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SilverScript Choice (PDP) (S5601-012-0)
Tier 1 (100)
Tier 2 (455)
Tier 3 (1042)
Tier 4 (918)
Tier 5 (546)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
Yes No Show either
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 Choice (PDP) (S5601-012-0)
Benefit Details           
The SilverScript Choice (PDP) (S5601-012-0)
Formulary Drugs Starting with the Letter K

in CMS PDP Region 6 which includes: PA WV
Plan Monthly Premium: $32.50 Deductible: $0 Qualifies for LIS: Yes
Drugs Starting with Letter K

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
KALETRA 100-25 MG TABLET   4 Non-Preferred Drug 43%43%None
KALETRA 50-200MG TABLET   5 Specialty Tier 33%N/ANone
KALYDECO 150 MG TABLET   5 Specialty Tier 33%N/AP
KALYDECO 25 MG GRANULES PACKET   5 Specialty Tier 33%N/AP
KALYDECO 50 MG GRANULES PACKET   5 Specialty Tier 33%N/AP
KALYDECO 75 MG GRANULES PACKET   5 Specialty Tier 33%N/AP
KARIVA 21-5 TABLET   3 Preferred Brand $43.00$107.50None
KCL 20 MEQ IN D5W-0.3% NACL IV SOLN   4 Non-Preferred Drug 43%43%None
KCL 20 MEQ IN D5W-0.45% NACL IV SOLN   4 Non-Preferred Drug 43%43%None
KCL 20 MEQ-NS 1,000 ML IV SOLN   4 Non-Preferred Drug 43%43%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Kcl 40 meq in d5w solution   4 Non-Preferred Drug 43%43%None
KCL 40 MEQ-NS 1,000 ML IV SOLN   4 Non-Preferred Drug 43%43%None
kcl 5 meq in d5w-0.2% nacl   4 Non-Preferred Drug 43%43%None
KELNOR 1-35 1-0.035MG TABLET   3 Preferred Brand $43.00$107.50None
KELNOR 1-50 TABLET [Zovia 1/50E]   3 Preferred Brand $43.00$107.50None
KETOCONAZOLE 2% CREAM   3 Preferred Brand $43.00$107.50None
KETOCONAZOLE 2% SHAMPOO   2 Generic $14.00$35.00None
KETOCONAZOLE 200 MG TABLET   3 Preferred Brand $43.00$107.50P
KETOROLAC 0.4% OPHTH SOLUTION Drops [Acular LS]   3 Preferred Brand $43.00$107.50None
KETOROLAC 0.5% OPHTH SOLUTION   3 Preferred Brand $43.00$107.50None
KINRIX VIAL   3 Preferred Brand $43.00$107.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
KIONEX 15 GM/60 ML SUSPENSION   3 Preferred Brand $43.00$107.50None
KISQALI 200 MG DAILY DOSE   5 Specialty Tier 33%N/AP
KISQALI 400 MG DAILY DOSE   5 Specialty Tier 33%N/AP
KISQALI 600 MG DAILY DOSE   5 Specialty Tier 33%N/AP
KISQALI FEMARA 200 MG CO-PACK   5 Specialty Tier 33%N/AP
KISQALI FEMARA 400 MG CO-PACK   5 Specialty Tier 33%N/AP
KISQALI FEMARA 600 MG CO-PACK   5 Specialty Tier 33%N/AP
KLOR-CON 10 MEQ TABLET   2 Generic $14.00$35.00None
KLOR-CON 20 MEQ PACKET   4 Non-Preferred Drug 43%43%None
KLOR-CON 8 MEQ TABLET   2 Generic $14.00$35.00None
KLOR-CON M10 tablet   2 Generic $14.00$35.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Klor-Con M15 Tablet   3 Preferred Brand $43.00$107.50None
KLOR-CON M20 TABLET TAB ER PRT [Klor-Con M20]   2 Generic $14.00$35.00None
KLOR-CON SPRINKLE ER 8 MEQ CAP   3 Preferred Brand $43.00$107.50None
KORLYM 300 MG TABLET   5 Specialty Tier 33%N/AP
KURVELO TABLET   3 Preferred Brand $43.00$107.50None
KUVAN 100 MG POWDER PACKET   5 Specialty Tier 33%N/AP
KUVAN 100MG TABLET SOLUBLE   5 Specialty Tier 33%N/AP
KUVAN 500 MG POWDER PACKET   5 Specialty Tier 33%N/AP
KYNAMRO 200 MG/ML SYRINGE   5 Specialty Tier 33%N/AP

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.