2021 Medicare Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
Express Scripts Medicare - Saver (PDP) (S5660-219-0) Benefit Details select insulin pay $35 copay | ||||||
This plan is available in CMS PDP Region 2 which includes: CT MA RI VT Monthly Premium: $27.40 Rx Deductible: $285 Initial Coverage Limit: $4,130 Qualifies for LIS: No Click on a letter below to view the Express Scripts Medicare - Saver (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 | ||||||
30-Day Supply Cost-Sharing |
90-Day Supply Cost-Sharing |
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Preferred Pharmacy | Standard Pharmacy | Mail- Order* | Preferred Pharmacy | Standard Pharmacy | Mail- Order* | |
Initial Deductible Phase Cost Sharing | ||||||
Tier 1: Preferred Generic: | $2.00(E) | $19.00(E) | n/a(E) | $6.00(E) | $57.00(E) | $0.00(E) |
Tier 2: Generic: | $7.00(E) | $20.00(E) | n/a(E) | $21.00(E) | $60.00(E) | $0.00(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: | $2.00 | $19.00 | n/a | $6.00 | $57.00 | $0.00 |
Tier 2: Generic: | $7.00 | $20.00 | n/a | $21.00 | $60.00 | $0.00 |
Tier 3: Preferred Brand: | $35.00 | $47.00 | n/a | $105.00 | $141.00 | $105.00 |
Tier 4: Non-Preferred Drug: | 50% | 50% | n/a | 50% | 50% | 50% |
Tier 5: Specialty Tier: | 28% | 28% | 28% | 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 $3.70 | The greater of 5% or $3.70 | ||||
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): | The greater of 5% or $9.20 | The greater of 5% or $9.20 | ||||
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) 2021 Formulary Browser by choosing a letter below: 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 |