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SilverScript Allure (PDP) (S5601-172-0)
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:
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 Allure (PDP) (S5601-172-0)
Benefit Details           
The SilverScript Allure (PDP) (S5601-172-0)
Formulary Drugs Starting with the Letter O

in CMS PDP Region 30 which includes: OR WA
Plan Monthly Premium: $80.00 Deductible: $0 Qualifies for LIS: No
Drugs Starting with Letter O

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
OCELLA 3MG/0.03MG TABLET   3 Preferred Brand 20%20%None
OCTAGAM 10% VIAL   5 Specialty Tier 33%N/AP
OCTAGAM 5% VIAL   5 Specialty Tier 33%N/AP
OCTREOTIDE 1,000 MCG/ML VIAL   5 Specialty Tier 33%N/AP
OCTREOTIDE ACET 0.05 MG/ML VL   4 Non-Preferred Drug 40%40%P
OCTREOTIDE ACET 100 MCG/ML VL   4 Non-Preferred Drug 40%40%P
OCTREOTIDE ACET 200 MCG/ML VL   4 Non-Preferred Drug 40%40%P
OCTREOTIDE ACET 500 MCG/ML VL   5 Specialty Tier 33%N/AP
OCUTRICIN EYE OINTMENT 400UNT/3.5MG/10UNT   3 Preferred Brand 20%20%None
ODEFSEY TABLET   5 Specialty Tier 33%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ODOMZO 200 MG CAPSULE   5 Specialty Tier 33%N/AP
OFEV 100 MG CAPSULE   5 Specialty Tier 33%N/AP
OFEV 150 MG CAPSULE   5 Specialty Tier 33%N/AP
OFLOXACIN 0.3 % DRP   2 Generic $5.00$12.50None
OFLOXACIN 0.3% EAR DROPS   4 Non-Preferred Drug 40%40%None
OLANZAPINE 10 MG TABLET [Zyprexa]   3 Preferred Brand 20%20%Q:60
/30Days
OLANZAPINE 10 MG VIAL   4 Non-Preferred Drug 40%40%Q:3
/1Days
OLANZAPINE 15 MG TABLET [Zyprexa]   3 Preferred Brand 20%20%Q:30
/30Days
OLANZAPINE 2.5 MG TABLET [Zyprexa]   3 Preferred Brand 20%20%Q:240
/30Days
OLANZAPINE 20 MG TABLET [Zyprexa]   3 Preferred Brand 20%20%Q:30
/30Days
OLANZAPINE 5 MG TABLET [Zyprexa]   3 Preferred Brand 20%20%Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
OLANZAPINE 7.5 MG TABLET [Zyprexa]   3 Preferred Brand 20%20%Q:30
/30Days
OLANZAPINE ODT 10 MG TABLET RAPDIS [Zyprexa Zydis]   4 Non-Preferred Drug 40%40%Q:60
/30Days
OLANZAPINE ODT 15 MG TABLET RAPDIS [Zyprexa Zydis]   4 Non-Preferred Drug 40%40%Q:30
/30Days
OLANZAPINE ODT 20 MG TABLET RAPDIS [Zyprexa Zydis]   4 Non-Preferred Drug 40%40%Q:30
/30Days
OLANZAPINE ODT 5 MG TABLET RAPDIS [Zyprexa Zydis]   4 Non-Preferred Drug 40%40%Q:30
/30Days
OLMESARTAN MEDOXOMIL 20 MG TAB [Benicar]   3 Preferred Brand 20%20%None
OLMESARTAN MEDOXOMIL 40 MG TAB [Benicar]   3 Preferred Brand 20%20%None
OLMESARTAN MEDOXOMIL 5 MG TAB [Benicar]   3 Preferred Brand 20%20%None
OLMESARTAN-HCTZ 20-12.5 MG TAB   3 Preferred Brand 20%20%None
OLMESARTAN-HCTZ 40-12.5 MG TABLET [Benicar HCT]   3 Preferred Brand 20%20%None
OLMESARTAN-HCTZ 40-25 MG TAB   3 Preferred Brand 20%20%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
olmsrtn-amldpn-hctz 20-5-12.5 [TRIBENZOR]   3 Preferred Brand 20%20%None
olmsrtn-amldpn-hctz 40-10-12.5 [TRIBENZOR]   3 Preferred Brand 20%20%None
olmsrtn-amldpn-hctz 40-10-25mg [TRIBENZOR]   3 Preferred Brand 20%20%None
olmsrtn-amldpn-hctz 40-5-12.5 [TRIBENZOR]   3 Preferred Brand 20%20%None
olmsrtn-amldpn-hctz 40-5-25 mg [TRIBENZOR]   3 Preferred Brand 20%20%None
Olopatadine 2 MG/ML Ophthalmic Solution   4 Non-Preferred Drug 40%40%None
OMEPRAZOLE DR 10 MG CAPSULE DR [Prilosec]   1 Preferred Generic $1.00$0.00None
OMEPRAZOLE DR 20 MG CAPSULE DR [Prilosec]   1 Preferred Generic $1.00$0.00None
OMEPRAZOLE DR 40 MG CAPSULE DR [Prilosec]   1 Preferred Generic $1.00$0.00None
ONDANSETRON 4 MG/5 ML SOLUTION   4 Non-Preferred Drug 40%40%P
ONDANSETRON HCL 24 MG TABLET   3 Preferred Brand 20%20%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ONDANSETRON HCL 4 MG TABLET   3 Preferred Brand 20%20%P
ONDANSETRON HCL 8 MG TABLET   3 Preferred Brand 20%20%P
ONDANSETRON ODT 4 MG TABLET   3 Preferred Brand 20%20%P
ONDANSETRON ODT 8 MG TABLET   3 Preferred Brand 20%20%P
ORFADIN 10 MG CAPSULE   5 Specialty Tier 33%N/AP
ORFADIN 2 MG CAPSULE   5 Specialty Tier 33%N/AP
ORFADIN 20 MG CAPSULE   5 Specialty Tier 33%N/AP
ORFADIN 4 MG/ML SUSPENSION   5 Specialty Tier 33%N/AP
ORFADIN 5 MG CAPSULE   5 Specialty Tier 33%N/AP
ORKAMBI 100 MG-125 MG TABLET   5 Specialty Tier 33%N/AP
ORKAMBI 100-125 MG GRANULE PKT GRAN PACK   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ORKAMBI 150-188 MG GRANULE PKT GRAN PACK   5 Specialty Tier 33%N/AP
ORKAMBI 200 MG-125 MG TABLET   5 Specialty Tier 33%N/AP
ORSYTHIA-28 TABLET [Vienva]   3 Preferred Brand 20%20%None
OSELTAMIVIR 6 MG/ML SUSPENSION [Tamiflu]   3 Preferred Brand 20%20%Q:1080
/365Days
OSELTAMIVIR PHOS 30 MG CAPSULE [Tamiflu]   3 Preferred Brand 20%20%Q:168
/365Days
OSELTAMIVIR PHOS 45 MG CAPSULE [Tamiflu]   3 Preferred Brand 20%20%Q:84
/365Days
OSELTAMIVIR PHOS 75 MG CAPSULE [Tamiflu]   3 Preferred Brand 20%20%Q:84
/365Days
OXACILLIN 1 GM VIAL   4 Non-Preferred Drug 40%40%None
Oxacillin 100 MG/ML Injectable Solution   5 Specialty Tier 33%N/ANone
Oxacillin 2000 MG Injection   4 Non-Preferred Drug 40%40%None
OXANDROLONE 10 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
OXANDROLONE 2.5 MG TABLET   3 Preferred Brand 20%20%P
OXCARBAZEPINE 150 MG TABLET   3 Preferred Brand 20%20%None
OXCARBAZEPINE 300 MG TABLET   3 Preferred Brand 20%20%None
OXCARBAZEPINE 300 MG/5 ML SUSP   4 Non-Preferred Drug 40%40%None
OXCARBAZEPINE 600 MG TABLET   3 Preferred Brand 20%20%None
OXYBUTYNIN 5 MG/5 ML SYRUP   3 Preferred Brand 20%20%None
OXYBUTYNIN 5MG TABLET   3 Preferred Brand 20%20%None
OXYBUTYNIN CL ER 10 MG TABLET   3 Preferred Brand 20%20%None
OXYBUTYNIN CL ER 15 MG TABLET   3 Preferred Brand 20%20%None
OXYBUTYNIN CL ER 5 MG TABLET   3 Preferred Brand 20%20%None
OXYCODON-ACETAMINOPHEN 2.5-325   3 Preferred Brand 20%20%Q:360
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
OXYCODON-ACETAMINOPHEN 7.5-325   3 Preferred Brand 20%20%Q:240
/30Days
OXYCODONE HCL 10 MG TABLET [Dazidox]   3 Preferred Brand 20%20%Q:180
/30Days
OXYCODONE HCL 15 MG TABLET [Roxybond]   3 Preferred Brand 20%20%Q:180
/30Days
OXYCODONE HCL 20 MG TABLET [Roxicodone]   3 Preferred Brand 20%20%Q:180
/30Days
OXYCODONE HCL 30 MG TABLET [Roxybond]   3 Preferred Brand 20%20%Q:180
/30Days
OXYCODONE HCL 5 MG TABLET [Roxybond]   3 Preferred Brand 20%20%Q:180
/30Days
OXYCODONE HCL 5 MG/5 ML SOLN Solution [Roxicodone]   4 Non-Preferred Drug 40%40%Q:900
/30Days
OXYCODONE-ACETAMINOPHEN 10-325 TABLET [Percocet]   3 Preferred Brand 20%20%Q:180
/30Days
OXYCODONE-ACETAMINOPHEN 5-325   3 Preferred Brand 20%20%Q:360
/30Days
OxyContin 10mg/1   3 Preferred Brand 20%20%P Q:60
/30Days
OxyContin 15mg/1   3 Preferred Brand 20%20%P Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
OxyContin 20mg/1   3 Preferred Brand 20%20%P Q:60
/30Days
OxyContin 30mg/1   3 Preferred Brand 20%20%P Q:60
/30Days
OxyContin 40mg/1   3 Preferred Brand 20%20%P Q:60
/30Days
OxyContin 60mg/1   3 Preferred Brand 20%20%P Q:60
/30Days
OxyContin 80mg/1   3 Preferred Brand 20%20%P Q:60
/30Days
OZEMPIC 0.25-0.5 MG DOSE PEN   3 Preferred Brand 20%20%Q:2
/28Days
OZEMPIC 1 MG DOSE PEN   3 Preferred Brand 20%20%Q:3
/28Days

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.