2010 Medicare Part D Plan Formulary Information |
Senior Advantage Medicare Medicaid Plan (H (H1170-008-0)
Benefit Details
|
The Senior Advantage Medicare Medicaid Plan (H (H1170-008-0) Formulary Drugs Starting with the Letter T in Gwinn County, GA: CMS MA Region 8 which includes: GA
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Drugs Starting with Letter T
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
TAMIFLU 75MG CAPSULE UD |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TAMIFLU ORAL SUSPENSION |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TAMOXIFEN CITRATE 20MG TABLET (30 CT) |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TAMOXIFEN CITRATE TABLETS 10MG 180 BOT |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TARCEVA 100MG TABLET |
3 |
Tier 3 |
25% | N/A | None |
TARCEVA 150MG TABLET |
3 |
Tier 3 |
25% | N/A | None |
TARCEVA 25MG TABLET |
3 |
Tier 3 |
25% | N/A | None |
TARGRETIN 1% GEL 60GM TUBE |
3 |
Tier 3 |
25% | N/A | None |
TARGRETIN 75MG (100 CT) |
3 |
Tier 3 |
25% | N/A | None |
TASIGNA 200MG CAPSULE 28 BLPK |
3 |
Tier 3 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAXOTERE 80MG/2ML VIAL |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TAZICEF 1GM VIAL |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TAZICEF 2GM ADD-VANTAGE |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TAZICEF 6GM/100ML VIAL |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TAZORAC 0.05% CREAM |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TAZORAC 0.05% GEL |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TAZORAC 0.1% CREAM |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TAZORAC 0.1% GEL |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TEGRETOL XR TABLETS 100MG 100 BOT |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TERAZOSIN HCL 10MG CAPSULE |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TERAZOSIN HCL 1MG CAPSULE |
1 |
Tier 1 |
$12.00 | $24.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TERAZOSIN HCL 2MG CAPSULE |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TERAZOSIN HCL 5MG CAPSULE |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TERBINAFINE HCL 250MG TABLET |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TERBUTALINE SULF 1MG/ML VL |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TERBUTALINE SULF 2.5MG TABLET |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TERBUTALINE SULFATE 5MG TABLET |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TERCONAZOLE 0.4% CREAM WITH APPLICATOR |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TERCONAZOLE 0.8% CREAM WITH APPLICATOR |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TESTOSTERONE CYPIONATE INJECTION |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TESTOSTERONE ENANTHATE INJECTION |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TESTRED 10MG CAPSULE |
2 |
Tier 2 |
$39.00 | $78.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TETANUS AND DIPHTHERIA TOXOIDS ADSORBED FOR ADULT USE 2 UNT/VIAL |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TETANUS TOXOID ADSORBED VIAL 5LF |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TETRACYCLINE 500MG CAPSULE |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TETRACYCLINE HCL CAPSULES 250MG 100 (10 X 10) NS |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TEXACORT 2.5% SOLUTION NON-ORAL |
2 |
Tier 2 |
$39.00 | $78.00 | None |
THALOMID 100MG CAPSULE 140 BOX |
3 |
Tier 3 |
25% | N/A | None |
THALOMID 150MG CAPSULE |
3 |
Tier 3 |
25% | N/A | None |
THALOMID 200MG CAPSULE 28 BLPK |
3 |
Tier 3 |
25% | N/A | None |
THALOMID 50MG CAPSULE 280 BOX |
3 |
Tier 3 |
25% | N/A | None |
THEOCHRON 100MG TABLET SA |
1 |
Tier 1 |
$12.00 | $24.00 | None |
THEOPHYLLINE 400MG TABLET SA |
1 |
Tier 1 |
$12.00 | $24.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THEOPHYLLINE ANHYDROUS ER TABLET 200MG (1000 CT) |
1 |
Tier 1 |
$12.00 | $24.00 | None |
THEOPHYLLINE TABLET ER 300MG (100 CT) |
1 |
Tier 1 |
$12.00 | $24.00 | None |
THEOPHYLLINE TABLET ER 450MG (100 CT) |
1 |
Tier 1 |
$12.00 | $24.00 | None |
THIOGUANINE TABLET LOID 40MG |
2 |
Tier 2 |
$39.00 | $78.00 | None |
THIOLA 100MG TABLET |
2 |
Tier 2 |
$39.00 | $78.00 | None |
THIORIDAZINE 100MG TABLET |
1 |
Tier 1 |
$12.00 | $24.00 | None |
THIORIDAZINE HCL 10MG TABLET (1000 CT) |
1 |
Tier 1 |
$12.00 | $24.00 | None |
THIORIDAZINE HCL 25MG TABLET (1000 CT) |
1 |
Tier 1 |
$12.00 | $24.00 | None |
THIORIDAZINE HCL 50MG TABLET (1000 CT) |
1 |
Tier 1 |
$12.00 | $24.00 | None |
THIOTEPA POWDER FOR INJECTION 15MG/VIL 1 VIAL SINGLE DOSE CRTN |
2 |
Tier 2 |
$39.00 | $78.00 | None |
THIOTHIXENE 10MG CAPSULE |
1 |
Tier 1 |
$12.00 | $24.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THIOTHIXENE 1MG CAPSULE (100 CT) |
1 |
Tier 1 |
$12.00 | $24.00 | None |
THIOTHIXENE 2MG CAPSULE |
1 |
Tier 1 |
$12.00 | $24.00 | None |
THIOTHIXENE 5MG CAPSULE |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TIKOSYN .125MG CAPSULE |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TIKOSYN .250MG CAPSULE |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TIKOSYN .5MG CAPSULE |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TIMENTIN 3.1GM VIAL |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TIMOLOL MAL SOL 0.25% OP 15ML BOT |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TIMOLOL MAL SOL 0.5% OP 10ML BOT |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TIMOLOL MALEATE 10MG TABLET |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TIMOLOL MALEATE 20MG TABLET |
1 |
Tier 1 |
$12.00 | $24.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIMOLOL MALEATE 5MG TABLET |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TIZANIDINE HCL 2MG TABLET (150 CT) |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TIZANIDINE HCL 4MG TABLET 150 BOT |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TOBRADEX EYE OINTMENT |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TOBRAMYCIN 10MG/ML VIAL |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TOBRAMYCIN 40MG/ML VIAL |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TOBRAMYCIN INHALATION SOLUTION |
3 |
Tier 3 |
25% | N/A | None |
TOBRAMYCIN OPHTHALMIC SOLUTION 0.3% 5ML BOT |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TOBRAMYCIN-DEXAMETH OPTH SUSP |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TOBREX 0.3% EYE OINTMENT |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TOLBUTAMIDE 500MG TABLET |
1 |
Tier 1 |
$12.00 | $24.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOPIRAMATE CAPSULES 25MG 60 CAPS BOT |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TOPIRAMATE SPRINKLE CAPSULES 15MG 60 BOT |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TOPIRAMATE TABLETS 100MG 1000 BOT |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TOPIRAMATE TABLETS 200MG 1000 BOT |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TOPIRAMATE TABLETS 25MG 1000 BOT |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TOPIRAMATE TABLETS 50MG 1000 BOT |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TOPOSAR INJECTION 20MG/ML 50ML VIAL MD CRTN |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TORISEL SOL 25MG/ML |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TPN ELECTROLYTES VIAL |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TRACLEER 125MG TABLET |
3 |
Tier 3 |
25% | N/A | None |
TRACLEER 62.5MG TABLET |
3 |
Tier 3 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRAMADOL HCL 50MG TABLET (500 CT) |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TRANSDERM-SCOP 1.5MG 24 PKG |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TRANYLCYPROMINE SULFATE 10MG TABLET |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TRAVASOL 3.5%-ELECTROLYTES |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TRAVASOL 8.5%/DEXTROSE 10% QUICK MIX CONT |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TRAVASOL 8.5%/DEXTROSE 20% QUICK MIX CONT |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TRAVASOL 8.5%/DEXTROSE 50% QUICK MIX CONT |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TRAVATAN Z 0.04MG DROPS 2.5ML BOT |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TRAZODONE HCL TABLET USP 100MG (500 CT) |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TRAZODONE HCL TABLET USP 150MG (100 CT) |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TRAZODONE HCL TABLET USP 50MG (500 CT) |
1 |
Tier 1 |
$12.00 | $24.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TREANDA FOR INJECTION 100MG/VIAL |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TRECATOR 250MG TABLET |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TRETINOIN 0.01% GEL 45GM TUBE |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TRETINOIN 0.025% GEL 45GM TUBE |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TRETINOIN 0.05% CREAM 45GM TUBE |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TRETINOIN 0.1% CREAM 45GM TUBE |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TRETINOIN 10MG CAPSULE |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TREXALL 10MG TABLET |
2 |
Tier 2 |
$39.00 | $78.00 | P |
TREXALL 15MG TABLET |
2 |
Tier 2 |
$39.00 | $78.00 | P |
TREXALL 5MG TABLET |
2 |
Tier 2 |
$39.00 | $78.00 | P |
TREXALL 7.5MG TABLET |
2 |
Tier 2 |
$39.00 | $78.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRI-NORINYL 28 TABLET |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TRIAMCINOLONE 0.1% OINTMENT |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TRIAMCINOLONE 0.1% PASTE |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TRIAMCINOLONE ACETONIDE 0.025% OINTMENT 80GM TUBE |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TRIAMCINOLONE ACETONIDE 0.1% LOTION 60ML BOTPL |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TRIAMCINOLONE ACETONIDE 0.025% CREAM 80GM TUBE |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TRIAMCINOLONE ACETONIDE 0.025% LOTION 2 FL OZ BOT |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TRIAMCINOLONE ACETONIDE 0.05% CREAM 15GM TUBE |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TRIAMTERENE/HCTZ 25/37.5MG CAPSULES (100 CT) |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TRIAMTERENE/HCTZ 37.5/25 TABLET |
1 |
Tier 1 |
$12.00 | $24.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIAMTERENE/HCTZ 50/25 CAPSULE |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TRIAMTERENE/HCTZ 75/50 TABLET |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TRIDERM 0.1% CREAM |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TRIFLUOPERAZINE 1MG TABLET |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TRIFLUOPERAZINE HCL 2MG TABLET |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TRIFLUOPERAZINE HCL 5MG TABLET |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT) |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TRIHEXYPHENIDYL HCL 5MG TABLET (100 CT) |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TRIHEXYPHENIDYL HCL ELIXIR 5%/2 16 FLO BOT |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TRIHEXYPHENIDYL HCL TABLET 2MG (1000 CT) |
1 |
Tier 1 |
$12.00 | $24.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIHIBIT PRESERVATIVE FREE |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TRILEPTAL 300MG/5ML SUSP |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TRIMETHOBENZAMIDE 100MG/ML |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TRIMETHOBENZAMIDE HCL 300MG CAPSULE |
1 |
Tier 1 |
$12.00 | $24.00 | P |
TRIMETHOPRIM 100MG TABLET |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TRIMIPRAMINE MALEATE 25MG CAPSULE |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TRIMIPRAMINE MALEATE 50MG CAPSULE |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TRIPEDIA PRESERVATIVE FREE 6.7;23.4; UNT/.5 ML; |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TRISENOX 10MG/10ML AMPULE |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TRIVORA-28 TABLET |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TRIZIVIR TABLET |
2 |
Tier 2 |
$39.00 | $78.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TROPHAMINE INJECTION SOLUTION |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TROPHAMINE INJECTION SOLUTION 6% |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TROPICACYL SOL 0.5% OP |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TROPICACYL SOL 1% OP |
1 |
Tier 1 |
$12.00 | $24.00 | None |
TRUVADA TABLET |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TWINJECT AUTO INJECTOR INJECTION 1% AUTO INJECTOR TWO PACK SYR |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TWINJECT AUTO INJECTOR INJECTION 1% AUTO TWO PACK SYR |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TWINRIX TF PF VACCINE 720UNT/20ML 10 X 1ML VIALSD |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TYKERB 250MG TABLET |
3 |
Tier 3 |
25% | N/A | None |
TYPHIM VI 25MCG/0.5ML VIAL |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TYSABRI 300MG/15ML VIAL |
2 |
Tier 2 |
$39.00 | $78.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TYZINE 0.1% NOSE DROPS |
2 |
Tier 2 |
$39.00 | $78.00 | None |