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SilverScript Allure (PDP) (S5601-154-0)
Tier 1 (119)
Tier 2 (430)
Tier 3 (1064)
Tier 4 (919)
Tier 5 (549)
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2019 Medicare Part D Plan Formulary Information
SilverScript Allure (PDP) (S5601-154-0)
Benefit Details           
The SilverScript Allure (PDP) (S5601-154-0)
Formulary Drugs Starting with the Letter A

in CMS PDP Region 12 which includes: AL TN
Plan Monthly Premium: $80.00 Deductible: $0 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
ABACAVIR 20 MG/ML SOLUTION   4 Non-Preferred Drug 40%40%None
ABACAVIR 300 MG TABLET   3 Preferred Brand 20%20%None
Abacavir Sulfate-Lamivudine-Zidovudine tablets [Trizivir]   5 Specialty Tier 33%N/ANone
ABACAVIR-LAMIVUDINE 600-300 MG   3 Preferred Brand 20%20%None
ABELCET INJECTION SUSPENSION 5MG/ML   5 Specialty Tier 33%N/AP
ABILIFY MAINTENA ER 300 MG SYR   4 Non-Preferred Drug 40%40%Q:1
/28Days
ABILIFY MAINTENA ER 300 MG VL   4 Non-Preferred Drug 40%40%Q:1
/28Days
ABILIFY MAINTENA ER 400 MG SUSER VIAL   4 Non-Preferred Drug 40%40%Q:1
/28Days
ABILIFY MAINTENA ER 400 MG SYR   4 Non-Preferred Drug 40%40%Q:1
/28Days
ABIRATERONE ACETATE 250 MG TABLET [ZYTIGA]   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Acamprosate Calcium DR 333 MG tablets [Campral]   4 Non-Preferred Drug 40%40%None
ACARBOSE 100 MG TABLET   3 Preferred Brand 20%20%None
ACARBOSE 25 MG TABLET   3 Preferred Brand 20%20%None
ACARBOSE 50 MG TABLET   3 Preferred Brand 20%20%None
ACEBUTOLOL 200 MG CAPSULE   2 Generic $5.00$12.50None
ACEBUTOLOL 400 MG CAPSULE   2 Generic $5.00$12.50None
ACETAMINOP-CODEINE 120-12 MG/5   3 Preferred Brand 20%20%Q:2700
/30Days
Acetaminophen 325 MG / Hydrocodone Bitartrate 5 MG Oral Tablet [Lorcet]   3 Preferred Brand 20%20%Q:240
/30Days
ACETAMINOPHEN-COD #2 TABLET   3 Preferred Brand 20%20%Q:400
/30Days
ACETAMINOPHEN-COD #3 TABLET   3 Preferred Brand 20%20%Q:360
/30Days
ACETAMINOPHEN-COD #4 TABLET   3 Preferred Brand 20%20%Q:180
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETAZOLAMIDE 125MG TABLET   3 Preferred Brand 20%20%None
ACETAZOLAMIDE 250MG TABLET (100 CT)   3 Preferred Brand 20%20%None
ACETAZOLAMIDE ER 500 MG CAP   4 Non-Preferred Drug 40%40%None
ACETIC ACID 2% EAR SOLUTION   3 Preferred Brand 20%20%None
ACETYLCYSTEINE 10% VIAL   3 Preferred Brand 20%20%P
Acetylcysteine 200 MG/ML Inhalant Solution   3 Preferred Brand 20%20%P
ACITRETIN 10 MG CAPSULE [Soriatane]   4 Non-Preferred Drug 40%40%P
ACITRETIN 17.5 MG CAPSULE [Soriatane]   4 Non-Preferred Drug 40%40%P
ACITRETIN 25 MG CAPSULE [Soriatane]   4 Non-Preferred Drug 40%40%P
ACTHIB VACCINE WITH DILUENT   3 Preferred Brand 20%20%None
ACTIMMUNE 100 MCG/0.5 ML VIAL   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACYCLOVIR 200 MG CAPSULE   2 Generic $5.00$12.50None
ACYCLOVIR 200 MG/5 ML SUSP   4 Non-Preferred Drug 40%40%None
ACYCLOVIR 400 MG TABLET   2 Generic $5.00$12.50None
ACYCLOVIR 800 MG TABLET   2 Generic $5.00$12.50None
Acyclovir sodium 500 mg vial   4 Non-Preferred Drug 40%40%P
ADACEL TDAP SYRINGE   3 Preferred Brand 20%20%None
ADACEL VIAL 2UNT/5UNT   3 Preferred Brand 20%20%None
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA]   5 Specialty Tier 33%N/AP Q:2
/28Days
ADEFOVIR DIPIVOXIL 10 MG TAB [Hepsera]   5 Specialty Tier 33%N/ANone
ADEMPAS 0.5 MG TABLET   5 Specialty Tier 33%N/AP Q:90
/30Days
ADEMPAS 1 MG TABLET   5 Specialty Tier 33%N/AP Q:90
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADEMPAS 1.5 MG TABLET   5 Specialty Tier 33%N/AP Q:90
/30Days
ADEMPAS 2 MG TABLET   5 Specialty Tier 33%N/AP Q:90
/30Days
ADEMPAS 2.5 MG TABLET   5 Specialty Tier 33%N/AP Q:90
/30Days
ADVAIR DISKUS MIS 100/50   3 Preferred Brand 20%20%Q:60
/30Days
ADVAIR DISKUS MIS 250/50   3 Preferred Brand 20%20%Q:60
/30Days
ADVAIR DISKUS MIS 500/50   3 Preferred Brand 20%20%Q:60
/30Days
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER   3 Preferred Brand 20%20%Q:12
/30Days
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL   3 Preferred Brand 20%20%Q:12
/30Days
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL   3 Preferred Brand 20%20%Q:12
/30Days
Afinitor 7.5mg/1 28 BLISTER PACK per CARTON / 1 TABLET per BLISTER PACK   5 Specialty Tier 33%N/AP Q:30
/30Days
AFINITOR DISPERZ 2 MG TABLET   5 Specialty Tier 33%N/AP Q:150
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AFINITOR DISPERZ 3 MG TABLET   5 Specialty Tier 33%N/AP Q:90
/30Days
AFINITOR DISPERZ 5 MG TABLET   5 Specialty Tier 33%N/AP Q:60
/30Days
AFINITOR TABLETS 10 MG   5 Specialty Tier 33%N/AP Q:30
/30Days
AFINITOR TABLETS 2.5 MG   5 Specialty Tier 33%N/AP Q:30
/30Days
AFINITOR TABLETS 5 MG   5 Specialty Tier 33%N/AP Q:30
/30Days
AIMOVIG 140 MG/ML AUTOINJECTOR   3 Preferred Brand 20%20%P Q:1
/30Days
AIMOVIG 70 MG/ML AUTOINJECTOR   3 Preferred Brand 20%20%P Q:1
/30Days
Ala-cort 2.5% cream   2 Generic $5.00$12.50None
ALBENDAZOLE 200 MG TABLET [Albenza]   5 Specialty Tier 33%N/ANone
ALBUTEROL SUL 2.5 MG/3 ML SOLN   2 Generic $5.00$12.50P
ALBUTEROL SULFATE 0.75mg/3mL 30 POUCH per CARTON / 1 VIAL, SINGLE-DOSE in 1 POUCH / 3 mL in 1 VIAL   2 Generic $5.00$12.50P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER   2 Generic $5.00$12.50P
ALBUTEROL SULFATE 2 MG TAB   4 Non-Preferred Drug 40%40%None
ALBUTEROL SULFATE 4 MG TAB   4 Non-Preferred Drug 40%40%None
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   2 Generic $5.00$12.50P
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT   3 Preferred Brand 20%20%None
ALCLOMETASONE DIPR 0.05% OINT   3 Preferred Brand 20%20%None
ALCLOMETASONE DIPRO 0.05% CRM   3 Preferred Brand 20%20%None
ALECENSA 150 MG CAPSULE   5 Specialty Tier 33%N/AP
ALENDRONATE SODIUM 10 MG TAB   1 Preferred Generic $1.00$0.00None
ALENDRONATE SODIUM 35 MG TABLET [Fosamax]   1 Preferred Generic $1.00$0.00None
ALENDRONATE SODIUM 40 MG TABLET   1 Preferred Generic $1.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALENDRONATE SODIUM 5 MG TABLET   1 Preferred Generic $1.00$0.00None
ALENDRONATE SODIUM 70 MG TABLET [Fosamax]   1 Preferred Generic $1.00$0.00None
ALFUZOSIN HCL ER 10 MG TABLET   2 Generic $5.00$12.50None
ALINIA 100 MG/5 ML SUSPENSION   5 Specialty Tier 33%N/ANone
ALINIA 500 MG TABLET   5 Specialty Tier 33%N/ANone
Aliskiren 150 MG / Hydrochlorothiazide 12.5 MG Oral Tablet [Tekturna HCT]   4 Non-Preferred Drug 40%40%None
Aliskiren 150 MG / Hydrochlorothiazide 25 MG Oral Tablet [Tekturna HCT]   4 Non-Preferred Drug 40%40%None
ALISKIREN 150 MG TABLET [Tekturna]   4 Non-Preferred Drug 40%40%None
Aliskiren 300 MG / Hydrochlorothiazide 12.5 MG Oral Tablet [Tekturna HCT]   4 Non-Preferred Drug 40%40%None
ALISKIREN 300 MG TABLET [Tekturna]   4 Non-Preferred Drug 40%40%None
ALLOPURINOL 100 MG TABLET   2 Generic $5.00$12.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALLOPURINOL 300 MG TABLET   2 Generic $5.00$12.50None
ALOSETRON HCL 0.5 MG TABLET [Lotronex]   5 Specialty Tier 33%N/AP
ALOSETRON HCL 1 MG TABLET [Lotronex]   5 Specialty Tier 33%N/AP
ALPHAGAN P 0.1% DROPS   3 Preferred Brand 20%20%None
ALPHAGAN P 0.15% EYE DROPS   3 Preferred Brand 20%20%None
ALPRAZOLAM 0.25 MG TABLET   3 Preferred Brand 20%20%Q:150
/30Days
ALPRAZOLAM 0.5 MG TABLET   3 Preferred Brand 20%20%Q:150
/30Days
ALPRAZOLAM 1 MG TABLET   3 Preferred Brand 20%20%Q:150
/30Days
ALPRAZOLAM 2 MG TABLET   3 Preferred Brand 20%20%Q:150
/30Days
ALREX 0.2% EYE DROPS   3 Preferred Brand 20%20%None
ALTAVERA-28 TABLET [Portia]   3 Preferred Brand 20%20%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALUNBRIG 180 MG TABLET   5 Specialty Tier 33%N/AP
ALUNBRIG 30 MG TABLET   5 Specialty Tier 33%N/AP
ALUNBRIG 90 MG TABLET   5 Specialty Tier 33%N/AP
ALUNBRIG 90 MG-180 MG TABLET PACK   5 Specialty Tier 33%N/AP
ALYACEN 1-35-28 TABLET   3 Preferred Brand 20%20%None
ALYQ 20 MG TABLET   5 Specialty Tier 33%N/AP Q:60
/30Days
AMANTADINE 100 MG CAPSULE   3 Preferred Brand 20%20%Q:120
/30Days
AMANTADINE 100 MG TABLET   3 Preferred Brand 20%20%None
AMANTADINE 50 MG/5 ML SOLUTION   2 Generic $5.00$12.50None
AMBISOME 50MG VIAL   5 Specialty Tier 33%N/AP
AMBRISENTAN 10 MG TABLET [LETAIRIS]   5 Specialty Tier 33%N/AP Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMBRISENTAN 5 MG TABLET [LETAIRIS]   5 Specialty Tier 33%N/AP Q:30
/30Days
AMIKACIN SULF 500 MG/2 ML VIAL   4 Non-Preferred Drug 40%40%None
AMILORIDE HCL 5 MG TABLET [Midamor]   3 Preferred Brand 20%20%None
AMILORIDE HCL-HCTZ 5-50 MG TABLET   2 Generic $5.00$12.50None
Amino acids 4.25% in dextrose 10% Injectable Solution [Clinimix 4.25/10]   4 Non-Preferred Drug 40%40%P
Amino acids 4.25% in dextrose 5% Injectable Solution [Clinimix 4.25/5]   4 Non-Preferred Drug 40%40%P
AMINOSYN II 10% SOL 6X2000 ML   4 Non-Preferred Drug 40%40%P
AMINOSYN PF INJECTION   4 Non-Preferred Drug 40%40%P
AMINOSYN-PF 7% IV SOLUTION   4 Non-Preferred Drug 40%40%P
AMIODARONE HCL 100 MG TABLET   4 Non-Preferred Drug 40%40%None
AMIODARONE HCL 200 MG TABLET   2 Generic $5.00$12.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMIODARONE HCL 400 MG TABLET   4 Non-Preferred Drug 40%40%None
AMITIZA 8MCG CAPSULE   3 Preferred Brand 20%20%Q:180
/30Days
AMITIZA CAPSULES 24MCG 60 CAP BOT   3 Preferred Brand 20%20%Q:60
/30Days
AMITRIPTYLINE HCL 10 MG TAB   3 Preferred Brand 20%20%None
AMITRIPTYLINE HCL 100 MG TAB   3 Preferred Brand 20%20%None
AMITRIPTYLINE HCL 150 MG TAB   3 Preferred Brand 20%20%None
AMITRIPTYLINE HCL 25 MG TAB   3 Preferred Brand 20%20%None
AMITRIPTYLINE HCL 50 MG TAB   3 Preferred Brand 20%20%None
AMITRIPTYLINE HCL 75 MG TAB   3 Preferred Brand 20%20%None
AMLODIPINE BESYLATE 10 MG TABLET [Norvasc]   1 Preferred Generic $1.00$0.00None
AMLODIPINE BESYLATE 2.5 MG TAB   1 Preferred Generic $1.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE BESYLATE 5 MG TABLET [Norvasc]   1 Preferred Generic $1.00$0.00None
AMLODIPINE-BENAZEPRIL 10-20 MG Capsule [Lotrel]   2 Generic $5.00$12.50None
AMLODIPINE-BENAZEPRIL 10-40 MG Capsule [Lotrel]   2 Generic $5.00$12.50None
AMLODIPINE-BENAZEPRIL 2.5-10 Capsule [Lotrel]   2 Generic $5.00$12.50None
AMLODIPINE-BENAZEPRIL 5-10 MG Capsule [Lotrel]   2 Generic $5.00$12.50None
AMLODIPINE-BENAZEPRIL 5-20 MG Capsule [Lotrel]   2 Generic $5.00$12.50None
AMLODIPINE-BENAZEPRIL 5-40 MG Capsule [Lotrel]   2 Generic $5.00$12.50None
AMLODIPINE-OLMESARTAN 10-20 MG [Azor]   3 Preferred Brand 20%20%None
AMLODIPINE-OLMESARTAN 10-40 MG [Azor]   3 Preferred Brand 20%20%None
AMLODIPINE-OLMESARTAN 5-20 MG [Azor]   3 Preferred Brand 20%20%None
AMLODIPINE-OLMESARTAN 5-40 MG [Azor]   3 Preferred Brand 20%20%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE-VALSARTAN 10-160 MG   3 Preferred Brand 20%20%None
AMLODIPINE-VALSARTAN 10-320 MG   3 Preferred Brand 20%20%None
AMLODIPINE-VALSARTAN 5-160 MG   3 Preferred Brand 20%20%None
AMLODIPINE-VALSARTAN 5-320 MG   3 Preferred Brand 20%20%None
AMMONIUM LACTATE 12% CREAM   3 Preferred Brand 20%20%None
AMMONIUM LACTATE 12% LOTION   3 Preferred Brand 20%20%None
AMNESTEEM 10 MG CAPSULE   4 Non-Preferred Drug 40%40%P
AMNESTEEM 20 MG CAPSULE   4 Non-Preferred Drug 40%40%P
AMNESTEEM 40 MG CAPSULE   4 Non-Preferred Drug 40%40%P
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE [Augmentin]   4 Non-Preferred Drug 40%40%None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET [Augmentin]   2 Generic $5.00$12.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE [Augmentin]   4 Non-Preferred Drug 40%40%None
AMOX-CLAV 200-28.5 MG/5 ML SUS   3 Preferred Brand 20%20%None
AMOX-CLAV 250-62.5 MG/5 ML SUS   3 Preferred Brand 20%20%None
AMOX-CLAV 400-57 MG/5 ML SUSP   3 Preferred Brand 20%20%None
AMOX-CLAV 500-125 MG TABLET [Augmentin]   2 Generic $5.00$12.50None
AMOX-CLAV 600-42.9 MG/5 ML SUS   3 Preferred Brand 20%20%None
AMOX-CLAV 875-125 MG TABLET [Augmentin]   2 Generic $5.00$12.50None
AMOX-CLAV ER 1,000-62.5 MG TABLET [Augmentin]   4 Non-Preferred Drug 40%40%None
AMOXAPINE 100MG TABLET   3 Preferred Brand 20%20%None
AMOXAPINE 150MG TABLET   3 Preferred Brand 20%20%None
AMOXAPINE 25MG TABLET   3 Preferred Brand 20%20%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXAPINE 50MG TABLET   3 Preferred Brand 20%20%None
AMOXICILLIN 125 MG/5 ML SUSP   2 Generic $5.00$12.50None
AMOXICILLIN 125MG TABLET CHEW   2 Generic $5.00$12.50None
AMOXICILLIN 200 MG/5 ML SUSP   2 Generic $5.00$12.50None
AMOXICILLIN 250 MG CAPSULE   2 Generic $5.00$12.50None
AMOXICILLIN 250 MG TAB CHEW   2 Generic $5.00$12.50None
AMOXICILLIN 250 MG/5 ML SUSP   2 Generic $5.00$12.50None
AMOXICILLIN 400 MG/5 ML SUSP   2 Generic $5.00$12.50None
AMOXICILLIN 500 MG CAPSULE   2 Generic $5.00$12.50None
AMOXICILLIN 500 MG TABLET   2 Generic $5.00$12.50None
AMOXICILLIN 875 MG TABLET   2 Generic $5.00$12.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPHETAMINE SALT COMBO 12.5MG TABLET   3 Preferred Brand 20%20%Q:90
/30Days
AMPHETAMINE SALT COMBO 15MG TABLET   3 Preferred Brand 20%20%Q:120
/30Days
AMPHETAMINE SALT COMBO 7.5MG TABLET   3 Preferred Brand 20%20%Q:240
/30Days
AMPHETAMINE SALTS 5 MG TAB   3 Preferred Brand 20%20%Q:360
/30Days
amphotericin b 50mg/10mL 10 mL in 1 VIAL   4 Non-Preferred Drug 40%40%P
AMPICILLIN 10 GM VIAL   4 Non-Preferred Drug 40%40%None
Ampicillin 1000 MG / Sulbactam 500 MG Injection   4 Non-Preferred Drug 40%40%None
Ampicillin 1000 MG Injection   4 Non-Preferred Drug 40%40%None
Ampicillin 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS   4 Non-Preferred Drug 40%40%None
Ampicillin 2000 MG / Sulbactam 1000 MG Injection   4 Non-Preferred Drug 40%40%None
AMPICILLIN CAPSULES 500MG 100 BOT   2 Generic $5.00$12.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPICILLIN-SULBACTAM 15 GM VL   4 Non-Preferred Drug 40%40%None
ANADROL-50 TABLET   5 Specialty Tier 33%N/AP
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE   4 Non-Preferred Drug 40%40%None
Anagrelide Hydrochloride 1mg/1 100 CAPSULE BOTTLE   4 Non-Preferred Drug 40%40%None
ANASTROZOLE 1 MG TABLET   2 Generic $5.00$12.50None
ANDRODERM 2 MG/24HR PATCH   4 Non-Preferred Drug 40%40%P Q:30
/30Days
ANDRODERM 4 MG/24HR PATCH   4 Non-Preferred Drug 40%40%P Q:30
/30Days
ANORO ELLIPTA 62.5-25 MCG INH   3 Preferred Brand 20%20%Q:60
/30Days
APOKYN 30 MG/3 ML CARTRIDGE   5 Specialty Tier 33%N/AP Q:60
/30Days
APREPITANT 125 MG CAPSULE [Emend]   4 Non-Preferred Drug 40%40%P
APREPITANT 125-80-80 MG PACK [Emend]   4 Non-Preferred Drug 40%40%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
APREPITANT 40 MG CAPSULE [Emend]   4 Non-Preferred Drug 40%40%P
APREPITANT 80 MG CAPSULE [Emend]   4 Non-Preferred Drug 40%40%P
APRI 0.15-0.03 TABLET   3 Preferred Brand 20%20%None
APRISO CP24   3 Preferred Brand 20%20%Q:120
/30Days
APTIOM 200 MG TABLET   4 Non-Preferred Drug 40%40%Q:180
/30Days
APTIOM 400 MG TABLET   4 Non-Preferred Drug 40%40%Q:90
/30Days
APTIOM 600 MG TABLET   4 Non-Preferred Drug 40%40%Q:60
/30Days
APTIOM 800 MG TABLET   4 Non-Preferred Drug 40%40%Q:60
/30Days
APTIVUS 250MG CAPSULE   5 Specialty Tier 33%N/ANone
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT   5 Specialty Tier 33%N/ANone
ARALAST NP 1,000 MG VIAL   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANELLE 7-9-5 TABLET   3 Preferred Brand 20%20%None
ARCALYST INJECTION 220MG/VIAL   5 Specialty Tier 33%N/AP
ARIPIPRAZOLE 1 MG/ML SOLUTION [Abilify]   5 Specialty Tier 33%N/AQ:900
/30Days
ARIPIPRAZOLE 10 MG TABLET [Abilify]   4 Non-Preferred Drug 40%40%Q:30
/30Days
ARIPIPRAZOLE 15 MG TABLET [Abilify]   4 Non-Preferred Drug 40%40%Q:30
/30Days
ARIPIPRAZOLE 2 MG TABLET [Abilify]   4 Non-Preferred Drug 40%40%Q:30
/30Days
ARIPIPRAZOLE 20 MG TABLET [Abilify]   4 Non-Preferred Drug 40%40%Q:30
/30Days
ARIPIPRAZOLE 30 MG TABLET [Abilify]   4 Non-Preferred Drug 40%40%Q:30
/30Days
ARIPIPRAZOLE 5 MG TABLET [Abilify]   4 Non-Preferred Drug 40%40%Q:30
/30Days
ARIPIPRAZOLE ODT 10 MG TABLET RAPDIS [Abilify Discmelt]   5 Specialty Tier 33%N/AQ:60
/30Days
ARIPIPRAZOLE ODT 15 MG TABLET RAPDIS [Abilify Discmelt]   5 Specialty Tier 33%N/AQ:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARISTADA ER 1064 MG/3.9 ML SYR   4 Non-Preferred Drug 40%40%Q:4
/56Days
ARISTADA ER 441 MG/1.6 ML SYRN   4 Non-Preferred Drug 40%40%Q:2
/28Days
ARISTADA ER 662 MG/2.4 ML SYRN   4 Non-Preferred Drug 40%40%Q:2
/28Days
ARISTADA ER 882 MG/3.2 ML SYRN   4 Non-Preferred Drug 40%40%Q:3
/28Days
ARISTADA INITIO ER 675 MG/2.4 SUSER SYR   4 Non-Preferred Drug 40%40%None
Armodafinil 150 MG TABLET [NUVIGIL]   4 Non-Preferred Drug 40%40%P Q:30
/30Days
Armodafinil 200 MG Oral Tablet [NUVIGIL]   4 Non-Preferred Drug 40%40%P Q:30
/30Days
Armodafinil 250 MG TABLET [NUVIGIL]   4 Non-Preferred Drug 40%40%P Q:30
/30Days
Armodafinil 50 MG TABLET [NUVIGIL]   4 Non-Preferred Drug 40%40%P Q:90
/30Days
ARNUITY ELLIPTA 100 MCG INH   3 Preferred Brand 20%20%Q:30
/30Days
ARNUITY ELLIPTA 200 MCG INH   3 Preferred Brand 20%20%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARNUITY ELLIPTA 50 MCG INH BLST W/DEV   3 Preferred Brand 20%20%Q:30
/30Days
ASACOL HD DR 800 MG TABLET   4 Non-Preferred Drug 40%40%None
Aspirin-Diphenhydramine ER 25-200 MG   4 Non-Preferred Drug 40%40%None
ATAZANAVIR SULFATE 150 MG CAP [Reyataz]   5 Specialty Tier 33%N/ANone
ATAZANAVIR SULFATE 200 MG CAP [Reyataz]   5 Specialty Tier 33%N/ANone
ATAZANAVIR SULFATE 300 MG CAP [Reyataz]   5 Specialty Tier 33%N/ANone
ATENOLOL 100 MG TABLET   1 Preferred Generic $1.00$0.00None
ATENOLOL 25 MG TABLET   1 Preferred Generic $1.00$0.00None
ATENOLOL 50 MG TABLET   1 Preferred Generic $1.00$0.00None
ATENOLOL-CHLORTHALIDONE 100-25   2 Generic $5.00$12.50None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   2 Generic $5.00$12.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATOMOXETINE HCL 10 MG CAPSULE [Strattera]   4 Non-Preferred Drug 40%40%Q:120
/30Days
ATOMOXETINE HCL 100 MG CAPSULE [Strattera]   4 Non-Preferred Drug 40%40%Q:30
/30Days
ATOMOXETINE HCL 18 MG CAPSULE [Strattera]   4 Non-Preferred Drug 40%40%Q:120
/30Days
ATOMOXETINE HCL 25 MG CAPSULE [Strattera]   4 Non-Preferred Drug 40%40%Q:120
/30Days
ATOMOXETINE HCL 40 MG CAPSULE [Strattera]   4 Non-Preferred Drug 40%40%Q:60
/30Days
ATOMOXETINE HCL 60 MG CAPSULE [Strattera]   4 Non-Preferred Drug 40%40%Q:30
/30Days
ATOMOXETINE HCL 80 MG CAPSULE [Strattera]   4 Non-Preferred Drug 40%40%Q:30
/30Days
ATORVASTATIN 10 MG TABLET [Lipitor]   1 Preferred Generic $1.00$0.00None
ATORVASTATIN 20 MG TABLET [Lipitor]   1 Preferred Generic $1.00$0.00None
ATORVASTATIN 40 MG TABLET [Lipitor]   1 Preferred Generic $1.00$0.00None
ATORVASTATIN 80 MG TABLET [Lipitor]   1 Preferred Generic $1.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATOVAQUONE 750 MG/5 ML SUSP [Mepron]   5 Specialty Tier 33%N/ANone
Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone]   4 Non-Preferred Drug 40%40%None
ATOVAQUONE-PROGUANIL 62.5-25 [Malarone]   4 Non-Preferred Drug 40%40%None
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC   5 Specialty Tier 33%N/ANone
ATROVENT HFA AER 17MCG   4 Non-Preferred Drug 40%40%Q:26
/30Days
AUBRA-28 TABLET   3 Preferred Brand 20%20%None
AURYXIA 210 MG TABLET   4 Non-Preferred Drug 40%40%P Q:360
/30Days
AUSTEDO 12 MG TABLET   5 Specialty Tier 33%N/AP Q:120
/30Days
AUSTEDO 6 MG TABLET   5 Specialty Tier 33%N/AP Q:60
/30Days
AUSTEDO 9 MG TABLET   5 Specialty Tier 33%N/AP Q:120
/30Days
AVIANE 0.1-0.02 TABLET   3 Preferred Brand 20%20%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVITA 0.025% CREAM   4 Non-Preferred Drug 40%40%P
Avita 0.25mg/g 45 g in 1 TUBE   4 Non-Preferred Drug 40%40%P
AZASITE 1% EYE DROPS   4 Non-Preferred Drug 40%40%None
AZATHIOPRINE 50 MG TABLET   3 Preferred Brand 20%20%P
AZELASTINE 0.15% NASAL SPRAY   4 Non-Preferred Drug 40%40%None
AZELASTINE 137 MCG NASAL SPRAY   3 Preferred Brand 20%20%None
AZELASTINE HCL 0.05% DROPS   3 Preferred Brand 20%20%None
AZITHROMYCIN 1 GM PWD PACKET   3 Preferred Brand 20%20%None
AZITHROMYCIN 100 MG/5 ML SUSP   3 Preferred Brand 20%20%None
AZITHROMYCIN 200 MG/5 ML SUSP   3 Preferred Brand 20%20%None
AZITHROMYCIN 250 MG TABLET   2 Generic $5.00$12.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZITHROMYCIN 250 MG TABLET   2 Generic $5.00$12.50None
AZITHROMYCIN 500 MG TABLET   2 Generic $5.00$12.50None
AZITHROMYCIN 500 MG TABLET [Zithromax Tri-Pak]   2 Generic $5.00$12.50None
AZITHROMYCIN 600 MG TABLET   2 Generic $5.00$12.50None
AZITHROMYCIN I.V. 500 MG VIAL   4 Non-Preferred Drug 40%40%None
AZOPT 1% EYE DROPS   4 Non-Preferred Drug 40%40%None
Aztreonam 1000 MG Injection [Azactam]   4 Non-Preferred Drug 40%40%None
Aztreonam 2000 MG Injection [Azactam]   4 Non-Preferred Drug 40%40%None
AZTREONAM FOR INJECTION   4 Non-Preferred Drug 40%40%None

Chart Legend:

Below are a few notes to help you understand the above 2019 Medicare Part D SilverScript Allure (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 $415 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. *Some Part D plans exclude one or more drug tiers from the deductible. If the drug tier field above is followed by * (example: 2*), then this drug tier is excluded from the plan’s deductible.
    • Tier 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 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 intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $3820) 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 2019 )

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.