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2019 Medicare Part D and Medicare Advantage Plan Formulary Browser

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SilverScript Plus (PDP) (S5601-025-0)
Tier 1 (119)
Tier 2 (430)
Tier 3 (1064)
Tier 4 (919)
Tier 5 (549)
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Uses Step Therapy:
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Cick on the first letter of your drug name to browse the formulary:

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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
SilverScript Plus (PDP) (S5601-025-0)
Benefits & Contact Info           
The SilverScript Plus (PDP) (S5601-025-0)
Formulary Drugs Starting with the Letter C

in CMS PDP Region 12 which includes: AL TN
Plan Monthly Premium: $49.50 Deductible: $0 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 40%40%None
CABOMETYX 20 MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
CABOMETYX 40 MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
CABOMETYX 60 MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
CALCIPOTRIENE 0.005% CREAM   4 Non-Preferred Drug 40%40%P Q:120
/30Days
CALCIPOTRIENE 0.005% SOLUTION   4 Non-Preferred Drug 40%40%P Q:120
/30Days
Calcipotriene 50ug/g 60 g per CARTON   4 Non-Preferred Drug 40%40%P Q:120
/30Days
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY   3 Preferred Brand $35.00$87.50P
CALCITRIOL 0.25 MCG CAPSULE [Rocaltrol]   3 Preferred Brand $35.00$87.50P
CALCITRIOL 0.5 MCG CAPSULE [Rocaltrol]   3 Preferred Brand $35.00$87.50P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CALCITRIOL 1MCG/ML SOLUTION ORAL   4 Non-Preferred Drug 40%40%P
CALCIUM ACETATE 667 MG TABLET [PhosLo]   3 Preferred Brand $35.00$87.50Q:360
/30Days
CALCIUM ACETATE CAPSULE 667 MG   4 Non-Preferred Drug 40%40%Q:360
/30Days
CALQUENCE 100 MG CAPSULE   5 Specialty Tier 33%N/AP
CAMILA 0.35 MG TABLET   3 Preferred Brand $35.00$87.50None
CANASA 1,000 MG SUPPOSITORY   4 Non-Preferred Drug 40%40%None
CAPRELSA 100 MG TABLET   5 Specialty Tier 33%N/AP
CAPRELSA 300 MG TABLET   5 Specialty Tier 33%N/AP
CARBAGLU 200 MG DISPER TABLET   5 Specialty Tier 33%N/AP
CARBAMAZEPINE 100 MG TAB CHEW   3 Preferred Brand $35.00$87.50None
CARBAMAZEPINE 100 MG/5 ML SUSP   4 Non-Preferred Drug 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARBAMAZEPINE 200 MG TABLET   3 Preferred Brand $35.00$87.50None
CARBAMAZEPINE ER 100 MG CAP CPMP 12HR [Carbatrol]   4 Non-Preferred Drug 40%40%None
CARBAMAZEPINE ER 100 MG TABLET   4 Non-Preferred Drug 40%40%None
CARBAMAZEPINE ER 200 MG CAP CPMP 12HR [Carbatrol]   4 Non-Preferred Drug 40%40%None
CARBAMAZEPINE ER 300 MG CAP CPMP 12HR [Carbatrol]   4 Non-Preferred Drug 40%40%None
CARBAMAZEPINE XR 200 MG TABLET   4 Non-Preferred Drug 40%40%None
CARBAMAZEPINE XR 400 MG TABLET   4 Non-Preferred Drug 40%40%None
CARBIDOPA AND LEVEDOPA ORALLY DISINTEGRATING TABLETS 10;100MG;MG 100 BOT   4 Non-Preferred Drug 40%40%None
CARBIDOPA AND LEVODOPA ODT 25;100MG;MG 100 BOT   4 Non-Preferred Drug 40%40%None
CARBIDOPA AND LEVODOPA ODT 25;250MG;MG 100 BOT   4 Non-Preferred Drug 40%40%None
CARBIDOPA-LEVO ER 25-100 TAB   3 Preferred Brand $35.00$87.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARBIDOPA-LEVO ER 50-200 TAB   3 Preferred Brand $35.00$87.50None
CARBIDOPA-LEVODOPA 10-100 TAB   2 Generic $5.00$0.00None
CARBIDOPA-LEVODOPA 25-100 TAB   2 Generic $5.00$0.00None
CARBIDOPA-LEVODOPA 25-250 TAB   2 Generic $5.00$0.00None
CARBIDOPA-LEVODOPA-ENTA 150 MG   4 Non-Preferred Drug 40%40%None
CARBIDOPA-LEVODOPA-ENTA 75 MG   4 Non-Preferred Drug 40%40%None
CARBIDOPA-LEVODOPA-ENTACAPONE 100 MG [Stalevo]   4 Non-Preferred Drug 40%40%None
CARBIDOPA-LEVODOPA-ENTACAPONE 125 MG [Stalevo]   4 Non-Preferred Drug 40%40%None
CARBIDOPA-LEVODOPA-ENTACAPONE 200 MG [Stalevo]   4 Non-Preferred Drug 40%40%None
CARBIDOPA-LEVODOPA-ENTACAPONE 50 MG [Stalevo]   4 Non-Preferred Drug 40%40%None
CARTEOLOL HCL 1% EYE DROPS   2 Generic $5.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARTIA XT 120MG CAPSULE SA   3 Preferred Brand $35.00$87.50None
CARTIA XT 180MG CAPSULE SA   3 Preferred Brand $35.00$87.50None
CARTIA XT 240MG CAPSULE SA   3 Preferred Brand $35.00$87.50None
CARTIA XT 300 MG CAPSULE   3 Preferred Brand $35.00$87.50None
CARVEDILOL 12.5 MG TABLET   2 Generic $5.00$0.00None
CARVEDILOL 25 MG TABLET   2 Generic $5.00$0.00None
CARVEDILOL 3.125 MG TABLET   2 Generic $5.00$0.00None
CARVEDILOL 6.25 MG TABLET   2 Generic $5.00$0.00None
CASPOFUNGIN ACETATE 50 MG VIAL   5 Specialty Tier 33%N/ANone
CASPOFUNGIN ACETATE 70 MG VIAL   5 Specialty Tier 33%N/ANone
CAYSTON KIT 75 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
CAZIANT 28 DAY TABLET   3 Preferred Brand $35.00$87.50None
CEFACLOR 125 MG/5 ML SUSP Oral Suspension [Ceclor]   4 Non-Preferred Drug 40%40%None
CEFACLOR 250 MG CAPSULES   3 Preferred Brand $35.00$87.50None
CEFACLOR 250 MG/5 ML SUSPEN Oral Suspension [Ceclor]   4 Non-Preferred Drug 40%40%None
CEFACLOR 375 MG/5 ML SUSPEN Oral Suspension [Ceclor]   4 Non-Preferred Drug 40%40%None
CEFACLOR 500 MG CAPSULES   3 Preferred Brand $35.00$87.50None
CEFACLOR ER 500MG TABLET SR 12HR   4 Non-Preferred Drug 40%40%None
CEFADROXIL 1 GM TABLET   3 Preferred Brand $35.00$87.50None
CEFADROXIL 250 MG/5 ML SUSP   3 Preferred Brand $35.00$87.50None
CEFADROXIL 500 MG CAPSULE   2 Generic $5.00$0.00None
CEFADROXIL 500 MG/5 ML SUSP   3 Preferred Brand $35.00$87.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFAZOLIN 1 GM VIAL 25/Box   4 Non-Preferred Drug 40%40%None
Cefazolin 10g/1 10 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 PACKAGE   4 Non-Preferred Drug 40%40%None
CEFAZOLIN 500 MG VIAL   4 Non-Preferred Drug 40%40%None
CEFDINIR 125 MG/5 ML SUSP   4 Non-Preferred Drug 40%40%None
CEFDINIR 250 MG/5 ML SUSP   4 Non-Preferred Drug 40%40%None
CEFDINIR 300 MG CAPSULE   3 Preferred Brand $35.00$87.50None
CEFEPIME HCL 1 GM VIAL [Maxipime]   4 Non-Preferred Drug 40%40%None
CEFEPIME HCL 2 GRAM VIAL [Maxipime]   4 Non-Preferred Drug 40%40%None
CEFIXIME 100 MG/5 ML SUSP [Suprax]   4 Non-Preferred Drug 40%40%None
CEFIXIME 200 MG/5 ML SUSP [Suprax]   4 Non-Preferred Drug 40%40%None
Cefotaxime 500 MG Injection   4 Non-Preferred Drug 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Cefotaxime sodium 1 gm vial   4 Non-Preferred Drug 40%40%None
CEFOXITIN 1 GM VIAL   4 Non-Preferred Drug 40%40%None
CEFOXITIN 10 GM VIAL   4 Non-Preferred Drug 40%40%None
CEFOXITIN 2 GM VIAL   4 Non-Preferred Drug 40%40%None
CEFPODOXIME 100 MG TABLET   3 Preferred Brand $35.00$87.50None
CEFPODOXIME 100 MG/5 ML SUSP   4 Non-Preferred Drug 40%40%None
CEFPODOXIME 200 MG TABLET   3 Preferred Brand $35.00$87.50None
CEFPODOXIME 50 MG/5 ML SUSP   4 Non-Preferred Drug 40%40%None
CEFPROZIL 125 MG/5 ML SUSP   3 Preferred Brand $35.00$87.50None
CEFPROZIL 250 MG TABLET   3 Preferred Brand $35.00$87.50None
CEFPROZIL 250 MG/5 ML SUSP   3 Preferred Brand $35.00$87.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFPROZIL 500 MG TABLET   3 Preferred Brand $35.00$87.50None
CEFTAZIDIME 1 GM VIAL   4 Non-Preferred Drug 40%40%None
CEFTAZIDIME FOR INJECTION 2GM/VIAL 10 X 2 CRTN   4 Non-Preferred Drug 40%40%None
CEFTAZIDIME FOR INJECTION 6GM/VIAL 6 X 6 CRTN   4 Non-Preferred Drug 40%40%None
CEFTRIAXONE 1 GM VIAL   4 Non-Preferred Drug 40%40%None
CEFTRIAXONE 10 GM VIAL   4 Non-Preferred Drug 40%40%None
CEFTRIAXONE 2 GM VIAL   4 Non-Preferred Drug 40%40%None
CEFTRIAXONE 250 MG VIAL   4 Non-Preferred Drug 40%40%None
CEFTRIAXONE 500 MG VIAL   4 Non-Preferred Drug 40%40%None
CEFUROXIME 1.5 GM/VIAL FOR INJECTION   4 Non-Preferred Drug 40%40%None
CEFUROXIME 750 MG FOR INJECTION   4 Non-Preferred Drug 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Cefuroxime 95 MG/ML Injectable Solution   4 Non-Preferred Drug 40%40%None
CEFUROXIME AXETIL 250 MG TAB   3 Preferred Brand $35.00$87.50None
CEFUROXIME AXETIL 500 MG TAB   3 Preferred Brand $35.00$87.50None
CELECOXIB 100 MG CAPSULE [Celebrex]   3 Preferred Brand $35.00$87.50Q:120
/30Days
CELECOXIB 200 MG CAPSULE [Celebrex]   3 Preferred Brand $35.00$87.50Q:60
/30Days
CELECOXIB 400 MG CAPSULE [Celebrex]   3 Preferred Brand $35.00$87.50Q:30
/30Days
CELECOXIB 50 MG CAPSULE [Celebrex]   3 Preferred Brand $35.00$87.50Q:240
/30Days
CELONTIN 300 MG KAPSEAL   4 Non-Preferred Drug 40%40%None
CEPHALEXIN 125 MG/5 ML SUSP   3 Preferred Brand $35.00$87.50None
CEPHALEXIN 250 MG CAPSULE   2 Generic $5.00$0.00None
CEPHALEXIN 250 MG/5 ML SUSP   3 Preferred Brand $35.00$87.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEPHALEXIN 500 MG CAPSULE   2 Generic $5.00$0.00None
CERDELGA 84 MG CAPSULE   5 Specialty Tier 33%N/AP
CETIRIZINE HCL 1 MG/ML SOLN   2 Generic $5.00$0.00None
CHANTIX 0.5 MG TABLET   4 Non-Preferred Drug 40%40%P
CHANTIX 1 MG CONT MONTH BOX   4 Non-Preferred Drug 40%40%P
CHANTIX 1 MG TABLET   4 Non-Preferred Drug 40%40%P
CHANTIX STARTING MONTH BOX   4 Non-Preferred Drug 40%40%P
CHEMET 100 MG CAPSULE   4 Non-Preferred Drug 40%40%None
CHLORHEXIDINE GLUCONATE 0.12% RINSE   2 Generic $5.00$0.00None
CHLOROQUINE PH 250 MG TABLET   4 Non-Preferred Drug 40%40%None
CHLOROQUINE PH 500 MG TABLET   4 Non-Preferred Drug 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CHLOROTHIAZIDE 250 MG TABLET   3 Preferred Brand $35.00$87.50None
Chlorothiazide 500mg 100 TABLET BOTTLE   3 Preferred Brand $35.00$87.50None
CHLORPROMAZINE 10 MG TABLET   4 Non-Preferred Drug 40%40%None
CHLORPROMAZINE 100 MG TABLET   4 Non-Preferred Drug 40%40%None
CHLORPROMAZINE 200 MG TABLET   4 Non-Preferred Drug 40%40%None
CHLORPROMAZINE 25 MG TABLET   4 Non-Preferred Drug 40%40%None
CHLORPROMAZINE 50 MG TABLET   4 Non-Preferred Drug 40%40%None
CHLORTHALIDONE 25 MG TABLET (100 CT)   3 Preferred Brand $35.00$87.50None
CHLORTHALIDONE 50 MG TABLET   3 Preferred Brand $35.00$87.50None
CHOLESTYRAMINE LIGHT POWDER   4 Non-Preferred Drug 40%40%None
CHOLESTYRAMINE PACKET   4 Non-Preferred Drug 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CICLOPIROX 0.77% CREAM   3 Preferred Brand $35.00$87.50None
CICLOPIROX 0.77% GEL   4 Non-Preferred Drug 40%40%None
CICLOPIROX 0.77% TOPICAL SUSP   3 Preferred Brand $35.00$87.50None
CICLOPIROX 1% SHAMPOO   4 Non-Preferred Drug 40%40%None
Cilastatin 250 MG / Imipenem 250 MG Injection   3 Preferred Brand $35.00$87.50None
Cilastatin 500 MG / Imipenem 500 MG Injection   3 Preferred Brand $35.00$87.50None
CILOSTAZOL 100 MG TABLET   2 Generic $5.00$0.00None
CILOSTAZOL 50 MG TABLET   2 Generic $5.00$0.00None
CILOXAN 0.3% OINTMENT   3 Preferred Brand $35.00$87.50None
CIMDUO 300-300 MG TABLET   5 Specialty Tier 33%N/ANone
CINACALCET HCL 30 MG TABLET [Sensipar]   5 Specialty Tier 33%N/AP Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CINACALCET HCL 60 MG TABLET [Sensipar]   5 Specialty Tier 33%N/AP Q:60
/30Days
CINACALCET HCL 90 MG TABLET [Sensipar]   5 Specialty Tier 33%N/AP Q:120
/30Days
CIPRODEX OTIC SUSPENSION   4 Non-Preferred Drug 40%40%None
CIPROFLOXACIN 0.3% EYE DROP [Ciloxan]   2 Generic $5.00$0.00None
CIPROFLOXACIN 250 MG TABLET (100 CT) [Cipro]   2 Generic $5.00$0.00None
CIPROFLOXACIN 500 MG/5 ML SUSP MC REC [Cipro]   4 Non-Preferred Drug 40%40%None
CIPROFLOXACIN HCL 100 MG Tablet [Cipro]   4 Non-Preferred Drug 40%40%None
CIPROFLOXACIN HCL 500 MG Tablet [Cipro]   2 Generic $5.00$0.00None
CIPROFLOXACIN HCL 750 MG Tablet [Cipro]   2 Generic $5.00$0.00None
CIPROFLOXACIN-D5W 200 MG/100 ML PIGGYBACK [Cipro]   4 Non-Preferred Drug 40%40%None
CITALOPRAM HBR 10 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
CITALOPRAM HBR 10 MG/5 ML SOLN   3 Preferred Brand $35.00$87.50None
CITALOPRAM HBR 20 MG TABLET   1 Preferred Generic $1.00$0.00None
CITALOPRAM HBR 40 MG TABLET   1 Preferred Generic $1.00$0.00None
CLARAVIS 10 MG CAPSULE   4 Non-Preferred Drug 40%40%P
CLARAVIS 20 MG CAPSULE   4 Non-Preferred Drug 40%40%P
Claravis 30mg 3 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK   4 Non-Preferred Drug 40%40%P
CLARAVIS 40 MG CAPSULE   4 Non-Preferred Drug 40%40%P
CLARITHROMYCIN 125 MG/5ML FOR ORAL SUSPENSION   4 Non-Preferred Drug 40%40%None
CLARITHROMYCIN 250 MG TABLET   3 Preferred Brand $35.00$87.50None
CLARITHROMYCIN 250 MG/5MLFOR ORAL SUSPENSION   4 Non-Preferred Drug 40%40%None
CLARITHROMYCIN 500 MG TABLET   3 Preferred Brand $35.00$87.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLARITHROMYCIN ER 500 MG TAB   3 Preferred Brand $35.00$87.50None
CLINDACIN PAC KIT   3 Preferred Brand $35.00$87.50None
Clindamycin 150 MG/ML 2ml   4 Non-Preferred Drug 40%40%None
CLINDAMYCIN 150mg/ml vl 25x6ml   4 Non-Preferred Drug 40%40%None
CLINDAMYCIN 75 MG/5 ML SOLN   4 Non-Preferred Drug 40%40%None
CLINDAMYCIN HCL 150 MG CAPSULE   2 Generic $5.00$0.00None
CLINDAMYCIN HCL 300 MG CAPSULE   2 Generic $5.00$0.00None
CLINDAMYCIN HCL 75 MG 200 CAPSULE BOTTLE   2 Generic $5.00$0.00None
CLINDAMYCIN PH 1% SOLUTION   3 Preferred Brand $35.00$87.50None
CLINDAMYCIN PH 600 MG/4 ML VL   4 Non-Preferred Drug 40%40%None
CLINDAMYCIN PHOSP 1% LOTION   4 Non-Preferred Drug 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE   4 Non-Preferred Drug 40%40%None
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX   3 Preferred Brand $35.00$87.50None
CLINDAMYCIN PHOSPHATE VAGINAL CREAM   3 Preferred Brand $35.00$87.50None
Clindamycin-d5w 300 mg/50 ml   4 Non-Preferred Drug 40%40%None
Clindamycin-d5w 600 mg/50 ml   4 Non-Preferred Drug 40%40%None
Clindamycin-d5w 900 mg/50 ml   4 Non-Preferred Drug 40%40%None
CLINIMIX 4.25%-25% SOLUTION IV SOLN   4 Non-Preferred Drug 40%40%P
CLINIMIX 5/20 SOLUTION   4 Non-Preferred Drug 40%40%P
CLINIMIX 5/25 SULFITE FREE INJECTIONS 1035MG-420MEQ 1000ML BAG   4 Non-Preferred Drug 40%40%P
CLINIMIX 5%-15% SOLUTION   4 Non-Preferred Drug 40%40%P
CLOBAZAM 10 MG TABLET [ONFI]   3 Preferred Brand $35.00$87.50P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLOBAZAM 2.5 MG/ML Oral Suspension [ONFI]   3 Preferred Brand $35.00$87.50P
CLOBAZAM 20 MG TABLET [ONFI]   3 Preferred Brand $35.00$87.50P
CLOMIPRAMINE 25 MG CAPSULE   4 Non-Preferred Drug 40%40%P
CLOMIPRAMINE 50 MG CAPSULE   4 Non-Preferred Drug 40%40%P
CLOMIPRAMINE 75 MG CAPSULE   4 Non-Preferred Drug 40%40%P
CLONAZEPAM 0.125 MG DIS TAB RAPDIS [Klonopin]   3 Preferred Brand $35.00$87.50Q:90
/30Days
CLONAZEPAM 0.25 MG ODT TAB RAPDIS [Klonopin]   3 Preferred Brand $35.00$87.50Q:90
/30Days
CLONAZEPAM 0.5 MG DIS TABLET RAPDIS [Klonopin]   3 Preferred Brand $35.00$87.50Q:90
/30Days
CLONAZEPAM 0.5 MG TABLET [Klonopin]   2 Generic $5.00$0.00Q:90
/30Days
CLONAZEPAM 1 MG DIS TABLET RAPDIS [Klonopin]   3 Preferred Brand $35.00$87.50Q:90
/30Days
CLONAZEPAM 1 MG TABLET [Klonopin]   2 Generic $5.00$0.00Q:90
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLONAZEPAM 2 MG ODT TAB RAPDIS [Klonopin]   3 Preferred Brand $35.00$87.50Q:300
/30Days
CLONAZEPAM 2 MG TABLET [Klonopin]   2 Generic $5.00$0.00Q:300
/30Days
Clonidine 0.1mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH   4 Non-Preferred Drug 40%40%None
Clonidine 0.2mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH   4 Non-Preferred Drug 40%40%None
Clonidine 0.3mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH   4 Non-Preferred Drug 40%40%None
CLONIDINE HCL 0.1 MG TABLET   2 Generic $5.00$0.00None
CLONIDINE HCL 0.2 MG TABLET   2 Generic $5.00$0.00None
CLONIDINE HCL 0.3 MG TABLET   2 Generic $5.00$0.00None
CLOPIDOGREL 75 MG TABLET [Plavix]   1 Preferred Generic $1.00$0.00None
CLORAZEPATE 15 MG TABLET   4 Non-Preferred Drug 40%40%P Q:180
/30Days
CLORAZEPATE 3.75 MG TABLET   4 Non-Preferred Drug 40%40%P Q:180
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLORAZEPATE 7.5 MG TABLET   4 Non-Preferred Drug 40%40%P Q:180
/30Days
CLOTRIMAZOLE 1% CREAM   3 Preferred Brand $35.00$87.50None
CLOTRIMAZOLE 1% SOLUTION   3 Preferred Brand $35.00$87.50None
CLOTRIMAZOLE 10 MG TROCHE   4 Non-Preferred Drug 40%40%None
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE 0.64; 10mg/g; mg/g 45 g in 1 TUBE   3 Preferred Brand $35.00$87.50None
CLOZAPINE 100 MG TABLET [Clozaril]   4 Non-Preferred Drug 40%40%None
CLOZAPINE 200 MG TABLET   4 Non-Preferred Drug 40%40%None
CLOZAPINE 25 MG TABLET [Clozaril]   3 Preferred Brand $35.00$87.50None
CLOZAPINE 50 MG TABLET   3 Preferred Brand $35.00$87.50None
CLOZAPINE ODT 100 MG TABLET RAPDIS [Fazaclo]   4 Non-Preferred Drug 40%40%P
CLOZAPINE ODT 12.5 MG TABLET RAPDIS [Fazaclo]   4 Non-Preferred Drug 40%40%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLOZAPINE ODT 150 MG TABLET RAPDIS [Fazaclo]   4 Non-Preferred Drug 40%40%P
CLOZAPINE ODT 200 MG TABLET RAPDIS [Fazaclo]   4 Non-Preferred Drug 40%40%P
CLOZAPINE ODT 25 MG TABLET RAPDIS [Fazaclo]   4 Non-Preferred Drug 40%40%P
COARTEM 20MG-120MG   4 Non-Preferred Drug 40%40%None
COLCRYS 0.6 MG TABLET   3 Preferred Brand $35.00$87.50Q:120
/30Days
COLESTIPOL HCL 1G TABLET   3 Preferred Brand $35.00$87.50None
COLESTIPOL HCL GRANULES PACKET   4 Non-Preferred Drug 40%40%None
COLISTIMETHATE 150 MG VIAL [Coly-Mycin M]   4 Non-Preferred Drug 40%40%None
COLOCORT 100MG ENEMA   4 Non-Preferred Drug 40%40%None
COMBIGAN 0.2%-0.5% DROPS   3 Preferred Brand $35.00$87.50None
COMBIVENT RESPIMAT INHAL SPRAY   4 Non-Preferred Drug 40%40%Q:8
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COMETRIQ 100 MG DAILY-DOSE PK   5 Specialty Tier 33%N/AP
COMETRIQ 140 MG DAILY-DOSE PK   5 Specialty Tier 33%N/AP
COMETRIQ 60 MG DAILY-DOSE PACK   5 Specialty Tier 33%N/AP
COMPLERA 200; 27.5; 300mg/1; mg/1; mg/1   5 Specialty Tier 33%N/ANone
COMPRO 25MG SUPPOSITORY   4 Non-Preferred Drug 40%40%None
CONSTULOSE 10 GM/15 ML SOLN   2 Generic $5.00$0.00None
COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN   5 Specialty Tier 33%N/AP Q:30
/30Days
COPAXONE 40 MG/ML SYRINGE   5 Specialty Tier 33%N/AP Q:12
/28Days
COPIKTRA 15 MG CAPSULE   5 Specialty Tier 33%N/AP
COPIKTRA 25 MG CAPSULE   5 Specialty Tier 33%N/AP
CORLANOR 5 MG TABLET   4 Non-Preferred Drug 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CORLANOR 7.5 MG TABLET   4 Non-Preferred Drug 40%40%None
Cortisone 25 MG Tablet   4 Non-Preferred Drug 40%40%None
COTELLIC 20 MG TABLET   5 Specialty Tier 33%N/AP
COUMADIN 1 MG TABLET   3 Preferred Brand $35.00$87.50None
COUMADIN 10MG TABLET   3 Preferred Brand $35.00$87.50None
COUMADIN 2.5 MG TABLET   3 Preferred Brand $35.00$87.50None
COUMADIN 2MG TABLET   3 Preferred Brand $35.00$87.50None
COUMADIN 3mg/1 1 BOTTLE per CARTON / 100 TABLET BOTTLE   3 Preferred Brand $35.00$87.50None
COUMADIN 4mg/1 1 BOTTLE in 1 CARTON / 100 TABLET BOTTLE   3 Preferred Brand $35.00$87.50None
COUMADIN 5MG TABLET   3 Preferred Brand $35.00$87.50None
COUMADIN 6MG TABLET   3 Preferred Brand $35.00$87.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COUMADIN 7.5MG TABLET   3 Preferred Brand $35.00$87.50None
Creon 256.11mg/1 1 BOTTLE per CARTON / 70 CAPSULE, DELAYED RELEASE in 1 BOTTLE   3 Preferred Brand $35.00$87.50None
CREON DELAYED RELEASE CAPSULES 12000MG 100 BOT   3 Preferred Brand $35.00$87.50None
CREON DELAYED RELEASE CAPSULES 24000MG 100 BOT   3 Preferred Brand $35.00$87.50None
CREON DELAYED RELEASE CAPSULES 6000MG 100 BOT   3 Preferred Brand $35.00$87.50None
CREON DR 36,000 UNITS CAPSULE   3 Preferred Brand $35.00$87.50None
CRIXIVAN 200MG CAPSULE   4 Non-Preferred Drug 40%40%None
CRIXIVAN 400mg, 180 CAPSULE BOTTLE   4 Non-Preferred Drug 40%40%None
CROMOLYN 20 MG/2 ML NEB SOLN   3 Preferred Brand $35.00$87.50P
CROMOLYN SODIUM 100 MG/5 ML   5 Specialty Tier 33%N/ANone
CROMOLYN SODIUM 4% 40MG 10ML BOT   2 Generic $5.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Cyclafem 1/35 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK   3 Preferred Brand $35.00$87.50None
CYCLAFEM 7-7-7-28 TABLET   3 Preferred Brand $35.00$87.50None
CYCLOBENZAPRINE 10 MG TABLET   3 Preferred Brand $35.00$87.50P
CYCLOBENZAPRINE 5 MG TABLET   3 Preferred Brand $35.00$87.50P
CYCLOPHOSPHAMIDE 25 MG CAPSULE   4 Non-Preferred Drug 40%40%P
CYCLOPHOSPHAMIDE 50 MG CAPSULE   4 Non-Preferred Drug 40%40%P
CYCLOSPORINE 100MG CAPSULE   4 Non-Preferred Drug 40%40%P
CYCLOSPORINE 25MG CAPSULE   4 Non-Preferred Drug 40%40%P
CYCLOSPORINE MODIFIED 100 MG   4 Non-Preferred Drug 40%40%P
CYCLOSPORINE MODIFIED 25 MG   4 Non-Preferred Drug 40%40%P
CYCLOSPORINE MODIFIED 50 MG   4 Non-Preferred Drug 40%40%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT   4 Non-Preferred Drug 40%40%P
CYPROHEPTADINE 4 MG TABLET   3 Preferred Brand $35.00$87.50P
CYPROHEPTADINE HYDROCHLORIDE SOLUTION USP SYRUP 2MG 473 ML BOTGL   3 Preferred Brand $35.00$87.50P
CYRED EQ 28 DAY TABLET [Solia]   3 Preferred Brand $35.00$87.50None
CYSTADANE 1 GRAM/1.7 ML POWDER   5 Specialty Tier 33%N/ANone
CYSTAGON 150MG CAPSULE   4 Non-Preferred Drug 40%40%P
CYSTAGON 50MG CAPSULE   4 Non-Preferred Drug 40%40%P
CYSTARAN 0.44% EYE DROPS   5 Specialty Tier 33%N/AP

Chart Legend:

Below are a few notes to help you understand the above 2019 Medicare Part D SilverScript Plus (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.