To access the Part D, or prescription drug coverage offered by our plan, you’ll use the Amerivantage formulary. A formulary is a list of medications covered by the plan.

We’ve contracted with over 68,000 pharmacies to give you options when it comes to where you’d like to go for prescription medications. Find a network pharmacy.

Our pharmacies with preferred cost sharing include Bartell Drugs, CVS Pharmacy, DaVita Rx, Food Lion, Giant Eagle Pharmacy, Hannaford, Harris Teeter Pharmacy, H-E-B PHARMACY, Kroger, Roundy's, Shopko, Walmart, and some independent pharmacies, including more than 5,000 Access Health pharmacies.

  • CVS Pharmacy participating pharmacies include CVS Pharmacy, CVS Pharmacy at Target, Longs Drug Stores, and Navarro Discount Pharmacies.
  • Kroger participating pharmacies include Kroger, Fred Meyer, King Soopers, City Market, Fry’s Food Stores, Smith’s Food & Drug Centers, Dillon Companies, Ralphs, Quality Food Centers, Baker, Owen, Payless, Gerbes, Jay-C, Mariano’s, Metro Market, Copps, Pick n’ Save, Scott's, Prodigy, and Good Neighbor.
  • Walmart participating pharmacies include Walmart, Neighborhood Market, and Sam’s Club.

DSNP Plans only: Your costs are the same whether you choose to use a pharmacy that offers preferred cost sharing or a pharmacy that offers standard cost sharing.

Prescription Costs

Below is a description of the drug payment stages and costs for your Medicare Part D prescription coverage under our plan. All costs are for a 1 month (30 day) supply at an in-network retail pharmacy. Our network includes pharmacies that offer standard cost sharing and pharmacies that offer preferred cost sharing. You may go to either type of network pharmacy to receive your covered prescription drugs. Your cost sharing may be less at pharmacies that offer preferred cost sharing.

In the Initial Coverage Stage section, the first cost listed is your retail cost at a retail pharmacy that offers preferred cost sharing.

Deductible $405
During this stage, you pay the full cost of your Tier 2 Generic, Tier 3 Preferred Brand, Tier 4 Non-preferred Brand and Tier 5 Specialty drugs.
Initial Coverage Stage 

During this stage the play pays its share of the cost of your Tier 1 Preferred Generic and Tier 6 Select Care Drugs and you pay your share of the cost. After you (or others on your behalf) have met your Tier 2 Generic, Tier 3 Preferred Brand, Tier 4 Non-preferred Drugs and Tier 5 Specialty drugs deductible, the play pays its share of the costs for these drugs and you pay your share of the cost.

  • Tier 1: Preferred Generic
    Preferred $0
    Standard $0
  • Tier 2: Generic
    Preferred $20
    Standard $20
  • Tier 3: Preferred Brand
    Preferred $47
    Standard $47
  • Tier 4: Nonpreferred
    Preferred $95
    Standard $100
  • Tier 5: Specialty Tier Drug
    Preferred 25%
    Standard 25%
  • Tier 6: Select Care Drug
    Preferred $0
    Standard $0

You stay in the initial coverage stage until the total amount for the prescription drugs you have filled reaches the $3,750 limit for the initial coverage stage.

Coverage Gap Stage

When the total amount for the prescription drugs you have filled and refilled reaches the $3,750 limit for the initial coverage stage, you will move to the coverage gap stage.

When you are in the coverage gap you will pay $0.00 for Tier 6 Select Care drugs.

For drugs not on Tier 6, you pay 35% of the negotiated price and a portion of the dispensing fee for brand-name drugs. Both the amount you pay and the amount discounted by the manufacturer count toward your out-of-pocket costs as if you had paid them and moves you through the coverage gap.

You pay no more than 44% of the cost for Generic drugs and the plan pays the rest. For the generic drugs, the amount paid by the plan (56%) does not count toward your out-of-pocket costs. Only the amount you play counts and moves you through the coverage gap. You continue paying the discounted price for brand name drugs and no more than 44% of the costs of the Generic drugs until your yearly out-of-pocket costs payments reach the maximum amount that Medicare has set in 2018, that amount is $5,000.

Catastrophic Coverage Stage

You qualify for the catastrophic coverage stage when your out-of- pocket costs have reached the $5,000.00 limit for the calendar year. One you are in the catastrophic coverage stage, you will stay in this payment stage until the end of the calendar year.

During this stage, the plan will pay most of the cost for your drugs.

  • Either – coinsurance of 5% of the cost of the drug
  • Or $3.35 for a generic drug or a drug that is treated like a generic and $8.35 for all other drugs.
Our plan pays the rest of the costs.

Drug Coverage Notes Most drugs are covered under Part D, but there are some drugs that can be covered under both Part B or Part D depending on what the drug is used for and how it is administered. Your provider may need to submit this information so a coverage determination can be made.
Out-of-network Generally you must use a network pharmacy to fill your prescriptions. We cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy, such as when you become ill while traveling outside of the service area. You will generally have to pay the full cost ( rather than your normal cost share) at the time you fill your prescription. You can ask us to reimburse you for our share of the costs.
Questions For more details about the benefits listed here and others, please refer to your Explanation of Coverage (EOC) or contact Member Services

Premiums and copays may vary based on the level of extra help you receive.

Some drugs may be covered under Part B or Part D depending upon the circumstances. Your provider may need to submit information (prior authorization) describing the use and setting of the drug to make the determination.

Medication Therapy Management

Downloadable Formulary – English
Downloadable Formulary – Spanish