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AARP MedicareRx Preferred (PDP) (S5820-037-0)
Tier 1 (155)
Tier 2 (720)
Tier 3 (959)
Tier 4 (1048)
Tier 5 (684)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
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Has Quantity Limits:
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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 
2021 Medicare Part D Plan Formulary Information
AARP MedicareRx Preferred (PDP) (S5820-037-0)
Benefit Details           
The AARP MedicareRx Preferred (PDP) (S5820-037-0)
Formulary Drugs Starting with the Letter A

in CMS PDP Region 38 which includes: PR
Plan Monthly Premium: $62.40 Deductible: $445 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 [Ziagen]   4 Non-Preferred Drug 40%40%Q:960
/30Days
ABACAVIR 300 MG TABLET [Ziagen]   4 Non-Preferred Drug 40%40%Q:60
/30Days
Abacavir Sulfate-Lamivudine-Zidovudine tablets [Trizivir]   5 Specialty Tier 25%N/AQ:60
/30Days
ABACAVIR-LAMIVUDINE 600-300 MG TABLET [Epzicom]   4 Non-Preferred Drug 40%40%Q:30
/30Days
ABELCET INJECTION SUSPENSION 5MG/ML   4 Non-Preferred Drug 40%40%P
ABILIFY MAINTENA ER 300 MG SYRINGE   5 Specialty Tier 25%N/ANone
ABILIFY MAINTENA ER 300 MG VIAL   5 Specialty Tier 25%N/ANone
ABILIFY MAINTENA ER 400 MG SUSER VIAL   5 Specialty Tier 25%N/ANone
ABILIFY MAINTENA ER 400 MG SYRINGE   5 Specialty Tier 25%N/ANone
ABIRATERONE 500 MG TABLET [ZYTIGA]   4 Non-Preferred Drug 40%40%P Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ABIRATERONE ACETATE 250 MG TABLET [ZYTIGA]   4 Non-Preferred Drug 40%40%P Q:120
/30Days
Acamprosate Calcium DR 333 MG tablets [Campral]   4 Non-Preferred Drug 40%40%None
ACARBOSE 100 MG TABLET [Precose]   3 Preferred Brand $29.00$87.00Q:90
/30Days
ACARBOSE 25 MG TABLET [Precose]   3 Preferred Brand $29.00$87.00Q:360
/30Days
ACARBOSE 50 MG TABLET [Precose]   3 Preferred Brand $29.00$87.00Q:180
/30Days
ACCUTANE 20 MG CAPSULE [ZENATANE]   4 Non-Preferred Drug 40%40%P
ACCUTANE 30 MG CAPSULE [ZENATANE]   4 Non-Preferred Drug 40%40%P
ACCUTANE 40 MG CAPSULE [ZENATANE]   4 Non-Preferred Drug 40%40%P
ACEBUTOLOL 200 MG CAPSULE [Sectral]   2 Generic $6.00$18.00None
ACEBUTOLOL 400 MG CAPSULE [Sectral]   2 Generic $6.00$18.00None
ACETAMINOP-CODEINE 120-12 MG/5   2 Generic $6.00$18.00Q:4500
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETAMINOPHEN-COD #2 TABLET   2 Generic $6.00$18.00Q:390
/30Days
ACETAMINOPHEN-COD #3 TABLET [Tylenol with Codeine No.3]   2 Generic $6.00$18.00Q:390
/30Days
ACETAMINOPHEN-COD #4 TABLET   2 Generic $6.00$18.00Q:390
/30Days
ACETAMN-CAF-DIHYDRCODEIN 320.5 CAPSULE [Trezix]   4 Non-Preferred Drug 40%40%Q:300
/30Days
ACETAZOLAMIDE 125MG TABLET   3 Preferred Brand $29.00$87.00None
ACETAZOLAMIDE 250 MG TABLET [Diamox]   3 Preferred Brand $29.00$87.00None
ACETAZOLAMIDE ER 500 MG CAPSULE   4 Non-Preferred Drug 40%40%None
ACETIC ACID 2% EAR SOLUTION [VoSoL]   2 Generic $6.00$18.00None
ACETYLCYSTEINE 10% VIAL   2 Generic $6.00$18.00P
ACETYLCYSTEINE 20% VIAL [Mucosil Acetylcysteine]   2 Generic $6.00$18.00P
ACITRETIN 10 MG CAPSULE [Soriatane]   4 Non-Preferred Drug 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACITRETIN 17.5 MG CAPSULE [Soriatane]   4 Non-Preferred Drug 40%40%None
ACITRETIN 25 MG CAPSULE [Soriatane]   4 Non-Preferred Drug 40%40%None
ACTEMRA 162 MG/0.9 ML SYRINGE   5 Specialty Tier 25%N/AP
ACTEMRA ACTPEN 162 MG/0.9 ML PEN INJCTR   5 Specialty Tier 25%N/AP
ACTHIB VACCINE WITH DILUENT   3 Preferred Brand $29.00$87.00Q:1
/1Days
ACTIMMUNE 100 MCG/0.5 ML VIAL   5 Specialty Tier 25%N/ANone
ACYCLOVIR 200 MG CAPSULE [Zovirax]   2 Generic $6.00$18.00None
ACYCLOVIR 200 MG/5 ML SUSP   4 Non-Preferred Drug 40%40%None
ACYCLOVIR 400 MG TABLET   2 Generic $6.00$18.00None
ACYCLOVIR 5% OINTMENT [Zovirax]   4 Non-Preferred Drug 40%40%Q:30
/30Days
ACYCLOVIR 800 MG TABLET   2 Generic $6.00$18.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Acyclovir sodium 500 mg vial   4 Non-Preferred Drug 40%40%P
ADACEL TDAP SYRINGE   3 Preferred Brand $29.00$87.00Q:1
/1Days
ADACEL VIAL 2UNT/5UNT   3 Preferred Brand $29.00$87.00Q:1
/1Days
ADAPALENE 0.1% CREAM (G) [Differin]   4 Non-Preferred Drug 40%40%None
ADAPALENE 0.1% GEL [Differin]   3 Preferred Brand $29.00$87.00None
ADEMPAS 0.5 MG TABLET   5 Specialty Tier 25%N/AP
ADEMPAS 1 MG TABLET   5 Specialty Tier 25%N/AP
ADEMPAS 1.5 MG TABLET   5 Specialty Tier 25%N/AP
ADEMPAS 2 MG TABLET   5 Specialty Tier 25%N/AP
ADEMPAS 2.5 MG TABLET   5 Specialty Tier 25%N/AP
ADVAIR DISKUS MIS 100/50   3 Preferred Brand $29.00$87.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADVAIR DISKUS MIS 250/50   3 Preferred Brand $29.00$87.00Q:60
/30Days
ADVAIR DISKUS MIS 500/50   3 Preferred Brand $29.00$87.00Q:60
/30Days
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER   3 Preferred Brand $29.00$87.00Q:12
/30Days
ADVAIR HFA INHALER 115;21MCG;MCG 120 ACTN INHL   3 Preferred Brand $29.00$87.00Q:12
/30Days
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL   3 Preferred Brand $29.00$87.00Q:12
/30Days
AFINITOR 10 MG TABLET   5 Specialty Tier 25%N/AP
AFINITOR DISPERZ 2 MG TABLET   5 Specialty Tier 25%N/AP
AFINITOR DISPERZ 3 MG TABLET   5 Specialty Tier 25%N/AP
AFINITOR DISPERZ 5 MG TABLET   5 Specialty Tier 25%N/AP
AIMOVIG 140 MG/ML AUTOINJECTOR   4 Non-Preferred Drug 40%40%P Q:1
/30Days
AIMOVIG 70 MG/ML AUTOINJECTOR   4 Non-Preferred Drug 40%40%P Q:2
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALA-CORT 2.5% CREAM (G) [Proctozone-HC]   2 Generic $6.00$18.00None
ALBENDAZOLE 200 MG TABLET [Albenza]   5 Specialty Tier 25%N/AQ:480
/30Days
ALBUTEROL 2.5 MG/0.5 ML SOL VIAL-NEB   2 Generic $6.00$18.00P
ALBUTEROL HFA 90 MCG INHALER HFA AER AD [Ventolin HFA]   2 Generic $6.00$18.00None
ALBUTEROL HFA 90 MCG INHALER HFA AER AD [Ventolin HFA]   2 Generic $6.00$18.00None
ALBUTEROL SUL 0.63 MG/3 ML SOL VIAL-NEB   2 Generic $6.00$18.00P
ALBUTEROL SUL 1.25 MG/3 ML SOL VIAL-NEB   2 Generic $6.00$18.00P
ALBUTEROL SUL 2.5 MG/3 ML SOLUTION VIAL-NEB   2 Generic $6.00$18.00P
ALBUTEROL SULF 2 MG/5 ML SYRUP   4 Non-Preferred Drug 40%40%None
ALBUTEROL SULFATE 2 MG TABLET   4 Non-Preferred Drug 40%40%None
ALBUTEROL SULFATE 4 MG TABLET   4 Non-Preferred Drug 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALCLOMETASONE DIPR 0.05% OINTMENT [Aclovate]   3 Preferred Brand $29.00$87.00None
ALCLOMETASONE DIPRO 0.05% CREAM   3 Preferred Brand $29.00$87.00None
ALECENSA 150 MG CAPSULE   5 Specialty Tier 25%N/AP Q:240
/30Days
ALENDRONATE SODIUM 10 MG TABLET [Fosamax]   1 Preferred Generic $1.00$3.00Q:30
/30Days
ALENDRONATE SODIUM 35 MG TABLET [Fosamax]   1 Preferred Generic $1.00$3.00Q:8
/28Days
ALENDRONATE SODIUM 70 MG TABLET [Fosamax]   1 Preferred Generic $1.00$3.00Q:4
/28Days
ALENDRONATE SODIUM 70 MG/75 ML   4 Non-Preferred Drug 40%40%None
ALFUZOSIN HCL ER 10 MG TABLET   2 Generic $6.00$18.00None
ALINIA 100 MG/5 ML SUSPENSION   4 Non-Preferred Drug 40%40%None
ALINIA 500 MG TABLET   4 Non-Preferred Drug 40%40%None
ALISKIREN 150 MG TABLET [Tekturna]   4 Non-Preferred Drug 40%40%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALISKIREN 300 MG TABLET [Tekturna]   4 Non-Preferred Drug 40%40%Q:30
/30Days
ALLOPURINOL 100 MG TABLET [Zyloprim]   1 Preferred Generic $1.00$3.00None
ALLOPURINOL 300 MG TABLET [Zyloprim]   1 Preferred Generic $1.00$3.00None
ALOCRIL 2% EYE DROPS   4 Non-Preferred Drug 40%40%None
ALOMIDE 0.1% EYE DROPS   4 Non-Preferred Drug 40%40%None
ALOSETRON HCL 0.5 MG TABLET [Lotronex]   5 Specialty Tier 25%N/AP
ALOSETRON HCL 1 MG TABLET [Lotronex]   5 Specialty Tier 25%N/AP
ALPHAGAN P 0.1% EYE DROPS   3 Preferred Brand $29.00$87.00None
ALPRAZOLAM 0.25 MG TABLET [Xanax]   2 Generic $6.00$18.00Q:120
/30Days
ALPRAZOLAM 0.5 MG TABLET   2 Generic $6.00$18.00Q:120
/30Days
ALPRAZOLAM 1 MG TABLET   2 Generic $6.00$18.00Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALPRAZOLAM 2 MG TABLET   2 Generic $6.00$18.00Q:150
/30Days
ALTAVERA-28 TABLET [Portia]   4 Non-Preferred Drug 40%40%None
ALUNBRIG 180 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
ALUNBRIG 30 MG TABLET   5 Specialty Tier 25%N/AP Q:120
/30Days
ALUNBRIG 90 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
ALUNBRIG 90 MG-180 MG TABLET PACK   5 Specialty Tier 25%N/AP Q:30
/30Days
ALYACEN 1-35-28 TABLET   4 Non-Preferred Drug 40%40%None
ALYQ 20 MG TABLET   4 Non-Preferred Drug 40%40%P Q:60
/30Days
AMABELZ 0.5 MG-0.1 MG TABLET [Mimvey Lo]   3 Preferred Brand $29.00$87.00None
AMABELZ 1 MG-0.5 MG TABLET [Mimvey]   3 Preferred Brand $29.00$87.00None
AMANTADINE 100 MG CAPSULE [Symmetrel]   3 Preferred Brand $29.00$87.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMANTADINE 100 MG TABLET   3 Preferred Brand $29.00$87.00None
AMANTADINE 50 MG/5 ML SOLUTION   2 Generic $6.00$18.00None
AMBISOME 50MG VIAL   4 Non-Preferred Drug 40%40%P
AMBRISENTAN 10 MG TABLET [LETAIRIS]   5 Specialty Tier 25%N/AP Q:30
/30Days
AMBRISENTAN 5 MG TABLET [LETAIRIS]   5 Specialty Tier 25%N/AP Q:30
/30Days
AMETHIA 0.15-0.03-0.01 MG TABLET   4 Non-Preferred Drug 40%40%None
AMIKACIN SULF 500 MG/2 ML VIAL   4 Non-Preferred Drug 40%40%None
AMILORIDE HCL 5 MG TABLET [Midamor]   2 Generic $6.00$18.00None
AMILORIDE HCL-HCTZ 5-50 MG TABLET [Moduretic]   2 Generic $6.00$18.00None
Amino Acids 15% Solution   4 Non-Preferred Drug 40%40%P
AMINOSYN II 15% IV SOLUTION   4 Non-Preferred Drug 40%40%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN-PF 7% IV SOLUTION   4 Non-Preferred Drug 40%40%P
AMIODARONE HCL 200 MG TABLET [Pacerone]   2 Generic $6.00$18.00None
AMITIZA 24 MCG 60 CAPSULE BOTTLE   3 Preferred Brand $29.00$87.00Q:60
/30Days
AMITIZA 8MCG CAPSULE   3 Preferred Brand $29.00$87.00Q:60
/30Days
AMITRIPTYLINE HCL 10 MG TABLET [Elavil]   3 Preferred Brand $29.00$87.00None
AMITRIPTYLINE HCL 100 MG TABLET   3 Preferred Brand $29.00$87.00None
AMITRIPTYLINE HCL 150 MG TABLET   3 Preferred Brand $29.00$87.00None
AMITRIPTYLINE HCL 25 MG TABLET   3 Preferred Brand $29.00$87.00None
AMITRIPTYLINE HCL 50 MG TABLET   3 Preferred Brand $29.00$87.00None
AMITRIPTYLINE HCL 75 MG TABLET   3 Preferred Brand $29.00$87.00None
AMLOD-VALSA-HCTZ 10-160-12.5 MG TABLET [Exforge HCT]   3 Preferred Brand $29.00$87.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLOD-VALSA-HCTZ 10-160-25 MG TABLET [Exforge HCT]   3 Preferred Brand $29.00$87.00Q:30
/30Days
AMLOD-VALSA-HCTZ 10-320-25 MG TABLET [Exforge HCT]   3 Preferred Brand $29.00$87.00Q:30
/30Days
AMLOD-VALSA-HCTZ 5-160-12.5 MG TABLET [Exforge HCT]   3 Preferred Brand $29.00$87.00Q:30
/30Days
AMLOD-VALSA-HCTZ 5-160-25 MG TABLET [Exforge HCT]   3 Preferred Brand $29.00$87.00Q:30
/30Days
AMLODIPINE BESYLATE 10 MG TABLET [Norvasc]   1 Preferred Generic $1.00$3.00None
AMLODIPINE BESYLATE 2.5 MG TABLET [Norvasc]   1 Preferred Generic $1.00$3.00None
AMLODIPINE BESYLATE 5 MG TABLET [Norvasc]   1 Preferred Generic $1.00$3.00None
AMLODIPINE-BENAZEPRIL 10-20 MG CAPSULE [Lotrel]   2 Generic $6.00$18.00Q:30
/30Days
AMLODIPINE-BENAZEPRIL 10-40 MG CAPSULE [Lotrel]   2 Generic $6.00$18.00Q:30
/30Days
AMLODIPINE-BENAZEPRIL 2.5-10 CAPSULE [Lotrel]   2 Generic $6.00$18.00Q:30
/30Days
AMLODIPINE-BENAZEPRIL 5-10 MG CAPSULE [Lotrel]   2 Generic $6.00$18.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE-BENAZEPRIL 5-20 MG CAPSULE [Lotrel]   2 Generic $6.00$18.00Q:30
/30Days
AMLODIPINE-BENAZEPRIL 5-40 MG CAPSULE [Lotrel]   2 Generic $6.00$18.00Q:30
/30Days
AMLODIPINE-VALSARTAN 10-160 MG TABLET [Exforge]   3 Preferred Brand $29.00$87.00Q:30
/30Days
AMLODIPINE-VALSARTAN 10-320 MG TABLET [Exforge]   3 Preferred Brand $29.00$87.00Q:30
/30Days
AMLODIPINE-VALSARTAN 5-160 MG TABLET [Exforge]   3 Preferred Brand $29.00$87.00Q:30
/30Days
AMLODIPINE-VALSARTAN 5-320 MG TABLET [Exforge]   3 Preferred Brand $29.00$87.00Q:30
/30Days
AMMONIUM LACTATE 12% CREAM (g) [Lac-Hydrin]   3 Preferred Brand $29.00$87.00None
AMMONIUM LACTATE 12% LOTION   3 Preferred Brand $29.00$87.00None
AMNESTEEM 10 MG CAPSULE [ZENATANE]   4 Non-Preferred Drug 40%40%P
AMNESTEEM 20 MG CAPSULE [ZENATANE]   4 Non-Preferred Drug 40%40%P
AMNESTEEM 40 MG CAPSULE [ZENATANE]   4 Non-Preferred Drug 40%40%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE [Augmentin]   2 Generic $6.00$18.00None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET [Augmentin]   2 Generic $6.00$18.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE [Augmentin]   2 Generic $6.00$18.00None
AMOX-CLAV 200-28.5 MG/5 ML SUS   2 Generic $6.00$18.00None
AMOX-CLAV 250-62.5 MG/5 ML SUS   2 Generic $6.00$18.00None
AMOX-CLAV 400-57 MG/5 ML ORAL SUSPENSION [Augmentin]   2 Generic $6.00$18.00None
AMOX-CLAV 500-125 MG TABLET [Augmentin]   2 Generic $6.00$18.00None
AMOX-CLAV 600-42.9 MG/5 ML SUS   2 Generic $6.00$18.00None
AMOX-CLAV 875-125 MG TABLET [Augmentin]   2 Generic $6.00$18.00None
AMOX-CLAV ER 1,000-62.5 MG TABLET [Augmentin]   4 Non-Preferred Drug 40%40%None
AMOXAPINE 100MG TABLET   3 Preferred Brand $29.00$87.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXAPINE 150MG TABLET   3 Preferred Brand $29.00$87.00None
AMOXAPINE 25MG TABLET   3 Preferred Brand $29.00$87.00None
AMOXAPINE 50MG TABLET   3 Preferred Brand $29.00$87.00None
AMOXICILLIN 125 MG/5 ML SUSP   2 Generic $6.00$18.00None
AMOXICILLIN 125MG TABLET CHEW   2 Generic $6.00$18.00None
AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION [Amoxil]   2 Generic $6.00$18.00None
AMOXICILLIN 250 MG CAPSULE [Trimox]   2 Generic $6.00$18.00None
AMOXICILLIN 250 MG TABLET CHEW   2 Generic $6.00$18.00None
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION [Trimox]   2 Generic $6.00$18.00None
AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION [Amoxil]   2 Generic $6.00$18.00None
AMOXICILLIN 500 MG CAPSULE [Trimox]   2 Generic $6.00$18.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN 500 MG TABLET   2 Generic $6.00$18.00None
AMOXICILLIN 875 MG TABLET   2 Generic $6.00$18.00None
AMPHETAMINE SALT COMBO 12.5MG TABLET   3 Preferred Brand $29.00$87.00Q:60
/30Days
AMPHETAMINE SALT COMBO 15MG TABLET   3 Preferred Brand $29.00$87.00Q:60
/30Days
AMPHETAMINE SALT COMBO 7.5MG TABLET   3 Preferred Brand $29.00$87.00Q:60
/30Days
AMPHETAMINE SALTS 5 MG TABLET   3 Preferred Brand $29.00$87.00Q:60
/30Days
amphotericin b 50mg/10mL 10 mL in 1 VIAL   4 Non-Preferred Drug 40%40%P
AMPICILLIN 1 GM VIAL   4 Non-Preferred Drug 40%40%None
AMPICILLIN 10 GM VIAL   4 Non-Preferred Drug 40%40%None
Ampicillin 1000 MG / Sulbactam 500 MG Injection   4 Non-Preferred Drug 40%40%None
Ampicillin 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS   4 Non-Preferred Drug 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPICILLIN CAPSULES 500MG 100 BOTTLE   2 Generic $6.00$18.00None
AMPICILLIN-SULBACTAM 15 GM VIAL [Unasyn]   4 Non-Preferred Drug 40%40%None
AMPICILLIN-SULBACTAM 3 GM VIAL [Unasyn]   4 Non-Preferred Drug 40%40%None
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE   3 Preferred Brand $29.00$87.00None
Anagrelide Hydrochloride 1mg/1 100 CAPSULE BOTTLE   3 Preferred Brand $29.00$87.00None
ANASTROZOLE 1 MG TABLET   1 Preferred Generic $1.00$3.00None
ANDRODERM 2 MG/24HR PATCH   3 Preferred Brand $29.00$87.00Q:30
/30Days
ANDRODERM 4 MG/24HR PATCH   3 Preferred Brand $29.00$87.00Q:30
/30Days
ANORO ELLIPTA 62.5-25 MCG INH   3 Preferred Brand $29.00$87.00Q:60
/30Days
APOKYN 30 MG/3 ML CARTRIDGE   5 Specialty Tier 25%N/AP Q:90
/30Days
Apraclonidine 5 MG/ML Ophthalmic Solution   3 Preferred Brand $29.00$87.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
APREPITANT 125 MG CAPSULE [Emend]   4 Non-Preferred Drug 40%40%P
APREPITANT 125-80-80 MG PACK [Emend]   4 Non-Preferred Drug 40%40%P
APREPITANT 40 MG CAPSULE [Emend]   4 Non-Preferred Drug 40%40%P
APREPITANT 80 MG CAPSULE [Emend]   4 Non-Preferred Drug 40%40%P
APRI 0.15-0.03 TABLET   4 Non-Preferred Drug 40%40%None
APRISO CP24   3 Preferred Brand $29.00$87.00Q:120
/30Days
APTIOM 200 MG TABLET   4 Non-Preferred Drug 40%40%Q:30
/30Days
APTIOM 400 MG TABLET   4 Non-Preferred Drug 40%40%Q:30
/30Days
APTIOM 600 MG TABLET   4 Non-Preferred Drug 40%40%Q:60
/30Days
APTIOM 800 MG TABLET   4 Non-Preferred Drug 40%40%Q:60
/30Days
APTIVUS 250MG CAPSULE   5 Specialty Tier 25%N/AQ:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARALAST NP 1,000 MG VIAL   5 Specialty Tier 25%N/AP
ARANELLE 7-9-5 TABLET   4 Non-Preferred Drug 40%40%None
ARANESP 10 MCG/0.4 ML SYRINGE   4 Non-Preferred Drug 40%40%P
ARANESP 100ug/0.5mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.5 mL in 1 SYRINGE   5 Specialty Tier 25%N/AP
ARANESP 100ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE   5 Specialty Tier 25%N/AP
ARANESP 200MCG/0.4ML SYRINGE   5 Specialty Tier 25%N/AP
ARANESP 200MCG/ML VIAL   5 Specialty Tier 25%N/AP
ARANESP 25ug/0.42mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.42 mL in 1 SYRING   4 Non-Preferred Drug 40%40%P
ARANESP 25ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE   4 Non-Preferred Drug 40%40%P
ARANESP 300MCG/ML VIAL   5 Specialty Tier 25%N/AP
ARANESP 500MCG/1ML SYRINGE   5 Specialty Tier 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP 60MCG/ML VIAL   4 Non-Preferred Drug 40%40%P
ARANESP 60ug/0.3mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.3 mL in 1 SYRINGE   4 Non-Preferred Drug 40%40%P
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR   5 Specialty Tier 25%N/AP
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR   5 Specialty Tier 25%N/AP
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR   4 Non-Preferred Drug 40%40%P
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD   4 Non-Preferred Drug 40%40%P
ARCALYST 220 MG VIAL   5 Specialty Tier 25%N/AP
ARIPIPRAZOLE 1 MG/ML SOLUTION [Abilify]   4 Non-Preferred Drug 40%40%Q:750
/30Days
ARIPIPRAZOLE 10 MG TABLET [Abilify]   4 Non-Preferred Drug 40%40%Q:30
/30Days
ARIPIPRAZOLE 15 MG TABLET [Abilify]   4 Non-Preferred Drug 40%40%Q:30
/30Days
ARIPIPRAZOLE 2 MG TABLET [Abilify]   4 Non-Preferred Drug 40%40%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARIPIPRAZOLE 20 MG TABLET [Abilify]   4 Non-Preferred Drug 40%40%Q:30
/30Days
ARIPIPRAZOLE 30 MG TABLET [Abilify]   4 Non-Preferred Drug 40%40%Q:30
/30Days
ARIPIPRAZOLE 5 MG TABLET [Abilify]   4 Non-Preferred Drug 40%40%Q:30
/30Days
ARIPIPRAZOLE ODT 10 MG TABLET RAPDIS [Abilify Discmelt]   4 Non-Preferred Drug 40%40%Q:90
/30Days
ARIPIPRAZOLE ODT 15 MG TABLET RAPDIS [Abilify Discmelt]   4 Non-Preferred Drug 40%40%Q:60
/30Days
ARISTADA ER 1064 MG/3.9 ML SYRINGE   5 Specialty Tier 25%N/ANone
ARISTADA ER 441 MG/1.6 ML SYRINGE   5 Specialty Tier 25%N/ANone
ARISTADA ER 662 MG/2.4 ML SYRINGE   5 Specialty Tier 25%N/ANone
ARISTADA ER 882 MG/3.2 ML SYRINGE   5 Specialty Tier 25%N/ANone
ARISTADA INITIO ER 675 MG/2.4 SUSER SYRINGE   5 Specialty Tier 25%N/ANone
ARMODAFINIL 150 MG TABLET [Nuvigil]   4 Non-Preferred Drug 40%40%P Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARMODAFINIL 200 MG TABLET [Nuvigil]   4 Non-Preferred Drug 40%40%P Q:30
/30Days
ARMODAFINIL 250 MG TABLET [Nuvigil]   4 Non-Preferred Drug 40%40%P Q:30
/30Days
ARMODAFINIL 50 MG TABLET [Nuvigil]   4 Non-Preferred Drug 40%40%P Q:60
/30Days
ARNUITY ELLIPTA 100 MCG INH   3 Preferred Brand $29.00$87.00Q:30
/30Days
ARNUITY ELLIPTA 200 MCG INH   3 Preferred Brand $29.00$87.00Q:30
/30Days
ARNUITY ELLIPTA 50 MCG INH BLST W/DEV   3 Preferred Brand $29.00$87.00Q:30
/30Days
ASENAPINE 10 MG SUBLIGUAL TABLET [Saphris]   4 Non-Preferred Drug 40%40%Q:60
/30Days
ASENAPINE 2.5 MG SUBLIGUAL TABLET [Saphris]   4 Non-Preferred Drug 40%40%Q:60
/30Days
ASENAPINE 5 MG SUBLIGUAL TABLET [Saphris]   4 Non-Preferred Drug 40%40%Q:60
/30Days
ASHLYNA 0.15-0.03-0.01 MG TABLET   4 Non-Preferred Drug 40%40%None
Aspirin-Diphenhydramine ER 25-200 MG   4 Non-Preferred Drug 40%40%Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATAZANAVIR SULFATE 150 MG CAPSULE [Reyataz]   4 Non-Preferred Drug 40%40%Q:30
/30Days
ATAZANAVIR SULFATE 200 MG CAPSULE [Reyataz]   4 Non-Preferred Drug 40%40%Q:60
/30Days
ATAZANAVIR SULFATE 300 MG CAPSULE [Reyataz]   4 Non-Preferred Drug 40%40%Q:30
/30Days
ATENOLOL 100 MG TABLET [Tenormin]   1 Preferred Generic $1.00$3.00None
ATENOLOL 25 MG TABLET   1 Preferred Generic $1.00$3.00None
ATENOLOL 50 MG TABLET [Tenormin]   1 Preferred Generic $1.00$3.00None
ATENOLOL-CHLORTHALIDONE 100-25   1 Preferred Generic $1.00$3.00None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   1 Preferred Generic $1.00$3.00None
ATOMOXETINE HCL 10 MG CAPSULE [Strattera]   4 Non-Preferred Drug 40%40%Q:60
/30Days
ATOMOXETINE HCL 100 MG CAPSULE [Strattera]   4 Non-Preferred Drug 40%40%Q:30
/30Days
ATOMOXETINE HCL 18 MG CAPSULE [Strattera]   4 Non-Preferred Drug 40%40%Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATOMOXETINE HCL 25 MG CAPSULE [Strattera]   4 Non-Preferred Drug 40%40%Q:60
/30Days
ATOMOXETINE HCL 40 MG CAPSULE [Strattera]   4 Non-Preferred Drug 40%40%Q:60
/30Days
ATOMOXETINE HCL 60 MG CAPSULE [Strattera]   4 Non-Preferred Drug 40%40%Q:30
/30Days
ATOMOXETINE HCL 80 MG CAPSULE [Strattera]   4 Non-Preferred Drug 40%40%Q:30
/30Days
ATORVASTATIN 10 MG TABLET [Lipitor]   1 Preferred Generic $1.00$3.00Q:30
/30Days
ATORVASTATIN 20 MG TABLET [Lipitor]   1 Preferred Generic $1.00$3.00Q:30
/30Days
ATORVASTATIN 40 MG TABLET [Lipitor]   1 Preferred Generic $1.00$3.00Q:30
/30Days
ATORVASTATIN 80 MG TABLET [Lipitor]   1 Preferred Generic $1.00$3.00Q:30
/30Days
ATOVAQUONE 750 MG/5 ML SUSP [Mepron]   5 Specialty Tier 25%N/ANone
Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone]   3 Preferred Brand $29.00$87.00None
ATOVAQUONE-PROGUANIL 62.5-25 [Malarone]   3 Preferred Brand $29.00$87.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC   5 Specialty Tier 25%N/AQ:30
/30Days
ATROPINE 1% EYE DROPS   3 Preferred Brand $29.00$87.00None
ATROVENT HFA AER 17MCG   4 Non-Preferred Drug 40%40%None
AUBAGIO 14 MG TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
AUBAGIO 7 MG TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
AUBRA EQ-28 TABLET [Vienva]   4 Non-Preferred Drug 40%40%None
AURYXIA 210 MG TABLET   4 Non-Preferred Drug 40%40%P
AUSTEDO 12 MG TABLET   5 Specialty Tier 25%N/AP Q:120
/30Days
AUSTEDO 6 MG TABLET   5 Specialty Tier 25%N/AP Q:120
/30Days
AUSTEDO 9 MG TABLET   5 Specialty Tier 25%N/AP Q:120
/30Days
AVIANE 0.1-0.02 TABLET   4 Non-Preferred Drug 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVONEX PEN 30 MCG/0.5 ML KIT   5 Specialty Tier 25%N/AQ:1
/28Days
AVONEX PREFILLED SYR 30 MCG KT   5 Specialty Tier 25%N/AQ:1
/28Days
AYVAKIT 100 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
AYVAKIT 200 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
AYVAKIT 300 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
AZATHIOPRINE 50 MG TABLET [Imuran]   2 Generic $6.00$18.00P
AZELAIC ACID 15% GEL [Finacea]   4 Non-Preferred Drug 40%40%None
AZELASTIN-FLUTIC 137-50MCG SPRAY/PUMP [Dymista]   4 Non-Preferred Drug 40%40%None
AZELASTINE 0.15% NASAL SPRAY   3 Preferred Brand $29.00$87.00None
AZELASTINE 137 MCG NASAL SPRAY   3 Preferred Brand $29.00$87.00None
AZELASTINE HCL 0.05% EYE DROPS [Optivar]   3 Preferred Brand $29.00$87.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZITHROMYCIN 100 MG/5 ML ORAL SUSPENSION [Zithromax]   2 Generic $6.00$18.00None
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [Zithromax]   2 Generic $6.00$18.00None
AZITHROMYCIN 250 MG TABLET   2 Generic $6.00$18.00None
AZITHROMYCIN 250 MG TABLET [Zithromax Z-Pak]   2 Generic $6.00$18.00None
AZITHROMYCIN 500 MG TABLET   2 Generic $6.00$18.00None
AZITHROMYCIN 500 MG TABLET [Zithromax Tri-Pak]   2 Generic $6.00$18.00None
AZITHROMYCIN 600 MG TABLET [Zithromax Z-Pak]   2 Generic $6.00$18.00None
AZITHROMYCIN I.V. 500 MG VIAL [Zithromax]   4 Non-Preferred Drug 40%40%None
AZOPT 1% EYE DROPS   3 Preferred Brand $29.00$87.00None
AZTREONAM FOR INJECTION   4 Non-Preferred Drug 40%40%None

Chart Legend:

Below are a few notes to help you understand the above 2021 Medicare Part D AARP MedicareRx Preferred (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 $445 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 $4,130) 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.

      * When the insulin copay is in green, example: $35.00, this Part D plan may offer particular forms of insulin as part of the Senior Savings Model.  The Senior Savings Model stipulates that some insulin will cost no more than $35 in the deductible, initial coverage, and coverage gap phases of your Part D plan. Please contact the drug plan for more details.

    • 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 2021 )

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.