SilverScript Choice (PDP) Formulary



Below is the 2023 Formulary, or prescription drug list, from SilverScript Choice (PDP) by Silverscript Insurance Company. A formulary is a continually updated list of available medications and prescription drug cost information. Examining a plans formulary can help you find a In Indiana, Kentucky. plan that covers your prescriptions. It also helps you compare costs among Medicare Part D and Medicare Advantage plans available to you. You’ll want to make sure the medicines you are currently taking are covered under any plans you are considering enrolling in.

This SilverScript Choice (PDP)(S5601-030) plan has a $505 drug deductible. A 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 $4660. 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 $4660 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 25% 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" by clicking the "Coverage Gap" link above the chart.

In 2023 if you have spent $7400 in expenditures you enter the Catastrophic Phase. During the Catastrophic Period you will begin to receive significant coverage. Silverscript Insurance Company 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 above the chart.



Plan Overview

Plan Name:SilverScript Choice (PDP)
Plan ID: S5601-030
Formulary
Provider: Silverscript Insurance Company
Plan Year:2023
Premium:$27.80
Deductible:$505
Initial Coverage Limit:$4660
Coverage Area:Indiana, Kentucky
Similar Plan:S5601-031


Change Table Options:

Drugs Starting Letter:
Coverage Phase:

*Tip Click the Drug name to Compare Coverage and Retail Cost for Every Plan In Your Area
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Drug
Name⇅
Tier
Level
Deductible
Apply
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
Sandimmune
4Y37%37%37%YN
Sapropterin Dihydrochloride
525%25%25%YN
Scemblix
525%25%25%300/30YN
Secuado
4Y37%37%37%30/30NN
Selegiline Hydrochloride
4Y37%37%37%NN
Selenium Sulfide
2Y$7$15$7NN
Selzentry
525%25%25%NN
Serevent
3Y17%17%17%60/30NN
Sertraline Hydrochloride
4Y37%37%37%300/30NN
Setlakin
2Y$7$15$7NN
Shingrix
3Y17%17%17%2/999NN
Signifor
525%25%25%YN
Sildenafil
2Y$7$15$790/30YN
Silodosin
2Y$7$15$730/30NN
Simbrinza
4Y37%37%37%NN
Sirolimus
4Y37%37%37%YN
Sirturo
525%25%25%YN
Sivextro
525%25%25%NN
Skyrizi
525%25%25%6/365YN
Sodium Chloride
4Y37%37%37%NN
Sodium Phenylbutyrate
525%25%25%YN
Sodium Polystyrene Sulfonate
2Y$7$15$7NN
Solifenacin Succinate
4Y37%37%37%30/30NY
Somavert
525%25%25%YN
Sorine
2Y$7$15$7NN
Sotalol Hydrochloride
2Y$7$15$7NN
Spironolactone
1Y$2$8$2NN
Spironolactone And Hydrochlorothiazide
2Y$7$15$7NN
Sprintec
2Y$7$15$7NN
Spritam
4Y37%37%37%NN
Sprycel
525%25%25%30/30YN
Sronyx
2Y$7$15$7NN
Streptomycin
4Y37%37%37%NN
Stribild
525%25%25%NN
Suboxone
4Y37%37%37%60/30NN
Sulfacetamide Sodium
4Y37%37%37%NN
Sulfacetamide Sodium And Prednisolone Sodium Phosp
2Y$7$15$7NN
Sulfadiazine
4Y37%37%37%NN
Sulfamethoxazole And Trimethoprim
2Y$7$15$7NN
Sulfasalazine
2Y$7$15$7NN
Sulindac
2Y$7$15$760/30NN
Sumatriptan
2Y$7$15$712/30NN
Sumatriptan Succinate
4Y37%37%37%4/30NN
Sunitinib Malate
525%25%25%30/30YN
Suprep Bowel Prep
4Y37%37%37%NN
Sutab
4Y37%37%37%NN
Syeda
2Y$7$15$7NN
Symbicort
3Y17%17%17%10/30NN
Sympazan
4Y37%37%37%60/30YN
Symtuza
525%25%25%NN
Synarel
525%25%25%NN
Synribo
525%25%25%YN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for S5601-030

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $505. 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 $4660
3. Coverage Gap: (AKA Donut Hole) After you reach the plans ICL but before the Catastrophic of $7400 in 2023.
4. Catastrophic: Anything over $7400 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 2022 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 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 Preferred: Your Cost for the Drug at the Providers In-Network Preferred Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Non-Preferred: Your Cost for the Prescription Drug at a Non-Preferred 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 plan's 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.

Last updated on
Source:CMS Formulary Data Q4 2022
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.

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*Licensed Agent Disclaimer: 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 (TTY users should call 1-877-486-2048) 24 hours a day/7 days a week to get information on all of your options.

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