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SilverScript Choice (PDP) (S5601-054-0)
Tier 1 (95)
Tier 2 (440)
Tier 3 (1061)
Tier 4 (911)
Tier 5 (602)
Requires Prior Authorization:
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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
SilverScript Choice (PDP) (S5601-054-0)
Benefit Details           
The SilverScript Choice (PDP) (S5601-054-0)
Formulary Drugs Starting with the Letter A

in CMS PDP Region 27 which includes: CO
Plan Monthly Premium: $29.70 Deductible: $370 Qualifies for LIS: Yes
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 41%41%None
ABACAVIR 300 MG TABLET [Ziagen]   3 Preferred Brand $35.00$105.00None
Abacavir Sulfate-Lamivudine-Zidovudine tablets [Trizivir]   5 Specialty Tier 26%N/ANone
ABACAVIR-LAMIVUDINE 600-300 MG TABLET [Epzicom]   3 Preferred Brand $35.00$105.00None
ABELCET INJECTION SUSPENSION 5MG/ML   4 Non-Preferred Drug 41%41%P
ABILIFY MAINTENA ER 300 MG SYRINGE   4 Non-Preferred Drug 41%41%Q:1
/28Days
ABILIFY MAINTENA ER 300 MG VIAL   4 Non-Preferred Drug 41%41%Q:1
/28Days
ABILIFY MAINTENA ER 400 MG SUSER VIAL   4 Non-Preferred Drug 41%41%Q:1
/28Days
ABILIFY MAINTENA ER 400 MG SYRINGE   4 Non-Preferred Drug 41%41%Q:1
/28Days
ABIRATERONE 500 MG TABLET [ZYTIGA]   5 Specialty Tier 26%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ABIRATERONE ACETATE 250 MG TABLET [ZYTIGA]   5 Specialty Tier 26%N/AP
Acamprosate Calcium DR 333 MG tablets [Campral]   4 Non-Preferred Drug 41%41%None
ACARBOSE 100 MG TABLET [Precose]   3 Preferred Brand $35.00$105.00Q:90
/30Days
ACARBOSE 25 MG TABLET [Precose]   3 Preferred Brand $35.00$105.00Q:90
/30Days
ACARBOSE 50 MG TABLET [Precose]   3 Preferred Brand $35.00$105.00Q:90
/30Days
ACCUTANE 20 MG CAPSULE [ZENATANE]   4 Non-Preferred Drug 41%41%P
ACCUTANE 30 MG CAPSULE [ZENATANE]   4 Non-Preferred Drug 41%41%P
ACCUTANE 40 MG CAPSULE [ZENATANE]   4 Non-Preferred Drug 41%41%P
ACEBUTOLOL 200 MG CAPSULE [Sectral]   2* Generic $5.00$15.00None
ACEBUTOLOL 400 MG CAPSULE [Sectral]   2* Generic $5.00$15.00None
ACETAMINOP-CODEINE 120-12 MG/5   3 Preferred Brand $35.00$105.00Q:2700
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETAMINOPHEN-COD #2 TABLET   3 Preferred Brand $35.00$105.00Q:180
/30Days
ACETAMINOPHEN-COD #3 TABLET [Tylenol with Codeine No.3]   3 Preferred Brand $35.00$105.00Q:180
/30Days
ACETAMINOPHEN-COD #4 TABLET   3 Preferred Brand $35.00$105.00Q:180
/30Days
ACETAZOLAMIDE 125MG TABLET   3 Preferred Brand $35.00$105.00None
ACETAZOLAMIDE 250 MG TABLET [Diamox]   3 Preferred Brand $35.00$105.00None
ACETAZOLAMIDE ER 500 MG CAPSULE   4 Non-Preferred Drug 41%41%None
ACETIC ACID 2% EAR SOLUTION [VoSoL]   3 Preferred Brand $35.00$105.00None
ACETYLCYSTEINE 10% VIAL   3 Preferred Brand $35.00$105.00P
ACETYLCYSTEINE 20% VIAL [Mucosil Acetylcysteine]   3 Preferred Brand $35.00$105.00P
ACITRETIN 10 MG CAPSULE [Soriatane]   4 Non-Preferred Drug 41%41%P
ACITRETIN 17.5 MG CAPSULE [Soriatane]   4 Non-Preferred Drug 41%41%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACITRETIN 25 MG CAPSULE [Soriatane]   4 Non-Preferred Drug 41%41%P
ACTHIB VACCINE WITH DILUENT   3 Preferred Brand $35.00$105.00None
ACTIMMUNE 100 MCG/0.5 ML VIAL   5 Specialty Tier 26%N/AP
ACYCLOVIR 200 MG CAPSULE [Zovirax]   2* Generic $5.00$15.00None
ACYCLOVIR 200 MG/5 ML SUSP   4 Non-Preferred Drug 41%41%None
ACYCLOVIR 400 MG TABLET   2* Generic $5.00$15.00None
ACYCLOVIR 800 MG TABLET   2* Generic $5.00$15.00None
Acyclovir sodium 500 mg vial   4 Non-Preferred Drug 41%41%P
ADACEL TDAP SYRINGE   3 Preferred Brand $35.00$105.00None
ADACEL VIAL 2UNT/5UNT   3 Preferred Brand $35.00$105.00None
ADEFOVIR DIPIVOXIL 10 MG TABLET [Hepsera]   5 Specialty Tier 26%N/AQ:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADEMPAS 0.5 MG TABLET   5 Specialty Tier 26%N/AP Q:90
/30Days
ADEMPAS 1 MG TABLET   5 Specialty Tier 26%N/AP Q:90
/30Days
ADEMPAS 1.5 MG TABLET   5 Specialty Tier 26%N/AP Q:90
/30Days
ADEMPAS 2 MG TABLET   5 Specialty Tier 26%N/AP Q:90
/30Days
ADEMPAS 2.5 MG TABLET   5 Specialty Tier 26%N/AP Q:90
/30Days
ADVAIR DISKUS MIS 100/50   3 Preferred Brand $35.00$105.00Q:60
/30Days
ADVAIR DISKUS MIS 250/50   3 Preferred Brand $35.00$105.00Q:60
/30Days
ADVAIR DISKUS MIS 500/50   3 Preferred Brand $35.00$105.00Q:60
/30Days
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER   3 Preferred Brand $35.00$105.00Q:12
/30Days
ADVAIR HFA INHALER 115;21MCG;MCG 120 ACTN INHL   3 Preferred Brand $35.00$105.00Q:12
/30Days
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL   3 Preferred Brand $35.00$105.00Q:12
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AFINITOR 10 MG TABLET   5 Specialty Tier 26%N/AP Q:30
/30Days
AFINITOR DISPERZ 2 MG TABLET   5 Specialty Tier 26%N/AP Q:150
/30Days
AFINITOR DISPERZ 3 MG TABLET   5 Specialty Tier 26%N/AP Q:90
/30Days
AFINITOR DISPERZ 5 MG TABLET   5 Specialty Tier 26%N/AP Q:60
/30Days
AIMOVIG 140 MG/ML AUTOINJECTOR   3 Preferred Brand $35.00$105.00P Q:1
/30Days
AIMOVIG 70 MG/ML AUTOINJECTOR   3 Preferred Brand $35.00$105.00P Q:1
/30Days
ALA-CORT 2.5% CREAM (G) [Proctozone-HC]   2* Generic $5.00$15.00Q:30
/30Days
ALBENDAZOLE 200 MG TABLET [Albenza]   5 Specialty Tier 26%N/ANone
ALBUTEROL 2.5 MG/0.5 ML SOL VIAL-NEB   3 Preferred Brand $35.00$105.00P
ALBUTEROL HFA 90 MCG INHALER HFA AER AD [Ventolin HFA]   3 Preferred Brand $35.00$105.00Q:36
/30Days
ALBUTEROL HFA 90 MCG INHALER HFA AER AD [Ventolin HFA]   3 Preferred Brand $35.00$105.00Q:17
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALBUTEROL HFA 90 MCG INHALER HFA AER AD [Ventolin HFA]   3 Preferred Brand $35.00$105.00Q:13
/30Days
ALBUTEROL SUL 0.63 MG/3 ML SOL VIAL-NEB   3 Preferred Brand $35.00$105.00P
ALBUTEROL SUL 1.25 MG/3 ML SOL VIAL-NEB   3 Preferred Brand $35.00$105.00P
ALBUTEROL SUL 2.5 MG/3 ML SOLUTION VIAL-NEB   2* Generic $5.00$15.00P
ALBUTEROL SULF 2 MG/5 ML SYRUP   3 Preferred Brand $35.00$105.00None
ALBUTEROL SULFATE 2 MG TABLET   4 Non-Preferred Drug 41%41%None
ALBUTEROL SULFATE 4 MG TABLET   4 Non-Preferred Drug 41%41%None
ALCLOMETASONE DIPR 0.05% OINTMENT [Aclovate]   3 Preferred Brand $35.00$105.00None
ALCLOMETASONE DIPRO 0.05% CREAM   3 Preferred Brand $35.00$105.00None
ALECENSA 150 MG CAPSULE   5 Specialty Tier 26%N/AP
ALENDRONATE SODIUM 10 MG TABLET [Fosamax]   1* Preferred Generic $0.00$0.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALENDRONATE SODIUM 35 MG TABLET [Fosamax]   1* Preferred Generic $0.00$0.00Q:4
/28Days
ALENDRONATE SODIUM 70 MG TABLET [Fosamax]   1* Preferred Generic $0.00$0.00Q:4
/28Days
ALFUZOSIN HCL ER 10 MG TABLET   2* Generic $5.00$15.00Q:30
/30Days
ALINIA 100 MG/5 ML SUSPENSION   5 Specialty Tier 26%N/ANone
ALINIA 500 MG TABLET   5 Specialty Tier 26%N/ANone
ALISKIREN 150 MG TABLET [Tekturna]   4 Non-Preferred Drug 41%41%None
ALISKIREN 300 MG TABLET [Tekturna]   4 Non-Preferred Drug 41%41%None
ALLOPURINOL 100 MG TABLET [Zyloprim]   2* Generic $5.00$15.00None
ALLOPURINOL 300 MG TABLET [Zyloprim]   2* Generic $5.00$15.00None
ALOSETRON HCL 0.5 MG TABLET [Lotronex]   5 Specialty Tier 26%N/AP Q:60
/30Days
ALOSETRON HCL 1 MG TABLET [Lotronex]   5 Specialty Tier 26%N/AP Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALPHAGAN P 0.1% EYE DROPS   3 Preferred Brand $35.00$105.00None
ALPHAGAN P 0.15% EYE DROPS   3 Preferred Brand $35.00$105.00None
ALPRAZOLAM 0.25 MG TABLET [Xanax]   3 Preferred Brand $35.00$105.00Q:120
/30Days
ALPRAZOLAM 0.5 MG TABLET   3 Preferred Brand $35.00$105.00Q:120
/30Days
ALPRAZOLAM 1 MG TABLET   3 Preferred Brand $35.00$105.00Q:150
/30Days
ALPRAZOLAM 2 MG TABLET   3 Preferred Brand $35.00$105.00Q:150
/30Days
ALREX 0.2% EYE DROPS   3 Preferred Brand $35.00$105.00None
ALTAVERA-28 TABLET [Portia]   3 Preferred Brand $35.00$105.00None
ALUNBRIG 180 MG TABLET   5 Specialty Tier 26%N/AP
ALUNBRIG 30 MG TABLET   5 Specialty Tier 26%N/AP
ALUNBRIG 90 MG TABLET   5 Specialty Tier 26%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALUNBRIG 90 MG-180 MG TABLET PACK   5 Specialty Tier 26%N/AP
ALYACEN 1-35-28 TABLET   3 Preferred Brand $35.00$105.00None
AMANTADINE 100 MG CAPSULE [Symmetrel]   3 Preferred Brand $35.00$105.00Q:120
/30Days
AMANTADINE 100 MG TABLET   3 Preferred Brand $35.00$105.00None
AMANTADINE 50 MG/5 ML SOLUTION   2* Generic $5.00$15.00None
AMBISOME 50MG VIAL   5 Specialty Tier 26%N/AP
AMBRISENTAN 10 MG TABLET [LETAIRIS]   5 Specialty Tier 26%N/AP Q:30
/30Days
AMBRISENTAN 5 MG TABLET [LETAIRIS]   5 Specialty Tier 26%N/AP Q:30
/30Days
AMIKACIN SULF 500 MG/2 ML VIAL   4 Non-Preferred Drug 41%41%None
AMILORIDE HCL 5 MG TABLET [Midamor]   2* Generic $5.00$15.00None
AMILORIDE HCL-HCTZ 5-50 MG TABLET [Moduretic]   2* Generic $5.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Amino acids 4.25% in dextrose 10% Injectable Solution [Clinimix 4.25/10]   4 Non-Preferred Drug 41%41%P
Amino acids 4.25% in dextrose 5% Injectable Solution [Clinimix 4.25/5]   4 Non-Preferred Drug 41%41%P
AMINOSYN-PF 7% IV SOLUTION   4 Non-Preferred Drug 41%41%P
AMIODARONE HCL 100 MG TABLET [Pacerone]   4 Non-Preferred Drug 41%41%None
AMIODARONE HCL 200 MG TABLET [Pacerone]   2* Generic $5.00$15.00None
AMIODARONE HCL 400 MG TABLET [Pacerone]   4 Non-Preferred Drug 41%41%None
AMITRIPTYLINE HCL 10 MG TABLET [Elavil]   3 Preferred Brand $35.00$105.00P
AMITRIPTYLINE HCL 100 MG TABLET   3 Preferred Brand $35.00$105.00P
AMITRIPTYLINE HCL 150 MG TABLET   3 Preferred Brand $35.00$105.00P
AMITRIPTYLINE HCL 25 MG TABLET   3 Preferred Brand $35.00$105.00P
AMITRIPTYLINE HCL 50 MG TABLET   3 Preferred Brand $35.00$105.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITRIPTYLINE HCL 75 MG TABLET   3 Preferred Brand $35.00$105.00P
AMLODIPINE BESYLATE 10 MG TABLET [Norvasc]   1* Preferred Generic $0.00$0.00None
AMLODIPINE BESYLATE 2.5 MG TABLET [Norvasc]   1* Preferred Generic $0.00$0.00None
AMLODIPINE BESYLATE 5 MG TABLET [Norvasc]   1* Preferred Generic $0.00$0.00None
AMLODIPINE-BENAZEPRIL 10-20 MG CAPSULE [Lotrel]   2* Generic $5.00$15.00Q:30
/30Days
AMLODIPINE-BENAZEPRIL 10-40 MG CAPSULE [Lotrel]   2* Generic $5.00$15.00Q:30
/30Days
AMLODIPINE-BENAZEPRIL 2.5-10 CAPSULE [Lotrel]   2* Generic $5.00$15.00Q:30
/30Days
AMLODIPINE-BENAZEPRIL 5-10 MG CAPSULE [Lotrel]   2* Generic $5.00$15.00Q:30
/30Days
AMLODIPINE-BENAZEPRIL 5-20 MG CAPSULE [Lotrel]   2* Generic $5.00$15.00Q:30
/30Days
AMLODIPINE-BENAZEPRIL 5-40 MG CAPSULE [Lotrel]   2* Generic $5.00$15.00Q:30
/30Days
AMLODIPINE-VALSARTAN 10-160 MG TABLET [Exforge]   3 Preferred Brand $35.00$105.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE-VALSARTAN 10-320 MG TABLET [Exforge]   3 Preferred Brand $35.00$105.00Q:30
/30Days
AMLODIPINE-VALSARTAN 5-160 MG TABLET [Exforge]   3 Preferred Brand $35.00$105.00Q:30
/30Days
AMLODIPINE-VALSARTAN 5-320 MG TABLET [Exforge]   3 Preferred Brand $35.00$105.00Q:30
/30Days
AMMONIUM LACTATE 12% CREAM (g) [Lac-Hydrin]   3 Preferred Brand $35.00$105.00None
AMMONIUM LACTATE 12% LOTION   3 Preferred Brand $35.00$105.00None
AMNESTEEM 10 MG CAPSULE [ZENATANE]   4 Non-Preferred Drug 41%41%P
AMNESTEEM 20 MG CAPSULE [ZENATANE]   4 Non-Preferred Drug 41%41%P
AMNESTEEM 40 MG CAPSULE [ZENATANE]   4 Non-Preferred Drug 41%41%P
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE [Augmentin]   4 Non-Preferred Drug 41%41%None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET [Augmentin]   3 Preferred Brand $35.00$105.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE [Augmentin]   4 Non-Preferred Drug 41%41%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOX-CLAV 200-28.5 MG/5 ML SUS   3 Preferred Brand $35.00$105.00None
AMOX-CLAV 250-62.5 MG/5 ML SUS   4 Non-Preferred Drug 41%41%None
AMOX-CLAV 400-57 MG/5 ML ORAL SUSPENSION [Augmentin]   3 Preferred Brand $35.00$105.00None
AMOX-CLAV 500-125 MG TABLET [Augmentin]   2* Generic $5.00$15.00None
AMOX-CLAV 600-42.9 MG/5 ML SUS   3 Preferred Brand $35.00$105.00None
AMOX-CLAV 875-125 MG TABLET [Augmentin]   2* Generic $5.00$15.00None
AMOX-CLAV ER 1,000-62.5 MG TABLET [Augmentin]   4 Non-Preferred Drug 41%41%None
AMOXAPINE 100MG TABLET   3 Preferred Brand $35.00$105.00None
AMOXAPINE 150MG TABLET   3 Preferred Brand $35.00$105.00None
AMOXAPINE 25MG TABLET   3 Preferred Brand $35.00$105.00None
AMOXAPINE 50MG TABLET   3 Preferred Brand $35.00$105.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN 125 MG/5 ML SUSP   2* Generic $5.00$15.00None
AMOXICILLIN 125MG TABLET CHEW   2* Generic $5.00$15.00None
AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION [Amoxil]   2* Generic $5.00$15.00None
AMOXICILLIN 250 MG CAPSULE [Trimox]   2* Generic $5.00$15.00None
AMOXICILLIN 250 MG TABLET CHEW   2* Generic $5.00$15.00None
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION [Trimox]   2* Generic $5.00$15.00None
AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION [Amoxil]   2* Generic $5.00$15.00None
AMOXICILLIN 500 MG CAPSULE [Trimox]   2* Generic $5.00$15.00None
AMOXICILLIN 500 MG TABLET   2* Generic $5.00$15.00None
AMOXICILLIN 875 MG TABLET   2* Generic $5.00$15.00None
AMPHETAMINE SALT COMBO 12.5MG TABLET   3 Preferred Brand $35.00$105.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPHETAMINE SALT COMBO 15MG TABLET   3 Preferred Brand $35.00$105.00Q:60
/30Days
AMPHETAMINE SALT COMBO 7.5MG TABLET   3 Preferred Brand $35.00$105.00Q:60
/30Days
AMPHETAMINE SALTS 5 MG TABLET   3 Preferred Brand $35.00$105.00Q:60
/30Days
amphotericin b 50mg/10mL 10 mL in 1 VIAL   4 Non-Preferred Drug 41%41%P
AMPICILLIN 1 GM VIAL   4 Non-Preferred Drug 41%41%None
AMPICILLIN 10 GM VIAL   4 Non-Preferred Drug 41%41%None
Ampicillin 1000 MG / Sulbactam 500 MG Injection   4 Non-Preferred Drug 41%41%None
Ampicillin 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS   4 Non-Preferred Drug 41%41%None
AMPICILLIN CAPSULES 500MG 100 BOTTLE   2* Generic $5.00$15.00None
AMPICILLIN-SULBACTAM 15 GM VIAL [Unasyn]   4 Non-Preferred Drug 41%41%None
AMPICILLIN-SULBACTAM 3 GM VIAL [Unasyn]   4 Non-Preferred Drug 41%41%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE   4 Non-Preferred Drug 41%41%None
Anagrelide Hydrochloride 1mg/1 100 CAPSULE BOTTLE   4 Non-Preferred Drug 41%41%None
ANASTROZOLE 1 MG TABLET   2* Generic $5.00$15.00None
ANDRODERM 2 MG/24HR PATCH   4 Non-Preferred Drug 41%41%P Q:30
/30Days
ANDRODERM 4 MG/24HR PATCH   4 Non-Preferred Drug 41%41%P Q:30
/30Days
ANORO ELLIPTA 62.5-25 MCG INH   3 Preferred Brand $35.00$105.00Q:60
/30Days
APOKYN 30 MG/3 ML CARTRIDGE   5 Specialty Tier 26%N/AP Q:60
/30Days
APREPITANT 125 MG CAPSULE [Emend]   4 Non-Preferred Drug 41%41%P
APREPITANT 125-80-80 MG PACK [Emend]   4 Non-Preferred Drug 41%41%P
APREPITANT 40 MG CAPSULE [Emend]   4 Non-Preferred Drug 41%41%P
APREPITANT 80 MG CAPSULE [Emend]   4 Non-Preferred Drug 41%41%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
APRI 0.15-0.03 TABLET   3 Preferred Brand $35.00$105.00None
APTIOM 200 MG TABLET   4 Non-Preferred Drug 41%41%None
APTIOM 400 MG TABLET   4 Non-Preferred Drug 41%41%None
APTIOM 600 MG TABLET   4 Non-Preferred Drug 41%41%None
APTIOM 800 MG TABLET   4 Non-Preferred Drug 41%41%None
APTIVUS 250MG CAPSULE   5 Specialty Tier 26%N/ANone
ARALAST NP 1,000 MG VIAL   5 Specialty Tier 26%N/AP
ARANELLE 7-9-5 TABLET   3 Preferred Brand $35.00$105.00None
ARCALYST 220 MG VIAL   5 Specialty Tier 26%N/AP
ARIPIPRAZOLE 1 MG/ML SOLUTION [Abilify]   5 Specialty Tier 26%N/AQ:900
/30Days
ARIPIPRAZOLE 10 MG TABLET [Abilify]   4 Non-Preferred Drug 41%41%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARIPIPRAZOLE 15 MG TABLET [Abilify]   4 Non-Preferred Drug 41%41%Q:30
/30Days
ARIPIPRAZOLE 2 MG TABLET [Abilify]   4 Non-Preferred Drug 41%41%Q:30
/30Days
ARIPIPRAZOLE 20 MG TABLET [Abilify]   4 Non-Preferred Drug 41%41%Q:30
/30Days
ARIPIPRAZOLE 30 MG TABLET [Abilify]   4 Non-Preferred Drug 41%41%Q:30
/30Days
ARIPIPRAZOLE 5 MG TABLET [Abilify]   4 Non-Preferred Drug 41%41%Q:30
/30Days
ARIPIPRAZOLE ODT 10 MG TABLET RAPDIS [Abilify Discmelt]   5 Specialty Tier 26%N/AQ:60
/30Days
ARIPIPRAZOLE ODT 15 MG TABLET RAPDIS [Abilify Discmelt]   5 Specialty Tier 26%N/AQ:60
/30Days
ARISTADA ER 1064 MG/3.9 ML SYRINGE   4 Non-Preferred Drug 41%41%Q:4
/56Days
ARISTADA ER 441 MG/1.6 ML SYRINGE   4 Non-Preferred Drug 41%41%Q:2
/28Days
ARISTADA ER 662 MG/2.4 ML SYRINGE   4 Non-Preferred Drug 41%41%Q:2
/28Days
ARISTADA ER 882 MG/3.2 ML SYRINGE   4 Non-Preferred Drug 41%41%Q:3
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARISTADA INITIO ER 675 MG/2.4 SUSER SYRINGE   4 Non-Preferred Drug 41%41%None
ARMODAFINIL 150 MG TABLET [Nuvigil]   3 Preferred Brand $35.00$105.00P Q:30
/30Days
ARMODAFINIL 200 MG TABLET [Nuvigil]   3 Preferred Brand $35.00$105.00P Q:30
/30Days
ARMODAFINIL 250 MG TABLET [Nuvigil]   3 Preferred Brand $35.00$105.00P Q:30
/30Days
ARMODAFINIL 50 MG TABLET [Nuvigil]   3 Preferred Brand $35.00$105.00P Q:30
/30Days
ARNUITY ELLIPTA 100 MCG INH   3 Preferred Brand $35.00$105.00Q:30
/30Days
ARNUITY ELLIPTA 200 MCG INH   3 Preferred Brand $35.00$105.00Q:30
/30Days
ARNUITY ELLIPTA 50 MCG INH BLST W/DEV   3 Preferred Brand $35.00$105.00Q:30
/30Days
ASENAPINE 10 MG SUBLIGUAL TABLET [Saphris]   4 Non-Preferred Drug 41%41%Q:60
/30Days
ASENAPINE 2.5 MG SUBLIGUAL TABLET [Saphris]   4 Non-Preferred Drug 41%41%Q:60
/30Days
ASENAPINE 5 MG SUBLIGUAL TABLET [Saphris]   4 Non-Preferred Drug 41%41%Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Aspirin-Diphenhydramine ER 25-200 MG   4 Non-Preferred Drug 41%41%Q:60
/30Days
ATAZANAVIR SULFATE 150 MG CAPSULE [Reyataz]   4 Non-Preferred Drug 41%41%None
ATAZANAVIR SULFATE 200 MG CAPSULE [Reyataz]   4 Non-Preferred Drug 41%41%None
ATAZANAVIR SULFATE 300 MG CAPSULE [Reyataz]   4 Non-Preferred Drug 41%41%None
ATENOLOL 100 MG TABLET [Tenormin]   1* Preferred Generic $0.00$0.00None
ATENOLOL 25 MG TABLET   1* Preferred Generic $0.00$0.00None
ATENOLOL 50 MG TABLET [Tenormin]   1* Preferred Generic $0.00$0.00None
ATENOLOL-CHLORTHALIDONE 100-25   2* Generic $5.00$15.00None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   2* Generic $5.00$15.00None
ATOMOXETINE HCL 10 MG CAPSULE [Strattera]   4 Non-Preferred Drug 41%41%Q:120
/30Days
ATOMOXETINE HCL 100 MG CAPSULE [Strattera]   4 Non-Preferred Drug 41%41%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATOMOXETINE HCL 18 MG CAPSULE [Strattera]   4 Non-Preferred Drug 41%41%Q:120
/30Days
ATOMOXETINE HCL 25 MG CAPSULE [Strattera]   4 Non-Preferred Drug 41%41%Q:120
/30Days
ATOMOXETINE HCL 40 MG CAPSULE [Strattera]   4 Non-Preferred Drug 41%41%Q:60
/30Days
ATOMOXETINE HCL 60 MG CAPSULE [Strattera]   4 Non-Preferred Drug 41%41%Q:30
/30Days
ATOMOXETINE HCL 80 MG CAPSULE [Strattera]   4 Non-Preferred Drug 41%41%Q:30
/30Days
ATORVASTATIN 10 MG TABLET [Lipitor]   1* Preferred Generic $0.00$0.00Q:30
/30Days
ATORVASTATIN 20 MG TABLET [Lipitor]   1* Preferred Generic $0.00$0.00Q:30
/30Days
ATORVASTATIN 40 MG TABLET [Lipitor]   1* Preferred Generic $0.00$0.00Q:30
/30Days
ATORVASTATIN 80 MG TABLET [Lipitor]   1* Preferred Generic $0.00$0.00Q:30
/30Days
ATOVAQUONE 750 MG/5 ML SUSP [Mepron]   5 Specialty Tier 26%N/AP
Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone]   4 Non-Preferred Drug 41%41%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATOVAQUONE-PROGUANIL 62.5-25 [Malarone]   4 Non-Preferred Drug 41%41%None
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC   5 Specialty Tier 26%N/ANone
ATROPINE 1% EYE DROPS   3 Preferred Brand $35.00$105.00None
ATROVENT HFA AER 17MCG   4 Non-Preferred Drug 41%41%Q:26
/30Days
AUBRA EQ-28 TABLET [Vienva]   3 Preferred Brand $35.00$105.00None
AURYXIA 210 MG TABLET   4 Non-Preferred Drug 41%41%P Q:360
/30Days
AUSTEDO 12 MG TABLET   5 Specialty Tier 26%N/AP Q:120
/30Days
AUSTEDO 6 MG TABLET   5 Specialty Tier 26%N/AP Q:60
/30Days
AUSTEDO 9 MG TABLET   5 Specialty Tier 26%N/AP Q:120
/30Days
AVIANE 0.1-0.02 TABLET   3 Preferred Brand $35.00$105.00None
AVITA 0.025% CREAM (g) [Tretin-X]   4 Non-Preferred Drug 41%41%P Q:45
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Avita 0.25mg/g 45 g in 1 TUBE   4 Non-Preferred Drug 41%41%P Q:45
/30Days
AYVAKIT 100 MG TABLET   5 Specialty Tier 26%N/AP Q:30
/30Days
AYVAKIT 200 MG TABLET   5 Specialty Tier 26%N/AP Q:30
/30Days
AYVAKIT 300 MG TABLET   5 Specialty Tier 26%N/AP Q:30
/30Days
AZASITE 1% EYE DROPS   4 Non-Preferred Drug 41%41%None
AZATHIOPRINE 50 MG TABLET [Imuran]   3 Preferred Brand $35.00$105.00P
AZELASTINE 0.15% NASAL SPRAY   3 Preferred Brand $35.00$105.00Q:30
/25Days
AZELASTINE 137 MCG NASAL SPRAY   3 Preferred Brand $35.00$105.00Q:30
/25Days
AZELASTINE HCL 0.05% EYE DROPS [Optivar]   3 Preferred Brand $35.00$105.00None
AZITHROMYCIN 1 GM POWDER PACKET   3 Preferred Brand $35.00$105.00None
AZITHROMYCIN 100 MG/5 ML ORAL SUSPENSION [Zithromax]   3 Preferred Brand $35.00$105.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [Zithromax]   3 Preferred Brand $35.00$105.00None
AZITHROMYCIN 250 MG TABLET   2* Generic $5.00$15.00None
AZITHROMYCIN 250 MG TABLET [Zithromax Z-Pak]   2* Generic $5.00$15.00None
AZITHROMYCIN 500 MG TABLET   2* Generic $5.00$15.00None
AZITHROMYCIN 500 MG TABLET [Zithromax Tri-Pak]   2* Generic $5.00$15.00None
AZITHROMYCIN 600 MG TABLET [Zithromax Z-Pak]   2* Generic $5.00$15.00None
AZITHROMYCIN I.V. 500 MG VIAL [Zithromax]   4 Non-Preferred Drug 41%41%None
AZOPT 1% EYE DROPS   4 Non-Preferred Drug 41%41%None
AZTREONAM FOR INJECTION   4 Non-Preferred Drug 41%41%None

Chart Legend:

Below are a few notes to help you understand the above 2021 Medicare Part D SilverScript 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 $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.