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Express Scripts Medicare - Saver (PDP) (S5660-228-0)
Tier 1 (101)
Tier 2 (809)
Tier 3 (639)
Tier 4 (898)
Tier 5 (459)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
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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
Express Scripts Medicare - Saver (PDP) (S5660-228-0)
Benefit Details           
The Express Scripts Medicare - Saver (PDP) (S5660-228-0)
Formulary Drugs Starting with the Letter H

in CMS PDP Region 12 which includes: AL TN
Plan Monthly Premium: $24.50 Deductible: $415 Qualifies for LIS: No
Drugs Starting with Letter H

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
HAILEY 24 FE 1 MG-20 MCG TABLET [Tarina Fe 1/20]   4 Non-Preferred Drug 32%N/ANone
HALOBETASOL PROP 0.05% CREAM   4 Non-Preferred Drug 32%N/ANone
Halobetasol Propionate 0.5mg/g 1 TUBE per CARTON / 50 g in 1 TUBE   4 Non-Preferred Drug 32%N/ANone
HALOPERIDOL 0.5 MG TABLET   2* Generic $4.00$8.00None
HALOPERIDOL 1 MG TABLET   2* Generic $4.00$8.00None
HALOPERIDOL 10 MG TABLET   2* Generic $4.00$8.00None
HALOPERIDOL 20MG TABLET (100 CT)   2* Generic $4.00$8.00None
HALOPERIDOL 2MG TABLET (100 CT)   2* Generic $4.00$8.00None
HALOPERIDOL 5 MG TABLET   2* Generic $4.00$8.00None
HALOPERIDOL DEC 100 MG/ML VIAL   4 Non-Preferred Drug 32%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
HALOPERIDOL DEC 100 MG/ML VIAL   4 Non-Preferred Drug 32%N/ANone
HALOPERIDOL DEC 50MG 10 X 1ML PKG   4 Non-Preferred Drug 32%N/ANone
HALOPERIDOL LAC 2 MG/ML CONC   2* Generic $4.00$8.00None
HALOPERIDOL LAC 5 MG/ML SYRING   2* Generic $4.00$8.00None
HALOPERIDOL LAC 5 MG/ML VIAL   2* Generic $4.00$8.00None
HAVRIX 1,440 UNITS/ML SYRINGE   3 Preferred Brand 18%18%None
HAVRIX 720 UNITS/0.5 ML VIAL   3 Preferred Brand 18%18%None
HAVRIX HEPATITIS A VACCINE INACTIVATED INJECTION SOLUTION 1440UNITS 10 X 1ML VIALSD   3 Preferred Brand 18%18%None
HAVRIX HEPATITIS A VACCINE INJECTION   3 Preferred Brand 18%18%None
HEPARIN 30,000 UNIT/30 ML VIAL   3 Preferred Brand 18%18%None
HEPARIN SOD 5,000 UNIT/ML VIAL   3 Preferred Brand 18%18%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
HEPARIN SODIUM INJECTION   3 Preferred Brand 18%18%None
HEPARIN SODIUM INJECTION   3 Preferred Brand 18%18%None
HEPATAMINE INJECTION 8%   3 Preferred Brand 18%18%P
Hepatitis B Surface Antigen Vaccine 0.01 MG/ML Prefilled 0.5 ML Syringe [Recombivax]   3 Preferred Brand 18%18%P
HEPATITIS B VACCINE RECOMBIANT ADULT FORMULATION INJECTION 10MCG 1ML VIALSD   3 Preferred Brand 18%18%P
HETLIOZ 20 MG CAPSULE   5 Specialty Tier 25%N/AP Q:30
/30Days
HIBERIX VACCINE WITH DILUENT   3 Preferred Brand 18%18%None
HUMALOG 100 UNITS/ML CARTRIDGE   3 Preferred Brand 18%18%None
HUMALOG 100 UNITS/ML VIAL   3 Preferred Brand 18%18%None
HUMALOG JR 100 UNIT/ML KWIKPEN   3 Preferred Brand 18%18%None
HUMALOG KWIKPEN INJECTION   3 Preferred Brand 18%18%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
HUMALOG MIX 50/50 VIAL   3 Preferred Brand 18%18%None
HUMALOG MIX 75/25 VIAL   3 Preferred Brand 18%18%None
HUMALOG MIX KWIKPEN INJECTION   3 Preferred Brand 18%18%None
HUMALOG MIX KWIKPEN INJECTION SUSPENSION   3 Preferred Brand 18%18%None
HUMIRA 10 MG/0.1 ML SYRINGEKIT   5 Specialty Tier 25%N/AP Q:2
/28Days
HUMIRA 10 MG/0.2 ML SYRINGE   5 Specialty Tier 25%N/AP Q:2
/28Days
Humira 2 KIT per CARTON / 1 KIT in 1 KIT   5 Specialty Tier 25%N/AP Q:4
/28Days
HUMIRA 20 MG/0.2 ML SYRINGEKIT   5 Specialty Tier 25%N/AP Q:2
/28Days
HUMIRA 40 MG/0.4 ML PEN IJ KIT   5 Specialty Tier 25%N/AP Q:4
/28Days
HUMIRA 40 MG/0.4 ML SYRINGEKIT   5 Specialty Tier 25%N/AP Q:4
/28Days
HUMIRA 40 MG/0.8 ML PEN   5 Specialty Tier 25%N/AP Q:4
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
HUMIRA PED CROHNS 80 MG/0.8 ML SYRINGEKIT   5 Specialty Tier 25%N/AP Q:3
/180Days
HUMIRA PEDIATR CROHN'S 80-40MG SYRINGEKIT   5 Specialty Tier 25%N/AP Q:2
/180Days
HUMIRA PEDIATRIC CROHN'S START   5 Specialty Tier 25%N/AP Q:3
/180Days
HUMIRA PEDIATRIC CROHN'S START   5 Specialty Tier 25%N/AP Q:6
/180Days
HUMIRA PEN KIT 40MG-70% 1 PKGCOM   5 Specialty Tier 25%N/AP Q:6
/180Days
HUMIRA PEN PSORIASIS-UVEITIS   5 Specialty Tier 25%N/AP Q:4
/180Days
HUMIRA(CF) PEN CRHN-UC-HS 80MG PEN IJ KIT   5 Specialty Tier 25%N/AP Q:3
/180Days
HUMIRA(CF) PEN PS-UV-AHS 80-40 PEN IJ KIT   5 Specialty Tier 25%N/AP Q:3
/180Days
HUMULIN 70/30 KWIKPEN   3 Preferred Brand 18%18%None
HUMULIN 70/30 VIAL   3 Preferred Brand 18%18%None
HUMULIN N 100 UNITS/ML KWIKPEN   3 Preferred Brand 18%18%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
HUMULIN N 100U/ML VIAL   3 Preferred Brand 18%18%None
HUMULIN R 100U/ML VIAL   3 Preferred Brand 18%18%None
HUMULIN R 500 UNITS/ML KWIKPEN   4 Non-Preferred Drug 32%N/ANone
HUMULIN R 500U/ML VIAL   4 Non-Preferred Drug 32%N/ANone
HYDRALAZINE 10 MG TABLET   2* Generic $4.00$8.00None
HYDRALAZINE 100 MG TABLET   2* Generic $4.00$8.00None
HYDRALAZINE 25 MG TABLET   2* Generic $4.00$8.00None
HYDRALAZINE 50 MG TABLET   2* Generic $4.00$8.00None
Hydrochlorothiazide 12.5 MG Oral Capsule   1* Preferred Generic $1.00$2.00None
HYDROCHLOROTHIAZIDE 12.5 MG TB   1* Preferred Generic $1.00$2.00None
HYDROCHLOROTHIAZIDE 25 MG TAB   1* Preferred Generic $1.00$2.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
HYDROCHLOROTHIAZIDE 50 MG TAB   1* Preferred Generic $1.00$2.00None
HYDROCODON-ACETAMINOPH 7.5-325   4 Non-Preferred Drug 32%N/AQ:360
/30Days
HYDROCODON-ACETAMINOPHEN 5-325   4 Non-Preferred Drug 32%N/AQ:360
/30Days
HYDROCODONE BITARTRATE AND IBUPROFEN TABLET 7.5-200MG (100 CT)   4 Non-Preferred Drug 32%N/AQ:50
/30Days
HYDROCODONE-ACETAMIN 10-325 MG Tablet [Norco]   4 Non-Preferred Drug 32%N/AQ:360
/30Days
HYDROCODONE-ACETAMIN 7.5-325/15 Solution [Hycet]   4 Non-Preferred Drug 32%N/AQ:5550
/30Days
HYDROCORTISONE 1% CREAM   2* Generic $4.00$8.00None
HYDROCORTISONE 1% OINTMENT   2* Generic $4.00$8.00None
HYDROCORTISONE 10 MG TABLET [Hydrocortone]   2* Generic $4.00$8.00None
HYDROCORTISONE 100 MG/60 ML   3 Preferred Brand 18%18%None
HYDROCORTISONE 2.5% CREAM   2* Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
HYDROCORTISONE 2.5% LOTION   4 Non-Preferred Drug 32%N/ANone
HYDROCORTISONE 2.5% OINTMENT   2* Generic $4.00$8.00None
HYDROCORTISONE 20 MG TABLET [Cortef]   2* Generic $4.00$8.00None
HYDROCORTISONE 5 MG TABLET [Cortef]   2* Generic $4.00$8.00None
HYDROCORTISONE VAL 0.2% CREAM   2* Generic $4.00$8.00None
HYDROCORTISONE VAL 0.2% OINTMT   4 Non-Preferred Drug 32%N/ANone
HYDROCORTISONE-ACETIC ACID SOLN   4 Non-Preferred Drug 32%N/ANone
HYDROMORPHONE 1 MG/ML SOLUTION [Dilaudid]   2* Generic $4.00$8.00Q:2400
/30Days
HYDROMORPHONE 10 MG/ML VIAL [Dilaudid-HP]   4 Non-Preferred Drug 32%N/AQ:240
/30Days
HYDROMORPHONE 2 MG TABLET [Dilaudid]   4 Non-Preferred Drug 32%N/AQ:180
/30Days
HYDROMORPHONE 2 MG/ML ISECURE Syringe [Simplist Dilaudid]   4 Non-Preferred Drug 32%N/AQ:1200
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
HYDROMORPHONE 4 MG TABLET [Dilaudid]   4 Non-Preferred Drug 32%N/AQ:180
/30Days
HYDROMORPHONE 50 MG/5 ML VIAL [Dilaudid-HP]   4 Non-Preferred Drug 32%N/AQ:240
/30Days
HYDROMORPHONE 8 MG TABLET [Dilaudid]   4 Non-Preferred Drug 32%N/AQ:180
/30Days
HYDROXYCHLOROQUINE 200 MG TAB   3 Preferred Brand 18%18%None
HYDROXYUREA 500 MG CAPSULE   2* Generic $4.00$8.00None
HYDROXYZINE HCL 10 MG TABLET   2* Generic $4.00$8.00P
HYDROXYZINE HCL 25 MG TABLET   2* Generic $4.00$8.00P
HYDROXYZINE HCL 50 MG TABLET   2* Generic $4.00$8.00P

Chart Legend:

Below are a few notes to help you understand the above 2019 Medicare Part D Express Scripts Medicare - Saver (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.