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SilverScript Choice (PDP) (S5601-050-0)
Tier 1 (95)
Tier 2 (440)
Tier 3 (1061)
Tier 4 (911)
Tier 5 (602)
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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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) (S5601-050-0)
Benefit Details           
The SilverScript Choice (PDP) (S5601-050-0)
Formulary Drugs Starting with the Letter X

in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY
Plan Monthly Premium: $33.90 Deductible: $240 Qualifies for LIS: Yes
Drugs Starting with Letter X

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Xalkori 200mg/1 60 CAPSULE BOTTLE   5 Specialty Tier 28%N/AP
Xalkori 250mg/1 60 CAPSULE BOTTLE   5 Specialty Tier 28%N/AP
XARELTO 10 MG TABLET   3 Preferred Brand $35.00$105.00Q:30
/30Days
XARELTO 15 MG TABLET   3 Preferred Brand $35.00$105.00Q:30
/30Days
XARELTO 2.5 MG TABLET   3 Preferred Brand $35.00$105.00Q:60
/30Days
XARELTO 20 MG TABLET   3 Preferred Brand $35.00$105.00Q:30
/30Days
XARELTO STARTER PACK   3 Preferred Brand $35.00$105.00Q:51
/30Days
XATMEP 2.5 MG/ML ORAL SOLUTION   4 Non-Preferred Drug 46%46%None
XCOPRI 100 MG TABLET   4 Non-Preferred Drug 46%46%None
XCOPRI 12.5-25 MG TITRATION PK TABLET DS PK   4 Non-Preferred Drug 46%46%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
XCOPRI 150 MG TABLET   4 Non-Preferred Drug 46%46%None
XCOPRI 150-200 MG TITRATION PK TABLET DS PK   4 Non-Preferred Drug 46%46%None
XCOPRI 200 MG TABLET   4 Non-Preferred Drug 46%46%None
XCOPRI 250 MG DAILY DOSE PACK TABLET   4 Non-Preferred Drug 46%46%Q:56
/28Days
XCOPRI 250 MG DAILY DOSE PACK TABLET   4 Non-Preferred Drug 46%46%None
XCOPRI 350 MG DAILY DOSE PACK TABLET   4 Non-Preferred Drug 46%46%None
XCOPRI 50 MG TABLET   4 Non-Preferred Drug 46%46%None
XCOPRI 50-100 MG TITRATION PAK TABLET DS PK   4 Non-Preferred Drug 46%46%None
XELJANZ 1 MG/ML SOLUTION   5 Specialty Tier 28%N/AP Q:240
/24Days
XELJANZ 10 MG TABLET   5 Specialty Tier 28%N/AP Q:60
/30Days
XELJANZ 5 MG TABLET   5 Specialty Tier 28%N/AP Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
XELJANZ XR 11 MG TABLET   5 Specialty Tier 28%N/AP Q:30
/30Days
XELJANZ XR 22 MG TABLET ER 24H   5 Specialty Tier 28%N/AP Q:30
/30Days
XGEVA 120mg/1.7mL 1 VIAL, SINGLE-USE per CARTON / 1.7 mL in 1 VIAL, SINGLE-USE   5 Specialty Tier 28%N/AP
XIFAXAN 550 MG TABLET   5 Specialty Tier 28%N/AP
XIGDUO XR 10 MG-1,000 MG TAB   3 Preferred Brand $35.00$105.00Q:30
/30Days
XIGDUO XR 10 MG-500 MG TABLET   3 Preferred Brand $35.00$105.00Q:30
/30Days
XIGDUO XR 2.5 MG-1,000 MG TABLET   3 Preferred Brand $35.00$105.00Q:60
/30Days
XIGDUO XR 5 MG-1,000 MG TABLET   3 Preferred Brand $35.00$105.00Q:60
/30Days
XIGDUO XR 5 MG-500 MG TABLET   3 Preferred Brand $35.00$105.00Q:60
/30Days
XOLAIR 150 MG/ML SYRINGE   5 Specialty Tier 28%N/AP
XOLAIR 150MG VIAL   5 Specialty Tier 28%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
XOLAIR 75 MG/0.5 ML SYRINGE   5 Specialty Tier 28%N/AP
XOSPATA 40 MG TABLET   5 Specialty Tier 28%N/AP
XPOVIO 100 MG ONCE WEEKLY DOSE TABLET   5 Specialty Tier 28%N/AP Q:8
/28Days
XPOVIO 100 MG ONCE WEEKLY DOSE TABLET   5 Specialty Tier 28%N/AP Q:20
/28Days
XPOVIO 40 MG ONCE WEEKLY DOSE TABLET   5 Specialty Tier 28%N/AP Q:4
/28Days
XPOVIO 40 MG ONCE WEEKLY DOSE TABLET   5 Specialty Tier 28%N/AP Q:8
/28Days
XPOVIO 40 MG TWICE WEEKLY DOSE TABLET   5 Specialty Tier 28%N/AP Q:16
/28Days
XPOVIO 40 MG TWICE WEEKLY DOSE TABLET   5 Specialty Tier 28%N/AP Q:8
/28Days
XPOVIO 60 MG ONCE WEEKLY DOSE TABLET   5 Specialty Tier 28%N/AP Q:4
/28Days
XPOVIO 60 MG ONCE WEEKLY DOSE TABLET   5 Specialty Tier 28%N/AP Q:12
/28Days
XPOVIO 60 MG TWICE WEEKLY DOSE TABLET   5 Specialty Tier 28%N/AP Q:24
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
XPOVIO 80 MG ONCE WEEKLY DOSE TABLET   5 Specialty Tier 28%N/AP Q:16
/28Days
XPOVIO 80 MG ONCE WEEKLY DOSE TABLET   5 Specialty Tier 28%N/AP Q:8
/28Days
XPOVIO 80 MG TWICE WEEKLY DOSE TABLET   5 Specialty Tier 28%N/AP Q:32
/28Days
XTANDI 40 MG CAPSULE   5 Specialty Tier 28%N/AP
XTANDI 40 MG TABLET   5 Specialty Tier 28%N/AP
XTANDI 80 MG TABLET   5 Specialty Tier 28%N/AP
Xulane Patch   4 Non-Preferred Drug 46%46%None
XULTOPHY 100 UNIT-3.6MG/ML PEN   3 Preferred Brand $35.00$105.00Q:15
/30Days
XYREM 500MG/ML ORAL SOLUTION   5 Specialty Tier 28%N/AP Q:540
/30Days

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.