Q1Medicare.com 2009 Medicare Part D or Medicare Advantage Plan Formulary Browser

2009 Medicare Part D Plan Formulary Information
First Health Part D-Premier (S5768-008-0) Benefit Details
The First Health Part D-Premier (S5768-008-0) Formulary Drugs Starting with the Letter T in CMS PDP Region 5 which includes: DC DE MD
Drugs Starting with Letter T Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter T Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TAMIFLU 30MG CAPSULE	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	Q:10 /5Days
TAMIFLU 45MG CAPSULE	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	Q:10 /5Days
TAMIFLU 75MG CAPSULE UD	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	Q:56 /365Days
TAMIFLU ORAL SUSPENSION	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
TAMOXIFEN CITRATE 10MG TABLET (180 CT)	1	Preferred Generic	$5.00	N/A	None
TAMOXIFEN CITRATE 20MG TABLET (30 CT)	1	Preferred Generic	$5.00	N/A	None
TARCEVA 100MG TABLET	4	Specialty-Generic and Brand	33%	N/A	P Q:30 /30Days
TARCEVA 150MG TABLET	4	Specialty-Generic and Brand	33%	N/A	P Q:30 /30Days
TARCEVA 25MG TABLET	4	Specialty-Generic and Brand	33%	N/A	P Q:30 /30Days
TARGRETIN 1% GEL 60GM TUBE	4	Specialty-Generic and Brand	33%	N/A	P Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TARGRETIN 75MG (100 CT)	4	Specialty-Generic and Brand	33%	N/A	P
TARKA 1/240MG TABLET SA	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	Q:60 /30Days
TARKA 2/180MG TABLET SA	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	Q:60 /30Days
TARKA 2/240MG TABLET SA	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	Q:60 /30Days
TARKA 4/240MG TABLET SA	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	Q:60 /30Days
TASIGNA 200MG CAPSULE 28 BLPK	4	Specialty-Generic and Brand	33%	N/A	P Q:120 /30Days
TASMAR 100MG TABLET	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
TASMAR 200MG TABLET	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
TAXOTERE 20MG/0.5ML VIAL	4	Specialty-Generic and Brand	33%	N/A	P
TAXOTERE 80MG/2ML VIAL	4	Specialty-Generic and Brand	33%	N/A	P
TAZORAC 0.05% CREAM	2	Preferred Brand	$29.00	N/A	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TAZORAC 0.05% GEL	2	Preferred Brand	$29.00	N/A	Q:30 /30Days
TAZORAC 0.1% CREAM	2	Preferred Brand	$29.00	N/A	Q:30 /30Days
TAZORAC 0.1% GEL	2	Preferred Brand	$29.00	N/A	Q:30 /30Days
TAZTIA XT 120MG CAPSULE SA (500 CT)	1	Preferred Generic	$5.00	N/A	None
TAZTIA XT 180MG CAPSULE SA (500 CT)	1	Preferred Generic	$5.00	N/A	None
TAZTIA XT 240MG CAPSULE SA	1	Preferred Generic	$5.00	N/A	None
TAZTIA XT 300MG CAPSULE SA (500 CT)	1	Preferred Generic	$5.00	N/A	None
TAZTIA XT 360MG CAPSULE SA	1	Preferred Generic	$5.00	N/A	None
TEGRETOL 100MG TABLET CHEW	2	Preferred Brand	$29.00	N/A	None
TEGRETOL 100MG/5ML SUSP	2	Preferred Brand	$29.00	N/A	None
TEGRETOL 200MG TABLET	2	Preferred Brand	$29.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TEGRETOL XR 100MG SA TABLET	2	Preferred Brand	$29.00	N/A	None
TEGRETOL XR 200MG SA TABLET	2	Preferred Brand	$29.00	N/A	None
TEGRETOL XR 400MG SA TABLET	2	Preferred Brand	$29.00	N/A	None
TERAZOSIN HCL 10MG CAPSULE	1	Preferred Generic	$5.00	N/A	None
TERAZOSIN HCL 1MG CAPSULE	1	Preferred Generic	$5.00	N/A	None
TERAZOSIN HCL 2MG CAPSULE	1	Preferred Generic	$5.00	N/A	None
TERAZOSIN HCL 5MG CAPSULE	1	Preferred Generic	$5.00	N/A	None
TERBINAFINE HCL 250MG TABLET	1	Preferred Generic	$5.00	N/A	None
TERBUTALINE SULF 2.5MG TABLET	1	Preferred Generic	$5.00	N/A	None
TERBUTALINE SULFATE 5MG TABLET	1	Preferred Generic	$5.00	N/A	None
TERCONAZOLE 0.4% CREAM WITH APPLICATOR	1	Preferred Generic	$5.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TERCONAZOLE 0.8% CREAM WITH APPLICATOR	1	Preferred Generic	$5.00	N/A	None
TERCONAZOLE 80MG SUPPOSITORY VAGINAL	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
TESTOSTERONE CYPIONATE INJECTION	1	Preferred Generic	$5.00	N/A	None
TESTOSTERONE CYPIONATE INJECTION 200MG 1 X 10ML VIALMD	1	Preferred Generic	$5.00	N/A	None
TESTOSTERONE ENANTHATE INJECTION	1	Preferred Generic	$5.00	N/A	None
TESTRED 10MG CAPSULE	2	Preferred Brand	$29.00	N/A	P
TETANUS AND DIPHTHERIA TOXOIDS ADSORBED FOR ADULT USE 2 UNT/VIAL	2	Preferred Brand	$29.00	N/A	None
TETANUS TOXOID ADSORBED VIAL 5LF	2	Preferred Brand	$29.00	N/A	None
TETRACYCLINE 500MG CAPSULE	1	Preferred Generic	$5.00	N/A	None
TETRACYCLINE HCL 250MG CAPSULE (1000 CT)	1	Preferred Generic	$5.00	N/A	None
TEV-TROPIN 5MG VIAL	4	Specialty-Generic and Brand	33%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TEVETEN 400MG TILTAB	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	Q:60 /30Days
TEVETEN 600MG TABLET	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	Q:30 /30Days
TEVETEN HCT 600-12.5MG TABLET	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	Q:30 /30Days
TEVETEN HCT 600-25MG TABLET	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	Q:30 /30Days
TEXACORT 2.5% SOLUTION NON-ORAL	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
THALITONE 15MG TABLET	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
THALOMID 100MG CAPSULE 140 BOX	4	Specialty-Generic and Brand	33%	N/A	P Q:28 /28Days
THALOMID 150MG CAPSULE	4	Specialty-Generic and Brand	33%	N/A	P Q:28 /28Days
THALOMID 200MG CAPSULE 28 BLPK	4	Specialty-Generic and Brand	33%	N/A	P Q:28 /28Days
THALOMID 50MG CAPSULE 280 BOX	4	Specialty-Generic and Brand	33%	N/A	P Q:28 /28Days
THEO-24 100MG CAPSULE SA	2	Preferred Brand	$29.00	N/A	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
THEO-24 200MG CAPSULE SA	2	Preferred Brand	$29.00	N/A	Q:30 /30Days
THEO-24 300MG CAPSULE SA	2	Preferred Brand	$29.00	N/A	Q:60 /30Days
THEO-24 400MG CAPSULE SA	2	Preferred Brand	$29.00	N/A	Q:30 /30Days
THEOCHRON 100MG TABLET SA	1	Preferred Generic	$5.00	N/A	None
THEOPHYLLINE 100MG TABLET SA	1	Preferred Generic	$5.00	N/A	None
THEOPHYLLINE 200MG TABLET SA	1	Preferred Generic	$5.00	N/A	None
THEOPHYLLINE 300MG TABLET SA	1	Preferred Generic	$5.00	N/A	None
THEOPHYLLINE 400MG TABLET SA	1	Preferred Generic	$5.00	N/A	None
THEOPHYLLINE 600MG TABLET SA	1	Preferred Generic	$5.00	N/A	None
THEOPHYLLINE ANHYDROUS ER TABLET 200MG (1000 CT)	1	Preferred Generic	$5.00	N/A	None
THEOPHYLLINE TABLET ER 300MG (100 CT)	1	Preferred Generic	$5.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
THEOPHYLLINE TABLET ER 450MG (100 CT)	1	Preferred Generic	$5.00	N/A	None
THIOGUANINE TABLET LOID 40MG	2	Preferred Brand	$29.00	N/A	None
THIOLA 100MG TABLET	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
THIORIDAZINE 100MG TABLET	1	Preferred Generic	$5.00	N/A	None
THIORIDAZINE HCL 10MG TABLET (1000 CT)	1	Preferred Generic	$5.00	N/A	None
THIORIDAZINE HCL 25MG TABLET (1000 CT)	1	Preferred Generic	$5.00	N/A	None
THIORIDAZINE HCL 50MG TABLET (1000 CT)	1	Preferred Generic	$5.00	N/A	None
THIOTEPA 15MG VIAL	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	P
THIOTHIXENE 10MG CAPSULE	1	Preferred Generic	$5.00	N/A	None
THIOTHIXENE 1MG CAPSULE (100 CT)	1	Preferred Generic	$5.00	N/A	None
THIOTHIXENE 2MG CAPSULE	1	Preferred Generic	$5.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
THIOTHIXENE 5MG CAPSULE	1	Preferred Generic	$5.00	N/A	None
THYMOGLOBULIN 25MG VIAL	4	Specialty-Generic and Brand	33%	N/A	P
THYROLAR-1 60MG TABLET	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
THYROLAR-1/2 30MG TABLET	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
THYROLAR-1/4 15MG TABLET	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
THYROLAR-2 120MG TABLET	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
THYROLAR-3 180MG TABLET	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
TICLOPIDINE HCL 250MG TABLET	1	Preferred Generic	$5.00	N/A	None
TIKOSYN .125MG CAPSULE	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
TIKOSYN .250MG CAPSULE	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
TIKOSYN .5MG CAPSULE	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TIMOLIDE 10/25 TABLET	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
TIMOLOL 0.25% GEL/SOLUTION	1	Preferred Generic	$5.00	N/A	None
TIMOLOL 0.5% GEL/SOLUTION	1	Preferred Generic	$5.00	N/A	None
TIMOLOL MAL SOL 0.25% OP 15ML BOT	1	Preferred Generic	$5.00	N/A	None
TIMOLOL MAL SOL 0.5% OP 10ML BOT	1	Preferred Generic	$5.00	N/A	None
TIMOLOL MALEATE 10MG TABLET	1	Preferred Generic	$5.00	N/A	None
TIMOLOL MALEATE 20MG TABLET	1	Preferred Generic	$5.00	N/A	None
TIMOLOL MALEATE 5MG TABLET	1	Preferred Generic	$5.00	N/A	None
TINDAMAX 250MG TABLET	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
TINDAMAX 500MG TABLET (60 CT)	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
TIZANIDINE HCL 2MG TABLET (150 CT)	1	Preferred Generic	$5.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TIZANIDINE HCL 4MG TABLET 150 BOT	1	Preferred Generic	$5.00	N/A	None
TOBRADEX EYE OINTMENT	2	Preferred Brand	$29.00	N/A	None
TOBRADEX SUSPENSION OPHTHALMIC 0.1%/0.3% 5ML BOT	2	Preferred Brand	$29.00	N/A	None
TOBRAMYCIN 10MG/ML VIAL	1	Preferred Generic	$5.00	N/A	None
TOBRAMYCIN 10MG/ML VIAL	1	Preferred Generic	$5.00	N/A	None
TOBRAMYCIN FOR INJECTION 1.2MG/VIAL	1	Preferred Generic	$5.00	N/A	None
TOBRAMYCIN INHALATION SOLUTION	4	Specialty-Generic and Brand	33%	N/A	P Q:280 /28Days
TOBRAMYCIN INJECTION SOLUTION 40MG 10 X 30ML VIAL	1	Preferred Generic	$5.00	N/A	None
TOBRAMYCIN OPHTHALMIC SOLUTION 0.3% 5ML BOT	1	Preferred Generic	$5.00	N/A	None
TOBRAMYCIN-DEXAMETH OPTH SUSP	1	Preferred Generic	$5.00	N/A	None
TOBRASOL 0.3% EYE DROPS	1	Preferred Generic	$5.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TOBREX 0.3% EYE OINTMENT	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
TOLAZAMIDE 250MG TABLET	1	Preferred Generic	$5.00	N/A	None
TOLAZAMIDE 500MG TABLET	1	Preferred Generic	$5.00	N/A	None
TOLBUTAMIDE 500MG TABLET	1	Preferred Generic	$5.00	N/A	None
TOLMETIN SODIUM 200MG TABLET	1	Preferred Generic	$5.00	N/A	None
TOLMETIN SODIUM 400MG CAPSULE	1	Preferred Generic	$5.00	N/A	None
TOLMETIN SODIUM 600MG TABLET	1	Preferred Generic	$5.00	N/A	None
TOPAMAX 100MG TABLET	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	P Q:90 /30Days
TOPAMAX 15MG SPRINKLE CAP	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	P
TOPAMAX 200MG TABLET	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	P Q:60 /30Days
TOPAMAX 25MG SPRINKLE CAP	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TOPAMAX 25MG TABLET	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	P Q:90 /30Days
TOPAMAX 50MG TABLET	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	P Q:90 /30Days
TOPIRAMATE TABLETS 100MG 1000 BOT	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	Q:90 /30Days
TOPIRAMATE TABLETS 200MG 1000 BOT	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	Q:60 /30Days
TOPIRAMATE TABLETS 25MG 1000 BOT	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	Q:90 /30Days
TOPIRAMATE TABLETS 50MG 1000 BOT	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	Q:90 /30Days
TOPROL XL 100MG TABLET SA	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
TOPROL XL 200MG TABLET SA	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
TOPROL XL 25MG TABLET SA	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
TOPROL XL 50MG TABLET SA	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
TORISEL SOL 25MG/ML	4	Specialty-Generic and Brand	33%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TORSEMIDE 100MG TABLET	1	Preferred Generic	$5.00	N/A	None
TORSEMIDE 10MG TABLET	1	Preferred Generic	$5.00	N/A	None
TORSEMIDE 20MG TABLET	1	Preferred Generic	$5.00	N/A	None
TORSEMIDE 5MG TABLET	1	Preferred Generic	$5.00	N/A	None
TPN ELECTROLYTES VIAL	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
TRACLEER 125MG TABLET	4	Specialty-Generic and Brand	33%	N/A	P Q:60 /30Days
TRACLEER 62.5MG TABLET	4	Specialty-Generic and Brand	33%	N/A	P Q:60 /30Days
TRAMADOL HCL 50MG TABLET (500 CT)	1	Preferred Generic	$5.00	N/A	None
TRAMADOL HCL-ACETAMINOPHEN 37.5-325MG TABLET (1000 CT)	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
TRANDOLAPRIL 1MG TABLET	1	Preferred Generic	$5.00	N/A	None
TRANDOLAPRIL 2MG TABLET	1	Preferred Generic	$5.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRANDOLAPRIL 4MG TABLET	1	Preferred Generic	$5.00	N/A	None
TRANYLCYPROMINE SULFATE 10MG TABLET	1	Preferred Generic	$5.00	N/A	None
TRAVATAN 0.004% EYE DROP 2.5ML BOT	2	Preferred Brand	$29.00	N/A	Q:5 /30Days
TRAVATAN Z 0.04MG DROPS 2.5ML BOT	2	Preferred Brand	$29.00	N/A	Q:5 /30Days
TRAZODONE 300MG TABLET	1	Preferred Generic	$5.00	N/A	None
TRAZODONE HCL TABLET USP 100MG (500 CT)	1	Preferred Generic	$5.00	N/A	None
TRAZODONE HCL TABLET USP 150MG (100 CT)	1	Preferred Generic	$5.00	N/A	None
TRAZODONE HCL TABLET USP 50MG (500 CT)	1	Preferred Generic	$5.00	N/A	None
TREANDA FOR INJECTION 100MG/VIAL	4	Specialty-Generic and Brand	33%	N/A	P
TRECATOR 250MG TABLET	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
TRETINOIN 0.01% GEL 45GM TUBE	1	Preferred Generic	$5.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRETINOIN 0.025% CREAM	1	Preferred Generic	$5.00	N/A	None
TRETINOIN 0.025% GEL 45GM TUBE	1	Preferred Generic	$5.00	N/A	None
TRETINOIN 0.05% CREAM 45GM TUBE	1	Preferred Generic	$5.00	N/A	None
TRETINOIN 0.1% CREAM 45GM TUBE	1	Preferred Generic	$5.00	N/A	None
TRETINOIN 10MG CAPSULE	4	Specialty-Generic and Brand	33%	N/A	P
TRI-LEGEST FE 5-7-9-7 TABLET	1	Preferred Generic	$5.00	N/A	None
TRI-PREVIFEM 7DAYSX3 28 168 CRTN	1	Preferred Generic	$5.00	N/A	None
TRI-SPRINTEC 7DAYSX3 28 TABLET	1	Preferred Generic	$5.00	N/A	None
TRIAMCINOLONE 0.1% OINTMENT	1	Preferred Generic	$5.00	N/A	None
TRIAMCINOLONE 0.1% PASTE	1	Preferred Generic	$5.00	N/A	None
TRIAMCINOLONE ACETONIDE 0.025% OINTMENT 80GM TUBE	1	Preferred Generic	$5.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRIAMCINOLONE ACETONIDE 0.1% LOTION 60ML BOTPL	1	Preferred Generic	$5.00	N/A	None
TRIAMCINOLONE ACETONIDE 0.025% CREAM 80GM TUBE	1	Preferred Generic	$5.00	N/A	None
TRIAMCINOLONE ACETONIDE 0.025% LOTION 2 FL OZ BOT	1	Preferred Generic	$5.00	N/A	None
TRIAMCINOLONE ACETONIDE 0.05% CREAM 15GM TUBE	1	Preferred Generic	$5.00	N/A	None
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT	1	Preferred Generic	$5.00	N/A	None
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE	1	Preferred Generic	$5.00	N/A	None
TRIAMCINOLONE ACETONIDE 0.1% CREAM 80GM TUBE	1	Preferred Generic	$5.00	N/A	None
TRIAMTERENE/HCTZ 25/37.5MG CAPSULES (100 CT)	1	Preferred Generic	$5.00	N/A	None
TRIAMTERENE/HCTZ 37.5/25 TABLET	1	Preferred Generic	$5.00	N/A	None
TRIAMTERENE/HCTZ 50/25 CAPSULE	1	Preferred Generic	$5.00	N/A	None
TRIAMTERENE/HCTZ 75/50 TABLET	1	Preferred Generic	$5.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRICOR 145MG TABLET	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	Q:30 /30Days
TRICOR 48MG TABLET	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	Q:30 /30Days
TRIFLUOPERAZINE 1MG TABLET	1	Preferred Generic	$5.00	N/A	None
TRIFLUOPERAZINE HCL 2MG TABLET	1	Preferred Generic	$5.00	N/A	None
TRIFLUOPERAZINE HCL 5MG TABLET	1	Preferred Generic	$5.00	N/A	None
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT)	1	Preferred Generic	$5.00	N/A	None
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT	1	Preferred Generic	$5.00	N/A	None
TRIGLIDE 160MG TABLET (30 CT)	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	Q:30 /30Days
TRIGLIDE 50MG TABLET (30 CT)	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	Q:30 /30Days
TRIHEXYPHENIDYL HCL 5MG TABLET (100 CT)	1	Preferred Generic	$5.00	N/A	None
TRIHEXYPHENIDYL HCL ELIXIR 5%/2 16 FLO BOT	1	Preferred Generic	$5.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRIHEXYPHENIDYL HCL TABLET 2MG (1000 CT)	1	Preferred Generic	$5.00	N/A	None
TRIHIBIT PRESERVATIVE FREE	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
TRILEPTAL 300MG/5ML SUSP	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	Q:1200 /30Days
TRILYTE WITH FLAVOR PACKETS 5.72GM/11.2GM	1	Preferred Generic	$5.00	N/A	None
TRIMETHOBENZAMIDE HCL 300MG CAPSULE	1	Preferred Generic	$5.00	N/A	None
TRIMETHOPRIM 100MG TABLET	1	Preferred Generic	$5.00	N/A	None
TRIMIPRAMINE MALEATE 25MG CAPSULE	1	Preferred Generic	$5.00	N/A	None
TRIMIPRAMINE MALEATE 50MG CAPSULE	1	Preferred Generic	$5.00	N/A	None
TRIMOX CAP 500MG	1	Preferred Generic	$5.00	N/A	None
TRINESSA 7DAYSX3 28 TABLET	1	Preferred Generic	$5.00	N/A	None
TRIPLE ANTIBIOTIC EYE OINT	1	Preferred Generic	$5.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRISENOX 10MG/10ML AMPULE	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	P
TRIVORA-28 TABLET	1	Preferred Generic	$5.00	N/A	None
TRIZIVIR TABLET	2	Preferred Brand	$29.00	N/A	None
TROPICAMIDE 0.5% EYE DROPS	1	Preferred Generic	$5.00	N/A	None
TROPICAMIDE 1% EYE DROPS	1	Preferred Generic	$5.00	N/A	None
TRUSOPT PLUS 2% EYE DROPS 10ML BOT	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
TRUVADA TABLET	4	Specialty-Generic and Brand	33%	N/A	Q:30 /30Days
TWINJECT 0.15MG AUTO-INJECTOR	2	Preferred Brand	$29.00	N/A	Q:1 /30Days
TWINJECT 0.3MG AUTO-INJECTOR	2	Preferred Brand	$29.00	N/A	Q:1 /30Days
TWINRIX TF PF VACCINE 720UNT/20ML 10 X 1ML VIALSD	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
TYGACIL 50MG VIAL 10 VILSU BOX	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TYKERB 250MG TABLET	4	Specialty-Generic and Brand	33%	N/A	P Q:150 /30Days
TYPHIM VI 25MCG/0.5ML VIAL	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
TYSABRI 300MG/15ML VIAL	4	Specialty-Generic and Brand	33%	N/A	P
TYZEKA 600MG TABLET (30 CT)	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	Q:30 /30Days
TYZINE 0.1% NOSE DROPS	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None
TYZINE PEDIATRIC 0.05% DROP	3	Non-Preferred Generic/Non-Preferred Brand	$58.00	N/A	None

Chart Legend:

Below are a few notes to help you understand the above 2009 Medicare Part D First Health Part D-Premier Plan Formulary.

Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region).
Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.
Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $295 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.
Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
- Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.
- No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.
Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
- Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
- Drug Description - This is the Medicare Part D plan’s description of this particular drug tier.
Cost Sharing - Copay / Coinsurance - These figures apply to the initial coverage phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
- Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the initial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $2700) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2013 Humana Walmart-Preferred Rx Plan the cost-sharing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
- Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
- None - This drug does not fall under any drug utilization management controls.
- P - Prior Authorization -This drug is subject to prior authorization.
- S - Step Therapy -This drug is subject to step therapy.
- Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.

(Chart Source: Centers for Medicare and Medicaid files: CMS Data October 2009 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Part D plan provider.