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SilverScript Choice (PDP) (S5601-022-0)
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2022 Medicare Part D Plan Formulary Information
SilverScript Choice (PDP) (S5601-022-0)
Benefit Details           
The SilverScript Choice (PDP) (S5601-022-0)
Formulary Drugs Starting with the Letter L

in CMS PDP Region 11 which includes: FL
Drugs Starting with Letter L

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
LABETALOL HCL 100 MG TABLET   3 Preferred Brand 17%17%None
LABETALOL HCL 200 MG TABLET [Trandate]   3 Preferred Brand 17%17%None
LABETALOL HCL 300 MG TABLET [Trandate]   3 Preferred Brand 17%17%None
LACOSAMIDE 10 MG/ML SOLUTION [Vimpat]   4 Non-Preferred Drug 35%35%Q:1200
/30Days
LACOSAMIDE 100 MG TABLET [Vimpat]   4 Non-Preferred Drug 35%35%Q:60
/30Days
LACOSAMIDE 150 MG TABLET [Vimpat]   4 Non-Preferred Drug 35%35%Q:60
/30Days
LACOSAMIDE 200 MG TABLET [Vimpat]   4 Non-Preferred Drug 35%35%Q:60
/30Days
LACOSAMIDE 50 MG TABLET [Vimpat]   4 Non-Preferred Drug 35%35%Q:120
/30Days
LACTULOSE 10 GM/15 ML SOLUTION [Generlac]   2* Generic $5.00$15.00None
LAMIVUDINE 10 MG/ML ORAL SOLUTION [Epivir]   4 Non-Preferred Drug 35%35%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LAMIVUDINE 150 MG TABLET [Epivir]   4 Non-Preferred Drug 35%35%None
LAMIVUDINE 300 MG TABLET [Epivir]   4 Non-Preferred Drug 35%35%None
LAMIVUDINE HBV 100 MG TABLET [Epivir HBV]   3 Preferred Brand 17%17%None
LAMIVUDINE-ZIDOVUDINE TABLET [Combivir]   4 Non-Preferred Drug 35%35%None
LAMOTRIGINE 100 MG TABLET [Subvenite]   2* Generic $5.00$15.00None
LAMOTRIGINE 150 MG TABLET [Subvenite]   2* Generic $5.00$15.00None
LAMOTRIGINE 200 MG TABLET [Subvenite]   2* Generic $5.00$15.00None
LAMOTRIGINE 25 MG DISPER TABLET CHW [Lamictal CD]   3 Preferred Brand 17%17%None
LAMOTRIGINE 25 MG TABLET [Subvenite]   2* Generic $5.00$15.00None
LAMOTRIGINE 5 MG DISPER TABLET CHW [Lamictal CD]   3 Preferred Brand 17%17%None
LANSOPRAZOLE DR 15 MG CAPSULE DR [Prevacid]   3 Preferred Brand 17%17%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LANSOPRAZOLE DR 30 MG CAPSULE DR [Prevacid]   3 Preferred Brand 17%17%Q:30
/30Days
LANTHANUM CARB 1,000 MG CHEWABLE TABLET [Fosrenol]   5 Specialty Tier 25%N/ANone
LANTHANUM CARB 500 MG TABLET CHEW [Fosrenol]   5 Specialty Tier 25%N/ANone
LANTHANUM CARB 750 MG TABLET CHEW [Fosrenol]   5 Specialty Tier 25%N/ANone
LAPATINIB 250 MG TABLET [Tykerb]   5 Specialty Tier 25%N/AP Q:180
/30Days
LARIN 1.5 MG-30 MCG TABLET   2* Generic $5.00$15.00None
LARIN 21 1-20 TABLET   2* Generic $5.00$15.00None
LARIN FE 1-20 TABLET   2* Generic $5.00$15.00None
LARIN FE 1.5-30 TABLET   2* Generic $5.00$15.00None
LARISSIA-28 TABLET [Vienva]   3 Preferred Brand 17%17%None
LATANOPROST 0.005% EYE DROPS   2* Generic $5.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LATUDA 120 MG TABLET   4 Non-Preferred Drug 35%35%Q:30
/30Days
LATUDA 20 MG TABLET   4 Non-Preferred Drug 35%35%Q:30
/30Days
LATUDA 40 MG TABLET   4 Non-Preferred Drug 35%35%Q:30
/30Days
LATUDA 60 MG TABLET   4 Non-Preferred Drug 35%35%Q:30
/30Days
LATUDA 80 MG TABLET   4 Non-Preferred Drug 35%35%Q:60
/30Days
LEENA 28 TABLET [Tri-Norinyl]   3 Preferred Brand 17%17%None
LEFLUNOMIDE 10 MG TABLET [Arava]   3 Preferred Brand 17%17%Q:30
/30Days
LEFLUNOMIDE 20 MG TABLET [Arava]   3 Preferred Brand 17%17%Q:30
/30Days
LENALIDOMIDE 10 MG CAPSULE [Revlimid]   5 Specialty Tier 25%N/AP Q:28
/28Days
LENALIDOMIDE 15 MG CAPSULE [Revlimid]   5 Specialty Tier 25%N/AP Q:28
/28Days
LENALIDOMIDE 25 MG CAPSULE [Revlimid]   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
LENALIDOMIDE 5 MG CAPSULE [Revlimid]   5 Specialty Tier 25%N/AP Q:28
/28Days
LENVIMA 10 MG DAILY DOSE   5 Specialty Tier 25%N/AP
LENVIMA 12 MG DAILY DOSE CAPSULE   5 Specialty Tier 25%N/AP
LENVIMA 14 MG DAILY DOSE   5 Specialty Tier 25%N/AP
LENVIMA 18 MG DAILY DOSE   5 Specialty Tier 25%N/AP
LENVIMA 20 MG DAILY DOSE   5 Specialty Tier 25%N/AP
LENVIMA 24 MG DAILY DOSE   5 Specialty Tier 25%N/AP
LENVIMA 4 MG CAPSULE   5 Specialty Tier 25%N/AP
LENVIMA 8 MG DAILY DOSE   5 Specialty Tier 25%N/AP
Lessina 3 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK   3 Preferred Brand 17%17%None
LETROZOLE 2.5 MG TABLET [Femara]   2* Generic $5.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEUCOVORIN CALCIUM 10MG TABLET   3 Preferred Brand 17%17%None
LEUCOVORIN CALCIUM 15MG 24 TABLET BOTTLE   4 Non-Preferred Drug 35%35%None
LEUCOVORIN CALCIUM 25 MG TABLET   4 Non-Preferred Drug 35%35%None
LEUCOVORIN CALCIUM 5 MG TABLET   3 Preferred Brand 17%17%None
LEUKERAN 2 MG TABLET   4 Non-Preferred Drug 35%35%None
LEUPROLIDE 2WK 14 MG/2.8 ML KT   4 Non-Preferred Drug 35%35%P
LEVALBUTEROL TAR HFA 45MCG INH [Xopenex]   3 Preferred Brand 17%17%Q:30
/30Days
LEVEMIR 100UNITS/ML VIAL   3 Preferred Brand 17%17%None
LEVEMIR FLEXTOUCH 100 UNITS/ML   3 Preferred Brand 17%17%None
LEVETIRACETAM 1,000 MG TABLET   2* Generic $5.00$15.00None
LEVETIRACETAM 100 MG/ML SOLUTION [Keppra]   2* Generic $5.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEVETIRACETAM 250 MG TABLET [Keppra]   2* Generic $5.00$15.00None
LEVETIRACETAM 500 MG TABLET [Roweepra]   2* Generic $5.00$15.00None
LEVETIRACETAM 750 MG TABLET [Keppra]   2* Generic $5.00$15.00None
LEVETIRACETAM ER 500 MG TABLET ER 24H [Roweepra]   3 Preferred Brand 17%17%None
LEVETIRACETAM ER 750 MG TABLET ER 24H [Roweepra]   3 Preferred Brand 17%17%None
LEVOBUNOLOL 0.5% EYE DROPS [Betagan]   2* Generic $5.00$15.00None
LEVOCARNITINE 1 G/10 ML SOLUTION   4 Non-Preferred Drug 35%35%None
LEVOCARNITINE 330 MG TABLET   4 Non-Preferred Drug 35%35%None
LEVOCETIRIZINE 5 MG TABLET [Xyzal Allergy 24 Hour]   2* Generic $5.00$15.00Q:30
/30Days
LEVOFLOXACIN 25 MG/ML SOLUTION [Levaquin]   4 Non-Preferred Drug 35%35%None
LEVOFLOXACIN 250 MG TABLET [LEVAQUIN]   2* Generic $5.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEVOFLOXACIN 500 MG TABLET [Levaquin]   2* Generic $5.00$15.00None
LEVOFLOXACIN 500 MG/100 ML-D5W PIGGYBACK [Levaquin]   4 Non-Preferred Drug 35%35%None
LEVOFLOXACIN 500 MG/20 ML VIAL [Levaquin]   4 Non-Preferred Drug 35%35%None
LEVOFLOXACIN 750 MG TABLET [Levaquin Leva-Pak]   2* Generic $5.00$15.00None
LEVOFLOXACIN 750 MG/150 ML-D5W PIGGYBACK [Levaquin]   4 Non-Preferred Drug 35%35%None
LEVONEST-28 TABLET   3 Preferred Brand 17%17%None
LEVONOR-ETH ESTRAD 0.1-0.02 MG Tablet [Vienva]   3 Preferred Brand 17%17%None
LEVONOR-ETH ESTRAD 0.15-0.03   3 Preferred Brand 17%17%None
LEVONOR-ETH ESTRAD 0.15-0.03   3 Preferred Brand 17%17%None
LEVONOR-ETH ESTRAD TRIPHASIC TABLET [Trivora]   3 Preferred Brand 17%17%None
Levora-28 tablet   3 Preferred Brand 17%17%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEVOTHYROXINE 100 MCG TABLET   2* Generic $5.00$15.00None
LEVOTHYROXINE 112 MCG TABLET   2* Generic $5.00$15.00None
LEVOTHYROXINE 125 MCG TABLET [Unithroid]   2* Generic $5.00$15.00None
LEVOTHYROXINE 137 MCG TABLET   2* Generic $5.00$15.00None
LEVOTHYROXINE 150 MCG TABLET   2* Generic $5.00$15.00None
LEVOTHYROXINE 175 MCG TABLET   2* Generic $5.00$15.00None
LEVOTHYROXINE 200 MCG TABLET [Unithroid]   2* Generic $5.00$15.00None
LEVOTHYROXINE 25 MCG TABLET   2* Generic $5.00$15.00None
LEVOTHYROXINE 300 MCG TABLET [Unithroid]   2* Generic $5.00$15.00None
LEVOTHYROXINE 50 MCG TABLET   2* Generic $5.00$15.00None
LEVOTHYROXINE 75 MCG TABLET   2* Generic $5.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEVOTHYROXINE 88 MCG TABLET   2* Generic $5.00$15.00None
LEXIVA 50mg/mL 225 mL in 1 BOTTLE   4 Non-Preferred Drug 35%35%None
LIDOCAINE 2% VISCOUS SOLUTION   2* Generic $5.00$15.00None
LIDOCAINE 5% OINTMENT [SOLUPAK]   4 Non-Preferred Drug 35%35%P Q:35
/30Days
LIDOCAINE 5% PATCH [Lidoderm]   4 Non-Preferred Drug 35%35%P Q:3
/1Days
LIDOCAINE HCL 4% SOLUTION [Xylocaine]   3 Preferred Brand 17%17%P Q:50
/30Days
LIDOCAINE-PRILOCAINE CREAM (g) [SOLUPICC]   3 Preferred Brand 17%17%P Q:30
/30Days
LINEZOLID 100 MG/5 ML ORAL SUSPENSION [Zyvox]   5 Specialty Tier 25%N/AP Q:1800
/28Days
LINEZOLID 600 MG TABLET [Zyvox]   4 Non-Preferred Drug 35%35%P Q:56
/28Days
LINEZOLID 600 MG/300 ML-D5W PIGGYBACK [Zyvox]   4 Non-Preferred Drug 35%35%P
LINZESS 145 MCG CAPSULE   4 Non-Preferred Drug 35%35%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LINZESS 290 MCG CAPSULE   4 Non-Preferred Drug 35%35%Q:30
/30Days
LINZESS 72 MCG CAPSULE   4 Non-Preferred Drug 35%35%Q:30
/30Days
LIOTHYRONINE SOD 25 MCG TABLET [Cytomel]   3 Preferred Brand 17%17%None
LIOTHYRONINE SOD 5 MCG TABLET [Cytomel]   3 Preferred Brand 17%17%None
LIOTHYRONINE SOD 50 MCG TABLET [Cytomel]   3 Preferred Brand 17%17%None
LISINOPRIL 10 MG TABLET   1* Preferred Generic $0.00$0.00None
LISINOPRIL 2.5 MG TABLET   1* Preferred Generic $0.00$0.00None
LISINOPRIL 20 MG TABLET   1* Preferred Generic $0.00$0.00None
LISINOPRIL 30 MG TABLET   1* Preferred Generic $0.00$0.00None
LISINOPRIL 40 MG TABLET [Zestril]   1* Preferred Generic $0.00$0.00None
LISINOPRIL 5 MG TABLET   1* Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LISINOPRIL-HCTZ 10-12.5 MG TABLET   1* Preferred Generic $0.00$0.00None
LISINOPRIL-HCTZ 20-12.5 MG TABLET   1* Preferred Generic $0.00$0.00None
LISINOPRIL-HCTZ 20-25 MG TABLET   1* Preferred Generic $0.00$0.00None
LITHIUM CARBONATE 150 MG CAPSULE CAPSULE   2* Generic $5.00$15.00None
LITHIUM CARBONATE 300 MG CAPSULE [Eskalith]   2* Generic $5.00$15.00None
LITHIUM CARBONATE 300 MG TABLET   2* Generic $5.00$15.00None
LITHIUM CARBONATE 600 MG CAPSULE   2* Generic $5.00$15.00None
LITHIUM CARBONATE ER 300 MG TABLET   2* Generic $5.00$15.00None
LITHIUM CARBONATE ER 450 MG TABLET [Eskalith CR]   2* Generic $5.00$15.00None
LOESTRIN 21 1.5/30 TABLET   2* Generic $5.00$15.00None
LOESTRIN 21 1/20 TABLET   2* Generic $5.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LOESTRIN FE 1.5/30 TABLET   2* Generic $5.00$15.00None
LOESTRIN FE 1/20 TABLET   2* Generic $5.00$15.00None
LOKELMA 10 GRAM POWDER PACKET   3 Preferred Brand 17%17%None
LOKELMA 5 GRAM POWDER PACKET   3 Preferred Brand 17%17%None
LONSURF 15 MG-6.14 MG TABLET   5 Specialty Tier 25%N/AP
LONSURF 20 MG-8.19 MG TABLET   5 Specialty Tier 25%N/AP
LOPERAMIDE 2 MG CAPSULE   3 Preferred Brand 17%17%None
LOPINAVIR-RITONAVIR 80-20MG/ML Solution [Kaletra]   4 Non-Preferred Drug 35%35%None
LOPINAVIR-RITONAVR 100-25MG TABLET [Kaletra]   4 Non-Preferred Drug 35%35%None
LOPINAVIR-RITONAVR 200-50MG TABLET [Kaletra]   5 Specialty Tier 25%N/ANone
LORAZEPAM 0.5 MG TABLET [Ativan]   2* Generic $5.00$15.00Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LORAZEPAM 1 MG TABLET [Ativan]   2* Generic $5.00$15.00Q:150
/30Days
LORAZEPAM 2 MG TABLET [Ativan]   2* Generic $5.00$15.00Q:150
/30Days
LORAZEPAM INTENSOL 2 MG/ML ORAL CONC   2* Generic $5.00$15.00Q:150
/30Days
LORBRENA 100 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
LORBRENA 25 MG TABLET   5 Specialty Tier 25%N/AP Q:90
/30Days
LORYNA 3 MG-0.02 MG TABLET [Yaz]   3 Preferred Brand 17%17%None
LOSARTAN POTASSIUM 100 MG TABLET [Cozaar]   1* Preferred Generic $0.00$0.00Q:30
/30Days
LOSARTAN POTASSIUM 25 MG TABLET [Cozaar]   1* Preferred Generic $0.00$0.00Q:60
/30Days
LOSARTAN POTASSIUM 50 MG TABLET [Cozaar]   1* Preferred Generic $0.00$0.00Q:60
/30Days
LOSARTAN-HCTZ 100-12.5 MG TABLET [Hyzaar]   1* Preferred Generic $0.00$0.00Q:30
/30Days
LOSARTAN-HCTZ 100-25 MG TABLET [Hyzaar]   1* Preferred Generic $0.00$0.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LOSARTAN-HCTZ 50-12.5 MG TABLET [Hyzaar]   1* Preferred Generic $0.00$0.00Q:30
/30Days
Lotemax 5mg/g 1 TUBE per CARTON / 3.5 g in 1 TUBE   3 Preferred Brand 17%17%None
LOTEMAX SM 0.38% OPHTH GEL DROPS   3 Preferred Brand 17%17%None
LOTEPREDNOL 0.5% OPHTHALMC GEL DROPS [Lotemax]   3 Preferred Brand 17%17%None
LOTEPREDNOL ETABONATE 0.5% DRP EYE DROPPER [Lotemax]   3 Preferred Brand 17%17%None
LOVASTATIN 10 MG TABLET   1* Preferred Generic $0.00$0.00None
LOVASTATIN 20 MG TABLET   1* Preferred Generic $0.00$0.00None
LOVASTATIN 40 MG TABLET [Mevacor]   1* Preferred Generic $0.00$0.00None
LOW-OGESTREL-28 TABLET [Low-Ogestrel]   2* Generic $5.00$15.00None
LOXAPINE 10 MG CAPSULE [Loxitane]   3 Preferred Brand 17%17%None
LOXAPINE 25 MG CAPSULE [Loxitane]   3 Preferred Brand 17%17%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LOXAPINE 5 MG CAPSULE [Loxitane]   3 Preferred Brand 17%17%None
LOXAPINE 50 MG CAPSULE [Loxitane]   3 Preferred Brand 17%17%None
LUMAKRAS 120 MG TABLET   5 Specialty Tier 25%N/AP Q:240
/30Days
LUMIGAN 0.01% EYE DROPS   3 Preferred Brand 17%17%None
LUPRON DEPOT 11.25 MG 3MO KIT   5 Specialty Tier 25%N/AP
LUPRON DEPOT 3.75 MG KIT   5 Specialty Tier 25%N/AP
LUTERA-28 TABLET   3 Preferred Brand 17%17%None
LYLEQ 0.35 MG TABLET [Sharobel 28-Day]   3 Preferred Brand 17%17%None
LYNPARZA 100 MG TABLET   5 Specialty Tier 25%N/AP Q:120
/30Days
LYNPARZA 150 MG TABLET   5 Specialty Tier 25%N/AP Q:120
/30Days
LYSODREN 500 MG TABLET   5 Specialty Tier 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LYZA 0.35 MG TABLET   3 Preferred Brand 17%17%None

Chart Legend:

Below are a few notes to help you understand the above 2022 Medicare Part D SilverScript Choice (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 $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 September 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.