2020 Medicare Prescription Drug Plan Cost-Sharing Details

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2020 Medicare Part D Prescription Drug
Formulary (Drug List) Cost-Sharing Details
Express Scripts Medicare - Saver (PDP) (S5660-247-0)
Benefits & Contact Info        
This plan is available in CMS PDP Region 31
which includes: ID UT

Monthly Premium: $21.20
Rx Deductible: $435
Initial Coverage Limit: $4,020 Qualifies for LIS: No


Click on a letter below to view the
Express Scripts Medicare - Saver (PDP) Formulary
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This Plan Uses Lower Cost-Sharing for Preferred Pharmacies
  30-Day Supply
Cost-Sharing
90-Day Supply
Cost-Sharing
Preferred Pharmacy Standard Pharmacy Mail- Order* Preferred Pharmacy Standard Pharmacy Mail- Order*
Initial Deductible Phase Cost Sharing
Tier 1: Preferred Generic: $1.00(E) $9.00(E) n/a(E) $3.00(E) $27.00(E) $0.00(E)
Tier 2: Generic: $4.00(E) $12.00(E) n/a(E) $12.00(E) $36.00(E) $8.00(E)
Tier 3: Preferred Brand: 100% 100% 100% 100% 100% 100%
Tier 4: Non-Preferred Drug: 100% 100% 100% 100% 100% 100%
Tier 5: Specialty Tier: 100% 100% 100% 100% 100% 100%
Initial Coverage Phase Cost-Sharing
Tier 1: Preferred Generic: $1.00 $9.00 n/a $3.00 $27.00 $0.00
Tier 2: Generic: $4.00 $12.00 n/a $12.00 $36.00 $8.00
Tier 3: Preferred Brand: $30.00 $39.00 n/a $90.00 $117.00 $90.00
Tier 4: Non-Preferred Drug: 41% 43% 43% n/a n/a n/a
Tier 5: Specialty Tier: 25% 25% 25% n/a n/a n/a
Coverage Gap (Donut Hole) Phase Cost Sharing
Plan offers no Gap Coverage 75% Generic and 75% Brand Donut Hole Discount applies
All Formulary Generic Drugs: 25% 25% 25% 25% 25% 25%
All Formulary Brand-Name Drugs: 25% 25% 25% 25% 25% 25%
Catastrophic Coverage Phase Cost Sharing
Generic & Preferred Multi-Source Drugs: The greater of 5% or $3.60 The greater of 5% or $3.60
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): The greater of 5% or $8.95 The greater of 5% or $8.95
Notes:
*The mail-order cost-sharing is the plan’s "preferred" mail-order cost-sharing.
(E) Drugs on this tier are excluded from the Initial Deductible and do not count toward meeting the deductible.
Go to the Express Scripts Medicare - Saver (PDP) 2020 Formulary Browser by choosing a letter below:
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