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2016 Medicare Part D and Medicare Advantage Plan Formulary Browser
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.
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SilverScript Choice (PDP) (S5601-062-0)
Tier 1 (102)
Tier 2 (451)
Tier 3 (968)
Tier 4 (1111)
Tier 5 (496)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
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Has Quantity Limits:
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  *required
 
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 
2016 Medicare Part D Plan Formulary Information
SilverScript Choice (PDP) (S5601-062-0)
Benefit Details           
The SilverScript Choice (PDP) (S5601-062-0)
Formulary Drugs Starting with the Letter C
in CMS PDP Region 31 which includes: ID UT
Plan Monthly Premium: $23.80 Deductible: $0 Qualifies for LIS: Yes
Drugs Starting with Letter C

Drug Name		 Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order
CABERGOLINE 0.5 MG TABLET   4 Non-Preferred Brand 42%42%None
CABOMETYX 20 MG TABLET   5 Specialty Tier 33%N/AP
CABOMETYX 40 MG TABLET   5 Specialty Tier 33%N/AP
CABOMETYX 60 MG TABLET   5 Specialty Tier 33%N/AP
CALCIPOTRIENE 0.005% CREAM   4 Non-Preferred Brand 42%42%None
Calcipotriene 50ug/g 60 g per CARTON   4 Non-Preferred Brand 42%42%None
CALCIPOTRIENE TOPICAL SOLUTION   4 Non-Preferred Brand 42%42%None
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY   3 Preferred Brand $45.00$112.50None
CALCITRIOL 0.25MCG CAPSULE   3 Preferred Brand $45.00$112.50P
CALCITRIOL 0.5MCG CAPSULE   3 Preferred Brand $45.00$112.50P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Calcitriol 1 mcg/ml ampul   4 Non-Preferred Brand 42%42%P
CALCITRIOL 1MCG/ML SOLUTION ORAL   4 Non-Preferred Brand 42%42%P
CALCIUM ACETATE CAPSULE 667 MG   4 Non-Preferred Brand 42%42%None
CAMILA 0.35MG TABLET   3 Preferred Brand $45.00$112.50None
CANASA RECTAL SUPPOSITORIES 1000MG 30 BOX   4 Non-Preferred Brand 42%42%None
CANCIDAS IV 50MG VIAL   5 Specialty Tier 33%N/ANone
CANCIDAS IV 70MG VIAL   5 Specialty Tier 33%N/ANone
CAPASTAT SULFATE 1g/1 1 INJECTION, POWDER, FOR SOLUTION per CARTON   4 Non-Preferred Brand 42%42%None
CAPRELSA 100mg/1 30 TABLET BOTTLE   5 Specialty Tier 33%N/AP
CAPRELSA 300mg/1 30 TABLET BOTTLE   5 Specialty Tier 33%N/AP
CAPTOPRIL 100MG TABLET   2 Generic $13.00$32.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CAPTOPRIL 12.5MG TABLET   2 Generic $13.00$32.50None
CAPTOPRIL 25MG TABLET   2 Generic $13.00$32.50None
CAPTOPRIL 50MG TABLET   2 Generic $13.00$32.50None
Captopril and Hydrochlorothiazide 25; 15mg 100 TABLET BOTTLE   2 Generic $13.00$32.50None
Captopril and Hydrochlorothiazide 25; 25mg 100 TABLET BOTTLE   2 Generic $13.00$32.50None
Captopril and Hydrochlorothiazide 50; 15mg 100 TABLET BOTTLE   2 Generic $13.00$32.50None
Captopril and Hydrochlorothiazide 50; 25mg 100 TABLET BOTTLE   2 Generic $13.00$32.50None
Carbaglu 200mg/1 5 TABLET BOTTLE   5 Specialty Tier 33%N/AP
CARBAMAZEPINE 100 MG/5 ML SUSP   4 Non-Preferred Brand 42%42%None
Carbamazepine 100mg, CHEWABLE 100 TABLET BOTTLE   3 Preferred Brand $45.00$112.50None
Carbamazepine 100mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE   4 Non-Preferred Brand 42%42%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Carbamazepine 200mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE   4 Non-Preferred Brand 42%42%None
Carbamazepine 300mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE   4 Non-Preferred Brand 42%42%None
CARBAMAZEPINE ER 100 MG TABLET   4 Non-Preferred Brand 42%42%None
CARBAMAZEPINE TABLET USP 200MG (1000 CT)   3 Preferred Brand $45.00$112.50None
CARBAMAZEPINE XR 200 MG TABLET   4 Non-Preferred Brand 42%42%None
CARBAMAZEPINE XR 400 MG TABLET   4 Non-Preferred Brand 42%42%None
CARBIDOPA AND LEVEDOPA ORALLY DISINTEGRATING TABLETS 10;100MG;MG 100 BOT   3 Preferred Brand $45.00$112.50None
Carbidopa and Levodopa 25; 100mg/1; mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, EXTENDED   3 Preferred Brand $45.00$112.50None
Carbidopa and Levodopa 50; 200mg/1; mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, EXTENDED   3 Preferred Brand $45.00$112.50None
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;100MG;MG 100 BOT   3 Preferred Brand $45.00$112.50None
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;250MG;MG 100 BOT   3 Preferred Brand $45.00$112.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Carbidopa-Levodopa-Entacapone 100 MG [Stalevo]   4 Non-Preferred Brand 42%42%None
Carbidopa-Levodopa-Entacapone 125 MG [Stalevo]   4 Non-Preferred Brand 42%42%None
Carbidopa-Levodopa-Entacapone 150 MG [Stalevo]   4 Non-Preferred Brand 42%42%None
Carbidopa-Levodopa-Entacapone 200 MG [Stalevo]   4 Non-Preferred Brand 42%42%None
Carbidopa-Levodopa-Entacapone 50 MG [Stalevo]   4 Non-Preferred Brand 42%42%None
Carbidopa-Levodopa-Entacapone 75 MG [Stalevo]   4 Non-Preferred Brand 42%42%None
CARBIDOPA/LEVO 10/100 TABLET   3 Preferred Brand $45.00$112.50None
CARBIDOPA/LEVO 25/100 TABLET   3 Preferred Brand $45.00$112.50None
CARBIDOPA/LEVO 25/250 TABLET   3 Preferred Brand $45.00$112.50None
Carboplatin 10mg/mL   4 Non-Preferred Brand 42%42%P
CARIMUNE NF 6GM VIAL   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CARTEOLOL HCL OPHTHALMIC SOLUTION USP 1% 15ML BOT   2 Generic $13.00$32.50None
CARTIA XT 120MG CAPSULE SA   3 Preferred Brand $45.00$112.50None
CARTIA XT 180MG CAPSULE SA   3 Preferred Brand $45.00$112.50None
CARTIA XT 240MG CAPSULE SA   3 Preferred Brand $45.00$112.50None
CARTIA XT 300MG CAPSULE SR 24 HR   3 Preferred Brand $45.00$112.50None
Carvedilol 12.5mg 100 FILM COATED TABLETS in BOTTLE, PLASTIC   2 Generic $13.00$32.50None
Carvedilol 25mg 100 FILM COATED TABLETS in BOTTLE, PLASTIC   2 Generic $13.00$32.50None
Carvedilol 3.125mg 100 FILM COATED TABLETS in BOTTLE, PLASTIC   2 Generic $13.00$32.50None
Carvedilol 6.25mg 100 FILM COATED TABLETS in BOTTLE, PLASTIC   2 Generic $13.00$32.50None
CAYSTON KIT 75 MG/VIAL   5 Specialty Tier 33%N/AP
CEFACLOR 250 MG CAPSULES   3 Preferred Brand $45.00$112.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CEFACLOR 250 MG/5 ML SUSP   4 Non-Preferred Brand 42%42%None
Cefaclor 375 mg/5 ml suspen   4 Non-Preferred Brand 42%42%None
CEFACLOR 500 MG CAPSULES   3 Preferred Brand $45.00$112.50None
CEFACLOR ER 500MG TABLET SR 12HR   4 Non-Preferred Brand 42%42%None
CEFACLOR SUS 125 MG/5ML   4 Non-Preferred Brand 42%42%None
CEFADROXIL 1G TABLET   4 Non-Preferred Brand 42%42%None
CEFADROXIL 250 MG/5 ML SUSP   3 Preferred Brand $45.00$112.50None
CEFADROXIL 500 MG CAPSULE   2 Generic $13.00$32.50None
Cefadroxil 500mg/5mL   3 Preferred Brand $45.00$112.50None
CEFAZOLIN 1 GM VIAL   4 Non-Preferred Brand 42%42%None
Cefazolin 10g/1 10 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 PACKAGE   4 Non-Preferred Brand 42%42%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CEFAZOLIN 1GM/D5W BAG   4 Non-Preferred Brand 42%42%None
CEFAZOLIN 500MG FOR INJECTION   4 Non-Preferred Brand 42%42%None
CEFDINIR 250MG/5ML SUSPENSION RECONSTITUTED ORAL   4 Non-Preferred Brand 42%42%None
CEFDINIR CAPSULES 300MG (60 CT)   3 Preferred Brand $45.00$112.50None
CEFDINIR FOR ORAL SUSPENSION 125MG/5ML (100 CT)   4 Non-Preferred Brand 42%42%None
CEFEPIME HCL 2 GRAM VIAL   4 Non-Preferred Brand 42%42%None
CEFEPIME INJ 1GM 20ML APX 10x1G VIAL   4 Non-Preferred Brand 42%42%None
CEFIXIME 100 MG/5 ML SUSP [Suprax]   3 Preferred Brand $45.00$112.50None
CEFIXIME 200 MG/5 ML SUSP [Suprax]   3 Preferred Brand $45.00$112.50None
Cefotaxime sodium 1 gm vial   4 Non-Preferred Brand 42%42%None
Cefotaxime sodium 2 gm vial   4 Non-Preferred Brand 42%42%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Cefotaxime sodium 500 mg vial   4 Non-Preferred Brand 42%42%None
Cefoxitin 1g/1 10 POWDER per CARTON   4 Non-Preferred Brand 42%42%None
Cefoxitin 2g/1 10 POWDER per CARTON   4 Non-Preferred Brand 42%42%None
CEFOXITIN FOR INJECTION SOLUTION   4 Non-Preferred Brand 42%42%None
CEFPODOXIME 100 MG/5 ML SUSP   4 Non-Preferred Brand 42%42%None
CEFPODOXIME 200 MG TABLET   4 Non-Preferred Brand 42%42%None
CEFPODOXIME 50 MG/5 ML SUSP   4 Non-Preferred Brand 42%42%None
CEFPODOXIME PROXETIL FILM COATED TABLET 100MG (20 CT)   4 Non-Preferred Brand 42%42%None
cefprozil 125 mg/5 ml susp   3 Preferred Brand $45.00$112.50None
cefprozil 250 mg/5 ml susp   3 Preferred Brand $45.00$112.50None
Cefprozil 250mg 100 FILM COATED TABLETS in BOTTLE   3 Preferred Brand $45.00$112.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CEFPROZIL TABLETS 500MG 100 BOT   3 Preferred Brand $45.00$112.50None
CEFTAZIDIME 1g 25 VIAL per CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL   4 Non-Preferred Brand 42%42%None
Ceftazidime and Dextrose 1g/50mL 24 CONTAINER in 1 CASE / 50 mL in 1 CONTAINER   4 Non-Preferred Brand 42%42%None
Ceftazidime and Dextrose 2g/50mL 24 CONTAINER in 1 CASE / 50 mL in 1 CONTAINER   4 Non-Preferred Brand 42%42%None
CEFTAZIDIME FOR INJECTION 2GM/VIAL 10 X 2 CRTN   4 Non-Preferred Brand 42%42%None
CEFTAZIDIME FOR INJECTION 6GM/VIAL 6 X 6 CRTN   4 Non-Preferred Brand 42%42%None
CEFTRIAXONE 10GM VIAL   4 Non-Preferred Brand 42%42%None
CEFTRIAXONE 250 MG VIAL   4 Non-Preferred Brand 42%42%None
CEFTRIAXONE FOR INJECTION   4 Non-Preferred Brand 42%42%None
CEFTRIAXONE FOR INJECTION   4 Non-Preferred Brand 42%42%None
Ceftriaxone Sodium 500mg   4 Non-Preferred Brand 42%42%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CEFUROXIME 1.5 GM/VIAL FOR INJECTION   4 Non-Preferred Brand 42%42%None
CEFUROXIME 7.5 GM FOR INJECTION   4 Non-Preferred Brand 42%42%None
CEFUROXIME 750 MG FOR INJECTION   4 Non-Preferred Brand 42%42%None
Cefuroxime Axetil 250 MG   3 Preferred Brand $45.00$112.50None
CEFUROXIME AXETIL 500 MG TAB   3 Preferred Brand $45.00$112.50None
CELECOXIB 100 MG CAPSULE [Celebrex]   4 Non-Preferred Brand 42%42%None
CELECOXIB 200 MG CAPSULE [Celebrex]   4 Non-Preferred Brand 42%42%None
CELECOXIB 400 MG CAPSULE [Celebrex]   4 Non-Preferred Brand 42%42%None
CELECOXIB 50 MG CAPSULE [Celebrex]   4 Non-Preferred Brand 42%42%None
CELONTIN 300 MG KAPSEAL   4 Non-Preferred Brand 42%42%None
Cephalexin 125mg/5mL 200 mL in 1 BOTTLE   3 Preferred Brand $45.00$112.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CEPHALEXIN 250 MG CAPSULE   2 Generic $13.00$32.50None
CEPHALEXIN 250 MG/5ML ORAL SUSP   3 Preferred Brand $45.00$112.50None
CEPHALEXIN CAPSULES 500 MG (500 CT)   2 Generic $13.00$32.50None
CERDELGA 84 MG CAPSULE   5 Specialty Tier 33%N/AP
CEREZYME 400 UNITS VIAL   5 Specialty Tier 33%N/AP
CERVARIX VACCINE SYRINGE   3 Preferred Brand $45.00$112.50None
Cetirizine Hydrochloride 1mg/mL 120 mL in 1 BOTTLE   3 Preferred Brand $45.00$112.50None
CHANTIX 0.5 MG TABLET   4 Non-Preferred Brand 42%42%P
CHANTIX 1 MG TABLET   4 Non-Preferred Brand 42%42%P
Chantix 1.0mg/1 56 FILM COATED TABLETS in BOX   4 Non-Preferred Brand 42%42%P
CHANTIX STARTING MONTH BOX   4 Non-Preferred Brand 42%42%P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CHEMET 100 MG CAPSULE   4 Non-Preferred Brand 42%42%None
CHLORHEXIDINE GLUCONATE 0.12% MOUTHWASH   2 Generic $13.00$32.50None
CHLOROQUINE PH 500 MG TABLET   3 Preferred Brand $45.00$112.50None
CHLOROQUINE PHOSPHATE 250 MG TABLET (50 CT)   3 Preferred Brand $45.00$112.50None
CHLOROTHIAZIDE 250 MG TABLET   3 Preferred Brand $45.00$112.50None
Chlorothiazide 500mg 100 TABLET BOTTLE   3 Preferred Brand $45.00$112.50None
CHLORPROMAZINE 10 MG TABLET   4 Non-Preferred Brand 42%42%None
CHLORPROMAZINE 25 MG TABLET   4 Non-Preferred Brand 42%42%None
CHLORPROMAZINE 25 MG/ML AMP   4 Non-Preferred Brand 42%42%None
CHLORPROMAZINE 50 MG TABLET   4 Non-Preferred Brand 42%42%None
CHLORPROMAZINE HCL 200 MG TABLET   4 Non-Preferred Brand 42%42%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Chlorpromazine Hydrochloride 100mg SUGAR COATED 1000 TABLET BOTTLE   4 Non-Preferred Brand 42%42%None
CHLORTHALIDONE 25 MG TABLET (100 CT)   3 Preferred Brand $45.00$112.50None
CHLORTHALIDONE 50 MG TABLET (1000 CT)   3 Preferred Brand $45.00$112.50None
CHOLESTYRAMINE LIGHT POWDER FOR ORAL SUSPENSION   4 Non-Preferred Brand 42%42%None
CICLOPIROX 0.77% TOPICAL SUSP   3 Preferred Brand $45.00$112.50None
CICLOPIROX 1% SHAMPOO   4 Non-Preferred Brand 42%42%None
CICLOPIROX GEL   4 Non-Preferred Brand 42%42%None
Ciclopirox Olamine 7.7mg/g 1 TUBE in 1 TUBE / 15 g in 1 TUBE   3 Preferred Brand $45.00$112.50None
Cilostazol 50mg/1 60 TABLET BOTTLE   3 Preferred Brand $45.00$112.50None
CILOSTAZOL TABLET 100MG (60 CT)   3 Preferred Brand $45.00$112.50None
CILOXAN 0.3% OINTMENT   3 Preferred Brand $45.00$112.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Cimzia 2 KIT per CARTON / 1 KIT in 1 KIT   5 Specialty Tier 33%N/AP
CIMZIA 200 MG/ML SYRINGE KIT   5 Specialty Tier 33%N/AP
Cinryze 500[iU]/5mL 1 VIAL per CARTON / 5 mL in 1 VIAL   5 Specialty Tier 33%N/AP
CIPRODEX OTIC SUSPENSION   4 Non-Preferred Brand 42%42%None
CIPROFLOXACIN 0.3% EYE DROP   2 Generic $13.00$32.50None
CIPROFLOXACIN 250 MG TABLET (100 CT)   2 Generic $13.00$32.50None
CIPROFLOXACIN 250 MG/5 ML SUSP   4 Non-Preferred Brand 42%42%None
Ciprofloxacin 400mg/40mL 1 VIAL per CARTON / 40 mL in 1 VIAL   4 Non-Preferred Brand 42%42%None
CIPROFLOXACIN 500 MG/5 ML SUSP   4 Non-Preferred Brand 42%42%None
Ciprofloxacin and Dextrose 2mg/mL 24 BAG in 1 CASE / 100 mL in 1 BAG   4 Non-Preferred Brand 42%42%None
Ciprofloxacin ER 212.6; 287.5mg/1; mg/1 50 TABLET, FILM COATED, in 1 BOTTLE, PLASTIC   4 Non-Preferred Brand 42%42%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Ciprofloxacin ER 425.2; 574.9mg/1; mg/1 50 TABLET, FILM COATED, in 1 BOTTLE, PLASTIC   4 Non-Preferred Brand 42%42%None
CIPROFLOXACIN HCL 100 MG TABLET   2 Generic $13.00$32.50None
CIPROFLOXACIN HCL 500 MG TAB   2 Generic $13.00$32.50None
CIPROFLOXACIN TABLETS 750 MG 100 BOT   2 Generic $13.00$32.50None
Cisplatin 100mg/100mL 1 VIAL per CARTON / 100 mL in 1 VIAL   4 Non-Preferred Brand 42%42%P
CITALOPRAM HBR 20 MG TABLET   1 Preferred Generic $3.00$7.50None
CITALOPRAM HBR ORAL SOLUTION 10MG 240 ML BOTPL   3 Preferred Brand $45.00$112.50None
CITALOPRAM HYDROBROMIDE TABLETS 40 MG 30 BOT   1 Preferred Generic $3.00$7.50None
CITOLOPRAM HBR 10 MG TABLET (100 CT)   1 Preferred Generic $3.00$7.50None
Cladribine 10 mg/10 ml vial   5 Specialty Tier 33%N/AP
CLARAVIS 10 MG CAPSULE   4 Non-Preferred Brand 42%42%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CLARAVIS 20 MG CAPSULE   4 Non-Preferred Brand 42%42%None
Claravis 30mg 3 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK   4 Non-Preferred Brand 42%42%None
CLARAVIS 40MG CAPSULE   4 Non-Preferred Brand 42%42%None
CLARITHROMYCIN 125 MG/5ML FOR ORAL SUSPENSION   4 Non-Preferred Brand 42%42%None
CLARITHROMYCIN 250 MG TABLET   4 Non-Preferred Brand 42%42%None
CLARITHROMYCIN 250 MG/5MLFOR ORAL SUSPENSION   4 Non-Preferred Brand 42%42%None
CLARITHROMYCIN 500 MG TABLET   4 Non-Preferred Brand 42%42%None
CLARITHROMYCIN ER 500 MG TABLET (60 CT)   3 Preferred Brand $45.00$112.50None
CLINDAMAX 1% GEL   4 Non-Preferred Brand 42%42%None
CLINDAMYCIN 600 MG/4 ML ADDVAN   4 Non-Preferred Brand 42%42%None
CLINDAMYCIN HCL 150 MG CAPSULE   2 Generic $13.00$32.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CLINDAMYCIN HCL 300 MG 100 CAPSULE in 1 BOTTLE   2 Generic $13.00$32.50None
CLINDAMYCIN HCL 75 MG 200 CAPSULE BOTTLE   2 Generic $13.00$32.50None
CLINDAMYCIN PEDIATR 75 MG/5 ML   4 Non-Preferred Brand 42%42%None
CLINDAMYCIN PHOSP 1% LOTION   4 Non-Preferred Brand 42%42%None
clindamycin phosphate 10mg/mL 1 BOTTLE per CARTON / 60 mL in 1 BOTTLE   3 Preferred Brand $45.00$112.50None
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE   4 Non-Preferred Brand 42%42%None
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX   3 Preferred Brand $45.00$112.50None
CLINDAMYCIN PHOSPHATE VAGINAL CREAM   4 Non-Preferred Brand 42%42%None
clindamycin-d5w 300 mg/50 ml   4 Non-Preferred Brand 42%42%None
clindamycin-d5w 600 mg/50 ml   4 Non-Preferred Brand 42%42%None
clindamycin-d5w 900 mg/50 ml   4 Non-Preferred Brand 42%42%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CLINIMIX 2.75%/5% INJECTION 1000ML BAG   4 Non-Preferred Brand 42%42%P
CLINIMIX 4.25/10 SOLUTION   4 Non-Preferred Brand 42%42%P
CLINIMIX 4.25/20 SOLUTION   4 Non-Preferred Brand 42%42%P
CLINIMIX 4.25/25 SOLUTION   4 Non-Preferred Brand 42%42%P
CLINIMIX 4.25/5 SOLUTION   4 Non-Preferred Brand 42%42%P
CLINIMIX 5/15 SOLUTION   4 Non-Preferred Brand 42%42%P
CLINIMIX 5/20 SOLUTION   4 Non-Preferred Brand 42%42%P
CLINIMIX 5/25 SULFITE FREE INJECTIONS 1035MG-420MEQ 1000ML BAG   4 Non-Preferred Brand 42%42%P
CLOBETASOL 0.05% OINTMENT   4 Non-Preferred Brand 42%42%None
CLOBETASOL E 0.05% CREAM   4 Non-Preferred Brand 42%42%None
Clobetasol Propionate 0.4625mg/mL 1 BOTTLE per CARTON / 50 mL in 1 BOTTLE   4 Non-Preferred Brand 42%42%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE   4 Non-Preferred Brand 42%42%None
CLOMIPRAMINE HCL 25MG CAPSULE   4 Non-Preferred Brand 42%42%None
CLOMIPRAMINE HCL 50MG CAPSULE   4 Non-Preferred Brand 42%42%None
CLOMIPRAMINE HCL 75MG CAPSULE   4 Non-Preferred Brand 42%42%None
Clonazepam 0.125mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PAC   3 Preferred Brand $45.00$112.50Q:960
/30Days
Clonazepam 0.25mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING per BLISTER PACK   3 Preferred Brand $45.00$112.50Q:480
/30Days
Clonazepam 0.5mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING per BLISTER PACK   3 Preferred Brand $45.00$112.50Q:240
/30Days
Clonazepam 0.5mg/1 100 TABLET BOTTLE   2 Generic $13.00$32.50Q:240
/30Days
Clonazepam 1mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING per BLISTER PACK   3 Preferred Brand $45.00$112.50Q:120
/30Days
Clonazepam 1mg/1 90 TABLET BOTTLE, PLASTIC   2 Generic $13.00$32.50Q:120
/30Days
Clonazepam 2mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING per BLISTER PACK   3 Preferred Brand $45.00$112.50Q:300
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Clonazepam 2mg/1 100 TABLET BOTTLE   2 Generic $13.00$32.50Q:300
/30Days
Clonidine 0.1mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH   4 Non-Preferred Brand 42%42%None
Clonidine 0.2mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH   4 Non-Preferred Brand 42%42%None
Clonidine 0.3mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH   4 Non-Preferred Brand 42%42%None
CLONIDINE HCL 0.1 MG TABLET   2 Generic $13.00$32.50None
CLONIDINE HCL 0.2MG TABLET (500 CT)   2 Generic $13.00$32.50None
CLONIDINE HCL TABLET 0.3MG (100 CT)   2 Generic $13.00$32.50None
CLOPIDOGREL 75 MG TABLET [Plavix]   1 Preferred Generic $3.00$7.50None
CLORAZEPATE 15 MG TABLET   2 Generic $13.00$32.50P Q:180
/30Days
Clorazepate Dipotassium 3.75mg/1 500 TABLET BOTTLE, PLASTIC   2 Generic $13.00$32.50P Q:120
/30Days
Clorazepate Dipotassium 7.5mg/1 500 TABLET BOTTLE, PLASTIC   2 Generic $13.00$32.50P Q:120
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CLOTRIMAZOLE 1% CREAM   3 Preferred Brand $45.00$112.50None
CLOTRIMAZOLE 10MG TROCHE   4 Non-Preferred Brand 42%42%None
CLOTRIMAZOLE SOLUTION TOPICAL 1% 30ML BOTPL   3 Preferred Brand $45.00$112.50None
Clozapine 100mg/1 100 TABLET BOTTLE   4 Non-Preferred Brand 42%42%None
CLOZAPINE 200MG TABLET (500 CT)   4 Non-Preferred Brand 42%42%None
CLOZAPINE 25MG TABLET (100 CT)   3 Preferred Brand $45.00$112.50None
CLOZAPINE 50MG TABLET (500 CT)   3 Preferred Brand $45.00$112.50None
CLOZAPINE ODT 100 MG TABLET   4 Non-Preferred Brand 42%42%P
CLOZAPINE ODT 12.5 MG TABLET   4 Non-Preferred Brand 42%42%P
CLOZAPINE ODT 150 MG TABLET   4 Non-Preferred Brand 42%42%P
CLOZAPINE ODT 200 MG TABLET   4 Non-Preferred Brand 42%42%P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CLOZAPINE ODT 25 MG TABLET   4 Non-Preferred Brand 42%42%P
COARTEM 20MG-120MG   4 Non-Preferred Brand 42%42%None
COLCRYS 0.6 MG TABLET   3 Preferred Brand $45.00$112.50Q:120
/30Days
COLESTIPOL HCL 1G TABLET   3 Preferred Brand $45.00$112.50None
COLESTIPOL HYDROCHLORIDE 5g/1 100 SUSPENSION in 1 BOTTLE   4 Non-Preferred Brand 42%42%None
colistimethate 150mg/2mL 1 VIAL per CARTON / 2 mL in 1 VIAL   4 Non-Preferred Brand 42%42%None
COLOCORT 100MG ENEMA   4 Non-Preferred Brand 42%42%None
COMBIGAN 0.2%-0.5% DROPS   3 Preferred Brand $45.00$112.50None
COMBIVENT RESPIMAT INHAL SPRAY   4 Non-Preferred Brand 42%42%Q:8
/30Days
COMETRIQ 100 MG DAILY-DOSE PK   5 Specialty Tier 33%N/AP
COMETRIQ 140 MG DAILY-DOSE PK   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
COMETRIQ 60 MG DAILY-DOSE PACK   5 Specialty Tier 33%N/AP
COMPLERA 200; 27.5; 300mg/1; mg/1; mg/1   5 Specialty Tier 33%N/ANone
COMPRO 25MG SUPPOSITORY   4 Non-Preferred Brand 42%42%None
CONSTULOSE 10 GM/15 ML SOLN   2 Generic $13.00$32.50None
COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN   5 Specialty Tier 33%N/AP Q:30
/30Days
COPAXONE 40 MG/ML SYRINGE   5 Specialty Tier 33%N/AP Q:12
/28Days
CORMAX 0.05% SOLUTION   4 Non-Preferred Brand 42%42%None
Cortisone 25 MG Tablet   4 Non-Preferred Brand 42%42%None
COTELLIC 20 MG TABLET   5 Specialty Tier 33%N/AP
COUMADIN 1 MG TABLET   4 Non-Preferred Brand 42%42%None
COUMADIN 10MG TABLET   4 Non-Preferred Brand 42%42%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
COUMADIN 2.5MG TABLET   4 Non-Preferred Brand 42%42%None
COUMADIN 2MG TABLET   4 Non-Preferred Brand 42%42%None
COUMADIN 3mg/1 1 BOTTLE per CARTON / 100 TABLET BOTTLE   4 Non-Preferred Brand 42%42%None
COUMADIN 4mg/1 1 BOTTLE in 1 CARTON / 100 TABLET BOTTLE   4 Non-Preferred Brand 42%42%None
COUMADIN 5MG TABLET   4 Non-Preferred Brand 42%42%None
COUMADIN 6MG TABLET   4 Non-Preferred Brand 42%42%None
COUMADIN 7.5MG TABLET   4 Non-Preferred Brand 42%42%None
Creon 256.11mg/1 1 BOTTLE per CARTON / 70 CAPSULE, DELAYED RELEASE in 1 BOTTLE   3 Preferred Brand $45.00$112.50None
CREON DELAYED RELEASE CAPSULES 12000MG 100 BOT   3 Preferred Brand $45.00$112.50None
CREON DELAYED RELEASE CAPSULES 24000MG 100 BOT   3 Preferred Brand $45.00$112.50None
CREON DELAYED RELEASE CAPSULES 6000MG 100 BOT   3 Preferred Brand $45.00$112.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CREON DR 36,000 UNITS CAPSULE   3 Preferred Brand $45.00$112.50None
CRESTOR 10MG TABLET   3 Preferred Brand $45.00$112.50Q:30
/30Days
CRESTOR 20MG TABLET   3 Preferred Brand $45.00$112.50Q:30
/30Days
CRESTOR 40mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC   3 Preferred Brand $45.00$112.50Q:30
/30Days
CRESTOR 5MG TABLET   3 Preferred Brand $45.00$112.50Q:30
/30Days
CRIXIVAN 200MG CAPSULE   4 Non-Preferred Brand 42%42%None
CRIXIVAN 400mg, 180 CAPSULE BOTTLE   4 Non-Preferred Brand 42%42%None
CROMOLYN 20 MG/2 ML NEB SOLN   3 Preferred Brand $45.00$112.50P
CROMOLYN SODIUM 100 MG/5 ML   5 Specialty Tier 33%N/ANone
CROMOLYN SODIUM 4% 40MG 10ML BOT   2 Generic $13.00$32.50None
CUBICIN 500MG VIAL   5 Specialty Tier 33%N/ANone
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CUVPOSA 1 MG/5 ML SOLUTION   4 Non-Preferred Brand 42%42%None
Cyclafem 1/35 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK   3 Preferred Brand $45.00$112.50None
Cyclafem 7/7/7 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK   3 Preferred Brand $45.00$112.50None
CYCLOBENZAPRINE HCL 10MG TABLET (1000 CT)   4 Non-Preferred Brand 42%42%P
Cyclobenzaprine Hydrochloride 5mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC   4 Non-Preferred Brand 42%42%P
CYCLOPHOSPHAMIDE 25 MG CAPSULE   4 Non-Preferred Brand 42%42%P
CYCLOPHOSPHAMIDE 50 MG CAPSULE   4 Non-Preferred Brand 42%42%P
Cyclosporine 100mg 30 BLISTER PACK per CARTON / 1 CAPSULE, LIQUID FILLED per BLISTER PACK   3 Preferred Brand $45.00$112.50P
CYCLOSPORINE 100MG CAPSULE   4 Non-Preferred Brand 42%42%P
Cyclosporine 25mg 30 BLISTER PACK per CARTON / 1 CAPSULE, LIQUID FILLED per BLISTER PACK   3 Preferred Brand $45.00$112.50P
CYCLOSPORINE 25MG CAPSULE   4 Non-Preferred Brand 42%42%P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Cyclosporine 50 mg/ml vial   4 Non-Preferred Brand 42%42%P
Cyclosporine 50mg 30 BLISTER PACK per CARTON / 1 CAPSULE, LIQUID FILLED per BLISTER PACK   3 Preferred Brand $45.00$112.50P
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT   3 Preferred Brand $45.00$112.50P
CYSTADANE POWDER FOR ORAL SOLUTION 180GM   5 Specialty Tier 33%N/ANone
CYSTAGON 150MG CAPSULE   4 Non-Preferred Brand 42%42%P
CYSTAGON 50MG CAPSULE   4 Non-Preferred Brand 42%42%P
CYTARABINE 20MG/ML VIAL   4 Non-Preferred Brand 42%42%P

Chart Legend:

Below are a few notes to help you understand the above 2016 Medicare Part D SilverScript Choice (PDP) Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug 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).

  • 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 $360 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 four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
    • Drug Description - This is the Medicare Part D plan’s description of this particular drug tier.
  • Cost Sharing - Copay / Coinsurance - These figures apply to 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 intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $3310) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2016 Humana Walmart-Preferred Rx Plan the cost-sharing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
    • 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 2016 )

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 Part D plan provider.





 
 


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  • Q1Medicare®, Q1Rx®, and Q1Group® are registered Service Marks of Q1Group LLC and may not be used in any advertising, publicity, or for commercial purposes without the express authorization of Q1Group.
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDPCompare.com and MACompare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
    Statement required by Medicare:
    "We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options."
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.
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