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2019 Medicare Part D Plan’s Negotiated Retail Drug Price

 Below you will find the average negotiated retail prescription drug price for your chosen Medicare Part D or Medicare Advantage plan, along with, tier cost-sharing details, your estimated cost for purchases during each coverage phase, tier cost-sharing details and your costs with explanations, and plan’s retail drug price history.
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2019 Medicare Prescription Drug Price Information
Express Scripts Medicare - Value (PDP) (S5660-114-0)
Benefit Details         
Monthly Premium: $30.20 Rx Deductible: $415 ICL: $3,820 Qualifies for LIS: Yes

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Express Scripts Medicare - Value (PDP) 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 
This Plan Uses Lower Cost-Sharing for Preferred Pharmacies
SYMDEKO 100/150 MG-150 MG TABS  
Plan’s average negotiated retail drug price in
CMS PDP Region 12, includes: AL TN 		$22,525.80* 30-Day Supply
$68,237.90* 90-Day Supply
Formulary (Drug List) Drug Tier:Tier #5: Specialty Tier
Does this plan offer any Gap Coverage?No Gap Coverage
Does this Drug have Gap Coverage?No, this drug IS NOT covered in the gap, but all drugs receive the donut hole discount.
Drug Usage Management Restrictions:Prior Authorization and Quantity Limit:56/28Days
Formulary (Drug List) Tier Cost-Sharing Details
  30-Day Supply
Cost-Sharing		 90-Day Supply
Cost-Sharing
Preferred Pharmacy Standard Pharmacy Mail- Order** Preferred Pharmacy Standard Pharmacy Mail- Order**
Initial $415 Deductible Cost Sharing:
 100% 100% 100% n/a n/a n/a
Initial Coverage Phase Cost-Sharing:
 25% 25% 25% n/a n/a n/a
Coverage Gap Phase Cost-Sharing Incl. Donut Hole Discount (Generics 63%):
 37% 37% 37% n/a n/a n/a
Coverage Gap Phase Cost-Sharing Incl. Donut Hole Discount (Brand 75%):
 25% 25% 25% n/a n/a n/a
Catastrophic Coverage Phase Cost-Sharing for Generic & Preferred Multi-Source Drugs:
 The greater of 5% or $3.40 The greater of 5% or $3.40
Catastrophic Coverage Phase Cost-Sharing for Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs):
 The greater of 5% or $8.50 The greater of 5% or $8.50
Your Estimated Cost for Purchases During Each Coverage Phase
  30-Day Supply
Cost-Sharing		 90-Day Supply
Cost-Sharing
Preferred Pharmacy Standard Pharmacy Mail- Order** Preferred Pharmacy Standard Pharmacy Mail- Order**
Your Estimated Cost in Deductible Phase:
 $3,008.65 $3,008.65 $3,008.65 n/a n/a n/a
Your Estimated Cost Initial Coverage Phase:
 $2,762.92 $2,762.92 $2,762.92 n/a n/a n/a
Your Estimated Cost in Gap if Drug is Generic (63% discount):
 $5,537.10$5,537.10$5,537.10 $7,822.71n/an/a
Your Estimated Cost in Gap if Drug is Brand-Name (75% discount):
 $2,199.97$2,199.97$2,199.97 $4,419.15n/an/a
Your Estimated Cost in Catastrophic Coverage Phase (Generic):
 $1,126.29 $1,126.29 $1,126.29 n/a n/a n/a
Your Estimated Cost in Catastrophic Coverage (Brand-Name or Non-Preferred Multi-Source Drugs):
 $1,126.29 $1,126.29 $1,126.29 n/a n/a n/a
Tier Cost-Sharing Details and Your Costs with Explanations
  30-Day Supply
Cost-Sharing		 90-Day Supply
Cost-Sharing
Preferred Pharmacy Standard Pharmacy Mail- Order** Preferred Pharmacy Standard Pharmacy Mail- Order**
--- If you purchase during the Initial Deductible Phase ---
Initial $415 Deductible Cost Sharing:
 100% 100% 100% n/a n/a n/a
Your Estimated Cost in Deductible Phase:
 $3,008.65 $3,008.65 $3,008.65 n/a n/a n/a
Explanation for 30-Day Preferred Pharmacy purchase:
  For a purchase of this drug made during the initial deductible phase, you cross over into other phases of your plan’s coverage (straddle claim).   So you pay 100% of the drug cost up to your deductible of $415 and the remaining amount ($22,525.80-$415) (price - deductible) falls into your initial coverage phase (ICP).   For the ICP portion of your coverage, your cost-sharing would be an additional $851.25 or $3,405.00 x 25% (overage up to your remaining coverage limit ($3,405.00) * cost-sharing). Since the amount of the retail drug price falling into the ICP $22,110.80 is greater than the remaining initial coverage limit $3405 ($3,820 - $415), $18,705.80 rolls into the coverage gap phase. For the portion that falls into the coverage gap phase, you would pay an additional $1,008.88 or ($4,035.53 x 25% -- 70% of the discount counts toward TrOOP and the 5% paid by your plan does not count toward TrOOP assuming this is a brand-name drug). Since the portion of the costs that fell into the coverage gap $18,705.80 x 95% exceeds the amount of TrOOP left ($3,833.75), $14,670.27 falls into the catastrophic coverage phase. For the portion that falls into the catastrophic coverage phase, you would pay an additional $733.51 or (5% of $14,670.27) since it is greater than the minimum catastrophic cost-share of $8.50.
--- If you purchase during the Initial Coverage Phase ---
Initial Coverage Phase Cost-Sharing:
 25% 25% 25% n/a n/a n/a
Your Estimated Cost Initial Coverage Phase:
 $2,762.92 $2,762.92 $2,762.92 n/a n/a n/a
Explanation for 30-Day Preferred Pharmacy purchase:
 The cost-sharing for purchases made during the initial coverage phase (ICP) would be $955.00 or ($3,820.00 x 25%). But since the retail drug price ($22,525.80) is greater than initial coverage limit ($3,820), the difference of $18,705.80 rolls into the coverage gap phase. For the portion that falls into the coverage gap phase, you would pay an additional $1,090.79 or ($4,363.16 x 25% -- 70% of the discount counts toward TrOOP and the 5% paid by your plan does not count toward TrOOP). The portion of the costs that fell into the coverage gap $4,363.16 exceeds the amount of TrOOP left ($4,145.00) so you only pay in the gap on the amount within the TrOOP. The excess over TrOOP, $14,342.64 falls into the catastrophic coverage phase. For the portion that falls into the catastrophic coverage phase, you would pay an additional $717.13 or (5% of $14,342.64) since it is greater than the minimum catastrophic cost-share of $8.50. So, your total cost for this one purchase is $2,762.92 or $955.00 (ICP) + $1,090.79 (Gap) + $717.13 (Cat.Cov.).
--- If you purchase during the Coverage Gap Phase (Donut Hole) ---
Your Estimated Cost in Gap if Drug is Generic (63% discount):
 $5,537.10$5,537.10$5,537.10 $7,822.71n/an/a
  Since this drug’s negotiated retail price ($22,525.80) is greater than the TrOOP limit ($5,100), in the donut hole phase, you would pay $5,100.00 ($13,783.78 x 37%) plus $437.10 in the catastrophic phase, (which is 5% of the remaining $8,742.02) because $437.10 is greater than the minimum catastrophic cost-share of $3.40. Although it rarely happens that you would be responsible for the entire $5,100 for a purchase in the coverage gap, it can occur, for example on an expensive generic drug with a $0 copay in the initial coverage phase.
Your Estimated Cost in Gap if Drug is Brand-Name (75% discount):
 $2,199.97$2,199.97$2,199.97 $4,419.15n/an/a
  Since 95% this drug’s negotiated retail price ($22,525.80) is greater than the TrOOP limit ($5,100), in the donut hole phase, you would pay $1,342.11 (($5,100 / 95%) x 25% -- 70% of the discount counts toward TrOOP and the 5% paid by your plan does not count toward TrOOP) plus $857.87 in the catastrophic phase, (which is 5% of the remaining $17,157.38) because $857.87 is greater than the minimum catastrophic cost-share of $8.50.  Although it rarely happens that you would be responsible for the entire $5,100 for a purchase in the coverage gap, it can occur, for example on an expensive generic drug with a $0 copay in the initial coverage phase.
--- If you purchase during the Catastrophic Coverage Phase ---
Catastrophic Coverage Phase Cost-Sharing for Generic & Preferred Multi-Source Drugs:
 The greater of 5% or $3.40 The greater of 5% or $3.40
Your Estimated Cost in Catastrophic Coverage Phase (Generic):
 $1,126.29 $1,126.29 $1,126.29 n/a n/a n/a
Explanation for 30-Day Preferred Pharmacy purchase:
 In the catastrophic coverage phase, you will pay the greater of 5% of the retail drug price or the minimum cost-share of $3.40. Calculating 5% of $22,525.80 = $1,126.29. Since $1,126.29 is more than $3.40, you would pay $1,126.29 for this drug at a preferred pharmacy, if it is a generic or preferred multi-source drug.
Catastrophic Coverage Phase Cost-Sharing for Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs):
 The greater of 5% or $8.50 The greater of 5% or $8.50
Your Estimated Cost in Catastrophic Coverage (Brand-Name or Non-Preferred Multi-Source Drugs):
 $1,126.29 $1,126.29 $1,126.29 n/a n/a n/a
Explanation for 30-Day Preferred Pharmacy purchase:
 In the catastrophic coverage phase, you will pay the greater of 5% of the retail drug price or the minimum cost-share of $8.50. Calculating 5% of $22,525.80 = $1,126.29. Since $1,126.29 is more than $8.50, you would pay $1,126.29 for this drug at any pharmacy, if it is not a generic or preferred multi-source drug.
Express Scripts Medicare - Value (PDP)
Average Negotiated Retail Drug Price History
 30-Day Supply90 Day Supply
September, 2019: $22,525.80$68,237.90
June, 2019: $22,590.80$68,367.40
March, 2019: $22,690.70$68,981.00
January, 2019: $22,797.20$70,038.00
September, 2018: $22,823.00$70,166.10
June, 2018: $22,876.00$70,282.10
March, 2018: n/an/a
January, 2018: n/an/a
September, 2017: n/an/a
June, 2017: n/an/a
March, 2017: n/an/a
January, 2017: n/an/a
September, 2016: 
June, 2016: 
April, 2016: 
January, 2016: 
September, 2015: 
June, 2015: 
April, 2015: 
January, 2015: 
September, 2014: 
June, 2014: 
March, 2014: 
January, 2014: 
October, 2013: 
January, 2013: --
April, 2012: --
September, 2010: --
Notes:
*The plan’s Average Retail Drug Price is based on three things: (1) the medication, (2) the specific Medicare Part D plan, and (3) the pharmacies in the plan’s service area. In this case, the average of the SYMDEKO 100/150 MG-150 MG TABS prices that the Express Scripts Medicare - Value (PDP) has negotiated with each of the retail pharmacies in the plan’s service area ( CMS PDP Region 12, includes: AL TN). In other words, when you use the Express Scripts Medicare - Value (PDP) to purchase SYMDEKO 100/150 MG-150 MG TABS, you may pay slightly more or slightly less than the figures shown in the table above depending on the pharmacy where you fill your prescription.

**The mail-order cost-sharing is the plan’s "preferred" mail-order cost-sharing.

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Chart Legend:

What does all this mean? Below are a few notes to help you understand the above 2019 Medicare Part D Express Scripts Medicare - Value (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). 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 $415 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. *Some Part D plans exclude one or more drug tiers from the deductible. If the drug tier field above is followed by * (example: 2*), then this drug tier is excluded from the plan’s deductible.
  • 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 $3820) 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.
    • 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 2019 )

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.




 
 

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  • 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.
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