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AARP MedicareRx Walgreens (PDP) (S5921-393-0)
Tier 1 (149)
Tier 2 (618)
Tier 3 (772)
Tier 4 (902)
Tier 5 (521)
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M N O P Q R S T U V W X Y Z 0-9 
2019 Medicare Part D Plan Formulary Information
AARP MedicareRx Walgreens (PDP) (S5921-393-0)
Benefits & Contact Info           
The AARP MedicareRx Walgreens (PDP) (S5921-393-0)
Formulary Drugs Starting with the Letter C

in CMS PDP Region 12 which includes: AL TN
Plan Monthly Premium: $28.10 Deductible: $415 Qualifies for LIS: No
Drugs Starting with Letter C

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
CABERGOLINE 0.5 MG TABLET   4 Non-Preferred Drug 32%32%None
CABLIVI 11 MG KIT   5 Specialty Tier 25%25%P Q:30
/30Days
CABOMETYX 20 MG TABLET   5 Specialty Tier 25%25%P Q:30
/30Days
CABOMETYX 40 MG TABLET   5 Specialty Tier 25%25%P Q:60
/30Days
CABOMETYX 60 MG TABLET   5 Specialty Tier 25%25%P Q:30
/30Days
CALCIPOTRIENE 0.005% CREAM   4 Non-Preferred Drug 32%32%None
CALCIPOTRIENE 0.005% SOLUTION   4 Non-Preferred Drug 32%32%None
Calcipotriene 50ug/g 60 g per CARTON   4 Non-Preferred Drug 32%32%None
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY   3 Preferred Brand $30.00$90.00Q:4
/28Days
CALCITRIOL 0.25 MCG CAPSULE [Rocaltrol]   2* Generic $5.00$15.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CALCITRIOL 0.5 MCG CAPSULE [Rocaltrol]   2* Generic $5.00$15.00P
CALCITRIOL 1MCG/ML SOLUTION ORAL   2* Generic $5.00$15.00P
CALCITRIOL 3 MCG/G OINTMENT   4 Non-Preferred Drug 32%32%None
CALCIUM ACETATE 667 MG TABLET   3 Preferred Brand $30.00$90.00None
CALCIUM ACETATE CAPSULE 667 MG   3 Preferred Brand $30.00$90.00None
CALQUENCE 100 MG CAPSULE   5 Specialty Tier 25%25%P Q:60
/30Days
CAMILA 0.35 MG TABLET   3 Preferred Brand $30.00$90.00None
CAMRESE LO TABLET   4 Non-Preferred Drug 32%32%None
CANASA 1,000 MG SUPPOSITORY   4 Non-Preferred Drug 32%32%None
CAPRELSA 100 MG TABLET   5 Specialty Tier 25%25%P
CAPRELSA 300 MG TABLET   5 Specialty Tier 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARAC CREAM   4 Non-Preferred Drug 32%32%P
CARAFATE SUS 1GM/10ML   4 Non-Preferred Drug 32%32%None
CARBAGLU 200 MG DISPER TABLET   5 Specialty Tier 25%25%None
CARBAMAZEPINE 100 MG TAB CHEW   3 Preferred Brand $30.00$90.00None
CARBAMAZEPINE 100 MG/5 ML SUSP   3 Preferred Brand $30.00$90.00None
CARBAMAZEPINE 200 MG TABLET   3 Preferred Brand $30.00$90.00None
CARBAMAZEPINE ER 100 MG CAP CPMP 12HR [Carbatrol]   3 Preferred Brand $30.00$90.00None
CARBAMAZEPINE ER 100 MG TABLET   3 Preferred Brand $30.00$90.00None
CARBAMAZEPINE ER 200 MG CAP CPMP 12HR [Carbatrol]   3 Preferred Brand $30.00$90.00None
CARBAMAZEPINE ER 300 MG CAP CPMP 12HR [Carbatrol]   3 Preferred Brand $30.00$90.00None
CARBAMAZEPINE XR 200 MG TABLET   3 Preferred Brand $30.00$90.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARBAMAZEPINE XR 400 MG TABLET   3 Preferred Brand $30.00$90.00None
CARBIDOPA AND LEVEDOPA ORALLY DISINTEGRATING TABLETS 10;100MG;MG 100 BOT   2* Generic $5.00$15.00None
CARBIDOPA AND LEVODOPA ODT 25;100MG;MG 100 BOT   2* Generic $5.00$15.00None
CARBIDOPA AND LEVODOPA ODT 25;250MG;MG 100 BOT   2* Generic $5.00$15.00None
CARBIDOPA-LEVO ER 25-100 TAB   2* Generic $5.00$15.00None
CARBIDOPA-LEVO ER 50-200 TAB   2* Generic $5.00$15.00None
CARBIDOPA-LEVODOPA 10-100 TAB   2* Generic $5.00$15.00None
CARBIDOPA-LEVODOPA 25-100 TAB   2* Generic $5.00$15.00None
CARBIDOPA-LEVODOPA 25-250 TAB   2* Generic $5.00$15.00None
CARBIDOPA-LEVODOPA-ENTA 150 MG   4 Non-Preferred Drug 32%32%None
CARBIDOPA-LEVODOPA-ENTA 75 MG   4 Non-Preferred Drug 32%32%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARBIDOPA-LEVODOPA-ENTACAPONE 100 MG [Stalevo]   4 Non-Preferred Drug 32%32%None
CARBIDOPA-LEVODOPA-ENTACAPONE 125 MG [Stalevo]   4 Non-Preferred Drug 32%32%None
CARBIDOPA-LEVODOPA-ENTACAPONE 200 MG [Stalevo]   4 Non-Preferred Drug 32%32%None
CARBIDOPA-LEVODOPA-ENTACAPONE 50 MG [Stalevo]   4 Non-Preferred Drug 32%32%None
CARTEOLOL HCL 1% EYE DROPS   2* Generic $5.00$15.00None
CARTIA XT 120MG CAPSULE SA   3 Preferred Brand $30.00$90.00None
CARTIA XT 180MG CAPSULE SA   3 Preferred Brand $30.00$90.00None
CARTIA XT 240MG CAPSULE SA   3 Preferred Brand $30.00$90.00None
CARTIA XT 300 MG CAPSULE   3 Preferred Brand $30.00$90.00None
CARVEDILOL 12.5 MG TABLET   1* Preferred Generic $0.00$0.00None
CARVEDILOL 25 MG TABLET   1* Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARVEDILOL 3.125 MG TABLET   1* Preferred Generic $0.00$0.00None
CARVEDILOL 6.25 MG TABLET   1* Preferred Generic $0.00$0.00None
CAYSTON KIT 75 MG/VIAL   5 Specialty Tier 25%25%P
CEFACLOR 250 MG CAPSULES   2* Generic $5.00$15.00None
CEFACLOR 500 MG CAPSULES   2* Generic $5.00$15.00None
CEFADROXIL 250 MG/5 ML SUSP   2* Generic $5.00$15.00None
CEFADROXIL 500 MG CAPSULE   2* Generic $5.00$15.00None
CEFADROXIL 500 MG/5 ML SUSP   2* Generic $5.00$15.00None
CEFAZOLIN 1 GM VIAL 25/Box   3 Preferred Brand $30.00$90.00None
Cefazolin 10g/1 10 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 PACKAGE   3 Preferred Brand $30.00$90.00None
CEFAZOLIN 500 MG VIAL   3 Preferred Brand $30.00$90.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFDINIR 125 MG/5 ML SUSP   3 Preferred Brand $30.00$90.00None
CEFDINIR 250 MG/5 ML SUSP   3 Preferred Brand $30.00$90.00None
CEFDINIR 300 MG CAPSULE   3 Preferred Brand $30.00$90.00None
CEFEPIME HCL 1 GM VIAL [Maxipime]   4 Non-Preferred Drug 32%32%None
CEFEPIME HCL 2 GRAM VIAL [Maxipime]   4 Non-Preferred Drug 32%32%None
CEFIXIME 100 MG/5 ML SUSP [Suprax]   4 Non-Preferred Drug 32%32%None
CEFIXIME 200 MG/5 ML SUSP [Suprax]   4 Non-Preferred Drug 32%32%None
Cefotaxime 500 MG Injection   4 Non-Preferred Drug 32%32%None
Cefotaxime sodium 1 gm vial   4 Non-Preferred Drug 32%32%None
CEFOTETAN 1GM VIAL 1EA x 10   4 Non-Preferred Drug 32%32%None
CEFOTETAN 2GM VIAL 1EA x 10   4 Non-Preferred Drug 32%32%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFOXITIN 1 GM VIAL   4 Non-Preferred Drug 32%32%None
CEFOXITIN 10 GM VIAL   4 Non-Preferred Drug 32%32%None
CEFOXITIN 2 GM VIAL   4 Non-Preferred Drug 32%32%None
CEFPODOXIME 100 MG TABLET   4 Non-Preferred Drug 32%32%None
CEFPODOXIME 100 MG/5 ML SUSP   4 Non-Preferred Drug 32%32%None
CEFPODOXIME 200 MG TABLET   4 Non-Preferred Drug 32%32%None
CEFPODOXIME 50 MG/5 ML SUSP   4 Non-Preferred Drug 32%32%None
CEFPROZIL 125 MG/5 ML SUSP   3 Preferred Brand $30.00$90.00None
CEFPROZIL 250 MG TABLET   3 Preferred Brand $30.00$90.00None
CEFPROZIL 250 MG/5 ML SUSP   3 Preferred Brand $30.00$90.00None
CEFPROZIL 500 MG TABLET   3 Preferred Brand $30.00$90.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFTAZIDIME 1 GM VIAL   4 Non-Preferred Drug 32%32%None
CEFTAZIDIME FOR INJECTION 2GM/VIAL 10 X 2 CRTN   4 Non-Preferred Drug 32%32%None
CEFTAZIDIME FOR INJECTION 6GM/VIAL 6 X 6 CRTN   4 Non-Preferred Drug 32%32%None
CEFTRIAXONE 1 GM VIAL   4 Non-Preferred Drug 32%32%None
CEFTRIAXONE 10 GM VIAL   4 Non-Preferred Drug 32%32%None
CEFTRIAXONE 2 GM VIAL   4 Non-Preferred Drug 32%32%None
CEFTRIAXONE 250 MG VIAL   4 Non-Preferred Drug 32%32%None
CEFTRIAXONE 500 MG VIAL   4 Non-Preferred Drug 32%32%None
CEFUROXIME 1.5 GM/VIAL FOR INJECTION   4 Non-Preferred Drug 32%32%None
CEFUROXIME 750 MG FOR INJECTION   4 Non-Preferred Drug 32%32%None
Cefuroxime 95 MG/ML Injectable Solution   4 Non-Preferred Drug 32%32%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFUROXIME AXETIL 250 MG TAB   2* Generic $5.00$15.00None
CEFUROXIME AXETIL 500 MG TAB   2* Generic $5.00$15.00None
CELONTIN 300 MG KAPSEAL   4 Non-Preferred Drug 32%32%None
CEPHALEXIN 125 MG/5 ML SUSP   2* Generic $5.00$15.00None
CEPHALEXIN 250 MG CAPSULE   2* Generic $5.00$15.00None
CEPHALEXIN 250 MG/5 ML SUSP   2* Generic $5.00$15.00None
CEPHALEXIN 500 MG CAPSULE   2* Generic $5.00$15.00None
CEPHALEXIN 750 MG CAPSULE   2* Generic $5.00$15.00None
CETIRIZINE HCL 1 MG/ML SOLN   2* Generic $5.00$15.00None
CHANTIX 0.5 MG TABLET   4 Non-Preferred Drug 32%32%None
CHANTIX 1 MG CONT MONTH BOX   4 Non-Preferred Drug 32%32%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CHANTIX 1 MG TABLET   4 Non-Preferred Drug 32%32%None
CHANTIX STARTING MONTH BOX   4 Non-Preferred Drug 32%32%None
CHEMET 100 MG CAPSULE   4 Non-Preferred Drug 32%32%None
CHENODAL 250 MG TABLET   5 Specialty Tier 25%25%None
CHLORDIAZEPOXIDE 10 MG CAPSULE   2* Generic $5.00$15.00None
CHLORDIAZEPOXIDE 25 MG CAPSULE   2* Generic $5.00$15.00None
CHLORDIAZEPOXIDE 5 MG CAPSULE   2* Generic $5.00$15.00None
CHLORHEXIDINE GLUCONATE 0.12% RINSE   2* Generic $5.00$15.00None
CHLOROQUINE PH 250 MG TABLET   2* Generic $5.00$15.00None
CHLOROQUINE PH 500 MG TABLET   2* Generic $5.00$15.00None
CHLOROTHIAZIDE 250 MG TABLET   3 Preferred Brand $30.00$90.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Chlorothiazide 500mg 100 TABLET BOTTLE   3 Preferred Brand $30.00$90.00None
CHLORPROMAZINE 10 MG TABLET   4 Non-Preferred Drug 32%32%None
CHLORPROMAZINE 100 MG TABLET   4 Non-Preferred Drug 32%32%None
CHLORPROMAZINE 200 MG TABLET   4 Non-Preferred Drug 32%32%None
CHLORPROMAZINE 25 MG TABLET   4 Non-Preferred Drug 32%32%None
CHLORPROMAZINE 50 MG TABLET   4 Non-Preferred Drug 32%32%None
CHLORTHALIDONE 25 MG TABLET (100 CT)   2* Generic $5.00$15.00None
CHLORTHALIDONE 50 MG TABLET   2* Generic $5.00$15.00None
CHLORZOXAZONE 500 MG TABLET   3 Preferred Brand $30.00$90.00None
CHOLBAM 250 MG CAPSULE   5 Specialty Tier 25%25%P
CHOLBAM 50 MG CAPSULE   5 Specialty Tier 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CHOLESTYRAMINE LIGHT POWDER   3 Preferred Brand $30.00$90.00None
CHOLESTYRAMINE PACKET   3 Preferred Brand $30.00$90.00None
CICLOPIROX 0.77% CREAM   3 Preferred Brand $30.00$90.00None
CICLOPIROX 0.77% GEL   3 Preferred Brand $30.00$90.00None
CICLOPIROX 0.77% TOPICAL SUSP   3 Preferred Brand $30.00$90.00None
CICLOPIROX 1% SHAMPOO   3 Preferred Brand $30.00$90.00None
CICLOPIROX 8% SOLUTION   3 Preferred Brand $30.00$90.00None
Cilastatin 250 MG / Imipenem 250 MG Injection   4 Non-Preferred Drug 32%32%None
Cilastatin 500 MG / Imipenem 500 MG Injection   4 Non-Preferred Drug 32%32%None
CILOSTAZOL 100 MG TABLET   3 Preferred Brand $30.00$90.00None
CILOSTAZOL 50 MG TABLET   3 Preferred Brand $30.00$90.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CIMDUO 300-300 MG TABLET   5 Specialty Tier 25%25%Q:60
/30Days
CIPROFLOXACIN 0.3% EYE DROP [Ciloxan]   2* Generic $5.00$15.00None
CIPROFLOXACIN 250 MG TABLET (100 CT) [Cipro]   2* Generic $5.00$15.00None
CIPROFLOXACIN 500 MG/5 ML SUSP MC REC [Cipro]   4 Non-Preferred Drug 32%32%None
CIPROFLOXACIN HCL 500 MG Tablet [Cipro]   2* Generic $5.00$15.00None
CIPROFLOXACIN HCL 750 MG Tablet [Cipro]   2* Generic $5.00$15.00None
CIPROFLOXACIN-D5W 200 MG/100 ML PIGGYBACK [Cipro]   4 Non-Preferred Drug 32%32%None
CITALOPRAM HBR 10 MG TABLET   1* Preferred Generic $0.00$0.00None
CITALOPRAM HBR 10 MG/5 ML SOLN   3 Preferred Brand $30.00$90.00None
CITALOPRAM HBR 20 MG TABLET   1* Preferred Generic $0.00$0.00None
CITALOPRAM HBR 40 MG TABLET   1* Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLARAVIS 10 MG CAPSULE   4 Non-Preferred Drug 32%32%P
CLARAVIS 20 MG CAPSULE   4 Non-Preferred Drug 32%32%P
Claravis 30mg 3 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK   4 Non-Preferred Drug 32%32%P
CLARAVIS 40 MG CAPSULE   4 Non-Preferred Drug 32%32%P
CLARITHROMYCIN 125 MG/5ML FOR ORAL SUSPENSION   4 Non-Preferred Drug 32%32%None
CLARITHROMYCIN 250 MG TABLET   3 Preferred Brand $30.00$90.00None
CLARITHROMYCIN 250 MG/5MLFOR ORAL SUSPENSION   4 Non-Preferred Drug 32%32%None
CLARITHROMYCIN 500 MG TABLET   3 Preferred Brand $30.00$90.00None
CLARITHROMYCIN ER 500 MG TAB   3 Preferred Brand $30.00$90.00None
CLENPIQ 10-3.5/160   3 Preferred Brand $30.00$90.00None
CLIMARA PRO DIS WEEKLY 4.40MG/1.39MG   4 Non-Preferred Drug 32%32%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Clindamycin 150 MG/ML 2ml   4 Non-Preferred Drug 32%32%None
CLINDAMYCIN 150mg/ml vl 25x6ml   4 Non-Preferred Drug 32%32%None
CLINDAMYCIN 75 MG/5 ML SOLN   4 Non-Preferred Drug 32%32%None
CLINDAMYCIN HCL 150 MG CAPSULE   2* Generic $5.00$15.00None
CLINDAMYCIN HCL 300 MG CAPSULE   2* Generic $5.00$15.00None
CLINDAMYCIN HCL 75 MG 200 CAPSULE BOTTLE   2* Generic $5.00$15.00None
CLINDAMYCIN PH 1% SOLUTION   3 Preferred Brand $30.00$90.00None
CLINDAMYCIN PH 600 MG/4 ML VL   4 Non-Preferred Drug 32%32%None
CLINDAMYCIN PHOSP 1% LOTION   3 Preferred Brand $30.00$90.00None
Clindamycin Phosphate and Benzoyl Peroxide 1 KIT   4 Non-Preferred Drug 32%32%None
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE   3 Preferred Brand $30.00$90.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX   3 Preferred Brand $30.00$90.00None
CLINDAMYCIN PHOSPHATE VAGINAL CREAM   3 Preferred Brand $30.00$90.00None
Clindamycin-d5w 300 mg/50 ml   4 Non-Preferred Drug 32%32%None
Clindamycin-d5w 600 mg/50 ml   4 Non-Preferred Drug 32%32%None
Clindamycin-d5w 900 mg/50 ml   4 Non-Preferred Drug 32%32%None
CLOBAZAM 10 MG TABLET [ONFI]   4 Non-Preferred Drug 32%32%P Q:60
/30Days
CLOBAZAM 2.5 MG/ML Oral Suspension [ONFI]   4 Non-Preferred Drug 32%32%P
CLOBAZAM 20 MG TABLET [ONFI]   4 Non-Preferred Drug 32%32%P Q:60
/30Days
CLOBETASOL 0.05% CREAM (g) [Temovate]   4 Non-Preferred Drug 32%32%None
CLOBETASOL 0.05% OINTMENT   4 Non-Preferred Drug 32%32%None
CLOBETASOL 0.05% SOLUTION   3 Preferred Brand $30.00$90.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLOBETASOL EMOLLIENT 0.05% CREAM (g) [Temovate E]   4 Non-Preferred Drug 32%32%None
Clobetasol Propionate 0.5 MG/ML Medicated Shampoo   4 Non-Preferred Drug 32%32%None
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE   4 Non-Preferred Drug 32%32%None
CLOMIPRAMINE 25 MG CAPSULE   4 Non-Preferred Drug 32%32%None
CLOMIPRAMINE 50 MG CAPSULE   4 Non-Preferred Drug 32%32%None
CLOMIPRAMINE 75 MG CAPSULE   4 Non-Preferred Drug 32%32%None
CLONAZEPAM 0.125 MG DIS TAB RAPDIS [Klonopin]   4 Non-Preferred Drug 32%32%Q:120
/30Days
CLONAZEPAM 0.25 MG ODT TAB RAPDIS [Klonopin]   4 Non-Preferred Drug 32%32%Q:120
/30Days
CLONAZEPAM 0.5 MG DIS TABLET RAPDIS [Klonopin]   4 Non-Preferred Drug 32%32%Q:120
/30Days
CLONAZEPAM 0.5 MG TABLET [Klonopin]   2* Generic $5.00$15.00Q:120
/30Days
CLONAZEPAM 1 MG DIS TABLET RAPDIS [Klonopin]   4 Non-Preferred Drug 32%32%Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLONAZEPAM 1 MG TABLET [Klonopin]   2* Generic $5.00$15.00Q:120
/30Days
CLONAZEPAM 2 MG ODT TAB RAPDIS [Klonopin]   4 Non-Preferred Drug 32%32%Q:300
/30Days
CLONAZEPAM 2 MG TABLET [Klonopin]   2* Generic $5.00$15.00Q:300
/30Days
Clonidine 0.1mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH   4 Non-Preferred Drug 32%32%None
Clonidine 0.2mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH   4 Non-Preferred Drug 32%32%None
Clonidine 0.3mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH   4 Non-Preferred Drug 32%32%None
CLONIDINE HCL 0.1 MG TABLET   2* Generic $5.00$15.00None
CLONIDINE HCL 0.2 MG TABLET   2* Generic $5.00$15.00None
CLONIDINE HCL 0.3 MG TABLET   2* Generic $5.00$15.00None
CLONIDINE HCL ER 0.1 MG TABLET   4 Non-Preferred Drug 32%32%P
CLOPIDOGREL 75 MG TABLET [Plavix]   2* Generic $5.00$15.00Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLORAZEPATE 15 MG TABLET   3 Preferred Brand $30.00$90.00Q:180
/30Days
CLORAZEPATE 3.75 MG TABLET   3 Preferred Brand $30.00$90.00Q:720
/30Days
CLORAZEPATE 7.5 MG TABLET   3 Preferred Brand $30.00$90.00Q:360
/30Days
CLOTRIMAZOLE 1% CREAM   2* Generic $5.00$15.00None
CLOTRIMAZOLE 1% SOLUTION   2* Generic $5.00$15.00None
CLOTRIMAZOLE 10 MG TROCHE   2* Generic $5.00$15.00None
CLOTRIMAZOLE-BETAMETHASONE LOT   4 Non-Preferred Drug 32%32%None
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE 0.64; 10mg/g; mg/g 45 g in 1 TUBE   3 Preferred Brand $30.00$90.00None
CLOZAPINE 100 MG TABLET [Clozaril]   3 Preferred Brand $30.00$90.00None
CLOZAPINE 200 MG TABLET   3 Preferred Brand $30.00$90.00None
CLOZAPINE 25 MG TABLET [Clozaril]   3 Preferred Brand $30.00$90.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLOZAPINE 50 MG TABLET   3 Preferred Brand $30.00$90.00None
CLOZAPINE ODT 100 MG TABLET RAPDIS [Fazaclo]   4 Non-Preferred Drug 32%32%Q:270
/30Days
CLOZAPINE ODT 12.5 MG TABLET RAPDIS [Fazaclo]   4 Non-Preferred Drug 32%32%Q:60
/30Days
CLOZAPINE ODT 150 MG TABLET RAPDIS [Fazaclo]   4 Non-Preferred Drug 32%32%Q:180
/30Days
CLOZAPINE ODT 200 MG TABLET RAPDIS [Fazaclo]   4 Non-Preferred Drug 32%32%Q:120
/30Days
CLOZAPINE ODT 25 MG TABLET RAPDIS [Fazaclo]   4 Non-Preferred Drug 32%32%Q:90
/30Days
COARTEM 20MG-120MG   4 Non-Preferred Drug 32%32%None
CODEINE SULFATE 30 mg tablet   3 Preferred Brand $30.00$90.00Q:180
/30Days
CODEINE SULFATE 60 MG TABLET   3 Preferred Brand $30.00$90.00Q:180
/30Days
COLCHICINE 0.6 MG CAPSULE [Mitigare]   3 Preferred Brand $30.00$90.00Q:120
/30Days
COLCHICINE 0.6 MG TABLET [Colcrys]   3 Preferred Brand $30.00$90.00Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COLCRYS 0.6 MG TABLET   3 Preferred Brand $30.00$90.00Q:120
/30Days
COLESTIPOL HCL 1G TABLET   3 Preferred Brand $30.00$90.00None
COLESTIPOL HCL GRANULES PACKET   4 Non-Preferred Drug 32%32%None
COLISTIMETHATE 150 MG VIAL [Coly-Mycin M]   4 Non-Preferred Drug 32%32%None
COLOCORT 100MG ENEMA   3 Preferred Brand $30.00$90.00None
COLY-MYCIN S OTIC SUSP DROP   4 Non-Preferred Drug 32%32%None
COMBIVENT RESPIMAT INHAL SPRAY   3 Preferred Brand $30.00$90.00None
COMETRIQ 100 MG DAILY-DOSE PK   5 Specialty Tier 25%25%P
COMETRIQ 140 MG DAILY-DOSE PK   5 Specialty Tier 25%25%P
COMETRIQ 60 MG DAILY-DOSE PACK   5 Specialty Tier 25%25%P
COMPLERA 200; 27.5; 300mg/1; mg/1; mg/1   5 Specialty Tier 25%25%Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COMPRO 25MG SUPPOSITORY   4 Non-Preferred Drug 32%32%None
CONSTULOSE 10 GM/15 ML SOLN   2* Generic $5.00$15.00None
COPIKTRA 15 MG CAPSULE   5 Specialty Tier 25%25%P Q:60
/30Days
COPIKTRA 25 MG CAPSULE   5 Specialty Tier 25%25%P Q:60
/30Days
CORLANOR 5 MG TABLET   4 Non-Preferred Drug 32%32%P Q:60
/30Days
CORLANOR 7.5 MG TABLET   4 Non-Preferred Drug 32%32%P Q:60
/30Days
COSENTYX 300 MG DOSE-2 PENS   5 Specialty Tier 25%25%P
COSOPT PF EYE DROPS   4 Non-Preferred Drug 32%32%None
COTELLIC 20 MG TABLET   5 Specialty Tier 25%25%P Q:90
/30Days
CRINONE 4% GEL   4 Non-Preferred Drug 32%32%P
CRINONE 8% GEL/PF APP   4 Non-Preferred Drug 32%32%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CRIXIVAN 200MG CAPSULE   3 Preferred Brand $30.00$90.00Q:270
/30Days
CRIXIVAN 400mg, 180 CAPSULE BOTTLE   3 Preferred Brand $30.00$90.00Q:270
/30Days
CROMOLYN 20 MG/2 ML NEB SOLN   3 Preferred Brand $30.00$90.00P
CROMOLYN SODIUM 100 MG/5 ML   4 Non-Preferred Drug 32%32%None
CROMOLYN SODIUM 4% 40MG 10ML BOT   2* Generic $5.00$15.00None
CUVPOSA 1 MG/5 ML SOLUTION   4 Non-Preferred Drug 32%32%None
Cyclafem 1/35 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK   4 Non-Preferred Drug 32%32%None
CYCLOBENZAPRINE 10 MG TABLET   2* Generic $5.00$15.00None
CYCLOBENZAPRINE 5 MG TABLET   2* Generic $5.00$15.00None
CYCLOPHOSPHAMIDE 25 MG CAPSULE   4 Non-Preferred Drug 32%32%P
CYCLOPHOSPHAMIDE 50 MG CAPSULE   4 Non-Preferred Drug 32%32%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CYCLOSPORINE 100MG CAPSULE   4 Non-Preferred Drug 32%32%P
CYCLOSPORINE 25MG CAPSULE   4 Non-Preferred Drug 32%32%P
CYCLOSPORINE MODIFIED 100 MG   4 Non-Preferred Drug 32%32%P
CYCLOSPORINE MODIFIED 25 MG   4 Non-Preferred Drug 32%32%P
CYCLOSPORINE MODIFIED 50 MG   4 Non-Preferred Drug 32%32%P
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT   4 Non-Preferred Drug 32%32%P
CYPROHEPTADINE 4 MG TABLET   3 Preferred Brand $30.00$90.00None
CYPROHEPTADINE HYDROCHLORIDE SOLUTION USP SYRUP 2MG 473 ML BOTGL   3 Preferred Brand $30.00$90.00None
CYRED EQ 28 DAY TABLET [Solia]   4 Non-Preferred Drug 32%32%None
CYSTADANE 1 GRAM/1.7 ML POWDER   5 Specialty Tier 25%25%None
CYSTAGON 150MG CAPSULE   4 Non-Preferred Drug 32%32%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CYSTAGON 50MG CAPSULE   4 Non-Preferred Drug 32%32%None
CYSTARAN 0.44% EYE DROPS   5 Specialty Tier 25%25%None

Chart Legend:

Below are a few notes to help you understand the above 2019 Medicare Part D AARP MedicareRx Walgreens (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 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 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 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 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 $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 June 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.