Q1Medicare.com 2021 Medicare Part D or Medicare Advantage Plan Formulary Browser

2021 Medicare Part D Plan Formulary Information
SilverScript Plus (PDP) (S5601-023-0) Benefit Details
The SilverScript Plus (PDP) (S5601-023-0) Formulary Drugs Starting with the Letter B in CMS PDP Region 11 which includes: FL Plan Monthly Premium: $62.70 Deductible: $0 Qualifies for LIS: No
Drugs Starting with Letter B Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter B Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Bacitracin 500 unit/gm Eye Ointment	3	Preferred Brand	$47.00	$120.00	None
BACITRACIN/POLYMYXIN B OINT 500UNT/10000UNT	2	Generic	$2.00	$0.00	None
BACLOFEN 10 MG TABLET	3	Preferred Brand	$47.00	$120.00	None
BACLOFEN 20 MG TABLET [Lioresal]	3	Preferred Brand	$47.00	$120.00	None
BALSALAZIDE DISODIUM 750 MG CAPSULE [Colazal]	3	Preferred Brand	$47.00	$120.00	None
BALVERSA 3 MG TABLET	5	Specialty Tier	33%	N/A	P Q:84 /28Days
BALVERSA 4 MG TABLET	5	Specialty Tier	33%	N/A	P Q:56 /28Days
BALVERSA 5 MG TABLET	5	Specialty Tier	33%	N/A	P Q:28 /28Days
Balziva 6 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK	3	Preferred Brand	$47.00	$120.00	None
Banzel 200mg/1	4	Non-Preferred Drug	49%	49%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BANZEL 400MG TABLET	4	Non-Preferred Drug	49%	49%	P
Banzel 40mg/mL	4	Non-Preferred Drug	49%	49%	P
BARACLUDE 0.05mg/mL 1 BOTTLE per CARTON / 210 mL in 1 BOTTLE	5	Specialty Tier	33%	N/A	None
BCG VACCINE 50mg/1 1 VIAL per CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL	4	Non-Preferred Drug	49%	49%	None
BELSOMRA 10 MG TABLET	4	Non-Preferred Drug	49%	49%	Q:30 /30Days
BELSOMRA 15 MG TABLET	4	Non-Preferred Drug	49%	49%	Q:30 /30Days
BELSOMRA 20 MG TABLET	4	Non-Preferred Drug	49%	49%	Q:30 /30Days
BELSOMRA 5 MG TABLET	4	Non-Preferred Drug	49%	49%	Q:30 /30Days
BENAZEPRIL HCL 10 MG TABLET	1	Preferred Generic	$0.00	$0.00	None
BENAZEPRIL HCL 20 MG TABLET	1	Preferred Generic	$0.00	$0.00	None
BENAZEPRIL HCL 40 MG TABLET	1	Preferred Generic	$0.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BENAZEPRIL HCL 5 MG TABLET	1	Preferred Generic	$0.00	$0.00	None
BENAZEPRIL-HCTZ 10-12.5 MG TABLET [Lotensin HCT]	3	Preferred Brand	$47.00	$120.00	None
BENAZEPRIL-HCTZ 20-12.5 MG TABLET [Lotensin HCT]	3	Preferred Brand	$47.00	$120.00	None
BENAZEPRIL-HCTZ 20-25 MG TABLET [Lotensin HCT]	3	Preferred Brand	$47.00	$120.00	None
BENAZEPRIL-HCTZ 5-6.25 MG TABLET [Lotensin HCT]	3	Preferred Brand	$47.00	$120.00	None
BENLYSTA 200 MG/ML AUTOINJECT	5	Specialty Tier	33%	N/A	P
BENLYSTA 200 MG/ML SYRINGE	5	Specialty Tier	33%	N/A	P
BENZTROPINE MES 0.5 MG TABLET [Cogentin]	3	Preferred Brand	$47.00	$120.00	P
BENZTROPINE MES 1 MG TABLET [Cogentin]	3	Preferred Brand	$47.00	$120.00	P
BENZTROPINE MES 2 MG TABLET [Cogentin]	3	Preferred Brand	$47.00	$120.00	P
BEPREVE 1.5% EYE DROPS	3	Preferred Brand	$47.00	$120.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BESIVANCE BESIFLOACIN OPTHALMIC SUSPENSION 0.6% 5 ML BOTDR	3	Preferred Brand	$47.00	$120.00	None
Betamethasone Dipropionate 0.64mg/g / 45 g TUBE	3	Preferred Brand	$47.00	$120.00	None
BETAMETHASONE DP 0.05% LOTION	3	Preferred Brand	$47.00	$120.00	None
BETAMETHASONE DP 0.05% OINTMENT [Maxivate]	4	Non-Preferred Drug	49%	49%	None
BETAMETHASONE DP AUG 0.05% CREAM (g) [RRB Pak]	3	Preferred Brand	$47.00	$120.00	None
BETAMETHASONE DP AUG 0.05% GEL	4	Non-Preferred Drug	49%	49%	None
BETAMETHASONE DP AUG 0.05% LOTION	4	Non-Preferred Drug	49%	49%	None
BETAMETHASONE DP AUG 0.05% OINTMENT [Diprolene]	4	Non-Preferred Drug	49%	49%	None
BETAMETHASONE VA 0.1% CREAM (G) [Valisone]	3	Preferred Brand	$47.00	$120.00	None
BETAMETHASONE VALER 0.1% LOTION [Valisone]	3	Preferred Brand	$47.00	$120.00	None
BETAMETHASONE VALER 0.1% OINTMENT [Valisone]	3	Preferred Brand	$47.00	$120.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BETASERON 0.3 MG KIT	5	Specialty Tier	33%	N/A	P Q:14 /28Days
BETAXOLOL HCL 0.5% EYE DROPS	3	Preferred Brand	$47.00	$120.00	None
BETHANECHOL 10 MG TABLET	3	Preferred Brand	$47.00	$120.00	None
BETHANECHOL 25 MG TABLET	3	Preferred Brand	$47.00	$120.00	None
BETHANECHOL 5 MG TABLET	3	Preferred Brand	$47.00	$120.00	None
BETHANECHOL 50 MG TABLET	3	Preferred Brand	$47.00	$120.00	None
BETOPTIC S OPHTHALMIC SUSPENSION 0.25% 10 ML BOT	4	Non-Preferred Drug	49%	49%	None
BEVESPI AEROSPHERE INHALER	3	Preferred Brand	$47.00	$120.00	Q:11 /30Days
BEXAROTENE 75 MG CAPSULE [Targretin]	5	Specialty Tier	33%	N/A	P
BEXSERO PREFILLED SYRINGE	4	Non-Preferred Drug	49%	49%	None
BICALUTAMIDE 50 MG TABLET	3	Preferred Brand	$47.00	$120.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BICILL LA PFS 600MU 1ML PED	4	Non-Preferred Drug	49%	49%	None
BICILLIN LA PFS 1200MU 2ML	4	Non-Preferred Drug	49%	49%	None
BICILLIN LA. 600000UNIT/ML 1ML	4	Non-Preferred Drug	49%	49%	None
BIDIL TABLET	4	Non-Preferred Drug	49%	49%	None
BIKTARVY 50-200-25 MG TABLET	5	Specialty Tier	33%	N/A	None
BISOPROLOL FUMARATE 10 MG TABLET	2	Generic	$2.00	$0.00	None
BISOPROLOL FUMARATE 5 MG TABLET	2	Generic	$2.00	$0.00	None
BISOPROLOL-HCTZ 10-6.25 MG TABLET	2	Generic	$2.00	$0.00	None
BISOPROLOL-HCTZ 2.5-6.25 MG TABLET	2	Generic	$2.00	$0.00	None
BISOPROLOL-HCTZ 5-6.25 MG TABLET	2	Generic	$2.00	$0.00	None
BIVIGAM 10% VIAL [Panzyga]	5	Specialty Tier	33%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BLEPHAMIDE 10-0.2% EYE OINTMENT	4	Non-Preferred Drug	49%	49%	None
BLISOVI FE 1.5-30 TABLET [Microgestin Fe 1.5/30]	3	Preferred Brand	$47.00	$120.00	None
BOOSTRIX TDAP VACCINE SYRINGE	3	Preferred Brand	$47.00	$120.00	None
BOOSTRIX TDAP VACCINE VIAL	3	Preferred Brand	$47.00	$120.00	None
BOSULIF 100 MG TABLET	5	Specialty Tier	33%	N/A	P
BOSULIF 400 MG TABLET	5	Specialty Tier	33%	N/A	P
BOSULIF 500 MG TABLET	5	Specialty Tier	33%	N/A	P
BRAFTOVI 75 MG CAPSULE	5	Specialty Tier	33%	N/A	P
BREO ELLIPTA 100-25 MCG INH	3	Preferred Brand	$47.00	$120.00	Q:60 /30Days
BREO ELLIPTA 200-25 MCG INH	3	Preferred Brand	$47.00	$120.00	Q:60 /30Days
BRIELLYN TABLET	3	Preferred Brand	$47.00	$120.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BRILINTA 60 MG TABLET	4	Non-Preferred Drug	49%	49%	None
BRILINTA 90mg/1 60 TABLET BOTTLE	4	Non-Preferred Drug	49%	49%	None
BRIMONIDINE 0.2% EYE DROPS [Alphagan]	2	Generic	$2.00	$0.00	None
BRIVIACT 10 MG TABLET	4	Non-Preferred Drug	49%	49%	P
BRIVIACT 10 MG/ML ORAL SOLUTION	4	Non-Preferred Drug	49%	49%	P
BRIVIACT 100 MG TABLET	4	Non-Preferred Drug	49%	49%	P
BRIVIACT 25 MG TABLET	4	Non-Preferred Drug	49%	49%	P
BRIVIACT 50 MG TABLET	4	Non-Preferred Drug	49%	49%	P
BRIVIACT 75 MG TABLET	4	Non-Preferred Drug	49%	49%	P
BROMOCRIPTINE 2.5 MG TABLET [Parlodel]	4	Non-Preferred Drug	49%	49%	None
BROMOCRIPTINE 5 MG CAPSULE [Parlodel]	4	Non-Preferred Drug	49%	49%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BROMSITE 0.075% EYE DROPS	4	Non-Preferred Drug	49%	49%	None
BRUKINSA 80 MG CAPSULE	5	Specialty Tier	33%	N/A	P Q:120 /30Days
BUDESONIDE 0.25 MG/2 ML SUSP AMPUL-NEB [Pulmicort]	4	Non-Preferred Drug	49%	49%	P
BUDESONIDE 0.5 MG/2 ML SUSP AMPUL-NEB [Pulmicort]	4	Non-Preferred Drug	49%	49%	P
BUDESONIDE EC 3 MG CAPSULE DR - ER [Entocort EC]	4	Non-Preferred Drug	49%	49%	None
BUDESONIDE ER 9 MG TABLETDR - ER [UCERIS]	4	Non-Preferred Drug	49%	49%	None
BUMETANIDE 0.5 MG TABLET [Bumex]	3	Preferred Brand	$47.00	$120.00	None
BUMETANIDE 1 MG TABLET [Bumex]	3	Preferred Brand	$47.00	$120.00	None
BUMETANIDE 1 MG/4 ML VIAL	4	Non-Preferred Drug	49%	49%	None
BUMETANIDE 2 MG TABLET [Bumex]	3	Preferred Brand	$47.00	$120.00	None
BUPRENORPHIN-NALOXON 8-2 MG SL SUSLIGUAL TABLET [Suboxone]	2	Generic	$2.00	$0.00	Q:90 /30Days
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	$47.00	$120.00	P Q:90 /30Days
BUPRENORPHINE 8 MG TABLET SUSLIGUAL [Subutex]	3	Preferred Brand	$47.00	$120.00	P Q:90 /30Days
BUPRENORPHN-NALOXN 2-0.5 MG TABLET SUSLIGUAL [Suboxone]	2	Generic	$2.00	$0.00	Q:90 /30Days
BUPROPION HCL 100 MG TABLET	3	Preferred Brand	$47.00	$120.00	Q:180 /30Days
BUPROPION HCL 75 MG TABLET	3	Preferred Brand	$47.00	$120.00	Q:180 /30Days
BUPROPION HCL SR 100 MG TABLET SR 12H [Wellbutrin SR]	2	Generic	$2.00	$0.00	Q:60 /30Days
BUPROPION HCL SR 150 MG TABLET	3	Preferred Brand	$47.00	$120.00	Q:60 /30Days
BUPROPION HCL SR 150 MG TABLET SR 12H [Wellbutrin SR]	2	Generic	$2.00	$0.00	Q:60 /30Days
BUPROPION HCL SR 200 MG TABLET	2	Generic	$2.00	$0.00	Q:60 /30Days
BUPROPION HCL XL 150 MG TABLET	3	Preferred Brand	$47.00	$120.00	Q:30 /30Days
BUPROPION HCL XL 300 MG TABLET	3	Preferred Brand	$47.00	$120.00	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BUSPIRONE HCL 15 MG TABLET	2	Generic	$2.00	$0.00	None
BUSPIRONE HCL 30 MG TABLET	3	Preferred Brand	$47.00	$120.00	None
BUSPIRONE HCL 5 MG TABLET	2	Generic	$2.00	$0.00	None
BUSPIRONE HCL 7.5 MG TABLET	3	Preferred Brand	$47.00	$120.00	None
BUSPIRONE HYDROCHLORIDE 10 MG TABLET	2	Generic	$2.00	$0.00	None
Butrans 10ug/h	3	Preferred Brand	$47.00	$120.00	P Q:4 /28Days
BUTRANS 15 MCG/HR PATCH	3	Preferred Brand	$47.00	$120.00	P Q:4 /28Days
Butrans 20ug/h	3	Preferred Brand	$47.00	$120.00	P Q:4 /28Days
Butrans 5ug/h	3	Preferred Brand	$47.00	$120.00	P Q:4 /28Days
BUTRANS 7.5 MCG/HR PATCH	3	Preferred Brand	$47.00	$120.00	P Q:4 /28Days
BYDUREON BCISE 2 MG AUTOINJECT	3	Preferred Brand	$47.00	$120.00	Q:3 /28Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BYETTA 10 MCG DOSE PEN INJ	4	Non-Preferred Drug	49%	49%	Q:2 /30Days
BYETTA 5 MCG DOSE PEN INJ	4	Non-Preferred Drug	49%	49%	Q:1 /30Days
Bystolic 10mg/1 30 TABLET BOTTLE	4	Non-Preferred Drug	49%	49%	Q:30 /30Days
Bystolic 2.5mg/1 30 TABLET BOTTLE	4	Non-Preferred Drug	49%	49%	Q:30 /30Days
BYSTOLIC 20 MG TABLET	4	Non-Preferred Drug	49%	49%	Q:60 /30Days
Bystolic 5mg 30 TABLET BOTTLE	4	Non-Preferred Drug	49%	49%	Q:30 /30Days

Chart Legend:

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