4 Non-Preferred Drug 37%37%Q:30
/30Days
ABELCET INJECTION SUSPENSION 5MG/ML   4 Non-Preferred Drug 37%37%P
ABILIFY MAINTENA ER 300 MG SYRINGE   4 Non-Preferred Drug 37%37%Q:1
/28Days
ABILIFY MAINTENA ER 300 MG VIAL   4 Non-Preferred Drug 37%37%Q:1
/28Days
ABILIFY MAINTENA ER 400 MG SUSER VIAL   4 Non-Preferred Drug 37%37%Q:1
/28Days
ABILIFY MAINTENA ER 400 MG SYRINGE   4 Non-Preferred Drug 37%37%Q:1
/28Days
ABIRATERONE ACETATE 250 MG TABLET [ZYTIGA]   5 Specialty Tier 26%N/AP Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Acamprosate Calcium DR 333 MG tablets [Campral]   4 Non-Preferred Drug 37%37%None
ACARBOSE 100 MG TABLET [Precose]   2* Generic $2.00$6.00Q:90
/30Days
ACARBOSE 25 MG TABLET [Precose]   2* Generic $2.00$6.00Q:90
/30Days
ACARBOSE 50 MG TABLET [Precose]   2* Generic $2.00$6.00Q:90
/30Days
ACEBUTOLOL 200 MG CAPSULE [Sectral]   2* Generic $2.00$6.00None
ACEBUTOLOL 400 MG CAPSULE [Sectral]   2* Generic $2.00$6.00None
ACETAMINOP-CODEINE 120-12 MG/5   2* Generic $2.00$6.00Q:900
/30Days
ACETAMINOPHEN-COD #2 TABLET   2* Generic $2.00$6.00Q:180
/30Days
ACETAMINOPHEN-COD #3 TABLET [Tylenol with Codeine No.3]   2* Generic $2.00$6.00Q:180
/30Days
ACETAMINOPHEN-COD #4 TABLET   2* Generic $2.00$6.00Q:180
/30Days
ACETAZOLAMIDE 125MG TABLET   3 Preferred Brand 20%20%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETAZOLAMIDE 250 MG TABLET [Diamox]   3 Preferred Brand 20%20%None
ACETAZOLAMIDE ER 500 MG CAPSULE   4 Non-Preferred Drug 37%37%None
ACETIC ACID 2% EAR SOLUTION [VoSoL]   3 Preferred Brand 20%20%None
ACETYLCYSTEINE 10% VIAL   4 Non-Preferred Drug 37%37%P
ACETYLCYSTEINE 20% VIAL [Mucosil Acetylcysteine]   4 Non-Preferred Drug 37%37%P
ACITRETIN 10 MG CAPSULE [Soriatane]   4 Non-Preferred Drug 37%37%None
ACITRETIN 17.5 MG CAPSULE [Soriatane]   4 Non-Preferred Drug 37%37%None
ACITRETIN 25 MG CAPSULE [Soriatane]   4 Non-Preferred Drug 37%37%None
ACTHIB VACCINE WITH DILUENT   3 Preferred Brand 20%20%None
ACTIMMUNE 100 MCG/0.5 ML VIAL   5 Specialty Tier 26%N/AP
ACYCLOVIR 200 MG CAPSULE [Zovirax]   2* Generic $2.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACYCLOVIR 200 MG/5 ML SUSP   4 Non-Preferred Drug 37%37%None
ACYCLOVIR 400 MG TABLET   2* Generic $2.00$6.00None
ACYCLOVIR 800 MG TABLET   2* Generic $2.00$6.00None
Acyclovir sodium 500 mg vial   4 Non-Preferred Drug 37%37%P
ADACEL TDAP SYRINGE   3 Preferred Brand 20%20%None
ADACEL VIAL 2UNT/5UNT   3 Preferred Brand 20%20%None
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA]   5 Specialty Tier 26%N/AP Q:2
/28Days
ADEFOVIR DIPIVOXIL 10 MG TABLET [Hepsera]   4 Non-Preferred Drug 37%37%P
ADEMPAS 0.5 MG TABLET   5 Specialty Tier 26%N/AP
ADEMPAS 1 MG TABLET   5 Specialty Tier 26%N/AP
ADEMPAS 1.5 MG TABLET   5 Specialty Tier 26%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADEMPAS 2 MG TABLET   5 Specialty Tier 26%N/AP
ADEMPAS 2.5 MG TABLET   5 Specialty Tier 26%N/AP
AFINITOR 10 MG TABLET   5 Specialty Tier 26%N/AP
AFINITOR DISPERZ 2 MG TABLET   5 Specialty Tier 26%N/AP
AFINITOR DISPERZ 3 MG TABLET   5 Specialty Tier 26%N/AP
AFINITOR DISPERZ 5 MG TABLET   5 Specialty Tier 26%N/AP
AIMOVIG 140 MG/ML AUTOINJECTOR   3 Preferred Brand 20%20%P Q:1
/30Days
AIMOVIG 70 MG/ML AUTOINJECTOR   3 Preferred Brand 20%20%P Q:2
/30Days
ALBENDAZOLE 200 MG TABLET [Albenza]   4 Non-Preferred Drug 37%37%None
ALBUTEROL 2.5 MG/0.5 ML SOL VIAL-NEB   2* Generic $2.00$6.00P Q:60
/30Days
ALBUTEROL HFA 90 MCG INHALER HFA AER AD [Ventolin HFA]   3 Preferred Brand 20%20%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALBUTEROL HFA 90 MCG INHALER HFA AER AD [Ventolin HFA]   3 Preferred Brand 20%20%None
ALBUTEROL HFA 90 MCG INHALER HFA AER AD [Ventolin HFA]   3 Preferred Brand 20%20%None
ALBUTEROL SUL 0.63 MG/3 ML SOL VIAL-NEB   2* Generic $2.00$6.00P Q:360
/30Days
ALBUTEROL SUL 1.25 MG/3 ML SOL VIAL-NEB   2* Generic $2.00$6.00P Q:360
/30Days
ALBUTEROL SUL 2.5 MG/3 ML SOLUTION VIAL-NEB   2* Generic $2.00$6.00P Q:360
/30Days
ALBUTEROL SULF 2 MG/5 ML SYRUP   2* Generic $2.00$6.00None
ALBUTEROL SULFATE 2 MG TABLET   4 Non-Preferred Drug 37%37%None
ALBUTEROL SULFATE 4 MG TABLET   4 Non-Preferred Drug 37%37%None
ALBUTEROL SULFATE 4MG TABLET SR 12HR   4 Non-Preferred Drug 37%37%None
ALBUTEROL SULFATE 8MG TABLET SR 12HR   4 Non-Preferred Drug 37%37%None
ALCLOMETASONE DIPR 0.05% OINTMENT [Aclovate]   2* Generic $2.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALCLOMETASONE DIPRO 0.05% CREAM   2* Generic $2.00$6.00None
ALECENSA 150 MG CAPSULE   5 Specialty Tier 26%N/AP Q:240
/30Days
ALENDRONATE SODIUM 10 MG TABLET [Fosamax]   1* Preferred Generic $0.00$0.00Q:30
/30Days
ALENDRONATE SODIUM 35 MG TABLET [Fosamax]   1* Preferred Generic $0.00$0.00Q:4
/28Days
ALENDRONATE SODIUM 70 MG TABLET [Fosamax]   1* Preferred Generic $0.00$0.00Q:4
/28Days
ALENDRONATE SODIUM 70 MG/75 ML   4 Non-Preferred Drug 37%37%Q:300
/28Days
ALFUZOSIN HCL ER 10 MG TABLET   2* Generic $2.00$6.00None
ALINIA 100 MG/5 ML SUSPENSION   4 Non-Preferred Drug 37%37%Q:180
/30Days
ALINIA 500 MG TABLET   4 Non-Preferred Drug 37%37%Q:6
/30Days
ALISKIREN 150 MG TABLET [Tekturna]   4 Non-Preferred Drug 37%37%None
ALISKIREN 300 MG TABLET [Tekturna]   4 Non-Preferred Drug 37%37%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALLOPURINOL 100 MG TABLET [Zyloprim]   1* Preferred Generic $0.00$0.00None
ALLOPURINOL 300 MG TABLET [Zyloprim]   1* Preferred Generic $0.00$0.00None
ALOSETRON HCL 0.5 MG TABLET [Lotronex]   5 Specialty Tier 26%N/AP Q:60
/30Days
ALOSETRON HCL 1 MG TABLET [Lotronex]   5 Specialty Tier 26%N/AP Q:60
/30Days
ALPHAGAN P 0.1% EYE DROPS   3 Preferred Brand 20%20%None
ALPRAZOLAM 0.25 MG TABLET [Xanax]   2* Generic $2.00$6.00Q:120
/30Days
ALPRAZOLAM 0.5 MG TABLET   2* Generic $2.00$6.00Q:120
/30Days
ALPRAZOLAM 1 MG TABLET   2* Generic $2.00$6.00Q:120
/30Days
ALPRAZOLAM 2 MG TABLET   2* Generic $2.00$6.00Q:120
/30Days
ALTAVERA-28 TABLET [Portia]   3 Preferred Brand 20%20%None
ALUNBRIG 180 MG TABLET   5 Specialty Tier 26%N/AP Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALUNBRIG 30 MG TABLET   5 Specialty Tier 26%N/AP Q:180
/30Days
ALUNBRIG 90 MG TABLET   5 Specialty Tier 26%N/AP Q:60
/30Days
ALUNBRIG 90 MG-180 MG TABLET PACK   5 Specialty Tier 26%N/AP Q:30
/180Days
ALYACEN 1-35-28 TABLET   3 Preferred Brand 20%20%None
Amabelz 0.5 MG/0.1 MG 28 TABLET/BLISTER PACK 3 PER CARTON   3 Preferred Brand 20%20%P
Amabelz 1 MG/0.5 MG 28 TABLET/BLISTER PACK 3 PER CARTON   3 Preferred Brand 20%20%P
AMANTADINE 100 MG CAPSULE [Symmetrel]   3 Preferred Brand 20%20%None
AMANTADINE 100 MG TABLET   3 Preferred Brand 20%20%None
AMANTADINE 50 MG/5 ML SOLUTION   2* Generic $2.00$6.00None
AMBISOME 50MG VIAL   4 Non-Preferred Drug 37%37%P
AMBRISENTAN 10 MG TABLET [LETAIRIS]   5 Specialty Tier 26%N/AP Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMBRISENTAN 5 MG TABLET [LETAIRIS]   5 Specialty Tier 26%N/AP Q:30
/30Days
AMCINONIDE 0.1% OINTMENT 60GM TUBE   4 Non-Preferred Drug 37%37%None
AMETHIA 0.15-0.03-0.01 MG TABLET   3 Preferred Brand 20%20%None
AMIKACIN SULF 500 MG/2 ML VIAL   4 Non-Preferred Drug 37%37%None
AMILORIDE HCL 5 MG TABLET [Midamor]   3 Preferred Brand 20%20%None
AMILORIDE HCL-HCTZ 5-50 MG TABLET [Moduretic]   2* Generic $2.00$6.00None
Amino acids 4.25% in dextrose 10% Injectable Solution [Clinimix 4.25/10]   4 Non-Preferred Drug 37%37%P
Amino acids 4.25% in dextrose 5% Injectable Solution [Clinimix 4.25/5]   4 Non-Preferred Drug 37%37%P
AMINOSYN II 10% SOL 6X2000 ML   4 Non-Preferred Drug 37%37%P
AMINOSYN II 15% IV SOLUTION   4 Non-Preferred Drug 37%37%P
AMINOSYN-PF 7% IV SOLUTION   4 Non-Preferred Drug 37%37%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMIODARONE HCL 100 MG TABLET [Pacerone]   4 Non-Preferred Drug 37%37%None
AMIODARONE HCL 200 MG TABLET [Pacerone]   2* Generic $2.00$6.00None
AMIODARONE HCL 400 MG TABLET [Pacerone]   4 Non-Preferred Drug 37%37%None
AMITIZA 24 MCG 60 CAPSULE BOTTLE   3 Preferred Brand 20%20%Q:60
/30Days
AMITIZA 8MCG CAPSULE   3 Preferred Brand 20%20%Q:60
/30Days
AMITRIPTYLINE HCL 10 MG TABLET [Elavil]   2* Generic $2.00$6.00P
AMITRIPTYLINE HCL 100 MG TABLET   2* Generic $2.00$6.00P
AMITRIPTYLINE HCL 150 MG TABLET   2* Generic $2.00$6.00P
AMITRIPTYLINE HCL 25 MG TABLET   2* Generic $2.00$6.00P
AMITRIPTYLINE HCL 50 MG TABLET   2* Generic $2.00$6.00P
AMITRIPTYLINE HCL 75 MG TABLET   2* Generic $2.00$6.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLOD-VALSA-HCTZ 10-160-12.5 MG [Exforge HCT]   2* Generic $2.00$6.00None
AMLOD-VALSA-HCTZ 10-160-25 MG [Exforge HCT]   2* Generic $2.00$6.00None
AMLOD-VALSA-HCTZ 10-320-25 MG [Exforge HCT]   2* Generic $2.00$6.00None
AMLOD-VALSA-HCTZ 5-160-12.5 MG [Exforge HCT]   2* Generic $2.00$6.00None
AMLOD-VALSA-HCTZ 5-160-25 MG [Exforge HCT]   2* Generic $2.00$6.00None
AMLODIPINE BESYLATE 10 MG TABLET [Norvasc]   1* Preferred Generic $0.00$0.00None
AMLODIPINE BESYLATE 2.5 MG TABLET [Norvasc]   1* Preferred Generic $0.00$0.00None
AMLODIPINE BESYLATE 5 MG TABLET [Norvasc]   1* Preferred Generic $0.00$0.00None
AMLODIPINE-BENAZEPRIL 10-20 MG CAPSULE [Lotrel]   2* Generic $2.00$6.00None
AMLODIPINE-BENAZEPRIL 10-40 MG CAPSULE [Lotrel]   2* Generic $2.00$6.00None
AMLODIPINE-BENAZEPRIL 2.5-10 CAPSULE [Lotrel]   2* Generic $2.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE-BENAZEPRIL 5-10 MG CAPSULE [Lotrel]   2* Generic $2.00$6.00None
AMLODIPINE-BENAZEPRIL 5-20 MG CAPSULE [Lotrel]   2* Generic $2.00$6.00None
AMLODIPINE-BENAZEPRIL 5-40 MG CAPSULE [Lotrel]   2* Generic $2.00$6.00None
AMLODIPINE-VALSARTAN 10-160 MG TABLET [Exforge]   2* Generic $2.00$6.00None
AMLODIPINE-VALSARTAN 10-320 MG TABLET [Exforge]   2* Generic $2.00$6.00None
AMLODIPINE-VALSARTAN 5-160 MG TABLET [Exforge]   2* Generic $2.00$6.00None
AMLODIPINE-VALSARTAN 5-320 MG TABLET [Exforge]   2* Generic $2.00$6.00None
AMMONIUM LACTATE 12% CREAM (g) [Lac-Hydrin]   3 Preferred Brand 20%20%None
AMMONIUM LACTATE 12% LOTION   3 Preferred Brand 20%20%None
AMNESTEEM 10 MG CAPSULE [ZENATANE]   4 Non-Preferred Drug 37%37%None
AMNESTEEM 20 MG CAPSULE [ZENATANE]   4 Non-Preferred Drug 37%37%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMNESTEEM 40 MG CAPSULE [ZENATANE]   4 Non-Preferred Drug 37%37%None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE [Augmentin]   2* Generic $2.00$6.00None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET [Augmentin]   4 Non-Preferred Drug 37%37%None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE [Augmentin]   4 Non-Preferred Drug 37%37%None
AMOX-CLAV 200-28.5 MG/5 ML SUS   3 Preferred Brand 20%20%None
AMOX-CLAV 250-62.5 MG/5 ML SUS   4 Non-Preferred Drug 37%37%None
AMOX-CLAV 400-57 MG/5 ML ORAL SUSPENSION [Augmentin]   2* Generic $2.00$6.00None
AMOX-CLAV 500-125 MG TABLET [Augmentin]   2* Generic $2.00$6.00None
AMOX-CLAV 600-42.9 MG/5 ML SUS   2* Generic $2.00$6.00None
AMOX-CLAV 875-125 MG TABLET [Augmentin]   2* Generic $2.00$6.00None
AMOX-CLAV ER 1,000-62.5 MG TABLET [Augmentin]   4 Non-Preferred Drug 37%37%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXAPINE 100MG TABLET   3 Preferred Brand 20%20%P
AMOXAPINE 150MG TABLET   3 Preferred Brand 20%20%P
AMOXAPINE 25MG TABLET   3 Preferred Brand 20%20%P
AMOXAPINE 50MG TABLET   3 Preferred Brand 20%20%P
AMOXICILLIN 125 MG/5 ML SUSP   2* Generic $2.00$6.00None
AMOXICILLIN 125MG TABLET CHEW   2* Generic $2.00$6.00None
AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION [Amoxil]   2* Generic $2.00$6.00None
AMOXICILLIN 250 MG CAPSULE [Trimox]   1* Preferred Generic $0.00$0.00None
AMOXICILLIN 250 MG TABLET CHEW   2* Generic $2.00$6.00None
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION [Trimox]   2* Generic $2.00$6.00None
AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION [Amoxil]   2* Generic $2.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN 500 MG CAPSULE [Trimox]   1* Preferred Generic $0.00$0.00None
AMOXICILLIN 500 MG TABLET   2* Generic $2.00$6.00None
AMOXICILLIN 875 MG TABLET   2* Generic $2.00$6.00None
AMPHETAMINE SALT COMBO 12.5MG TABLET   3 Preferred Brand 20%20%P Q:90
/30Days
AMPHETAMINE SALT COMBO 15MG TABLET   3 Preferred Brand 20%20%P Q:90
/30Days
AMPHETAMINE SALT COMBO 7.5MG TABLET   3 Preferred Brand 20%20%P Q:90
/30Days
AMPHETAMINE SALTS 5 MG TABLET   3 Preferred Brand 20%20%P Q:90
/30Days
amphotericin b 50mg/10mL 10 mL in 1 VIAL   4 Non-Preferred Drug 37%37%P
AMPICILLIN 1 GM VIAL   4 Non-Preferred Drug 37%37%None
AMPICILLIN 10 GM VIAL   4 Non-Preferred Drug 37%37%None
Ampicillin 1000 MG / Sulbactam 500 MG Injection   4 Non-Preferred Drug 37%37%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Ampicillin 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS   4 Non-Preferred Drug 37%37%None
AMPICILLIN CAPSULES 500MG 100 BOTTLE   2* Generic $2.00$6.00None
AMPICILLIN-SULBACTAM 15 GM VIAL [Unasyn]   4 Non-Preferred Drug 37%37%None
AMPICILLIN-SULBACTAM 3 GM VIAL [Unasyn]   4 Non-Preferred Drug 37%37%None
ANADROL-50 TABLET   5 Specialty Tier 26%N/AP
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE   3 Preferred Brand 20%20%None
Anagrelide Hydrochloride 1mg/1 100 CAPSULE BOTTLE   3 Preferred Brand 20%20%None
ANASTROZOLE 1 MG TABLET   2* Generic $2.00$6.00Q:30
/30Days
ANORO ELLIPTA 62.5-25 MCG INH   3 Preferred Brand 20%20%Q:60
/30Days
APOKYN 30 MG/3 ML CARTRIDGE   5 Specialty Tier 26%N/AP
Apraclonidine 5 MG/ML Ophthalmic Solution   3 Preferred Brand 20%20%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
APREPITANT 125 MG CAPSULE [Emend]   4 Non-Preferred Drug 37%37%P Q:5
/30Days
APREPITANT 125-80-80 MG PACK [Emend]   4 Non-Preferred Drug 37%37%P Q:15
/30Days
APREPITANT 40 MG CAPSULE [Emend]   4 Non-Preferred Drug 37%37%P Q:1
/28Days
APREPITANT 80 MG CAPSULE [Emend]   4 Non-Preferred Drug 37%37%P Q:10
/30Days
APRI 0.15-0.03 TABLET   3 Preferred Brand 20%20%None
APTIOM 200 MG TABLET   4 Non-Preferred Drug 37%37%S
APTIOM 400 MG TABLET   4 Non-Preferred Drug 37%37%S
APTIOM 600 MG TABLET   4 Non-Preferred Drug 37%37%S
APTIOM 800 MG TABLET   4 Non-Preferred Drug 37%37%S
APTIVUS 250MG CAPSULE   5 Specialty Tier 26%N/AQ:120
/30Days
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT   5 Specialty Tier 26%N/AQ:380
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANELLE 7-9-5 TABLET   3 Preferred Brand 20%20%None
ARCALYST INJECTION 220MG/VIAL   5 Specialty Tier 26%N/AP
ARIPIPRAZOLE 1 MG/ML SOLUTION [Abilify]   4 Non-Preferred Drug 37%37%Q:900
/30Days
ARIPIPRAZOLE 10 MG TABLET [Abilify]   4 Non-Preferred Drug 37%37%Q:90
/30Days
ARIPIPRAZOLE 15 MG TABLET [Abilify]   4 Non-Preferred Drug 37%37%Q:60
/30Days
ARIPIPRAZOLE 2 MG TABLET [Abilify]   4 Non-Preferred Drug 37%37%Q:450
/30Days
ARIPIPRAZOLE 20 MG TABLET [Abilify]   4 Non-Preferred Drug 37%37%Q:30
/30Days
ARIPIPRAZOLE 30 MG TABLET [Abilify]   4 Non-Preferred Drug 37%37%Q:30
/30Days
ARIPIPRAZOLE 5 MG TABLET [Abilify]   4 Non-Preferred Drug 37%37%Q:180
/30Days
ARIPIPRAZOLE ODT 10 MG TABLET RAPDIS [Abilify Discmelt]   5 Specialty Tier 26%N/AQ:90
/30Days
ARIPIPRAZOLE ODT 15 MG TABLET RAPDIS [Abilify Discmelt]   5 Specialty Tier 26%N/AQ:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARMODAFINIL 150 MG TABLET [Nuvigil]   3 Preferred Brand 20%20%P Q:30
/30Days
ARMODAFINIL 200 MG TABLET [Nuvigil]   4 Non-Preferred Drug 37%37%P Q:30
/30Days
ARMODAFINIL 250 MG TABLET [Nuvigil]   4 Non-Preferred Drug 37%37%P Q:30
/30Days
ARMODAFINIL 50 MG TABLET [Nuvigil]   4 Non-Preferred Drug 37%37%P Q:60
/30Days
ARNUITY ELLIPTA 100 MCG INH   3 Preferred Brand 20%20%Q:30
/30Days
ARNUITY ELLIPTA 200 MCG INH   3 Preferred Brand 20%20%Q:30
/30Days
ARNUITY ELLIPTA 50 MCG INH BLST W/DEV   3 Preferred Brand 20%20%Q:30
/30Days
ASHLYNA 0.15-0.03-0.01 MG TABLET   3 Preferred Brand 20%20%None
Aspirin-Diphenhydramine ER 25-200 MG   4 Non-Preferred Drug 37%37%S Q:60
/30Days
ATAZANAVIR SULFATE 150 MG CAPSULE [Reyataz]   4 Non-Preferred Drug 37%37%Q:60
/30Days
ATAZANAVIR SULFATE 200 MG CAPSULE [Reyataz]   4 Non-Preferred Drug 37%37%Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATAZANAVIR SULFATE 300 MG CAPSULE [Reyataz]   4 Non-Preferred Drug 37%37%Q:30
/30Days
ATENOLOL 100 MG TABLET [Tenormin]   1* Preferred Generic $0.00$0.00None
ATENOLOL 25 MG TABLET   1* Preferred Generic $0.00$0.00None
ATENOLOL 50 MG TABLET [Tenormin]   1* Preferred Generic $0.00$0.00None
ATENOLOL-CHLORTHALIDONE 100-25   2* Generic $2.00$6.00None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   2* Generic $2.00$6.00None
ATOMOXETINE HCL 10 MG CAPSULE [Strattera]   4 Non-Preferred Drug 37%37%Q:60
/30Days
ATOMOXETINE HCL 100 MG CAPSULE [Strattera]   4 Non-Preferred Drug 37%37%Q:30
/30Days
ATOMOXETINE HCL 18 MG CAPSULE [Strattera]   4 Non-Preferred Drug 37%37%Q:60
/30Days
ATOMOXETINE HCL 25 MG CAPSULE [Strattera]   4 Non-Preferred Drug 37%37%Q:60
/30Days
ATOMOXETINE HCL 40 MG CAPSULE [Strattera]   4 Non-Preferred Drug 37%37%Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATOMOXETINE HCL 60 MG CAPSULE [Strattera]   4 Non-Preferred Drug 37%37%Q:30
/30Days
ATOMOXETINE HCL 80 MG CAPSULE [Strattera]   4 Non-Preferred Drug 37%37%Q:30
/30Days
ATORVASTATIN 10 MG TABLET [Lipitor]   1* Preferred Generic $0.00$0.00None
ATORVASTATIN 20 MG TABLET [Lipitor]   1* Preferred Generic $0.00$0.00None
ATORVASTATIN 40 MG TABLET [Lipitor]   1* Preferred Generic $0.00$0.00None
ATORVASTATIN 80 MG TABLET [Lipitor]   1* Preferred Generic $0.00$0.00None
ATOVAQUONE 750 MG/5 ML SUSP [Mepron]   5 Specialty Tier 26%N/AP
Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone]   4 Non-Preferred Drug 37%37%None
ATOVAQUONE-PROGUANIL 62.5-25 [Malarone]   4 Non-Preferred Drug 37%37%None
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC   5 Specialty Tier 26%N/AQ:30
/30Days
ATROPINE 1% EYE DROPS   4 Non-Preferred Drug 37%37%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATROVENT HFA AER 17MCG   4 Non-Preferred Drug 37%37%Q:26
/30Days
AUBRA EQ-28 TABLET [Vienva]   3 Preferred Brand 20%20%None
AVIANE 0.1-0.02 TABLET   3 Preferred Brand 20%20%None
AVITA 0.025% CREAM (g) [Tretin-X]   4 Non-Preferred Drug 37%37%P Q:45
/30Days
Avita 0.25mg/g 45 g in 1 TUBE   4 Non-Preferred Drug 37%37%P Q:45
/30Days
AYVAKIT 100 MG TABLET   5 Specialty Tier 26%N/AP Q:30
/30Days
AYVAKIT 200 MG TABLET   5 Specialty Tier 26%N/AP Q:30
/30Days
AYVAKIT 300 MG TABLET   5 Specialty Tier 26%N/AP Q:30
/30Days
AZATHIOPRINE 50 MG TABLET [Imuran]   3 Preferred Brand 20%20%P
AZELASTINE 0.15% NASAL SPRAY   4 Non-Preferred Drug 37%37%Q:30
/25Days
AZELASTINE 137 MCG NASAL SPRAY   4 Non-Preferred Drug 37%37%Q:30
/25Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZELASTINE HCL 0.05% EYE DROPS [Optivar]   4 Non-Preferred Drug 37%37%None
AZITHROMYCIN 1 GM POWDER PACKET   4 Non-Preferred Drug 37%37%None
AZITHROMYCIN 100 MG/5 ML ORAL SUSPENSION [Zithromax]   3 Preferred Brand 20%20%None
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [Zithromax]   3 Preferred Brand 20%20%None
AZITHROMYCIN 250 MG TABLET   2* Generic $2.00$6.00None
AZITHROMYCIN 250 MG TABLET [Zithromax Z-Pak]   2* Generic $2.00$6.00None
AZITHROMYCIN 500 MG TABLET   2* Generic $2.00$6.00None
AZITHROMYCIN 500 MG TABLET [Zithromax Tri-Pak]   2* Generic $2.00$6.00None
AZITHROMYCIN 600 MG TABLET [Zithromax Z-Pak]   2* Generic $2.00$6.00None
AZITHROMYCIN I.V. 500 MG VIAL [Zithromax]   4 Non-Preferred Drug 37%37%None
AZOPT 1% EYE DROPS   4 Non-Preferred Drug 37%37%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZTREONAM FOR INJECTION   4 Non-Preferred Drug 37%37%None

Chart Legend:

Below are a few notes to help you understand the above 2021 Medicare Part D Anthem MediBlue Rx Enhanced (PDP) 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 $445 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 $4130) 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.

      * When the text "$35 or less" appears, this Part D plan may offer this particular insulin as part of the Senior Savings Model.  The Senior Savings Model stipulates that the insulin will cost no more than $35 in the deductible, initial coverage, and coverage gap phases of your Part D plan. Please contact the drug plan for more details.

    • 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 October 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.