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UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP) (H5322-003-0)
Tier 1 (362)
Tier 2 (633)
Tier 3 (869)
Tier 4 (1008)
Tier 5 (787)
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2022 Medicare Part D Plan Formulary Information
UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP) (H5322-003-0)
Benefits & Contact Info           
The UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP) (H5322-003-0)
Formulary Drugs Starting with the Letter A

in Miami-Dade County, FL: CMS MA Region 9 which includes: FL
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 Tier 4 25%25%Q:960
/30Days
ABACAVIR 300 MG TABLET [Ziagen]   4 Tier 4 25%25%Q:60
/30Days
Abacavir Sulfate-Lamivudine-Zidovudine tablets [Trizivir]   5 Tier 5 25%25%Q:60
/30Days
ABACAVIR-LAMIVUDINE 600-300 MG TABLET [Epzicom]   4 Tier 4 25%25%Q:30
/30Days
ABELCET INJECTION SUSPENSION 5MG/ML   4 Tier 4 25%25%P
ABILIFY MAINTENA ER 300 MG SYRINGE   5 Tier 5 25%25%None
ABILIFY MAINTENA ER 300 MG VIAL   5 Tier 5 25%25%None
ABILIFY MAINTENA ER 400 MG SUSER VIAL   5 Tier 5 25%25%None
ABILIFY MAINTENA ER 400 MG SYRINGE   5 Tier 5 25%25%None
ABIRATERONE 500 MG TABLET [ZYTIGA]   5 Tier 5 25%25%P Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ABIRATERONE ACETATE 250 MG TABLET [ZYTIGA]   4 Tier 4 25%25%P Q:120
/30Days
Acamprosate Calcium DR 333 MG tablets [Campral]   4 Tier 4 25%25%None
ACARBOSE 100 MG TABLET [Precose]   1 Tier 1 25%25%Q:90
/30Days
ACARBOSE 25 MG TABLET [Precose]   1 Tier 1 25%25%Q:360
/30Days
ACARBOSE 50 MG TABLET [Precose]   1 Tier 1 25%25%Q:180
/30Days
ACCUTANE 20 MG CAPSULE [ZENATANE]   4 Tier 4 25%25%P
ACCUTANE 30 MG CAPSULE [ZENATANE]   4 Tier 4 25%25%P
ACCUTANE 40 MG CAPSULE [ZENATANE]   4 Tier 4 25%25%P
ACEBUTOLOL 200 MG CAPSULE [Sectral]   2 Tier 2 25%25%None
ACEBUTOLOL 400 MG CAPSULE [Sectral]   2 Tier 2 25%25%None
ACETAMINOP-CODEINE 120-12 MG/5   2 Tier 2 25%25%Q:4500
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETAMINOPHEN-COD #2 TABLET   2 Tier 2 25%25%Q:390
/30Days
ACETAMINOPHEN-COD #3 TABLET [Tylenol with Codeine No.3]   2 Tier 2 25%25%Q:390
/30Days
ACETAMINOPHEN-COD #4 TABLET   2 Tier 2 25%25%Q:390
/30Days
ACETAMN-CAF-DIHYDRCODEIN 320.5 CAPSULE [Trezix]   4 Tier 4 25%25%Q:300
/30Days
ACETAZOLAMIDE 125MG TABLET   3 Tier 3 25%25%None
ACETAZOLAMIDE 250 MG TABLET [Diamox]   3 Tier 3 25%25%None
ACETAZOLAMIDE ER 500 MG CAPSULE ER [Diamox Sequels]   4 Tier 4 25%25%None
ACETIC ACID 2% EAR SOLUTION [VoSoL]   2 Tier 2 25%25%None
ACETYLCYSTEINE 10% VIAL   2 Tier 2 25%25%P
ACETYLCYSTEINE 20% VIAL [Mucosil Acetylcysteine]   2 Tier 2 25%25%P
ACITRETIN 10 MG CAPSULE [Soriatane]   4 Tier 4 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACITRETIN 17.5 MG CAPSULE [Soriatane]   4 Tier 4 25%25%None
ACITRETIN 25 MG CAPSULE [Soriatane]   4 Tier 4 25%25%None
ACTEMRA 162 MG/0.9 ML SYRINGE   5 Tier 5 25%25%P Q:4
/28Days
ACTEMRA ACTPEN 162 MG/0.9 ML PEN INJCTR   5 Tier 5 25%25%P Q:4
/28Days
ACTHIB VACCINE WITH DILUENT   3 Tier 3 25%25%Q:1
/1Days
ACTIMMUNE 100 MCG/0.5 ML VIAL   5 Tier 5 25%25%None
ACYCLOVIR 200 MG CAPSULE [Zovirax]   2 Tier 2 25%25%None
ACYCLOVIR 200 MG/5 ML SUSP   3 Tier 3 25%25%None
ACYCLOVIR 400 MG TABLET   1 Tier 1 25%25%None
ACYCLOVIR 5% OINTMENT [Zovirax]   4 Tier 4 25%25%Q:30
/30Days
ACYCLOVIR 800 MG TABLET   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Acyclovir sodium 500 mg vial   4 Tier 4 25%25%P
ADACEL TDAP SYRINGE   3 Tier 3 25%25%Q:1
/1Days
ADACEL VIAL 2UNT/5UNT   3 Tier 3 25%25%Q:1
/1Days
ADAPALENE 0.1% CREAM (G) [Differin]   4 Tier 4 25%25%None
ADAPALENE 0.1% GEL [Differin]   3 Tier 3 25%25%None
ADEFOVIR DIPIVOXIL 10 MG TABLET [Hepsera]   4 Tier 4 25%25%None
ADEMPAS 0.5 MG TABLET   5 Tier 5 25%25%P
ADEMPAS 1 MG TABLET   5 Tier 5 25%25%P
ADEMPAS 1.5 MG TABLET   5 Tier 5 25%25%P
ADEMPAS 2 MG TABLET   5 Tier 5 25%25%P
ADEMPAS 2.5 MG TABLET   5 Tier 5 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADVAIR DISKUS MIS 100/50   3 Tier 3 25%25%Q:60
/30Days
ADVAIR DISKUS MIS 250/50   3 Tier 3 25%25%Q:60
/30Days
ADVAIR DISKUS MIS 500/50   3 Tier 3 25%25%Q:60
/30Days
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER   3 Tier 3 25%25%Q:12
/30Days
ADVAIR HFA INHALER 115;21MCG;MCG 120 ACTN INHL   3 Tier 3 25%25%Q:12
/30Days
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL   3 Tier 3 25%25%Q:12
/30Days
AFINITOR 10 MG TABLET   5 Tier 5 25%25%P
AFINITOR DISPERZ 2 MG TABLET   5 Tier 5 25%25%P
AFINITOR DISPERZ 3 MG TABLET   5 Tier 5 25%25%P
AFINITOR DISPERZ 5 MG TABLET   5 Tier 5 25%25%P
AIMOVIG 140 MG/ML AUTOINJECTOR   4 Tier 4 25%25%P Q:1
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AIMOVIG 70 MG/ML AUTOINJECTOR   4 Tier 4 25%25%P Q:2
/30Days
ALA-CORT 2.5% CREAM (G) [Proctozone-HC]   2 Tier 2 25%25%None
ALBENDAZOLE 200 MG TABLET [Albenza]   4 Tier 4 25%25%Q:480
/30Days
ALBUTEROL 2.5 MG/0.5 ML SOL VIAL-NEB   2 Tier 2 25%25%P
ALBUTEROL HFA 90 MCG INHALER HFA AER AD [Ventolin HFA]   2 Tier 2 25%25%None
ALBUTEROL HFA 90 MCG INHALER HFA AER AD [Ventolin HFA]   2 Tier 2 25%25%None
ALBUTEROL SUL 0.63 MG/3 ML SOL VIAL-NEB   2 Tier 2 25%25%P
ALBUTEROL SUL 1.25 MG/3 ML SOL VIAL-NEB   2 Tier 2 25%25%P
ALBUTEROL SUL 2.5 MG/3 ML SOLUTION VIAL-NEB   2 Tier 2 25%25%P
ALBUTEROL SULF 2 MG/5 ML SYRUP   4 Tier 4 25%25%None
ALBUTEROL SULFATE 2 MG TABLET   4 Tier 4 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALBUTEROL SULFATE 4 MG TABLET   4 Tier 4 25%25%None
ALCLOMETASONE DIPR 0.05% OINTMENT [Aclovate]   3 Tier 3 25%25%None
ALCLOMETASONE DIPRO 0.05% CREAM   3 Tier 3 25%25%None
ALECENSA 150 MG CAPSULE   5 Tier 5 25%25%P Q:240
/30Days
ALENDRONATE SOD 70 MG/75 ML SOLUTION [Fosamax]   4 Tier 4 25%25%None
ALENDRONATE SODIUM 10 MG TABLET [Fosamax]   1 Tier 1 25%25%Q:30
/30Days
ALENDRONATE SODIUM 35 MG TABLET [Fosamax]   1 Tier 1 25%25%Q:8
/28Days
ALENDRONATE SODIUM 70 MG TABLET [Fosamax]   1 Tier 1 25%25%Q:4
/28Days
ALFUZOSIN HCL ER 10 MG TABLET   2 Tier 2 25%25%None
ALISKIREN 150 MG TABLET [Tekturna]   1 Tier 1 25%25%Q:30
/30Days
ALISKIREN 300 MG TABLET [Tekturna]   1 Tier 1 25%25%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALLOPURINOL 100 MG TABLET [Zyloprim]   1 Tier 1 25%25%None
ALLOPURINOL 300 MG TABLET [Zyloprim]   1 Tier 1 25%25%None
ALOCRIL 2% EYE DROPS   4 Tier 4 25%25%None
ALOMIDE 0.1% EYE DROPS   4 Tier 4 25%25%None
ALOSETRON HCL 0.5 MG TABLET [Lotronex]   5 Tier 5 25%25%P
ALOSETRON HCL 1 MG TABLET [Lotronex]   5 Tier 5 25%25%P
ALPHAGAN P 0.1% EYE DROPS   3 Tier 3 25%25%None
ALPRAZOLAM 0.25 MG TABLET [Xanax]   1 Tier 1 25%25%Q:120
/30Days
ALPRAZOLAM 0.5 MG TABLET   1 Tier 1 25%25%Q:120
/30Days
ALPRAZOLAM 1 MG TABLET   1 Tier 1 25%25%Q:120
/30Days
ALPRAZOLAM 2 MG TABLET   1 Tier 1 25%25%Q:150
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALTAVERA-28 TABLET [Portia]   4 Tier 4 25%25%None
ALUNBRIG 180 MG TABLET   5 Tier 5 25%25%P Q:30
/30Days
ALUNBRIG 30 MG TABLET   5 Tier 5 25%25%P Q:120
/30Days
ALUNBRIG 90 MG TABLET   5 Tier 5 25%25%P Q:30
/30Days
ALUNBRIG 90 MG-180 MG TABLET PACK   5 Tier 5 25%25%P Q:60
/365Days
ALYACEN 1-35-28 TABLET   4 Tier 4 25%25%None
ALYQ 20 MG TABLET   4 Tier 4 25%25%P Q:60
/30Days
AMANTADINE 100 MG CAPSULE [Symmetrel]   3 Tier 3 25%25%None
AMANTADINE 100 MG TABLET   3 Tier 3 25%25%None
AMANTADINE 50 MG/5 ML SOLUTION   2 Tier 2 25%25%None
AMBISOME 50MG VIAL   5 Tier 5 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMBRISENTAN 10 MG TABLET [LETAIRIS]   5 Tier 5 25%25%P Q:30
/30Days
AMBRISENTAN 5 MG TABLET [LETAIRIS]   5 Tier 5 25%25%P Q:30
/30Days
AMETHIA 0.15-0.03-0.01 MG TABLET   4 Tier 4 25%25%None
AMIKACIN SULF 500 MG/2 ML VIAL   4 Tier 4 25%25%None
AMILORIDE HCL 5 MG TABLET [Midamor]   2 Tier 2 25%25%None
AMILORIDE HCL-HCTZ 5-50 MG TABLET [Moduretic]   2 Tier 2 25%25%None
AMINOSYN II 15% IV SOLUTION   4 Tier 4 25%25%P
AMINOSYN-PF 7% IV SOLUTION   4 Tier 4 25%25%P
AMIODARONE HCL 200 MG TABLET [Pacerone]   1 Tier 1 25%25%None
AMITRIPTYLINE HCL 10 MG TABLET [Elavil]   4 Tier 4 25%25%None
AMITRIPTYLINE HCL 100 MG TABLET   4 Tier 4 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITRIPTYLINE HCL 150 MG TABLET   4 Tier 4 25%25%None
AMITRIPTYLINE HCL 25 MG TABLET [Elavil]   4 Tier 4 25%25%None
AMITRIPTYLINE HCL 50 MG TABLET   4 Tier 4 25%25%None
AMITRIPTYLINE HCL 75 MG TABLET   4 Tier 4 25%25%None
AMLOD-VALSA-HCTZ 10-160-12.5 MG TABLET [Exforge HCT]   1 Tier 1 25%25%Q:30
/30Days
AMLOD-VALSA-HCTZ 10-160-25 MG TABLET [Exforge HCT]   1 Tier 1 25%25%Q:30
/30Days
AMLOD-VALSA-HCTZ 10-320-25 MG TABLET [Exforge HCT]   1 Tier 1 25%25%Q:30
/30Days
AMLOD-VALSA-HCTZ 5-160-12.5 MG TABLET [Exforge HCT]   1 Tier 1 25%25%Q:30
/30Days
AMLOD-VALSA-HCTZ 5-160-25 MG TABLET [Exforge HCT]   1 Tier 1 25%25%Q:30
/30Days
AMLODIPINE BESYLATE 10 MG TABLET [Norvasc]   1 Tier 1 25%25%None
AMLODIPINE BESYLATE 2.5 MG TABLET [Norvasc]   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE BESYLATE 5 MG TABLET [Norvasc]   1 Tier 1 25%25%None
AMLODIPINE-ATORVAST 10-20 MG [Caduet]   1 Tier 1 25%25%Q:30
/30Days
AMLODIPINE-ATORVAST 10-40 MG [Caduet]   1 Tier 1 25%25%Q:30
/30Days
Amlodipine-Atorvastatin 10-10 mg [Caduet]   1 Tier 1 25%25%Q:30
/30Days
Amlodipine-Atorvastatin 10-80 mg [Caduet]   1 Tier 1 25%25%Q:30
/30Days
Amlodipine-Atorvastatin 2.5-10 mg [Caduet]   1 Tier 1 25%25%Q:30
/30Days
Amlodipine-Atorvastatin 2.5-20 mg [Caduet]   1 Tier 1 25%25%Q:30
/30Days
Amlodipine-Atorvastatin 2.5-40 mg [Caduet]   1 Tier 1 25%25%Q:30
/30Days
Amlodipine-Atorvastatin 5-10 mg [Caduet]   1 Tier 1 25%25%Q:30
/30Days
Amlodipine-Atorvastatin 5-20 mg [Caduet]   1 Tier 1 25%25%Q:30
/30Days
Amlodipine-Atorvastatin 5-40 mg [Caduet]   1 Tier 1 25%25%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Amlodipine-Atorvastatin 5-80 mg [Caduet]   1 Tier 1 25%25%Q:30
/30Days
AMLODIPINE-BENAZEPRIL 10-20 MG CAPSULE [Lotrel]   1 Tier 1 25%25%Q:30
/30Days
AMLODIPINE-BENAZEPRIL 10-40 MG CAPSULE [Lotrel]   1 Tier 1 25%25%Q:30
/30Days
AMLODIPINE-BENAZEPRIL 2.5-10 CAPSULE [Lotrel]   1 Tier 1 25%25%Q:30
/30Days
AMLODIPINE-BENAZEPRIL 5-10 MG CAPSULE [Lotrel]   1 Tier 1 25%25%Q:30
/30Days
AMLODIPINE-BENAZEPRIL 5-20 MG CAPSULE [Lotrel]   1 Tier 1 25%25%Q:30
/30Days
AMLODIPINE-BENAZEPRIL 5-40 MG CAPSULE [Lotrel]   1 Tier 1 25%25%Q:30
/30Days
AMLODIPINE-OLMESARTAN 10-20 MG TABLET [AZOR]   1 Tier 1 25%25%Q:30
/30Days
AMLODIPINE-OLMESARTAN 10-40 MG TABLET [AZOR]   1 Tier 1 25%25%Q:30
/30Days
AMLODIPINE-OLMESARTAN 5-20 MG TABLET [AZOR]   1 Tier 1 25%25%Q:30
/30Days
AMLODIPINE-OLMESARTAN 5-40 MG TABLET [AZOR]   1 Tier 1 25%25%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE-VALSARTAN 10-160 MG TABLET [Exforge]   1 Tier 1 25%25%Q:30
/30Days
AMLODIPINE-VALSARTAN 10-320 MG TABLET [Exforge]   1 Tier 1 25%25%Q:30
/30Days
AMLODIPINE-VALSARTAN 5-160 MG TABLET [Exforge]   1 Tier 1 25%25%Q:30
/30Days
AMLODIPINE-VALSARTAN 5-320 MG TABLET [Exforge]   1 Tier 1 25%25%Q:30
/30Days
AMMONIUM LACTATE 12% CREAM (g) [Lac-Hydrin]   3 Tier 3 25%25%None
AMMONIUM LACTATE 12% LOTION   3 Tier 3 25%25%None
AMNESTEEM 10 MG CAPSULE [ZENATANE]   4 Tier 4 25%25%P
AMNESTEEM 20 MG CAPSULE [ZENATANE]   4 Tier 4 25%25%P
AMNESTEEM 40 MG CAPSULE [ZENATANE]   4 Tier 4 25%25%P
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE [Augmentin]   2 Tier 2 25%25%None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET [Augmentin]   2 Tier 2 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE [Augmentin]   2 Tier 2 25%25%None
AMOX-CLAV 200-28.5 MG/5 ML SUS   2 Tier 2 25%25%None
AMOX-CLAV 250-62.5 MG/5 ML SUS   2 Tier 2 25%25%None
AMOX-CLAV 400-57 MG/5 ML ORAL SUSPENSION [Augmentin]   2 Tier 2 25%25%None
AMOX-CLAV 500-125 MG TABLET [Augmentin]   2 Tier 2 25%25%None
AMOX-CLAV 600-42.9 MG/5 ML SUS   2 Tier 2 25%25%None
AMOX-CLAV 875-125 MG TABLET [Augmentin]   2 Tier 2 25%25%None
AMOX-CLAV ER 1,000-62.5 MG TABLET [Augmentin]   4 Tier 4 25%25%None
AMOXAPINE 100MG TABLET   3 Tier 3 25%25%None
AMOXAPINE 150MG TABLET   3 Tier 3 25%25%None
AMOXAPINE 25MG TABLET   3 Tier 3 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXAPINE 50MG TABLET   3 Tier 3 25%25%None
AMOXICILLIN 125 MG/5 ML SUSP   1 Tier 1 25%25%None
AMOXICILLIN 125MG TABLET CHEW   1 Tier 1 25%25%None
AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION [Amoxil]   1 Tier 1 25%25%None
AMOXICILLIN 250 MG CAPSULE [Trimox]   1 Tier 1 25%25%None
AMOXICILLIN 250 MG TABLET CHEW   1 Tier 1 25%25%None
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION [Trimox]   1 Tier 1 25%25%None
AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION [Amoxil]   1 Tier 1 25%25%None
AMOXICILLIN 500 MG CAPSULE [Trimox]   1 Tier 1 25%25%None
AMOXICILLIN 500 MG TABLET   1 Tier 1 25%25%None
AMOXICILLIN 875 MG TABLET   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPHETAMINE SALT COMBO 12.5MG TABLET   3 Tier 3 25%25%Q:60
/30Days
AMPHETAMINE SALT COMBO 15MG TABLET   3 Tier 3 25%25%Q:60
/30Days
AMPHETAMINE SALT COMBO 7.5MG TABLET   3 Tier 3 25%25%Q:60
/30Days
AMPHETAMINE SALTS 5 MG TABLET   3 Tier 3 25%25%Q:60
/30Days
amphotericin b 50mg/10mL 10 mL in 1 VIAL   4 Tier 4 25%25%P
AMPICILLIN 1 GM VIAL   4 Tier 4 25%25%None
AMPICILLIN 10 GM BOTTLE VIAL   4 Tier 4 25%25%None
Ampicillin 1000 MG / Sulbactam 500 MG Injection   4 Tier 4 25%25%None
Ampicillin 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS   4 Tier 4 25%25%None
AMPICILLIN CAPSULES 500MG 100 BOTTLE   2 Tier 2 25%25%None
AMPICILLIN-SULBACTAM 15 GM VIAL [Unasyn]   4 Tier 4 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPICILLIN-SULBACTAM 3 GM VIAL [Unasyn]   4 Tier 4 25%25%None
ANAGRELIDE HCL 1 MG CAPSULE [Agrylin]   3 Tier 3 25%25%None
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE   3 Tier 3 25%25%None
ANASTROZOLE 1 MG TABLET   1 Tier 1 25%25%None
ANDRODERM 2 MG/24HR PATCH   3 Tier 3 25%25%Q:30
/30Days
ANDRODERM 4 MG/24HR PATCH   3 Tier 3 25%25%Q:30
/30Days
ANORO ELLIPTA 62.5-25 MCG INH   3 Tier 3 25%25%Q:60
/30Days
APOKYN 30 MG/3 ML CARTRIDGE   5 Tier 5 25%25%P Q:90
/30Days
Apraclonidine 5 MG/ML Ophthalmic Solution   3 Tier 3 25%25%None
APREPITANT 125 MG CAPSULE [Emend]   4 Tier 4 25%25%P Q:2
/28Days
APREPITANT 125-80-80 MG PACK [Emend]   4 Tier 4 25%25%P Q:6
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
APREPITANT 40 MG CAPSULE [Emend]   4 Tier 4 25%25%P Q:4
/28Days
APREPITANT 80 MG CAPSULE [Emend]   4 Tier 4 25%25%P Q:4
/28Days
APRI 0.15-0.03 TABLET   4 Tier 4 25%25%None
APRISO CP24   3 Tier 3 25%25%Q:120
/30Days
APTIOM 200 MG TABLET   5 Tier 5 25%25%Q:30
/30Days
APTIOM 400 MG TABLET   5 Tier 5 25%25%Q:30
/30Days
APTIOM 600 MG TABLET   5 Tier 5 25%25%Q:60
/30Days
APTIOM 800 MG TABLET   5 Tier 5 25%25%Q:60
/30Days
APTIVUS 250MG CAPSULE   5 Tier 5 25%25%Q:120
/30Days
ARALAST NP 1,000 MG VIAL   5 Tier 5 25%25%P
ARANELLE 7-9-5 TABLET   4 Tier 4 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP 10 MCG/0.4 ML SYRINGE   4 Tier 4 25%25%P
ARANESP 100ug/0.5mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.5 mL in 1 SYRINGE   5 Tier 5 25%25%P
ARANESP 100ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE   5 Tier 5 25%25%P
ARANESP 200MCG/0.4ML SYRINGE   5 Tier 5 25%25%P
ARANESP 200MCG/ML VIAL   5 Tier 5 25%25%P
ARANESP 25ug/0.42mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.42 mL in 1 SYRING   4 Tier 4 25%25%P
ARANESP 25ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE   4 Tier 4 25%25%P
ARANESP 300MCG/ML VIAL   5 Tier 5 25%25%P
ARANESP 500MCG/1ML SYRINGE   5 Tier 5 25%25%P
ARANESP 60MCG/ML VIAL   4 Tier 4 25%25%P
ARANESP 60ug/0.3mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.3 mL in 1 SYRINGE   4 Tier 4 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR   5 Tier 5 25%25%P
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR   5 Tier 5 25%25%P
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR   4 Tier 4 25%25%P
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD   4 Tier 4 25%25%P
ARCALYST 220 MG VIAL   5 Tier 5 25%25%P
ARIPIPRAZOLE 1 MG/ML SOLUTION [Abilify]   4 Tier 4 25%25%Q:750
/30Days
ARIPIPRAZOLE 10 MG TABLET [Abilify]   3 Tier 3 25%25%Q:30
/30Days
ARIPIPRAZOLE 15 MG TABLET [Abilify]   3 Tier 3 25%25%Q:30
/30Days
ARIPIPRAZOLE 2 MG TABLET [Abilify]   3 Tier 3 25%25%Q:30
/30Days
ARIPIPRAZOLE 20 MG TABLET [Abilify]   3 Tier 3 25%25%Q:30
/30Days
ARIPIPRAZOLE 30 MG TABLET [Abilify]   3 Tier 3 25%25%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARIPIPRAZOLE 5 MG TABLET [Abilify]   3 Tier 3 25%25%Q:30
/30Days
ARIPIPRAZOLE ODT 10 MG TABLET RAPDIS [Abilify Discmelt]   5 Tier 5 25%25%Q:90
/30Days
ARIPIPRAZOLE ODT 15 MG TABLET RAPDIS [Abilify Discmelt]   5 Tier 5 25%25%Q:60
/30Days
ARISTADA ER 1064 MG/3.9 ML SYRINGE   5 Tier 5 25%25%None
ARISTADA ER 441 MG/1.6 ML SYRINGE   5 Tier 5 25%25%None
ARISTADA ER 662 MG/2.4 ML SYRINGE   5 Tier 5 25%25%None
ARISTADA ER 882 MG/3.2 ML SYRINGE   5 Tier 5 25%25%None
ARISTADA INITIO ER 675 MG/2.4 SUSER SYRINGE   5 Tier 5 25%25%None
ARMODAFINIL 150 MG TABLET [Nuvigil]   4 Tier 4 25%25%P Q:30
/30Days
ARMODAFINIL 200 MG TABLET [Nuvigil]   4 Tier 4 25%25%P Q:30
/30Days
ARMODAFINIL 250 MG TABLET [Nuvigil]   4 Tier 4 25%25%P Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARMODAFINIL 50 MG TABLET [Nuvigil]   4 Tier 4 25%25%P Q:60
/30Days
ARNUITY ELLIPTA 100 MCG INH   3 Tier 3 25%25%Q:30
/30Days
ARNUITY ELLIPTA 200 MCG INH   3 Tier 3 25%25%Q:30
/30Days
ARNUITY ELLIPTA 50 MCG INH BLST W/DEV   3 Tier 3 25%25%Q:30
/30Days
ASENAPINE 10 MG SUBLIGUAL TABLET [Saphris]   4 Tier 4 25%25%Q:60
/30Days
ASENAPINE 2.5 MG SUBLIGUAL TABLET [Saphris]   4 Tier 4 25%25%Q:60
/30Days
ASENAPINE 5 MG SUBLIGUAL TABLET [Saphris]   4 Tier 4 25%25%Q:60
/30Days
ASHLYNA 0.15-0.03-0.01 MG TABLET   4 Tier 4 25%25%None
ASPIRIN-DIPYRIDAM ER 25-200 MG CPMP 12HR [Aggrenox]   3 Tier 3 25%25%Q:60
/30Days
ATAZANAVIR SULFATE 150 MG CAPSULE [Reyataz]   4 Tier 4 25%25%Q:30
/30Days
ATAZANAVIR SULFATE 200 MG CAPSULE [Reyataz]   4 Tier 4 25%25%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 Tier 4 25%25%Q:30
/30Days
ATENOLOL 100 MG TABLET [Tenormin]   1 Tier 1 25%25%None
ATENOLOL 25 MG TABLET   1 Tier 1 25%25%None
ATENOLOL 50 MG TABLET [Tenormin]   1 Tier 1 25%25%None
ATENOLOL-CHLORTHALIDONE 100-25   1 Tier 1 25%25%None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   1 Tier 1 25%25%None
ATOMOXETINE HCL 10 MG CAPSULE [Strattera]   4 Tier 4 25%25%Q:60
/30Days
ATOMOXETINE HCL 100 MG CAPSULE [Strattera]   4 Tier 4 25%25%Q:30
/30Days
ATOMOXETINE HCL 18 MG CAPSULE [Strattera]   4 Tier 4 25%25%Q:60
/30Days
ATOMOXETINE HCL 25 MG CAPSULE [Strattera]   4 Tier 4 25%25%Q:60
/30Days
ATOMOXETINE HCL 40 MG CAPSULE [Strattera]   4 Tier 4 25%25%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 Tier 4 25%25%Q:30
/30Days
ATOMOXETINE HCL 80 MG CAPSULE [Strattera]   4 Tier 4 25%25%Q:30
/30Days
ATORVASTATIN 10 MG TABLET [Lipitor]   1 Tier 1 25%25%Q:30
/30Days
ATORVASTATIN 20 MG TABLET [Lipitor]   1 Tier 1 25%25%Q:30
/30Days
ATORVASTATIN 40 MG TABLET [Lipitor]   1 Tier 1 25%25%Q:30
/30Days
ATORVASTATIN 80 MG TABLET [Lipitor]   1 Tier 1 25%25%Q:30
/30Days
ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION [Mepron]   5 Tier 5 25%25%None
Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone]   3 Tier 3 25%25%None
ATOVAQUONE-PROGUANIL 62.5-25 [Malarone]   3 Tier 3 25%25%None
ATROPINE 1% EYE DROPS   3 Tier 3 25%25%None
ATROVENT HFA AER 17MCG   4 Tier 4 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AUBAGIO 14 MG TABLET   5 Tier 5 25%25%Q:30
/30Days
AUBAGIO 7 MG TABLET   5 Tier 5 25%25%Q:30
/30Days
AUBRA EQ-28 TABLET [Vienva]   4 Tier 4 25%25%None
AURYXIA 210 MG TABLET   5 Tier 5 25%25%P
AUSTEDO 12 MG TABLET   5 Tier 5 25%25%P Q:120
/30Days
AUSTEDO 6 MG TABLET   5 Tier 5 25%25%P Q:120
/30Days
AUSTEDO 9 MG TABLET   5 Tier 5 25%25%P Q:120
/30Days
AVIANE 0.1-0.02 TABLET   4 Tier 4 25%25%None
AVONEX PEN 30 MCG/0.5 ML KIT   5 Tier 5 25%25%Q:1
/28Days
AVONEX PREFILLED SYR 30 MCG KT   5 Tier 5 25%25%Q:1
/28Days
AYVAKIT 100 MG TABLET   5 Tier 5 25%25%P Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AYVAKIT 200 MG TABLET   5 Tier 5 25%25%P Q:30
/30Days
AYVAKIT 25 MG TABLET   5 Tier 5 25%25%P Q:30
/30Days
AYVAKIT 300 MG TABLET   5 Tier 5 25%25%P Q:30
/30Days
AYVAKIT 50 MG TABLET   5 Tier 5 25%25%P Q:30
/30Days
AZATHIOPRINE 50 MG TABLET [Imuran]   2 Tier 2 25%25%P
AZELAIC ACID 15% GEL [Finacea]   4 Tier 4 25%25%Q:50
/30Days
AZELASTIN-FLUTIC 137-50MCG SPRAY/PUMP [Dymista]   4 Tier 4 25%25%None
AZELASTINE 0.15% NASAL SPRAY   3 Tier 3 25%25%None
AZELASTINE 137 MCG NASAL SPRAY   3 Tier 3 25%25%None
AZELASTINE HCL 0.05% EYE DROPS [Optivar]   3 Tier 3 25%25%None
AZITHROMYCIN 100 MG/5 ML ORAL SUSPENSION [Zithromax]   1 Tier 1 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [Zithromax]   1 Tier 1 25%25%None
AZITHROMYCIN 250 MG TABLET [Zithromax Z-Pak]   1 Tier 1 25%25%None
AZITHROMYCIN 250 MG TABLET [Zithromax Z-Pak]   1 Tier 1 25%25%None
AZITHROMYCIN 500 MG TABLET   1 Tier 1 25%25%None
AZITHROMYCIN 500 MG TABLET [Zithromax Tri-Pak]   1 Tier 1 25%25%None
AZITHROMYCIN 600 MG TABLET [Zithromax Z-Pak]   1 Tier 1 25%25%None
AZITHROMYCIN I.V. 500 MG VIAL [Zithromax]   4 Tier 4 25%25%None
AZTREONAM FOR INJECTION   4 Tier 4 25%25%None

Chart Legend:

Below are a few notes to help you understand the above 2022 Medicare Part D UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP) Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug or Medicare Advantage plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region). The plan name is followed by the plan type (PDP, HMO, HMO-POS, PPO, PFFS, etc.)

  • Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.

  • Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $480 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 $4,430) 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 January 2022 )

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.