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Humana Premier Rx Plan (PDP) (S5884-162-0)
Tier 1 (239)
Tier 2 (606)
Tier 3 (721)
Tier 4 (1115)
Tier 5 (620)
Requires Prior Authorization:
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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) (S5884-162-0)
Benefit Details           
This plan covers select insulin pay $35 copay.
See individual insulin cost-sharing below.
The Humana Premier Rx Plan (PDP) (S5884-162-0)
Formulary Drugs Starting with the Letter S

in CMS PDP Region 16 which includes: WI
Plan Monthly Premium: $63.30 Deductible: $445 Qualifies for LIS: No
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   4 Non-Preferred Drug 49%49%Q:4
/30Days
SANDIMMUNE 100MG/ML TUBEX   4 Non-Preferred Drug 49%49%P
SANTYL OINTMENT   3 Preferred Brand $45.00$125.00Q:180
/30Days
SAPHRIS 10 MG TABLET SL BLACK CHERRY   4 Non-Preferred Drug 49%49%P Q:60
/30Days
SAPHRIS 2.5 MG TABLET SL BLACK CHERRY   4 Non-Preferred Drug 49%49%P Q:60
/30Days
SAPHRIS 5 MG TABLET SL BLACK CHERRY   4 Non-Preferred Drug 49%49%P Q:60
/30Days
SAPROPTERIN 100 MG POWDER PACK [KUVAN]   5 Specialty Tier 25%N/AP
SAPROPTERIN 100 MG TABLET SOL [KUVAN]   5 Specialty Tier 25%N/AP
SAPROPTERIN 500 MG POWDER PACK [KUVAN]   5 Specialty Tier 25%N/AP
SAVELLA TABLETS 100MG 60 COUNT BOT   3 Preferred Brand $45.00$125.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SAVELLA TABLETS 12.5MG 60 COUNT BOT   3 Preferred Brand $45.00$125.00Q:60
/30Days
SAVELLA TABLETS 25MG 60 COUNT BOT   3 Preferred Brand $45.00$125.00Q:60
/30Days
SAVELLA TABLETS TITRATION PACK KIT 12.5;25;50MG;MG;MG 55 COUNT PKGCOM   3 Preferred Brand $45.00$125.00Q:60
/30Days
SAVELLA TALBETS 50MG 60 COUNT BOT   3 Preferred Brand $45.00$125.00Q:60
/30Days
SCOPOLAMINE 1 MG/3 DAY PATCH TD 3 [Transderm Scop]   4 Non-Preferred Drug 49%49%Q:10
/30Days
SECUADO 3.8 MG/24 HR PATCH   5 Specialty Tier 25%N/AP Q:30
/30Days
SECUADO 5.7 MG/24 HR PATCH   5 Specialty Tier 25%N/AP Q:30
/30Days
SECUADO 7.6 MG/24 HR PATCH   5 Specialty Tier 25%N/AP Q:30
/30Days
SELEGILINE HCL 5 MG TABLET   3 Preferred Brand $45.00$125.00None
SELEGILINE HCL 5MG CAPSULE   3 Preferred Brand $45.00$125.00None
SELENIUM SULFIDE 2.5mg/100mL 118 mL in 1 BOTTLE   2* Generic $4.00$0.00Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SELZENTRY 150mg/1 60 FILM COATED TABLETS in BOTTLE   5 Specialty Tier 25%N/AQ:240
/30Days
SELZENTRY 20 MG/ML ORAL SOLUTION   5 Specialty Tier 25%N/AQ:1800
/30Days
SELZENTRY 25 MG TABLET   5 Specialty Tier 25%N/AQ:240
/30Days
SELZENTRY 300mg/1 60 FILM COATED TABLETS in BOTTLE   5 Specialty Tier 25%N/AQ:120
/30Days
SELZENTRY 75 MG TABLET   5 Specialty Tier 25%N/AQ:120
/30Days
SERTRALINE 20 MG/ML ORAL CONC [Zoloft]   3 Preferred Brand $45.00$125.00None
SERTRALINE HCL 100 MG TABLET   1* Preferred Generic $1.00$0.00Q:60
/30Days
SERTRALINE HCL 25 MG TABLET   1* Preferred Generic $1.00$0.00Q:90
/30Days
SERTRALINE HCL 50 MG TABLET   1* Preferred Generic $1.00$0.00Q:90
/30Days
SETLAKIN 0.15 MG-0.03 MG TAB   4 Non-Preferred Drug 49%49%Q:91
/90Days
SEVELAMER 0.8 GM POWDER PACKET [RENVELA]   5 Specialty Tier 25%N/AQ:540
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SEVELAMER 2.4 GM POWDER PACKET POWDER PACK [Renvela]   5 Specialty Tier 25%N/AQ:180
/30Days
SEVELAMER CARBONATE 800 MG TABLET [Renvela]   4 Non-Preferred Drug 49%49%Q:540
/30Days
SHAROBEL 0.35 MG TABLET   4 Non-Preferred Drug 49%49%None
SHINGRIX VIAL KIT   4 Non-Preferred Drug 49%49%Q:2
/999Days
Signifor .6 mg/mL   5 Specialty Tier 25%N/AP Q:60
/30Days
Signifor .9 mg/mL   5 Specialty Tier 25%N/AP Q:60
/30Days
SIGNIFOR 0.3 MG/ML AMPULE   5 Specialty Tier 25%N/AP Q:60
/30Days
SILDENAFIL 10 MG/ML ORAL SUSPENSION [Revatio]   5 Specialty Tier 25%N/AP Q:180
/30Days
SILDENAFIL 20 MG TABLET [Revatio]   3 Preferred Brand $45.00$125.00P Q:90
/30Days
SILVER SULFADIAZINE 1% CREAM   2* Generic $4.00$0.00None
SIMVASTATIN 10 MG 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
SIMVASTATIN 20 MG TABLET   1* Preferred Generic $1.00$0.00None
SIMVASTATIN 40 MG TABLET   1* Preferred Generic $1.00$0.00None
SIMVASTATIN 5 MG TABLET [Zocor]   1* Preferred Generic $1.00$0.00None
SIMVASTATIN 80 MG TABLET   1* Preferred Generic $1.00$0.00None
Sirolimus 0.5 MG Tablet [Rapamune]   4 Non-Preferred Drug 49%49%P
SIROLIMUS 1 MG TABLET [Rapamune]   4 Non-Preferred Drug 49%49%P
SIROLIMUS 1 MG/ML SOLUTION [Rapamune]   4 Non-Preferred Drug 49%49%P
SIROLIMUS 2 MG TABLET [Rapamune]   4 Non-Preferred Drug 49%49%P
SIRTURO 100 MG TABLET   5 Specialty Tier 25%N/AP Q:68
/28Days
SIRTURO 20 MG TABLET   5 Specialty Tier 25%N/AP Q:340
/28Days
SIVEXTRO 200 MG TABLET   5 Specialty Tier 25%N/AQ:6
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SIVEXTRO 200 MG VIAL   5 Specialty Tier 25%N/AQ:6
/28Days
SKYRIZI 150 MG DOSE KIT-2 SYRINGEKIT   5 Specialty Tier 25%N/AP Q:6
/365Days
SLYND 4 MG TABLET   4 Non-Preferred Drug 49%49%None
SODIUM CHLORIDE 0.45% SOLUTION IV SOLUTION   4 Non-Preferred Drug 49%49%None
SODIUM CHLORIDE 0.9% IV SOLUTION   4 Non-Preferred Drug 49%49%None
SODIUM PHENYLBUTYRATE POWDER [Buphenyl]   5 Specialty Tier 25%N/ANone
SODIUM POLYSTYRENE SULF POWDER   3 Preferred Brand $45.00$125.00None
SOLIFENACIN 10 MG TABLET [VESIcare]   2* Generic $4.00$0.00Q:30
/30Days
SOLIFENACIN 5 MG TABLET [VESIcare]   2* Generic $4.00$0.00Q:30
/30Days
SOLIQUA 100 UNIT-33 MCG/ML PEN   3 Preferred Brand $35.00$125.00Q:15
/24Days
SOLTAMOX 20 MG/10 ML SOLUTION   5 Specialty Tier 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SOMAVERT 10 MG VIAL   5 Specialty Tier 25%N/AP Q:60
/30Days
SOMAVERT 15 MG VIAL   5 Specialty Tier 25%N/AP Q:60
/30Days
SOMAVERT 20 MG VIAL   5 Specialty Tier 25%N/AP Q:60
/30Days
SOMAVERT 25 MG VIAL   5 Specialty Tier 25%N/AP Q:30
/30Days
SOMAVERT 30 MG VIAL   5 Specialty Tier 25%N/AP Q:30
/30Days
SORINE SOLTALOL HCL TABLETS 240MG 100 BOXUD   2* Generic $4.00$0.00None
SORINE SOTALOL HCL TABLETS 120MG 100 BOXUD   2* Generic $4.00$0.00None
SORINE SOTALOL HCL TABLETS 160MG 100 BOXUD   2* Generic $4.00$0.00None
SORINE SOTALOL HCL TABLETS 80MG 100 BOXUD   2* Generic $4.00$0.00None
SOTALOL 120 MG TABLET [Sorine]   2* Generic $4.00$0.00None
SOTALOL 160 MG TABLET [Sorine]   2* Generic $4.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SOTALOL 240 MG TABLET [Sorine]   2* Generic $4.00$0.00None
SOTALOL 80 MG TABLET [Sorine]   2* Generic $4.00$0.00None
SOTALOL AF 120 MG TABLET [Sorine]   2* Generic $4.00$0.00None
SOTALOL AF 160 MG TABLET [Sorine]   2* Generic $4.00$0.00None
SOTALOL AF 80 MG TABLET [Sorine]   2* Generic $4.00$0.00None
SOVALDI 150 MG PELLET PACKET   5 Specialty Tier 25%N/AP Q:28
/28Days
SOVALDI 200 MG PELLET PACKET   5 Specialty Tier 25%N/AP Q:56
/28Days
SOVALDI 400 MG TABLET   5 Specialty Tier 25%N/AP Q:28
/28Days
SPIRIVA 18 MCG CP-HANDIHALER   3 Preferred Brand $45.00$125.00Q:30
/30Days
SPIRIVA RESPIMAT 1.25 MCG INH   3 Preferred Brand $45.00$125.00Q:4
/28Days
SPIRIVA RESPIMAT INHAL SPRAY   3 Preferred Brand $45.00$125.00Q:4
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SPIRONOLACTONE 100 MG TABLET [Aldactone]   2* Generic $4.00$0.00None
SPIRONOLACTONE 25 MG TABLET [Aldactone]   2* Generic $4.00$0.00None
SPIRONOLACTONE 50 MG TABLET [Aldactone]   2* Generic $4.00$0.00None
SPIRONOLACTONE-HCTZ 25-25 TABLET [Aldactazide]   2* Generic $4.00$0.00None
SPRINTEC 0.25-0.035 TABLET   4 Non-Preferred Drug 49%49%None
SPRITAM 1,000 MG TABLET   4 Non-Preferred Drug 49%49%S Q:90
/30Days
SPRITAM 250 MG TABLET   4 Non-Preferred Drug 49%49%S Q:360
/30Days
SPRITAM 500 MG TABLET   4 Non-Preferred Drug 49%49%S Q:180
/30Days
SPRITAM 750 MG TABLET   4 Non-Preferred Drug 49%49%S Q:120
/30Days
SPRYCEL 100mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE   5 Specialty Tier 25%N/AP Q:60
/30Days
SPRYCEL 140mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE   5 Specialty Tier 25%N/AP Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SPRYCEL 20MG TABLET   5 Specialty Tier 25%N/AP Q:90
/30Days
SPRYCEL 50MG TABLET   5 Specialty Tier 25%N/AP Q:60
/30Days
SPRYCEL 70MG TABLET   5 Specialty Tier 25%N/AP Q:60
/30Days
SPRYCEL 80mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE   5 Specialty Tier 25%N/AP Q:60
/30Days
SPS 15 GM/60 ML SUSPENSION   3 Preferred Brand $45.00$125.00None
SRONYX 0.10-0.02 MG TABLET   4 Non-Preferred Drug 49%49%None
SSD 1% CREAM   2* Generic $4.00$0.00None
STELARA 90 MG/ML SYRINGE   5 Specialty Tier 25%N/AP Q:3
/84Days
STIOLTO RESPIMAT INHAL SPRAY   3 Preferred Brand $45.00$125.00Q:4
/28Days
STIVARGA 40 MG TABLET   5 Specialty Tier 25%N/AP Q:84
/28Days
STRIBILD TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
STRIVERDI RESPIMAT INHAL SPRAY   3 Preferred Brand $45.00$125.00Q:4
/30Days
SUCRAID 8500[iU]/mL   5 Specialty Tier 25%N/ANone
SUCRALFATE 1GM TABLET   2* Generic $4.00$0.00None
SULF-PRED 10-0.23% EYE DROPS   2* Generic $4.00$0.00None
SULFACETAMIDE 10% EYE DROPS [Sulf-10]   2* Generic $4.00$0.00None
SULFACETAMIDE 10% EYE OINTMENT   3 Preferred Brand $45.00$125.00None
Sulfadiazine 500mg/1 100 TABLET BOTTLE   4 Non-Preferred Drug 49%49%None
SULFAMETHOXAZOLE-TMP DS TABLET [Septra DS]   1* Preferred Generic $1.00$0.00None
SULFAMETHOXAZOLE-TMP ORAL SUSPENSION [Sultrex Pediatric]   4 Non-Preferred Drug 49%49%None
SULFAMETHOXAZOLE-TMP SS TABLET [Septra]   1* Preferred Generic $1.00$0.00None
SULFASALAZINE 500 MG TABLET [Sulfazine]   2* Generic $4.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SULFASALAZINE DR 500 MG TABLET [Sulfazine EC]   2* Generic $4.00$0.00None
SULINDAC 150 MG TABLET   2* Generic $4.00$0.00None
SULINDAC 200 MG TABLET [Clinoril]   2* Generic $4.00$0.00None
SUMATRIPTAN 4 MG/0.5 ML CART   4 Non-Preferred Drug 49%49%Q:6
/30Days
SUMATRIPTAN 4 MG/0.5 ML INJECT PEN INJCTR [Sumavel DosePro System]   4 Non-Preferred Drug 49%49%Q:6
/30Days
SUMATRIPTAN 6 MG/0.5 ML INJECT   4 Non-Preferred Drug 49%49%Q:6
/30Days
SUMATRIPTAN 6 MG/0.5 ML INJECT   4 Non-Preferred Drug 49%49%Q:6
/30Days
Sumatriptan 6 mg/0.5 ml vial   4 Non-Preferred Drug 49%49%Q:6
/30Days
SUMATRIPTAN SUCC 100 MG TABLET [Imitrex]   2* Generic $4.00$0.00Q:9
/30Days
SUMATRIPTAN SUCC 25 MG TABLET [Imitrex]   2* Generic $4.00$0.00Q:9
/30Days
SUMATRIPTAN SUCC 50 MG TABLET [Migraine Pack]   2* Generic $4.00$0.00Q:9
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SUPRAX 400 MG CAPSULE   4 Non-Preferred Drug 49%49%None
SUPREP BOWEL PREP KIT SOLUTION RECON   3 Preferred Brand $45.00$125.00None
SUTAB 1.479-0.225-0.188 GM TABLET   4 Non-Preferred Drug 49%49%None
SUTENT 12.5MG CAPSULE   5 Specialty Tier 25%N/AP Q:28
/28Days
SUTENT 25mg/1 28 CAPSULE BOTTLE   5 Specialty Tier 25%N/AP Q:28
/28Days
SUTENT 37.5 MG CAPSULE   5 Specialty Tier 25%N/AP Q:28
/28Days
SUTENT 50MG CAPSULE   5 Specialty Tier 25%N/AP Q:28
/28Days
SYEDA 28 TABLET [Zarah]   4 Non-Preferred Drug 49%49%None
SYMBICORT 160-4.5MCG HFA AEROSOL WITH ADAPTER   3 Preferred Brand $45.00$125.00Q: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 Preferred Brand $45.00$125.00Q:10
/30Days
SYMFI 600-300-300 MG TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SYMFI LO 400-300-300 MG TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
SYMJEPI 0.15 MG/0.3 ML SYRINGE   3 Preferred Brand $45.00$125.00Q:4
/30Days
SYMJEPI 0.3 MG/0.3 ML SYRINGE   3 Preferred Brand $45.00$125.00Q:4
/30Days
SYMLINPEN 120 PEN INJECTOR   5 Specialty Tier 25%N/AQ:11
/30Days
SYMLINPEN 60 PEN INJECTOR   5 Specialty Tier 25%N/AQ:11
/28Days
SYMPAZAN 10 MG FILM   5 Specialty Tier 25%N/AP Q:60
/30Days
SYMPAZAN 20 MG FILM   5 Specialty Tier 25%N/AP Q:60
/30Days
SYMPAZAN 5 MG FILM   5 Specialty Tier 25%N/AP Q:60
/30Days
SYMTUZA 800-150-200-10 MG TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
SYNAREL 2MG/ML NASAL SPRAY   5 Specialty Tier 25%N/ANone
SYNJARDY 12.5-1,000 MG TABLET   3 Preferred Brand $45.00$125.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SYNJARDY 12.5-500 MG TABLET   3 Preferred Brand $45.00$125.00Q:60
/30Days
SYNJARDY 5-1,000 MG TABLET   3 Preferred Brand $45.00$125.00Q:60
/30Days
SYNJARDY XR 10-1,000 MG TABLET BP 24H   3 Preferred Brand $45.00$125.00Q:30
/30Days
SYNJARDY XR 12.5-1,000 MG TABLET BP 24H   3 Preferred Brand $45.00$125.00Q:60
/30Days
SYNJARDY XR 25-1,000 MG TABLET BP 24H   3 Preferred Brand $45.00$125.00Q:30
/30Days
SYNJARDY XR 5-1,000 MG TABLET BP 24H   3 Preferred Brand $45.00$125.00Q:60
/30Days
SYNRIBO 3.5 MG/ML VIAL   5 Specialty Tier 25%N/AP Q:28
/28Days
SYNTHROID 100 MCG TABLET   3 Preferred Brand $45.00$125.00None
SYNTHROID 112 MCG TABLET   3 Preferred Brand $45.00$125.00None
SYNTHROID 125 MCG TABLET   3 Preferred Brand $45.00$125.00None
Synthroid 137ug/1 90 TABLET BOTTLE   3 Preferred Brand $45.00$125.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SYNTHROID 150 MCG TABLET   3 Preferred Brand $45.00$125.00None
SYNTHROID 175 MCG TABLET   3 Preferred Brand $45.00$125.00None
SYNTHROID 200 MCG TABLET   3 Preferred Brand $45.00$125.00None
SYNTHROID 25 MCG TABLET   3 Preferred Brand $45.00$125.00None
SYNTHROID 300 MCG TABLET   3 Preferred Brand $45.00$125.00None
SYNTHROID 50 MCG TABLET   3 Preferred Brand $45.00$125.00None
SYNTHROID 75 MCG TABLET   3 Preferred Brand $45.00$125.00None
SYNTHROID 88 MCG TABLET   3 Preferred Brand $45.00$125.00None

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.