Q1Medicare.com
Powered by Q1Group LLC
Education and Decision Support Tools for the Medicare Community
  • ☰ MENU
  • Home
  • Contact
  • MAPD
  • PDP
  • 2017
  • FAQs
  • Latest Medicare News

2017 Medicare Part D or 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

EnvisionRxPlus (PDP) (S7694-025-0)
Tier 1 (311)
Tier 2 (520)
Tier 3 (181)
Tier 4 (1470)
Tier 5 (547)
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 
2017 Medicare Part D Plan Formulary Information
EnvisionRxPlus (PDP) (S7694-025-0)
Benefits & Contact Info           
The EnvisionRxPlus (PDP) (S7694-025-0)
Formulary Drugs Starting with the Letter A

in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY
Plan Monthly Premium: $52.70 Deductible: $400 Qualifies for LIS: No
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 300 MG TABLET   4 Non-Preferred Drug 33%33%Q:60
/30Days
Abacavir Sulfate-Lamivudine-Zidovudine tablets [Trizivir]   5 Specialty Tier 25%N/AQ:60
/30Days
ABELCENT INJECTION SUSPENSION 5MG/ML   5 Specialty Tier 25%N/AP
ABILIFY MAINTENA ER 300 MG SYR   5 Specialty Tier 25%N/AS Q:1
/26Days
ABILIFY MAINTENA ER 300 MG VL   4 Non-Preferred Drug 33%33%S Q:1
/26Days
ABILIFY MAINTENA ER 400 MG SYR   5 Specialty Tier 25%N/AS Q:1
/26Days
ABRAXANE 100MG VIAL   5 Specialty Tier 25%N/AP
Acamprosate Calcium DR 333 MG tablets [Campral]   4 Non-Preferred Drug 33%33%None
ACARBOSE 100 MG TABLET   4 Non-Preferred Drug 33%33%Q:90
/30Days
ACARBOSE 25 MG TABLET   4 Non-Preferred Drug 33%33%Q:150
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Acarbose 50mg/1 100 TABLET BOTTLE   4 Non-Preferred Drug 33%33%Q:150
/30Days
ACEBUTOLOL 200MG CAPSULE   2 Generic 12%12%None
ACEBUTOLOL 400MG CAPSULE   2 Generic 12%12%None
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE   4 Non-Preferred Drug 33%33%None
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD   2 Generic 12%12%Q:5000
/30Days
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT)   2 Generic 12%12%Q:400
/30Days
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT)   2 Generic 12%12%Q:400
/30Days
ACETAMINOPHEN-COD #4 TABLET   2 Generic 12%12%Q:400
/30Days
ACETAZOLAMIDE 125MG TABLET   2 Generic 12%12%None
ACETAZOLAMIDE 250MG TABLET (100 CT)   4 Non-Preferred Drug 33%33%None
ACETIC ACID 2% EAR SOLUTION   2 Generic 12%12%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETYLCYSTEINE 10% VIAL   4 Non-Preferred Drug 33%33%P
ACETYLCYSTEINE 20% VIAL   4 Non-Preferred Drug 33%33%P
ACITRETIN 10 MG CAPSULE [Soriatane]   5 Specialty Tier 25%N/AP
ACITRETIN 17.5 MG CAPSULE [Soriatane]   5 Specialty Tier 25%N/AP
ACITRETIN 25 MG CAPSULE [Soriatane]   5 Specialty Tier 25%N/AP
ACTEMRA 162 MG/0.9 ML SYRINGE   5 Specialty Tier 25%N/AP
ACTEMRA 400 MG/20 ML VIAL   5 Specialty Tier 25%N/AP
ACTEMRA 80 MG/4 ML VIAL   5 Specialty Tier 25%N/AP
ACTEMRA INJECTION 200MG/10ML   5 Specialty Tier 25%N/AP
ACTHIB VACCINE WITH DILUENT   4 Non-Preferred Drug 33%33%None
ACTIMMUNE 100 MCG/0.5 ML VIAL   5 Specialty Tier 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Acyclovir 200mg 100 CAPSULE BOTTLE   1 Preferred Generic 10%10%None
Acyclovir 200mg/5mL 473 mL BOTTLE   4 Non-Preferred Drug 33%33%None
Acyclovir 400mg/1   1 Preferred Generic 10%10%None
ACYCLOVIR 800 MG TABLET   1 Preferred Generic 10%10%None
Acyclovir sodium 500 mg vial   4 Non-Preferred Drug 33%33%P
ADACEL VIAL 2UNT/5UNT   4 Non-Preferred Drug 33%33%None
ADAGEN 250U/ML VIAL   5 Specialty Tier 25%N/ANone
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA]   5 Specialty Tier 25%N/AP Q:2
/28Days
ADCIRCA TABLETS 20MG 60 BOTTLE   5 Specialty Tier 25%N/AP Q:60
/30Days
ADEFOVIR DIPIVOXIL 10 MG TAB [Hepsera]   5 Specialty Tier 25%N/ANone
ADEMPAS 0.5 MG TABLET   5 Specialty Tier 25%N/AP Q:90
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADEMPAS 1 MG TABLET   5 Specialty Tier 25%N/AP Q:90
/30Days
ADEMPAS 1.5 MG TABLET   5 Specialty Tier 25%N/AP Q:90
/30Days
ADEMPAS 2 MG TABLET   5 Specialty Tier 25%N/AP Q:90
/30Days
ADEMPAS 2.5 MG TABLET   5 Specialty Tier 25%N/AP Q:90
/30Days
ADRUCIL 50mg/mL 10 VIAL in 1 TRAY / 10 mL in 1 VIAL   4 Non-Preferred Drug 33%33%P
ADVAIR DISKUS MIS 100/50   3 Preferred Brand 15%15%Q:60
/30Days
ADVAIR DISKUS MIS 250/50   3 Preferred Brand 15%15%Q:60
/30Days
ADVAIR DISKUS MIS 500/50   3 Preferred Brand 15%15%Q:60
/30Days
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER   3 Preferred Brand 15%15%Q:12
/30Days
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL   3 Preferred Brand 15%15%Q:12
/30Days
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL   3 Preferred Brand 15%15%Q:12
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AFEDITAB CR 30MG TABLET SA   4 Non-Preferred Drug 33%33%Q:60
/30Days
AFEDITAB CR 60MG TABLET SA   4 Non-Preferred Drug 33%33%Q:60
/30Days
Afinitor 7.5mg/1 28 BLISTER PACK per CARTON / 1 TABLET per BLISTER PACK   5 Specialty Tier 25%N/AP Q:30
/30Days
AFINITOR DISPERZ 2 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
AFINITOR DISPERZ 3 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
AFINITOR DISPERZ 5 MG TABLET   5 Specialty Tier 25%N/AP Q:60
/30Days
AFINITOR TABLETS 10 MG   5 Specialty Tier 25%N/AP Q:30
/30Days
AFINITOR TABLETS 2.5 MG   5 Specialty Tier 25%N/AP Q:30
/30Days
AFINITOR TABLETS 5 MG   5 Specialty Tier 25%N/AP Q:30
/30Days
AGGRENOX 25-200MG CAPSULE   4 Non-Preferred Drug 33%33%None
AK-CON 0.1% EYE DROPS   2 Generic 12%12%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALBENZA 200 MG TABLET   5 Specialty Tier 25%N/ANone
ALBUTEROL SULFATE 0.75mg/3mL 30 POUCH per CARTON / 1 VIAL, SINGLE-DOSE in 1 POUCH / 3 mL in 1 VIAL   4 Non-Preferred Drug 33%33%P
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER   4 Non-Preferred Drug 33%33%P
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   2 Generic 12%12%P
ALBUTEROL SULFATE SOLUTION FOR INHALATION   2 Generic 12%12%P
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT   2 Generic 12%12%None
ALBUTEROL SULFATE TABLET 2MG (500 CT)   4 Non-Preferred Drug 33%33%None
ALBUTEROL TABLET 4MG (500 CT)   4 Non-Preferred Drug 33%33%None
ALDURAZYME 2.9MG/5ML VIAL   5 Specialty Tier 25%N/AP
ALECENSA 150 MG CAPSULE   3 Preferred Brand 15%15%None
ALENDRONATE SODIUM 10MG TABLET   2 Generic 12%12%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALENDRONATE SODIUM 35 MG TABLET   2 Generic 12%12%Q:4
/28Days
ALENDRONATE SODIUM 40MG TABLET   2 Generic 12%12%Q:30
/30Days
ALENDRONATE SODIUM 5MG TABLET   2 Generic 12%12%Q:30
/30Days
Alendronate Sodium 70mg/1 4 BLISTER PACK in 1 BOX / 1 TABLET in 1 BLISTER PACK   2 Generic 12%12%Q:4
/28Days
ALFUZOSIN HYDROCHLORIDE 10mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE   2 Generic 12%12%Q:30
/30Days
ALIMTA 500MG VIAL   5 Specialty Tier 25%N/AP
ALINIA 100MG/5ML SUSPENSION   4 Non-Preferred Drug 33%33%Q:150
/30Days
ALINIA 500 MG TABLET   4 Non-Preferred Drug 33%33%Q:40
/30Days
ALLOPURINOL 100 MG TABLETS   1 Preferred Generic 10%10%None
Allopurinol 300mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET per BLISTER PACK   1 Preferred Generic 10%10%None
ALOSETRON HCL 0.5 MG TABLET [Lotronex]   5 Specialty Tier 25%N/AQ:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALOSETRON HCL 1 MG TABLET [Lotronex]   5 Specialty Tier 25%N/AQ:60
/30Days
ALPHAGAN P 0.1% DROPS   3 Preferred Brand 15%15%None
ALPHAGAN P 0.15% EYE DROPS   3 Preferred Brand 15%15%None
ALPRAZOLAM 0.25 MG TABLET   1 Preferred Generic 10%10%Q:120
/30Days
ALPRAZOLAM 0.5 MG TABLET   1 Preferred Generic 10%10%Q:120
/30Days
ALPRAZOLAM 1 MG TABLET   1 Preferred Generic 10%10%Q:240
/30Days
Alprazolam 1mg/mL 1 BOTTLE in 1 CONTAINER / 30 mL in 1 BOTTLE   4 Non-Preferred Drug 33%33%None
ALPRAZOLAM 2 MG TABLET   1 Preferred Generic 10%10%Q:150
/30Days
ALREX 0.2% EYE DROPS   4 Non-Preferred Drug 33%33%None
AMANTADINE 100MG CAPSULE   4 Non-Preferred Drug 33%33%None
AMANTADINE 100MG TABLET   4 Non-Preferred Drug 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Amantadine Hydrochloride 50mg/5mL 473 mL in 1 BOTTLE   2 Generic 12%12%None
AMBISOME 50MG VIAL   5 Specialty Tier 25%N/AP
AMCINONIDE 0.1% CREAM   4 Non-Preferred Drug 33%33%None
AMCINONIDE 0.1% OINTMENT 60GM TUBE   4 Non-Preferred Drug 33%33%None
AMIFOSTINE 50mg/mL 3 VIAL, SINGLE-USE per CARTON / 10 mL in 1 VIAL, SINGLE-USE   5 Specialty Tier 25%N/AP
AMIKACIN SULFATE 500 MG/2 ML VIAL   4 Non-Preferred Drug 33%33%None
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET   1 Preferred Generic 10%10%None
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT   2 Generic 12%12%None
Aminophylline 25mg/mL 5 TRAY per CARTON / 5 AMPULE in 1 TRAY / 10 mL in 1 AMPULE   1 Preferred Generic 10%10%None
AMINOSYN 7%-ELECTROLYTE SOL   4 Non-Preferred Drug 33%33%P
AMINOSYN HBC INJECTION SULFITE FREE 7%   4 Non-Preferred Drug 33%33%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN II 10% IV SOLUTION   4 Non-Preferred Drug 33%33%P
AMINOSYN II 7% IV SOLUTION   4 Non-Preferred Drug 33%33%P
AMINOSYN II 8.5% ELECTROLYT   4 Non-Preferred Drug 33%33%P
AMINOSYN II 8.5% ELECTROLYT   4 Non-Preferred Drug 33%33%P
AMINOSYN PF INJECTION   4 Non-Preferred Drug 33%33%P
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5%   4 Non-Preferred Drug 33%33%P
AMINOSYN-PF 7% IV SOLUTION   4 Non-Preferred Drug 33%33%P
AMINOSYN-RF 5.2% IV SOLUTION   4 Non-Preferred Drug 33%33%P
AMIODARONE HCL 200MG 60 TABLET BOTTLE   2 Generic 12%12%None
AMIODARONE HCL 400MG TABLET   4 Non-Preferred Drug 33%33%None
AMIODARONE HCL 50 MG INJECTION   4 Non-Preferred Drug 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITRIPTYLINE HCL 100MG TABLET   4 Non-Preferred Drug 33%33%P
AMITRIPTYLINE HCL 10MG TABLET   4 Non-Preferred Drug 33%33%P
AMITRIPTYLINE HCL 150 MG TAB   4 Non-Preferred Drug 33%33%P
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)   4 Non-Preferred Drug 33%33%P
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)   4 Non-Preferred Drug 33%33%P
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT   4 Non-Preferred Drug 33%33%P
AMLOD-VALSA-HCTZ 10-160-12.5 MG [EXFORGE HCT]   4 Non-Preferred Drug 33%33%Q:30
/30Days
AMLOD-VALSA-HCTZ 10-160-25 MG [EXFORGE HCT]   4 Non-Preferred Drug 33%33%Q:30
/30Days
AMLOD-VALSA-HCTZ 10-320-25 MG [EXFORGE HCT]   4 Non-Preferred Drug 33%33%Q:30
/30Days
AMLOD-VALSA-HCTZ 5-160-12.5 MG [EXFORGE HCT]   4 Non-Preferred Drug 33%33%Q:30
/30Days
AMLOD-VALSA-HCTZ 5-160-25 MG [EXFORGE HCT]   4 Non-Preferred Drug 33%33%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE BESYLATE 10MG TABLET (90 CT)   1 Preferred Generic 10%10%None
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)   1 Preferred Generic 10%10%None
AMLODIPINE BESYLATE 5MG TABLET (90 CT)   1 Preferred Generic 10%10%None
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE   2 Generic 12%12%Q:30
/30Days
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE   2 Generic 12%12%Q:45
/30Days
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE   2 Generic 12%12%Q:45
/30Days
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE   2 Generic 12%12%Q:45
/30Days
Amlodipine-Atorvastatin 10-10 mg [Caduet]   4 Non-Preferred Drug 33%33%None
Amlodipine-Atorvastatin 10-20 mg [Caduet]   4 Non-Preferred Drug 33%33%None
Amlodipine-Atorvastatin 10-40 mg [Caduet]   4 Non-Preferred Drug 33%33%None
Amlodipine-Atorvastatin 10-80 mg [Caduet]   4 Non-Preferred Drug 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Amlodipine-Atorvastatin 2.5-10 mg [Caduet]   2 Generic 12%12%None
Amlodipine-Atorvastatin 2.5-20 mg [Caduet]   2 Generic 12%12%None
Amlodipine-Atorvastatin 2.5-40 mg [Caduet]   2 Generic 12%12%None
Amlodipine-Atorvastatin 5-10 mg [Caduet]   4 Non-Preferred Drug 33%33%None
Amlodipine-Atorvastatin 5-20 mg [Caduet]   4 Non-Preferred Drug 33%33%None
Amlodipine-Atorvastatin 5-40 mg [Caduet]   4 Non-Preferred Drug 33%33%None
Amlodipine-Atorvastatin 5-80 mg [Caduet]   4 Non-Preferred Drug 33%33%None
AMLODIPINE-BENAZEPRIL 10-40 MG   2 Generic 12%12%Q:30
/30Days
AMLODIPINE-BENAZEPRIL 5-40 MG   2 Generic 12%12%Q:30
/30Days
AMLODIPINE-VALSARTAN 10-160 MG   2 Generic 12%12%Q:30
/30Days
AMLODIPINE-VALSARTAN 10-320 MG   2 Generic 12%12%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE-VALSARTAN 5-160 MG   2 Generic 12%12%Q:30
/30Days
AMLODIPINE-VALSARTAN 5-320 MG   2 Generic 12%12%Q:30
/30Days
AMMONIUM LACTATE 12% LOTION   2 Generic 12%12%None
AMOX TR-K CLV 500-125 MG TAB   4 Non-Preferred Drug 33%33%None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE   2 Generic 12%12%None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET   4 Non-Preferred Drug 33%33%None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE   4 Non-Preferred Drug 33%33%None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   4 Non-Preferred Drug 33%33%None
AMOX-CLAV 200-28.5 MG/5 ML SUS   4 Non-Preferred Drug 33%33%None
AMOXAPINE 100MG TABLET   2 Generic 12%12%S
AMOXAPINE 150MG TABLET   2 Generic 12%12%S
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXAPINE 25MG TABLET   2 Generic 12%12%S
AMOXAPINE 50MG TABLET   2 Generic 12%12%S
AMOXICILLIN 125MG TABLET CHEW   1 Preferred Generic 10%10%None
AMOXICILLIN 250MG 500 CHEWABLE TABLET in BOTTLE   1 Preferred Generic 10%10%None
AMOXICILLIN 250MG CAPSULE   1 Preferred Generic 10%10%None
AMOXICILLIN 50 MG/ML / CLAVULANATE 12.5 MG/ML ORAL SUSPENSION   4 Non-Preferred Drug 33%33%None
AMOXICILLIN 500MG 500 CAPSULE BOTTLE   1 Preferred Generic 10%10%None
AMOXICILLIN 500MG TABLET (100 CT)   1 Preferred Generic 10%10%None
AMOXICILLIN 875MG TABLET   1 Preferred Generic 10%10%None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT   4 Non-Preferred Drug 33%33%None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS EXTENDED RELEASE 1000;62.5MG;MG   4 Non-Preferred Drug 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT   4 Non-Preferred Drug 33%33%None
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT   1 Preferred Generic 10%10%None
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL   1 Preferred Generic 10%10%None
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   1 Preferred Generic 10%10%None
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL   1 Preferred Generic 10%10%None
AMPHETAMINE SALT COMBO 12.5MG TABLET   4 Non-Preferred Drug 33%33%Q:90
/30Days
AMPHETAMINE SALT COMBO 15MG TABLET   4 Non-Preferred Drug 33%33%Q:90
/30Days
AMPHETAMINE SALT COMBO 30MG TABLET   4 Non-Preferred Drug 33%33%Q:60
/30Days
AMPHETAMINE SALT COMBO 7.5MG TABLET   2 Generic 12%12%Q:90
/30Days
AMPHETAMINE SALTS 20MG TABLET   4 Non-Preferred Drug 33%33%Q:90
/30Days
AMPHETAMINE SALTS 5 MG TAB   4 Non-Preferred Drug 33%33%Q:90
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
amphotericin b 50mg/10mL 10 mL in 1 VIAL   4 Non-Preferred Drug 33%33%P
Ampicillin 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS   4 Non-Preferred Drug 33%33%None
AMPICILLIN CAPSULES 250MG 100 BOT   1 Preferred Generic 10%10%None
AMPICILLIN CAPSULES 500MG 100 BOT   1 Preferred Generic 10%10%None
AMPICILLIN FOR INJECTION POWDER   4 Non-Preferred Drug 33%33%None
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT   2 Generic 12%12%None
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT   2 Generic 12%12%None
AMPICILLIN POWDER FOR INJECTION 1 GM/ML   4 Non-Preferred Drug 33%33%None
AMPICILLIN-SULBACTAM 15 GM VIAL   4 Non-Preferred Drug 33%33%None
AMPICILLIN-SULBACTAM 3 GM VIAL   4 Non-Preferred Drug 33%33%None
AMPYRA ER 10 MG TABLET   5 Specialty Tier 25%N/AP Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANADROL-50 TABLET   5 Specialty Tier 25%N/ANone
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE   2 Generic 12%12%None
Anagrelide Hydrochloride 1mg/1 100 CAPSULE BOTTLE   2 Generic 12%12%None
Anastrozole 1mg/1 90 FILM COATED TABLETS in BOTTLE, PLASTIC   4 Non-Preferred Drug 33%33%None
ANDRODERM 2 MG/24HR PATCH   3 Preferred Brand 15%15%None
ANDRODERM 4 MG/24HR PATCH   3 Preferred Brand 15%15%None
ANDROGEL 1.62% (1.25G) GEL PCKT   3 Preferred Brand 15%15%None
ANDROGEL 1.62% (2.5G) GEL PCKT   3 Preferred Brand 15%15%None
ANDROGEL 1% (50MG) GEL PACKET   3 Preferred Brand 15%15%None
Androgel 10mg/g 30 PACKET in 1 CARTON / 2.5 g in 1 PACKET   3 Preferred Brand 15%15%None
Androgel 16.2mg/g 1 BOTTLE, PUMP per CARTON / 88 g in 1 BOTTLE, PUMP   3 Preferred Brand 15%15%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
APOKYN 30 MG/3 ML CARTRIDGE   5 Specialty Tier 25%N/AP Q:60
/28Days
APRI 0.15-0.03 TABLET   4 Non-Preferred Drug 33%33%None
APRISO CP24   3 Preferred Brand 15%15%Q:120
/30Days
APTIOM 200 MG TABLET   5 Specialty Tier 25%N/AS Q:30
/30Days
APTIOM 400 MG TABLET   5 Specialty Tier 25%N/AS Q:30
/30Days
APTIOM 600 MG TABLET   5 Specialty Tier 25%N/AS Q:60
/30Days
APTIOM 800 MG TABLET   5 Specialty Tier 25%N/AS Q:30
/30Days
APTIVUS 250MG CAPSULE   5 Specialty Tier 25%N/AQ:120
/30Days
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT   5 Specialty Tier 25%N/AQ:285
/28Days
ARANELLE 7-9-5 TABLET   4 Non-Preferred Drug 33%33%None
ARCALYST INJECTION 220MG/VIAL   5 Specialty Tier 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARIPIPRAZOLE 10 MG TABLET [Abilify]   4 Non-Preferred Drug 33%33%Q:30
/30Days
ARIPIPRAZOLE 15 MG TABLET [Abilify]   4 Non-Preferred Drug 33%33%Q:30
/30Days
ARIPIPRAZOLE 2 MG TABLET [Abilify]   4 Non-Preferred Drug 33%33%Q:30
/30Days
ARIPIPRAZOLE 20 MG TABLET [Abilify]   5 Specialty Tier 25%N/AQ:30
/30Days
ARIPIPRAZOLE 30 MG TABLET [Abilify]   5 Specialty Tier 25%N/AQ:30
/30Days
ARIPIPRAZOLE 5 MG TABLET [Abilify]   4 Non-Preferred Drug 33%33%Q:30
/30Days
ARIPIPRAZOLE ODT 10 MG TABLET [Abilify]   4 Non-Preferred Drug 33%33%Q:90
/30Days
ARIPIPRAZOLE ODT 15 MG TABLET [Abilify]   4 Non-Preferred Drug 33%33%Q:60
/30Days
Armodafinil 150 MG TABLET [NUVIGIL]   4 Non-Preferred Drug 33%33%P Q:30
/30Days
Armodafinil 200 MG TABLET [NUVIGIL]   4 Non-Preferred Drug 33%33%P Q:30
/30Days
Armodafinil 250 MG TABLET [NUVIGIL]   4 Non-Preferred Drug 33%33%P Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARNUITY ELLIPTA 100 MCG INH   3 Preferred Brand 15%15%Q:30
/30Days
ARNUITY ELLIPTA 200 MCG INH   3 Preferred Brand 15%15%Q:30
/30Days
ASPIRIN-DIPYRIDAM ER 25-200 MG [Aggrenox]   4 Non-Preferred Drug 33%33%None
ASTAGRAF XL 0.5 MG CAPSULE   4 Non-Preferred Drug 33%33%P
ASTAGRAF XL 1 MG CAPSULE   4 Non-Preferred Drug 33%33%P
ASTAGRAF XL 5 MG CAPSULE   4 Non-Preferred Drug 33%33%P
ASTEPRO 0.15% NASAL SPRAY 30 ML   3 Preferred Brand 15%15%Q:30
/25Days
Atelvia 35mg/1 36 DOSE PACK CASE / 4 TABLET, DELAYED RELEASE in 1 DOSE PACK   3 Preferred Brand 15%15%S Q:4
/28Days
ATENOLOL 100 MG100 TABLET BOTTLE   1 Preferred Generic 10%10%None
ATENOLOL 25 MG 100 TABLET BOTTLE   1 Preferred Generic 10%10%None
ATENOLOL TABLET USP 50MG (100 CT)   1 Preferred Generic 10%10%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATENOLOL-CHLORTHALIDONE 100-25   1 Preferred Generic 10%10%None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   1 Preferred Generic 10%10%None
ATORVASTATIN 10 MG TABLET [Lipitor]   2 Generic 12%12%Q:30
/30Days
ATORVASTATIN 20 MG TABLET [Lipitor]   2 Generic 12%12%Q:30
/30Days
ATORVASTATIN 40 MG TABLET [Lipitor]   2 Generic 12%12%Q:30
/30Days
ATORVASTATIN 80 MG TABLET [Lipitor]   2 Generic 12%12%Q:30
/30Days
ATOVAQUONE 750 MG/5 ML SUSP [Mepron]   5 Specialty Tier 25%N/ANone
Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone]   4 Non-Preferred Drug 33%33%None
Atovaquone-Proguanil 62.5-25 [Malarone]   4 Non-Preferred Drug 33%33%None
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC   5 Specialty Tier 25%N/AQ:30
/30Days
Atropine 1% Eye Drops   4 Non-Preferred Drug 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATROVENT HFA AER 17MCG   4 Non-Preferred Drug 33%33%None
AUBAGIO 14 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
AUBAGIO 7 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
AUBRA-28 TABLET   4 Non-Preferred Drug 33%33%None
AVASTIN 400 MG/16 ML VIAL   3 Preferred Brand 15%15%None
AVIANE 0.1-0.02 TABLET   4 Non-Preferred Drug 33%33%None
AVONEX ADMIN PACK 30 MCG VL   5 Specialty Tier 25%N/AQ:4
/28Days
AVONEX PEN 30 MCG/0.5 ML KIT   5 Specialty Tier 25%N/AQ:4
/28Days
AVONEX PREFILLED SYR 30 MCG KT   5 Specialty Tier 25%N/AQ:1
/28Days
Azacitidine 100 mg vial [Vidaza]   5 Specialty Tier 25%N/AP
AZACTAM INJECTION 2GM/50ML   4 Non-Preferred Drug 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZASAN 100MG TABLET   4 Non-Preferred Drug 33%33%P
AZASAN 75MG TABLET   4 Non-Preferred Drug 33%33%P
AZASITE 1% EYE DROPS   4 Non-Preferred Drug 33%33%None
AZATHIOPRINE 50 MG TABLET   2 Generic 12%12%P
AZELASTINE 0.15% NASAL SPRAY   4 Non-Preferred Drug 33%33%Q:30
/25Days
AZELASTINE 137 MCG NASAL SPRAY   4 Non-Preferred Drug 33%33%Q:30
/25Days
AZELASTINE HYDROCHLORIDE OPHTHALMIC SOLUTION   4 Non-Preferred Drug 33%33%None
AZILECT 0.5MG TABLET   4 Non-Preferred Drug 33%33%None
AZILECT 1MG TABLET   4 Non-Preferred Drug 33%33%None
AZITHROMYCIN 1 GM PWD PACKET   4 Non-Preferred Drug 33%33%None
AZITHROMYCIN 100 MG/5 ML SUSP   4 Non-Preferred Drug 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Azithromycin 200mg/5mL 22.5 mL in 1 BOTTLE   4 Non-Preferred Drug 33%33%None
AZITHROMYCIN 250 MG TABLET   1 Preferred Generic 10%10%None
AZITHROMYCIN 250 MG TABLET   1 Preferred Generic 10%10%None
Azithromycin 500mg/1 10 VIAL, SINGLE-USE in 1 TRAY / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION   4 Non-Preferred Drug 33%33%None
Azithromycin 500mg/1 30 FILM COATED TABLETS in BOTTLE   1 Preferred Generic 10%10%None
Azithromycin 600mg/1 30 FILM COATED TABLETS in BOTTLE   1 Preferred Generic 10%10%None
AZOR 10MG-20MG TABLET   4 Non-Preferred Drug 33%33%Q:30
/30Days
AZOR 10MG-40MG TABLET (30 CT)   4 Non-Preferred Drug 33%33%Q:30
/30Days
AZOR 5MG-20MG TABLET (30 CT)   4 Non-Preferred Drug 33%33%Q:30
/30Days
AZOR 5MG-40MG TABLET   4 Non-Preferred Drug 33%33%Q:30
/30Days
AZTREONAM FOR INJECTION   2 Generic 12%12%None


Chart Legend:

What does all this mean? Below are a few notes to help you understand the above 2017 Medicare Part D EnvisionRxPlus (PDP) Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug 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).

  • 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 the standard $400 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 wit 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 four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
    • Drug Description - This is the Medicare Part D plan’s description of this particular drug tier.
  • Cost Sharing - Copay / Coinsurance - These figures apply to 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 which tier the drug is in. 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 intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $3700) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2017 Humana Walmart-Preferred Rx Plan the cost-sharing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
    • 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 2017 )

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 Part D plan provider.





Click the +1 button if you have found this page useful:  

Medicare Supplements
fill the gaps in your
Original Medicare
1. Select Your State:
» Medicare Supplement FAQs

Advertisement





.

Advertisement



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.