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Express Scripts Medicare - Value (PDP) (S5660-113-0)
Tier 1 (122)
Tier 2 (707)
Tier 3 (679)
Tier 4 (1039)
Tier 5 (506)
Requires Prior Authorization:
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Uses Step Therapy:
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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 - Value (PDP) (S5660-113-0)
Benefit Details           
The Express Scripts Medicare - Value (PDP) (S5660-113-0)
Formulary Drugs Starting with the Letter B

in CMS PDP Region 11 which includes: FL
Plan Monthly Premium: $55.10 Deductible: $435 Qualifies for LIS: No
Drugs Starting with Letter B

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Bacitracin 500 unit/gm Eye Ointment   4 Non-Preferred Drug 45%N/ANone
BACITRACIN/POLYMYXIN B OINT 500UNT/10000UNT   2 Generic $3.00$6.00None
BACLOFEN 10 MG TABLET   3 Preferred Brand $25.00$75.00None
BACLOFEN 20 MG TABLET [Lioresal]   3 Preferred Brand $25.00$75.00None
BALSALAZIDE DISODIUM 750 MG CAPSULE [Colazal]   4 Non-Preferred Drug 45%N/ANone
BALVERSA 3 MG TABLET   5 Specialty Tier 25%N/AP
BALVERSA 4 MG TABLET   5 Specialty Tier 25%N/AP
BALVERSA 5 MG TABLET   5 Specialty Tier 25%N/AP
Balziva 6 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK   4 Non-Preferred Drug 45%N/ANone
Banzel 200mg/1   5 Specialty Tier 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BANZEL 400MG TABLET   5 Specialty Tier 25%N/AP
Banzel 40mg/mL   5 Specialty Tier 25%N/AP
BAQSIMI 3 MG SPRAY TWO PACK   3 Preferred Brand $25.00$75.00None
BARACLUDE 0.05mg/mL 1 BOTTLE per CARTON / 210 mL in 1 BOTTLE   5 Specialty Tier 25%N/AQ:600
/30Days
BCG VACCINE 50mg/1 1 VIAL per CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL   3 Preferred Brand $25.00$75.00None
BENAZEPRIL HCL 10 MG TABLET   1 Preferred Generic $1.00$0.00None
BENAZEPRIL HCL 20 MG TABLET   1 Preferred Generic $1.00$0.00None
BENAZEPRIL HCL 40 MG TABLET   1 Preferred Generic $1.00$0.00None
BENAZEPRIL HCL 5 MG TABLET   1 Preferred Generic $1.00$0.00None
BENAZEPRIL HCL-HCTZ TABLET 5-6.25MG (100 CT)   2 Generic $3.00$6.00None
BENAZEPRIL-HCTZ 10-12.5 MG TABLET [Lotensin HCT]   2 Generic $3.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BENAZEPRIL-HCTZ 20-12.5 MG TABLET [Lotensin HCT]   2 Generic $3.00$6.00None
BENAZEPRIL-HCTZ 20-25 MG TABLET [Lotensin HCT]   2 Generic $3.00$6.00None
BENLYSTA 200 MG/ML AUTOINJECT   5 Specialty Tier 25%N/AP
BENLYSTA 200 MG/ML SYRINGE   5 Specialty Tier 25%N/AP
BENZNIDAZOLE 100 MG TABLET   4 Non-Preferred Drug 45%N/ANone
BENZNIDAZOLE 12.5 MG TABLET   4 Non-Preferred Drug 45%N/ANone
BENZTROPINE MES 0.5 MG TABLET [Cogentin]   3 Preferred Brand $25.00$75.00P
BENZTROPINE MES 1 MG TABLET [Cogentin]   3 Preferred Brand $25.00$75.00P
BENZTROPINE MES 2 MG TABLET [Cogentin]   3 Preferred Brand $25.00$75.00P
BESER 0.05% LOTION [Cutivate]   3 Preferred Brand $25.00$75.00None
BESIVANCE BESIFLOACIN OPTHALMIC SUSPENSION 0.6% 5 ML BOTDR   4 Non-Preferred Drug 45%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Betamethasone Dipropionate 0.64mg/g / 45 g TUBE   4 Non-Preferred Drug 45%N/ANone
BETAMETHASONE DP 0.05% LOTION   4 Non-Preferred Drug 45%N/ANone
BETAMETHASONE DP 0.05% OINTMENT   4 Non-Preferred Drug 45%N/ANone
BETAMETHASONE DP AUG 0.05% CREAM (g) [RRB Pak]   2 Generic $3.00$6.00None
BETAMETHASONE DP AUG 0.05% GEL   4 Non-Preferred Drug 45%N/ANone
BETAMETHASONE DP AUG 0.05% LOTION   4 Non-Preferred Drug 45%N/ANone
BETAMETHASONE DP AUG 0.05% OINTMENT [Diprolene]   4 Non-Preferred Drug 45%N/ANone
BETAMETHASONE VA 0.1% CREAM   2 Generic $3.00$6.00None
BETAMETHASONE VALERATE 0.1% LOTION   4 Non-Preferred Drug 45%N/ANone
BETAMETHASONE VALERATE OINTMENT USP   2 Generic $3.00$6.00None
BETHANECHOL 10 MG TABLET   4 Non-Preferred Drug 45%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BETHANECHOL 25 MG TABLET   4 Non-Preferred Drug 45%N/ANone
BETHANECHOL 5 MG TABLET   3 Preferred Brand $25.00$75.00None
BETHANECHOL 50 MG TABLET   4 Non-Preferred Drug 45%N/ANone
BEXAROTENE 75 MG CAPSULE [Targretin]   5 Specialty Tier 25%N/AP
BEXSERO PREFILLED SYRINGE   3 Preferred Brand $25.00$75.00None
BICALUTAMIDE 50 MG TABLET   3 Preferred Brand $25.00$75.00None
BICILL LA PFS 600MU 1ML PED   4 Non-Preferred Drug 45%N/ANone
BICILLIN LA PFS 1200MU 2ML   4 Non-Preferred Drug 45%N/ANone
BICILLIN LA. 600000UNIT/ML 1ML   4 Non-Preferred Drug 45%N/ANone
BIDIL TABLET   3 Preferred Brand $25.00$75.00None
BIKTARVY 50-200-25 MG TABLET   5 Specialty Tier 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BISOPROLOL FUMARATE 10 MG TABLET   2 Generic $3.00$6.00None
BISOPROLOL FUMARATE 5 MG TABLET   2 Generic $3.00$6.00None
BISOPROLOL-HCTZ 10-6.25 MG TABLET   1 Preferred Generic $1.00$0.00None
BISOPROLOL-HCTZ 2.5-6.25 MG TABLET   1 Preferred Generic $1.00$0.00None
BISOPROLOL-HCTZ 5-6.25 MG TABLET   1 Preferred Generic $1.00$0.00None
BLISOVI 24 FE TABLET [Tarina Fe 1/20]   4 Non-Preferred Drug 45%N/ANone
BLISOVI FE 1.5-30 TABLET [Microgestin Fe 1.5/30]   4 Non-Preferred Drug 45%N/ANone
BOOSTRIX TDAP VACCINE SYRINGE   3 Preferred Brand $25.00$75.00None
BOOSTRIX TDAP VACCINE VIAL   3 Preferred Brand $25.00$75.00None
BOSULIF 100 MG TABLET   5 Specialty Tier 25%N/AP Q:90
/30Days
BOSULIF 400 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BOSULIF 500 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
BRAFTOVI 75 MG CAPSULE   5 Specialty Tier 25%N/AP Q:180
/30Days
BREO ELLIPTA 100-25 MCG INH   3 Preferred Brand $25.00$75.00Q:60
/30Days
BREO ELLIPTA 200-25 MCG INH   3 Preferred Brand $25.00$75.00Q:60
/30Days
BRIELLYN TABLET   4 Non-Preferred Drug 45%N/ANone
BRILINTA 60 MG TABLET   4 Non-Preferred Drug 45%N/AQ:60
/30Days
BRILINTA 90mg/1 60 TABLET BOTTLE   4 Non-Preferred Drug 45%N/AQ:60
/30Days
BRIMONIDINE 0.2% EYE DROPS [Alphagan]   2 Generic $3.00$6.00None
BRIMONIDINE TARTRATE 0.15% DROPS   4 Non-Preferred Drug 45%N/ANone
BRIVIACT 10 MG TABLET   4 Non-Preferred Drug 45%N/AQ:60
/30Days
BRIVIACT 10 MG/ML ORAL SOLUTION   4 Non-Preferred Drug 45%N/AQ:600
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BRIVIACT 100 MG TABLET   4 Non-Preferred Drug 45%N/AQ:60
/30Days
BRIVIACT 25 MG TABLET   4 Non-Preferred Drug 45%N/AQ:60
/30Days
BRIVIACT 50 MG TABLET   4 Non-Preferred Drug 45%N/AQ:60
/30Days
BRIVIACT 75 MG TABLET   4 Non-Preferred Drug 45%N/AQ:60
/30Days
BROMOCRIPTINE 2.5 MG TABLET [Parlodel]   4 Non-Preferred Drug 45%N/ANone
BROMOCRIPTINE MESYLATE 5MG CAPSULE [Parlodel]   4 Non-Preferred Drug 45%N/ANone
BRUKINSA 80 MG CAPSULE   4 Non-Preferred Drug 45%N/AP
BUDESONIDE 0.25 MG/2 ML SUSP AMPUL-NEB [Pulmicort]   3 Preferred Brand $25.00$75.00P Q:120
/30Days
BUDESONIDE 0.5 MG/2 ML SUSP AMPUL-NEB [Pulmicort]   3 Preferred Brand $25.00$75.00P Q:120
/30Days
BUDESONIDE 1 MG/2 ML INH SUSP AMPUL-NEB [Pulmicort]   4 Non-Preferred Drug 45%N/AP Q:60
/30Days
BUDESONIDE EC 3 MG CAPSULE DR - ER [Entocort EC]   4 Non-Preferred Drug 45%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BUDESONIDE ER 9 MG TABLET DR - ER [UCERIS]   5 Specialty Tier 25%N/ANone
BUMETANIDE 0.5 MG TABLET   2 Generic $3.00$6.00None
BUMETANIDE 1 MG TABLET   2 Generic $3.00$6.00None
BUMETANIDE 1 MG/4 ML VIAL   4 Non-Preferred Drug 45%N/ANone
BUMETANIDE 2 MG TABLET [Bumex]   2 Generic $3.00$6.00None
BUPRENORP-NALOX 12-3 MG SL FILM [Suboxone]   2 Generic $3.00$6.00Q:60
/30Days
BUPRENORP-NALOX 2-0.5 MG SL FILM [Suboxone]   2 Generic $3.00$6.00Q:360
/30Days
BUPRENORP-NALOX 4-1 MG SL FILM [Suboxone]   2 Generic $3.00$6.00Q:90
/30Days
BUPRENORP-NALOX 8-2 MG SL FILM [Suboxone]   2 Generic $3.00$6.00Q:90
/30Days
BUPRENORPHINE 10 MCG/HR PATCH [Butrans]   3 Preferred Brand $25.00$75.00P Q:4
/28Days
BUPRENORPHINE 15 MCG/HR PATCH [Butrans]   3 Preferred Brand $25.00$75.00P Q:4
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BUPRENORPHINE 2 MG TABLET SUSLIGUAL [Subutex]   3 Preferred Brand $25.00$75.00P
BUPRENORPHINE 20 MCG/HR PATCH [Butrans]   3 Preferred Brand $25.00$75.00P Q:4
/28Days
BUPRENORPHINE 5 MCG/HR PATCH [Butrans]   3 Preferred Brand $25.00$75.00P Q:4
/28Days
BUPRENORPHINE 8 MG TABLET SUSLIGUAL [Subutex]   3 Preferred Brand $25.00$75.00P
BUPROPION HCL 100 MG TABLET   2 Generic $3.00$6.00Q:180
/30Days
BUPROPION HCL 75 MG TABLET   2 Generic $3.00$6.00Q:180
/30Days
BUPROPION HCL SR 100 MG TABLET SR 12H [Wellbutrin SR]   3 Preferred Brand $25.00$75.00Q:60
/30Days
BUPROPION HCL SR 150 MG TABLET   3 Preferred Brand $25.00$75.00Q:60
/30Days
BUPROPION HCL SR 150 MG TABLET SR 12H [Wellbutrin SR]   3 Preferred Brand $25.00$75.00Q:60
/30Days
BUPROPION HCL SR 200 MG TABLET   3 Preferred Brand $25.00$75.00Q:60
/30Days
BUPROPION HCL XL 150 MG TABLET   2 Generic $3.00$6.00Q:90
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BUPROPION HCL XL 300 MG TABLET   2 Generic $3.00$6.00Q:30
/30Days
BUSPIRONE HCL 15 MG TABLET   2 Generic $3.00$6.00None
BUSPIRONE HCL 30 MG TABLET   2 Generic $3.00$6.00None
BUSPIRONE HCL 5 MG TABLET   2 Generic $3.00$6.00None
BUSPIRONE HCL 7.5 MG TABLET   2 Generic $3.00$6.00None
BUSPIRONE HYDROCHLORIDE 10 MG TABLET   2 Generic $3.00$6.00None
BUTORPHANOL 10 MG/ML SPRAY [Stadol NS]   2 Generic $3.00$6.00Q:10
/28Days
BUTRANS 7.5 MCG/HR PATCH   4 Non-Preferred Drug 45%N/AP Q:8
/28Days
BYDUREON 2 MG PEN INJECT   4 Non-Preferred Drug 45%N/AP Q:4
/28Days
BYDUREON BCISE 2 MG AUTOINJECT   4 Non-Preferred Drug 45%N/AP Q:4
/28Days
BYETTA 10 MCG DOSE PEN INJ   4 Non-Preferred Drug 45%N/AP Q:2
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BYETTA 5 MCG DOSE PEN INJ   4 Non-Preferred Drug 45%N/AP Q:1
/30Days
Bystolic 10mg/1 30 TABLET BOTTLE   4 Non-Preferred Drug 45%N/ANone
Bystolic 2.5mg/1 30 TABLET BOTTLE   4 Non-Preferred Drug 45%N/ANone
BYSTOLIC 20 MG TABLET   4 Non-Preferred Drug 45%N/ANone
Bystolic 5mg 30 TABLET BOTTLE   4 Non-Preferred Drug 45%N/ANone

Chart Legend:

Below are a few notes to help you understand the above 2020 Medicare Part D Express Scripts Medicare - Value (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.