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Farm Bureau Select Rx (PDP) (S2668-006-0)
Tier 1 (314)
Tier 2 (1510)
Tier 3 (297)
Tier 4 (859)
Tier 5 (890)
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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M N O P Q R S T U V W X Y Z 0-9 
2019 Medicare Part D Plan Formulary Information
Farm Bureau Select Rx (PDP) (S2668-006-0)
Benefit Details           
The Farm Bureau Select Rx (PDP) (S2668-006-0)
Formulary Drugs Starting with the Letter X

in CMS PDP Region 12 which includes: AL TN
Plan Monthly Premium: $99.00 Deductible: $0 Qualifies for LIS: No
Drugs Starting with Letter X

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Xalkori 200mg/1 60 CAPSULE BOTTLE   5 Specialty Tier 33%33%P
Xalkori 250mg/1 60 CAPSULE BOTTLE   5 Specialty Tier 33%33%P
XARELTO 10 MG TABLET   3 Preferred Brand $40.00$120.00Q:30
/30Days
XARELTO 15 MG TABLET   3 Preferred Brand $40.00$120.00Q:60
/30Days
XARELTO 2.5 MG TABLET   3 Preferred Brand $40.00$120.00Q:60
/30Days
XARELTO 20 MG TABLET   3 Preferred Brand $40.00$120.00Q:30
/30Days
XARELTO STARTER PACK   3 Preferred Brand $40.00$120.00Q:102
/365Days
XATMEP 2.5 MG/ML ORAL SOLUTION   5 Specialty Tier 33%33%None
XELJANZ 10 MG TABLET   5 Specialty Tier 33%33%P
XELJANZ 5 MG TABLET   5 Specialty Tier 33%33%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
XELJANZ XR 11 MG TABLET   5 Specialty Tier 33%33%P
XERMELO 250 MG TABLET   5 Specialty Tier 33%33%P Q:90
/30Days
XGEVA 120mg/1.7mL 1 VIAL, SINGLE-USE per CARTON / 1.7 mL in 1 VIAL, SINGLE-USE   5 Specialty Tier 33%33%P
XIFAXAN 200MG TABLET   5 Specialty Tier 33%33%P
XIFAXAN 550 MG TABLET   5 Specialty Tier 33%33%P
XIIDRA 5% EYE DROPS   4 Non-Preferred Drug 45%45%Q:60
/30Days
XOFLUZA 20 MG TABLET (40 MG DOSE)   3 Preferred Brand $40.00$120.00Q:4
/365Days
XOFLUZA 40 MG TABLET (80 MG DOSE)   3 Preferred Brand $40.00$120.00Q:4
/365Days
XOLAIR 150 MG/ML SYRINGE   5 Specialty Tier 33%33%P
XOLAIR 150MG VIAL   5 Specialty Tier 33%33%P
XOLAIR 75 MG/0.5 ML SYRINGE   5 Specialty Tier 33%33%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
XOSPATA 40 MG TABLET   5 Specialty Tier 33%33%P
XTAMPZA ER 13.5 MG CAPSULE   3 Preferred Brand $40.00$120.00None
XTAMPZA ER 18 MG CAPSULE   3 Preferred Brand $40.00$120.00None
XTAMPZA ER 27 MG CAPSULE   3 Preferred Brand $40.00$120.00None
XTAMPZA ER 36 MG CAPSULE   3 Preferred Brand $40.00$120.00None
XTAMPZA ER 9 MG CAPSULE   3 Preferred Brand $40.00$120.00None
XTANDI 40 MG CAPSULE   5 Specialty Tier 33%33%P
Xulane Patch   4 Non-Preferred Drug 45%45%None
XURIDEN GRANULE PACKET   5 Specialty Tier 33%33%P Q:120
/30Days
XYOSTED 100 MG/0.5 ML AUTO INJCT   4 Non-Preferred Drug 45%45%P
XYOSTED 50 MG/0.5 ML AUTO INJCT   4 Non-Preferred Drug 45%45%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
XYOSTED 75 MG/0.5 ML AUTO INJCT   4 Non-Preferred Drug 45%45%P
XYREM 500MG/ML ORAL SOLUTION   5 Specialty Tier 33%33%P Q:540
/30Days

Chart Legend:

Below are a few notes to help you understand the above 2019 Medicare Part D Farm Bureau Select Rx (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.