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Express Scripts Medicare - Value (PDP) (S5660-114-0)
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Tier 2 (808)
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2019 Medicare Part D Plan Formulary Information
Express Scripts Medicare - Value (PDP) (S5660-114-0)
Benefits & Contact Info           
The Express Scripts Medicare - Value (PDP) (S5660-114-0)
Formulary Drugs Starting with the Letter D

in CMS PDP Region 12 which includes: AL TN
Plan Monthly Premium: $30.20 Deductible: $415 Qualifies for LIS: Yes
Drugs Starting with Letter D

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
D5%-1/2NS-KCL 10 MEQ/L IV SOL IV SOLN   2 Generic $3.00$6.00None
D5%-1/2NS-KCL 40 MEQ/L IV SOL IV SOLN   2 Generic $3.00$6.00None
DALFAMPRIDINE ER 10 MG TABLET ER 12H [Ampyra]   5 Specialty Tier 25%N/AP Q:60
/30Days
DALIRESP 250 MCG TABLET   4 Non-Preferred Drug 41%N/AP
DALIRESP 500 MCG TABLET   4 Non-Preferred Drug 41%N/AP Q:30
/30Days
DANAZOL 100 MG CAPSULE   4 Non-Preferred Drug 41%N/ANone
DANAZOL 50MG CAPSULE   4 Non-Preferred Drug 41%N/ANone
DANAZOL CAPSULES USP 200MG (100 CT)   4 Non-Preferred Drug 41%N/ANone
DANTROLENE SODIUM 100MG CAPSULE   4 Non-Preferred Drug 41%N/ANone
DANTROLENE SODIUM 25MG CAPSULE   4 Non-Preferred Drug 41%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DANTROLENE SODIUM 50MG CAPSULE   4 Non-Preferred Drug 41%N/ANone
DAPSONE 25 MG TABLET   3 Preferred Brand $25.00$75.00None
DAPSONE 5% GEL   3 Preferred Brand $25.00$75.00None
DAPSONE TABLETS 100MG 30 BLPK   3 Preferred Brand $25.00$75.00None
DAPTACEL VACCINE 15;5;5;3; LF/.5ML   3 Preferred Brand $25.00$75.00None
DAPTOMYCIN 350 MG VIAL [Cubicin RF]   3 Preferred Brand $25.00$75.00None
DAPTOMYCIN 500 MG VIAL [Cubicin]   5 Specialty Tier 25%N/ANone
DARAPRIM 25 MG TABLET   5 Specialty Tier 25%N/AP
DAURISMO 100 MG TABLET   4 Non-Preferred Drug 41%N/AP
DAURISMO 25 MG TABLET   4 Non-Preferred Drug 41%N/AP
DDAVP 10 MCG/0.1 ML SOLUTION   3 Preferred Brand $25.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEBLITANE 0.35 MG TABLET   3 Preferred Brand $25.00$75.00None
DEFERASIROX 125 MG TABLET DISPER [Exjade]   5 Specialty Tier 25%N/AP
DEFERASIROX 250 MG TABLET DISPER [Exjade]   5 Specialty Tier 25%N/AP
DEFERASIROX 500 MG TABLET DISPER [Exjade]   5 Specialty Tier 25%N/AP
DELSTRIGO 100-300-300 MG TABLET   4 Non-Preferred Drug 41%N/ANone
Delyla-28 tablet   4 Non-Preferred Drug 41%N/ANone
DELZICOL DR 400 MG CAPSULE   4 Non-Preferred Drug 41%N/ANone
DEMECLOCYCLINE 150 MG TABLET   4 Non-Preferred Drug 41%N/ANone
DEMECLOCYCLINE 300 MG TABLET   4 Non-Preferred Drug 41%N/ANone
DEMSER CAPSULES 250MG (100 CT)   4 Non-Preferred Drug 41%N/AP
DEPEN 250MG TITRATAB   5 Specialty Tier 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DESCOVY 200-25 MG TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
DESIPRAMINE 10 MG TABLET [Norpramin]   4 Non-Preferred Drug 41%N/ANone
DESIPRAMINE 100 MG TABLET [Norpramin]   4 Non-Preferred Drug 41%N/ANone
DESIPRAMINE 150 MG TABLET [Norpramin]   4 Non-Preferred Drug 41%N/ANone
DESIPRAMINE 25 MG TABLET [Norpramin]   4 Non-Preferred Drug 41%N/ANone
DESIPRAMINE 50 MG TABLET [Norpramin]   4 Non-Preferred Drug 41%N/ANone
DESIPRAMINE 75 MG TABLET [Norpramin]   4 Non-Preferred Drug 41%N/ANone
DESMOPRESSIN ACETATE 0.1 MG TB   3 Preferred Brand $25.00$75.00None
DESMOPRESSIN ACETATE 0.2 MG TB   3 Preferred Brand $25.00$75.00None
DESMOPRESSIN ACETATE NASAL SOLUTION 0.1% 5 ML BOTSPR   3 Preferred Brand $25.00$75.00None
DESOGESTR-ETH ESTRAD   4 Non-Preferred Drug 41%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Desvenlafaxine Succinate ER 100 mg [Pristiq]   3 Preferred Brand $25.00$75.00Q:30
/30Days
Desvenlafaxine Succinate ER 25 mg tb [Pristiq]   3 Preferred Brand $25.00$75.00Q:30
/30Days
Desvenlafaxine Succinate ER 50 mg tb [Pristiq]   3 Preferred Brand $25.00$75.00Q:30
/30Days
DEXAMETHASONE 0.1% EYE DROP   2 Generic $3.00$6.00None
DEXAMETHASONE 0.5MG TABLET   2 Generic $3.00$6.00None
DEXAMETHASONE 0.5MG/0.5ML DROP   2 Generic $3.00$6.00None
DEXAMETHASONE 0.5MG/5ML ELX   2 Generic $3.00$6.00None
DEXAMETHASONE 0.75MG TABLET   2 Generic $3.00$6.00None
DEXAMETHASONE 1.5MG TABLET   2 Generic $3.00$6.00None
DEXAMETHASONE 10 DAY 1.5 MG TABLET DS PK [ZonaCort 7 Day]   2 Generic $3.00$6.00None
DEXAMETHASONE 13 DAY 1.5 MG TABLET DS PK [ZonaCort 7 Day]   2 Generic $3.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEXAMETHASONE 1MG TABLET   2 Generic $3.00$6.00None
DEXAMETHASONE 2MG TABLET   2 Generic $3.00$6.00None
DEXAMETHASONE 4MG TABLET   2 Generic $3.00$6.00None
DEXAMETHASONE 6 DAY 1.5 MG TABLET DS PK [ZonaCort 7 Day]   2 Generic $3.00$6.00None
DEXAMETHASONE 6MG TABLET   2 Generic $3.00$6.00None
DEXCHLORPHENIRAMINE 2 MG/5 ML SYRUP [RyClora]   3 Preferred Brand $25.00$75.00None
DEXILANT CAPSULES DELAYED RELEASE 30 MG   4 Non-Preferred Drug 41%N/AQ:30
/30Days
DEXILANT DR 60 MG CAPSULE   4 Non-Preferred Drug 41%N/AQ:30
/30Days
DEXTROAMP-AMPHET ER 10 MG CAP   3 Preferred Brand $25.00$75.00Q:30
/30Days
DEXTROAMP-AMPHET ER 15 MG CAP   3 Preferred Brand $25.00$75.00Q:30
/30Days
DEXTROAMP-AMPHET ER 20 MG CAP   3 Preferred Brand $25.00$75.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEXTROAMP-AMPHET ER 25 MG CAP   3 Preferred Brand $25.00$75.00Q:60
/30Days
DEXTROAMP-AMPHET ER 30 MG CAP   3 Preferred Brand $25.00$75.00Q:60
/30Days
DEXTROAMP-AMPHET ER 5 MG CAP   3 Preferred Brand $25.00$75.00Q:60
/30Days
DEXTROSE 10%-1/4NS IV TUBEX   3 Preferred Brand $25.00$75.00None
Dextrose 10%-water iv solution   3 Preferred Brand $25.00$75.00None
DEXTROSE 2.5%-1/2NS IV SOLUTION   3 Preferred Brand $25.00$75.00None
DEXTROSE 5%-0.45% NACL IV SOLN   3 Preferred Brand $25.00$75.00None
DEXTROSE 5%-0.9% NACL IV SOLN   3 Preferred Brand $25.00$75.00None
DEXTROSE 5%-1/4NS IV SOLUTION   3 Preferred Brand $25.00$75.00None
DEXTROSE 5%-WATER IV SOLN   3 Preferred Brand $25.00$75.00None
DEXTROSE IN SODIUM CHLORIDE INJECTION   3 Preferred Brand $25.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEXTROSE IN SODIUM CHLORIDE INJECTION 1000ML X 12 CASE   3 Preferred Brand $25.00$75.00None
DEXTROSE IN SODIUM CHLORIDE INJECTION 500ML X 24 BAG   3 Preferred Brand $25.00$75.00None
DIASTAT 2.5 MG PEDI SYSTEM   4 Non-Preferred Drug 41%N/ANone
DIASTAT ACUDIAL 12.5-15-20 MG   4 Non-Preferred Drug 41%N/ANone
DIASTAT ACUDIAL 5-7.5-10 MG KT   4 Non-Preferred Drug 41%N/ANone
DIAZEPAM 10 MG TABLET [Valium]   2 Generic $3.00$6.00P Q:120
/30Days
DIAZEPAM 2 MG TABLET [Valium]   2 Generic $3.00$6.00P Q:120
/30Days
DIAZEPAM 5 MG TABLET [Valium]   2 Generic $3.00$6.00P Q:120
/30Days
DIAZEPAM 5 MG/5 ML SOLUTION   2 Generic $3.00$6.00P Q:1200
/30Days
DIAZEPAM 5 MG/ML ORAL CONC   2 Generic $3.00$6.00P Q:240
/30Days
DICLOFENAC 0.1% EYE DROPS [Voltaren]   2 Generic $3.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DICLOFENAC POT 50 MG TABLET   2 Generic $3.00$6.00None
DICLOFENAC SOD EC 25 MG TAB   2 Generic $3.00$6.00None
DICLOFENAC SOD EC 50 MG TAB   2 Generic $3.00$6.00None
DICLOFENAC SOD EC 75 MG TAB   2 Generic $3.00$6.00None
DICLOFENAC SOD ER 100 MG TABLET ER 24H [Voltaren-XR]   2 Generic $3.00$6.00None
Diclofenac sodium 1.5% soln   2 Generic $3.00$6.00Q:300
/28Days
Diclofenac Sodium 1% gel   2 Generic $3.00$6.00Q:1000
/28Days
Diclofenac Sodium 3% gel   5 Specialty Tier 25%N/AP Q:100
/28Days
DICLOXACILLIN 250MG CAPSULE   2 Generic $3.00$6.00None
DICLOXACILLIN SODIUM 500MG CAP   2 Generic $3.00$6.00None
DICYCLOMINE 10 MG CAPSULE   2 Generic $3.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DICYCLOMINE 20 MG TABLET   2 Generic $3.00$6.00None
DICYCLOMINE HCL 10MG/5ML SYRUP   2 Generic $3.00$6.00None
DIDANOSINE DR 200 MG CAPSULE DR [Videx EC]   3 Preferred Brand $25.00$75.00Q:30
/30Days
DIDANOSINE DR 250 MG CAPSULE [Videx EC]   3 Preferred Brand $25.00$75.00Q:30
/30Days
DIDANOSINE DR 400 MG CAPSULE [Videx EC]   3 Preferred Brand $25.00$75.00Q:30
/30Days
DIFLUNISAL 500 MG TABLET   4 Non-Preferred Drug 41%N/ANone
DIGITEK 125 MCG TABLET   3 Preferred Brand $25.00$75.00Q:30
/30Days
DIGITEK 250 MCG TABLET   3 Preferred Brand $25.00$75.00None
DIGOX 125 MCG TABLET   2 Generic $3.00$6.00Q:30
/30Days
DIGOX 250 MCG TABLET   2 Generic $3.00$6.00None
DIGOXIN 0.05 MG/ML SOLUTION [Lanoxin]   2 Generic $3.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DIGOXIN 125 MCG TABLET [Lanoxin]   2 Generic $3.00$6.00Q:30
/30Days
DIGOXIN 250 MCG TABLET [Lanoxin]   2 Generic $3.00$6.00None
DILANTIN CAPSULES 30 MG ER   4 Non-Preferred Drug 41%N/ANone
DILT XR 120 MG CAPSULE   3 Preferred Brand $25.00$75.00None
DILT XR 180 MG CAPSULE   3 Preferred Brand $25.00$75.00None
DILT XR 240 MG CAPSULE   3 Preferred Brand $25.00$75.00None
DILTIAZEM 120 MG TABLET [Cardizem]   2 Generic $3.00$6.00None
DILTIAZEM 24HR ER 120 MG CAPSULE [Tiazac]   3 Preferred Brand $25.00$75.00None
DILTIAZEM 24HR ER 240 MG CAPSULE [Tiazac]   3 Preferred Brand $25.00$75.00None
DILTIAZEM 24HR ER 300 MG CAPSULE [Tiazac]   3 Preferred Brand $25.00$75.00None
DILTIAZEM 30 MG TABLET [Cardizem]   2 Generic $3.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DILTIAZEM 60 MG TABLET [Cardizem]   2 Generic $3.00$6.00None
DILTIAZEM 90 MG TABLET [Cardizem]   2 Generic $3.00$6.00None
Diph-Tetanus Tox-Acell Pert adsorbed and IPV vaccine 0.5 ML Prefilled Syringe [Kinrix]   3 Preferred Brand $25.00$75.00None
Diph-Tetanus Tox-Acell Pert-Hepatitis B-Polio IPV Vac 0.5 ML Prefilled Syringe [Pediarix]   3 Preferred Brand $25.00$75.00None
Diphtheria Toxoid Vaccine 25 UNT/ML / Tetanus Toxoid Vaccine 5 UNT per 0.5 ML Injectable Suspension   3 Preferred Brand $25.00$75.00None
Diphtheria toxoid vaccine, inact 4 UNT/ML / tetanus toxoid vaccine, inact 4 UNT/ML Inj Sus   3 Preferred Brand $25.00$75.00None
DIPYRIDAMOLE 25 MG TABLET   4 Non-Preferred Drug 41%N/ANone
DIPYRIDAMOLE 50 MG TABLET   4 Non-Preferred Drug 41%N/ANone
DIPYRIDAMOLE 75 MG TABLET   4 Non-Preferred Drug 41%N/ANone
DISULFIRAM 250 MG TABLET   4 Non-Preferred Drug 41%N/ANone
DISULFIRAM 500 MG TABLET   4 Non-Preferred Drug 41%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DIVALPROEX DR 125 MG CAP SPRNK   4 Non-Preferred Drug 41%N/ANone
DIVALPROEX SOD DR 125 MG TAB   2 Generic $3.00$6.00None
DIVALPROEX SOD DR 250 MG TAB   2 Generic $3.00$6.00None
DIVALPROEX SOD DR 500 MG TAB   2 Generic $3.00$6.00None
DIVALPROEX SOD ER 500 MG TAB   4 Non-Preferred Drug 41%N/ANone
DIVALPROEX SODIUM ER TABLETS 250MG 100 BOT   4 Non-Preferred Drug 41%N/ANone
DOFETILIDE 125 MCG CAPSULE [Tikosyn]   3 Preferred Brand $25.00$75.00None
DOFETILIDE 250 MCG CAPSULE [Tikosyn]   3 Preferred Brand $25.00$75.00None
DOFETILIDE 500 MCG CAPSULE [Tikosyn]   3 Preferred Brand $25.00$75.00None
DONEPEZIL HCL 10 MG TABLET   2 Generic $3.00$6.00Q:69
/30Days
DONEPEZIL HCL 5 MG TABLET   2 Generic $3.00$6.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DONEPEZIL HCL ODT 10 MG TABLET   2 Generic $3.00$6.00Q:69
/30Days
DONEPEZIL HCL ODT 5 MG TABLET   2 Generic $3.00$6.00Q:30
/30Days
DOPTELET 20 MG TABLET   5 Specialty Tier 25%N/AP
DOPTELET 20 MG TABLET   5 Specialty Tier 25%N/AP
DORZOLAMIDE HCL OPHTHALMIC 2% 10 ML BOTDR   2 Generic $3.00$6.00None
Dorzolamide Hydrochloride and Timolol Maleate 20; 5mg/mL; mg/mL 1 BOTTLE, DROPPER in 1 BOX / 10 mL   4 Non-Preferred Drug 41%N/ANone
DORZOLAMIDE-TIMOLOL 2%-0.5% DROPERETTE [Cosopt PF]   3 Preferred Brand $25.00$75.00None
DOVATO 50-300 MG TABLET   5 Specialty Tier 25%N/ANone
DOXAZOSIN MESYLATE 1 MG TAB   2 Generic $3.00$6.00Q:30
/30Days
DOXAZOSIN MESYLATE 2 MG TAB   2 Generic $3.00$6.00Q:30
/30Days
DOXAZOSIN MESYLATE 4 MG TAB   2 Generic $3.00$6.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DOXAZOSIN MESYLATE 8 MG TAB   2 Generic $3.00$6.00Q:60
/30Days
DOXEPIN 10 MG/ML ORAL CONC   4 Non-Preferred Drug 41%N/AP
DOXEPIN 10MG CAPSULE   4 Non-Preferred Drug 41%N/AP
DOXEPIN 50 MG CAPSULE   4 Non-Preferred Drug 41%N/AP
DOXEPIN 75MG CAPSULE   4 Non-Preferred Drug 41%N/AP
DOXEPIN HCL 25MG CAPSULE (100 CT)   4 Non-Preferred Drug 41%N/AP
Doxepin Hydrochloride 150mg/1 100 CAPSULE BOTTLE   4 Non-Preferred Drug 41%N/AP
DOXEPIN HYDROCHLORIDE CAPSULES 100MG 100 BOT   4 Non-Preferred Drug 41%N/AP
DOXY 100 VIAL   4 Non-Preferred Drug 41%N/ANone
doxycycline 25 mg/5 ml susp   4 Non-Preferred Drug 41%N/ANone
Doxycycline 75mg/1   4 Non-Preferred Drug 41%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DOXYCYCLINE HYCLATE 100 MG CAP   3 Preferred Brand $25.00$75.00None
DOXYCYCLINE HYCLATE 100 MG TAB   3 Preferred Brand $25.00$75.00None
DOXYCYCLINE HYCLATE 150 MG TAB   2 Generic $3.00$6.00None
DOXYCYCLINE HYCLATE 20MG TABLET (100 CT)   3 Preferred Brand $25.00$75.00None
DOXYCYCLINE HYCLATE 50 MG CAP   3 Preferred Brand $25.00$75.00None
DOXYCYCLINE HYCLATE 75 MG TAB   2 Generic $3.00$6.00None
DOXYCYCLINE MONO 100 MG CAP   4 Non-Preferred Drug 41%N/ANone
DOXYCYCLINE MONO 100 MG TABLET   4 Non-Preferred Drug 41%N/ANone
DOXYCYCLINE MONO 150 MG TABLET   4 Non-Preferred Drug 41%N/ANone
DOXYCYCLINE MONO 50 MG CAP   4 Non-Preferred Drug 41%N/ANone
DOXYCYCLINE MONO 50 MG TABLET   4 Non-Preferred Drug 41%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DOXYCYCLINE MONO 75 MG TABLET   4 Non-Preferred Drug 41%N/ANone
DRONABINOL 10 MG CAPSULE [Marinol]   4 Non-Preferred Drug 41%N/AP Q:60
/30Days
DRONABINOL 2.5 MG CAPSULE [Marinol]   4 Non-Preferred Drug 41%N/AP Q:60
/30Days
DRONABINOL 5 MG CAPSULE [Marinol]   4 Non-Preferred Drug 41%N/AP Q:60
/30Days
DROSP-EE-LEVOMEF 3-0.02-0.451 TABLET [Beyaz]   4 Non-Preferred Drug 41%N/ANone
DROSPIRENONE-EE 3-0.02 MG TAB   4 Non-Preferred Drug 41%N/ANone
DROSPIRENONE-EE 3-0.03 MG TAB   4 Non-Preferred Drug 41%N/ANone
DROXIA 200MG CAPSULE   3 Preferred Brand $25.00$75.00None
DROXIA 300MG CAPSULE   3 Preferred Brand $25.00$75.00None
DROXIA 400MG CAPSULE   3 Preferred Brand $25.00$75.00None
DULERA INHALATION AEROSOL   3 Preferred Brand $25.00$75.00Q:13
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DULERA INHALATION AEROSOL   3 Preferred Brand $25.00$75.00Q:13
/30Days
DULOXETINE HCL DR 20 MG CAPSULE DR [Cymbalta]   3 Preferred Brand $25.00$75.00Q:60
/30Days
DULOXETINE HCL DR 30 MG CAPSULE DR [Cymbalta]   3 Preferred Brand $25.00$75.00Q:60
/30Days
DULOXETINE HCL DR 40 MG CAPSULE DR [Irenka]   3 Preferred Brand $25.00$75.00Q:90
/30Days
DULOXETINE HCL DR 60 MG CAPSULE DR [Cymbalta]   3 Preferred Brand $25.00$75.00Q:60
/30Days
DUPIXENT 200 MG/1.14 ML SYRINGE   5 Specialty Tier 25%N/AP
DUPIXENT 300 MG/2 ML SAFE SYRG   5 Specialty Tier 25%N/AP
duramorph 0.5 mg/ml ampule   4 Non-Preferred Drug 41%N/AQ:4000
/30Days
duramorph 1 mg/ml ampule   4 Non-Preferred Drug 41%N/AQ:2000
/30Days
DUREZOL 0.05% EYE DROPS   3 Preferred Brand $25.00$75.00None

Chart Legend:

Below are a few notes to help you understand the above 2019 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). 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 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.