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2020 Medicare Part D and Medicare Advantage Plan Formulary Browser

This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.
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Express Scripts Medicare - Choice (PDP) (S5660-181-0)
Tier 1 (218)
Tier 2 (1184)
Tier 3 (722)
Tier 4 (643)
Tier 5 (524)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
Yes No Show either
  *required
 
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 
2020 Medicare Part D Plan Formulary Information
Express Scripts Medicare - Choice (PDP) (S5660-181-0)
Benefit Details           
The Express Scripts Medicare - Choice (PDP) (S5660-181-0)
Formulary Drugs Starting with the Letter S

in CMS PDP Region 11 which includes: FL
Plan Monthly Premium: $87.60 Deductible: $250 Qualifies for LIS: No
Drugs Starting with Letter S

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
SANDIMMUNE 100MG/ML TUBEX   3 Preferred Brand $42.00$126.00P
SANTYL OINTMENT   3 Preferred Brand $42.00$126.00None
SAPHRIS 10 MG TABLET SL BLACK CHERRY   4 Non-Preferred Drug 46%N/AQ:60
/30Days
SAPHRIS 2.5 MG TABLET SL BLACK CHERRY   4 Non-Preferred Drug 46%N/AQ:60
/30Days
SAPHRIS 5 MG TABLET SL BLACK CHERRY   4 Non-Preferred Drug 46%N/AQ:60
/30Days
SAVELLA TABLETS 100MG 60 COUNT BOT   3 Preferred Brand $42.00$126.00Q:60
/30Days
SAVELLA TABLETS 12.5MG 60 COUNT BOT   3 Preferred Brand $42.00$126.00Q:60
/30Days
SAVELLA TABLETS 25MG 60 COUNT BOT   3 Preferred Brand $42.00$126.00Q:60
/30Days
SAVELLA TABLETS TITRATION PACK KIT 12.5;25;50MG;MG;MG 55 COUNT PKGCOM   3 Preferred Brand $42.00$126.00Q:55
/30Days
SAVELLA TALBETS 50MG 60 COUNT BOT   3 Preferred Brand $42.00$126.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SCOPOLAMINE 1 MG/3 DAY PATCH TD 3 [Transderm Scop]   3 Preferred Brand $42.00$126.00Q:10
/30Days
SECUADO 3.8 MG/24 HR PATCH   4 Non-Preferred Drug 46%N/AQ:30
/30Days
SECUADO 5.7 MG/24 HR PATCH   4 Non-Preferred Drug 46%N/AQ:30
/30Days
SECUADO 7.6 MG/24 HR PATCH   4 Non-Preferred Drug 46%N/AQ:30
/30Days
SELEGILINE HCL 5 MG TABLET   3 Preferred Brand $42.00$126.00None
SELEGILINE HCL 5MG CAPSULE   3 Preferred Brand $42.00$126.00None
SELENIUM SULFIDE 2.5mg/100mL 118 mL in 1 BOTTLE   2* Generic $7.00$4.00None
SELZENTRY 150mg/1 60 FILM COATED TABLETS in BOTTLE   5 Specialty Tier 28%N/AQ:60
/30Days
SELZENTRY 20 MG/ML ORAL SOLN   4 Non-Preferred Drug 46%N/ANone
SELZENTRY 25 MG TABLET   3 Preferred Brand $42.00$126.00Q:120
/30Days
SELZENTRY 300mg/1 60 FILM COATED TABLETS in BOTTLE   5 Specialty Tier 28%N/AQ:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SELZENTRY 75 MG TABLET   5 Specialty Tier 28%N/AQ:60
/30Days
SENSIPAR 30MG TABLET   3 Preferred Brand $42.00$126.00Q:60
/30Days
SENSIPAR 60MG TABLET   5 Specialty Tier 28%N/AQ:60
/30Days
SENSIPAR 90MG TABLET   5 Specialty Tier 28%N/AQ:120
/30Days
SEREVENT DIS AER 50MCG   3 Preferred Brand $42.00$126.00Q:60
/30Days
SERTRALINE 20 MG/ML ORAL CONC   2* Generic $7.00$4.00None
SERTRALINE HCL 100 MG TABLET   1* Preferred Generic $2.00$0.00Q:60
/30Days
SERTRALINE HCL 25 MG TABLET   1* Preferred Generic $2.00$0.00Q:30
/30Days
SERTRALINE HCL 50 MG TABLET   1* Preferred Generic $2.00$0.00Q:60
/30Days
SETLAKIN 0.15 MG-0.03 MG TAB   2* Generic $7.00$4.00None
SEVELAMER 0.8 GM POWDER PACKET [RENVELA]   5 Specialty Tier 28%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SEVELAMER 2.4 GM POWDER PACKET POWD PACK [Renvela]   5 Specialty Tier 28%N/ANone
SEVELAMER CARBONATE 800 MG TABLET [RENVELA]   2* Generic $7.00$4.00Q:540
/30Days
SEVELAMER HCL 400 MG TABLET [RenaGel]   3 Preferred Brand $42.00$126.00None
SEVELAMER HCL 800 MG TABLET [RenaGel]   3 Preferred Brand $42.00$126.00None
SHAROBEL 0.35 MG TABLET   2* Generic $7.00$4.00None
SHINGRIX VIAL KIT   3 Preferred Brand $42.00$126.00Q:2
/999Days
Signifor .3 mg/mL   5 Specialty Tier 28%N/AP
Signifor .6 mg/mL   5 Specialty Tier 28%N/AP
Signifor .9 mg/mL   5 Specialty Tier 28%N/AP
SILDENAFIL 10 MG/ML ORAL SUSPENSION [Revatio]   5 Specialty Tier 28%N/AP Q:224
/30Days
SILDENAFIL 20 MG TABLET [Revatio]   3 Preferred Brand $42.00$126.00P Q:90
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SILVER SULFADIAZINE 1% CREAM   2* Generic $7.00$4.00None
SIMBRINZA 1%-0.2% EYE DROPS   4 Non-Preferred Drug 46%N/ANone
SIMVASTATIN 10 MG TABLET   1* Preferred Generic $2.00$0.00Q:30
/30Days
SIMVASTATIN 20 MG TABLET   1* Preferred Generic $2.00$0.00Q:30
/30Days
SIMVASTATIN 40 MG TABLET   1* Preferred Generic $2.00$0.00Q:30
/30Days
SIMVASTATIN 5 MG TABLET [Zocor]   1* Preferred Generic $2.00$0.00Q:30
/30Days
SIMVASTATIN 80 MG TABLET   1* Preferred Generic $2.00$0.00Q:30
/30Days
Sirolimus 0.5 MG Tablet [Rapamune]   2* Generic $7.00$4.00P
SIROLIMUS 1 MG TABLET [Rapamune]   3 Preferred Brand $42.00$126.00P
SIROLIMUS 1 MG/ML SOLUTION [Rapamune]   5 Specialty Tier 28%N/AP
SIROLIMUS 2 MG TABLET [Rapamune]   5 Specialty Tier 28%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SIRTURO 100 MG TABLET   5 Specialty Tier 28%N/AP
SKLICE 0.5% LOTION   3 Preferred Brand $42.00$126.00None
SKYRIZI 150 MG DOSE KIT-2 SYRINGEKIT   5 Specialty Tier 28%N/AP Q:1
/28Days
SODIUM CHLORIDE 0.45% Sodium Chloride Injection, USP   3 Preferred Brand $42.00$126.00None
SODIUM CHLORIDE 0.9% IRRIG.   3 Preferred Brand $42.00$126.00None
SODIUM CHLORIDE 0.9% IV SOLN   3 Preferred Brand $42.00$126.00None
SODIUM CHLORIDE 3% IV SOLUTION   3 Preferred Brand $42.00$126.00None
SODIUM CHLORIDE INJECTION USP 5%   3 Preferred Brand $42.00$126.00None
SODIUM POLYSTYREN SULF 15 G/60 ML ORAL SUSPENSION [SPS]   2* Generic $7.00$4.00None
SODIUM POLYSTYRENE SULF POWDER   2* Generic $7.00$4.00None
SOLIFENACIN 10 MG TABLET [VESIcare]   3 Preferred Brand $42.00$126.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SOLIFENACIN 5 MG TABLET [VESIcare]   3 Preferred Brand $42.00$126.00None
SOLIQUA 100 UNIT-33 MCG/ML PEN   3 Preferred Brand $42.00$126.00None
SOLTAMOX 20 MG/10 ML SOLN Solution   4 Non-Preferred Drug 46%N/ANone
SOMATULINE DEPOT 120 MG/0.5 ML SYRINGE   5 Specialty Tier 28%N/AP
SOMATULINE DEPOT 60 MG/0.2 ML SYRINGE   5 Specialty Tier 28%N/AP
SOMATULINE DEPOT 90 MG/0.3 ML SYRINGE   5 Specialty Tier 28%N/AP
SOMAVERT 10 MG VIAL   5 Specialty Tier 28%N/AP Q:30
/30Days
SOMAVERT 15 MG VIAL   5 Specialty Tier 28%N/AP Q:30
/30Days
SOMAVERT 20 MG VIAL   5 Specialty Tier 28%N/AP Q:30
/30Days
SOMAVERT 25 MG VIAL   5 Specialty Tier 28%N/AP Q:30
/30Days
SOMAVERT 30 MG VIAL   5 Specialty Tier 28%N/AP Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SORINE SOLTALOL HCL TABLETS 240MG 100 BOXUD   2* Generic $7.00$4.00None
SORINE SOTALOL HCL TABLETS 120MG 100 BOXUD   2* Generic $7.00$4.00None
SORINE SOTALOL HCL TABLETS 160MG 100 BOXUD   2* Generic $7.00$4.00None
SORINE SOTALOL HCL TABLETS 80MG 100 BOXUD   2* Generic $7.00$4.00None
SOTALOL 120 MG TABLET [Sorine]   2* Generic $7.00$4.00None
SOTALOL 160 MG TABLET [Sorine]   2* Generic $7.00$4.00None
SOTALOL 240 MG TABLET [Sorine]   2* Generic $7.00$4.00None
SOTALOL 80 MG TABLET [Sorine]   2* Generic $7.00$4.00None
SOTALOL AF 120 MG TABLET   2* Generic $7.00$4.00None
SOTALOL AF 160 MG TABLET [Sorine]   2* Generic $7.00$4.00None
SOTALOL AF 80 MG TABLET [Sorine]   2* Generic $7.00$4.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SOTYLIZE 5 MG/ML ORAL SOLUTION   3 Preferred Brand $42.00$126.00None
SPIRONOLACTONE 100 MG TABLET [Aldactone]   2* Generic $7.00$4.00None
SPIRONOLACTONE 25 MG TABLET [Aldactone]   1* Preferred Generic $2.00$0.00None
SPIRONOLACTONE 50 MG TABLET [Aldactone]   2* Generic $7.00$4.00None
SPIRONOLACTONE-HCTZ 25-25 TABLET [Aldactazide]   2* Generic $7.00$4.00None
SPRINTEC 0.25-0.035 TABLET   2* Generic $7.00$4.00None
SPRITAM 1,000 MG TABLET   4 Non-Preferred Drug 46%N/ANone
SPRITAM 250 MG TABLET   4 Non-Preferred Drug 46%N/ANone
SPRITAM 500 MG TABLET   4 Non-Preferred Drug 46%N/ANone
SPRITAM 750 MG TABLET   4 Non-Preferred Drug 46%N/ANone
SPRYCEL 100mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE   5 Specialty Tier 28%N/AP Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SPRYCEL 140mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE   5 Specialty Tier 28%N/AP Q:30
/30Days
SPRYCEL 20MG TABLET   5 Specialty Tier 28%N/AP Q:60
/30Days
SPRYCEL 50MG TABLET   5 Specialty Tier 28%N/AP Q:30
/30Days
SPRYCEL 70MG TABLET   5 Specialty Tier 28%N/AP Q:60
/30Days
SPRYCEL 80mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE   5 Specialty Tier 28%N/AP Q:30
/30Days
SPS 15 GM/60 ML SUSPENSION   3 Preferred Brand $42.00$126.00None
SRONYX 0.10-0.02 MG TABLET   2* Generic $7.00$4.00None
SSD 1% CREAM   3 Preferred Brand $42.00$126.00None
STAVUDINE 15 MG CAPSULE [Zerit]   2* Generic $7.00$4.00Q:60
/30Days
STAVUDINE 20 MG CAPSULE [Zerit]   2* Generic $7.00$4.00Q:60
/30Days
STAVUDINE 30 MG CAPSULE [Zerit]   2* Generic $7.00$4.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
STAVUDINE 40 MG CAPSULE [Zerit]   2* Generic $7.00$4.00Q:60
/30Days
STELARA 45 MG/0.5 ML SYRINGE   5 Specialty Tier 28%N/AP
STELARA 45 MG/0.5 ML VIAL   5 Specialty Tier 28%N/AP
STELARA 90 MG/ML SYRINGE   5 Specialty Tier 28%N/AP
Stimate 1.5mg/mL 1 BOTTLE, SPRAY per CARTON / 2.5 mL in 1 BOTTLE, SPRAY   5 Specialty Tier 28%N/ANone
STIVARGA 40 MG TABLET   5 Specialty Tier 28%N/AP Q:84
/28Days
STREPTOMYCIN FOR INJECTION 1GM/VIL   3 Preferred Brand $42.00$126.00None
STRIBILD TABLET   5 Specialty Tier 28%N/AQ:30
/30Days
SUBOXONE 12 MG-3 MG SL FILM   4 Non-Preferred Drug 46%N/AQ:60
/30Days
Suboxone 2; 0.5mg/1; mg/1 30 POUCH per CARTON / 1 FILM, SOLUBLE in 1 POUCH   4 Non-Preferred Drug 46%N/AQ:360
/30Days
SUBOXONE 4 MG-1 MG SL FILM   4 Non-Preferred Drug 46%N/AQ:90
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Suboxone 8; 2mg/1; mg/1 30 POUCH per CARTON / 1 FILM, SOLUBLE in 1 POUCH   4 Non-Preferred Drug 46%N/AQ:90
/30Days
SUCRAID 8500[iU]/mL   5 Specialty Tier 28%N/ANone
SUCRALFATE 1GM TABLET   2* Generic $7.00$4.00None
SULF-PRED 10-0.23% EYE DROPS   2* Generic $7.00$4.00None
SULFACETAMIDE 10% EYE DROPS [Sulf-10]   2* Generic $7.00$4.00None
SULFACETAMIDE 10% EYE OINTMENT   2* Generic $7.00$4.00None
SULFACETAMIDE SOD 10% TOP SUSP   2* Generic $7.00$4.00None
Sulfadiazine 500mg/1 100 TABLET BOTTLE   4 Non-Preferred Drug 46%N/ANone
SULFAMETHOXAZOLE-TMP DS TABLET [Septra DS]   2* Generic $7.00$4.00None
SULFAMETHOXAZOLE-TMP SS TABLET [Septra]   2* Generic $7.00$4.00None
SULFAMETHOXAZOLE-TMP SUSP Oral Suspension [Sultrex Pediatric]   2* Generic $7.00$4.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SULFAMYLON 8.5% CREAM   3 Preferred Brand $42.00$126.00None
SULFASALAZINE 500 MG TABLET   2* Generic $7.00$4.00None
SULFASALAZINE DR 500 MG TABLET [Sulfazine EC]   2* Generic $7.00$4.00None
SULINDAC 150 MG TABLET   2* Generic $7.00$4.00None
SULINDAC 200 MG TABLET   2* Generic $7.00$4.00None
Sumatriptan 20 MG/ACTUAT Nasal Spray   2* Generic $7.00$4.00Q:18
/28Days
SUMATRIPTAN 4 MG/0.5 ML CART   3 Preferred Brand $42.00$126.00Q:8
/28Days
Sumatriptan 4 mg/0.5 ml inject   3 Preferred Brand $42.00$126.00Q:8
/28Days
Sumatriptan 5 MG/ACTUAT Nasal Spray   4 Non-Preferred Drug 46%N/AQ:36
/28Days
SUMATRIPTAN 6 MG/0.5 ML INJECT   3 Preferred Brand $42.00$126.00Q:8
/28Days
SUMATRIPTAN 6 MG/0.5 ML INJECT   3 Preferred Brand $42.00$126.00Q:8
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SUMATRIPTAN 6 MG/0.5 ML SYRNG Syringe [Sumavel DosePro System]   3 Preferred Brand $42.00$126.00Q:8
/28Days
Sumatriptan 6 mg/0.5 ml vial   3 Preferred Brand $42.00$126.00Q:8
/28Days
SUMATRIPTAN SUCC 100 MG TABLET   2* Generic $7.00$4.00Q:18
/28Days
SUMATRIPTAN SUCC 25 MG TABLET [Imitrex]   2* Generic $7.00$4.00Q:18
/28Days
SUMATRIPTAN SUCC 50 MG TABLET [Migraine Pack]   2* Generic $7.00$4.00Q:18
/28Days
SUPRAX 400 MG CAPSULE   4 Non-Preferred Drug 46%N/ANone
SUPRAX 500 MG/5 ML SUSPENSION   4 Non-Preferred Drug 46%N/ANone
SUPREP BOWEL PREP KIT SOLN RECON   4 Non-Preferred Drug 46%N/ANone
SUTENT 12.5MG CAPSULE   5 Specialty Tier 28%N/AP Q:30
/30Days
SUTENT 25mg/1 28 CAPSULE BOTTLE   5 Specialty Tier 28%N/AP Q:30
/30Days
SUTENT 37.5 MG CAPSULE   5 Specialty Tier 28%N/AP Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SUTENT 50MG CAPSULE   5 Specialty Tier 28%N/AP Q:30
/30Days
SYEDA 28 TABLET [Zarah]   2* Generic $7.00$4.00None
SYLATRON 200 MCG KIT   5 Specialty Tier 28%N/AP
SYLATRON 300 MCG KIT   5 Specialty Tier 28%N/AP
SYMDEKO 100/150 MG-150 MG TABS   5 Specialty Tier 28%N/AP Q:56
/28Days
SYMDEKO 50/75 MG-75 MG TABLET SEQ   5 Specialty Tier 28%N/AP Q:56
/28Days
SYMFI 600-300-300 MG TABLET   4 Non-Preferred Drug 46%N/ANone
SYMFI LO 400-300-300 MG TABLET   4 Non-Preferred Drug 46%N/AQ:30
/30Days
SYMLINPEN 120 PEN INJECTOR   5 Specialty Tier 28%N/AP Q:11
/30Days
SYMLINPEN 60 PEN INJECTOR   5 Specialty Tier 28%N/AP Q:6
/30Days
SYMPAZAN 10 MG FILM   4 Non-Preferred Drug 46%N/AP Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SYMPAZAN 20 MG FILM   4 Non-Preferred Drug 46%N/AP Q:60
/30Days
SYMPAZAN 5 MG FILM   4 Non-Preferred Drug 46%N/AP Q:60
/30Days
SYMTUZA 800-150-200-10 MG TABLET   4 Non-Preferred Drug 46%N/ANone
SYNAREL 2MG/ML NASAL SPRAY   4 Non-Preferred Drug 46%N/ANone
SYNJARDY 12.5-1,000 MG TABLET   3 Preferred Brand $42.00$126.00Q:60
/30Days
SYNJARDY 12.5-500 MG TABLET   3 Preferred Brand $42.00$126.00Q:60
/30Days
SYNJARDY 5-1,000 MG TABLET   3 Preferred Brand $42.00$126.00Q:60
/30Days
SYNJARDY XR 10-1,000 MG TABLET BP 24H   3 Preferred Brand $42.00$126.00Q:60
/30Days
SYNJARDY XR 12.5-1,000 MG TABLET BP 24H   3 Preferred Brand $42.00$126.00Q:60
/30Days
SYNJARDY XR 25-1,000 MG TABLET BP 24H   3 Preferred Brand $42.00$126.00Q:30
/30Days
SYNJARDY XR 5-1,000 MG TABLET BP 24H   3 Preferred Brand $42.00$126.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SYNRIBO 3.5 MG/ML VIAL   4 Non-Preferred Drug 46%N/AP

Chart Legend:

Below are a few notes to help you understand the above 2020 Medicare Part D Express Scripts Medicare - Choice (PDP) Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug or Medicare Advantage 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 $435 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.
    • Tier Number* - Some Part D drug plans exclude one or more drug tiers from the plan’s 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 - This is what you will pay for formulary drugs in 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 initial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $4020) 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 2020 )

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 Medicare plan provider.









Tips & Disclaimers
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  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
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  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDPCompare.com and MACompare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
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    "We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options."
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.