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2021 Medicare Prescription Drug Plan Cost-Sharing Details
| 2021 Medicare Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
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Express Scripts Medicare - Saver (PDP) (S5660-227-0) Benefit Details 
 select insulin pay $35 copay | ||||||
| This plan is available in CMS PDP Region 11 Monthly Premium: $27.20 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 | ||||||