Q1GROUP LLC | Q1Medicare.com - a non-government resource for the Medicare community
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

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.

AARP MedicareRx Preferred (PDP) (S5820-024-0)
Tier 1 (124)
Tier 2 (660)
Tier 3 (1183)
Tier 4 (1031)
Tier 5 (593)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
Yes No Show either
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 
2016 Medicare Part D Plan Formulary Information
AARP MedicareRx Preferred (PDP) (S5820-024-0)
Benefit Details           
The AARP MedicareRx Preferred (PDP) (S5820-024-0)
Formulary Drugs Starting with the Letter A

in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY
Plan Monthly Premium: $61.70 Deductible: $0 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
A-HYDROCORT 100MG VIAL   4 Non-Preferred Brand 40%40%None
ABACAVIR 300 MG TABLET   4 Non-Preferred Brand 40%40%Q:90
/30Days
Abacavir Sulfate-Lamivudine-Zidovudine tablets [Trizivir]   5 Specialty Tier 33%33%Q:90
/30Days
ABELCENT INJECTION SUSPENSION 5MG/ML   4 Non-Preferred Brand 40%40%P
ABILIFY MAINTENA ER 300 MG SYR   5 Specialty Tier 33%33%None
ABILIFY MAINTENA ER 300 MG VL   5 Specialty Tier 33%33%None
ABILIFY MAINTENA ER 400 MG SYR   5 Specialty Tier 33%33%None
ABRAXANE 100MG VIAL   5 Specialty Tier 33%33%P
ABSTRAL 100 MCG TAB SUBLINGUAL   5 Specialty Tier 33%33%P Q:120
/30Days
ABSTRAL 200 MCG TAB SUBLINGUAL   5 Specialty Tier 33%33%P Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ABSTRAL 300 MCG TAB SUBLINGUAL   5 Specialty Tier 33%33%P Q:120
/30Days
ABSTRAL 400 MCG TAB SUBLINGUAL   5 Specialty Tier 33%33%P Q:120
/30Days
ABSTRAL 600 MCG TAB SUBLINGUAL   5 Specialty Tier 33%33%P Q:120
/30Days
ABSTRAL 800 MCG TAB SUBLINGUAL   5 Specialty Tier 33%33%P Q:120
/30Days
Acamprosate Calcium DR 333 MG tablets [Campral]   4 Non-Preferred Brand 40%40%None
ACARBOSE 100 MG TABLET   3 Preferred Brand $35.00$90.00Q:90
/30Days
ACARBOSE 25 MG TABLET   3 Preferred Brand $35.00$90.00Q:360
/30Days
Acarbose 50mg/1 100 TABLET BOTTLE   3 Preferred Brand $35.00$90.00Q:180
/30Days
ACEBUTOLOL 200MG CAPSULE   3 Preferred Brand $35.00$90.00None
ACEBUTOLOL 400MG CAPSULE   3 Preferred Brand $35.00$90.00None
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE   3 Preferred Brand $35.00$90.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD   2 Generic $10.00$0.00Q:4200
/30Days
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT)   2 Generic $10.00$0.00Q:390
/30Days
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT)   2 Generic $10.00$0.00Q:390
/30Days
ACETAMINOPHEN-COD #4 TABLET   2 Generic $10.00$0.00Q:390
/30Days
ACETAZOLAMIDE 125MG TABLET   3 Preferred Brand $35.00$90.00None
ACETAZOLAMIDE 250MG TABLET (100 CT)   3 Preferred Brand $35.00$90.00None
Acetazolamide 500mg/5mL 1 VIAL in 1 CARTON / 5 mL in 1 VIAL   4 Non-Preferred Brand 40%40%None
ACETAZOLAMIDE ER CAPSULES 500MG 100 BOT   4 Non-Preferred Brand 40%40%None
ACETIC ACID 2% EAR SOLUTION   2 Generic $10.00$0.00None
ACETYLCYSTEINE 10% VIAL   2 Generic $10.00$0.00P
ACETYLCYSTEINE 20% VIAL   2 Generic $10.00$0.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACITRETIN 10 MG CAPSULE [Soriatane]   5 Specialty Tier 33%33%None
ACITRETIN 17.5 MG CAPSULE [Soriatane]   5 Specialty Tier 33%33%None
ACITRETIN 25 MG CAPSULE [Soriatane]   5 Specialty Tier 33%33%None
ACTHIB VACCINE WITH DILUENT   3 Preferred Brand $35.00$90.00None
ACTIMMUNE 100 MCG/0.5 ML VIAL   5 Specialty Tier 33%33%None
Acyclovir 200mg 100 CAPSULE BOTTLE   2 Generic $10.00$0.00None
Acyclovir 200mg/5mL 473 mL BOTTLE   2 Generic $10.00$0.00None
Acyclovir 400mg/1   2 Generic $10.00$0.00None
Acyclovir 5% Ointment   4 Non-Preferred Brand 40%40%Q:30
/30Days
ACYCLOVIR 800 MG TABLET   2 Generic $10.00$0.00None
Acyclovir sodium 500 mg vial   4 Non-Preferred Brand 40%40%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADACEL VIAL 2UNT/5UNT   3 Preferred Brand $35.00$90.00None
ADAGEN 250U/ML VIAL   5 Specialty Tier 33%33%None
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA]   5 Specialty Tier 33%33%P
ADAPALENE 0.1% CREAM   3 Preferred Brand $35.00$90.00None
ADAPALENE 0.1% GEL   3 Preferred Brand $35.00$90.00None
ADCIRCA TABLETS 20MG 60 BOTTLE   5 Specialty Tier 33%33%P Q:60
/30Days
ADEMPAS 0.5 MG TABLET   5 Specialty Tier 33%33%P
ADEMPAS 1 MG TABLET   5 Specialty Tier 33%33%P
ADEMPAS 1.5 MG TABLET   5 Specialty Tier 33%33%P
ADEMPAS 2 MG TABLET   5 Specialty Tier 33%33%P
ADEMPAS 2.5 MG TABLET   5 Specialty Tier 33%33%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADRUCIL 50mg/mL 10 VIAL in 1 TRAY / 10 mL in 1 VIAL   4 Non-Preferred Brand 40%40%P
ADVAIR DISKUS MIS 100/50   3 Preferred Brand $35.00$90.00Q:60
/30Days
ADVAIR DISKUS MIS 250/50   3 Preferred Brand $35.00$90.00Q:60
/30Days
ADVAIR DISKUS MIS 500/50   3 Preferred Brand $35.00$90.00Q:60
/30Days
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER   3 Preferred Brand $35.00$90.00None
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL   3 Preferred Brand $35.00$90.00None
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL   3 Preferred Brand $35.00$90.00None
AFEDITAB CR 30MG TABLET SA   2 Generic $10.00$0.00Q:60
/30Days
AFEDITAB CR 60MG TABLET SA   2 Generic $10.00$0.00Q:60
/30Days
Afinitor 7.5mg/1 28 BLISTER PACK per CARTON / 1 TABLET per BLISTER PACK   5 Specialty Tier 33%33%P
AFINITOR DISPERZ 2 MG TABLET   5 Specialty Tier 33%33%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AFINITOR DISPERZ 3 MG TABLET   5 Specialty Tier 33%33%P
AFINITOR DISPERZ 5 MG TABLET   5 Specialty Tier 33%33%P
AFINITOR TABLETS 10 MG   5 Specialty Tier 33%33%P
AFINITOR TABLETS 2.5 MG   5 Specialty Tier 33%33%P
AFINITOR TABLETS 5 MG   5 Specialty Tier 33%33%P
AGGRENOX 25-200MG CAPSULE   4 Non-Preferred Brand 40%40%Q:60
/30Days
AK-CON 0.1% EYE DROPS   2 Generic $10.00$0.00None
ALA-CORT 1% CREAM   2 Generic $10.00$0.00None
ALBENZA 200 MG TABLET   5 Specialty Tier 33%33%None
ALBUTEROL SULFATE 0.75mg/3mL 30 POUCH per CARTON / 1 VIAL, SINGLE-DOSE in 1 POUCH / 3 mL in 1 VIAL   2 Generic $10.00$0.00P
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER   2 Generic $10.00$0.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   2 Generic $10.00$0.00P
ALBUTEROL SULFATE SOLUTION FOR INHALATION   2 Generic $10.00$0.00P
ALBUTEROL SULFATE TABLET 2MG (500 CT)   3 Preferred Brand $35.00$90.00None
ALBUTEROL TABLET 4MG (500 CT)   3 Preferred Brand $35.00$90.00None
ALCLOMETASONE DIPROPIONATE 0.05% CREAM   3 Preferred Brand $35.00$90.00None
Alclometasone Dipropionate 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE   3 Preferred Brand $35.00$90.00None
ALDURAZYME 2.9MG/5ML VIAL   5 Specialty Tier 33%33%None
ALECENSA 150 MG CAPSULE   5 Specialty Tier 33%33%P Q:240
/30Days
ALENDRONATE SODIUM 10MG TABLET   1 Preferred Generic $3.00$0.00Q:30
/30Days
ALENDRONATE SODIUM 35 MG TABLET   1 Preferred Generic $3.00$0.00Q:8
/28Days
ALENDRONATE SODIUM 40MG TABLET   1 Preferred Generic $3.00$0.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALENDRONATE SODIUM 5MG TABLET   1 Preferred Generic $3.00$0.00Q:30
/30Days
Alendronate Sodium 70 mg/75 ml   4 Non-Preferred Brand 40%40%None
Alendronate Sodium 70mg/1 4 BLISTER PACK in 1 BOX / 1 TABLET in 1 BLISTER PACK   1 Preferred Generic $3.00$0.00Q:4
/28Days
ALFUZOSIN HYDROCHLORIDE 10mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE   2 Generic $10.00$0.00None
ALIMTA 500MG VIAL   5 Specialty Tier 33%33%P
ALINIA 100MG/5ML SUSPENSION   4 Non-Preferred Brand 40%40%None
ALINIA 500 MG TABLET   4 Non-Preferred Brand 40%40%None
ALLOPURINOL 100 MG TABLETS   1 Preferred Generic $3.00$0.00None
Allopurinol 300mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET per BLISTER PACK   1 Preferred Generic $3.00$0.00None
ALOCRIL 2% EYE DROPS   4 Non-Preferred Brand 40%40%None
ALOMIDE 0.1% EYE DROPS   4 Non-Preferred Brand 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALORA 0.025 MG PATCH   4 Non-Preferred Brand 40%40%None
ALORA 0.05 MG PATCH   4 Non-Preferred Brand 40%40%None
ALORA 0.075 MG PATCH   4 Non-Preferred Brand 40%40%None
ALORA 0.1 MG PATCH   4 Non-Preferred Brand 40%40%None
ALOSETRON HCL 0.5 MG TABLET [Lotronex]   5 Specialty Tier 33%33%P
ALOSETRON HCL 1 MG TABLET [Lotronex]   5 Specialty Tier 33%33%P
ALPHAGAN P 0.1% DROPS   3 Preferred Brand $35.00$90.00None
ALPRAZOLAM 0.25 MG TABLET   2 Generic $10.00$0.00Q:120
/30Days
ALPRAZOLAM 0.5 MG TABLET   2 Generic $10.00$0.00Q:120
/30Days
ALPRAZOLAM 1 MG TABLET   2 Generic $10.00$0.00Q:120
/30Days
ALPRAZOLAM 2 MG TABLET   2 Generic $10.00$0.00Q:150
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALTABAX 10mg/g 30 g in 1 TUBE   4 Non-Preferred Brand 40%40%None
AMANTADINE 100MG CAPSULE   3 Preferred Brand $35.00$90.00None
AMANTADINE 100MG TABLET   3 Preferred Brand $35.00$90.00None
Amantadine Hydrochloride 50mg/5mL 473 mL in 1 BOTTLE   3 Preferred Brand $35.00$90.00None
AMBISOME 50MG VIAL   4 Non-Preferred Brand 40%40%P
Amethia 2 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK   3 Preferred Brand $35.00$90.00None
Amethyst 20; 90ug/1; ug/1 1 BLISTER PACK per CARTON / 28 TABLET per BLISTER PACK   3 Preferred Brand $35.00$90.00None
AMIFOSTINE 50mg/mL 3 VIAL, SINGLE-USE per CARTON / 10 mL in 1 VIAL, SINGLE-USE   5 Specialty Tier 33%33%None
AMIKACIN SULFATE 500 MG/2 ML VIAL   4 Non-Preferred Brand 40%40%None
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET   2 Generic $10.00$0.00None
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT   2 Generic $10.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Amino Acids 15% Solution   4 Non-Preferred Brand 40%40%P
Aminophylline 25mg/mL 5 TRAY per CARTON / 5 AMPULE in 1 TRAY / 10 mL in 1 AMPULE   4 Non-Preferred Brand 40%40%None
AMINOSYN 7%-ELECTROLYTE SOL   4 Non-Preferred Brand 40%40%P
AMINOSYN HBC INJECTION SULFITE FREE 7%   4 Non-Preferred Brand 40%40%P
AMINOSYN II 10% IV SOLUTION   4 Non-Preferred Brand 40%40%P
AMINOSYN II 15% IV SOLUTION   4 Non-Preferred Brand 40%40%P
AMINOSYN II 7% IV SOLUTION   4 Non-Preferred Brand 40%40%P
AMINOSYN II 8.5% ELECTROLYT   4 Non-Preferred Brand 40%40%P
AMINOSYN II 8.5% IV SOLUTION   4 Non-Preferred Brand 40%40%P
AMINOSYN M 3.5% IV SOLUTION   4 Non-Preferred Brand 40%40%P
AMINOSYN PF INJECTION   4 Non-Preferred Brand 40%40%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5%   4 Non-Preferred Brand 40%40%P
AMINOSYN-PF 7% IV SOLUTION   4 Non-Preferred Brand 40%40%P
AMINOSYN-RF 5.2% IV SOLUTION   4 Non-Preferred Brand 40%40%P
AMIODARONE HCL 200MG 60 TABLET BOTTLE   2 Generic $10.00$0.00None
AMIODARONE HCL 50 MG INJECTION   4 Non-Preferred Brand 40%40%None
AMITIZA 8MCG CAPSULE   3 Preferred Brand $35.00$90.00Q:60
/30Days
AMITIZA CAPSULES 24MCG 60 CAP BOT   3 Preferred Brand $35.00$90.00Q:60
/30Days
AMITRIPTYLINE HCL 100MG TABLET   3 Preferred Brand $35.00$90.00None
AMITRIPTYLINE HCL 10MG TABLET   3 Preferred Brand $35.00$90.00None
AMITRIPTYLINE HCL 150 MG TAB   3 Preferred Brand $35.00$90.00None
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)   3 Preferred Brand $35.00$90.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)   3 Preferred Brand $35.00$90.00None
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT   3 Preferred Brand $35.00$90.00None
AMLODIPINE BESYLATE 10MG TABLET (90 CT)   1 Preferred Generic $3.00$0.00None
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)   1 Preferred Generic $3.00$0.00None
AMLODIPINE BESYLATE 5MG TABLET (90 CT)   1 Preferred Generic $3.00$0.00None
AMMONIUM CHLORIDE 5 MEQ/ML   4 Non-Preferred Brand 40%40%None
AMMONIUM LACTATE 12% CREAM   3 Preferred Brand $35.00$90.00None
AMMONIUM LACTATE 12% LOTION   3 Preferred Brand $35.00$90.00None
AMOX TR-K CLV 500-125 MG TAB   2 Generic $10.00$0.00None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE   2 Generic $10.00$0.00None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET   2 Generic $10.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE   2 Generic $10.00$0.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   2 Generic $10.00$0.00None
AMOX-CLAV 200-28.5 MG/5 ML SUSPENSION   2 Generic $10.00$0.00None
AMOXAPINE 100MG TABLET   3 Preferred Brand $35.00$90.00None
AMOXAPINE 150MG TABLET   3 Preferred Brand $35.00$90.00None
AMOXAPINE 25MG TABLET   3 Preferred Brand $35.00$90.00None
AMOXAPINE 50MG TABLET   3 Preferred Brand $35.00$90.00None
AMOXICILLIN 125MG TABLET CHEW   2 Generic $10.00$0.00None
AMOXICILLIN 250MG 500 CHEWABLE TABLET in BOTTLE   2 Generic $10.00$0.00None
AMOXICILLIN 250MG CAPSULE   2 Generic $10.00$0.00None
AMOXICILLIN 50 MG/ML / CLAVULANATE 12.5 MG/ML ORAL SUSPENSION   2 Generic $10.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN 500MG 500 CAPSULE BOTTLE   2 Generic $10.00$0.00None
AMOXICILLIN 500MG TABLET (100 CT)   2 Generic $10.00$0.00None
AMOXICILLIN 875MG TABLET   2 Generic $10.00$0.00None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT   2 Generic $10.00$0.00None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS EXTENDED RELEASE 1000;62.5MG;MG   4 Non-Preferred Brand 40%40%None
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT   2 Generic $10.00$0.00None
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT   2 Generic $10.00$0.00None
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL   2 Generic $10.00$0.00None
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   2 Generic $10.00$0.00None
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL   2 Generic $10.00$0.00None
AMPHETAMINE SALT COMBO 12.5MG TABLET   3 Preferred Brand $35.00$90.00Q: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 $35.00$90.00Q:60
/30Days
AMPHETAMINE SALT COMBO 30MG TABLET   3 Preferred Brand $35.00$90.00Q:60
/30Days
AMPHETAMINE SALT COMBO 7.5MG TABLET   3 Preferred Brand $35.00$90.00Q:60
/30Days
AMPHETAMINE SALTS 20MG TABLET   3 Preferred Brand $35.00$90.00Q:90
/30Days
AMPHETAMINE SALTS 5 MG TAB   3 Preferred Brand $35.00$90.00Q:60
/30Days
amphotericin b 50mg/10mL 10 mL in 1 VIAL   4 Non-Preferred Brand 40%40%P
Ampicillin 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS   4 Non-Preferred Brand 40%40%None
AMPICILLIN CAPSULES 250MG 100 BOT   3 Preferred Brand $35.00$90.00None
AMPICILLIN CAPSULES 500MG 100 BOT   3 Preferred Brand $35.00$90.00None
AMPICILLIN FOR INJECTION POWDER   4 Non-Preferred Brand 40%40%None
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT   3 Preferred Brand $35.00$90.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT   3 Preferred Brand $35.00$90.00None
AMPICILLIN POWDER FOR INJECTION 1 GM/ML   4 Non-Preferred Brand 40%40%None
AMPICILLIN-SULBACTAM 15 GM VIAL   4 Non-Preferred Brand 40%40%None
AMPICILLIN-SULBACTAM 3 GM VIAL   4 Non-Preferred Brand 40%40%None
AMPICILLIN-SULBACTAM FOR INJECTION   4 Non-Preferred Brand 40%40%None
AMPYRA ER 10 MG TABLET   5 Specialty Tier 33%33%P Q:60
/30Days
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE   2 Generic $10.00$0.00None
Anagrelide Hydrochloride 1mg/1 100 CAPSULE BOTTLE   2 Generic $10.00$0.00None
Anastrozole 1mg/1 90 FILM COATED TABLETS in BOTTLE, PLASTIC   2 Generic $10.00$0.00None
ANDRODERM 2 MG/24HR PATCH   3 Preferred Brand $35.00$90.00P Q:30
/30Days
ANDRODERM 4 MG/24HR PATCH   3 Preferred Brand $35.00$90.00P Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANDROGEL 1.62% (1.25G) GEL PCKT   3 Preferred Brand $35.00$90.00P
ANDROGEL 1.62% (2.5G) GEL PCKT   3 Preferred Brand $35.00$90.00P
Androgel 16.2mg/g 1 BOTTLE, PUMP per CARTON / 88 g in 1 BOTTLE, PUMP   3 Preferred Brand $35.00$90.00P
ANORO ELLIPTA 62.5-25 MCG INH   3 Preferred Brand $35.00$90.00Q:60
/30Days
APOKYN 30 MG/3 ML CARTRIDGE   5 Specialty Tier 33%33%P
Apraclonidine Ophthalmic 5mg/mL 1 BOTTLE, DROPPER per CARTON / 10 mL in 1 BOTTLE, DROPPER   3 Preferred Brand $35.00$90.00None
APRI 0.15-0.03 TABLET   3 Preferred Brand $35.00$90.00None
APRISO CP24   3 Preferred Brand $35.00$90.00Q:120
/30Days
APTIOM 200 MG TABLET   4 Non-Preferred Brand 40%40%Q:30
/30Days
APTIOM 400 MG TABLET   4 Non-Preferred Brand 40%40%Q:30
/30Days
APTIOM 600 MG TABLET   4 Non-Preferred Brand 40%40%Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
APTIOM 800 MG TABLET   4 Non-Preferred Brand 40%40%Q:30
/30Days
APTIVUS 250MG CAPSULE   5 Specialty Tier 33%33%Q:180
/30Days
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT   5 Specialty Tier 33%33%Q:450
/30Days
ARALAST NP 500 MG VIAL   5 Specialty Tier 33%33%P
ARANELLE 7-9-5 TABLET   3 Preferred Brand $35.00$90.00None
ARANESP 10 MCG/0.4 ML SYRINGE   4 Non-Preferred Brand 40%40%P
ARANESP 100ug/0.5mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.5 mL in 1 SYRINGE   5 Specialty Tier 33%33%P
ARANESP 100ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE   5 Specialty Tier 33%33%P
ARANESP 200MCG/0.4ML SYRINGE   5 Specialty Tier 33%33%P
ARANESP 200MCG/ML VIAL   5 Specialty Tier 33%33%P
ARANESP 25ug/0.42mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.42 mL in 1 SYRING   4 Non-Preferred Brand 40%40%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP 25ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE   4 Non-Preferred Brand 40%40%P
ARANESP 300MCG/ML VIAL   5 Specialty Tier 33%33%P
ARANESP 500MCG/1ML SYRINGE   5 Specialty Tier 33%33%P
ARANESP 60MCG/ML VIAL   5 Specialty Tier 33%33%P
ARANESP 60ug/0.3mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.3 mL in 1 SYRINGE   5 Specialty Tier 33%33%P
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR   5 Specialty Tier 33%33%P
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR   5 Specialty Tier 33%33%P
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR   4 Non-Preferred Brand 40%40%P
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD   4 Non-Preferred Brand 40%40%P
ARCALYST INJECTION 220MG/VIAL   5 Specialty Tier 33%33%P
ARGATROBAN 100mg/mL 1 VIAL per CARTON / 2.5 mL in 1 VIAL   5 Specialty Tier 33%33%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Argatroban 125mg/125mL 2 VIAL, SINGLE-USE per CARTON / 125 mL in 1 VIAL, SINGLE-USE   5 Specialty Tier 33%33%P
ARIPIPRAZOLE 10 MG TABLET [Abilify]   4 Non-Preferred Brand 40%40%Q:30
/30Days
ARIPIPRAZOLE 15 MG TABLET [Abilify]   4 Non-Preferred Brand 40%40%Q:30
/30Days
ARIPIPRAZOLE 2 MG TABLET [Abilify]   4 Non-Preferred Brand 40%40%Q:30
/30Days
ARIPIPRAZOLE 20 MG TABLET [Abilify]   4 Non-Preferred Brand 40%40%Q:30
/30Days
ARIPIPRAZOLE 30 MG TABLET [Abilify]   4 Non-Preferred Brand 40%40%Q:30
/30Days
ARIPIPRAZOLE 5 MG TABLET [Abilify]   4 Non-Preferred Brand 40%40%Q:30
/30Days
ARIPIPRAZOLE ODT 10 MG TABLET [Abilify]   5 Specialty Tier 33%33%Q:90
/30Days
ARIPIPRAZOLE ODT 15 MG TABLET [Abilify]   5 Specialty Tier 33%33%Q:60
/30Days
ARISTADA ER 441 MG/1.6 ML SYRN   5 Specialty Tier 33%33%None
ARISTADA ER 662 MG/2.4 ML SYRN   5 Specialty Tier 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARISTADA ER 882 MG/3.2 ML SYRN   5 Specialty Tier 33%33%None
ARNUITY ELLIPTA 100 MCG INH   3 Preferred Brand $35.00$90.00Q:30
/30Days
ARNUITY ELLIPTA 200 MCG INH   3 Preferred Brand $35.00$90.00Q:30
/30Days
ARRANON 250MG VIAL   5 Specialty Tier 33%33%None
Ashlyna 0.15-0.03-0.01 mg tablet   3 Preferred Brand $35.00$90.00None
ASPIRIN-DIPYRIDAM ER 25-200 MG [Aggrenox]   4 Non-Preferred Brand 40%40%Q:60
/30Days
ATENOLOL 100 MG100 TABLET BOTTLE   1 Preferred Generic $3.00$0.00None
ATENOLOL 25 MG 100 TABLET BOTTLE   1 Preferred Generic $3.00$0.00None
ATENOLOL TABLET USP 50MG (100 CT)   1 Preferred Generic $3.00$0.00None
ATENOLOL-CHLORTHALIDONE 100-25   1 Preferred Generic $3.00$0.00None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   1 Preferred Generic $3.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATGAM 50MG/ML AMPUL   5 Specialty Tier 33%33%None
ATORVASTATIN 10 MG TABLET [Lipitor]   1 Preferred Generic $3.00$0.00Q:30
/30Days
ATORVASTATIN 20 MG TABLET [Lipitor]   1 Preferred Generic $3.00$0.00Q:30
/30Days
ATORVASTATIN 40 MG TABLET [Lipitor]   1 Preferred Generic $3.00$0.00Q:30
/30Days
ATORVASTATIN 80 MG TABLET [Lipitor]   1 Preferred Generic $3.00$0.00Q:30
/30Days
ATOVAQUONE 750 MG/5 ML SUSP [Mepron]   5 Specialty Tier 33%33%None
Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone]   3 Preferred Brand $35.00$90.00None
Atovaquone-Proguanil 62.5-25 [Malarone]   3 Preferred Brand $35.00$90.00None
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC   5 Specialty Tier 33%33%Q:60
/30Days
ATROPINE 0.05MG/ML SYRINGE   4 Non-Preferred Brand 40%40%None
ATROPINE 0.1MG/ML SYRINGE   4 Non-Preferred Brand 40%40%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 Brand 40%40%None
AUBAGIO 14 MG TABLET   5 Specialty Tier 33%33%P Q:30
/30Days
AUBAGIO 7 MG TABLET   5 Specialty Tier 33%33%P Q:30
/30Days
AUBRA-28 TABLET   3 Preferred Brand $35.00$90.00None
AVANDIA 2 MG TABLET   4 Non-Preferred Brand 40%40%P Q:120
/30Days
AVANDIA 4 MG TABLET   4 Non-Preferred Brand 40%40%P Q:60
/30Days
AVASTIN 100MG/4ML VIAL   5 Specialty Tier 33%33%P
AVASTIN 400 MG/16 ML VIAL   5 Specialty Tier 33%33%P
AVELOX IV 400MG/250ML   4 Non-Preferred Brand 40%40%None
AVIANE 0.1-0.02 TABLET   3 Preferred Brand $35.00$90.00None
AVITA 0.025% CREAM   4 Non-Preferred Brand 40%40%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Avita 0.25mg/g 45 g in 1 TUBE   4 Non-Preferred Brand 40%40%P
AVONEX ADMIN PACK 30 MCG VL   5 Specialty Tier 33%33%P
AVONEX PEN 30 MCG/0.5 ML KIT   5 Specialty Tier 33%33%P
AVONEX PREFILLED SYR 30 MCG KT   5 Specialty Tier 33%33%P
Azacitidine 100 mg vial [Vidaza]   5 Specialty Tier 33%33%P
AZACTAM INJECTION 1GM/50ML   4 Non-Preferred Brand 40%40%None
AZACTAM INJECTION 2GM/50ML   4 Non-Preferred Brand 40%40%None
AZASITE 1% EYE DROPS   4 Non-Preferred Brand 40%40%None
AZATHIOPRINE 50 MG TABLET   2 Generic $10.00$0.00P
AZATHIOPRINE SODIUM 100 MG VIAL   5 Specialty Tier 33%33%P
AZELASTINE 0.15% NASAL SPRAY   3 Preferred Brand $35.00$90.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZELASTINE 137 MCG NASAL SPRAY   3 Preferred Brand $35.00$90.00Q:60
/30Days
AZELASTINE HYDROCHLORIDE OPHTHALMIC SOLUTION   3 Preferred Brand $35.00$90.00None
AZILECT 0.5MG TABLET   3 Preferred Brand $35.00$90.00None
AZILECT 1MG TABLET   3 Preferred Brand $35.00$90.00None
AZITHROMYCIN 100 MG/5 ML SUSP   2 Generic $10.00$0.00None
Azithromycin 200mg/5mL 22.5 mL in 1 BOTTLE   2 Generic $10.00$0.00None
AZITHROMYCIN 250 MG TABLET   2 Generic $10.00$0.00None
AZITHROMYCIN 250 MG TABLET   2 Generic $10.00$0.00None
Azithromycin 500mg/1 10 VIAL, SINGLE-USE in 1 TRAY / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION   4 Non-Preferred Brand 40%40%None
Azithromycin 500mg/1 30 FILM COATED TABLETS in BOTTLE   2 Generic $10.00$0.00None
Azithromycin 600mg/1 30 FILM COATED TABLETS in BOTTLE   2 Generic $10.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Azithromycin i.v. 500 mg vial   4 Non-Preferred Brand 40%40%None
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT   3 Preferred Brand $35.00$90.00None
AZTREONAM FOR INJECTION   3 Preferred Brand $35.00$90.00None

Chart Legend:

Below are a few notes to help you understand the above 2016 Medicare Part D AARP MedicareRx Preferred (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 standard $360 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 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 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 intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $3310) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2016 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 September 2016 )

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.