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AARP MedicareRx Walgreens (PDP) (S5921-393-0)
Tier 1 (149)
Tier 2 (618)
Tier 3 (773)
Tier 4 (934)
Tier 5 (551)
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Cick on the first letter of your drug name to browse the formulary:

A B C D E F G H I J K L 
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)
Benefit Details           
The AARP MedicareRx Walgreens (PDP) (S5921-393-0)
Formulary Drugs Starting with the Letter A

in CMS PDP Region 12 which includes: AL TN
Plan Monthly Premium: $28.10 Deductible: $415 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 32%32%Q:1440
/30Days
ABACAVIR 300 MG TABLET   4 Non-Preferred Drug 32%32%Q:90
/30Days
Abacavir Sulfate-Lamivudine-Zidovudine tablets [Trizivir]   5 Specialty Tier 25%25%Q:90
/30Days
ABACAVIR-LAMIVUDINE 600-300 MG   4 Non-Preferred Drug 32%32%Q:60
/30Days
ABELCET INJECTION SUSPENSION 5MG/ML   4 Non-Preferred Drug 32%32%P
ABILIFY MAINTENA ER 300 MG SYR   5 Specialty Tier 25%25%None
ABILIFY MAINTENA ER 300 MG VL   5 Specialty Tier 25%25%None
ABILIFY MAINTENA ER 400 MG SUSER VIAL   5 Specialty Tier 25%25%None
ABILIFY MAINTENA ER 400 MG SYR   5 Specialty Tier 25%25%None
ABIRATERONE ACETATE 250 MG TABLET [ZYTIGA]   4 Non-Preferred Drug 32%32%P Q:240
/30Days
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 32%32%None
ACARBOSE 100 MG TABLET   3 Preferred Brand $30.00$90.00Q:90
/30Days
ACARBOSE 25 MG TABLET   3 Preferred Brand $30.00$90.00Q:360
/30Days
ACARBOSE 50 MG TABLET   3 Preferred Brand $30.00$90.00Q:180
/30Days
ACETAMINOP-CODEINE 120-12 MG/5   2* Generic $5.00$15.00Q:4500
/30Days
Acetaminophen 325 MG / Hydrocodone Bitartrate 5 MG Oral Tablet [Lorcet]   3 Preferred Brand $30.00$90.00Q:360
/30Days
ACETAMINOPHEN-COD #2 TABLET   2* Generic $5.00$15.00Q:390
/30Days
ACETAMINOPHEN-COD #3 TABLET   2* Generic $5.00$15.00Q:390
/30Days
ACETAMINOPHEN-COD #4 TABLET   2* Generic $5.00$15.00Q:390
/30Days
ACETAZOLAMIDE 125MG TABLET   3 Preferred Brand $30.00$90.00None
ACETAZOLAMIDE 250MG TABLET (100 CT)   3 Preferred Brand $30.00$90.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETAZOLAMIDE ER 500 MG CAP   4 Non-Preferred Drug 32%32%None
ACETIC ACID 2% EAR SOLUTION   2* Generic $5.00$15.00None
ACETYLCYSTEINE 10% VIAL   2* Generic $5.00$15.00P
Acetylcysteine 200 MG/ML Inhalant Solution   2* Generic $5.00$15.00P
ACITRETIN 10 MG CAPSULE [Soriatane]   4 Non-Preferred Drug 32%32%None
ACITRETIN 17.5 MG CAPSULE [Soriatane]   4 Non-Preferred Drug 32%32%None
ACITRETIN 25 MG CAPSULE [Soriatane]   4 Non-Preferred Drug 32%32%None
ACTEMRA 162 MG/0.9 ML SYRINGE   5 Specialty Tier 25%25%P
ACTEMRA ACTPEN 162 MG/0.9 ML PEN INJCTR   5 Specialty Tier 25%25%P
ACTHIB VACCINE WITH DILUENT   3 Preferred Brand $30.00$90.00None
ACTIMMUNE 100 MCG/0.5 ML VIAL   5 Specialty Tier 25%25%None
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$15.00None
ACYCLOVIR 200 MG/5 ML SUSP   4 Non-Preferred Drug 32%32%None
ACYCLOVIR 400 MG TABLET   2* Generic $5.00$15.00None
ACYCLOVIR 800 MG TABLET   2* Generic $5.00$15.00None
Acyclovir sodium 500 mg vial   4 Non-Preferred Drug 32%32%P
ADACEL TDAP SYRINGE   3 Preferred Brand $30.00$90.00None
ADACEL VIAL 2UNT/5UNT   3 Preferred Brand $30.00$90.00None
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA]   5 Specialty Tier 25%25%P
ADAPALENE 0.1% CREAM   4 Non-Preferred Drug 32%32%None
ADAPALENE 0.1% GEL   3 Preferred Brand $30.00$90.00None
ADCIRCA TABLETS 20MG 60 BOTTLE   5 Specialty Tier 25%25%P Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADEMPAS 0.5 MG TABLET   5 Specialty Tier 25%25%P
ADEMPAS 1 MG TABLET   5 Specialty Tier 25%25%P
ADEMPAS 1.5 MG TABLET   5 Specialty Tier 25%25%P
ADEMPAS 2 MG TABLET   5 Specialty Tier 25%25%P
ADEMPAS 2.5 MG TABLET   5 Specialty Tier 25%25%P
Afinitor 7.5mg/1 28 BLISTER PACK per CARTON / 1 TABLET per BLISTER PACK   5 Specialty Tier 25%25%P
AFINITOR DISPERZ 2 MG TABLET   5 Specialty Tier 25%25%P
AFINITOR DISPERZ 3 MG TABLET   5 Specialty Tier 25%25%P
AFINITOR DISPERZ 5 MG TABLET   5 Specialty Tier 25%25%P
AFINITOR TABLETS 10 MG   5 Specialty Tier 25%25%P
AFINITOR TABLETS 2.5 MG   5 Specialty Tier 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AFINITOR TABLETS 5 MG   5 Specialty Tier 25%25%P
AIMOVIG 140 MG/ML AUTOINJECTOR   4 Non-Preferred Drug 32%32%P Q:1
/30Days
AIMOVIG 70 MG/ML AUTOINJECTOR   4 Non-Preferred Drug 32%32%P Q:2
/30Days
Ala-cort 2.5% cream   2* Generic $5.00$15.00None
ALBENDAZOLE 200 MG TABLET [Albenza]   5 Specialty Tier 25%25%Q:480
/30Days
ALBENZA 200 MG TABLET   5 Specialty Tier 25%25%Q:480
/30Days
ALBUTEROL SUL 2.5 MG/3 ML SOLN   3 Preferred Brand $30.00$90.00P
ALBUTEROL SULFATE 0.75mg/3mL 30 POUCH per CARTON / 1 VIAL, SINGLE-DOSE in 1 POUCH / 3 mL in 1 VIAL   3 Preferred Brand $30.00$90.00P
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER   3 Preferred Brand $30.00$90.00P
ALBUTEROL SULFATE 2 MG TAB   4 Non-Preferred Drug 32%32%None
ALBUTEROL SULFATE 4 MG TAB   4 Non-Preferred Drug 32%32%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   3 Preferred Brand $30.00$90.00P
ALCLOMETASONE DIPR 0.05% OINT   3 Preferred Brand $30.00$90.00None
ALCLOMETASONE DIPRO 0.05% CRM   3 Preferred Brand $30.00$90.00None
ALECENSA 150 MG CAPSULE   5 Specialty Tier 25%25%P Q:240
/30Days
ALENDRONATE SODIUM 10 MG TAB   1* Preferred Generic $0.00$0.00Q:30
/30Days
ALENDRONATE SODIUM 35 MG TABLET [Fosamax]   1* Preferred Generic $0.00$0.00Q:8
/28Days
ALENDRONATE SODIUM 40 MG TABLET   1* Preferred Generic $0.00$0.00Q:30
/30Days
ALENDRONATE SODIUM 5 MG TABLET   1* Preferred Generic $0.00$0.00Q:30
/30Days
ALENDRONATE SODIUM 70 MG TABLET [Fosamax]   1* Preferred Generic $0.00$0.00Q:4
/28Days
ALENDRONATE SODIUM 70 MG/75 ML   3 Preferred Brand $30.00$90.00None
ALFUZOSIN HCL ER 10 MG TABLET   2* Generic $5.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALINIA 100 MG/5 ML SUSPENSION   4 Non-Preferred Drug 32%32%None
ALINIA 500 MG TABLET   4 Non-Preferred Drug 32%32%None
ALLOPURINOL 100 MG TABLET   1* Preferred Generic $0.00$0.00None
ALLOPURINOL 300 MG TABLET   1* Preferred Generic $0.00$0.00None
ALOSETRON HCL 0.5 MG TABLET [Lotronex]   5 Specialty Tier 25%25%P
ALOSETRON HCL 1 MG TABLET [Lotronex]   5 Specialty Tier 25%25%P
ALPHAGAN P 0.1% DROPS   3 Preferred Brand $30.00$90.00None
ALPRAZOLAM 0.25 MG TABLET   2* Generic $5.00$15.00Q:120
/30Days
ALPRAZOLAM 0.5 MG TABLET   2* Generic $5.00$15.00Q:120
/30Days
ALPRAZOLAM 1 MG TABLET   2* Generic $5.00$15.00Q:120
/30Days
ALPRAZOLAM 2 MG TABLET   2* Generic $5.00$15.00Q:150
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALTAVERA-28 TABLET [Portia]   4 Non-Preferred Drug 32%32%None
ALUNBRIG 180 MG TABLET   5 Specialty Tier 25%25%P Q:30
/30Days
ALUNBRIG 30 MG TABLET   5 Specialty Tier 25%25%P Q:120
/30Days
ALUNBRIG 90 MG TABLET   5 Specialty Tier 25%25%P Q:30
/30Days
ALUNBRIG 90 MG-180 MG TABLET PACK   5 Specialty Tier 25%25%P Q:30
/30Days
ALYACEN 1-35-28 TABLET   4 Non-Preferred Drug 32%32%None
ALYQ 20 MG TABLET   5 Specialty Tier 25%25%P Q:60
/30Days
AMANTADINE 100 MG CAPSULE   3 Preferred Brand $30.00$90.00None
AMANTADINE 50 MG/5 ML SOLUTION   2* Generic $5.00$15.00None
AMBISOME 50MG VIAL   4 Non-Preferred Drug 32%32%P
AMETHIA 0.15-0.03-0.01 MG TABLET   4 Non-Preferred Drug 32%32%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMETHIA LO TABLET   4 Non-Preferred Drug 32%32%None
AMIKACIN SULF 500 MG/2 ML VIAL   4 Non-Preferred Drug 32%32%None
AMILORIDE HCL 5 MG TABLET [Midamor]   2* Generic $5.00$15.00None
Amino Acids 15% Solution   4 Non-Preferred Drug 32%32%P
AMINOSYN II 10% SOL 6X2000 ML   4 Non-Preferred Drug 32%32%P
AMINOSYN II 15% IV SOLUTION   4 Non-Preferred Drug 32%32%P
AMINOSYN PF INJECTION   4 Non-Preferred Drug 32%32%P
AMINOSYN-PF 7% IV SOLUTION   4 Non-Preferred Drug 32%32%P
AMIODARONE HCL 200 MG TABLET   1* Preferred Generic $0.00$0.00None
AMITRIPTYLINE HCL 10 MG TAB   3 Preferred Brand $30.00$90.00None
AMITRIPTYLINE HCL 100 MG TAB   3 Preferred Brand $30.00$90.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITRIPTYLINE HCL 150 MG TAB   3 Preferred Brand $30.00$90.00None
AMITRIPTYLINE HCL 25 MG TAB   3 Preferred Brand $30.00$90.00None
AMITRIPTYLINE HCL 50 MG TAB   3 Preferred Brand $30.00$90.00None
AMITRIPTYLINE HCL 75 MG TAB   3 Preferred Brand $30.00$90.00None
AMLODIPINE BESYLATE 10 MG TABLET [Norvasc]   1* Preferred Generic $0.00$0.00None
AMLODIPINE BESYLATE 2.5 MG TAB   1* Preferred Generic $0.00$0.00None
AMLODIPINE BESYLATE 5 MG TABLET [Norvasc]   1* Preferred Generic $0.00$0.00None
AMLODIPINE-VALSARTAN 10-160 MG   3 Preferred Brand $30.00$90.00Q:30
/30Days
AMLODIPINE-VALSARTAN 10-320 MG   3 Preferred Brand $30.00$90.00Q:30
/30Days
AMLODIPINE-VALSARTAN 5-160 MG   3 Preferred Brand $30.00$90.00Q:30
/30Days
AMLODIPINE-VALSARTAN 5-320 MG   3 Preferred Brand $30.00$90.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMMONIUM LACTATE 12% CREAM   3 Preferred Brand $30.00$90.00None
AMMONIUM LACTATE 12% LOTION   3 Preferred Brand $30.00$90.00None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE [Augmentin]   2* Generic $5.00$15.00None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET [Augmentin]   2* Generic $5.00$15.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE [Augmentin]   2* Generic $5.00$15.00None
AMOX-CLAV 200-28.5 MG/5 ML SUS   2* Generic $5.00$15.00None
AMOX-CLAV 250-62.5 MG/5 ML SUS   2* Generic $5.00$15.00None
AMOX-CLAV 400-57 MG/5 ML SUSP   2* Generic $5.00$15.00None
AMOX-CLAV 500-125 MG TABLET [Augmentin]   2* Generic $5.00$15.00None
AMOX-CLAV 600-42.9 MG/5 ML SUS   2* Generic $5.00$15.00None
AMOX-CLAV 875-125 MG TABLET [Augmentin]   2* Generic $5.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOX-CLAV ER 1,000-62.5 MG TABLET [Augmentin]   4 Non-Preferred Drug 32%32%None
AMOXAPINE 100MG TABLET   3 Preferred Brand $30.00$90.00None
AMOXAPINE 150MG TABLET   3 Preferred Brand $30.00$90.00None
AMOXAPINE 25MG TABLET   3 Preferred Brand $30.00$90.00None
AMOXAPINE 50MG TABLET   3 Preferred Brand $30.00$90.00None
AMOXICILLIN 125 MG/5 ML SUSP   2* Generic $5.00$15.00None
AMOXICILLIN 125MG TABLET CHEW   2* Generic $5.00$15.00None
AMOXICILLIN 200 MG/5 ML SUSP   2* Generic $5.00$15.00None
AMOXICILLIN 250 MG CAPSULE   2* Generic $5.00$15.00None
AMOXICILLIN 250 MG TAB CHEW   2* Generic $5.00$15.00None
AMOXICILLIN 250 MG/5 ML SUSP   2* Generic $5.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN 400 MG/5 ML SUSP   2* Generic $5.00$15.00None
AMOXICILLIN 500 MG CAPSULE   2* Generic $5.00$15.00None
AMOXICILLIN 500 MG TABLET   2* Generic $5.00$15.00None
AMOXICILLIN 875 MG TABLET   2* Generic $5.00$15.00None
AMPHETAMINE SALT COMBO 12.5MG TABLET   3 Preferred Brand $30.00$90.00Q:60
/30Days
AMPHETAMINE SALT COMBO 15MG TABLET   3 Preferred Brand $30.00$90.00Q:60
/30Days
AMPHETAMINE SALT COMBO 7.5MG TABLET   3 Preferred Brand $30.00$90.00Q:60
/30Days
AMPHETAMINE SALTS 5 MG TAB   3 Preferred Brand $30.00$90.00Q:60
/30Days
amphotericin b 50mg/10mL 10 mL in 1 VIAL   4 Non-Preferred Drug 32%32%P
AMPICILLIN 10 GM VIAL   4 Non-Preferred Drug 32%32%None
Ampicillin 1000 MG / Sulbactam 500 MG Injection   4 Non-Preferred Drug 32%32%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Ampicillin 1000 MG Injection   4 Non-Preferred Drug 32%32%None
Ampicillin 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS   4 Non-Preferred Drug 32%32%None
Ampicillin 2000 MG / Sulbactam 1000 MG Injection   4 Non-Preferred Drug 32%32%None
AMPICILLIN CAPSULES 500MG 100 BOT   2* Generic $5.00$15.00None
AMPICILLIN-SULBACTAM 15 GM VL   4 Non-Preferred Drug 32%32%None
AMPYRA ER 10 MG TABLET   5 Specialty Tier 25%25%Q:60
/30Days
ANADROL-50 TABLET   4 Non-Preferred Drug 32%32%P
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE   3 Preferred Brand $30.00$90.00None
Anagrelide Hydrochloride 1mg/1 100 CAPSULE BOTTLE   3 Preferred Brand $30.00$90.00None
ANASTROZOLE 1 MG TABLET   1* Preferred Generic $0.00$0.00None
ANDRODERM 2 MG/24HR PATCH   3 Preferred Brand $30.00$90.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANDRODERM 4 MG/24HR PATCH   3 Preferred Brand $30.00$90.00Q:30
/30Days
ANORO ELLIPTA 62.5-25 MCG INH   3 Preferred Brand $30.00$90.00Q:60
/30Days
APOKYN 30 MG/3 ML CARTRIDGE   5 Specialty Tier 25%25%P Q:90
/30Days
Apraclonidine 5 MG/ML Ophthalmic Solution   3 Preferred Brand $30.00$90.00None
APREPITANT 125 MG CAPSULE [Emend]   4 Non-Preferred Drug 32%32%P
APREPITANT 125-80-80 MG PACK [Emend]   4 Non-Preferred Drug 32%32%P
APREPITANT 40 MG CAPSULE [Emend]   4 Non-Preferred Drug 32%32%P
APREPITANT 80 MG CAPSULE [Emend]   4 Non-Preferred Drug 32%32%P
APRI 0.15-0.03 TABLET   4 Non-Preferred Drug 32%32%None
APRISO CP24   3 Preferred Brand $30.00$90.00Q:120
/30Days
APTIOM 200 MG TABLET   4 Non-Preferred Drug 32%32%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
APTIOM 400 MG TABLET   4 Non-Preferred Drug 32%32%Q:30
/30Days
APTIOM 600 MG TABLET   4 Non-Preferred Drug 32%32%Q:60
/30Days
APTIOM 800 MG TABLET   4 Non-Preferred Drug 32%32%Q:60
/30Days
APTIVUS 250MG CAPSULE   5 Specialty Tier 25%25%Q:180
/30Days
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT   5 Specialty Tier 25%25%Q:450
/30Days
ARALAST NP 1,000 MG VIAL   5 Specialty Tier 25%25%P
ARANESP 10 MCG/0.4 ML SYRINGE   4 Non-Preferred Drug 32%32%P
ARANESP 100ug/0.5mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.5 mL in 1 SYRINGE   5 Specialty Tier 25%25%P
ARANESP 100ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE   5 Specialty Tier 25%25%P
ARANESP 200MCG/0.4ML SYRINGE   5 Specialty Tier 25%25%P
ARANESP 200MCG/ML VIAL   5 Specialty Tier 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP 25ug/0.42mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.42 mL in 1 SYRING   4 Non-Preferred Drug 32%32%P
ARANESP 25ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE   4 Non-Preferred Drug 32%32%P
ARANESP 300MCG/ML VIAL   5 Specialty Tier 25%25%P
ARANESP 500MCG/1ML SYRINGE   5 Specialty Tier 25%25%P
ARANESP 60MCG/ML VIAL   5 Specialty Tier 25%25%P
ARANESP 60ug/0.3mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.3 mL in 1 SYRINGE   5 Specialty Tier 25%25%P
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR   5 Specialty Tier 25%25%P
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR   5 Specialty Tier 25%25%P
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR   4 Non-Preferred Drug 32%32%P
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD   4 Non-Preferred Drug 32%32%P
ARCALYST INJECTION 220MG/VIAL   5 Specialty Tier 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARIPIPRAZOLE 1 MG/ML SOLUTION [Abilify]   4 Non-Preferred Drug 32%32%Q:750
/30Days
ARIPIPRAZOLE 10 MG TABLET [Abilify]   4 Non-Preferred Drug 32%32%Q:30
/30Days
ARIPIPRAZOLE 15 MG TABLET [Abilify]   4 Non-Preferred Drug 32%32%Q:30
/30Days
ARIPIPRAZOLE 2 MG TABLET [Abilify]   4 Non-Preferred Drug 32%32%Q:30
/30Days
ARIPIPRAZOLE 20 MG TABLET [Abilify]   4 Non-Preferred Drug 32%32%Q:30
/30Days
ARIPIPRAZOLE 30 MG TABLET [Abilify]   4 Non-Preferred Drug 32%32%Q:30
/30Days
ARIPIPRAZOLE 5 MG TABLET [Abilify]   4 Non-Preferred Drug 32%32%Q:30
/30Days
ARIPIPRAZOLE ODT 10 MG TABLET RAPDIS [Abilify Discmelt]   4 Non-Preferred Drug 32%32%Q:90
/30Days
ARIPIPRAZOLE ODT 15 MG TABLET RAPDIS [Abilify Discmelt]   4 Non-Preferred Drug 32%32%Q:60
/30Days
ARISTADA ER 1064 MG/3.9 ML SYR   5 Specialty Tier 25%25%None
ARISTADA ER 441 MG/1.6 ML SYRN   5 Specialty Tier 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARISTADA ER 662 MG/2.4 ML SYRN   5 Specialty Tier 25%25%None
ARISTADA ER 882 MG/3.2 ML SYRN   5 Specialty Tier 25%25%None
ARISTADA INITIO ER 675 MG/2.4 SUSER SYR   5 Specialty Tier 25%25%None
ASHLYNA 0.15-0.03-0.01 MG TAB   4 Non-Preferred Drug 32%32%None
Aspirin-Diphenhydramine ER 25-200 MG   3 Preferred Brand $30.00$90.00Q:60
/30Days
ATAZANAVIR SULFATE 150 MG CAP [Reyataz]   5 Specialty Tier 25%25%Q:60
/30Days
ATAZANAVIR SULFATE 200 MG CAP [Reyataz]   5 Specialty Tier 25%25%Q:90
/30Days
ATAZANAVIR SULFATE 300 MG CAP [Reyataz]   5 Specialty Tier 25%25%Q:60
/30Days
ATENOLOL 100 MG TABLET   1* Preferred Generic $0.00$0.00None
ATENOLOL 25 MG TABLET   1* Preferred Generic $0.00$0.00None
ATENOLOL 50 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
ATENOLOL-CHLORTHALIDONE 100-25   1* Preferred Generic $0.00$0.00None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   1* Preferred Generic $0.00$0.00None
ATOMOXETINE HCL 10 MG CAPSULE [Strattera]   4 Non-Preferred Drug 32%32%Q:60
/30Days
ATOMOXETINE HCL 100 MG CAPSULE [Strattera]   4 Non-Preferred Drug 32%32%Q:30
/30Days
ATOMOXETINE HCL 18 MG CAPSULE [Strattera]   4 Non-Preferred Drug 32%32%Q:60
/30Days
ATOMOXETINE HCL 25 MG CAPSULE [Strattera]   4 Non-Preferred Drug 32%32%Q:60
/30Days
ATOMOXETINE HCL 40 MG CAPSULE [Strattera]   4 Non-Preferred Drug 32%32%Q:60
/30Days
ATOMOXETINE HCL 60 MG CAPSULE [Strattera]   4 Non-Preferred Drug 32%32%Q:30
/30Days
ATOMOXETINE HCL 80 MG CAPSULE [Strattera]   4 Non-Preferred Drug 32%32%Q:30
/30Days
ATORVASTATIN 10 MG TABLET [Lipitor]   1* Preferred Generic $0.00$0.00Q:30
/30Days
ATORVASTATIN 20 MG TABLET [Lipitor]   1* Preferred Generic $0.00$0.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATORVASTATIN 40 MG TABLET [Lipitor]   1* Preferred Generic $0.00$0.00Q:30
/30Days
ATORVASTATIN 80 MG TABLET [Lipitor]   1* Preferred Generic $0.00$0.00Q:30
/30Days
ATOVAQUONE 750 MG/5 ML SUSP [Mepron]   5 Specialty Tier 25%25%None
Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone]   3 Preferred Brand $30.00$90.00None
ATOVAQUONE-PROGUANIL 62.5-25 [Malarone]   3 Preferred Brand $30.00$90.00None
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC   5 Specialty Tier 25%25%Q:60
/30Days
ATROPINE 1% EYE DROPS   3 Preferred Brand $30.00$90.00None
ATROVENT HFA AER 17MCG   4 Non-Preferred Drug 32%32%None
AUBRA-28 TABLET   4 Non-Preferred Drug 32%32%None
AUGMENTIN 125-31.25 MG/5 ML   4 Non-Preferred Drug 32%32%None
AURYXIA 210 MG TABLET   4 Non-Preferred Drug 32%32%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVIANE 0.1-0.02 TABLET   4 Non-Preferred Drug 32%32%None
AZATHIOPRINE 50 MG TABLET   2* Generic $5.00$15.00P
AZELAIC ACID 15% GEL [Finacea]   4 Non-Preferred Drug 32%32%None
AZELASTINE 0.15% NASAL SPRAY   3 Preferred Brand $30.00$90.00None
AZELASTINE 137 MCG NASAL SPRAY   3 Preferred Brand $30.00$90.00None
AZELASTINE HCL 0.05% DROPS   3 Preferred Brand $30.00$90.00None
AZITHROMYCIN 100 MG/5 ML SUSP   2* Generic $5.00$15.00None
AZITHROMYCIN 200 MG/5 ML SUSP   2* Generic $5.00$15.00None
AZITHROMYCIN 250 MG TABLET   2* Generic $5.00$15.00None
AZITHROMYCIN 250 MG TABLET   2* Generic $5.00$15.00None
AZITHROMYCIN 500 MG TABLET   2* Generic $5.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZITHROMYCIN 500 MG TABLET [Zithromax Tri-Pak]   2* Generic $5.00$15.00None
AZITHROMYCIN 600 MG TABLET   2* Generic $5.00$15.00None
AZITHROMYCIN I.V. 500 MG VIAL   4 Non-Preferred Drug 32%32%None
AZOPT 1% EYE DROPS   3 Preferred Brand $30.00$90.00None
AZTREONAM FOR INJECTION   4 Non-Preferred Drug 32%32%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 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.