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Humana Premier Rx Plan (PDP) (S5884-157-0)
Tier 1 (239)
Tier 2 (606)
Tier 3 (721)
Tier 4 (1115)
Tier 5 (620)
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Uses Step Therapy:
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Has Quantity Limits:
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Cick on the first letter of your drug name to browse the formulary:

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2021 Medicare Part D Plan Formulary Information
Humana Premier Rx Plan (PDP) (S5884-157-0)
Benefit Details           
This plan covers select insulin pay $35 copay.
See individual insulin cost-sharing below.
The Humana Premier Rx Plan (PDP) (S5884-157-0)
Formulary Drugs Starting with the Letter E

in CMS PDP Region 11 which includes: FL
Plan Monthly Premium: $66.10 Deductible: $445 Qualifies for LIS: No
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
EDURANT 27.5mg/1   5 Specialty Tier 25%N/AQ:30
/30Days
EFAVIR-EMTRI-TENOF 600-200-300 TABLET [Atripla]   5 Specialty Tier 25%N/AQ:30
/30Days
EFAVIR-LAMIV-TENOF 400-300-300 TABLET [SYMFI LO]   5 Specialty Tier 25%N/AQ:30
/30Days
EFAVIR-LAMIV-TENOF 600-300-300 TABLET [SYMFI]   5 Specialty Tier 25%N/AQ:30
/30Days
EFAVIRENZ 200 MG CAPSULE [Sustiva]   4 Non-Preferred Drug 49%49%Q:120
/30Days
EFAVIRENZ 50 MG CAPSULE [Sustiva]   4 Non-Preferred Drug 49%49%Q:480
/30Days
EFAVIRENZ 600 MG TABLET [Sustiva]   4 Non-Preferred Drug 49%49%Q:30
/30Days
EGRIFTA SV 2 MG VIAL   5 Specialty Tier 25%N/AP Q:30
/30Days
ELIQUIS 2.5 MG TABLET   3 Preferred Brand $45.00$125.00Q:60
/30Days
ELIQUIS 5 MG STARTER PACK   3 Preferred Brand $45.00$125.00Q:74
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ELIQUIS 5 MG TABLET   3 Preferred Brand $45.00$125.00Q:74
/30Days
ELMIRON 100mg GELATIN COATED 100 CAPSULE BOTTLE   5 Specialty Tier 25%N/AQ:90
/30Days
EMCYT 140MG CAPSULE   5 Specialty Tier 25%N/ANone
EMGALITY 120 MG/ML PEN INJCTR   4 Non-Preferred Drug 49%49%P Q:2
/30Days
EMGALITY 120 MG/ML SYRINGE   4 Non-Preferred Drug 49%49%P Q:2
/30Days
EMOQUETTE 28 DAY TABLET [Solia]   4 Non-Preferred Drug 49%49%None
Empagliflozin 5 MG / Metformin hydrochloride 500 MG Oral Tablet [Synjardy]   3 Preferred Brand $45.00$125.00Q:60
/30Days
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H   5 Specialty Tier 25%N/AQ:30
/30Days
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H   5 Specialty Tier 25%N/AQ:30
/30Days
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H   5 Specialty Tier 25%N/AQ:30
/30Days
EMTRICITABINE 200 MG CAPSULE [Emtriva]   4 Non-Preferred Drug 49%49%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
EMTRICITABINE-TENOFV 100-150MG TABLET [Truvada]   5 Specialty Tier 25%N/AQ:30
/30Days
EMTRICITABINE-TENOFV 133-200MG TABLET [Truvada]   5 Specialty Tier 25%N/AQ:30
/30Days
EMTRICITABINE-TENOFV 167-250MG TABLET [Truvada]   5 Specialty Tier 25%N/AQ:30
/30Days
EMTRICITABINE-TENOFV 200-300MG TABLET [Truvada]   5 Specialty Tier 25%N/AQ:30
/30Days
EMTRIVA 10MG/ML SOLUTION   4 Non-Preferred Drug 49%49%Q:680
/28Days
EMTRIVA 200MG CAPSULE   4 Non-Preferred Drug 49%49%Q:30
/30Days
ENALAPRIL MALEATE 10 MG TABLET   2* Generic $4.00$0.00None
ENALAPRIL MALEATE 2.5 MG TABLET   2* Generic $4.00$0.00None
ENALAPRIL MALEATE 20 MG TABLET   2* Generic $4.00$0.00None
ENALAPRIL MALEATE 5 MG TABLET   2* Generic $4.00$0.00None
ENALAPRIL-HCTZ 10-25 MG TABLET [Vaseretic]   1* Preferred Generic $1.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ENALAPRIL-HCTZ 5-12.5 MG TABLET [Vaseretic]   1* Preferred Generic $1.00$0.00None
ENBREL 25 MG/0.5 ML SYRINGE   5 Specialty Tier 25%N/AP Q:8
/28Days
ENBREL 25 MG/0.5 ML VIAL   5 Specialty Tier 25%N/AP Q:8
/28Days
ENBREL 25MG KIT   5 Specialty Tier 25%N/AP Q:8
/28Days
ENBREL 50 MG/ML MINI CARTRIDGE   5 Specialty Tier 25%N/AP Q:8
/28Days
ENBREL 50 MG/ML SURECLICK PEN INJECTOR   5 Specialty Tier 25%N/AP Q:8
/28Days
ENBREL 50 MG/ML SYRINGE   5 Specialty Tier 25%N/AP Q:8
/28Days
ENDOCET 10MG-325MG TABLET   3 Preferred Brand $45.00$125.00Q:360
/30Days
ENDOCET 5/325 TABLET   3 Preferred Brand $45.00$125.00Q:360
/30Days
ENDOCET 7.5-325MG TABLET   3 Preferred Brand $45.00$125.00Q:360
/30Days
ENGERIX B INJECTION   4 Non-Preferred Drug 49%49%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ENGERIX-B 20 MCG/ML SYRINGE   4 Non-Preferred Drug 49%49%P
ENOXAPARIN 100 MG/ML SYRINGE [Lovenox]   4 Non-Preferred Drug 49%49%Q:28
/28Days
ENOXAPARIN 120 MG/0.8 ML SYRINGE [Lovenox]   4 Non-Preferred Drug 49%49%Q:22
/28Days
ENOXAPARIN 150 MG/ML SYRINGE [Lovenox]   4 Non-Preferred Drug 49%49%Q:28
/28Days
ENOXAPARIN 30 MG/0.3 ML SYRINGE [Lovenox]   4 Non-Preferred Drug 49%49%Q:17
/28Days
ENOXAPARIN 40 MG/0.4 ML SYRINGE [Lovenox]   4 Non-Preferred Drug 49%49%Q:11
/28Days
ENOXAPARIN 60 MG/0.6 ML SYRINGE [Lovenox]   4 Non-Preferred Drug 49%49%Q:17
/28Days
ENOXAPARIN 80 MG/0.8 ML SYRINGE [Lovenox]   4 Non-Preferred Drug 49%49%Q:22
/28Days
ENSKYCE 28 TABLET [Solia]   4 Non-Preferred Drug 49%49%None
ENSTILAR 0.005%-0.064% FOAM   4 Non-Preferred Drug 49%49%Q:120
/30Days
ENTACAPONE 200 MG TABLET [Comtan]   3 Preferred Brand $45.00$125.00Q:300
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ENTECAVIR 0.5 MG TABLET [Baraclude]   4 Non-Preferred Drug 49%49%Q:30
/30Days
ENTECAVIR 1 MG TABLET [Baraclude]   4 Non-Preferred Drug 49%49%Q:30
/30Days
ENTRESTO 24 MG-26 MG TABLET   3 Preferred Brand $45.00$125.00Q:60
/30Days
ENTRESTO 49 MG-51 MG TABLET   3 Preferred Brand $45.00$125.00Q:60
/30Days
ENTRESTO 97 MG-103 MG TABLET   3 Preferred Brand $45.00$125.00Q:60
/30Days
ENULOSE 10 GM/15 ML SOLUTION   2* Generic $4.00$0.00None
ENVARSUS XR 0.75 MG TABLET   4 Non-Preferred Drug 49%49%P
ENVARSUS XR 1 MG TABLET   4 Non-Preferred Drug 49%49%P
ENVARSUS XR 4 MG TABLET ER 24H   5 Specialty Tier 25%N/AP
EPCLUSA 200 MG-50 MG TABLET   5 Specialty Tier 25%N/AP Q:28
/28Days
EPCLUSA 400 MG-100 MG TABLET   5 Specialty Tier 25%N/AP Q:28
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
EPIDIOLEX 100 MG/ML SOLUTION   5 Specialty Tier 25%N/AP
EPINEPHRINE 0.15 MG AUTO-INJECT   3 Preferred Brand $45.00$125.00Q:4
/30Days
EPINEPHRINE 0.15 MG AUTO-INJECT [Twinject]   3 Preferred Brand $45.00$125.00Q:4
/30Days
EPINEPHRINE 0.3 MG AUTO-INJECT   4 Non-Preferred Drug 49%49%Q:4
/30Days
EPINEPHRINE 0.3 MG AUTO-INJECT [Twinject]   4 Non-Preferred Drug 49%49%Q:4
/30Days
EPITOL 200MG TABLET   3 Preferred Brand $45.00$125.00None
EPIVIR HBV 25MG/5ML TUBEX   4 Non-Preferred Drug 49%49%None
ERAXIS 100mg/30mL 30 mL in 1 VIAL, SINGLE-USE   5 Specialty Tier 25%N/ANone
ERAXIS(WATER DIL) 50 MG VIAL   4 Non-Preferred Drug 49%49%None
Ergotamine-caffeine 1-100mg tablet   3 Preferred Brand $45.00$125.00Q:40
/30Days
ERIVEDGE 150 MG CAPSULE   5 Specialty Tier 25%N/AP Q:28
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ERLEADA 60 MG TABLET   5 Specialty Tier 25%N/AP Q:120
/30Days
ERLOTINIB HCL 100 MG TABLET [Tarceva]   5 Specialty Tier 25%N/AP Q:30
/30Days
ERLOTINIB HCL 150 MG TABLET [Tarceva]   5 Specialty Tier 25%N/AP Q:30
/30Days
ERLOTINIB HCL 25 MG TABLET [Tarceva]   5 Specialty Tier 25%N/AP Q:90
/30Days
ERRIN 0.35 MG TABLET [Sharobel 28-Day]   4 Non-Preferred Drug 49%49%None
ERTAPENEM 1 GRAM VIAL [Invanz]   4 Non-Preferred Drug 49%49%None
ERY 2% PADS 2% 60 PADS JAR   3 Preferred Brand $45.00$125.00Q:60
/30Days
ERYTHROCIN LACT 500 MG VIAL   4 Non-Preferred Drug 49%49%None
ERYTHROMYCIN 0.5% EYE OINTMENT [Romycin]   2* Generic $4.00$0.00None
ERYTHROMYCIN 2% SOLUTION   4 Non-Preferred Drug 49%49%Q:120
/30Days
ERYTHROMYCIN DR 250 MG CAPSULE DR [ERYC]   4 Non-Preferred Drug 49%49%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ESBRIET 267 MG CAPSULE   5 Specialty Tier 25%N/AP Q:270
/30Days
ESBRIET 267 MG TABLET   5 Specialty Tier 25%N/AP Q:270
/30Days
ESBRIET 801 MG TABLET   5 Specialty Tier 25%N/AP Q:90
/30Days
ESCITALOPRAM 10 MG TABLET [Lexapro]   1* Preferred Generic $1.00$0.00Q:45
/30Days
ESCITALOPRAM 20 MG TABLET [Lexapro]   1* Preferred Generic $1.00$0.00Q:30
/30Days
ESCITALOPRAM 5 MG TABLET [Lexapro]   1* Preferred Generic $1.00$0.00Q:30
/30Days
ESCITALOPRAM OXALATE 5 MG/5 ML [Lexapro]   4 Non-Preferred Drug 49%49%Q:600
/30Days
ESOMEPRAZOLE MAG DR 20 MG CAPSULE [Nexium]   3 Preferred Brand $45.00$125.00Q:60
/30Days
ESOMEPRAZOLE MAG DR 40 MG CAPSULE [Nexium]   3 Preferred Brand $45.00$125.00Q:60
/30Days
Estradiol / Norethindrone Acetate 0.5; 0.1mg/1; mg/1 1 BLISTER PACK per CARTON / 28 TABLET, FILM C   3 Preferred Brand $45.00$125.00None
ESTRADIOL 0.01% CREAM   3 Preferred Brand $45.00$125.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Estradiol 0.025 mg patch   4 Non-Preferred Drug 49%49%Q:8
/28Days
ESTRADIOL 0.0375MG PATCH(2/WK) PATCH TDSW [Vivelle-Dot]   4 Non-Preferred Drug 49%49%Q:8
/28Days
Estradiol 0.05 mg patch   4 Non-Preferred Drug 49%49%Q:8
/28Days
ESTRADIOL 0.05 MG PATCH (1/WK) [Climara]   4 Non-Preferred Drug 49%49%Q:4
/28Days
ESTRADIOL 0.06 MG PATCH (1/WK) [Climara]   4 Non-Preferred Drug 49%49%Q:4
/28Days
Estradiol 0.075 mg patch   4 Non-Preferred Drug 49%49%Q:8
/28Days
Estradiol 0.1 mg patch   4 Non-Preferred Drug 49%49%Q:8
/28Days
ESTRADIOL 0.1 MG PATCH (1/WK) [Climara]   4 Non-Preferred Drug 49%49%Q:4
/28Days
ESTRADIOL 0.5 MG TABLET   1* Preferred Generic $1.00$0.00None
ESTRADIOL 1 MG TABLET   1* Preferred Generic $1.00$0.00None
ESTRADIOL 10 MCG VAGINAL INSRT   4 Non-Preferred Drug 49%49%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ESTRADIOL 2MG TABLET   1* Preferred Generic $1.00$0.00None
ESTRADIOL TDS 0.025 MG/DAY   4 Non-Preferred Drug 49%49%Q:4
/28Days
ESTRADIOL TDS 0.0375 MG/DAY   4 Non-Preferred Drug 49%49%Q:4
/28Days
ESTRADIOL TDS 0.075 MG/DAY   4 Non-Preferred Drug 49%49%Q:4
/28Days
ESTRADIOL VALERATE 20mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE   4 Non-Preferred Drug 49%49%None
ESTRADIOL VALERATE 40mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE   4 Non-Preferred Drug 49%49%None
ESTRADIOL-NORETH 1.0-0.5MG TABLET   3 Preferred Brand $45.00$125.00None
ESTRING 2MG VAGINAL RING   4 Non-Preferred Drug 49%49%Q:1
/90Days
ESZOPICLONE 1 MG TABLET [Lunesta]   2* Generic $4.00$0.00Q:30
/30Days
ESZOPICLONE 2 MG TABLET [Lunesta]   2* Generic $4.00$0.00Q:30
/30Days
ESZOPICLONE 3 MG TABLET [Lunesta]   2* Generic $4.00$0.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ETHAMBUTOL HCL 400 MG TABLET   3 Preferred Brand $45.00$125.00None
Ethambutol Hydrochloride 100mg/1   3 Preferred Brand $45.00$125.00None
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6   4 Non-Preferred Drug 49%49%None
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TABLET 21   4 Non-Preferred Drug 49%49%None
ETHOSUXIMIDE 250 MG CAPSULE [Zarontin]   3 Preferred Brand $45.00$125.00None
ETHOSUXIMIDE 250 MG/5 ML SOLUTION   4 Non-Preferred Drug 49%49%None
ETHYNODIOL-ETH ESTRA 1MG-35MCG [ZOVIA]   4 Non-Preferred Drug 49%49%None
ETHYNODIOL-ETH ESTRA 1MG-50MCG [ZOVIA]   4 Non-Preferred Drug 49%49%None
ETODOLAC 200 MG CAPSULE [Lodine]   3 Preferred Brand $45.00$125.00None
ETODOLAC 300 MG CAPSULE [Lodine]   3 Preferred Brand $45.00$125.00None
ETODOLAC 400 MG TABLET [Lodine]   3 Preferred Brand $45.00$125.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ETODOLAC 500 MG TABLET [Lodine]   3 Preferred Brand $45.00$125.00None
ETODOLAC ER 400 MG TABLET ER 24H [Lodine XL]   4 Non-Preferred Drug 49%49%None
ETODOLAC ER 500 MG TABLET ER 24H [Lodine XL]   4 Non-Preferred Drug 49%49%None
ETODOLAC ER 600 MG TABLET ER 24H [Lodine XL]   4 Non-Preferred Drug 49%49%None
EUTHYROX 100 MCG TABLET   1* Preferred Generic $1.00$0.00None
EUTHYROX 112 MCG TABLET   1* Preferred Generic $1.00$0.00None
EUTHYROX 125 MCG TABLET   1* Preferred Generic $1.00$0.00None
EUTHYROX 137 MCG TABLET   1* Preferred Generic $1.00$0.00None
EUTHYROX 150 MCG TABLET   1* Preferred Generic $1.00$0.00None
EUTHYROX 175 MCG TABLET   1* Preferred Generic $1.00$0.00None
EUTHYROX 200 MCG TABLET   1* Preferred Generic $1.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
EUTHYROX 25 MCG TABLET   1* Preferred Generic $1.00$0.00None
EUTHYROX 50 MCG TABLET   1* Preferred Generic $1.00$0.00None
EUTHYROX 75 MCG TABLET   1* Preferred Generic $1.00$0.00None
EUTHYROX 88 MCG TABLET   1* Preferred Generic $1.00$0.00None
EVEROLIMUS 0.25 MG TABLET [Zortress]   4 Non-Preferred Drug 49%49%P Q:60
/30Days
EVEROLIMUS 0.5 MG TABLET [Zortress]   5 Specialty Tier 25%N/AP Q:120
/30Days
EVEROLIMUS 0.75 MG TABLET [Zortress]   5 Specialty Tier 25%N/AP Q:60
/30Days
EVOTAZ 300 MG-150 MG TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
EVRYSDI 60 MG/80 ML(0.75MG/ML) SOLUTION RECON   5 Specialty Tier 25%N/AP Q:240
/30Days
EXEMESTANE 25 MG TABLET [Aromasin]   4 Non-Preferred Drug 49%49%Q:60
/30Days
EZETIMIBE 10 MG TABLET [Zetia]   3 Preferred Brand $45.00$125.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
EZETIMIBE-SIMVASTATIN 10-10 MG TABLET [Vytorin]   3 Preferred Brand $45.00$125.00Q:30
/30Days
EZETIMIBE-SIMVASTATIN 10-20 MG TABLET [Vytorin]   3 Preferred Brand $45.00$125.00Q:30
/30Days
EZETIMIBE-SIMVASTATIN 10-40 MG TABLET [Vytorin]   3 Preferred Brand $45.00$125.00Q:30
/30Days
EZETIMIBE-SIMVASTATIN 10-80 MG TABLET [Vytorin]   3 Preferred Brand $45.00$125.00Q:30
/30Days

Chart Legend:

Below are a few notes to help you understand the above 2021 Medicare Part D Humana Premier Rx Plan (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 $4,130) 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 insulin copay is in green, example: $35.00, this Part D plan may offer particular forms of insulin as part of the Senior Savings Model.  The Senior Savings Model stipulates that some 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 September 2021 )

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.