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SilverScript Choice (PDP) (S5601-024-0)
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2019 Medicare Part D Plan Formulary Information
SilverScript Choice (PDP) (S5601-024-0)
Benefit Details           
The SilverScript Choice (PDP) (S5601-024-0)
Formulary Drugs Starting with the Letter D

in CMS PDP Region 12 which includes: AL TN
Plan Monthly Premium: $29.60 Deductible: $0 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   4 Non-Preferred Drug 47%47%None
D5%-1/2NS-KCL 40 MEQ/L IV SOL IV SOLN   4 Non-Preferred Drug 47%47%None
DALFAMPRIDINE ER 10 MG TABLET ER 12H [Ampyra]   5 Specialty Tier 33%N/AP
DALIRESP 250 MCG TABLET   4 Non-Preferred Drug 47%47%None
DALIRESP 500 MCG TABLET   4 Non-Preferred Drug 47%47%None
DANAZOL 100 MG CAPSULE   4 Non-Preferred Drug 47%47%None
DANAZOL 50MG CAPSULE   4 Non-Preferred Drug 47%47%None
DANAZOL CAPSULES USP 200MG (100 CT)   4 Non-Preferred Drug 47%47%None
DANTROLENE SODIUM 100MG CAPSULE   4 Non-Preferred Drug 47%47%None
DANTROLENE SODIUM 25MG CAPSULE   4 Non-Preferred Drug 47%47%None
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 47%47%None
DAPSONE 25 MG TABLET   3 Preferred Brand $44.00$110.00None
DAPSONE TABLETS 100MG 30 BLPK   3 Preferred Brand $44.00$110.00None
DAPTACEL VACCINE 15;5;5;3; LF/.5ML   3 Preferred Brand $44.00$110.00None
DAPTOMYCIN 350 MG VIAL [Cubicin RF]   5 Specialty Tier 33%N/ANone
DAPTOMYCIN 500 MG VIAL [Cubicin]   5 Specialty Tier 33%N/ANone
DAURISMO 100 MG TABLET   5 Specialty Tier 33%N/AP
DAURISMO 25 MG TABLET   5 Specialty Tier 33%N/AP
DEBLITANE 0.35 MG TABLET   3 Preferred Brand $44.00$110.00None
DELESTROGEN INJECTION 10MG/5ML VIALMD   4 Non-Preferred Drug 47%47%None
DELSTRIGO 100-300-300 MG TABLET   5 Specialty Tier 33%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Delyla-28 tablet   3 Preferred Brand $44.00$110.00None
DELZICOL DR 400 MG CAPSULE   4 Non-Preferred Drug 47%47%None
DEMSER CAPSULES 250MG (100 CT)   5 Specialty Tier 33%N/AP
DEPEN 250MG TITRATAB   5 Specialty Tier 33%N/ANone
DEPO-PROVERA 400MG/ML VIAL   4 Non-Preferred Drug 47%47%P
DESCOVY 200-25 MG TABLET   5 Specialty Tier 33%N/ANone
DESIPRAMINE 10 MG TABLET [Norpramin]   4 Non-Preferred Drug 47%47%None
DESIPRAMINE 100 MG TABLET [Norpramin]   4 Non-Preferred Drug 47%47%None
DESIPRAMINE 150 MG TABLET [Norpramin]   4 Non-Preferred Drug 47%47%None
DESIPRAMINE 25 MG TABLET [Norpramin]   4 Non-Preferred Drug 47%47%None
DESIPRAMINE 50 MG TABLET [Norpramin]   4 Non-Preferred Drug 47%47%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DESIPRAMINE 75 MG TABLET [Norpramin]   4 Non-Preferred Drug 47%47%None
DESMOPRESSIN ACETATE 0.1 MG TB   3 Preferred Brand $44.00$110.00None
DESMOPRESSIN ACETATE 0.2 MG TB   3 Preferred Brand $44.00$110.00None
DESMOPRESSIN ACETATE NASAL SOLUTION 0.1% 5 ML BOTSPR   4 Non-Preferred Drug 47%47%None
DESOGESTR-ETH ESTRA 0.15-0.03MG   3 Preferred Brand $44.00$110.00None
DESOGESTR-ETH ESTRAD   3 Preferred Brand $44.00$110.00None
Desvenlafaxine Succinate ER 100 mg [Pristiq]   4 Non-Preferred Drug 47%47%P Q:30
/30Days
Desvenlafaxine Succinate ER 25 mg tb [Pristiq]   4 Non-Preferred Drug 47%47%P Q:30
/30Days
Desvenlafaxine Succinate ER 50 mg tb [Pristiq]   4 Non-Preferred Drug 47%47%P Q:30
/30Days
DEXAMETHASONE 0.1% EYE DROP   3 Preferred Brand $44.00$110.00None
DEXAMETHASONE 0.5MG TABLET   2 Generic $15.00$37.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEXAMETHASONE 0.5MG/0.5ML DROP   4 Non-Preferred Drug 47%47%None
DEXAMETHASONE 0.5MG/5ML ELX   3 Preferred Brand $44.00$110.00None
DEXAMETHASONE 0.75MG TABLET   2 Generic $15.00$37.50None
DEXAMETHASONE 1.5MG TABLET   2 Generic $15.00$37.50None
DEXAMETHASONE 1MG TABLET   2 Generic $15.00$37.50None
DEXAMETHASONE 2MG TABLET   2 Generic $15.00$37.50None
DEXAMETHASONE 4MG TABLET   2 Generic $15.00$37.50None
DEXAMETHASONE 6MG TABLET   2 Generic $15.00$37.50None
DEXILANT CAPSULES DELAYED RELEASE 30 MG   4 Non-Preferred Drug 47%47%Q:30
/30Days
DEXILANT DR 60 MG CAPSULE   4 Non-Preferred Drug 47%47%Q:30
/30Days
DEXMETHYLPHENIDATE HCL 10MG TABLET   3 Preferred Brand $44.00$110.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEXMETHYLPHENIDATE HCL 2.5MG TABLET   3 Preferred Brand $44.00$110.00Q:120
/30Days
DEXMETHYLPHENIDATE HCL 5MG TABLET   3 Preferred Brand $44.00$110.00Q:120
/30Days
DEXTROAMP-AMPHET ER 10 MG CAP   4 Non-Preferred Drug 47%47%Q:90
/30Days
DEXTROAMP-AMPHET ER 15 MG CAP   4 Non-Preferred Drug 47%47%Q:30
/30Days
DEXTROAMP-AMPHET ER 20 MG CAP   4 Non-Preferred Drug 47%47%Q:30
/30Days
DEXTROAMP-AMPHET ER 25 MG CAP   4 Non-Preferred Drug 47%47%Q:30
/30Days
DEXTROAMP-AMPHET ER 30 MG CAP   4 Non-Preferred Drug 47%47%Q:30
/30Days
DEXTROAMP-AMPHET ER 5 MG CAP   4 Non-Preferred Drug 47%47%Q:90
/30Days
DEXTROAMP-AMPHETAMIN 20 MG TAB   3 Preferred Brand $44.00$110.00Q:90
/30Days
DEXTROAMP-AMPHETAMIN 30 MG TAB   3 Preferred Brand $44.00$110.00Q:60
/30Days
DEXTROAMPHETAMINE SACCHARATE AND SULFATE AMPHETAMINE ASPARTATE 10MG TABLET (100 CT)   3 Preferred Brand $44.00$110.00Q:180
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DEXTROSE 10%-1/4NS IV TUBEX   4 Non-Preferred Drug 47%47%None
Dextrose 10%-water iv solution   4 Non-Preferred Drug 47%47%None
DEXTROSE 2.5%-1/2NS IV SOLUTION   4 Non-Preferred Drug 47%47%None
DEXTROSE 5%-0.45% NACL IV SOLN   4 Non-Preferred Drug 47%47%None
DEXTROSE 5%-0.9% NACL IV SOLN   4 Non-Preferred Drug 47%47%None
DEXTROSE 5%-1/4NS IV SOLUTION   4 Non-Preferred Drug 47%47%None
DEXTROSE 5%-WATER IV SOLN   4 Non-Preferred Drug 47%47%None
DEXTROSE IN SODIUM CHLORIDE INJECTION   4 Non-Preferred Drug 47%47%None
DEXTROSE IN SODIUM CHLORIDE INJECTION 1000ML X 12 CASE   4 Non-Preferred Drug 47%47%None
DEXTROSE IN SODIUM CHLORIDE INJECTION 500ML X 24 BAG   4 Non-Preferred Drug 47%47%None
DIASTAT 2.5 MG PEDI SYSTEM   4 Non-Preferred Drug 47%47%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DIASTAT ACUDIAL 12.5-15-20 MG   4 Non-Preferred Drug 47%47%None
DIASTAT ACUDIAL 5-7.5-10 MG KT   4 Non-Preferred Drug 47%47%None
DIAZEPAM 10 MG TABLET [Valium]   2 Generic $15.00$37.50P Q:120
/30Days
DIAZEPAM 2 MG TABLET [Valium]   2 Generic $15.00$37.50P Q:120
/30Days
DIAZEPAM 5 MG TABLET [Valium]   2 Generic $15.00$37.50P Q:120
/30Days
DIAZEPAM 5 MG/5 ML SOLUTION   3 Preferred Brand $44.00$110.00P Q:1200
/30Days
DIAZEPAM 5 MG/ML ORAL CONC   3 Preferred Brand $44.00$110.00P Q:240
/30Days
DICLOFENAC 0.1% EYE DROPS [Voltaren]   3 Preferred Brand $44.00$110.00None
DICLOFENAC POT 50 MG TABLET   3 Preferred Brand $44.00$110.00Q:120
/30Days
DICLOFENAC SOD EC 25 MG TAB   2 Generic $15.00$37.50None
DICLOFENAC SOD EC 50 MG TAB   2 Generic $15.00$37.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DICLOFENAC SOD EC 75 MG TAB   2 Generic $15.00$37.50None
DICLOFENAC SOD ER 100 MG TABLET ER 24H [Voltaren-XR]   2 Generic $15.00$37.50None
DICLOXACILLIN 250MG CAPSULE   3 Preferred Brand $44.00$110.00None
DICLOXACILLIN SODIUM 500MG CAP   3 Preferred Brand $44.00$110.00None
DICYCLOMINE 10 MG CAPSULE   3 Preferred Brand $44.00$110.00None
DICYCLOMINE 20 MG TABLET   3 Preferred Brand $44.00$110.00None
DICYCLOMINE HCL 10MG/5ML SYRUP   4 Non-Preferred Drug 47%47%None
DIDANOSINE DR 200 MG CAPSULE DR [Videx EC]   4 Non-Preferred Drug 47%47%None
DIDANOSINE DR 250 MG CAPSULE [Videx EC]   4 Non-Preferred Drug 47%47%None
DIDANOSINE DR 400 MG CAPSULE [Videx EC]   4 Non-Preferred Drug 47%47%None
Dificid 200mg/1 1 BOTTLE per CARTON / 20 FILM COATED TABLETS in BOTTLE   5 Specialty Tier 33%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DIFLUNISAL 500 MG TABLET   3 Preferred Brand $44.00$110.00None
DIGITEK 125 MCG TABLET   3 Preferred Brand $44.00$110.00Q:30
/30Days
DIGITEK 250 MCG TABLET   3 Preferred Brand $44.00$110.00P
DIGOX 125 MCG TABLET   3 Preferred Brand $44.00$110.00Q:30
/30Days
DIGOX 250 MCG TABLET   3 Preferred Brand $44.00$110.00P
DIGOXIN 0.05 MG/ML SOLUTION [Lanoxin]   4 Non-Preferred Drug 47%47%P
DIGOXIN 125 MCG TABLET [Lanoxin]   3 Preferred Brand $44.00$110.00Q:30
/30Days
DIGOXIN 250 MCG TABLET [Lanoxin]   3 Preferred Brand $44.00$110.00P
DIHYDROERGOTAMINE 4 MG/ML SPRAY   5 Specialty Tier 33%N/AQ:8
/30Days
DILANTIN 50MG INFATAB   4 Non-Preferred Drug 47%47%None
DILANTIN CAPSULES 30 MG ER   4 Non-Preferred Drug 47%47%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DILANTIN EXTENDED ORAL CAPSULE 100MG (100 CT)   4 Non-Preferred Drug 47%47%None
DILANTIN-125 SUS 125/5ML   4 Non-Preferred Drug 47%47%None
DILT XR 120 MG CAPSULE   3 Preferred Brand $44.00$110.00None
DILT XR 180 MG CAPSULE   3 Preferred Brand $44.00$110.00None
DILT XR 240 MG CAPSULE   3 Preferred Brand $44.00$110.00None
DILTIAZEM 120 MG TABLET [Cardizem]   2 Generic $15.00$37.50None
DILTIAZEM 12HR ER 120 MG CAPSULE [Tiazac]   4 Non-Preferred Drug 47%47%None
DILTIAZEM 12HR ER 60 MG CAPSULE [Cardizem SR]   4 Non-Preferred Drug 47%47%None
DILTIAZEM 12HR ER 90 MG CAPSULE [Cardizem SR]   4 Non-Preferred Drug 47%47%None
DILTIAZEM 24HR ER 120 MG CAPSULE [Tiazac]   3 Preferred Brand $44.00$110.00None
DILTIAZEM 24HR ER 180 MG CAPSULE [Tiazac]   3 Preferred Brand $44.00$110.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DILTIAZEM 24HR ER 240 MG CAPSULE [Tiazac]   3 Preferred Brand $44.00$110.00None
DILTIAZEM 24HR ER 300 MG CAPSULE [Tiazac]   3 Preferred Brand $44.00$110.00None
DILTIAZEM 24HR ER 360 MG CAP [Tiazac]   3 Preferred Brand $44.00$110.00None
DILTIAZEM 24HR ER 420 MG CAP [Tiazac]   3 Preferred Brand $44.00$110.00None
DILTIAZEM 30 MG TABLET [Cardizem]   2 Generic $15.00$37.50None
DILTIAZEM 60 MG TABLET [Cardizem]   2 Generic $15.00$37.50None
DILTIAZEM 90 MG TABLET [Cardizem]   2 Generic $15.00$37.50None
Diph-Tetanus Tox-Acell Pert adsorbed and IPV vaccine 0.5 ML Prefilled Syringe [Kinrix]   3 Preferred Brand $44.00$110.00None
Diph-Tetanus Tox-Acell Pert-Hepatitis B-Polio IPV Vac 0.5 ML Prefilled Syringe [Pediarix]   3 Preferred Brand $44.00$110.00None
Diphenoxylate Hydrochloride and Atropine Sulfate 0.025; 2.5mg 100 TABLET BOTTLE   3 Preferred Brand $44.00$110.00None
DIPHENOXYLATE/ATROPINE LIQ   4 Non-Preferred Drug 47%47%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Diphtheria Toxoid Vaccine 25 UNT/ML / Tetanus Toxoid Vaccine 5 UNT per 0.5 ML Injectable Suspension   3 Preferred Brand $44.00$110.00P
Diphtheria toxoid vaccine, inact 4 UNT/ML / tetanus toxoid vaccine, inact 4 UNT/ML Inj Sus   3 Preferred Brand $44.00$110.00P
DISOPYRAMIDE 100 MG CAPSULE   4 Non-Preferred Drug 47%47%None
DISOPYRAMIDE PHOSPHATE 150MG CAPSULE USP (100 CT)   4 Non-Preferred Drug 47%47%None
DISULFIRAM 250 MG TABLET   3 Preferred Brand $44.00$110.00None
DISULFIRAM 500 MG TABLET   3 Preferred Brand $44.00$110.00None
DIVALPROEX DR 125 MG CAP SPRNK   4 Non-Preferred Drug 47%47%None
DIVALPROEX SOD DR 125 MG TAB   3 Preferred Brand $44.00$110.00None
DIVALPROEX SOD DR 250 MG TAB   3 Preferred Brand $44.00$110.00None
DIVALPROEX SOD DR 500 MG TAB   3 Preferred Brand $44.00$110.00None
DIVALPROEX SOD ER 500 MG TAB   4 Non-Preferred Drug 47%47%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DIVALPROEX SODIUM ER TABLETS 250MG 100 BOT   4 Non-Preferred Drug 47%47%None
DOFETILIDE 125 MCG CAPSULE [Tikosyn]   4 Non-Preferred Drug 47%47%None
DOFETILIDE 250 MCG CAPSULE [Tikosyn]   4 Non-Preferred Drug 47%47%None
DOFETILIDE 500 MCG CAPSULE [Tikosyn]   4 Non-Preferred Drug 47%47%None
DONEPEZIL HCL 10 MG TABLET   2 Generic $15.00$37.50None
DONEPEZIL HCL 5 MG TABLET   2 Generic $15.00$37.50Q:30
/30Days
DONEPEZIL HCL ODT 10 MG TABLET   3 Preferred Brand $44.00$110.00None
DONEPEZIL HCL ODT 5 MG TABLET   3 Preferred Brand $44.00$110.00Q:30
/30Days
DORZOLAMIDE HCL OPHTHALMIC 2% 10 ML BOTDR   3 Preferred Brand $44.00$110.00None
Dorzolamide Hydrochloride and Timolol Maleate 20; 5mg/mL; mg/mL 1 BOTTLE, DROPPER in 1 BOX / 10 mL   3 Preferred Brand $44.00$110.00None
DOVATO 50-300 MG TABLET   5 Specialty Tier 33%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DOXAZOSIN MESYLATE 1 MG TAB   2 Generic $15.00$37.50None
DOXAZOSIN MESYLATE 2 MG TAB   2 Generic $15.00$37.50None
DOXAZOSIN MESYLATE 4 MG TAB   2 Generic $15.00$37.50None
DOXAZOSIN MESYLATE 8 MG TAB   2 Generic $15.00$37.50None
DOXEPIN 10 MG/ML ORAL CONC   3 Preferred Brand $44.00$110.00None
DOXEPIN 10MG CAPSULE   3 Preferred Brand $44.00$110.00None
DOXEPIN 50 MG CAPSULE   3 Preferred Brand $44.00$110.00None
DOXEPIN 75MG CAPSULE   3 Preferred Brand $44.00$110.00None
DOXEPIN HCL 25MG CAPSULE (100 CT)   3 Preferred Brand $44.00$110.00None
Doxepin Hydrochloride 150mg/1 100 CAPSULE BOTTLE   3 Preferred Brand $44.00$110.00None
DOXEPIN HYDROCHLORIDE CAPSULES 100MG 100 BOT   3 Preferred Brand $44.00$110.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DOXY 100 VIAL   4 Non-Preferred Drug 47%47%None
DOXYCYCLINE HYCLATE 100 MG CAP   3 Preferred Brand $44.00$110.00None
DOXYCYCLINE HYCLATE 100 MG TAB   3 Preferred Brand $44.00$110.00None
DOXYCYCLINE HYCLATE 20MG TABLET (100 CT)   3 Preferred Brand $44.00$110.00None
DOXYCYCLINE HYCLATE 50 MG CAP   3 Preferred Brand $44.00$110.00None
DOXYCYCLINE MONO 100 MG CAP   2 Generic $15.00$37.50None
DOXYCYCLINE MONO 100 MG TABLET   3 Preferred Brand $44.00$110.00None
DOXYCYCLINE MONO 150 MG TABLET   3 Preferred Brand $44.00$110.00None
DOXYCYCLINE MONO 50 MG CAP   2 Generic $15.00$37.50None
DOXYCYCLINE MONO 50 MG TABLET   3 Preferred Brand $44.00$110.00None
DOXYCYCLINE MONO 75 MG TABLET   3 Preferred Brand $44.00$110.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DRONABINOL 10 MG CAPSULE [Marinol]   4 Non-Preferred Drug 47%47%P Q:60
/30Days
DRONABINOL 2.5 MG CAPSULE [Marinol]   4 Non-Preferred Drug 47%47%P Q:60
/30Days
DRONABINOL 5 MG CAPSULE [Marinol]   4 Non-Preferred Drug 47%47%P Q:60
/30Days
DROSPIRENONE-EE 3-0.02 MG TAB   3 Preferred Brand $44.00$110.00None
DROSPIRENONE-EE 3-0.03 MG TAB   3 Preferred Brand $44.00$110.00None
DROXIA 200MG CAPSULE   3 Preferred Brand $44.00$110.00None
DROXIA 300MG CAPSULE   3 Preferred Brand $44.00$110.00None
DROXIA 400MG CAPSULE   3 Preferred Brand $44.00$110.00None
DULOXETINE HCL DR 20 MG CAPSULE DR [Cymbalta]   3 Preferred Brand $44.00$110.00Q:180
/30Days
DULOXETINE HCL DR 30 MG CAPSULE DR [Cymbalta]   3 Preferred Brand $44.00$110.00Q:120
/30Days
DULOXETINE HCL DR 60 MG CAPSULE DR [Cymbalta]   3 Preferred Brand $44.00$110.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
DUREZOL 0.05% EYE DROPS   4 Non-Preferred Drug 47%47%None
DUTASTERIDE 0.5 MG CAPSULE   3 Preferred Brand $44.00$110.00Q:30
/30Days

Chart Legend:

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