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2024 Medicare Part D or Medicare Advantage Plan Formulary Browser

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MedicareBlue Rx Premier (PDP) (S5743-004-0)
Tier 1 (360)
Tier 2 (831)
Tier 3 (874)
Tier 4 (751)
Tier 5 (699)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
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Has Quantity Limits:
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Cick on the first letter of your drug name to browse the formulary:

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
MedicareBlue Rx Premier (PDP) (S5743-004-0)
Benefits & Contact Info           
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 MedicareBlue Rx Premier (PDP) (S5743-004-0)
Formulary Drugs Starting with the Letter A

in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY
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 Non-Preferred Drug 40%40%Q:960
/30Days
ABACAVIR 300 MG TABLET [Ziagen]   3 Preferred Brand 20%20%Q:60
/30Days
ABACAVIR-LAMIVUDINE 600-300 MG TABLET [Epzicom]   4 Non-Preferred Drug 40%40%Q:30
/30Days
ABILIFY ASIMTUFII 720 MG/2.4ML SUSER SYRINGE   5 Specialty Tier 33%N/AQ:2
/56Days
ABILIFY ASIMTUFII 960 MG/3.2ML SUSER SYRINGE   5 Specialty Tier 33%N/AQ:3
/56Days
ABILIFY MAINTENA ER 300 MG SYRINGE   5 Specialty Tier 33%N/AQ:1
/28Days
ABILIFY MAINTENA ER 300 MG VIAL   5 Specialty Tier 33%N/AQ:1
/28Days
ABILIFY MAINTENA ER 400 MG SUSER VIAL   5 Specialty Tier 33%N/AQ:1
/28Days
ABILIFY MAINTENA ER 400 MG SYRINGE   5 Specialty Tier 33%N/AQ:1
/28Days
ABIRATERONE ACETATE 250 MG TABLET [ZYTIGA]   5 Specialty Tier 33%N/AP Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ABRYSVO 120 MCG / 0.5 ML INJECTION Prefilled Syringe   3 Preferred Brand 20%20%None
Acamprosate Calcium DR 333 MG tablets [Campral]   4 Non-Preferred Drug 40%40%None
ACARBOSE 100 MG TABLET [Precose]   2 Generic $0.00$0.00Q:90
/30Days
ACARBOSE 25 MG TABLET [Precose]   2 Generic $0.00$0.00Q:360
/30Days
ACARBOSE 50 MG TABLET [Precose]   2 Generic $0.00$0.00Q:180
/30Days
ACCUTANE 10 MG CAPSULE [ZENATANE]   4 Non-Preferred Drug 40%40%None
ACCUTANE 20 MG CAPSULE [ZENATANE]   4 Non-Preferred Drug 40%40%None
ACCUTANE 30 MG CAPSULE [ZENATANE]   4 Non-Preferred Drug 40%40%None
ACCUTANE 40 MG CAPSULE [ZENATANE]   4 Non-Preferred Drug 40%40%None
ACEBUTOLOL 200 MG CAPSULE [Sectral]   2 Generic $0.00$0.00None
ACEBUTOLOL 400 MG CAPSULE [Sectral]   2 Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETAMINOP-CODEINE 120-12 MG/5 SOLUTION   3 Preferred Brand 20%20%Q:2700
/30Days
ACETAMINOPHEN-COD #2 TABLET   3 Preferred Brand 20%20%Q:360
/30Days
ACETAMINOPHEN-COD #3 TABLET [Tylenol with Codeine No.3]   3 Preferred Brand 20%20%Q:360
/30Days
ACETAMINOPHEN-COD #4 TABLET   3 Preferred Brand 20%20%Q:180
/30Days
ACETAZOLAMIDE 125 MG TABLET [Diamox]   2 Generic $0.00$0.00None
ACETAZOLAMIDE 250 MG TABLET [Diamox]   2 Generic $0.00$0.00None
ACETAZOLAMIDE ER 500 MG CAPSULE ER [Diamox Sequels]   2 Generic $0.00$0.00None
ACETIC ACID 2% EAR SOLUTION [VoSoL]   2 Generic $0.00$0.00None
ACETYLCYSTEINE 10% VIAL [Mucosil Acetylcysteine]   2 Generic $0.00$0.00P
ACETYLCYSTEINE 20% VIAL [Mucosil Acetylcysteine]   2 Generic $0.00$0.00P
ACITRETIN 10 MG CAPSULE [Soriatane]   4 Non-Preferred Drug 40%40%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 Non-Preferred Drug 40%40%None
ACITRETIN 25 MG CAPSULE [Soriatane]   4 Non-Preferred Drug 40%40%None
ACTHIB VACCINE WITH DILUENT   3 Preferred Brand 20%20%None
ACTIMMUNE 100 MCG/0.5 ML VIAL   5 Specialty Tier 33%N/AP
ACYCLOVIR 200 MG CAPSULE [Zovirax]   2 Generic $0.00$0.00None
ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION [Zovirax Suspension]   4 Non-Preferred Drug 40%40%None
ACYCLOVIR 400 MG TABLET   2 Generic $0.00$0.00None
ACYCLOVIR 5% OINTMENT [Zovirax]   4 Non-Preferred Drug 40%40%P
ACYCLOVIR 800 MG TABLET   2 Generic $0.00$0.00None
ACYCLOVIR SODIUM 500 MG VIAL   4 Non-Preferred Drug 40%40%P
ADACEL TDAP SYRINGE   3 Preferred Brand 20%20%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADACEL VIAL 2UNT/5UNT   3 Preferred Brand 20%20%None
ADEFOVIR DIPIVOXIL 10 MG TABLET [Hepsera]   4 Non-Preferred Drug 40%40%None
ADEMPAS 0.5 MG TABLET   5 Specialty Tier 33%N/AP Q:90
/30Days
ADEMPAS 1 MG TABLET   5 Specialty Tier 33%N/AP Q:90
/30Days
ADEMPAS 1.5 MG TABLET   5 Specialty Tier 33%N/AP Q:90
/30Days
ADEMPAS 2 MG TABLET   5 Specialty Tier 33%N/AP Q:90
/30Days
ADEMPAS 2.5 MG TABLET   5 Specialty Tier 33%N/AP Q:90
/30Days
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER   3 Preferred Brand 20%20%Q:12
/30Days
ADVAIR HFA INHALER 115;21MCG;MCG 120 ACTN INHL   3 Preferred Brand 20%20%Q:12
/30Days
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL   3 Preferred Brand 20%20%Q:12
/30Days
AIMOVIG 140 MG/ML AUTOINJECTOR   3 Preferred Brand 20%20%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   3 Preferred Brand 20%20%P Q:2
/30Days
ALA-CORT 2.5% CREAM (G) [Proctozone-HC]   2 Generic $0.00$0.00Q:454
/30Days
ALBENDAZOLE 200 MG TABLET [Albenza]   4 Non-Preferred Drug 40%40%None
ALBUTEROL 2.5 MG/0.5 ML SOL VIAL-NEB   2 Generic $0.00$0.00P
ALBUTEROL HFA 90 MCG INHALER HFA AER AD [Ventolin HFA]   3 Preferred Brand 20%20%Q:36
/30Days
ALBUTEROL HFA 90 MCG INHALER HFA AER AD [Ventolin HFA]   3 Preferred Brand 20%20%Q:36
/30Days
ALBUTEROL SUL 0.63 MG/3 ML SOLUTION VIAL-NEB [Accuneb]   2 Generic $0.00$0.00P
ALBUTEROL SUL 1.25 MG/3 ML SOLUTION VIAL-NEB [Accuneb]   2 Generic $0.00$0.00P
ALBUTEROL SULF 2 MG/5 ML SYRUP   2 Generic $0.00$0.00None
ALBUTEROL SULFATE 2 MG TABLET   3 Preferred Brand 20%20%None
ALBUTEROL SULFATE 2.5 MG/3 ML SOLUTION VIAL-NEB   2 Generic $0.00$0.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALBUTEROL SULFATE 4 MG TABLET   3 Preferred Brand 20%20%None
ALCLOMETASONE DIPR 0.05% OINTMENT [Aclovate]   3 Preferred Brand 20%20%Q:120
/30Days
ALCLOMETASONE DIPRO 0.05% CREAM (G) [Aclovate]   3 Preferred Brand 20%20%Q:120
/30Days
ALECENSA 150 MG CAPSULE   5 Specialty Tier 33%N/AP Q:240
/30Days
ALENDRONATE SODIUM 10 MG TABLET [Fosamax]   1 Preferred Generic $0.00$0.00Q:120
/30Days
ALENDRONATE SODIUM 35 MG TABLET [Fosamax]   1 Preferred Generic $0.00$0.00Q:4
/28Days
ALENDRONATE SODIUM 70 MG TABLET [Fosamax]   1 Preferred Generic $0.00$0.00Q:4
/28Days
ALFUZOSIN HCL ER 10 MG TABLET   1 Preferred Generic $0.00$0.00Q:30
/30Days
ALISKIREN 150 MG TABLET [Tekturna]   3 Preferred Brand 20%20%Q:30
/30Days
ALISKIREN 300 MG TABLET [Tekturna]   3 Preferred Brand 20%20%Q:30
/30Days
ALLOPURINOL 100 MG TABLET [Zyloprim]   1 Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALLOPURINOL 300 MG TABLET [Zyloprim]   1 Preferred Generic $0.00$0.00None
ALOSETRON HCL 0.5 MG TABLET [Lotronex]   4 Non-Preferred Drug 40%40%P Q:60
/30Days
ALOSETRON HCL 1 MG TABLET [Lotronex]   5 Specialty Tier 33%N/AP Q:60
/30Days
ALPHAGAN P 0.1% EYE DROPS   3 Preferred Brand 20%20%None
ALPRAZOLAM 0.25 MG TABLET [Xanax]   2 Generic $0.00$0.00Q:120
/30Days
ALPRAZOLAM 0.5 MG TABLET [Xanax]   2 Generic $0.00$0.00Q:120
/30Days
ALPRAZOLAM 1 MG TABLET [Xanax]   2 Generic $0.00$0.00Q:120
/30Days
ALPRAZOLAM 2 MG TABLET [Xanax]   2 Generic $0.00$0.00Q:150
/30Days
ALTAVERA-28 TABLET [Portia]   3 Preferred Brand 20%20%None
ALUNBRIG 180 MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
ALUNBRIG 30 MG TABLET   5 Specialty Tier 33%N/AP Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALUNBRIG 90 MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
ALUNBRIG 90 MG-180 MG TABLET PACK   5 Specialty Tier 33%N/AP Q:30
/30Days
ALYACEN 1-35-28 TABLET   3 Preferred Brand 20%20%None
ALYQ 20 MG TABLET   5 Specialty Tier 33%N/AP Q:60
/30Days
AMABELZ 0.5 MG-0.1 MG TABLET [Mimvey Lo]   4 Non-Preferred Drug 40%40%None
AMABELZ 1 MG-0.5 MG TABLET [Mimvey]   3 Preferred Brand 20%20%None
AMANTADINE 100 MG CAPSULE [Symmetrel]   2 Generic $0.00$0.00None
AMANTADINE 100 MG TABLET   2 Generic $0.00$0.00None
AMANTADINE 50 MG/5 ML SOLUTION   2 Generic $0.00$0.00None
AMBISOME 50MG VIAL   5 Specialty Tier 33%N/AP
AMBRISENTAN 10 MG TABLET [LETAIRIS]   4 Non-Preferred Drug 40%40%P Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMBRISENTAN 5 MG TABLET [LETAIRIS]   4 Non-Preferred Drug 40%40%P Q:30
/30Days
AMETHIA 0.15-0.03-0.01 MG TABLET   3 Preferred Brand 20%20%None
AMIKACIN SULF 500 MG/2 ML VIAL   4 Non-Preferred Drug 40%40%None
AMILORIDE HCL 5 MG TABLET [Midamor]   2 Generic $0.00$0.00None
AMILORIDE HCL-HCTZ 5-50 MG TABLET [Moduretic]   2 Generic $0.00$0.00None
AMIODARONE HCL 100 MG TABLET [Pacerone]   4 Non-Preferred Drug 40%40%None
AMIODARONE HCL 200 MG TABLET [Pacerone]   2 Generic $0.00$0.00None
AMIODARONE HCL 400 MG TABLET [Pacerone]   2 Generic $0.00$0.00None
AMITRIPTYLINE HCL 10 MG TABLET [Elavil]   2 Generic $0.00$0.00None
AMITRIPTYLINE HCL 100 MG TABLET   2 Generic $0.00$0.00None
AMITRIPTYLINE HCL 150 MG TABLET   2 Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITRIPTYLINE HCL 25 MG TABLET [Elavil]   2 Generic $0.00$0.00None
AMITRIPTYLINE HCL 50 MG TABLET   2 Generic $0.00$0.00None
AMITRIPTYLINE HCL 75 MG TABLET   2 Generic $0.00$0.00None
AMLOD-VALSA-HCTZ 10-160-12.5MG TABLET [Exforge HCT]   2 Generic $0.00$0.00Q:30
/30Days
AMLOD-VALSA-HCTZ 10-160-25 MG TABLET [Exforge HCT]   2 Generic $0.00$0.00Q:30
/30Days
AMLOD-VALSA-HCTZ 10-320-25 MG TABLET [Exforge HCT]   2 Generic $0.00$0.00Q:30
/30Days
AMLOD-VALSA-HCTZ 5-160-12.5 MG TABLET [Exforge HCT]   2 Generic $0.00$0.00Q:30
/30Days
AMLOD-VALSA-HCTZ 5-160-25 MG TABLET [Exforge HCT]   2 Generic $0.00$0.00Q:30
/30Days
AMLODIPINE BESYLATE 10 MG TABLET [Norvasc]   1 Preferred Generic $0.00$0.00None
AMLODIPINE BESYLATE 2.5 MG TABLET [Norvasc]   1 Preferred Generic $0.00$0.00None
AMLODIPINE BESYLATE 5 MG TABLET [Norvasc]   1 Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE-ATORVAST 10-10 MG [Caduet]   2 Generic $0.00$0.00None
AMLODIPINE-ATORVAST 10-20 MG [Caduet]   2 Generic $0.00$0.00None
AMLODIPINE-ATORVAST 10-40 MG [Caduet]   2 Generic $0.00$0.00None
Amlodipine-Atorvastatin 10-80 mg [Caduet]   2 Generic $0.00$0.00None
Amlodipine-Atorvastatin 2.5-10 mg [Caduet]   2 Generic $0.00$0.00None
Amlodipine-Atorvastatin 2.5-20 mg [Caduet]   2 Generic $0.00$0.00None
Amlodipine-Atorvastatin 2.5-40 mg [Caduet]   2 Generic $0.00$0.00None
Amlodipine-Atorvastatin 5-10 mg [Caduet]   2 Generic $0.00$0.00None
Amlodipine-Atorvastatin 5-20 mg [Caduet]   2 Generic $0.00$0.00None
Amlodipine-Atorvastatin 5-40 mg [Caduet]   2 Generic $0.00$0.00None
Amlodipine-Atorvastatin 5-80 mg [Caduet]   2 Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE-BENAZEPRIL 10-20 MG CAPSULE [Lotrel]   1 Preferred Generic $0.00$0.00None
AMLODIPINE-BENAZEPRIL 10-40 MG CAPSULE [Lotrel]   1 Preferred Generic $0.00$0.00None
AMLODIPINE-BENAZEPRIL 2.5-10 CAPSULE [Lotrel]   1 Preferred Generic $0.00$0.00None
AMLODIPINE-BENAZEPRIL 5-10 MG CAPSULE [Lotrel]   1 Preferred Generic $0.00$0.00None
AMLODIPINE-BENAZEPRIL 5-20 MG CAPSULE [Lotrel]   1 Preferred Generic $0.00$0.00None
AMLODIPINE-BENAZEPRIL 5-40 MG CAPSULE [Lotrel]   1 Preferred Generic $0.00$0.00None
AMLODIPINE-OLMESARTAN 10-20 MG TABLET [AZOR]   2 Generic $0.00$0.00Q:30
/30Days
AMLODIPINE-OLMESARTAN 10-40 MG TABLET [AZOR]   2 Generic $0.00$0.00Q:30
/30Days
AMLODIPINE-OLMESARTAN 5-20 MG TABLET [AZOR]   2 Generic $0.00$0.00Q:30
/30Days
AMLODIPINE-OLMESARTAN 5-40 MG TABLET [AZOR]   2 Generic $0.00$0.00Q:30
/30Days
AMLODIPINE-VALSARTAN 10-160 MG TABLET [Exforge]   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
AMLODIPINE-VALSARTAN 10-320 MG TABLET [Exforge]   1 Preferred Generic $0.00$0.00Q:30
/30Days
AMLODIPINE-VALSARTAN 5-160 MG TABLET [Exforge]   1 Preferred Generic $0.00$0.00Q:30
/30Days
AMLODIPINE-VALSARTAN 5-320 MG TABLET [Exforge]   1 Preferred Generic $0.00$0.00Q:30
/30Days
AMMONIUM LACTATE 12% CREAM (g) [Lac-Hydrin]   2 Generic $0.00$0.00None
AMMONIUM LACTATE 12% LOTION   2 Generic $0.00$0.00None
AMNESTEEM 10 MG CAPSULE [ZENATANE]   4 Non-Preferred Drug 40%40%None
AMNESTEEM 20 MG CAPSULE [ZENATANE]   4 Non-Preferred Drug 40%40%None
AMNESTEEM 40 MG CAPSULE [ZENATANE]   4 Non-Preferred Drug 40%40%None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE [Augmentin]   2 Generic $0.00$0.00None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET [Augmentin]   2 Generic $0.00$0.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE [Augmentin]   2 Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOX-CLAV 200-28.5 MG/5 ML SUS   2 Generic $0.00$0.00None
AMOX-CLAV 250-62.5 MG/5 ML ORAL SUSPENSION [Augmentin]   3 Preferred Brand 20%20%None
AMOX-CLAV 400-57 MG/5 ML ORAL SUSPENSION [Augmentin]   2 Generic $0.00$0.00None
AMOX-CLAV 500-125 MG TABLET [Augmentin]   2 Generic $0.00$0.00None
AMOX-CLAV 600-42.9 MG/5 ML SUS   2 Generic $0.00$0.00None
AMOX-CLAV 875-125 MG TABLET [Augmentin]   2 Generic $0.00$0.00None
AMOX-CLAV ER 1,000-62.5 MG TABLET [Augmentin]   4 Non-Preferred Drug 40%40%None
AMOXAPINE 100MG TABLET   3 Preferred Brand 20%20%None
AMOXAPINE 150MG TABLET   3 Preferred Brand 20%20%None
AMOXAPINE 25MG TABLET   3 Preferred Brand 20%20%None
AMOXAPINE 50MG TABLET   3 Preferred Brand 20%20%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN 125 MG/5 ML SUSP   1 Preferred Generic $0.00$0.00None
AMOXICILLIN 125MG CHEWABLE TABLET   2 Generic $0.00$0.00None
AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION [Amoxil]   1 Preferred Generic $0.00$0.00None
AMOXICILLIN 250 MG CHEWABLE TABLET   2 Generic $0.00$0.00None
AMOXICILLIN 250 MG CAPSULE [Trimox]   1 Preferred Generic $0.00$0.00None
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION [Trimox]   1 Preferred Generic $0.00$0.00None
AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION [Amoxil]   2 Generic $0.00$0.00None
AMOXICILLIN 500 MG CAPSULE [Trimox]   1 Preferred Generic $0.00$0.00None
AMOXICILLIN 500 MG TABLET   1 Preferred Generic $0.00$0.00None
AMOXICILLIN 875 MG TABLET   1 Preferred Generic $0.00$0.00None
AMPHETAMINE SALT COMBO 12.5MG TABLET   3 Preferred Brand 20%20%Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPHETAMINE SALT COMBO 15MG TABLET   3 Preferred Brand 20%20%Q:60
/30Days
AMPHETAMINE SALT COMBO 7.5MG TABLET   3 Preferred Brand 20%20%Q:60
/30Days
AMPHETAMINE SALTS 5 MG TABLET   3 Preferred Brand 20%20%Q:60
/30Days
AMPHOTERICIN B 50 MG VIAL [Fungizone]   4 Non-Preferred Drug 40%40%P
AMPHOTERICIN B LIPOSOME 50 MG VIAL [AmBisome]   5 Specialty Tier 33%N/AP
AMPICILLIN 1 GM VIAL   4 Non-Preferred Drug 40%40%None
AMPICILLIN 10 GM BOTTLE VIAL   4 Non-Preferred Drug 40%40%None
AMPICILLIN CAPSULES 500MG 100 BOTTLE   2 Generic $0.00$0.00None
AMPICILLIN-SULBACTAM 3 GM VIAL [Unasyn]   4 Non-Preferred Drug 40%40%None
ANAGRELIDE HCL 0.5 MG CAPSULE [Agrylin]   3 Preferred Brand 20%20%None
ANAGRELIDE HCL 1 MG CAPSULE [Agrylin]   3 Preferred Brand 20%20%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANASTROZOLE 1 MG TABLET   1 Preferred Generic $0.00$0.00None
ANORO ELLIPTA 62.5-25 MCG INH   3 Preferred Brand 20%20%Q:60
/30Days
APOKYN 30 MG/3 ML CARTRIDGE   5 Specialty Tier 33%N/AP Q:60
/30Days
APOMORPHINE 30 MG/3 ML CARTRIDGE [Apokyn]   5 Specialty Tier 33%N/AP Q:60
/30Days
APREPITANT 125 MG CAPSULE [Emend]   4 Non-Preferred Drug 40%40%P
APREPITANT 125-80-80 MG PACK CAPSULE DS PK [Emend]   4 Non-Preferred Drug 40%40%P
APREPITANT 40 MG CAPSULE [Emend]   4 Non-Preferred Drug 40%40%P
APREPITANT 80 MG CAPSULE [Emend]   4 Non-Preferred Drug 40%40%P
APRI 0.15-0.03 TABLET   3 Preferred Brand 20%20%None
APTIOM 200 MG TABLET   5 Specialty Tier 33%N/ANone
APTIOM 400 MG TABLET   5 Specialty Tier 33%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
APTIOM 600 MG TABLET   5 Specialty Tier 33%N/ANone
APTIOM 800 MG TABLET   5 Specialty Tier 33%N/ANone
APTIVUS 250MG CAPSULE   5 Specialty Tier 33%N/AQ:120
/30Days
ARANELLE 7-9-5 TABLET   3 Preferred Brand 20%20%None
ARANESP 10 MCG/0.4 ML SYRINGE   4 Non-Preferred Drug 40%40%P
ARANESP 100ug/0.5mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.5 mL in 1 SYRINGE   4 Non-Preferred Drug 40%40%P
ARANESP 100ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE   5 Specialty Tier 33%N/AP
ARANESP 200MCG/0.4ML SYRINGE   5 Specialty Tier 33%N/AP
ARANESP 200MCG/ML VIAL   5 Specialty Tier 33%N/AP
ARANESP 25ug/0.42mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.42 mL in 1 SYRING   4 Non-Preferred Drug 40%40%P
ARANESP 25ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE   4 Non-Preferred Drug 40%40%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP 500MCG/1ML SYRINGE   5 Specialty Tier 33%N/AP
ARANESP 60MCG/ML VIAL   4 Non-Preferred Drug 40%40%P
ARANESP 60ug/0.3mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.3 mL in 1 SYRINGE   4 Non-Preferred Drug 40%40%P
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR   5 Specialty Tier 33%N/AP
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR   5 Specialty Tier 33%N/AP
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR   4 Non-Preferred Drug 40%40%P
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD   4 Non-Preferred Drug 40%40%P
ARCALYST 220 MG VIAL   5 Specialty Tier 33%N/AP
AREXVY 120 MCG / 0.5 ML INJECTION SINGLE-DOSE VIAL 0.5 ML   3 Preferred Brand 20%20%None
ARIPIPRAZOLE 1 MG/ML SOLUTION [Abilify]   4 Non-Preferred Drug 40%40%P Q:750
/30Days
ARIPIPRAZOLE 10 MG TABLET [Abilify]   2 Generic $0.00$0.00P Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARIPIPRAZOLE 15 MG TABLET [Abilify]   2 Generic $0.00$0.00P Q:30
/30Days
ARIPIPRAZOLE 2 MG TABLET [Abilify]   2 Generic $0.00$0.00P Q:45
/30Days
ARIPIPRAZOLE 20 MG TABLET [Abilify]   2 Generic $0.00$0.00P Q:30
/30Days
ARIPIPRAZOLE 30 MG TABLET [Abilify]   2 Generic $0.00$0.00P Q:30
/30Days
ARIPIPRAZOLE 5 MG TABLET [Abilify]   2 Generic $0.00$0.00P Q:45
/30Days
ARIPIPRAZOLE ODT 10 MG TABLET RAPDIS [Abilify Discmelt]   4 Non-Preferred Drug 40%40%P Q:60
/30Days
ARIPIPRAZOLE ODT 15 MG TABLET RAPDIS [Abilify Discmelt]   4 Non-Preferred Drug 40%40%P Q:60
/30Days
ARISTADA ER 1064 MG/3.9 ML SYRINGE   4 Non-Preferred Drug 40%40%Q:4
/56Days
ARISTADA ER 441 MG/1.6 ML SYRINGE   4 Non-Preferred Drug 40%40%Q:2
/28Days
ARISTADA ER 662 MG/2.4 ML SYRINGE   4 Non-Preferred Drug 40%40%Q:2
/28Days
ARISTADA ER 882 MG/3.2 ML SYRINGE   4 Non-Preferred Drug 40%40%Q:3
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARISTADA INITIO ER 675 MG/2.4 SUSER SYRINGE   4 Non-Preferred Drug 40%40%Q:2
/42Days
ARMODAFINIL 150 MG TABLET [Nuvigil]   3 Preferred Brand 20%20%P Q:30
/30Days
ARMODAFINIL 200 MG TABLET [Nuvigil]   3 Preferred Brand 20%20%P Q:30
/30Days
ARMODAFINIL 250 MG TABLET [Nuvigil]   3 Preferred Brand 20%20%P Q:30
/30Days
ARMODAFINIL 50 MG TABLET [Nuvigil]   3 Preferred Brand 20%20%P Q:30
/30Days
ARNUITY ELLIPTA 100 MCG INH   3 Preferred Brand 20%20%Q:30
/30Days
ARNUITY ELLIPTA 200 MCG INH   3 Preferred Brand 20%20%Q:30
/30Days
ARNUITY ELLIPTA 50 MCG INH BLST W/DEV   3 Preferred Brand 20%20%Q:30
/30Days
ASENAPINE 10 MG SUBLIGUAL TABLET [Saphris]   4 Non-Preferred Drug 40%40%P Q:60
/30Days
ASENAPINE 2.5 MG TABLET SUBLIGUAL [Saphris]   4 Non-Preferred Drug 40%40%P Q:60
/30Days
ASENAPINE 5 MG SUBLIGUAL TABLET [Saphris]   4 Non-Preferred Drug 40%40%P Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ASHLYNA 0.15-0.03-0.01 MG TABLET   3 Preferred Brand 20%20%None
ASMANEX HFA 100 MCG INHALER HFA AER AD   3 Preferred Brand 20%20%Q:13
/30Days
ASMANEX HFA 200 MCG INHALER HFA AER AD   3 Preferred Brand 20%20%Q:13
/30Days
ASMANEX HFA 50 MCG INHALER HFA AER AD   3 Preferred Brand 20%20%Q:13
/30Days
ASMANEX TWISTHALER 110 MCG #30 AER POW BA   3 Preferred Brand 20%20%Q:1
/30Days
ASMANEX TWISTHALER 220 MCG #120 AER POW BA   3 Preferred Brand 20%20%Q:1
/30Days
ASMANEX TWISTHALER 220 MCG #30 AER POW BA   3 Preferred Brand 20%20%Q:1
/30Days
ASMANEX TWISTHALER 220 MCG #60 AER POW BA   3 Preferred Brand 20%20%Q:1
/30Days
ASPIRIN-DIPYRIDAM ER 25-200 MG CPMP 12HR [Aggrenox]   4 Non-Preferred Drug 40%40%None
ATAZANAVIR SULFATE 150 MG CAPSULE [Reyataz]   4 Non-Preferred Drug 40%40%Q:30
/30Days
ATAZANAVIR SULFATE 200 MG CAPSULE [Reyataz]   4 Non-Preferred Drug 40%40%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 Non-Preferred Drug 40%40%Q:30
/30Days
ATENOLOL 100 MG TABLET [Tenormin]   1 Preferred Generic $0.00$0.00None
ATENOLOL 25 MG TABLET [Tenormin]   1 Preferred Generic $0.00$0.00None
ATENOLOL 50 MG TABLET [Tenormin]   1 Preferred Generic $0.00$0.00None
ATENOLOL-CHLORTHALIDONE 100-25 TABLET [Tenoretic]   1 Preferred Generic $0.00$0.00None
ATENOLOL-CHLORTHALIDONE 50-25 TABLET [Tenoretic]   1 Preferred Generic $0.00$0.00None
ATOMOXETINE HCL 10 MG CAPSULE [Strattera]   4 Non-Preferred Drug 40%40%Q:60
/30Days
ATOMOXETINE HCL 100 MG CAPSULE [Strattera]   4 Non-Preferred Drug 40%40%Q:30
/30Days
ATOMOXETINE HCL 18 MG CAPSULE [Strattera]   4 Non-Preferred Drug 40%40%Q:60
/30Days
ATOMOXETINE HCL 25 MG CAPSULE [Strattera]   4 Non-Preferred Drug 40%40%Q:60
/30Days
ATOMOXETINE HCL 40 MG CAPSULE [Strattera]   4 Non-Preferred Drug 40%40%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 Non-Preferred Drug 40%40%Q:30
/30Days
ATOMOXETINE HCL 80 MG CAPSULE [Strattera]   4 Non-Preferred Drug 40%40%Q:30
/30Days
ATORVASTATIN 10 MG TABLET [Lipitor]   1 Preferred Generic $0.00$0.00Q:45
/30Days
ATORVASTATIN 20 MG TABLET [Lipitor]   1 Preferred Generic $0.00$0.00Q:45
/30Days
ATORVASTATIN 40 MG TABLET [Lipitor]   1 Preferred Generic $0.00$0.00Q:45
/30Days
ATORVASTATIN 80 MG TABLET [Lipitor]   1 Preferred Generic $0.00$0.00Q:30
/30Days
ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION [Mepron]   4 Non-Preferred Drug 40%40%P Q:600
/30Days
Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone]   3 Preferred Brand 20%20%None
ATOVAQUONE-PROGUANIL 62.5-25 [Malarone]   3 Preferred Brand 20%20%None
ATROPINE 1% EYE DROPS [Isopto Atropine]   3 Preferred Brand 20%20%None
ATROVENT HFA AER 17MCG   4 Non-Preferred Drug 40%40%Q:26
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AUBRA EQ-28 TABLET [Vienva]   3 Preferred Brand 20%20%None
AURYXIA 210 MG TABLET   5 Specialty Tier 33%N/AP Q:360
/30Days
AUVELITY ER 45-105 MG TABLET IR ER   5 Specialty Tier 33%N/AQ:60
/30Days
AVIANE 0.1-0.02 TABLET   3 Preferred Brand 20%20%None
AVONEX PEN 30 MCG/0.5 ML KIT   5 Specialty Tier 33%N/AP Q:1
/28Days
AVONEX PREFILLED SYR 30 MCG KT   5 Specialty Tier 33%N/AP Q:1
/28Days
AYVAKIT 100 MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
AYVAKIT 200 MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
AYVAKIT 25 MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
AYVAKIT 300 MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
AYVAKIT 50 MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZASAN 100 MG TABLET   4 Non-Preferred Drug 40%40%P
AZASAN 75 MG TABLET   4 Non-Preferred Drug 40%40%P
AZATHIOPRINE 100 MG TABLET [Azasan]   4 Non-Preferred Drug 40%40%P
AZATHIOPRINE 50 MG TABLET [Imuran]   2 Generic $0.00$0.00P
AZATHIOPRINE 75 MG TABLET [Azasan]   4 Non-Preferred Drug 40%40%P
AZELAIC ACID 15% GEL [Finacea]   3 Preferred Brand 20%20%None
AZELASTINE 137 MCG NASAL SPRAY   3 Preferred Brand 20%20%Q:60
/30Days
AZELASTINE HCL 0.05% EYE DROPS [Optivar]   3 Preferred Brand 20%20%None
AZELEX 20% CREAM (G)   4 Non-Preferred Drug 40%40%None
AZITHROMYCIN 1 GM POWDER PACKET   4 Non-Preferred Drug 40%40%None
AZITHROMYCIN 100 MG/5 ML ORAL SUSPENSION [Zithromax Powder]   2 Generic $0.00$0.00None
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]   2 Generic $0.00$0.00None
AZITHROMYCIN 250 MG TABLET [Zithromax Z-Pak]   2 Generic $0.00$0.00None
AZITHROMYCIN 250 MG TABLET [Zithromax Z-Pak]   2 Generic $0.00$0.00None
AZITHROMYCIN 500 MG TABLET [Zithromax Tri-Pak]   2 Generic $0.00$0.00None
AZITHROMYCIN 500 MG TABLET [Zithromax Tri-Pak]   2 Generic $0.00$0.00None
AZITHROMYCIN 600 MG TABLET [Zithromax Z-Pak]   2 Generic $0.00$0.00None
AZITHROMYCIN I.V. 500 MG VIAL [Zithromax Powder]   4 Non-Preferred Drug 40%40%None
AZTREONAM FOR INJECTION   4 Non-Preferred Drug 40%40%None

Chart Legend:

Below are a few notes to help you understand the above 2024 Medicare Part D MedicareBlue Rx Premier (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 November 2023)

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.