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 will be the same whether you use a pharmacies that offers preferred cost sharing or a pharmacy that offers standard cost sharing.

Deductible Because you receive “Extra Help” with your prescription drugs, this payment stage does not apply.
Initial Coverage Stage 
  • Tier 1: Preferred Generic
    Preferred $0.00
    Standard $0.00
  • Tier 2: Generic
    Preferred $0.00
    Standard $0.00
  • Tier 3: Preferred Brand
    Preferred $0.00
    Standard $0.00
  • Tier 4: Non-preferred Drugs
    Preferred $0.00
    Standard $0.00
  • Tier 5: Specialty Drugs
    Preferred $0.00
    Standard $0.00
  • Tier 6: Select Care Drug
    Preferred $0.00
    Standard $0.00
Coverage Gap Stage Because you receive “Extra Help” with your prescription drugs, this payment stage does not apply.
Catastrophic Coverage Stage You pay $0 for your covered Part D drugs.
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