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Express Scripts Medicare - Choice (PDP) (S5660-198-0)
Tier 1 (218)
Tier 2 (1184)
Tier 3 (722)
Tier 4 (643)
Tier 5 (524)
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Cick on the first letter of your drug name to browse the formulary:

A B C D E F G H I J K L 
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) (S5660-198-0)
Benefit Details           
The Express Scripts Medicare - Choice (PDP) (S5660-198-0)
Formulary Drugs Starting with the Letter A

in CMS PDP Region 28 which includes: AZ
Plan Monthly Premium: $87.60 Deductible: $250 Qualifies for LIS: No
Drugs Starting with Letter A

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
ABACAVIR 20 MG/ML SOLUTION   3 Preferred Brand $42.00$126.00Q:900
/30Days
ABACAVIR 300 MG TABLET   4 Non-Preferred Drug 48%N/AQ:60
/30Days
Abacavir Sulfate-Lamivudine-Zidovudine tablets [Trizivir]   5 Specialty Tier 28%N/AQ:60
/30Days
ABACAVIR-LAMIVUDINE 600-300 MG TABLET [Epzicom]   4 Non-Preferred Drug 48%N/AQ:30
/30Days
ABELCET INJECTION SUSPENSION 5MG/ML   5 Specialty Tier 28%N/AP
ABILIFY MAINTENA ER 300 MG SYRINGE   4 Non-Preferred Drug 48%N/AQ:1
/28Days
ABILIFY MAINTENA ER 300 MG VIAL   4 Non-Preferred Drug 48%N/AQ:1
/28Days
ABILIFY MAINTENA ER 400 MG SUSER VIAL   4 Non-Preferred Drug 48%N/AQ:1
/28Days
ABILIFY MAINTENA ER 400 MG SYRINGE   4 Non-Preferred Drug 48%N/AQ:1
/28Days
ABIRATERONE ACETATE 250 MG TABLET [ZYTIGA]   4 Non-Preferred Drug 48%N/AP Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Acamprosate Calcium DR 333 MG tablets [Campral]   4 Non-Preferred Drug 48%N/ANone
ACARBOSE 100 MG TABLET   2* Generic $7.00$4.00Q:90
/30Days
ACARBOSE 25 MG TABLET   2* Generic $7.00$4.00Q:360
/30Days
ACARBOSE 50 MG TABLET   2* Generic $7.00$4.00Q:180
/30Days
ACEBUTOLOL 200 MG CAPSULE [Sectral]   2* Generic $7.00$4.00None
ACEBUTOLOL 400 MG CAPSULE [Sectral]   2* Generic $7.00$4.00None
ACETAMINOP-CODEINE 120-12 MG/5   2* Generic $7.00$4.00Q:4500
/30Days
ACETAMINOPHEN-COD #2 TABLET   2* Generic $7.00$4.00Q:360
/30Days
ACETAMINOPHEN-COD #3 TABLET [Tylenol with Codeine No.3]   2* Generic $7.00$4.00Q:360
/30Days
ACETAMINOPHEN-COD #4 TABLET   2* Generic $7.00$4.00Q:180
/30Days
ACETAZOLAMIDE 125MG TABLET   3 Preferred Brand $42.00$126.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETAZOLAMIDE 250 MG TABLET [Diamox]   3 Preferred Brand $42.00$126.00None
ACETAZOLAMIDE ER 500 MG CAPSULE   2* Generic $7.00$4.00None
ACETIC ACID 2% EAR SOLUTION   2* Generic $7.00$4.00None
ACETYLCYSTEINE 10% VIAL   2* Generic $7.00$4.00P
ACETYLCYSTEINE 20% VIAL [Mucosil Acetylcysteine]   2* Generic $7.00$4.00P
ACITRETIN 10 MG CAPSULE [Soriatane]   4 Non-Preferred Drug 48%N/ANone
ACITRETIN 17.5 MG CAPSULE [Soriatane]   4 Non-Preferred Drug 48%N/ANone
ACITRETIN 25 MG CAPSULE [Soriatane]   4 Non-Preferred Drug 48%N/ANone
ACTHIB VACCINE WITH DILUENT   3 Preferred Brand $42.00$126.00None
ACTIMMUNE 100 MCG/0.5 ML VIAL   5 Specialty Tier 28%N/AP
ACYCLOVIR 200 MG CAPSULE   2* Generic $7.00$4.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACYCLOVIR 200 MG/5 ML SUSP   3 Preferred Brand $42.00$126.00None
ACYCLOVIR 400 MG TABLET   2* Generic $7.00$4.00None
ACYCLOVIR 5% OINTMENT [Zovirax]   4 Non-Preferred Drug 48%N/AP Q:30
/30Days
ACYCLOVIR 800 MG TABLET   2* Generic $7.00$4.00None
Acyclovir sodium 500 mg vial   4 Non-Preferred Drug 48%N/AP
ADACEL TDAP SYRINGE   3 Preferred Brand $42.00$126.00None
ADACEL VIAL 2UNT/5UNT   3 Preferred Brand $42.00$126.00None
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA]   5 Specialty Tier 28%N/AP Q:2
/28Days
ADEMPAS 0.5 MG TABLET   5 Specialty Tier 28%N/AP Q:90
/30Days
ADEMPAS 1 MG TABLET   5 Specialty Tier 28%N/AP Q:90
/30Days
ADEMPAS 1.5 MG TABLET   5 Specialty Tier 28%N/AP Q:90
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADEMPAS 2 MG TABLET   5 Specialty Tier 28%N/AP Q:90
/30Days
ADEMPAS 2.5 MG TABLET   5 Specialty Tier 28%N/AP Q:90
/30Days
ADVAIR DISKUS MIS 100/50   3 Preferred Brand $42.00$126.00Q:60
/30Days
ADVAIR DISKUS MIS 250/50   3 Preferred Brand $42.00$126.00Q:60
/30Days
ADVAIR DISKUS MIS 500/50   3 Preferred Brand $42.00$126.00Q:60
/30Days
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER   3 Preferred Brand $42.00$126.00Q:12
/30Days
ADVAIR HFA INHALER 115;21MCG;MCG 120 ACTN INHL   3 Preferred Brand $42.00$126.00Q:12
/30Days
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL   3 Preferred Brand $42.00$126.00Q:12
/30Days
AFINITOR 10 MG TABLET   5 Specialty Tier 28%N/AP Q:30
/30Days
AFINITOR 2.5 MG TABLET   5 Specialty Tier 28%N/AP Q:30
/30Days
AFINITOR 5 MG TABLET   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
Afinitor 7.5mg/1 28 BLISTER PACK per CARTON / 1 TABLET per BLISTER PACK   5 Specialty Tier 28%N/AP Q:30
/30Days
AFINITOR DISPERZ 2 MG TABLET   5 Specialty Tier 28%N/AP Q:150
/30Days
AFINITOR DISPERZ 3 MG TABLET   5 Specialty Tier 28%N/AP Q:90
/30Days
AFINITOR DISPERZ 5 MG TABLET   5 Specialty Tier 28%N/AP Q:60
/30Days
AIMOVIG 140 MG/ML AUTOINJECTOR   3 Preferred Brand $42.00$126.00P Q:1
/30Days
AIMOVIG 70 MG/ML AUTOINJECTOR   3 Preferred Brand $42.00$126.00P Q:1
/30Days
ALBENDAZOLE 200 MG TABLET [Albenza]   5 Specialty Tier 28%N/AQ:120
/30Days
ALBUTEROL 2.5 MG/0.5 ML SOL VIAL-NEB   2* Generic $7.00$4.00P
ALBUTEROL SUL 0.63 MG/3 ML SOL VIAL-NEB   2* Generic $7.00$4.00P
ALBUTEROL SUL 1.25 MG/3 ML SOL VIAL-NEB   2* Generic $7.00$4.00P
ALBUTEROL SUL 2.5 MG/3 ML SOLN   2* Generic $7.00$4.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALBUTEROL SULFATE 2 MG TABLET   4 Non-Preferred Drug 48%N/ANone
ALBUTEROL SULFATE 4 MG TABLET   4 Non-Preferred Drug 48%N/ANone
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOTTLE   2* Generic $7.00$4.00None
ALCLOMETASONE DIPR 0.05% OINTMENT   2* Generic $7.00$4.00None
ALCLOMETASONE DIPRO 0.05% CREAM   2* Generic $7.00$4.00None
ALECENSA 150 MG CAPSULE   5 Specialty Tier 28%N/AP Q:240
/30Days
ALENDRONATE SODIUM 10 MG TABLET [Fosamax]   1* Preferred Generic $2.00$0.00Q:30
/30Days
ALENDRONATE SODIUM 35 MG TABLET [Fosamax]   1* Preferred Generic $2.00$0.00Q:4
/28Days
ALENDRONATE SODIUM 70 MG TABLET [Fosamax]   1* Preferred Generic $2.00$0.00Q:4
/28Days
ALFUZOSIN HCL ER 10 MG TABLET   2* Generic $7.00$4.00None
ALINIA 100 MG/5 ML SUSPENSION   5 Specialty Tier 28%N/AQ:360
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALINIA 500 MG TABLET   5 Specialty Tier 28%N/AQ:14
/30Days
Aliskiren 150 MG / Hydrochlorothiazide 12.5 MG Oral Tablet [Tekturna HCT]   4 Non-Preferred Drug 48%N/ANone
Aliskiren 150 MG / Hydrochlorothiazide 25 MG Oral Tablet [Tekturna HCT]   4 Non-Preferred Drug 48%N/ANone
ALISKIREN 150 MG TABLET [Tekturna]   3 Preferred Brand $42.00$126.00None
Aliskiren 300 MG / Hydrochlorothiazide 12.5 MG Oral Tablet [Tekturna HCT]   4 Non-Preferred Drug 48%N/ANone
ALISKIREN 300 MG TABLET [Tekturna]   3 Preferred Brand $42.00$126.00None
ALLOPURINOL 100 MG TABLET [Zyloprim]   1* Preferred Generic $2.00$0.00None
ALLOPURINOL 300 MG TABLET [Zyloprim]   1* Preferred Generic $2.00$0.00None
ALOSETRON HCL 0.5 MG TABLET [Lotronex]   5 Specialty Tier 28%N/ANone
ALOSETRON HCL 1 MG TABLET [Lotronex]   5 Specialty Tier 28%N/ANone
ALPHAGAN P 0.1% EYE DROPS   3 Preferred Brand $42.00$126.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALPRAZOLAM 0.25 MG TABLET [Xanax]   4 Non-Preferred Drug 48%N/AQ:90
/30Days
ALPRAZOLAM 0.5 MG TABLET   4 Non-Preferred Drug 48%N/AQ:90
/30Days
ALPRAZOLAM 1 MG TABLET   4 Non-Preferred Drug 48%N/AQ:90
/30Days
ALPRAZOLAM 2 MG TABLET   4 Non-Preferred Drug 48%N/AQ:150
/30Days
ALUNBRIG 180 MG TABLET   5 Specialty Tier 28%N/AP Q:30
/30Days
ALUNBRIG 30 MG TABLET   5 Specialty Tier 28%N/AP Q:60
/30Days
ALUNBRIG 90 MG TABLET   5 Specialty Tier 28%N/AP Q:30
/30Days
ALUNBRIG 90 MG-180 MG TABLET PACK   5 Specialty Tier 28%N/AP Q:30
/30Days
ALYACEN 1-35-28 TABLET   2* Generic $7.00$4.00None
ALYQ 20 MG TABLET   5 Specialty Tier 28%N/AP Q:60
/30Days
AMANTADINE 100 MG CAPSULE   4 Non-Preferred Drug 48%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMANTADINE 100 MG TABLET   4 Non-Preferred Drug 48%N/ANone
AMANTADINE 50 MG/5 ML SOLUTION   2* Generic $7.00$4.00None
AMBISOME 50MG VIAL   5 Specialty Tier 28%N/AP
AMBRISENTAN 10 MG TABLET [LETAIRIS]   5 Specialty Tier 28%N/AP Q:30
/30Days
AMBRISENTAN 5 MG TABLET [LETAIRIS]   5 Specialty Tier 28%N/AP Q:30
/30Days
AMETHIA 0.15-0.03-0.01 MG TABLET   2* Generic $7.00$4.00None
AMETHIA LO TABLET   2* Generic $7.00$4.00None
AMIKACIN SULF 500 MG/2 ML VIAL   2* Generic $7.00$4.00None
AMILORIDE HCL 5 MG TABLET [Midamor]   3 Preferred Brand $42.00$126.00None
AMILORIDE HCL-HCTZ 5-50 MG TABLET   2* Generic $7.00$4.00None
Amino Acids 15% Solution   4 Non-Preferred Drug 48%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN II 10% SOL 6X2000 ML   3 Preferred Brand $42.00$126.00P
AMINOSYN II 15% IV SOLUTION   3 Preferred Brand $42.00$126.00P
AMINOSYN-PF 7% IV SOLUTION   3 Preferred Brand $42.00$126.00P
AMIODARONE HCL 100 MG TABLET [Pacerone]   2* Generic $7.00$4.00None
AMIODARONE HCL 200 MG TABLET [Pacerone]   2* Generic $7.00$4.00None
AMIODARONE HCL 400 MG TABLET [Pacerone]   2* Generic $7.00$4.00None
AMITIZA 24 MCG 60 CAPSULE BOTTLE   4 Non-Preferred Drug 48%N/AQ:60
/30Days
AMITIZA 8MCG CAPSULE   4 Non-Preferred Drug 48%N/AQ:60
/30Days
AMITRIPTYLINE HCL 10 MG TABLET [Elavil]   2* Generic $7.00$4.00P
AMITRIPTYLINE HCL 100 MG TABLET   2* Generic $7.00$4.00P
AMITRIPTYLINE HCL 150 MG TABLET   2* Generic $7.00$4.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITRIPTYLINE HCL 25 MG TABLET   2* Generic $7.00$4.00P
AMITRIPTYLINE HCL 50 MG TABLET   2* Generic $7.00$4.00P
AMITRIPTYLINE HCL 75 MG TABLET   2* Generic $7.00$4.00P
AMLOD-VALSA-HCTZ 10-160-12.5 MG [Exforge HCT]   4 Non-Preferred Drug 48%N/ANone
AMLOD-VALSA-HCTZ 10-160-25 MG [Exforge HCT]   4 Non-Preferred Drug 48%N/ANone
AMLOD-VALSA-HCTZ 10-320-25 MG [Exforge HCT]   4 Non-Preferred Drug 48%N/ANone
AMLOD-VALSA-HCTZ 5-160-12.5 MG [Exforge HCT]   2* Generic $7.00$4.00None
AMLOD-VALSA-HCTZ 5-160-25 MG [Exforge HCT]   2* Generic $7.00$4.00None
AMLODIPINE BESYLATE 10 MG TABLET [Norvasc]   1* Preferred Generic $2.00$0.00None
AMLODIPINE BESYLATE 2.5 MG TABLET [Norvasc]   1* Preferred Generic $2.00$0.00None
AMLODIPINE BESYLATE 5 MG TABLET [Norvasc]   1* Preferred Generic $2.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE-ATORVAST 10-20 MG [Caduet]   4 Non-Preferred Drug 48%N/AQ:30
/30Days
AMLODIPINE-ATORVAST 10-40 MG [Caduet]   4 Non-Preferred Drug 48%N/AQ:30
/30Days
Amlodipine-Atorvastatin 10-10 mg [Caduet]   4 Non-Preferred Drug 48%N/AQ:30
/30Days
Amlodipine-Atorvastatin 10-80 mg [Caduet]   4 Non-Preferred Drug 48%N/AQ:30
/30Days
Amlodipine-Atorvastatin 2.5-10 mg [Caduet]   2* Generic $7.00$4.00Q:30
/30Days
Amlodipine-Atorvastatin 2.5-20 mg [Caduet]   4 Non-Preferred Drug 48%N/AQ:30
/30Days
Amlodipine-Atorvastatin 2.5-40 mg [Caduet]   2* Generic $7.00$4.00Q:30
/30Days
Amlodipine-Atorvastatin 5-10 mg [Caduet]   4 Non-Preferred Drug 48%N/AQ:30
/30Days
Amlodipine-Atorvastatin 5-20 mg [Caduet]   4 Non-Preferred Drug 48%N/AQ:30
/30Days
Amlodipine-Atorvastatin 5-40 mg [Caduet]   4 Non-Preferred Drug 48%N/AQ:30
/30Days
Amlodipine-Atorvastatin 5-80 mg [Caduet]   4 Non-Preferred Drug 48%N/AQ:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE-BENAZEPRIL 10-20 MG CAPSULE [Lotrel]   2* Generic $7.00$4.00None
AMLODIPINE-BENAZEPRIL 10-40 MG CAPSULE [Lotrel]   2* Generic $7.00$4.00None
AMLODIPINE-BENAZEPRIL 2.5-10 CAPSULE [Lotrel]   2* Generic $7.00$4.00None
AMLODIPINE-BENAZEPRIL 5-10 MG CAPSULE [Lotrel]   2* Generic $7.00$4.00None
AMLODIPINE-BENAZEPRIL 5-20 MG CAPSULE [Lotrel]   2* Generic $7.00$4.00None
AMLODIPINE-BENAZEPRIL 5-40 MG CAPSULE [Lotrel]   2* Generic $7.00$4.00None
AMLODIPINE-OLMESARTAN 10-20 MG TABLET [AZOR]   3 Preferred Brand $42.00$126.00None
AMLODIPINE-OLMESARTAN 10-40 MG TABLET [AZOR]   3 Preferred Brand $42.00$126.00None
AMLODIPINE-OLMESARTAN 5-20 MG TABLET [AZOR]   3 Preferred Brand $42.00$126.00None
AMLODIPINE-OLMESARTAN 5-40 MG TABLET [AZOR]   3 Preferred Brand $42.00$126.00None
AMLODIPINE-VALSARTAN 10-160 MG TABLET [Exforge]   2* Generic $7.00$4.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE-VALSARTAN 10-320 MG TABLET [Exforge]   2* Generic $7.00$4.00None
AMLODIPINE-VALSARTAN 5-160 MG TABLET [Exforge]   2* Generic $7.00$4.00None
AMLODIPINE-VALSARTAN 5-320 MG TABLET [Exforge]   2* Generic $7.00$4.00None
AMMONIUM LACTATE 12% CREAM (g) [Lac-Hydrin]   2* Generic $7.00$4.00None
AMMONIUM LACTATE 12% LOTION   2* Generic $7.00$4.00None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE [Augmentin]   2* Generic $7.00$4.00None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET [Augmentin]   2* Generic $7.00$4.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE [Augmentin]   2* Generic $7.00$4.00None
AMOX-CLAV 200-28.5 MG/5 ML SUS   2* Generic $7.00$4.00None
AMOX-CLAV 250-62.5 MG/5 ML SUS   2* Generic $7.00$4.00None
AMOX-CLAV 400-57 MG/5 ML SUSP   2* Generic $7.00$4.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOX-CLAV 500-125 MG TABLET [Augmentin]   2* Generic $7.00$4.00None
AMOX-CLAV 600-42.9 MG/5 ML SUS   2* Generic $7.00$4.00None
AMOX-CLAV 875-125 MG TABLET [Augmentin]   2* Generic $7.00$4.00None
AMOX-CLAV ER 1,000-62.5 MG TABLET [Augmentin]   2* Generic $7.00$4.00None
AMOXAPINE 100MG TABLET   4 Non-Preferred Drug 48%N/ANone
AMOXAPINE 150MG TABLET   4 Non-Preferred Drug 48%N/ANone
AMOXAPINE 25MG TABLET   4 Non-Preferred Drug 48%N/ANone
AMOXAPINE 50MG TABLET   4 Non-Preferred Drug 48%N/ANone
AMOXICILLIN 125 MG/5 ML SUSP   2* Generic $7.00$4.00None
AMOXICILLIN 125MG TABLET CHEW   2* Generic $7.00$4.00None
AMOXICILLIN 200 MG/5 ML SUSP   2* Generic $7.00$4.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN 250 MG CAPSULE   2* Generic $7.00$4.00None
AMOXICILLIN 250 MG TABLET CHEW   2* Generic $7.00$4.00None
AMOXICILLIN 250 MG/5 ML SUSP   2* Generic $7.00$4.00None
AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION [Amoxil]   2* Generic $7.00$4.00None
AMOXICILLIN 500 MG CAPSULE   2* Generic $7.00$4.00None
AMOXICILLIN 500 MG TABLET   2* Generic $7.00$4.00None
AMOXICILLIN 875 MG TABLET   2* Generic $7.00$4.00None
amphotericin b 50mg/10mL 10 mL in 1 VIAL   4 Non-Preferred Drug 48%N/AP
AMPICILLIN 10 GM VIAL   2* Generic $7.00$4.00None
Ampicillin 1000 MG / Sulbactam 500 MG Injection   2* Generic $7.00$4.00None
Ampicillin 1000 MG Injection   2* Generic $7.00$4.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Ampicillin 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS   2* Generic $7.00$4.00None
AMPICILLIN CAPSULES 500MG 100 BOTTLE   2* Generic $7.00$4.00None
AMPICILLIN-SULBACTAM 15 GM VIAL [Unasyn]   2* Generic $7.00$4.00None
AMPICILLIN-SULBACTAM 3 GM VIAL [Unasyn]   2* Generic $7.00$4.00None
ANADROL-50 TABLET   4 Non-Preferred Drug 48%N/AP
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE   2* Generic $7.00$4.00None
Anagrelide Hydrochloride 1mg/1 100 CAPSULE BOTTLE   2* Generic $7.00$4.00None
ANASTROZOLE 1 MG TABLET   2* Generic $7.00$4.00None
ANORO ELLIPTA 62.5-25 MCG INH   3 Preferred Brand $42.00$126.00Q:60
/30Days
APOKYN 30 MG/3 ML CARTRIDGE   5 Specialty Tier 28%N/AP Q:60
/30Days
Apraclonidine 5 MG/ML Ophthalmic Solution   2* Generic $7.00$4.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
APREPITANT 125 MG CAPSULE [Emend]   3 Preferred Brand $42.00$126.00P
APREPITANT 125-80-80 MG PACK [Emend]   3 Preferred Brand $42.00$126.00P
APREPITANT 40 MG CAPSULE [Emend]   3 Preferred Brand $42.00$126.00P
APREPITANT 80 MG CAPSULE [Emend]   3 Preferred Brand $42.00$126.00P
APRI 0.15-0.03 TABLET   2* Generic $7.00$4.00None
APRISO CP24   3 Preferred Brand $42.00$126.00None
APTIOM 200 MG TABLET   4 Non-Preferred Drug 48%N/AQ:180
/30Days
APTIOM 400 MG TABLET   4 Non-Preferred Drug 48%N/AQ:90
/30Days
APTIOM 600 MG TABLET   4 Non-Preferred Drug 48%N/AQ:60
/30Days
APTIOM 800 MG TABLET   4 Non-Preferred Drug 48%N/AQ:60
/30Days
APTIVUS 250MG CAPSULE   4 Non-Preferred Drug 48%N/AQ:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT   4 Non-Preferred Drug 48%N/AQ:300
/30Days
ARANELLE 7-9-5 TABLET   2* Generic $7.00$4.00None
ARCALYST INJECTION 220MG/VIAL   5 Specialty Tier 28%N/AP
ARIKAYCE 590 MG/8.4 ML VIAL-NEB   5 Specialty Tier 28%N/AP
ARIPIPRAZOLE 1 MG/ML SOLUTION [Abilify]   5 Specialty Tier 28%N/ANone
ARIPIPRAZOLE 10 MG TABLET [Abilify]   3 Preferred Brand $42.00$126.00Q:30
/30Days
ARIPIPRAZOLE 15 MG TABLET [Abilify]   3 Preferred Brand $42.00$126.00Q:30
/30Days
ARIPIPRAZOLE 2 MG TABLET [Abilify]   3 Preferred Brand $42.00$126.00Q:30
/30Days
ARIPIPRAZOLE 20 MG TABLET [Abilify]   3 Preferred Brand $42.00$126.00Q:30
/30Days
ARIPIPRAZOLE 30 MG TABLET [Abilify]   3 Preferred Brand $42.00$126.00Q:30
/30Days
ARIPIPRAZOLE 5 MG TABLET [Abilify]   3 Preferred Brand $42.00$126.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARIPIPRAZOLE ODT 10 MG TABLET RAPDIS [Abilify Discmelt]   5 Specialty Tier 28%N/AQ:60
/30Days
ARIPIPRAZOLE ODT 15 MG TABLET RAPDIS [Abilify Discmelt]   5 Specialty Tier 28%N/AQ:60
/30Days
ARNUITY ELLIPTA 100 MCG INH   3 Preferred Brand $42.00$126.00Q:30
/30Days
ARNUITY ELLIPTA 200 MCG INH   3 Preferred Brand $42.00$126.00Q:30
/30Days
ARNUITY ELLIPTA 50 MCG INH BLST W/DEV   3 Preferred Brand $42.00$126.00Q:30
/30Days
ASHLYNA 0.15-0.03-0.01 MG TABLET   2* Generic $7.00$4.00None
Aspirin-Diphenhydramine ER 25-200 MG   3 Preferred Brand $42.00$126.00None
ATAZANAVIR SULFATE 150 MG CAPSULE [Reyataz]   5 Specialty Tier 28%N/AQ:30
/30Days
ATAZANAVIR SULFATE 200 MG CAPSULE [Reyataz]   5 Specialty Tier 28%N/AQ:60
/30Days
ATAZANAVIR SULFATE 300 MG CAPSULE [Reyataz]   5 Specialty Tier 28%N/AQ:30
/30Days
ATENOLOL 100 MG TABLET [Tenormin]   1* Preferred Generic $2.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATENOLOL 25 MG TABLET   1* Preferred Generic $2.00$0.00None
ATENOLOL 50 MG TABLET [Tenormin]   1* Preferred Generic $2.00$0.00None
ATENOLOL-CHLORTHALIDONE 100-25   2* Generic $7.00$4.00None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   2* Generic $7.00$4.00None
ATOMOXETINE HCL 10 MG CAPSULE [Strattera]   3 Preferred Brand $42.00$126.00Q:60
/30Days
ATOMOXETINE HCL 100 MG CAPSULE [Strattera]   3 Preferred Brand $42.00$126.00Q:30
/30Days
ATOMOXETINE HCL 18 MG CAPSULE [Strattera]   3 Preferred Brand $42.00$126.00Q:60
/30Days
ATOMOXETINE HCL 25 MG CAPSULE [Strattera]   3 Preferred Brand $42.00$126.00Q:60
/30Days
ATOMOXETINE HCL 40 MG CAPSULE [Strattera]   3 Preferred Brand $42.00$126.00Q:60
/30Days
ATOMOXETINE HCL 60 MG CAPSULE [Strattera]   3 Preferred Brand $42.00$126.00Q:30
/30Days
ATOMOXETINE HCL 80 MG CAPSULE [Strattera]   3 Preferred Brand $42.00$126.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATORVASTATIN 10 MG TABLET [Lipitor]   1* Preferred Generic $2.00$0.00Q:30
/30Days
ATORVASTATIN 20 MG TABLET [Lipitor]   1* Preferred Generic $2.00$0.00Q:30
/30Days
ATORVASTATIN 40 MG TABLET [Lipitor]   1* Preferred Generic $2.00$0.00Q:30
/30Days
ATORVASTATIN 80 MG TABLET [Lipitor]   1* Preferred Generic $2.00$0.00Q:30
/30Days
ATOVAQUONE 750 MG/5 ML SUSP [Mepron]   5 Specialty Tier 28%N/ANone
Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone]   3 Preferred Brand $42.00$126.00None
ATOVAQUONE-PROGUANIL 62.5-25 [Malarone]   2* Generic $7.00$4.00None
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC   5 Specialty Tier 28%N/AQ:30
/30Days
ATROPINE 1% EYE DROPS   3 Preferred Brand $42.00$126.00None
ATROVENT HFA AER 17MCG   3 Preferred Brand $42.00$126.00Q:26
/30Days
AUBRA-28 TABLET [Vienva]   2* Generic $7.00$4.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AURYXIA 210 MG TABLET   4 Non-Preferred Drug 48%N/AP Q:360
/30Days
AVIANE 0.1-0.02 TABLET   2* Generic $7.00$4.00None
AVITA 0.025% CREAM (g) [Tretin-X]   3 Preferred Brand $42.00$126.00P
AYVAKIT 100 MG TABLET   4 Non-Preferred Drug 48%N/AP Q:30
/30Days
AYVAKIT 200 MG TABLET   4 Non-Preferred Drug 48%N/AP Q:30
/30Days
AYVAKIT 300 MG TABLET   4 Non-Preferred Drug 48%N/AP Q:30
/30Days
AZATHIOPRINE 50 MG TABLET   2* Generic $7.00$4.00P
AZELASTINE 0.15% NASAL SPRAY   2* Generic $7.00$4.00Q:60
/30Days
AZELASTINE 137 MCG NASAL SPRAY   2* Generic $7.00$4.00Q:60
/30Days
AZELASTINE HCL 0.05% EYE DROPS [Optivar]   2* Generic $7.00$4.00None
AZITHROMYCIN 1 GM POWDER PACKET   3 Preferred Brand $42.00$126.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZITHROMYCIN 100 MG/5 ML SUSP   2* Generic $7.00$4.00None
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [Zithromax]   2* Generic $7.00$4.00None
AZITHROMYCIN 250 MG TABLET   2* Generic $7.00$4.00None
AZITHROMYCIN 250 MG TABLET [Zithromax Z-Pak]   2* Generic $7.00$4.00None
AZITHROMYCIN 500 MG TABLET   2* Generic $7.00$4.00None
AZITHROMYCIN 500 MG TABLET [Zithromax Tri-Pak]   2* Generic $7.00$4.00None
AZITHROMYCIN 600 MG TABLET [Zithromax Z-Pak]   2* Generic $7.00$4.00None
AZITHROMYCIN I.V. 500 MG VIAL   2* Generic $7.00$4.00None
AZOPT 1% EYE DROPS   4 Non-Preferred Drug 48%N/ANone
AZTREONAM FOR INJECTION   2* Generic $7.00$4.00None

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.