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 pharmacy that offers preferred cost sharing or a pharmacy that offers standard cost sharing.

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

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

Deductible Because you receive “Extra Help” with your prescription drugs, this payment stage does not apply.
Initial Coverage Stage  During this stage, the plan pays its share of the cost of your Tier 1 Preferred Generic, Tier 2 Generic, Tier 3 Preferred Brand, Tier 4 Non-preferred Drug, Tier 5 Specialty, and Tier 6 Select Care Drugs and you pay your share of the cost. The amount you pay will be determined by the covered Part D prescription and your low-income subsidy coverage. Please refer to your LIS Rider for the specific amount you pay.
  • Tier 1: Preferred Generic
    Preferred $0
    Standard $0
  • Tier 2: Generic
    Preferred $0-$3.35
    Standard $0-$3.35
  • Tier 3: Preferred Brand
    Preferred $0-$8.35
    Standard $0-$8.35
  • Tier 4: Non-preferred Drugs
    Preferred $0-$8.35
    Standard $0-$8.35
  • Tier 5: Specialty Drugs
    Preferred $0-$8.35
    Standard $0-$8.35
  • Tier 6: Select Care Drugs
    Preferred $0
    Standard $0
You stay in the initial coverage stage until the total amount for the prescription drugs you have filled and refilled 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 on to the coverage gap stage.

When you are in the coverage gap stage you will continue to pay $0.00 for your Tier 6 Select Care Drugs.

For Tier 2 Generic, Tier 3 Preferred Brand, Tier 4 Non-preferred Drugs, Tier 5 Specialty drugs, you will pay your LIS level cost sharing.

$0-3.35 for Generic drugs

$0-8.35 for Brand drugs

Please refer to your LIS Rider for the specific amount you pay.
Catastrophic Coverage Stage You qualify for the catastrophic coverage stage when your out-of-pocket costs have reached the $5,000 limit for the calendar year. Once you are in the catastrophic coverage stage, you will stay in this payment stage until the end of the calendar year.

Our plan pays the whole cost of the drug.

You pay $0 for your covered Part D drugs.
Drug Coverage 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

Medication Therapy Management

Downloadable Formulary