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2020 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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2020 Medicare Prescription Drug Price Information
Express Scripts Medicare - Value (PDP) (S5660-113-0)
Benefit Details         
Monthly Premium: $55.10 Rx Deductible: $435 ICL: $4,020 Qualifies for LIS: No

Click on a letter below to view the
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
UPTRAVI 200-800 TITRATION PACK  
Plan’s average negotiated retail drug price in
CMS PDP Region 11, includes: FL 		$27,454.00* 30-Day Supply
$33,196.80* 90-Day Supply
Formulary (Drug List) drug tier:Tier #4: Non-Preferred Drug
Does this plan offer any Gap coverage?No
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
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 $435 Deductible Cost Sharing:
 100% 100% 100% n/a n/a n/a
Initial Coverage Phase Cost-Sharing:
 45% 47% 47% n/a n/a n/a
Coverage Gap Phase Cost-Sharing Incl. Donut Hole Discount (Generics 75%):
 25% 25% 25% 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 $3.60 The greater of 5% or $3.60
Catastrophic Coverage Phase Cost-Sharing for Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs):
 The greater of 5% or $8.95 The greater of 5% or $8.95
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:
 $4,125.58 $4,182.19 $3,031.21 n/a n/a n/a
Your Estimated Cost Initial Coverage Phase:
 $3,936.70 $2,709.54 $2,709.54 n/a n/a n/a
Your Estimated Cost in Gap if Drug is Generic (75% discount):
 $6,452.70$6,452.70$6,452.70 $6,739.84n/an/a
Your Estimated Cost in Gap if Drug is Brand-Name (75% discount):
 $2,709.54$2,709.54$2,709.54 $2,913.97n/an/a
Your Estimated Cost in Catastrophic Coverage Phase (Generic):
 $1,372.70 $1,372.70 $1,372.70 n/a n/a n/a
Your Estimated Cost in Catastrophic Coverage (Brand-Name or Non-Preferred Multi-Source Drugs):
 $1,372.70 $1,372.70 $1,372.70 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 $435 Deductible Cost Sharing:
 100% 100% 100% n/a n/a n/a
Your Estimated Cost in Deductible Phase:
 $4,125.58 $4,182.19 $3,031.21 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 $435 and the remaining amount ($27,454.00-$435) (price - deductible) falls into your initial coverage phase (ICP).   For the ICP portion of your coverage, your cost-sharing would be an additional $1,613.25 or $3,585.00 x 45% (overage up to your remaining coverage limit ($3,585.00) * cost-sharing). Since the amount of the retail drug price falling into the ICP $27,019.00 is greater than the remaining initial coverage limit $3585 ($4,020 - $435), $23,434.00 rolls into the coverage gap phase. For the portion that falls into the coverage gap phase, you would pay an additional $1,132.04 or ($4,528.16 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 $23,434.00 x 95% exceeds the amount of TrOOP left ($4,301.75), $18,905.84 falls into the catastrophic coverage phase. For the portion that falls into the catastrophic coverage phase, you would pay an additional $945.29 or (5% of $18,905.84) since it is greater than the minimum catastrophic cost-share of $8.95.
--- If you purchase during the Initial Coverage Phase ---
Initial Coverage Phase Cost-Sharing:
 45% 47% 47% n/a n/a n/a
Your Estimated Cost Initial Coverage Phase:
 $3,936.70 $2,709.54 $2,709.54 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 $1,809.00 or ($4,020.00 x 45%). But since the retail drug price ($27,454.00) is greater than initial coverage limit ($4,020), the difference of $23,434.00 rolls into the coverage gap phase. For the portion that falls into the coverage gap phase, you would pay an additional $1,195.00 or ($4,780.00 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 $4,780.00 exceeds the amount of TrOOP left ($4,541.00) so you only pay in the gap on the amount within the TrOOP. The excess over TrOOP, $18,654.00 falls into the catastrophic coverage phase. For the portion that falls into the catastrophic coverage phase, you would pay an additional $932.70 or (5% of $18,654.00) since it is greater than the minimum catastrophic cost-share of $8.95. So, your total cost for this one purchase is $3,936.70 or $1,809.00 (ICP) + $1,195.00 (Gap) + $932.70 (Cat.Cov.).
--- If you purchase during the Coverage Gap Phase (Donut Hole) ---
Your Estimated Cost in Gap if Drug is Generic (75% discount):
 $6,452.70$6,452.70$6,452.70 $6,739.84n/an/a
  Since this drug’s negotiated retail price ($27,454.00) is greater than the TrOOP limit ($6,350), in the donut hole phase, you would pay $6,350.00 ($25,400.00 x 25%) plus $102.70 in the catastrophic phase, (which is 5% of the remaining $2,054.00) because $102.70 is greater than the minimum catastrophic cost-share of $3.60. Although it rarely happens that you would be responsible for the entire $6,350 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):
 $2,709.54$2,709.54$2,709.54 $2,913.97n/an/a
  Since 95% this drug’s negotiated retail price ($27,454.00) is greater than the TrOOP limit ($6,350), in the donut hole phase, you would pay $1,671.05 (($6,350 / 95%) x 25% -- 70% of the discount counts toward TrOOP and the 5% paid by your plan does not count toward TrOOP) plus $1,038.49 in the catastrophic phase, (which is 5% of the remaining $20,769.79) because $1,038.49 is greater than the minimum catastrophic cost-share of $8.95.  Although it rarely happens that you would be responsible for the entire $6,350 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 $3.60 The greater of 5% or $3.60
Your Estimated Cost in Catastrophic Coverage Phase (Generic):
 $1,372.70 $1,372.70 $1,372.70 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 $3.60. Calculating 5% of $27,454.00 = $1,372.70. Since $1,372.70 is more than $3.60, you would pay $1,372.70 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 $8.95 The greater of 5% or $8.95
Your Estimated Cost in Catastrophic Coverage (Brand-Name or Non-Preferred Multi-Source Drugs):
 $1,372.70 $1,372.70 $1,372.70 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 $8.95. Calculating 5% of $27,454.00 = $1,372.70. Since $1,372.70 is more than $8.95, you would pay $1,372.70 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, 2020: $27,454.00$33,196.80
June, 2020: $27,476.00$33,285.60
March, 2020: $27,556.00$83,280.00
January, 2020: $26,404.00$80,160.00
September, 2019: $26,399.30$79,972.10
June, 2019: $26,475.40$80,123.60
March, 2019: $25,991.80$94,514.80
January, 2019: $24,650.70$88,830.40
September, 2018: $24,650.80$88,830.40
June, 2018: $24,650.80$88,830.50
March, 2018: $25,201.20$77,266.90
January, 2018: $23,181.70$71,139.90
September, 2017: $23,269.30$71,405.40
June, 2017: $23,287.70$71,389.30
March, 2017: $22,413.40$68,428.60
January, 2017: $22,459.90$68,616.40
September, 2016: $22,755.92$68,121.92
June, 2016: $22,792.09$68,035.98
April, 2016: n/an/a
January, 2016: n/an/a
September, 2015: n/an/a
June, 2015: n/an/a
April, 2015: n/an/a
January, 2015: n/an/a
September, 2014: n/an/a
June, 2014: n/an/a
March, 2014: n/an/a
January, 2014: n/an/a
October, 2013: n/an/a
January, 2013: n/a--
April, 2012: n/a--
September, 2010: n/a--
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 UPTRAVI 200-800 TITRATION PACK 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 11, includes: FL). In other words, when you use the Express Scripts Medicare - Value (PDP) to purchase UPTRAVI 200-800 TITRATION PACK, 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.

Return to the Express Scripts Medicare - Value (PDP) 2020 Formulary Browser by choosing a letter below:
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Chart Legend:

What does all this mean? Below are a few notes to help you understand the above 2020 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 $435 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.
  • 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 $4020) 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 2020 )

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.




 
 

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  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
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  • 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.
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  • 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.
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  • 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.
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