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Express Scripts Medicare - Value (PDP) (S5660-131-0)
Tier 1 (298)
Tier 2 (1095)
Tier 3 (1248)
Tier 4 (410)
Tier 5 (483)
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M N O P Q R S T U V W X Y Z 0-9 
2016 Medicare Part D Plan Formulary Information
Express Scripts Medicare - Value (PDP) (S5660-131-0)
Benefit Details           
The Express Scripts Medicare - Value (PDP) (S5660-131-0)
Formulary Drugs Starting with the Letter A

in CMS PDP Region 29 which includes: NV
Plan Monthly Premium: $68.20 Deductible: $360 Qualifies for LIS: No
Drugs Starting with Letter A

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
A-HYDROCORT 100MG VIAL   2 Generic $9.00$27.00None
ABACAVIR 300 MG TABLET   3 Preferred Brand 23%25%None
Abacavir Sulfate-Lamivudine-Zidovudine tablets [Trizivir]   5 Specialty Tier 25%N/ANone
ABELCENT INJECTION SUSPENSION 5MG/ML   5 Specialty Tier 25%N/AP
ABILIFY MAINTENA ER 300 MG SYR   5 Specialty Tier 25%N/ANone
ABILIFY MAINTENA ER 300 MG VL   5 Specialty Tier 25%N/ANone
ABILIFY MAINTENA ER 400 MG SYR   5 Specialty Tier 25%N/ANone
ABRAXANE 100MG VIAL   5 Specialty Tier 25%N/ANone
Acamprosate Calcium DR 333 MG tablets [Campral]   2 Generic $9.00$27.00None
ACARBOSE 100 MG TABLET   2 Generic $9.00$27.00Q:93
/31Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACARBOSE 25 MG TABLET   2 Generic $9.00$27.00Q:372
/31Days
Acarbose 50mg/1 100 TABLET BOTTLE   2 Generic $9.00$27.00Q:186
/31Days
ACEBUTOLOL 200MG CAPSULE   2 Generic $9.00$27.00None
ACEBUTOLOL 400MG CAPSULE   2 Generic $9.00$27.00None
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE   3 Preferred Brand 23%25%None
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD   2 Generic $9.00$27.00Q:4650
/31Days
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT)   2 Generic $9.00$27.00Q:372
/31Days
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT)   2 Generic $9.00$27.00Q:372
/31Days
ACETAMINOPHEN-COD #4 TABLET   2 Generic $9.00$27.00Q:186
/31Days
ACETASOL HC SOLUTION 10ML 10 ML BOT   4 Non-Preferred Brand 48%50%None
ACETAZOLAMIDE 125MG TABLET   2 Generic $9.00$27.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETAZOLAMIDE 250MG TABLET (100 CT)   2 Generic $9.00$27.00None
Acetazolamide 500mg/5mL 1 VIAL in 1 CARTON / 5 mL in 1 VIAL   2 Generic $9.00$27.00None
ACETAZOLAMIDE ER CAPSULES 500MG 100 BOT   3 Preferred Brand 23%25%None
ACETIC ACID 2% EAR SOLUTION   2 Generic $9.00$27.00None
ACETYLCYSTEINE 10% VIAL   2 Generic $9.00$27.00P
ACETYLCYSTEINE 20% VIAL   2 Generic $9.00$27.00P
ACITRETIN 10 MG CAPSULE [Soriatane]   5 Specialty Tier 25%N/ANone
ACITRETIN 17.5 MG CAPSULE [Soriatane]   5 Specialty Tier 25%N/ANone
ACITRETIN 25 MG CAPSULE [Soriatane]   5 Specialty Tier 25%N/ANone
ACTEMRA 162 MG/0.9 ML SYRINGE   5 Specialty Tier 25%N/AP
ACTEMRA 400 MG/20 ML VIAL   5 Specialty Tier 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACTEMRA 80 MG/4 ML VIAL   5 Specialty Tier 25%N/AP
ACTEMRA INJECTION 200MG/10ML   5 Specialty Tier 25%N/AP
ACTHIB VACCINE WITH DILUENT   3 Preferred Brand 23%25%None
ACTIMMUNE 100 MCG/0.5 ML VIAL   5 Specialty Tier 25%N/ANone
Acyclovir 200mg 100 CAPSULE BOTTLE   2 Generic $9.00$27.00None
Acyclovir 200mg/5mL 473 mL BOTTLE   3 Preferred Brand 23%25%None
Acyclovir 400mg/1   2 Generic $9.00$27.00None
Acyclovir 5% Ointment   4 Non-Preferred Brand 48%50%None
ACYCLOVIR 800 MG TABLET   2 Generic $9.00$27.00None
Acyclovir sodium 500 mg vial   4 Non-Preferred Brand 48%50%P
ADACEL VIAL 2UNT/5UNT   3 Preferred Brand 23%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADAGEN 250U/ML VIAL   5 Specialty Tier 25%N/ANone
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA]   5 Specialty Tier 25%N/AP Q:2
/28Days
ADAPALENE 0.1% CREAM   4 Non-Preferred Brand 48%50%P
ADAPALENE 0.1% GEL   4 Non-Preferred Brand 48%50%P
Adapalene 0.3% gel   2 Generic $9.00$27.00P
ADEFOVIR DIPIVOXIL 10 MG TAB [Hepsera]   5 Specialty Tier 25%N/ANone
ADEMPAS 0.5 MG TABLET   5 Specialty Tier 25%N/AP
ADEMPAS 1 MG TABLET   5 Specialty Tier 25%N/AP
ADEMPAS 1.5 MG TABLET   5 Specialty Tier 25%N/AP
ADEMPAS 2 MG TABLET   5 Specialty Tier 25%N/AP
ADEMPAS 2.5 MG TABLET   5 Specialty Tier 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Adrenalin 1 mg/ml vial   2 Generic $9.00$27.00None
ADRUCIL 50mg/mL 10 VIAL in 1 TRAY / 10 mL in 1 VIAL   3 Preferred Brand 23%25%None
ADVAIR DISKUS MIS 100/50   4 Non-Preferred Brand 48%50%Q:60
/30Days
ADVAIR DISKUS MIS 250/50   4 Non-Preferred Brand 48%50%Q:60
/30Days
ADVAIR DISKUS MIS 500/50   4 Non-Preferred Brand 48%50%Q:60
/30Days
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER   4 Non-Preferred Brand 48%50%Q:24
/31Days
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL   4 Non-Preferred Brand 48%50%Q:24
/31Days
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL   4 Non-Preferred Brand 48%50%Q:24
/31Days
Afinitor 7.5mg/1 28 BLISTER PACK per CARTON / 1 TABLET per BLISTER PACK   5 Specialty Tier 25%N/AP
AFINITOR DISPERZ 2 MG TABLET   5 Specialty Tier 25%N/AP
AFINITOR DISPERZ 3 MG TABLET   5 Specialty Tier 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AFINITOR DISPERZ 5 MG TABLET   5 Specialty Tier 25%N/AP
AFINITOR TABLETS 10 MG   5 Specialty Tier 25%N/AP Q:62
/31Days
AFINITOR TABLETS 2.5 MG   5 Specialty Tier 25%N/AP
AFINITOR TABLETS 5 MG   5 Specialty Tier 25%N/AP
AK-CON 0.1% EYE DROPS   1 Preferred Generic $0.00$3.00None
ALBENZA 200 MG TABLET   5 Specialty Tier 25%N/ANone
ALBUTEROL SULFATE 0.75mg/3mL 30 POUCH per CARTON / 1 VIAL, SINGLE-DOSE in 1 POUCH / 3 mL in 1 VIAL   2 Generic $9.00$27.00P
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER   2 Generic $9.00$27.00P
ALBUTEROL SULFATE 4MG TABLET SR 12HR   4 Non-Preferred Brand 48%50%None
ALBUTEROL SULFATE 8MG TABLET SR 12HR   4 Non-Preferred Brand 48%50%None
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   1 Preferred Generic $0.00$3.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALBUTEROL SULFATE SOLUTION FOR INHALATION   1 Preferred Generic $0.00$3.00P
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT   1 Preferred Generic $0.00$3.00None
ALBUTEROL SULFATE TABLET 2MG (500 CT)   4 Non-Preferred Brand 48%50%None
ALBUTEROL TABLET 4MG (500 CT)   4 Non-Preferred Brand 48%50%None
ALCLOMETASONE DIPROPIONATE 0.05% CREAM   3 Preferred Brand 23%25%None
Alclometasone Dipropionate 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE   2 Generic $9.00$27.00None
ALDURAZYME 2.9MG/5ML VIAL   5 Specialty Tier 25%N/ANone
ALECENSA 150 MG CAPSULE   4 Non-Preferred Brand 48%50%P Q:248
/31Days
ALENDRONATE SODIUM 10MG TABLET   2 Generic $9.00$27.00Q:31
/31Days
ALENDRONATE SODIUM 35 MG TABLET   2 Generic $9.00$27.00Q:4
/28Days
ALENDRONATE SODIUM 40MG TABLET   2 Generic $9.00$27.00Q:31
/31Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALENDRONATE SODIUM 5MG TABLET   2 Generic $9.00$27.00Q:31
/31Days
Alendronate Sodium 70 mg/75 ml   3 Preferred Brand 23%25%Q:1350
/31Days
Alendronate Sodium 70mg/1 4 BLISTER PACK in 1 BOX / 1 TABLET in 1 BLISTER PACK   2 Generic $9.00$27.00Q:4
/28Days
ALFUZOSIN HYDROCHLORIDE 10mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE   3 Preferred Brand 23%25%None
ALIMTA 500MG VIAL   5 Specialty Tier 25%N/ANone
ALINIA 100MG/5ML SUSPENSION   3 Preferred Brand 23%25%None
ALINIA 500 MG TABLET   3 Preferred Brand 23%25%None
ALLOPURINOL 100 MG TABLETS   1 Preferred Generic $0.00$3.00None
Allopurinol 300mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET per BLISTER PACK   1 Preferred Generic $0.00$3.00None
ALOSETRON HCL 0.5 MG TABLET [Lotronex]   5 Specialty Tier 25%N/ANone
ALOSETRON HCL 1 MG TABLET [Lotronex]   5 Specialty Tier 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALOXI 0.25 MG/5 ML   5 Specialty Tier 25%N/ANone
ALPHAGAN P 0.1% DROPS   3 Preferred Brand 23%25%None
ALPRAZOLAM 0.25 MG TABLET   2 Generic $9.00$27.00None
ALPRAZOLAM 0.5 MG TABLET   2 Generic $9.00$27.00None
ALPRAZOLAM 1 MG TABLET   2 Generic $9.00$27.00None
Alprazolam 1mg/mL 1 BOTTLE in 1 CONTAINER / 30 mL in 1 BOTTLE   2 Generic $9.00$27.00P
ALPRAZOLAM 2 MG TABLET   2 Generic $9.00$27.00None
ALTABAX 10mg/g 30 g in 1 TUBE   3 Preferred Brand 23%25%None
AMANTADINE 100MG CAPSULE   3 Preferred Brand 23%25%None
AMANTADINE 100MG TABLET   3 Preferred Brand 23%25%None
Amantadine Hydrochloride 50mg/5mL 473 mL in 1 BOTTLE   2 Generic $9.00$27.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMBISOME 50MG VIAL   5 Specialty Tier 25%N/AP
AMCINONIDE 0.1% CREAM   4 Non-Preferred Brand 48%50%None
AMCINONIDE 0.1% LOTION   2 Generic $9.00$27.00None
AMCINONIDE 0.1% OINTMENT 60GM TUBE   4 Non-Preferred Brand 48%50%None
Amethia 2 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK   4 Non-Preferred Brand 48%50%None
Amethyst 20; 90ug/1; ug/1 1 BLISTER PACK per CARTON / 28 TABLET per BLISTER PACK   3 Preferred Brand 23%25%None
AMIFOSTINE 50mg/mL 3 VIAL, SINGLE-USE per CARTON / 10 mL in 1 VIAL, SINGLE-USE   5 Specialty Tier 25%N/ANone
AMIKACIN SULFATE 500 MG/2 ML VIAL   3 Preferred Brand 23%25%None
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET   1 Preferred Generic $0.00$3.00None
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT   2 Generic $9.00$27.00None
Amino Acids 15% Solution   3 Preferred Brand 23%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN 7%-ELECTROLYTE SOL   3 Preferred Brand 23%25%P
AMINOSYN HBC INJECTION SULFITE FREE 7%   3 Preferred Brand 23%25%P
AMINOSYN II 10% IV SOLUTION   3 Preferred Brand 23%25%P
AMINOSYN II 15% IV SOLUTION   3 Preferred Brand 23%25%P
AMINOSYN II 7% IV SOLUTION   3 Preferred Brand 23%25%P
AMINOSYN II 8.5% ELECTROLYT   3 Preferred Brand 23%25%P
AMINOSYN II 8.5% IV SOLUTION   3 Preferred Brand 23%25%P
AMINOSYN M 3.5% IV SOLUTION   3 Preferred Brand 23%25%P
AMINOSYN PF INJECTION   3 Preferred Brand 23%25%P
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5%   3 Preferred Brand 23%25%P
AMINOSYN-PF 7% IV SOLUTION   3 Preferred Brand 23%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN-RF 5.2% IV SOLUTION   3 Preferred Brand 23%25%P
AMIODARONE HCL 200MG 60 TABLET BOTTLE   2 Generic $9.00$27.00None
AMIODARONE HCL 400MG TABLET   3 Preferred Brand 23%25%None
AMIODARONE HCL 50 MG INJECTION   2 Generic $9.00$27.00P
AMITIZA 8MCG CAPSULE   3 Preferred Brand 23%25%None
AMITIZA CAPSULES 24MCG 60 CAP BOT   3 Preferred Brand 23%25%None
AMITRIPTYLINE HCL 100MG TABLET   1 Preferred Generic $0.00$3.00P
AMITRIPTYLINE HCL 10MG TABLET   1 Preferred Generic $0.00$3.00P
AMITRIPTYLINE HCL 150 MG TAB   1 Preferred Generic $0.00$3.00P
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)   1 Preferred Generic $0.00$3.00P
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)   1 Preferred Generic $0.00$3.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT   1 Preferred Generic $0.00$3.00P
AMLOD-VALSA-HCTZ 10-160-12.5 MG [EXFORGE HCT]   3 Preferred Brand 23%25%None
AMLOD-VALSA-HCTZ 10-160-25 MG [EXFORGE HCT]   3 Preferred Brand 23%25%None
AMLOD-VALSA-HCTZ 10-320-25 MG [EXFORGE HCT]   3 Preferred Brand 23%25%None
AMLOD-VALSA-HCTZ 5-160-12.5 MG [EXFORGE HCT]   3 Preferred Brand 23%25%None
AMLOD-VALSA-HCTZ 5-160-25 MG [EXFORGE HCT]   3 Preferred Brand 23%25%None
AMLODIPINE BESYLATE 10MG TABLET (90 CT)   1 Preferred Generic $0.00$3.00None
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)   1 Preferred Generic $0.00$3.00None
AMLODIPINE BESYLATE 5MG TABLET (90 CT)   1 Preferred Generic $0.00$3.00None
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE   3 Preferred Brand 23%25%None
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE   3 Preferred Brand 23%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE   3 Preferred Brand 23%25%None
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE   3 Preferred Brand 23%25%None
Amlodipine-Atorvastatin 10-10 mg [Caduet]   2 Generic $9.00$27.00Q:31
/31Days
Amlodipine-Atorvastatin 10-20 mg [Caduet]   2 Generic $9.00$27.00Q:31
/31Days
Amlodipine-Atorvastatin 10-40 mg [Caduet]   2 Generic $9.00$27.00Q:31
/31Days
Amlodipine-Atorvastatin 10-80 mg [Caduet]   2 Generic $9.00$27.00Q:31
/31Days
Amlodipine-Atorvastatin 2.5-10 mg [Caduet]   2 Generic $9.00$27.00Q:31
/31Days
Amlodipine-Atorvastatin 2.5-20 mg [Caduet]   2 Generic $9.00$27.00Q:31
/31Days
Amlodipine-Atorvastatin 2.5-40 mg [Caduet]   2 Generic $9.00$27.00Q:31
/31Days
Amlodipine-Atorvastatin 5-10 mg [Caduet]   2 Generic $9.00$27.00Q:31
/31Days
Amlodipine-Atorvastatin 5-20 mg [Caduet]   2 Generic $9.00$27.00Q:31
/31Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Amlodipine-Atorvastatin 5-40 mg [Caduet]   2 Generic $9.00$27.00Q:31
/31Days
Amlodipine-Atorvastatin 5-80 mg [Caduet]   2 Generic $9.00$27.00Q:31
/31Days
AMLODIPINE-BENAZEPRIL 10-40 MG   3 Preferred Brand 23%25%None
AMLODIPINE-BENAZEPRIL 5-40 MG   3 Preferred Brand 23%25%None
AMLODIPINE-VALSARTAN 10-160 MG   3 Preferred Brand 23%25%None
AMLODIPINE-VALSARTAN 10-320 MG   3 Preferred Brand 23%25%None
AMLODIPINE-VALSARTAN 5-160 MG   3 Preferred Brand 23%25%None
AMLODIPINE-VALSARTAN 5-320 MG   3 Preferred Brand 23%25%None
AMMONIUM LACTATE 12% CREAM   2 Generic $9.00$27.00None
AMMONIUM LACTATE 12% LOTION   2 Generic $9.00$27.00None
AMOX TR-K CLV 500-125 MG TAB   2 Generic $9.00$27.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE   2 Generic $9.00$27.00None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET   3 Preferred Brand 23%25%None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE   2 Generic $9.00$27.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   3 Preferred Brand 23%25%None
AMOX-CLAV 200-28.5 MG/5 ML SUSPENSION   2 Generic $9.00$27.00None
AMOXAPINE 100MG TABLET   2 Generic $9.00$27.00None
AMOXAPINE 150MG TABLET   2 Generic $9.00$27.00None
AMOXAPINE 25MG TABLET   2 Generic $9.00$27.00None
AMOXAPINE 50MG TABLET   2 Generic $9.00$27.00None
AMOXICILLIN 125MG TABLET CHEW   1 Preferred Generic $0.00$3.00None
AMOXICILLIN 250MG 500 CHEWABLE TABLET in BOTTLE   1 Preferred Generic $0.00$3.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN 250MG CAPSULE   1 Preferred Generic $0.00$3.00None
AMOXICILLIN 50 MG/ML / CLAVULANATE 12.5 MG/ML ORAL SUSPENSION   3 Preferred Brand 23%25%None
AMOXICILLIN 500MG 500 CAPSULE BOTTLE   1 Preferred Generic $0.00$3.00None
AMOXICILLIN 500MG TABLET (100 CT)   1 Preferred Generic $0.00$3.00None
AMOXICILLIN 875MG TABLET   1 Preferred Generic $0.00$3.00None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT   2 Generic $9.00$27.00None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS EXTENDED RELEASE 1000;62.5MG;MG   3 Preferred Brand 23%25%None
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT   2 Generic $9.00$27.00None
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT   1 Preferred Generic $0.00$3.00None
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL   2 Generic $9.00$27.00None
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   1 Preferred Generic $0.00$3.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL   2 Generic $9.00$27.00None
amphotericin b 50mg/10mL 10 mL in 1 VIAL   4 Non-Preferred Brand 48%50%P
Ampicillin 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS   2 Generic $9.00$27.00None
AMPICILLIN CAPSULES 250MG 100 BOT   1 Preferred Generic $0.00$3.00None
AMPICILLIN CAPSULES 500MG 100 BOT   1 Preferred Generic $0.00$3.00None
AMPICILLIN FOR INJECTION POWDER   3 Preferred Brand 23%25%None
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT   1 Preferred Generic $0.00$3.00None
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT   2 Generic $9.00$27.00None
AMPICILLIN POWDER FOR INJECTION 1 GM/ML   3 Preferred Brand 23%25%None
AMPICILLIN-SULBACTAM 15 GM VIAL   2 Generic $9.00$27.00None
AMPICILLIN-SULBACTAM 3 GM VIAL   4 Non-Preferred Brand 48%50%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPICILLIN-SULBACTAM FOR INJECTION   4 Non-Preferred Brand 48%50%None
AMPYRA ER 10 MG TABLET   5 Specialty Tier 25%N/AP
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE   2 Generic $9.00$27.00None
Anagrelide Hydrochloride 1mg/1 100 CAPSULE BOTTLE   3 Preferred Brand 23%25%None
Anastrozole 1mg/1 90 FILM COATED TABLETS in BOTTLE, PLASTIC   2 Generic $9.00$27.00None
ANDROGEL 1.62% (1.25G) GEL PCKT   3 Preferred Brand 23%25%P
ANDROGEL 1.62% (2.5G) GEL PCKT   3 Preferred Brand 23%25%P
ANDROGEL 1% (50MG) GEL PACKET   3 Preferred Brand 23%25%P
Androgel 10mg/g 30 PACKET in 1 CARTON / 2.5 g in 1 PACKET   3 Preferred Brand 23%25%P
Androgel 16.2mg/g 1 BOTTLE, PUMP per CARTON / 88 g in 1 BOTTLE, PUMP   3 Preferred Brand 23%25%P
ANDROID 10 MG CAPSULE   4 Non-Preferred Brand 48%50%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANORO ELLIPTA 62.5-25 MCG INH   4 Non-Preferred Brand 48%50%Q:60
/31Days
Apexicon E 0.05% Cream   2 Generic $9.00$27.00None
APOKYN 30 MG/3 ML CARTRIDGE   5 Specialty Tier 25%N/ANone
Apraclonidine Ophthalmic 5mg/mL 1 BOTTLE, DROPPER per CARTON / 10 mL in 1 BOTTLE, DROPPER   3 Preferred Brand 23%25%None
APRI 0.15-0.03 TABLET   2 Generic $9.00$27.00None
APRISO CP24   3 Preferred Brand 23%25%None
APTIOM 200 MG TABLET   4 Non-Preferred Brand 48%50%None
APTIOM 400 MG TABLET   4 Non-Preferred Brand 48%50%None
APTIOM 600 MG TABLET   5 Specialty Tier 25%N/ANone
APTIOM 800 MG TABLET   4 Non-Preferred Brand 48%50%None
APTIVUS 250MG CAPSULE   5 Specialty Tier 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT   5 Specialty Tier 25%N/ANone
ARALAST NP 500 MG VIAL   5 Specialty Tier 25%N/ANone
ARANELLE 7-9-5 TABLET   2 Generic $9.00$27.00None
ARCALYST INJECTION 220MG/VIAL   5 Specialty Tier 25%N/AP
Arcapta Neohaler 75ug/1 30 BLISTER PACK in 1 BOX / 1 CAPSULE per BLISTER PACK   4 Non-Preferred Brand 48%50%Q:60
/31Days
ARIPIPRAZOLE 10 MG TABLET [Abilify]   3 Preferred Brand 23%25%Q:93
/31Days
ARIPIPRAZOLE 15 MG TABLET [Abilify]   3 Preferred Brand 23%25%Q:62
/31Days
ARIPIPRAZOLE 2 MG TABLET [Abilify]   3 Preferred Brand 23%25%Q:465
/31Days
ARIPIPRAZOLE 20 MG TABLET [Abilify]   5 Specialty Tier 25%N/AQ:62
/31Days
ARIPIPRAZOLE 30 MG TABLET [Abilify]   5 Specialty Tier 25%N/AQ:31
/31Days
ARIPIPRAZOLE 5 MG TABLET [Abilify]   3 Preferred Brand 23%25%Q:186
/31Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARIPIPRAZOLE ODT 10 MG TABLET [Abilify]   3 Preferred Brand 23%25%Q:93
/31Days
ARIPIPRAZOLE ODT 15 MG TABLET [Abilify]   3 Preferred Brand 23%25%Q:62
/31Days
ARNUITY ELLIPTA 100 MCG INH   3 Preferred Brand 23%25%Q:30
/30Days
ARNUITY ELLIPTA 200 MCG INH   3 Preferred Brand 23%25%Q:30
/30Days
ARRANON 250MG VIAL   3 Preferred Brand 23%25%None
ASACOL HD 800mg/1 12 BOTTLE CASE / 180 TABLET, DELAYED RELEASE in 1 BOTTLE   3 Preferred Brand 23%25%None
Ashlyna 0.15-0.03-0.01 mg tablet   2 Generic $9.00$27.00None
ASMANEX TWISTHALER 110 MCG #30   3 Preferred Brand 23%25%Q:30
/31Days
ASMANEX TWISTHALER 220 MCG #30   3 Preferred Brand 23%25%Q:30
/31Days
ASMANEX TWISTHALER 220MCG #120   3 Preferred Brand 23%25%Q:240
/31Days
ASMANEX TWISTHALER 220MCG #60   3 Preferred Brand 23%25%Q:60
/31Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ASPIRIN-DIPYRIDAM ER 25-200 MG [Aggrenox]   3 Preferred Brand 23%25%None
ATENOLOL 100 MG100 TABLET BOTTLE   1 Preferred Generic $0.00$3.00None
ATENOLOL 25 MG 100 TABLET BOTTLE   1 Preferred Generic $0.00$3.00None
ATENOLOL TABLET USP 50MG (100 CT)   1 Preferred Generic $0.00$3.00None
ATENOLOL-CHLORTHALIDONE 100-25   1 Preferred Generic $0.00$3.00None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   1 Preferred Generic $0.00$3.00None
ATORVASTATIN 10 MG TABLET [Lipitor]   2 Generic $9.00$27.00Q:31
/31Days
ATORVASTATIN 20 MG TABLET [Lipitor]   2 Generic $9.00$27.00Q:31
/31Days
ATORVASTATIN 40 MG TABLET [Lipitor]   2 Generic $9.00$27.00Q:31
/31Days
ATORVASTATIN 80 MG TABLET [Lipitor]   2 Generic $9.00$27.00Q:31
/31Days
ATOVAQUONE 750 MG/5 ML SUSP [Mepron]   5 Specialty Tier 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone]   3 Preferred Brand 23%25%None
Atovaquone-Proguanil 62.5-25 [Malarone]   2 Generic $9.00$27.00None
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC   5 Specialty Tier 25%N/ANone
ATROPINE 0.05MG/ML SYRINGE   2 Generic $9.00$27.00None
ATROPINE 0.1MG/ML SYRINGE   2 Generic $9.00$27.00None
Atropine 1% Eye Drops   3 Preferred Brand 23%25%None
ATROVENT HFA AER 17MCG   3 Preferred Brand 23%25%Q:39
/31Days
AUBRA-28 TABLET   2 Generic $9.00$27.00None
AUGMENTIN 125; 31.25mg/5mL; mg/5mL 100 mL in 1 BOTTLE   5 Specialty Tier 25%N/ANone
AVASTIN 100MG/4ML VIAL   3 Preferred Brand 23%25%None
AVASTIN 400 MG/16 ML VIAL   3 Preferred Brand 23%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVIANE 0.1-0.02 TABLET   2 Generic $9.00$27.00None
AVITA 0.025% CREAM   2 Generic $9.00$27.00P
AVODART 0.5MG SOFTGEL   3 Preferred Brand 23%25%None
Azacitidine 100 mg vial [Vidaza]   5 Specialty Tier 25%N/ANone
AZACTAM INJECTION 1GM/50ML   3 Preferred Brand 23%25%None
AZACTAM INJECTION 2GM/50ML   5 Specialty Tier 25%N/ANone
AZASITE 1% EYE DROPS   3 Preferred Brand 23%25%None
AZATHIOPRINE 50 MG TABLET   2 Generic $9.00$27.00P
AZATHIOPRINE SODIUM 100 MG VIAL   3 Preferred Brand 23%25%P
AZELASTINE 0.15% NASAL SPRAY   2 Generic $9.00$27.00Q:60
/31Days
AZELASTINE 137 MCG NASAL SPRAY   3 Preferred Brand 23%25%Q:60
/31Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZELASTINE HYDROCHLORIDE OPHTHALMIC SOLUTION   3 Preferred Brand 23%25%None
AZELEX 20% CREAM 30GM TUBE   3 Preferred Brand 23%25%None
AZILECT 0.5MG TABLET   3 Preferred Brand 23%25%None
AZILECT 1MG TABLET   3 Preferred Brand 23%25%None
AZITHROMYCIN 1 GM PWD PACKET   2 Generic $9.00$27.00None
AZITHROMYCIN 100 MG/5 ML SUSP   3 Preferred Brand 23%25%None
Azithromycin 200mg/5mL 22.5 mL in 1 BOTTLE   3 Preferred Brand 23%25%None
AZITHROMYCIN 250 MG TABLET   1 Preferred Generic $0.00$3.00None
AZITHROMYCIN 250 MG TABLET   1 Preferred Generic $0.00$3.00None
Azithromycin 500mg/1 10 VIAL, SINGLE-USE in 1 TRAY / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION   3 Preferred Brand 23%25%None
Azithromycin 500mg/1 30 FILM COATED TABLETS in BOTTLE   2 Generic $9.00$27.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Azithromycin 600mg/1 30 FILM COATED TABLETS in BOTTLE   2 Generic $9.00$27.00None
Azithromycin i.v. 500 mg vial   2 Generic $9.00$27.00None
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT   4 Non-Preferred Brand 48%50%None
AZTREONAM FOR INJECTION   4 Non-Preferred Brand 48%50%None

Chart Legend:

Below are a few notes to help you understand the above 2016 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).

  • 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 the standard $360 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 wit 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 four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
    • Drug Description - This is the Medicare Part D plan’s description of this particular drug tier.
  • 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 which tier the drug is in. 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 $3310) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2016 Humana Walmart-Preferred Rx Plan the cost-sharing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
    • 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 2016 )

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.







Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • 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.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • 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.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • 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.