A non-government resource for the Medicare community
Powered by Q1Group LLC
A non-government Medicare community resource
  • Menu
  • Home
  • Contact
  • MAPD
  • PDP
  • 2024
  • 2025
  • FAQs
  • Articles
  • Search
  • Contact
  • 2024
  • 2025
  • FAQs
  • Articles
  • Latest Medicare News
  • Search

2024 Medicare Part D and Medicare Advantage Plan Formulary Browser

Select your search style and criteria below or use this example to get started

Search by:
State & Plan   ZIP & Plan   PlanID   FormularyID

Search Criteria
PDP     MAPD
Scroll down to see formulary results.

Mutual of Omaha Rx Essential (PDP) (S7126-127-0)
Tier 1 (289)
Tier 2 (649)
Tier 3 (714)
Tier 4 (998)
Tier 5 (572)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
Yes No Show either
  *required
 
Cick on the first letter of your drug name to browse the formulary:

A B C D E F G H I J K L 
M N O P Q R S T U V W X Y Z 0-9 
2024 Medicare Part D Plan Formulary Information
Mutual of Omaha Rx Essential (PDP) (S7126-127-0)
Benefit Details           
Insulin on a Medicare Part D plan's formulary will have a monthly copay of $35 or less.
Call drug plan for more details.
The Mutual of Omaha Rx Essential (PDP) (S7126-127-0)
Formulary Drugs Starting with the Letter E

in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY
Drugs Starting with Letter E

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
E.E.S. 400 FILMTAB TABLET   4 Non-Preferred Drug 48%N/ANone
EC-NAPROXEN DR 500 MG TABLET [EC-Naprosyn]   2 Generic $15.00$37.50None
EDURANT 27.5mg/1   5 Specialty Tier 25%N/ANone
EFAVIR-EMTRI-TENOF 600-200-300 TABLET [Atripla]   5 Specialty Tier 25%N/ANone
EFAVIR-LAMIV-TENOF 400-300-300 TABLET [SYMFI LO]   5 Specialty Tier 25%N/ANone
EFAVIR-LAMIV-TENOF 600-300-300 TABLET [SYMFI]   5 Specialty Tier 25%N/ANone
EFAVIRENZ 200 MG CAPSULE [Sustiva]   4 Non-Preferred Drug 48%N/ANone
EFAVIRENZ 50 MG CAPSULE [Sustiva]   4 Non-Preferred Drug 48%N/ANone
EFAVIRENZ 600 MG TABLET [Sustiva]   4 Non-Preferred Drug 48%N/ANone
ELIGARD 22.5 MG SYRINGE   3 Preferred Brand 20%20%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ELIGARD 30 MG SYRINGE KIT   3 Preferred Brand 20%20%P
ELIGARD 7.5 MG SYRINGE KIT   3 Preferred Brand 20%20%P
ELIQUIS 2.5 MG TABLET   3 Preferred Brand 20%20%Q:60
/30Days
ELIQUIS 5 MG STARTER PACK   3 Preferred Brand 20%20%Q:148
/365Days
ELIQUIS 5 MG TABLET   3 Preferred Brand 20%20%Q:60
/30Days
ELURYNG VAGINAL RING [NuvaRing]   4 Non-Preferred Drug 48%N/ANone
EMGALITY 120 MG/ML PEN INJCTR   3 Preferred Brand 20%20%P Q:2
/30Days
EMGALITY 120 MG/ML SYRINGE   3 Preferred Brand 20%20%P Q:2
/30Days
Empagliflozin 5 MG / Metformin hydrochloride 500 MG Oral Tablet [Synjardy]   3 Preferred Brand 20%20%Q:60
/30Days
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H   5 Specialty Tier 25%N/ANone
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H   5 Specialty Tier 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H   5 Specialty Tier 25%N/ANone
EMTRICITABINE 200 MG CAPSULE [Emtriva]   4 Non-Preferred Drug 48%N/ANone
EMTRICITABINE-TENOFV 100-150MG TABLET [Truvada]   4 Non-Preferred Drug 48%N/AQ:30
/30Days
EMTRICITABINE-TENOFV 133-200MG TABLET [Truvada]   4 Non-Preferred Drug 48%N/AQ:30
/30Days
EMTRICITABINE-TENOFV 167-250MG TABLET [Truvada]   4 Non-Preferred Drug 48%N/AQ:30
/30Days
EMTRICITABINE-TENOFV 200-300MG TABLET [Truvada]   4 Non-Preferred Drug 48%N/AQ:30
/30Days
EMTRIVA 10MG/ML SOLUTION   4 Non-Preferred Drug 48%N/ANone
EMVERM 100 MG TABLET CHEW   5 Specialty Tier 25%N/ANone
ENALAPRIL MALEATE 10 MG TABLET [Vasotec]   2 Generic $15.00$37.50None
ENALAPRIL MALEATE 2.5 MG TABLET   2 Generic $15.00$37.50None
ENALAPRIL MALEATE 20 MG TABLET   2 Generic $15.00$37.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ENALAPRIL MALEATE 5 MG TABLET   2 Generic $15.00$37.50None
ENALAPRIL-HCTZ 10-25 MG TABLET [Vaseretic]   1* Preferred Generic $0.00$0.00None
ENALAPRIL-HCTZ 5-12.5 MG TABLET [Vaseretic]   1* Preferred Generic $0.00$0.00None
ENBREL 25 MG/0.5 ML SYRINGE   5 Specialty Tier 25%N/AP Q:8
/28Days
ENBREL 25 MG/0.5 ML VIAL   5 Specialty Tier 25%N/AP Q:8
/28Days
ENBREL 50 MG/ML MINI CARTRIDGE   5 Specialty Tier 25%N/AP Q:8
/28Days
ENBREL 50 MG/ML SURECLICK PEN INJECTOR   5 Specialty Tier 25%N/AP Q:8
/28Days
ENBREL 50 MG/ML SYRINGE   5 Specialty Tier 25%N/AP Q:8
/28Days
ENDARI 5 GRAM POWDER PACKET   5 Specialty Tier 25%N/AP
ENDOCET 10MG-325MG TABLET   3 Preferred Brand 20%20%Q:360
/30Days
ENDOCET 2.5-325 MG TABLET [Percocet]   3 Preferred Brand 20%20%Q:360
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ENDOCET 5/325 TABLET   3 Preferred Brand 20%20%Q:360
/30Days
ENDOCET 7.5-325MG TABLET   3 Preferred Brand 20%20%Q:360
/30Days
ENGERIX B INJECTION   1* Preferred Generic $0.00$0.00P
ENGERIX-B 20 MCG/ML SYRINGE   1* Preferred Generic $0.00$0.00P
ENGERIX-B 20 MCG/ML VIAL   1* Preferred Generic $0.00$0.00P
ENOXAPARIN 100 MG/ML SYRINGE [Lovenox]   4 Non-Preferred Drug 48%N/AQ:28
/28Days
ENOXAPARIN 120 MG/0.8 ML SYRINGE [Lovenox]   4 Non-Preferred Drug 48%N/AQ:22.4
/28Days
ENOXAPARIN 150 MG/ML SYRINGE [Lovenox]   4 Non-Preferred Drug 48%N/AQ:28
/28Days
ENOXAPARIN 30 MG/0.3 ML SYRINGE [Lovenox]   4 Non-Preferred Drug 48%N/AQ:16.8
/28Days
ENOXAPARIN 40 MG/0.4 ML SYRINGE [Lovenox]   4 Non-Preferred Drug 48%N/AQ:11.2
/28Days
ENOXAPARIN 60 MG/0.6 ML SYRINGE [Lovenox]   4 Non-Preferred Drug 48%N/AQ:16.8
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ENOXAPARIN 80 MG/0.8 ML SYRINGE [Lovenox]   4 Non-Preferred Drug 48%N/AQ:22.4
/28Days
ENSKYCE 28 TABLET [Solia]   2 Generic $15.00$37.50None
ENTACAPONE 200 MG TABLET [Comtan]   4 Non-Preferred Drug 48%N/ANone
ENTECAVIR 0.5 MG TABLET [Baraclude]   4 Non-Preferred Drug 48%N/ANone
ENTECAVIR 1 MG TABLET [Baraclude]   4 Non-Preferred Drug 48%N/ANone
ENTRESTO 24 MG-26 MG TABLET   3 Preferred Brand 20%20%Q:60
/30Days
ENTRESTO 49 MG-51 MG TABLET   3 Preferred Brand 20%20%Q:60
/30Days
ENTRESTO 97 MG-103 MG TABLET   3 Preferred Brand 20%20%Q:60
/30Days
ENULOSE 10 GM/15 ML SOLUTION   2 Generic $15.00$37.50None
ENVARSUS XR 0.75 MG TABLET ER 24H   4 Non-Preferred Drug 48%N/AP
ENVARSUS XR 1 MG TABLET   4 Non-Preferred Drug 48%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ENVARSUS XR 4 MG TABLET ER 24H   4 Non-Preferred Drug 48%N/AP
EPCLUSA 150-37.5 MG PELLET PACK   5 Specialty Tier 25%N/AP Q:28
/28Days
EPCLUSA 200 MG-50 MG TABLET   5 Specialty Tier 25%N/AP Q:56
/28Days
EPCLUSA 200-50 MG PELLET PACK   5 Specialty Tier 25%N/AP Q:56
/28Days
EPCLUSA 400 MG-100 MG TABLET   5 Specialty Tier 25%N/AP Q:28
/28Days
EPIDIOLEX 100 MG/ML SOLUTION   4 Non-Preferred Drug 48%N/AP
EPINASTINE HCL 0.05% EYE DROPS [Elestat]   3 Preferred Brand 20%20%None
EPINEPHRINE 0.15 MG AUTO-INJCT [Twinject]   3 Preferred Brand 20%20%Q:2
/30Days
EPINEPHRINE 0.3 MG AUTO-INJECT [Twinject]   3 Preferred Brand 20%20%Q:2
/30Days
EPITOL 200MG TABLET   4 Non-Preferred Drug 48%N/ANone
EPLERENONE 25 MG TABLET [Inspra]   3 Preferred Brand 20%20%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
EPLERENONE 50 MG TABLET [Inspra]   3 Preferred Brand 20%20%None
EPRONTIA 25 MG/ML SOLUTION   4 Non-Preferred Drug 48%N/AP
Ergotamine-caffeine 1-100mg tablet   3 Preferred Brand 20%20%None
ERIVEDGE 150 MG CAPSULE   5 Specialty Tier 25%N/AP Q:30
/30Days
ERLEADA 240 MG TABLET   4 Non-Preferred Drug 48%N/AP Q:30
/30Days
ERLEADA 60 MG TABLET   4 Non-Preferred Drug 48%N/AP Q:120
/30Days
ERLOTINIB HCL 100 MG TABLET [Tarceva]   5 Specialty Tier 25%N/AP Q:30
/30Days
ERLOTINIB HCL 150 MG TABLET [Tarceva]   5 Specialty Tier 25%N/AP Q:30
/30Days
ERLOTINIB HCL 25 MG TABLET [Tarceva]   5 Specialty Tier 25%N/AP Q:60
/30Days
ERRIN 0.35 MG TABLET [Sharobel 28-Day]   2 Generic $15.00$37.50None
ERTAPENEM 1 GRAM VIAL [Invanz]   4 Non-Preferred Drug 48%N/AP Q:14
/14Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ERY 2% PADS 2% 60 PADS JAR   3 Preferred Brand 20%20%None
ERY-TAB DR 250 MG TABLET DR   4 Non-Preferred Drug 48%N/ANone
ERY-TAB DR 333 MG TABLET DR   4 Non-Preferred Drug 48%N/ANone
ERYTHROCIN 250 MG FILMTAB TABLET   4 Non-Preferred Drug 48%N/ANone
ERYTHROMYCIN 0.5% EYE OINTMENT [Romycin]   2 Generic $15.00$37.50Q:3.5
/14Days
ERYTHROMYCIN 2% SOLUTION   2 Generic $15.00$37.50None
ERYTHROMYCIN 250 MG TABLET   4 Non-Preferred Drug 48%N/ANone
ERYTHROMYCIN 500 MG TABLET   4 Non-Preferred Drug 48%N/ANone
ERYTHROMYCIN DR 250 MG CAPSULE DR [ERYC]   4 Non-Preferred Drug 48%N/ANone
ERYTHROMYCIN DR 250 MG TABLET DR [Ery-Tab]   4 Non-Preferred Drug 48%N/ANone
ERYTHROMYCIN DR 333 MG TABLET DR [Ery-Tab]   4 Non-Preferred Drug 48%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ERYTHROMYCIN DR 500 MG TABLET DR [Ery-Tab]   4 Non-Preferred Drug 48%N/ANone
ERYTHROMYCIN ES 400 MG TABLET [E.E.S.]   4 Non-Preferred Drug 48%N/ANone
ESCITALOPRAM 10 MG TABLET [Lexapro]   2 Generic $15.00$37.50Q:30
/30Days
ESCITALOPRAM 20 MG TABLET [Lexapro]   2 Generic $15.00$37.50Q:30
/30Days
ESCITALOPRAM 5 MG TABLET [Lexapro]   2 Generic $15.00$37.50Q:30
/30Days
ESCITALOPRAM OXALATE 5 MG/5 ML SOLUTION [Lexapro]   4 Non-Preferred Drug 48%N/ANone
ESOMEPRAZOLE MAG DR 20 MG CAPSULE DR [Nexium 24HR Clear Minis]   4 Non-Preferred Drug 48%N/AQ:30
/30Days
ESOMEPRAZOLE MAG DR 40 MG CAPSULE DR [Nexium]   4 Non-Preferred Drug 48%N/AQ:60
/30Days
ESTARYLLA 0.25-0.035 MG TABLET [VyLibra]   2 Generic $15.00$37.50None
Estradiol / Norethindrone Acetate 0.5; 0.1mg/1; mg/1 1 BLISTER PACK per CARTON / 28 TABLET, FILM C   3 Preferred Brand 20%20%None
ESTRADIOL 0.01% CREAM/APPL [Estrace]   4 Non-Preferred Drug 48%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Estradiol 0.025 mg patch   3 Preferred Brand 20%20%Q:8
/28Days
ESTRADIOL 0.025 MG PATCH(1/WK) [FemPatch]   3 Preferred Brand 20%20%Q:4
/28Days
ESTRADIOL 0.0375MG PATCH(1/WKClimara]   3 Preferred Brand 20%20%Q:4
/28Days
ESTRADIOL 0.0375MG PATCH(2/WK) TDSW [Vivelle-Dot]   3 Preferred Brand 20%20%Q:8
/28Days
ESTRADIOL 0.05 MG PATCH (1/WK) [Climara]   3 Preferred Brand 20%20%Q:4
/28Days
ESTRADIOL 0.05 MG PATCH (2/WK) PATCH TDSW [Vivelle-Dot]   3 Preferred Brand 20%20%Q:8
/28Days
ESTRADIOL 0.06 MG PATCH (1/WK) [Climara]   3 Preferred Brand 20%20%Q:4
/28Days
Estradiol 0.075 mg patch   3 Preferred Brand 20%20%Q:8
/28Days
ESTRADIOL 0.075 MG PATCH(1/WKClimara]   3 Preferred Brand 20%20%Q:4
/28Days
Estradiol 0.1 mg patch   3 Preferred Brand 20%20%Q:8
/28Days
ESTRADIOL 0.1 MG PATCH (1/WK) [Climara]   3 Preferred Brand 20%20%Q:4
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ESTRADIOL 0.5 MG TABLET   2 Generic $15.00$37.50None
ESTRADIOL 1 MG TABLET   2 Generic $15.00$37.50None
ESTRADIOL 10 MCG VAGINAL INSRT   4 Non-Preferred Drug 48%N/ANone
ESTRADIOL 2MG TABLET   2 Generic $15.00$37.50None
ESTRADIOL 50 MG/5 ML VIAL [Delestrogen]   4 Non-Preferred Drug 48%N/ANone
ESTRADIOL VALERATE 100 MG/5 ML VIAL [Gynogen LA]   4 Non-Preferred Drug 48%N/ANone
ESTRADIOL VALERATE 200 MG/5 ML VIAL [Delestrogen]   4 Non-Preferred Drug 48%N/ANone
ESTRADIOL-NORETH 1.0-0.5MG TABLET   3 Preferred Brand 20%20%None
ETHAMBUTOL HCL 400 MG TABLET   3 Preferred Brand 20%20%None
Ethambutol Hydrochloride 100mg/1   3 Preferred Brand 20%20%None
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6   2 Generic $15.00$37.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TABLET 21   2 Generic $15.00$37.50None
ETHOSUXIMIDE 250 MG CAPSULE [Zarontin]   3 Preferred Brand 20%20%None
ETHOSUXIMIDE 250 MG/5 ML SOLUTION [Zarontin]   3 Preferred Brand 20%20%None
ETHYNODIOL-ETH ESTRA 1MG-35MCG [ZOVIA]   2 Generic $15.00$37.50None
ETHYNODIOL-ETH ESTRA 1MG-50MCG [ZOVIA]   2 Generic $15.00$37.50None
ETODOLAC 200 MG CAPSULE [Lodine]   3 Preferred Brand 20%20%None
ETODOLAC 300 MG CAPSULE [Lodine]   3 Preferred Brand 20%20%None
ETODOLAC 400 MG TABLET [Lodine]   3 Preferred Brand 20%20%None
ETODOLAC 500 MG TABLET [Lodine]   3 Preferred Brand 20%20%None
ETONOGESTREL-EE VAGINAL RING [NuvaRing]   4 Non-Preferred Drug 48%N/ANone
ETRAVIRINE 100 MG TABLET [INTELENCE]   5 Specialty Tier 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ETRAVIRINE 200 MG TABLET [INTELENCE]   5 Specialty Tier 25%N/ANone
EUTHYROX 100 MCG TABLET   1* Preferred Generic $0.00$0.00None
EUTHYROX 112 MCG TABLET   1* Preferred Generic $0.00$0.00None
EUTHYROX 125 MCG TABLET   1* Preferred Generic $0.00$0.00None
EUTHYROX 137 MCG TABLET   1* Preferred Generic $0.00$0.00None
EUTHYROX 150 MCG TABLET   1* Preferred Generic $0.00$0.00None
EUTHYROX 175 MCG TABLET   1* Preferred Generic $0.00$0.00None
EUTHYROX 200 MCG TABLET   1* Preferred Generic $0.00$0.00None
EUTHYROX 25 MCG TABLET   1* Preferred Generic $0.00$0.00None
EUTHYROX 50 MCG TABLET   1* Preferred Generic $0.00$0.00None
EUTHYROX 75 MCG 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
EUTHYROX 88 MCG TABLET   1* Preferred Generic $0.00$0.00None
EVEROLIMUS 0.25 MG TABLET [Zortress]   4 Non-Preferred Drug 48%N/AP
EVEROLIMUS 0.5 MG TABLET [Zortress]   5 Specialty Tier 25%N/AP
EVEROLIMUS 0.75 MG TABLET [Zortress]   5 Specialty Tier 25%N/AP
EVEROLIMUS 1 MG TABLET [Zortress]   5 Specialty Tier 25%N/AP
EVEROLIMUS 10 MG TABLET [Afinitor]   5 Specialty Tier 25%N/AP Q:30
/30Days
EVEROLIMUS 2 MG TABLET FOR SUSP [Afinitor DISPERZ]   5 Specialty Tier 25%N/AP Q:330
/30Days
EVEROLIMUS 2.5 MG TABLET [Afinitor]   5 Specialty Tier 25%N/AP Q:30
/30Days
EVEROLIMUS 3 MG TABLET FOR SUSP [Afinitor DISPERZ]   5 Specialty Tier 25%N/AP Q:240
/30Days
EVEROLIMUS 5 MG TABLET [Afinitor]   5 Specialty Tier 25%N/AP Q:30
/30Days
EVEROLIMUS 5 MG TABLET FOR SUSP [Afinitor DISPERZ]   5 Specialty Tier 25%N/AP Q:180
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
EVEROLIMUS 7.5 MG TABLET [Afinitor]   5 Specialty Tier 25%N/AP Q:30
/30Days
EVOTAZ 300 MG-150 MG TABLET   5 Specialty Tier 25%N/ANone
EXEMESTANE 25 MG TABLET [Aromasin]   4 Non-Preferred Drug 48%N/ANone
EZETIMIBE 10 MG TABLET [Zetia]   3 Preferred Brand 20%20%None
EZETIMIBE-SIMVASTATIN 10-10 MG TABLET [Vytorin]   3 Preferred Brand 20%20%Q:30
/30Days
EZETIMIBE-SIMVASTATIN 10-20 MG TABLET [Vytorin]   3 Preferred Brand 20%20%Q:30
/30Days
EZETIMIBE-SIMVASTATIN 10-40 MG TABLET [Vytorin]   3 Preferred Brand 20%20%Q:30
/30Days
EZETIMIBE-SIMVASTATIN 10-80 MG TABLET [Vytorin]   3 Preferred Brand 20%20%Q:30
/30Days

Chart Legend:

Below are a few notes to help you understand the above 2024 Medicare Part D Mutual of Omaha Rx Essential (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 $545 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 $5,030) 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.

      *All forms of insulin covered by any Medicare Part D plan will have a copay of $35 or less through all phases of coverage. 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 2024)

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
  • Q1Medicare®, Q1Rx®, and Q1Group® are registered Service Marks of Q1Group LLC and may not be used in any advertising, publicity, or for commercial purposes without the express authorization of Q1Group.
  • 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 PDPCompare.com and MACompare.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.
    Statement required by Medicare:
    "We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options."
  • 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.