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                      Medicare-Approved 2023 Performance Formulary: 23028

  5 Tier Performance Formulary

Download the latest comprehensive copy of the Medicare Part-D formulary with prior authorization here

For detailed instructions on how to use this site, please click here

All drugs returned upon search are covered on the formulary. The formulary status (e.g., tier) and any applicable coverage restrictions (e.g., prior authorization, quantity limit) are denoted by symbols. A “Definition of Symbols” is displayed immediately following the search results.


To access the 2024 Performance Formulary, click here.


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Important Message About What You Pay for Vaccines – Our plan covers most Part D vaccines at no cost to you. Call Member Services for more information.

Important Message About What You Pay for Insulin – You won’t pay more than $35 for a one-month supply of each Part D insulin product covered by our plan, no matter what cost-sharing tier it’s on. Freedom Blue PPO Prestige members can save even more with $20 copays for qualifying Tier 3 Select Insulin products.



Formulary Id: 23028
Formulary Effective Date: 12/01/2023
CMS Approval Date:
CMS Version:
CMS Marketing Materials Id:

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