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AARP MedicareRx Walgreens (PDP) (S5921-412-0)
Tier 1 (147)
Tier 2 (635)
Tier 3 (795)
Tier 4 (864)
Tier 5 (630)
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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2020 Medicare Part D Plan Formulary Information
AARP MedicareRx Walgreens (PDP) (S5921-412-0)
Benefit Details           
The AARP MedicareRx Walgreens (PDP) (S5921-412-0)
Formulary Drugs Starting with the Letter F

in CMS PDP Region 31 which includes: ID UT
Plan Monthly Premium: $33.50 Deductible: $435 Qualifies for LIS: No
Drugs Starting with Letter F

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
FALMINA-28 TABLET   4 Non-Preferred Drug 32%32%None
FAMOTIDINE 20 MG TABLET   2* Generic $5.00$15.00None
FAMOTIDINE 40 MG TABLET   2* Generic $5.00$15.00None
FANAPT 1 MG TABLET   4 Non-Preferred Drug 32%32%S Q:60
/30Days
FANAPT 10 MG TABLET   4 Non-Preferred Drug 32%32%S Q:60
/30Days
FANAPT 12 MG TABLET   4 Non-Preferred Drug 32%32%S Q:60
/30Days
FANAPT 2 MG TABLET   4 Non-Preferred Drug 32%32%S Q:60
/30Days
FANAPT 4 MG TABLET   4 Non-Preferred Drug 32%32%S Q:60
/30Days
FANAPT 6 MG TABLET   4 Non-Preferred Drug 32%32%S Q:60
/30Days
FANAPT 8 MG TABLET   4 Non-Preferred Drug 32%32%S Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FANAPT TITR TABLETS   4 Non-Preferred Drug 32%32%S
FARYDAK 10 MG CAPSULE   5 Specialty Tier 25%25%P
FARYDAK 20 MG CAPSULE   5 Specialty Tier 25%25%P
FASENRA 30 MG/ML SYRINGE   5 Specialty Tier 25%25%P
FASENRA PEN 30 MG/ML AUTO INJCT   5 Specialty Tier 25%25%P
FAYOSIM TABLET TBDSPK 3MO [Quartette]   4 Non-Preferred Drug 32%32%None
FEBUXOSTAT 40 MG TABLET [Uloric]   3 Preferred Brand $40.00$120.00S
FEBUXOSTAT 80 MG TABLET [Uloric]   3 Preferred Brand $40.00$120.00S
FELBAMATE 400 MG TABLET   4 Non-Preferred Drug 32%32%None
FELBAMATE 600 MG TABLET [Felbatol]   4 Non-Preferred Drug 32%32%None
FELBAMATE 600 MG/5 ML ORAL SUSPENSION [Felbatol]   5 Specialty Tier 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FELODIPINE ER 10 MG TABLET   3 Preferred Brand $40.00$120.00None
FELODIPINE ER 2.5 MG TABLET ER 24H [Plendil]   3 Preferred Brand $40.00$120.00None
FELODIPINE ER 5 MG TABLET   3 Preferred Brand $40.00$120.00None
FEMRING 0.05 MG/DAY VAGINAL RING   4 Non-Preferred Drug 32%32%None
FEMRING 0.10 MG/DAY VAGINAL RING   4 Non-Preferred Drug 32%32%None
FEMYNOR 28 TABLET [VyLibra]   4 Non-Preferred Drug 32%32%None
FENOFIBRATE 160 MG TABLET [LIPOFEN]   2* Generic $5.00$15.00None
FENOFIBRATE 54 MG 90 TABLET BOTTLE [LIPOFEN]   2* Generic $5.00$15.00None
FENTANYL 100 MCG/HR PATCH TD72 [Duragesic]   3 Preferred Brand $40.00$120.00Q:15
/30Days
FENTANYL 12 MCG/HR PATCH TD72 [Duragesic]   3 Preferred Brand $40.00$120.00Q:15
/30Days
FENTANYL 25 MCG/HR PATCH TD72 [Duragesic]   3 Preferred Brand $40.00$120.00Q:15
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FENTANYL 50 MCG/HR PATCH TD72 [Duragesic]   3 Preferred Brand $40.00$120.00Q:15
/30Days
FENTANYL 75 MCG/HR PATCH TD72 [Duragesic]   3 Preferred Brand $40.00$120.00Q:15
/30Days
FENTANYL CIT OTFC 1,200 MCG LOZENGE HD [Actiq]   5 Specialty Tier 25%25%P Q:120
/30Days
FENTANYL CIT OTFC 1,600 MCG LOZENGE HD [Actiq]   5 Specialty Tier 25%25%P Q:120
/30Days
FENTANYL CITRATE OTFC 200 MCG LOZENGE HD [Actiq]   5 Specialty Tier 25%25%P Q:120
/30Days
FENTANYL CITRATE OTFC 400 MCG LOZENGE HD [Actiq]   5 Specialty Tier 25%25%P Q:120
/30Days
FENTANYL CITRATE OTFC 600 MCG LOZENGE HD [Actiq]   5 Specialty Tier 25%25%P Q:120
/30Days
FENTANYL CITRATE OTFC 800 MCG LOZENGE HD [Actiq]   5 Specialty Tier 25%25%P Q:120
/30Days
FERRIPROX 1,000 MG TABLET   5 Specialty Tier 25%25%P
FERRIPROX 100 MG/ML SOLUTION   5 Specialty Tier 25%25%P
FERRIPROX 500 MG TABLET   5 Specialty Tier 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FETZIMA 20-40 MG TITRATION PAK   4 Non-Preferred Drug 32%32%S
FETZIMA ER 120 MG CAPSULE   4 Non-Preferred Drug 32%32%S Q:30
/30Days
FETZIMA ER 20 MG CAPSULE   4 Non-Preferred Drug 32%32%S Q:30
/30Days
FETZIMA ER 40 MG CAPSULE   4 Non-Preferred Drug 32%32%S Q:30
/30Days
FETZIMA ER 80 MG CAPSULE   4 Non-Preferred Drug 32%32%S Q:30
/30Days
FINACEA 15% FOAM   4 Non-Preferred Drug 32%32%None
FINASTERIDE 5 MG TABLET [Proscar]   2* Generic $5.00$15.00None
FIRAZYR 30 MG/3 ML SYRINGE   5 Specialty Tier 25%25%P Q:270
/30Days
FIRMAGON 2 X 120 MG KIT   5 Specialty Tier 25%25%P
FIRMAGON 80 MG KIT   3 Preferred Brand $40.00$120.00P
FLAC OTIC OIL 0.01% EAR DROPS [Flac]   4 Non-Preferred Drug 32%32%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FLEBOGAMMA DIF INJECTION   5 Specialty Tier 25%25%P
FLECAINIDE ACETATE 100 MG TABLET [Tambocor]   2* Generic $5.00$15.00None
FLECAINIDE ACETATE 150 MG TABLET [Tambocor]   2* Generic $5.00$15.00None
FLECAINIDE ACETATE 50 MG TABLET [Tambocor]   2* Generic $5.00$15.00None
FLUCONAZOLE 10 MG/ML ORAL SUSPENSION [Diflucan]   2* Generic $5.00$15.00None
FLUCONAZOLE 100 MG TABLET [Diflucan]   2* Generic $5.00$15.00None
FLUCONAZOLE 150 MG TABLET [Diflucan]   2* Generic $5.00$15.00None
FLUCONAZOLE 200 MG TABLET [Diflucan]   2* Generic $5.00$15.00None
FLUCONAZOLE 40 MG/ML ORAL SUSPENSION [Diflucan]   2* Generic $5.00$15.00None
FLUCONAZOLE 50 MG TABLET [Diflucan]   2* Generic $5.00$15.00None
FLUCONAZOLE-NACL 200 MG/100 ML PIGGYBACK [Diflucan]   4 Non-Preferred Drug 32%32%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FLUCONAZOLE-NACL 400 MG/200 ML PIGGYBACK [Diflucan]   4 Non-Preferred Drug 32%32%None
FLUCYTOSINE 250 MG CAPSULE [Ancobon]   5 Specialty Tier 25%25%None
FLUCYTOSINE 500 MG CAPSULE [Ancobon]   5 Specialty Tier 25%25%None
FLUDROCORTISONE 0.1 MG TABLET   2* Generic $5.00$15.00None
FLUNISOLIDE NASAL SOLUTION 0.025% 25ML INHL   3 Preferred Brand $40.00$120.00None
FLUOCINOLONE 0.01% CREAM (g)   3 Preferred Brand $40.00$120.00None
FLUOCINOLONE 0.01% SCALP OIL [Derma-Smoothe/FS]   4 Non-Preferred Drug 32%32%None
FLUOCINOLONE 0.01% SOLUTION [Synalar]   3 Preferred Brand $40.00$120.00None
FLUOCINOLONE 0.025% CREAM (g) [Synalar]   3 Preferred Brand $40.00$120.00None
FLUOCINOLONE 0.025% OINTMENT   3 Preferred Brand $40.00$120.00None
FLUOCINOLONE OIL 0.01% EAR DROPS [Flac]   4 Non-Preferred Drug 32%32%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FLUOCINONIDE 0.05% GEL   3 Preferred Brand $40.00$120.00None
FLUOCINONIDE 0.05% OINTMENT [Lidex]   3 Preferred Brand $40.00$120.00None
FLUOCINONIDE 0.05% SOLUTION   3 Preferred Brand $40.00$120.00None
FLUOCINONIDE-E 0.05% CREAM   3 Preferred Brand $40.00$120.00None
Fluorometholone 0.1% drops   3 Preferred Brand $40.00$120.00None
FLUOROURACIL 0.5% CREAM   4 Non-Preferred Drug 32%32%None
FLUOROURACIL 2% TOPICAL SOLUTION   3 Preferred Brand $40.00$120.00None
FLUOROURACIL 5% CREAM (g) [Efudex]   4 Non-Preferred Drug 32%32%None
FLUOROURACIL 5% TOPICAL SOLUTION   3 Preferred Brand $40.00$120.00None
Fluoxetine 20mg/5mL 120 mL in 1 BOTTLE, PLASTIC   2* Generic $5.00$15.00None
FLUOXETINE HCL 10 MG CAPSULE [Selfemra]   2* Generic $5.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FLUOXETINE HCL 20 MG CAPSULE   2* Generic $5.00$15.00None
FLUOXETINE HCL 40 MG CAPSULE [Prozac]   2* Generic $5.00$15.00None
FLUPHENAZINE 1 MG TABLET   2* Generic $5.00$15.00None
FLUPHENAZINE 10 MG TABLET [Prolixin]   2* Generic $5.00$15.00None
FLUPHENAZINE 2.5 MG TABLET   2* Generic $5.00$15.00None
FLUPHENAZINE 2.5 MG/5 ML ELIX   4 Non-Preferred Drug 32%32%None
FLUPHENAZINE 2.5MG/ML VIAL   4 Non-Preferred Drug 32%32%None
FLUPHENAZINE 5 MG TABLET   2* Generic $5.00$15.00None
FLUPHENAZINE 5MG/ML CONC   3 Preferred Brand $40.00$120.00None
FLUPHENAZINE DEC 125 MG/5 ML VIAL [Prolixin Decanoate]   4 Non-Preferred Drug 32%32%None
FLURBIPROFEN 0.03% EYE DROPS [Ocufen]   2* Generic $5.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FLUTAMIDE 125 MG CAPSULE   3 Preferred Brand $40.00$120.00None
FLUTICASONE PROP 0.005% OINTMENT [Cutivate]   3 Preferred Brand $40.00$120.00None
Fluticasone Propionate 0.5mg/g 1 TUBE per CARTON / 30 g in 1 TUBE   3 Preferred Brand $40.00$120.00None
FLUTICASONE PROPIONATE 50 MCG SPRAY SUSPENSION   2* Generic $5.00$15.00None
FLUVOXAMINE MALEATE 100 MG TABLET [Luvox]   3 Preferred Brand $40.00$120.00None
FLUVOXAMINE MALEATE 25 MG TABLET [Luvox]   3 Preferred Brand $40.00$120.00None
FLUVOXAMINE MALEATE 50 MG TABLET [Luvox]   3 Preferred Brand $40.00$120.00None
FONDAPARINUX 10 MG/0.8 ML SYRINGE [Arixtra]   4 Non-Preferred Drug 32%32%None
FONDAPARINUX 2.5 MG/0.5 ML SYRINGE [Arixtra]   4 Non-Preferred Drug 32%32%None
FONDAPARINUX 5 MG/0.4 ML SYRINGE [Arixtra]   4 Non-Preferred Drug 32%32%None
FONDAPARINUX 7.5 MG/0.6 ML SYRINGE [Arixtra]   4 Non-Preferred Drug 32%32%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Forteo 250ug/mL 1 SYRINGE per CARTON / 2.4 mL in 1 SYRINGE   5 Specialty Tier 25%25%P Q:2
/28Days
FOSAMPRENAVIR 700 MG TABLET [Lexiva]   5 Specialty Tier 25%25%Q:120
/30Days
FOSINOPRIL SODIUM 10 MG TABLET   2* Generic $5.00$15.00Q:60
/30Days
FOSINOPRIL SODIUM 20 MG TABLET   2* Generic $5.00$15.00Q:60
/30Days
FOSINOPRIL SODIUM 40 MG TABLET   2* Generic $5.00$15.00Q:60
/30Days
FREAMINE HBC INJECTION   4 Non-Preferred Drug 32%32%P
FUROSEMIDE 10 MG/ML SOLUTION   1* Preferred Generic $0.00$0.00None
FUROSEMIDE 100 MG/10 ML VIAL   4 Non-Preferred Drug 32%32%P
Furosemide 10mg/mL 10 CARTON in 1 CONTAINER / 1 SYRINGE, PLASTIC in 1 CARTON / 4 mL in 1 SYRINGE, P   4 Non-Preferred Drug 32%32%P
FUROSEMIDE 20 MG TABLET   1* Preferred Generic $0.00$0.00None
FUROSEMIDE 40 MG TABLET [Lasix]   1* Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FUROSEMIDE 40MG/5ML TUBEX   1* Preferred Generic $0.00$0.00None
FUROSEMIDE 80 MG TABLET   1* Preferred Generic $0.00$0.00None
FUZEON 90 MG VIAL   5 Specialty Tier 25%25%Q:60
/30Days
FYCOMPA 0.5 MG/ML ORAL SUSP   5 Specialty Tier 25%25%None
FYCOMPA 10 MG TABLET   5 Specialty Tier 25%25%None
FYCOMPA 12 MG TABLET   5 Specialty Tier 25%25%None
FYCOMPA 2 MG TABLET   5 Specialty Tier 25%25%None
FYCOMPA 4 MG TABLET   5 Specialty Tier 25%25%None
FYCOMPA 6 MG TABLET   5 Specialty Tier 25%25%None
FYCOMPA 8 MG TABLET   5 Specialty Tier 25%25%None

Chart Legend:

Below are a few notes to help you understand the above 2020 Medicare Part D AARP MedicareRx Walgreens (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.