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SilverScript Allure (PDP) (S5601-154-0)
Tier 1 (119)
Tier 2 (430)
Tier 3 (1064)
Tier 4 (919)
Tier 5 (549)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
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Cick on the first letter of your drug name to browse the formulary:

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2019 Medicare Part D Plan Formulary Information
SilverScript Allure (PDP) (S5601-154-0)
Benefit Details           
The SilverScript Allure (PDP) (S5601-154-0)
Formulary Drugs Starting with the Letter B

in CMS PDP Region 12 which includes: AL TN
Plan Monthly Premium: $80.00 Deductible: $0 Qualifies for LIS: No
Drugs Starting with Letter B

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Bacitracin 500 unit/gm Eye Ointment   3 Preferred Brand 20%20%None
BACITRACIN/POLYMYXIN B OINT 500UNT/10000UNT   2 Generic $5.00$12.50None
BACLOFEN 10 MG TABLET   3 Preferred Brand 20%20%None
BACLOFEN 20 MG TABLET   3 Preferred Brand 20%20%None
BALSALAZIDE DISODIUM 750MG CAPSULE (280 CT)   4 Non-Preferred Drug 40%40%None
BALVERSA 3 MG TABLET   5 Specialty Tier 33%N/AP
BALVERSA 4 MG TABLET   5 Specialty Tier 33%N/AP
BALVERSA 5 MG TABLET   5 Specialty Tier 33%N/AP
Balziva 6 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK   3 Preferred Brand 20%20%None
Banzel 200mg/1   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Banzel 40mg/mL   5 Specialty Tier 33%N/AP
BANZEL TABLET 400MG   5 Specialty Tier 33%N/AP
BARACLUDE 0.05mg/mL 1 BOTTLE per CARTON / 210 mL in 1 BOTTLE   5 Specialty Tier 33%N/ANone
BCG VACCINE 50mg/1 1 VIAL per CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL   4 Non-Preferred Drug 40%40%None
BELSOMRA 10 MG TABLET   4 Non-Preferred Drug 40%40%Q:30
/30Days
BELSOMRA 15 MG TABLET   4 Non-Preferred Drug 40%40%Q:30
/30Days
BELSOMRA 20 MG TABLET   4 Non-Preferred Drug 40%40%Q:30
/30Days
BELSOMRA 5 MG TABLET   4 Non-Preferred Drug 40%40%Q:30
/30Days
BENAZEPRIL HCL 10 MG TABLET   1 Preferred Generic $1.00$0.00None
BENAZEPRIL HCL 20 MG TABLET   1 Preferred Generic $1.00$0.00None
BENAZEPRIL HCL 40 MG TABLET   1 Preferred Generic $1.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BENAZEPRIL HCL 5 MG TABLET   1 Preferred Generic $1.00$0.00None
BENAZEPRIL HCL-HCTZ TABLET 10-12.5MG (100 CT)   3 Preferred Brand 20%20%None
BENAZEPRIL HCL-HCTZ TABLET 20-12.5MG (100 CT)   3 Preferred Brand 20%20%None
BENAZEPRIL HCL-HCTZ TABLET 20-25MG (100 CT)   3 Preferred Brand 20%20%None
BENAZEPRIL HCL-HCTZ TABLET 5-6.25MG (100 CT)   3 Preferred Brand 20%20%None
BENLYSTA 200 MG/ML AUTOINJECT   5 Specialty Tier 33%N/AP
BENLYSTA 200 MG/ML SYRINGE   5 Specialty Tier 33%N/AP
BENZTROPINE MES 0.5 MG Tablet [Cogentin]   3 Preferred Brand 20%20%P
BENZTROPINE MES 1 MG TABLET [Cogentin]   3 Preferred Brand 20%20%P
BENZTROPINE MES 2 MG TABLET [Cogentin]   3 Preferred Brand 20%20%P
BEPREVE 1.5% EYE DROPS   3 Preferred Brand 20%20%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BERINERT 500 UNIT KIT   5 Specialty Tier 33%N/AP Q:24
/30Days
BESIVANCE BESIFLOACIN OPTHALMIC SUSPENSION 0.6% 5 ML BOTDR   3 Preferred Brand 20%20%None
Betamethasone Dipropionate 0.64mg/g / 45 g TUBE   3 Preferred Brand 20%20%None
BETAMETHASONE DP 0.05% LOT   3 Preferred Brand 20%20%None
Betamethasone DP 0.05% ointment   4 Non-Preferred Drug 40%40%None
BETAMETHASONE DP AUG 0.05% CRM   3 Preferred Brand 20%20%None
BETAMETHASONE DP AUG 0.05% GEL   4 Non-Preferred Drug 40%40%None
BETAMETHASONE DP AUG 0.05% LOT   4 Non-Preferred Drug 40%40%None
BETAMETHASONE DP AUG 0.05% OIN   4 Non-Preferred Drug 40%40%None
BETAMETHASONE VA 0.1% CREAM   3 Preferred Brand 20%20%None
BETAMETHASONE VALERATE 0.1% LOTION   3 Preferred Brand 20%20%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BETAMETHASONE VALERATE OINTMENT USP   3 Preferred Brand 20%20%None
BETASERON 0.3 MG KIT   5 Specialty Tier 33%N/AP Q:14
/28Days
Betaxolol 5 MG/ML Ophthalmic Solution   3 Preferred Brand 20%20%None
BETHANECHOL 10 MG TABLET   3 Preferred Brand 20%20%None
BETHANECHOL 25 MG TABLET   3 Preferred Brand 20%20%None
BETHANECHOL 5 MG TABLET   3 Preferred Brand 20%20%None
BETHANECHOL 50 MG TABLET   3 Preferred Brand 20%20%None
BETOPTIC S OPHTHALMIC SUSPENSION 0.25% 10 ML BOT   4 Non-Preferred Drug 40%40%None
BEVESPI AEROSPHERE INHALER   3 Preferred Brand 20%20%Q:11
/30Days
BEXAROTENE 75 MG CAPSULE [Targretin]   5 Specialty Tier 33%N/AP
BEXSERO PREFILLED SYRINGE   4 Non-Preferred Drug 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BICALUTAMIDE 50 MG TABLET   3 Preferred Brand 20%20%None
BICILL LA PFS 600MU 1ML PED   4 Non-Preferred Drug 40%40%None
BICILLIN LA PFS 1200MU 2ML   4 Non-Preferred Drug 40%40%None
BICILLIN LA. 600000UNIT/ML 1ML   4 Non-Preferred Drug 40%40%None
BIKTARVY 50-200-25 MG TABLET   5 Specialty Tier 33%N/ANone
BISOPROLOL FUMARATE 10 MG TAB   2 Generic $5.00$12.50None
BISOPROLOL FUMARATE 5 MG TAB   2 Generic $5.00$12.50None
BISOPROLOL-HCTZ 10-6.25 MG TAB   2 Generic $5.00$12.50None
BISOPROLOL-HCTZ 2.5-6.25 MG TB   2 Generic $5.00$12.50None
BISOPROLOL-HCTZ 5-6.25 MG TAB   2 Generic $5.00$12.50None
BIVIGAM LIQUID 10% VIAL   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BLEPHAMIDE 10-0.2% EYE OINT   4 Non-Preferred Drug 40%40%None
BLISOVI FE 1.5-30 TABLET   3 Preferred Brand 20%20%None
BOOSTRIX TDAP VACCINE SYRINGE   3 Preferred Brand 20%20%None
BOOSTRIX TDAP VACCINE VIAL   3 Preferred Brand 20%20%None
BOSENTAN 125 MG TABLET [Tracleer]   5 Specialty Tier 33%N/AP Q:60
/30Days
BOSENTAN 62.5 MG TABLET [Tracleer]   5 Specialty Tier 33%N/AP Q:120
/30Days
BOSULIF 100 MG TABLET   5 Specialty Tier 33%N/AP
BOSULIF 400 MG TABLET   5 Specialty Tier 33%N/AP
BOSULIF 500 MG TABLET   5 Specialty Tier 33%N/AP
BRAFTOVI 50 MG CAPSULE   5 Specialty Tier 33%N/AP
BRAFTOVI 75 MG CAPSULE   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BREO ELLIPTA 100-25 MCG INH   3 Preferred Brand 20%20%Q:60
/30Days
BREO ELLIPTA 200-25 MCG INH   3 Preferred Brand 20%20%Q:60
/30Days
BRIELLYN TABLET   3 Preferred Brand 20%20%None
BRILINTA 60 MG TABLET   3 Preferred Brand 20%20%None
BRILINTA 90mg/1 60 TABLET BOTTLE   3 Preferred Brand 20%20%None
BRIMONIDINE 0.2% EYE DROP   2 Generic $5.00$12.50None
BRIVIACT 10 MG TABLET   4 Non-Preferred Drug 40%40%P
BRIVIACT 10 MG/ML ORAL SOLN   4 Non-Preferred Drug 40%40%P
BRIVIACT 100 MG TABLET   4 Non-Preferred Drug 40%40%P
BRIVIACT 25 MG TABLET   4 Non-Preferred Drug 40%40%P
BRIVIACT 50 MG TABLET   4 Non-Preferred Drug 40%40%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BRIVIACT 75 MG TABLET   4 Non-Preferred Drug 40%40%P
BROMOCRIPTINE 2.5 MG TABLET [Parlodel]   4 Non-Preferred Drug 40%40%None
BROMOCRIPTINE MESYLATE 5MG CAPSULE [Parlodel]   4 Non-Preferred Drug 40%40%None
BROMSITE 0.075% EYE DROPS   4 Non-Preferred Drug 40%40%None
BUDESONIDE 0.25 MG/2 ML SUSP AMPUL-NEB [Pulmicort]   4 Non-Preferred Drug 40%40%P
BUDESONIDE 0.5 MG/2 ML SUSP AMPUL-NEB [Pulmicort]   4 Non-Preferred Drug 40%40%P
BUDESONIDE EC 3 MG CAPSULE CAPDR - ER [Entocort EC]   4 Non-Preferred Drug 40%40%None
BUMETANIDE 0.25MG/ML VIAL   4 Non-Preferred Drug 40%40%None
BUMETANIDE 0.5 MG TABLET   3 Preferred Brand 20%20%None
BUMETANIDE 1 MG TABLET   3 Preferred Brand 20%20%None
BUMETANIDE 2 MG TABLET   3 Preferred Brand 20%20%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BUPRENORPHIN-NALOXON 2-0.5 MG SL [Suboxone]   2 Generic $5.00$12.50Q:90
/30Days
BUPRENORPHIN-NALOXON 8-2 MG SL [Suboxone]   2 Generic $5.00$12.50Q:90
/30Days
BUPRENORPHINE 2 MG TABLET Subligual [Subutex]   3 Preferred Brand 20%20%P Q:90
/30Days
BUPRENORPHINE 8 MG TABLET Subligual [Subutex]   3 Preferred Brand 20%20%P Q:90
/30Days
BUPROPION HCL 100 MG TABLET   3 Preferred Brand 20%20%None
BUPROPION HCL 75 MG TABLET   3 Preferred Brand 20%20%None
BUPROPION HCL SR 100 MG TABLET   2 Generic $5.00$12.50None
BUPROPION HCL SR 150 MG TABLET   2 Generic $5.00$12.50None
BUPROPION HCL SR 150 MG TABLET   3 Preferred Brand 20%20%None
BUPROPION HCL SR 200 MG TABLET   2 Generic $5.00$12.50None
BUPROPION HCL XL 150 MG TABLET   3 Preferred Brand 20%20%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BUPROPION HCL XL 300 MG TABLET   3 Preferred Brand 20%20%None
BUSPIRONE HCL 15 MG TABLET   2 Generic $5.00$12.50None
BUSPIRONE HCL 30 MG TABLET   3 Preferred Brand 20%20%None
BUSPIRONE HCL 5 MG TABLET   2 Generic $5.00$12.50None
BUSPIRONE HCL 7.5 MG TABLET   2 Generic $5.00$12.50None
BUSPIRONE HYDROCHLORIDE 10 MG TABLETS   2 Generic $5.00$12.50None
Butrans 10ug/h   3 Preferred Brand 20%20%P Q:4
/28Days
BUTRANS 15 MCG/HR PATCH   3 Preferred Brand 20%20%P Q:4
/28Days
Butrans 20ug/h   3 Preferred Brand 20%20%P Q:4
/28Days
Butrans 5ug/h   3 Preferred Brand 20%20%P Q:4
/28Days
BUTRANS 7.5 MCG/HR PATCH   3 Preferred Brand 20%20%P Q:4
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BYDUREON 2 MG PEN INJECT   3 Preferred Brand 20%20%Q:4
/28Days
BYDUREON BCISE 2 MG AUTOINJECT   3 Preferred Brand 20%20%Q:3
/28Days
BYETTA 10 MCG DOSE PEN INJ   4 Non-Preferred Drug 40%40%Q:2
/30Days
BYETTA 5 MCG DOSE PEN INJ   4 Non-Preferred Drug 40%40%Q:1
/30Days
Bystolic 10mg/1 30 TABLET BOTTLE   4 Non-Preferred Drug 40%40%Q:30
/30Days
Bystolic 2.5mg/1 30 TABLET BOTTLE   4 Non-Preferred Drug 40%40%Q:30
/30Days
BYSTOLIC 20 MG TABLET   4 Non-Preferred Drug 40%40%Q:60
/30Days
Bystolic 5mg 30 TABLET BOTTLE   4 Non-Preferred Drug 40%40%Q:30
/30Days

Chart Legend:

Below are a few notes to help you understand the above 2019 Medicare Part D SilverScript Allure (PDP) Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region). The plan name is followed by the plan type (PDP, HMO, HMO-POS, PPO, PFFS, etc.)

  • Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.

  • Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $415 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.

  • Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
    • Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.

    • No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.

  • Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
  • Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
    • Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have five (5) tiers 1=Preferred Generics, 2=Generics, 3=Preferred Brands, 4=Non-preferred Brands, 5=Specialty Drugs. *Some Part D plans exclude one or more drug tiers from the deductible. If the drug tier field above is followed by * (example: 2*), then this drug tier is excluded from the plan’s deductible.
    • Tier Description - This is the Medicare Part D plan’s description of this particular drug tier.
  • Cost Sharing - Copay / Coinsurance - These figures apply to the initial coverage phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
    • Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $3820) at a "Preferred" network pharmacy. In most cases, the "Preferred" network pharmacy cost-sharing is lower than the standard (non-preferred) network pharmacy cost-sharing.
    • Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
  • Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
    • None - This drug does not fall under any drug utilization management controls.
    • P - Prior Authorization -This drug is subject to prior authorization.
    • S - Step Therapy -This drug is subject to step therapy.
    • Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.




(Chart Source: Centers for Medicare and Medicaid files: CMS Data September 2019 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Part D plan provider.