2017 AARP MedicareRx Walgreens (PDP) Formulary



Below is the Formulary, or drug list, for AARP MedicareRx Walgreens (PDP) from Unitedhealthcare Ins. Co. And Unitedhealthcare Ny This formulary is a list of prescription medications that are covered under Unitedhealthcare Ins. Co. And Unitedhealthcare Ny's 2017 Part-D Plan. The AARP MedicareRx Walgreens (PDP) plan has a $400 drug deductible. This deductible is the amount of expenses that must be paid out of pocket before the Initial Coverage period begins. However some drugs do not require that the deductible is met before you receive coverage. You can see if the deductible is required below in the "Does the Deductible Apply" column. The Initial Coverage Limit (ICL) for this plan is $3700. The Initial Coverage Period is the period after the Deductible has been met but before the Coverage Gap phase. Once you and your plan provider have spent $3700 on covered drugs. (combined amount plus your deductible) You will enter the coverage gap. (AKA "donut hole") Once you reach the coverage gap you will be required to pay 45% of the plan's cost for covered brand-name prescription drugs unless your plan offers additional coverage. You can see if this plan offers coverage in the "donut hole" be clicking the "Coverage Gap" link on the left above the chart. In 2017 if you have spent $4700 in expenditures you enter the Catastrophic Phase. During the Catastrophic Period you will begin to receive significant coverage. AARP MedicareRx Walgreens (PDP) will begin paying approximately 95% of your covered medication expenses. You can see if this plan covers your drugs in the Catastrophic Phase by clicking the "Catastrophic" link on the left above the chart.

See More on AARP MedicareRx Walgreens (PDP)





Plan Name:
AARP MedicareRx Walgreens (PDP)
Plan ID:
S5921-383
Provider: Unitedhealthcare Ins. Co. And Unitedhealthcare Ny
Plan Year:2017
Premium:$22.50
Deductible:$400
Initial Coverage Limit:$3700
Coverage Area:Florida




Current Table info:


Coverage Level:
Initial Coverage
Days Supply:
30 Days
Drugs Starting With Letter: B

Change Table Options:


Drugs Starting Letter:
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 
Coverage Level:
Drug Days Pricing:60 Day
90 Day











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(Click the Drug Name to Compare every Plans Price)

Drug Name Drug Strength Units in Package Tier Level Amount Limit Days Limit Prior Authorization
Y/N
Step Therapy
Y/N
Does the Deduct Apply Cost Preferred Max Cost Non Preferred Max Cost Mail Max
Bacitracin 5000[USP'U]/mL 1 Vial In 1 Carton > 10 Ml In 1 Vial
4
N N Y 32%N33%NNAN
Bacitracin 500[USP'U]/g 1 Tube In 1 Carton > 3.5 G In 1 Tube
2
N N N $3N$18NNAN
Bacitracin Zinc And Polymyxin B Sulfate 500; 10000[USP'U]/g; [USP'U]/g 1 Tube In 1 Carton > 3.5 G In 1 Tube
2
N N N $3N$18NNAN
Baclofen 20mg 500 Tablet In 1 Bottle, Plastic
2
N N N $3N$18NNAN
Baclofen 10mg 500 Tablet In 1 Bottle, Plastic
2
N N N $3N$18NNAN
Bactroban 20mg/g 10 Carton In 1 Package > 1 G In 1 Tube
4
Y N Y 32%N33%NNAN
Balsalazide Disodium 750mg 280 Capsule In 1 Bottle
4
N N Y 32%N33%NNAN
Balziva 6 Pouch In 1 Carton > 1 Blister Pack In 1 Pouch > 1 Kit In 1 Blister Pack
4
N N Y 32%N33%NNAN
Banzel 200mg 120 Tablet, Film Coated In 1 Bottle
4
N N Y 32%N33%NNAN
Banzel 400mg 120 Tablet, Film Coated In 1 Bottle
4
N N Y 32%N33%NNAN
Banzel 40mg/mL 1 Bottle In 1 Carton > 460 Ml In 1 Bottle
4
N N Y 32%N33%NNAN
Baraclude .05mg/mL 1 Bottle In 1 Carton > 210 Ml In 1 Bottle
5
N N Y 25%N25%NNAN
Bcg Vaccine 50mg 1 Vial In 1 Carton
3
N N Y $27N$47NNAN
Beleodaq 1 Vial, Single-use In 1 Carton > 10 Ml In 1 Vial, Single-use
5
Y N Y 25%N25%NNAN
Belsomra 3 Case In 1 Carton > 10 Tablet, Film Coated In 1 Blister Pack
3
30 30 N N Y $27N$47NNAN
Belsomra 3 Case In 1 Carton > 10 Tablet, Film Coated In 1 Blister Pack
3
30 30 N N Y $27N$47NNAN
Belsomra 3 Case In 1 Carton > 10 Tablet, Film Coated In 1 Blister Pack
3
30 30 N N Y $27N$47NNAN
Belsomra 3 Case In 1 Carton > 10 Tablet, Film Coated In 1 Blister Pack
3
30 30 N N Y $27N$47NNAN
Benazepril Hydrochloride 5mg 100 Tablet, Film Coated In 1 Bottle, Plastic
1
60 30 N N N $0N$15NNAN
Benazepril Hydrochloride 10mg 100 Tablet, Film Coated In 1 Bottle, Plastic
1
60 30 N N N $0N$15NNAN
Benazepril Hydrochloride 20mg 100 Tablet, Film Coated In 1 Bottle, Plastic
1
60 30 N N N $0N$15NNAN
Benazepril Hydrochloride 40mg 100 Tablet, Film Coated In 1 Bottle, Plastic
1
60 30 N N N $0N$15NNAN
Benazepril Hydrochloride And Hydrochlorothiazide 5; 6.25mg/1; mg 100 Tablet, Film Coated In 1 Bottle, Plastic
1
30 30 N N N $0N$15NNAN
Benazepril Hydrochloride And Hydrochlorothiazide 10; 12.5mg/1; mg 100 Tablet, Film Coated In 1 Bottle, Plastic
1
30 30 N N N $0N$15NNAN
Benazepril Hydrochloride And Hydrochlorothiazide 20; 12.5mg/1; mg 100 Tablet, Film Coated In 1 Bottle, Plastic
1
30 30 N N N $0N$15NNAN
Benazepril Hydrochloride And Hydrochlorothiazide 20; 25mg/1; mg 100 Tablet, Film Coated In 1 Bottle, Plastic
1
30 30 N N N $0N$15NNAN
Benicar 5mg 30 Tablet, Film Coated In 1 Bottle, Plastic
3
60 30 N N Y $27N$47NNAN
Benicar 20mg 90 Tablet, Film Coated In 1 Bottle, Plastic
3
30 30 N N Y $27N$47NNAN
Benicar 40mg 90 Tablet, Film Coated In 1 Bottle, Plastic
3
30 30 N N Y $27N$47NNAN
Benicar Hct 12.5; 20mg/1; mg 90 Tablet, Film Coated In 1 Bottle, Plastic
3
30 30 N N Y $27N$47NNAN
Benicar Hct 12.5; 40mg/1; mg 30 Tablet, Film Coated In 1 Bottle, Plastic
3
30 30 N N Y $27N$47NNAN
Benicar Hct 25; 40mg/1; mg 90 Tablet, Film Coated In 1 Bottle, Plastic
3
30 30 N N Y $27N$47NNAN
Benlysta 120mg/1.5mL 1 Vial In 1 Carton > 1.5 Ml In 1 Vial
5
Y N Y 25%N25%NNAN
Benlysta 1 Vial In 1 Carton > 5 Ml In 1 Vial
5
Y N Y 25%N25%NNAN
Benztropine Mesylate .5mg 100 Tablet In 1 Bottle, Plastic
2
N N N $3N$18NNAN
Benztropine Mesylate 1mg 100 Tablet In 1 Bottle, Plastic
2
N N N $3N$18NNAN
Benztropine Mesylate 1000 Tablet In 1 Bottle
2
N N N $3N$18NNAN
Benztropine Mesylate 5 Ampule In 1 Carton > 2 Ml In 1 Ampule
4
N N Y 32%N33%NNAN
Bepreve 15mg/mL 1 Bottle, Dropper In 1 Carton > 10 Ml In 1 Bottle, Dropper
4
N N Y 32%N33%NNAN
Berinert 1 Kit In 1 Carton
5
Y N Y 25%N25%NNAN
Betamethasone Dipropionate .5mg/mL 1 Bottle In 1 Carton > 60 Ml In 1 Bottle
3
N N Y $27N$47NNAN
Betamethasone Dipropionate .5mg/mL 60 Ml In 1 Bottle
2
N N N $3N$18NNAN
Betamethasone Dipropionate .5mg/g 1 Tube In 1 Carton > 45 G In 1 Tube
3
N N Y $27N$47NNAN
Betamethasone Dipropionate 1 Tube In 1 Carton > 50 G In 1 Tube
2
N N N $3N$18NNAN
Betamethasone Dipropionate .64mg/g 1 Tube In 1 Carton > 45 G In 1 Tube
3
N N Y $27N$47NNAN
Betamethasone Dipropionate .5mg/g 1 Tube In 1 Carton > 50 G In 1 Tube
2
N N N $3N$18NNAN
Betamethasone Dipropionate 1 Tube In 1 Box > 50 G In 1 Tube
2
N N N $3N$18NNAN
Betamethasone Valerate 1.2mg/g 1 Tube In 1 Carton > 45 G In 1 Tube
3
N N Y $27N$47NNAN
Betamethasone Valerate 1mg/g 1 Tube In 1 Carton > 45 G In 1 Tube
3
N N Y $27N$47NNAN
Betamethasone Valerate 1mg/mL 1 Bottle, Plastic In 1 Carton > 60 Ml In 1 Bottle, Plastic
3
N N Y $27N$47NNAN
Betaxolol 5mg/mL 1 Vial In 1 Carton > 10 Ml In 1 Vial
3
N N Y $27N$47NNAN
Bethanechol Chloride 25mg 100 Tablet In 1 Bottle
2
N N N $3N$18NNAN
Bethanechol Chloride 50mg 100 Tablet In 1 Bottle
2
N N N $3N$18NNAN
Betimol 1 Bottle In 1 Carton > 5 Ml In 1 Bottle
4
N N Y 32%N33%NNAN
Betimol 5.12mg/mL 1 Bottle In 1 Carton > 15 Ml In 1 Bottle
4
N N Y 32%N33%NNAN
Bicalutamide 50mg 30 Tablet, Film Coated In 1 Bottle, Plastic
2
N N N $3N$18NNAN
Bicillin C-r 900/300 900000; 300000[iU]/2mL; [iU]/2mL 10 Syringe In 1 Package
4
N N Y 32%N33%NNAN
Bicillin Cr 600000; 600000[iU]/2mL; [iU]/2mL 10 Syringe In 1 Package
4
N N Y 32%N33%NNAN
Bicillin L-a 600000[iU]/mL 10 Syringe In 1 Package
4
N N Y 32%N33%NNAN
Bicillin L-a 1200000[iU]/2mL 10 Syringe In 1 Package
4
N N Y 32%N33%NNAN
Bicillin L-a 2400000[iU]/4mL 10 Syringe In 1 Package
4
N N Y 32%N33%NNAN
Bicnu 1 Kit In 1 Carton * 30 Ml In 1 Vial, Single-dose * 3 Ml In 1 Vial
5
N N Y 25%N25%NNAN
Biltricide 600mg 6 Tablet, Film Coated In 1 Bottle
4
N N Y 32%N33%NNAN
Binosto 70mg 4 Tablet, Effervescent In 1 Carton
4
4 28 N N Y 32%N33%NNAN
Bisoprolol Fumarate 5mg 100 Tablet, Film Coated In 1 Bottle
2
N N N $3N$18NNAN
Bisoprolol Fumarate 10mg 100 Tablet, Film Coated In 1 Bottle
2
N N N $3N$18NNAN
Bivigam 10g/100mL 100 Ml In 1 Vial, Glass
4
Y N Y 32%N33%NNAN
Bleomycin 30[USP'U] 1 Vial, Single-use In 1 Carton > 1 Injection, Powder, Lyophilized, For Solution In 1 Vial, Single-use
4
Y N Y 32%N33%NNAN
Blephamide 2; 100mg/g; mg/g 1 Tube In 1 Carton > 3.5 G In 1 Tube
4
N N Y 32%N33%NNAN
Blephamide 2; 100mg/mL; mg/mL 1 Bottle, Dropper In 1 Carton > 10 Ml In 1 Bottle, Dropper
4
N N Y 32%N33%NNAN
Boostrix 8; 2.5; 8; 5; 2.5ug/.5mL; ug/.5mL; ug/.5mL; [iU]/.5mL; [iU]/.5mL 10 Vial In 1 Carton
3
N N Y $27N$47NNAN
Boostrix 8; 2.5; 8; 5; 2.5ug/.5mL; ug/.5mL; ug/.5mL; [iU]/.5mL; [iU]/.5mL 10 Syringe In 1 Carton
3
N N Y $27N$47NNAN
Bosulif 100mg 120 Tablet, Film Coated In 1 Bottle
5
180 30 Y N Y 25%N25%NNAN
Bosulif 500mg 30 Tablet, Film Coated In 1 Bottle
5
30 30 Y N Y 25%N25%NNAN
Botox 100[USP'U] 1 Vial In 1 Carton > 1 Injection, Powder, Lyophilized, For Solution In 1 Vial
4
9 30 Y N Y 32%N33%NNAN
Botox 1 Vial In 1 Carton > 1 Injection, Powder, Lyophilized, For Solution In 1 Vial
4
9 30 Y N Y 32%N33%NNAN
Breo Ellipta 100; 25ug/1; ug 1 Tray In 1 Carton > 1 Inhaler In 1 Tray > 30 Powder In 1 Inhaler
3
60 30 N N Y $27N$47NNAN
Briellyn 3 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
4
N N Y 32%N33%NNAN
Brilinta 90mg 60 Tablet In 1 Bottle
4
60 30 N N Y 32%N33%NNAN
Brimonidine Tartrate 2mg/mL 1 Bottle, Dropper In 1 Carton > 10 Ml In 1 Bottle, Dropper
2
N N N $3N$18NNAN
Bromocriptine Mesylate 5mg 30 Capsule In 1 Bottle, Unit-dose
4
N N Y 32%N33%NNAN
Bromocriptine Mesylate 2.5mg 100 Tablet In 1 Bottle, Plastic
4
N N Y 32%N33%NNAN
Budesonide .25mg/2mL 6 Pouch In 1 Carton > 2 Ml In 1 Vial, Single-dose
4
Y N Y 32%N33%NNAN
Budesonide .5mg/2mL 6 Pouch In 1 Carton > 2 Ml In 1 Vial, Single-dose
4
Y N Y 32%N33%NNAN
Budesonide 3mg 100 Capsule In 1 Bottle, Plastic
4
N N Y 32%N33%NNAN
Bumetanide .5mg 100 Tablet In 1 Bottle
2
N N N $3N$18NNAN
Bumetanide 2mg 100 Tablet In 1 Bottle
2
N N N $3N$18NNAN
Bumetanide 500 Tablet In 1 Bottle
2
N N N $3N$18NNAN
Bumetanide .25mg/mL 10 Vial In 1 Box > 4 Ml In 1 Vial
4
N N Y 32%N33%NNAN
Buprenorphine Hcl 2mg 30 Tablet In 1 Bottle
3
90 30 Y N Y $27N$47NNAN
Buprenorphine Hcl 8mg 30 Tablet In 1 Bottle
3
90 30 Y N Y $27N$47NNAN
Buprenorphine Hydrochloride .3mg/mL 10 Cartridge In 1 Carton > 1 Ml In 1 Cartridge
4
N N Y 32%N33%NNAN
Buprenorphine Hydrochloride And Naloxone Hydrochlo 30 Tablet In 1 Bottle
3
90 30 Y N Y $27N$47NNAN
Buprenorphine Hydrochloride And Naloxone Hydrochlo 30 Tablet In 1 Bottle
3
90 30 Y N Y $27N$47NNAN
Buproban 150mg 100 Tablet, Extended Release In 1 Bottle, Plastic
2
N N N $3N$18NNAN
Bupropion Hydrochloride 200mg 60 Tablet, Film Coated, Extended Release In 1 Bottle
2
N N N $3N$18NNAN
Bupropion Hydrochloride 150mg 100 Tablet, Extended Release In 1 Bottle
2
N N N $3N$18NNAN
Bupropion Hydrochloride 100mg 60 Tablet, Film Coated, Extended Release In 1 Bottle, Plastic
2
N N N $3N$18NNAN
Bupropion Hydrochloride 75mg 1000 Tablet, Film Coated In 1 Bottle
2
N N N $3N$18NNAN
Bupropion Hydrochloride 100mg 100 Tablet, Film Coated In 1 Bottle
2
N N N $3N$18NNAN
Bupropion Hydrochloride 150mg 500 Tablet, Film Coated, Extended Release In 1 Bottle
2
N N N $3N$18NNAN
Bupropion Hydrochloride 300mg 30 Tablet, Film Coated, Extended Release In 1 Bottle
2
N N N $3N$18NNAN
Buspirone Hcl 5mg 100 Tablet In 1 Bottle, Plastic
2
N N N $3N$18NNAN
Buspirone Hcl 15mg 180 Tablet In 1 Bottle, Plastic
2
N N N $3N$18NNAN
Buspirone Hydrochloride 10mg 100 Tablet In 1 Bottle
2
N N N $3N$18NNAN
Buspirone Hydrochloride 30mg 60 Tablet In 1 Bottle, Plastic
2
N N N $3N$18NNAN
Buspirone Hydrochloride 7.5mg 500 Tablet In 1 Bottle
2
N N N $3N$18NNAN
Busulfex 6mg/mL 8 Vial In 1 Package
5
N N Y 25%N25%NNAN
Butalbital, Acetaminophen, And Caffeine 325; 50; 40mg/1; mg/1; mg 500 Tablet In 1 Bottle, Plastic
3
180 30 N N Y $27N$47NNAN
Butalbital, Aspirin, And Caffeine 325; 50; 40mg/1; mg/1; mg 100 Capsule In 1 Bottle
3
180 30 N N Y $27N$47NNAN
Butorphanol Tartrate 10mg/mL 1 Bottle, Spray In 1 Container > 15 Ml In 1 Bottle, Spray
3
5 30 N N Y $27N$47NNAN
Butorphanol Tartrate 1mg/mL 10 Vial, Single-dose In 1 Carton > 1 Ml In 1 Vial, Single-dose
4
N N Y 32%N33%NNAN
Butorphanol Tartrate 2mg/mL 10 Vial, Single-dose In 1 Carton > 1 Ml In 1 Vial, Single-dose
4
N N Y 32%N33%NNAN
Bydureon 1 Tray In 1 Carton > 4 Cartridge In 1 Tray > .65 Ml In 1 Cartridge
3
4 28 N N Y $27N$47NNAN
Bystolic 30 Tablet In 1 Bottle
3
30 30 N N Y $27N$47NNAN
Bystolic 5mg 30 Tablet In 1 Bottle
3
30 30 N N Y $27N$47NNAN
Bystolic 30 Tablet In 1 Bottle
3
30 30 N N Y $27N$47NNAN
Bystolic 20mg 90 Tablet In 1 Bottle
3
60 30 N N Y $27N$47NNAN



Medicare Help's Additional Notes:

Coverage Levels for S5921-383

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1.Pre-Deductable: Before you reach the plans deductible of $400. Some plans offer select Pre-deductible drug Coverage
2.Initial Coverage: (ICL) After you reach the plans deductible but before the Initial Coverage limit of $3700
3.Coverage Gap: (AKA Donut Hole) After you reach the plans ICL but before the Catastrophic of $4950 in 2017.
4.Catastrophic: Anything over $4950 you will receive a significant increase in coverage.

Definitions:

Premium: A monthly flat fee that varies by plan.
Deductible: The amount you must pay each year for your prescriptions before your plan begins to pay its share of your covered drugs. The max in 2017 is $320. Some plans have a $0 Deductible.
Tier Level: Medicare drug plans place drugs into different "tiers" on their formularies. Drugs in each tier have a different cost. A drug in a lower tier will generally cost you less.
Quantity Limit Amount/Days: Certain drugs have a Quantity Limit. That means the plan will only cover the drug up to a designated quantity or amount. If your prescribing doctor feels it is necessary to exceed the set limit, he or she must get prior approval before the higher quantity will be covered.
Prior Authorization: Certain Drugs require you or your doctor to get prior authorization in order to be covered. Usually just an additional form. If you dont get approval, the plan may not cover the drug.
Does the Deduct Apply: Some drugs do not require that the deductible is met before you receive coverage.
Step Therapy: Means you must first try one drug to treat your medical condition before the plan will cover another drug for the same condition. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.
Cost Prefered: Your Cost for the Drug at the Providers In Network Prefered Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Non Pref: Your Cost for the Prescription Drug at a Non-Prefered Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Mail: Your Cost for Prescription Drugs through a Mail Order Pharmacy. As a Percent of the total drug cost or a flat rate.


What if a drug I need is not listed?

Please check the formulary for different brand and generic names. If you still cannot locate your drugs, your plan may not offer coverage. Talk to your doctor first about changing your prescription to a drug on your plans formulary. If this is not an option, you can request an exception to have the plan review its coverage decision based on your individual circumstances.

Source:CMS Formulary Data Oct. 2016
Source:NDC Directory by FDA.gov

**We make every attempt to keep our information accurate. But please check with the plan providers to verify all information.