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AARP MedicareRx Preferred (PDP) (S5820-015-0)
Tier 1 (155)
Tier 2 (720)
Tier 3 (959)
Tier 4 (1048)
Tier 5 (684)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
Yes No Show either
Cick on the first letter of your drug name to browse the formulary:

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M N O P Q R S T U V W X Y Z 0-9 
2021 Medicare Part D Plan Formulary Information
AARP MedicareRx Preferred (PDP) (S5820-015-0)
Benefit Details           
This plan covers select insulin pay $35 copay.
See individual insulin cost-sharing below.
The AARP MedicareRx Preferred (PDP) (S5820-015-0)
Formulary Drugs Starting with the Letter F

in CMS PDP Region 16 which includes: WI
Plan Monthly Premium: $92.80 Deductible: $0 Qualifies for LIS: No
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   4 Non-Preferred Drug 40%40%None
FAMCICLOVIR 125 MG TABLET   3 Preferred Brand $45.00$120.00Q:60
/30Days
FAMCICLOVIR 250 MG TABLET   3 Preferred Brand $45.00$120.00Q:60
/30Days
FAMCICLOVIR 500 MG TABLET   3 Preferred Brand $45.00$120.00Q:90
/30Days
FAMOTIDINE 20 MG TABLET   2 Generic $10.00$0.00None
FAMOTIDINE 40 MG TABLET   2 Generic $10.00$0.00None
FANAPT 1 MG TABLET   4 Non-Preferred Drug 40%40%S Q:60
/30Days
FANAPT 10 MG TABLET   4 Non-Preferred Drug 40%40%S Q:60
/30Days
FANAPT 12 MG TABLET   4 Non-Preferred Drug 40%40%S Q:60
/30Days
FANAPT 2 MG TABLET   4 Non-Preferred Drug 40%40%S Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FANAPT 4 MG TABLET   4 Non-Preferred Drug 40%40%S Q:60
/30Days
FANAPT 6 MG TABLET   4 Non-Preferred Drug 40%40%S Q:60
/30Days
FANAPT 8 MG TABLET   4 Non-Preferred Drug 40%40%S Q:60
/30Days
FANAPT TITR TABLETS   4 Non-Preferred Drug 40%40%S
FARXIGA 10 MG TABLET   3 Preferred Brand $45.00$120.00Q:30
/30Days
FARXIGA 5 MG TABLET   3 Preferred Brand $45.00$120.00Q:30
/30Days
FARYDAK 10 MG CAPSULE   5 Specialty Tier 33%N/AP
FARYDAK 15 MG CAPSULE   5 Specialty Tier 33%N/AP
FARYDAK 20 MG CAPSULE   5 Specialty Tier 33%N/AP
FASENRA 30 MG/ML SYRINGE   5 Specialty Tier 33%N/AP
FASENRA PEN 30 MG/ML AUTO INJCT   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FAYOSIM TABLET TBDSPK 3MO [Quartette]   4 Non-Preferred Drug 40%40%None
FEBUXOSTAT 40 MG TABLET [Uloric]   3 Preferred Brand $45.00$120.00S
FEBUXOSTAT 80 MG TABLET [Uloric]   3 Preferred Brand $45.00$120.00S
FELBAMATE 400 MG TABLET   4 Non-Preferred Drug 40%40%None
FELBAMATE 600 MG TABLET [Felbatol]   4 Non-Preferred Drug 40%40%None
FELBAMATE 600 MG/5 ML ORAL SUSPENSION [Felbatol]   5 Specialty Tier 33%N/ANone
FELODIPINE ER 10 MG TABLET   3 Preferred Brand $45.00$120.00None
FELODIPINE ER 2.5 MG TABLET ER 24H [Plendil]   3 Preferred Brand $45.00$120.00None
FELODIPINE ER 5 MG TABLET   3 Preferred Brand $45.00$120.00None
FEMRING 0.05 MG/DAY VAGINAL RING   4 Non-Preferred Drug 40%40%None
FEMRING 0.10 MG/DAY VAGINAL RING   4 Non-Preferred Drug 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FEMYNOR 28 TABLET [VyLibra]   4 Non-Preferred Drug 40%40%None
FENOFIBRATE 134 MG CAPSULE [Tricor]   3 Preferred Brand $45.00$120.00None
FENOFIBRATE 145 MG TABLET [Tricor]   3 Preferred Brand $45.00$120.00None
FENOFIBRATE 160 MG TABLET [Triglide]   2 Generic $10.00$0.00None
FENOFIBRATE 200 MG CAPSULE [Tricor]   3 Preferred Brand $45.00$120.00None
FENOFIBRATE 48 MG TABLET [Tricor]   3 Preferred Brand $45.00$120.00None
FENOFIBRATE 54 MG 90 TABLET BOTTLE [LIPOFEN]   2 Generic $10.00$0.00None
FENOFIBRATE 67 MG CAPSULE [Tricor]   3 Preferred Brand $45.00$120.00None
FENOFIBRIC ACID DR 135 MG CAPSULE [TRILIPIX]   3 Preferred Brand $45.00$120.00None
FENOFIBRIC ACID DR 45 MG CAPSULE DR [Trilipix]   3 Preferred Brand $45.00$120.00None
FENTANYL 100 MCG/HR PATCH TD72 [Duragesic]   3 Preferred Brand $45.00$120.00Q:15
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FENTANYL 12 MCG/HR PATCH TD72 [Duragesic]   3 Preferred Brand $45.00$120.00Q:15
/30Days
FENTANYL 25 MCG/HR PATCH TD72 [Duragesic]   3 Preferred Brand $45.00$120.00Q:15
/30Days
FENTANYL 50 MCG/HR PATCH TD72 [Duragesic]   3 Preferred Brand $45.00$120.00Q:15
/30Days
FENTANYL 75 MCG/HR PATCH TD72 [Duragesic]   3 Preferred Brand $45.00$120.00Q:15
/30Days
FENTANYL CIT OTFC 1,200 MCG LOZENGE HD [Actiq]   5 Specialty Tier 33%N/AP Q:120
/30Days
FENTANYL CIT OTFC 1,600 MCG LOZENGE HD [Actiq]   5 Specialty Tier 33%N/AP Q:120
/30Days
FENTANYL CITRATE OTFC 200 MCG LOZENGE HD [Actiq]   4 Non-Preferred Drug 40%40%P Q:120
/30Days
FENTANYL CITRATE OTFC 400 MCG LOZENGE HD [Actiq]   5 Specialty Tier 33%N/AP Q:120
/30Days
FENTANYL CITRATE OTFC 600 MCG LOZENGE HD [Actiq]   5 Specialty Tier 33%N/AP Q:120
/30Days
FENTANYL CITRATE OTFC 800 MCG LOZENGE HD [Actiq]   5 Specialty Tier 33%N/AP Q:120
/30Days
FERRIPROX 1,000 MG TABLET   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FERRIPROX 100 MG/ML SOLUTION   5 Specialty Tier 33%N/AP
FERRIPROX 500 MG TABLET   5 Specialty Tier 33%N/AP
FETZIMA 20-40 MG TITRATION PAK   4 Non-Preferred Drug 40%40%S
FETZIMA ER 120 MG CAPSULE   4 Non-Preferred Drug 40%40%S Q:30
/30Days
FETZIMA ER 20 MG CAPSULE   4 Non-Preferred Drug 40%40%S Q:30
/30Days
FETZIMA ER 40 MG CAPSULE   4 Non-Preferred Drug 40%40%S Q:30
/30Days
FETZIMA ER 80 MG CAPSULE   4 Non-Preferred Drug 40%40%S Q:30
/30Days
FINACEA 15% FOAM   4 Non-Preferred Drug 40%40%None
FINASTERIDE 5 MG TABLET [Proscar]   2 Generic $10.00$0.00None
FINTEPLA 2.2 MG/ML SOLUTION   5 Specialty Tier 33%N/AP Q:360
/30Days
FIRMAGON 2 X 120 MG KIT   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FIRMAGON 80 MG KIT   4 Non-Preferred Drug 40%40%P
FLAC OTIC OIL 0.01% EAR DROPS [Flac]   4 Non-Preferred Drug 40%40%None
FLAREX 0.1% EYE DROPS EYE DROPPER   4 Non-Preferred Drug 40%40%None
FLEBOGAMMA DIF 10% VIAL   5 Specialty Tier 33%N/AP
FLECAINIDE ACETATE 100 MG TABLET [Tambocor]   2 Generic $10.00$0.00None
FLECAINIDE ACETATE 150 MG TABLET [Tambocor]   2 Generic $10.00$0.00None
FLECAINIDE ACETATE 50 MG TABLET [Tambocor]   2 Generic $10.00$0.00None
FLOVENT DISKUS 100ug/1 60 POWDER, METERED in 1 INHALER   3 Preferred Brand $45.00$120.00Q:120
/30Days
FLOVENT DISKUS 250ug/1 60 POWDER, METERED in 1 INHALER   3 Preferred Brand $45.00$120.00Q:120
/30Days
FLOVENT DISKUS POWDER 50MCG 60 CTR   3 Preferred Brand $45.00$120.00Q:120
/30Days
FLOVENT HFA 110ug/1 120 AEROSOL, METERED in 1 INHALER   3 Preferred Brand $45.00$120.00Q:12
/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 Preferred Brand $45.00$120.00Q:24
/30Days
FLOVENT HFA 44ug/1 120 AEROSOL, METERED in 1 INHALER   3 Preferred Brand $45.00$120.00Q:11
/30Days
FLUCONAZOLE 10 MG/ML ORAL SUSPENSION [Diflucan]   2 Generic $10.00$0.00None
FLUCONAZOLE 100 MG TABLET [Diflucan]   2 Generic $10.00$0.00None
FLUCONAZOLE 150 MG TABLET [Diflucan]   2 Generic $10.00$0.00None
FLUCONAZOLE 200 MG TABLET [Diflucan]   2 Generic $10.00$0.00None
FLUCONAZOLE 40 MG/ML ORAL SUSPENSION [Diflucan]   2 Generic $10.00$0.00None
FLUCONAZOLE 50 MG TABLET [Diflucan]   2 Generic $10.00$0.00None
FLUCONAZOLE-NACL 200 MG/100 ML PIGGYBACK [Diflucan]   4 Non-Preferred Drug 40%40%None
FLUCONAZOLE-NACL 400 MG/200 ML PIGGYBACK [Diflucan]   4 Non-Preferred Drug 40%40%None
FLUCYTOSINE 250 MG CAPSULE [Ancobon]   5 Specialty Tier 33%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 Specialty Tier 33%N/ANone
FLUDROCORTISONE 0.1 MG TABLET [Florinef]   2 Generic $10.00$0.00None
FLUNISOLIDE NASAL SOLUTION 0.025% 25ML INHL   3 Preferred Brand $45.00$120.00None
FLUOCINOLONE 0.01% CREAM (g)   3 Preferred Brand $45.00$120.00None
FLUOCINOLONE 0.01% SCALP OIL [Derma-Smoothe/FS]   4 Non-Preferred Drug 40%40%None
FLUOCINOLONE 0.01% SOLUTION [Synalar]   3 Preferred Brand $45.00$120.00None
FLUOCINOLONE 0.025% CREAM (G) [Synalar]   3 Preferred Brand $45.00$120.00None
FLUOCINOLONE 0.025% OINTMENT   3 Preferred Brand $45.00$120.00None
FLUOCINOLONE OIL 0.01% EAR DROPS [Flac]   4 Non-Preferred Drug 40%40%None
FLUOCINONIDE 0.05% CREAM (G) [Lidex]   3 Preferred Brand $45.00$120.00None
FLUOCINONIDE 0.05% GEL [Lidex]   3 Preferred Brand $45.00$120.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FLUOCINONIDE 0.05% OINTMENT [Lidex]   3 Preferred Brand $45.00$120.00None
FLUOCINONIDE 0.05% SOLUTION   3 Preferred Brand $45.00$120.00None
FLUOCINONIDE-E 0.05% CREAM   3 Preferred Brand $45.00$120.00None
Fluorometholone 0.1% drops   3 Preferred Brand $45.00$120.00None
FLUOROURACIL 2% TOPICAL SOLUTION   3 Preferred Brand $45.00$120.00None
FLUOROURACIL 5% CREAM (g) [Efudex]   4 Non-Preferred Drug 40%40%None
FLUOROURACIL 5% TOPICAL SOLUTION   3 Preferred Brand $45.00$120.00None
Fluoxetine 20mg/5mL 120 mL in 1 BOTTLE, PLASTIC   2 Generic $10.00$0.00None
FLUOXETINE DR 90 MG CAPSULE   4 Non-Preferred Drug 40%40%None
FLUOXETINE HCL 10 MG CAPSULE [Selfemra]   2 Generic $10.00$0.00None
FLUOXETINE HCL 20 MG CAPSULE   2 Generic $10.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FLUOXETINE HCL 40 MG CAPSULE [Prozac]   2 Generic $10.00$0.00None
FLUPHENAZINE 1 MG TABLET   2 Generic $10.00$0.00None
FLUPHENAZINE 10 MG TABLET [Prolixin]   2 Generic $10.00$0.00None
FLUPHENAZINE 2.5 MG TABLET   2 Generic $10.00$0.00None
FLUPHENAZINE 2.5 MG/5 ML ELIX   4 Non-Preferred Drug 40%40%None
FLUPHENAZINE 2.5MG/ML VIAL   4 Non-Preferred Drug 40%40%None
FLUPHENAZINE 5 MG TABLET   2 Generic $10.00$0.00None
FLUPHENAZINE 5MG/ML CONC   3 Preferred Brand $45.00$120.00None
FLUPHENAZINE DEC 125 MG/5 ML VIAL [Prolixin Decanoate]   4 Non-Preferred Drug 40%40%None
FLURBIPROFEN 0.03% EYE DROPS [Ocufen]   2 Generic $10.00$0.00None
Flurbiprofen 100mg/1 100 BOTTLE in 1 BOTTLE / 100 FILM COATED TABLETS in BOTTLE   2 Generic $10.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FLUTAMIDE 125 MG CAPSULE [Eulexin]   3 Preferred Brand $45.00$120.00None
FLUTICASONE PROP 0.005% OINTMENT [Cutivate]   3 Preferred Brand $45.00$120.00None
Fluticasone Propionate 0.5mg/g 1 TUBE per CARTON / 30 g in 1 TUBE   3 Preferred Brand $45.00$120.00None
FLUTICASONE PROPIONATE 50 MCG SPRAY SUSPENSION   2 Generic $10.00$0.00None
FLUTICASONE-SALMETEROL 100-50 BLST W/DEV [Advair]   3 Preferred Brand $45.00$120.00Q:60
/30Days
FLUTICASONE-SALMETEROL 113-14 [Advair Diskus, Advair HFA, AIRDUO RESPICLICK]   3 Preferred Brand $45.00$120.00Q:1
/30Days
FLUTICASONE-SALMETEROL 232-14 [Advair Diskus, Advair HFA, AIRDUO RESPICLICK]   3 Preferred Brand $45.00$120.00Q:1
/30Days
FLUTICASONE-SALMETEROL 250-50 BLST W/DEV [Advair]   3 Preferred Brand $45.00$120.00Q:60
/30Days
FLUTICASONE-SALMETEROL 500-50 BLST W/DEV [Advair]   3 Preferred Brand $45.00$120.00Q:60
/30Days
FLUTICASONE-SALMETEROL 55-14 [Advair Diskus, Advair HFA, AIRDUO RESPICLICK]   3 Preferred Brand $45.00$120.00Q:1
/30Days
FLUVOXAMINE MALEATE 100 MG TABLET [Luvox]   3 Preferred Brand $45.00$120.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FLUVOXAMINE MALEATE 25 MG TABLET [Luvox]   3 Preferred Brand $45.00$120.00None
FLUVOXAMINE MALEATE 50 MG TABLET [Luvox]   3 Preferred Brand $45.00$120.00None
FML FORTE 0.25% EYE DROPS   4 Non-Preferred Drug 40%40%None
FML S.O.P. 0.1% OINTMENT   4 Non-Preferred Drug 40%40%None
FONDAPARINUX 10 MG/0.8 ML SYRINGE [Arixtra]   4 Non-Preferred Drug 40%40%None
FONDAPARINUX 2.5 MG/0.5 ML SYR SYRINGE [Arixtra]   4 Non-Preferred Drug 40%40%None
FONDAPARINUX 5 MG/0.4 ML SYRINGE [Arixtra]   4 Non-Preferred Drug 40%40%None
FONDAPARINUX 7.5 MG/0.6 ML SYRINGE [Arixtra]   4 Non-Preferred Drug 40%40%None
Forteo 250ug/mL 1 SYRINGE per CARTON / 2.4 mL in 1 SYRINGE   5 Specialty Tier 33%N/AP Q:2
/28Days
FOSAMPRENAVIR 700 MG TABLET [Lexiva]   5 Specialty Tier 33%N/AQ:120
/30Days
FOSINOPRIL SODIUM 10 MG TABLET [Monopril]   1 Preferred Generic $5.00$0.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FOSINOPRIL SODIUM 20 MG TABLET [Monopril]   1 Preferred Generic $5.00$0.00Q:60
/30Days
FOSINOPRIL SODIUM 40 MG TABLET [Monopril]   1 Preferred Generic $5.00$0.00Q:60
/30Days
FOSINOPRIL-HCTZ 10-12.5 MG TABLET [Monopril-HCT]   2 Generic $10.00$0.00Q:120
/30Days
FOSINOPRIL-HCTZ 20-12.5 MG TABLET [Monopril-HCT]   2 Generic $10.00$0.00Q:120
/30Days
FOTIVDA 0.89 MG CAPSULE   5 Specialty Tier 33%N/AP Q:30
/30Days
FOTIVDA 1.34 MG CAPSULE   5 Specialty Tier 33%N/AP Q:30
/30Days
FUROSEMIDE 10 MG/ML SOLUTION   1 Preferred Generic $5.00$0.00None
FUROSEMIDE 100 MG/10 ML VIAL   4 Non-Preferred Drug 40%40%P
Furosemide 10mg/mL 10 CARTON in 1 CONTAINER / 1 SYRINGE, PLASTIC in 1 CARTON / 4 mL in 1 SYRINGE, P   4 Non-Preferred Drug 40%40%P
FUROSEMIDE 20 MG TABLET [Lasix]   1 Preferred Generic $5.00$0.00None
FUROSEMIDE 40 MG TABLET [Lasix]   1 Preferred Generic $5.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FUROSEMIDE 40MG/5ML TUBEX   1 Preferred Generic $5.00$0.00None
FUROSEMIDE 80 MG TABLET [Lasix]   1 Preferred Generic $5.00$0.00None
FUZEON 90 MG VIAL   5 Specialty Tier 33%N/AQ:60
/30Days
FYAVOLV 0.5 MG-2.5 MCG TABLET [Jevantique]   3 Preferred Brand $45.00$120.00None
FYAVOLV 1 MG-5 MCG TABLET [Jinteli 1/5]   3 Preferred Brand $45.00$120.00None
FYCOMPA 0.5 MG/ML ORAL SUSP   5 Specialty Tier 33%N/AQ:720
/30Days
FYCOMPA 10 MG TABLET   5 Specialty Tier 33%N/AQ:30
/30Days
FYCOMPA 12 MG TABLET   5 Specialty Tier 33%N/AQ:30
/30Days
FYCOMPA 2 MG TABLET   4 Non-Preferred Drug 40%40%Q:30
/30Days
FYCOMPA 4 MG TABLET   5 Specialty Tier 33%N/AQ:30
/30Days
FYCOMPA 6 MG TABLET   5 Specialty Tier 33%N/AQ:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FYCOMPA 8 MG TABLET   5 Specialty Tier 33%N/AQ:30
/30Days

Chart Legend:

Below are a few notes to help you understand the above 2021 Medicare Part D AARP MedicareRx Preferred (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.