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Express Scripts Medicare - Choice (PDP) (S5660-181-0)
Tier 1 (168)
Tier 2 (847)
Tier 3 (531)
Tier 4 (1141)
Tier 5 (525)
Tier 6 (70)
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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2021 Medicare Part D Plan Formulary Information
Express Scripts Medicare - Choice (PDP) (S5660-181-0)
Benefit Details           
This plan covers select insulin pay $11 copay.
See individual insulin cost-sharing below.
The Express Scripts Medicare - Choice (PDP) (S5660-181-0)
Formulary Drugs Starting with the Letter G

in CMS PDP Region 11 which includes: FL
Plan Monthly Premium: $84.30 Deductible: $100 Qualifies for LIS: No
Drugs Starting with Letter G

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
GABAPENTIN 100 MG CAPSULE [Neurontin]   2* Generic $7.00$4.00Q:270
/30Days
GABAPENTIN 250 MG/5 ML SOLUTION [Neurontin]   4 Non-Preferred Drug 50%50%Q:2160
/30Days
GABAPENTIN 300 MG CAPSULE [Neurontin]   2* Generic $7.00$4.00Q:360
/30Days
GABAPENTIN 400 MG CAPSULE [Neurontin]   2* Generic $7.00$4.00Q:270
/30Days
GABAPENTIN 600 MG TABLET   2* Generic $7.00$4.00Q:180
/30Days
GABAPENTIN 800 MG TABLET   2* Generic $7.00$4.00Q:120
/30Days
GALANTAMINE 4 MG/ML ORAL SOLUTION   4 Non-Preferred Drug 50%50%Q:200
/30Days
GALANTAMINE ER 16 MG CAPSULE 24H PEL [Reminyl]   4 Non-Preferred Drug 50%50%Q:30
/30Days
GALANTAMINE ER 24 MG CAPSULE 24H PEL [Reminyl]   4 Non-Preferred Drug 50%50%Q:30
/30Days
GALANTAMINE ER 8 MG CAPSULE 24H PEL [Reminyl]   4 Non-Preferred Drug 50%50%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
GALANTAMINE HBR 12 MG TABLET [Reminyl]   4 Non-Preferred Drug 50%50%Q:60
/30Days
GALANTAMINE HBR 4 MG TABLET [Reminyl]   4 Non-Preferred Drug 50%50%Q:60
/30Days
GALANTAMINE HBR 8 MG TABLET [Reminyl]   4 Non-Preferred Drug 50%50%Q:60
/30Days
Gamunex-C 10g/100mL 10 mL in 1 VIAL, GLASS   5 Specialty Tier 31%N/AP
GARDASIL 9 SYRINGE   4 Non-Preferred Drug 50%50%None
GARDASIL 9 VIAL   4 Non-Preferred Drug 50%50%None
GATTEX 5 MG 30-VIAL KIT   5 Specialty Tier 31%N/AP
GAVILYTE-C SOLUTION   2* Generic $7.00$4.00None
GAVILYTE-N SOLUTION   2* Generic $7.00$4.00None
GAVRETO 100 MG CAPSULE   4 Non-Preferred Drug 50%50%P Q:120
/30Days
GEMFIBROZIL 600 MG TABLET   1* Preferred Generic $2.00$0.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
GENERLAC 10 GM/15 ML SOLUTION   2* Generic $7.00$4.00None
GENGRAF 100 MG CAPSULE   4 Non-Preferred Drug 50%50%P
GENGRAF 100MG/ML SOLUTION   4 Non-Preferred Drug 50%50%P
GENGRAF 25 MG CAPSULE   4 Non-Preferred Drug 50%50%P
GENOTROPIN 13.8MG CARTRIDGE   5 Specialty Tier 31%N/AP
GENOTROPIN 5 MG CARTRIDGE   5 Specialty Tier 31%N/AP
GENOTROPIN MINIQUICK 0.2MG   5 Specialty Tier 31%N/AP
GENOTROPIN MINIQUICK 0.4MG   5 Specialty Tier 31%N/AP
GENOTROPIN MINIQUICK 0.6MG   5 Specialty Tier 31%N/AP
GENOTROPIN MINIQUICK 0.8MG   5 Specialty Tier 31%N/AP
GENOTROPIN MINIQUICK 1.2MG   5 Specialty Tier 31%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
GENOTROPIN MINIQUICK 1.4MG   5 Specialty Tier 31%N/AP
GENOTROPIN MINIQUICK 1.6MG   5 Specialty Tier 31%N/AP
GENOTROPIN MINIQUICK 1.8MG   5 Specialty Tier 31%N/AP
GENOTROPIN MINIQUICK 1MG   5 Specialty Tier 31%N/AP
GENOTROPIN MINIQUICK 2MG   5 Specialty Tier 31%N/AP
GENTAK 3MG/GM EYE OINTMENT   2* Generic $7.00$4.00None
GENTAMICIN 3 MG/ML EYE DROPS   3* Preferred Brand $42.00$126.00None
Gentamicin Sulfate 40mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 2 mL in 1 VIAL, SINGLE-DOSE   4 Non-Preferred Drug 50%50%P
GENTAMICIN SULFATE CREAM USP 0.1% 15GM TUBE   4 Non-Preferred Drug 50%50%None
Gentamicin Sulfate in Sodium Chloride 60mg/50mL 50 mL in 1 BAG   4 Non-Preferred Drug 50%50%P
GENTAMICIN SULFATE OINTMENT USP 0.1% 15GM TUBE   3* Preferred Brand $42.00$126.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
GENVOYA TABLET   5 Specialty Tier 31%N/AQ:30
/30Days
GILOTRIF 20 MG TABLET   5 Specialty Tier 31%N/AP Q:30
/30Days
GILOTRIF 30 MG TABLET   5 Specialty Tier 31%N/AP Q:30
/30Days
GILOTRIF 40 MG TABLET   5 Specialty Tier 31%N/AP Q:30
/30Days
GLATIRAMER 20 MG/ML SYRINGE [Glatopa]   5 Specialty Tier 31%N/AP Q:30
/30Days
GLATIRAMER 40 MG/ML SYRINGE [Copaxone]   5 Specialty Tier 31%N/AP Q:12
/28Days
Glatopa 20 mg/ml syringe   5 Specialty Tier 31%N/AP Q:30
/30Days
GLATOPA 40 MG/ML SYRINGE   5 Specialty Tier 31%N/AP Q:12
/28Days
GLIMEPIRIDE 1 MG TABLET   1* Preferred Generic $2.00$0.00Q:240
/30Days
GLIMEPIRIDE 2 MG TABLET   1* Preferred Generic $2.00$0.00Q:120
/30Days
GLIMEPIRIDE 4 MG TABLET   1* Preferred Generic $2.00$0.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
GLIPIZIDE 10 MG TABLET   1* Preferred Generic $2.00$0.00Q:120
/30Days
GLIPIZIDE 5 MG TABLET   1* Preferred Generic $2.00$0.00Q:240
/30Days
GLIPIZIDE ER 10 MG TABLET ER 24 [Glucotrol XL]   2* Generic $7.00$4.00Q:60
/30Days
GLIPIZIDE ER 2.5MG TABLET SR OSMOTIC PUSH 24HR   2* Generic $7.00$4.00Q:240
/30Days
GLIPIZIDE ER 5 MG TABLET ER 24 [Glucotrol XL]   2* Generic $7.00$4.00Q:120
/30Days
GLIPIZIDE-METFORMIN 2.5-250 MG TABLET [Metaglip]   1* Preferred Generic $2.00$0.00Q:240
/30Days
GLIPIZIDE-METFORMIN 2.5-500 MG TABLET [Metaglip]   1* Preferred Generic $2.00$0.00Q:120
/30Days
GLIPIZIDE-METFORMIN 5-500 MG TABLET [Metaglip]   1* Preferred Generic $2.00$0.00Q:120
/30Days
GLUCAGEN 1MG HYPOKIT   3* Preferred Brand $42.00$126.00None
GLUCAGON 1 MG EMERGENCY KIT VIAL   3* Preferred Brand $42.00$126.00None
Glucose 50 MG/ML / Potassium Chloride 0.02 MEQ/ML / Sodium Chloride 0.154 MEQ/ML Injectable Solution   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
GLYCOPYRROLATE 1 MG TABLET [Robinul]   4 Non-Preferred Drug 50%50%None
GLYCOPYRROLATE TABLET 2MG (100 CT)   4 Non-Preferred Drug 50%50%None
GLYXAMBI 10 MG-5 MG TABLET   4 Non-Preferred Drug 50%50%Q:30
/30Days
GLYXAMBI 25 MG-5 MG TABLET   4 Non-Preferred Drug 50%50%Q:30
/30Days
GRANISETRON HCL 1 MG TABLET [Kytril]   4 Non-Preferred Drug 50%50%P Q:60
/30Days
GRISEOFULVIN 125 MG/5 ML ORAL SUSPENSION [Grifulvin V]   4 Non-Preferred Drug 50%50%None
GRISEOFULVIN MICRO 500 MG TABLET   4 Non-Preferred Drug 50%50%None
GRISEOFULVIN ULTRA 125 MG TABLET [Gris-Peg]   4 Non-Preferred Drug 50%50%None
GRISEOFULVIN ULTRA 250 MG TABLET [Gris-Peg]   4 Non-Preferred Drug 50%50%None
GVOKE 0.5 MG/0.1 ML SYRINGE   3* Preferred Brand $42.00$126.00None
GVOKE 1 MG/0.2 ML SYRINGE   3* Preferred Brand $42.00$126.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
GVOKE HYPOPEN 2-PK 1 MG/0.2 ML AUTO INJECTOR   3* Preferred Brand $42.00$126.00None
GVOKE HYPOPEN 2PK 0.5MG/0.1 ML AUTO INJECTOR   3* Preferred Brand $42.00$126.00None

Chart Legend:

Below are a few notes to help you understand the above 2021 Medicare Part D Express Scripts Medicare - 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.