2010 Medicare Part D Plan Formulary Information |
Evercare Plan DH (HMO) (H4514-001-0)
Benefit Details
|
The Evercare Plan DH (HMO) (H4514-001-0) Formulary Drugs Starting with the Letter T in Walle County, TX: CMS MA Region 17 which includes: TX
|
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 30MG CAPSULE |
2 |
Tier 2 |
15% | 15% | Q:31 /31Days |
TAMIFLU 45MG CAPSULE |
2 |
Tier 2 |
15% | 15% | Q:31 /31Days |
TAMIFLU 75MG CAPSULE UD |
2 |
Tier 2 |
15% | 15% | Q:31 /31Days |
TAMIFLU ORAL SUSPENSION |
2 |
Tier 2 |
15% | 15% | Q:194 /31Days |
TAMOXIFEN CITRATE 20MG TABLET (30 CT) |
1 |
Tier 1 |
15% | 15% | None |
TAMOXIFEN CITRATE TABLETS 10MG 180 BOT |
1 |
Tier 1 |
15% | 15% | None |
TAZICEF 1GM VIAL |
2 |
Tier 2 |
15% | 15% | None |
TAZICEF 2GM ADD-VANTAGE |
2 |
Tier 2 |
15% | 15% | None |
TAZICEF 6GM/100ML VIAL |
2 |
Tier 2 |
15% | 15% | None |
TAZTIA XT 120MG CAPSULE SA (500 CT) |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAZTIA XT 180MG CAPSULE SA (500 CT) |
1 |
Tier 1 |
15% | 15% | None |
TAZTIA XT 240MG CAPSULE SA |
1 |
Tier 1 |
15% | 15% | None |
TAZTIA XT 300MG CAPSULE SA (500 CT) |
1 |
Tier 1 |
15% | 15% | None |
TAZTIA XT 360MG CAPSULE SA |
1 |
Tier 1 |
15% | 15% | None |
TEGRETOL CHEWABLE TABLETS 100MG 100 BOT |
2 |
Tier 2 |
15% | 15% | None |
TEGRETOL SUSPENSION 100MG/5ML 450 ML BOT |
2 |
Tier 2 |
15% | 15% | None |
TEGRETOL TABLETS 200MG 100 BOT |
2 |
Tier 2 |
15% | 15% | None |
TEGRETOL XR TABLETS 100MG 100 BOT |
2 |
Tier 2 |
15% | 15% | None |
TEGRETOL XR TABLETS 200MG 100 BOT |
2 |
Tier 2 |
15% | 15% | None |
TEGRETOL XR TABLETS 400MG 100 BOT |
2 |
Tier 2 |
15% | 15% | None |
TEKTURNA 150MG TABLET |
2 |
Tier 2 |
15% | 15% | S Q:31 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TEKTURNA 300MG TABLET |
2 |
Tier 2 |
15% | 15% | S Q:31 /31Days |
TEKTURNA HCT 150-12.5MG TABLET |
2 |
Tier 2 |
15% | 15% | S Q:31 /31Days |
TEKTURNA HCT 150MG-25MG TABLET |
2 |
Tier 2 |
15% | 15% | S Q:31 /31Days |
TEKTURNA HCT 300-12.5MG TABLET |
2 |
Tier 2 |
15% | 15% | S Q:31 /31Days |
TEKTURNA HCT 300MG-25MG TABLET |
2 |
Tier 2 |
15% | 15% | S Q:31 /31Days |
TERAZOSIN HCL 10MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
TERAZOSIN HCL 1MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
TERAZOSIN HCL 2MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
TERAZOSIN HCL 5MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
TERBINAFINE HCL 250MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
TERBUTALINE SULF 1MG/ML VL |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TERBUTALINE SULF 2.5MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
TERBUTALINE SULFATE 5MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
TERCONAZOLE 0.4% CREAM WITH APPLICATOR |
1 |
Tier 1 |
15% | 15% | None |
TERCONAZOLE 0.8% CREAM WITH APPLICATOR |
1 |
Tier 1 |
15% | 15% | None |
TERCONAZOLE 80MG SUPPOSITORY VAGINAL |
1 |
Tier 1 |
15% | 15% | None |
TESTOSTERONE CYPIONATE INJECTION |
1 |
Tier 1 |
15% | 15% | P |
TESTOSTERONE ENANTHATE INJECTION |
1 |
Tier 1 |
15% | 15% | P |
TETANUS AND DIPHTHERIA TOXOIDS ADSORBED FOR ADULT USE 2 UNT/VIAL |
2 |
Tier 2 |
15% | 15% | None |
TETANUS TOXOID ADSORBED VIAL 5LF |
2 |
Tier 2 |
15% | 15% | None |
TETRACYCLINE 500MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
TETRACYCLINE HCL CAPSULES 250MG 100 (10 X 10) NS |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TEXACORT |
1 |
Tier 1 |
15% | 15% | None |
THEO-24 100MG CAPSULE SA |
2 |
Tier 2 |
15% | 15% | None |
THEO-24 200MG CAPSULE SA |
2 |
Tier 2 |
15% | 15% | None |
THEO-24 300MG CAPSULE SA |
2 |
Tier 2 |
15% | 15% | None |
THEO-24 400MG CAPSULE SA |
2 |
Tier 2 |
15% | 15% | None |
THEOCHRON 100MG TABLET SA |
1 |
Tier 1 |
15% | 15% | None |
THEOCHRON 100MG TABLET SA |
1 |
Tier 1 |
15% | 15% | None |
THEOCHRON 200MG TABLET SA 100 EA |
1 |
Tier 1 |
15% | 15% | None |
THEOCHRON TABLETS EXTENDED RELEASE 300MG 100 BOT |
1 |
Tier 1 |
15% | 15% | None |
THEOPHYLLINE 200MG TABLET SA |
1 |
Tier 1 |
15% | 15% | None |
THEOPHYLLINE 300MG TABLET SA |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THEOPHYLLINE 400MG TABLET SA |
1 |
Tier 1 |
15% | 15% | None |
THEOPHYLLINE 600MG TABLET SA |
1 |
Tier 1 |
15% | 15% | None |
THEOPHYLLINE ANHYDROUS ER TABLET 200MG (1000 CT) |
1 |
Tier 1 |
15% | 15% | None |
THEOPHYLLINE TABLET ER 300MG (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
THEOPHYLLINE TABLET ER 450MG (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
THERMAZENE 50GM CREAM |
1 |
Tier 1 |
15% | 15% | None |
THIORIDAZINE 100MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
THIORIDAZINE HCL 10MG TABLET (1000 CT) |
1 |
Tier 1 |
15% | 15% | None |
THIORIDAZINE HCL 25MG TABLET (1000 CT) |
1 |
Tier 1 |
15% | 15% | None |
THIORIDAZINE HCL 50MG TABLET (1000 CT) |
1 |
Tier 1 |
15% | 15% | None |
THIOTHIXENE 10MG CAPSULE |
1 |
Tier 1 |
15% | 15% | 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 |
15% | 15% | None |
THIOTHIXENE 2MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
THIOTHIXENE 5MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
THYROLAR-1 60MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
THYROLAR-1/2 30MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
THYROLAR-1/4 15MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
THYROLAR-2 120MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
THYROLAR-3 180MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
TICLOPIDINE HCL 250MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
TIMOLOL MAL SOL 0.25% OP 15ML BOT |
1 |
Tier 1 |
15% | 15% | None |
TIMOLOL MAL SOL 0.5% OP 10ML BOT |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIMOLOL MALEATE 10MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
TIMOLOL MALEATE 20MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
TIMOLOL MALEATE 5MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
TINDAMAX 250MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
TINDAMAX 500MG TABLET (60 CT) |
2 |
Tier 2 |
15% | 15% | None |
TIS-U-SOL IRRIGATION SOLUTION |
1 |
Tier 1 |
15% | 15% | None |
TIZANIDINE HCL 2MG TABLET (150 CT) |
1 |
Tier 1 |
15% | 15% | None |
TIZANIDINE HCL 4MG TABLET 150 BOT |
1 |
Tier 1 |
15% | 15% | None |
TOBRADEX EYE OINTMENT |
2 |
Tier 2 |
15% | 15% | None |
TOBRAMYCIN 10MG/ML VIAL |
1 |
Tier 1 |
15% | 15% | None |
TOBRAMYCIN 40MG/ML VIAL |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOBRAMYCIN 60MG/0.9% NACL |
1 |
Tier 1 |
15% | 15% | None |
TOBRAMYCIN 80MG/0.9% NACL |
1 |
Tier 1 |
15% | 15% | None |
TOBRAMYCIN OPHTHALMIC SOLUTION 0.3% 5ML BOT |
1 |
Tier 1 |
15% | 15% | None |
TOBRAMYCIN-DEXAMETH OPTH SUSP |
1 |
Tier 1 |
15% | 15% | None |
TOBRASOL 0.3% EYE DROPS |
1 |
Tier 1 |
15% | 15% | None |
TOBREX 0.3% EYE OINTMENT |
2 |
Tier 2 |
15% | 15% | None |
TOLAZAMIDE TABLETS 250MG 100 BOT |
1 |
Tier 1 |
15% | 15% | None |
TOLAZAMIDE TABLETS 500MG 100 BOT |
1 |
Tier 1 |
15% | 15% | None |
TOLBUTAMIDE 500MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
TOLMETIN SODIUM 200MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
TOLMETIN SODIUM 400MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOLMETIN SODIUM 600MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
TOPIRAMATE CAPSULES 25MG 60 CAPS BOT |
1 |
Tier 1 |
15% | 15% | None |
TOPIRAMATE SPRINKLE CAPSULES 15MG 60 BOT |
1 |
Tier 1 |
15% | 15% | None |
TOPIRAMATE TABLETS 100MG 1000 BOT |
1 |
Tier 1 |
15% | 15% | None |
TOPIRAMATE TABLETS 200MG 1000 BOT |
1 |
Tier 1 |
15% | 15% | None |
TOPIRAMATE TABLETS 25MG 1000 BOT |
1 |
Tier 1 |
15% | 15% | None |
TOPIRAMATE TABLETS 50MG 1000 BOT |
1 |
Tier 1 |
15% | 15% | None |
TOPOSAR INJECTION 20MG/ML 50ML VIAL MD CRTN |
1 |
Tier 1 |
15% | 15% | None |
TORSEMIDE 100MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
TORSEMIDE 10MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
TORSEMIDE 20MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TORSEMIDE 5MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
TPN ELECTROLYTES VIAL |
2 |
Tier 2 |
15% | 15% | None |
TRAMADOL HCL 50MG TABLET (500 CT) |
1 |
Tier 1 |
15% | 15% | None |
TRAMADOL HCL-ACETAMINOPHEN 37.5-325MG TABLET (1000 CT) |
1 |
Tier 1 |
15% | 15% | None |
TRANDOLAPRIL 1MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
TRANDOLAPRIL 2MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
TRANDOLAPRIL 4MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
TRANYLCYPROMINE SULFATE 10MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
TRAVASOL 3.5%-ELECTROLYTES |
1 |
Tier 1 |
15% | 15% | P |
TRAVASOL 8.5%-ELECTROLYTES |
1 |
Tier 1 |
15% | 15% | P |
TRAVATAN Z 0.04MG DROPS 2.5ML BOT |
2 |
Tier 2 |
15% | 15% | Q:5 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRAZODONE 300MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
TRAZODONE HCL TABLET USP 100MG (500 CT) |
1 |
Tier 1 |
15% | 15% | None |
TRAZODONE HCL TABLET USP 150MG (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
TRAZODONE HCL TABLET USP 50MG (500 CT) |
1 |
Tier 1 |
15% | 15% | None |
TRETINOIN 0.01% GEL 45GM TUBE |
1 |
Tier 1 |
15% | 15% | P |
TRETINOIN 0.025% CREAM |
1 |
Tier 1 |
15% | 15% | P |
TRETINOIN 0.025% GEL 45GM TUBE |
1 |
Tier 1 |
15% | 15% | P |
TRETINOIN 0.025% GEL 45GM TUBE |
1 |
Tier 1 |
15% | 15% | P |
TRETINOIN 0.05% CREAM 45GM TUBE |
1 |
Tier 1 |
15% | 15% | P |
TRETINOIN 0.1% CREAM 45GM TUBE |
1 |
Tier 1 |
15% | 15% | P |
TREZIX 16-356-30 CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRI-LEGEST FE 5-7-9-7 TABLET |
1 |
Tier 1 |
15% | 15% | None |
TRI-SPRINTEC 7DAYSX3 28 TABLET |
1 |
Tier 1 |
15% | 15% | None |
TRIAMCINOLONE 0.1% OINTMENT |
1 |
Tier 1 |
15% | 15% | None |
TRIAMCINOLONE 0.1% PASTE |
1 |
Tier 1 |
15% | 15% | None |
TRIAMCINOLONE ACETONIDE 0.025% OINTMENT 80GM TUBE |
1 |
Tier 1 |
15% | 15% | None |
TRIAMCINOLONE ACETONIDE 0.1% LOTION 60ML BOTPL |
1 |
Tier 1 |
15% | 15% | None |
TRIAMCINOLONE ACETONIDE 0.025% CREAM 80GM TUBE |
1 |
Tier 1 |
15% | 15% | None |
TRIAMCINOLONE ACETONIDE 0.025% LOTION 2 FL OZ BOT |
1 |
Tier 1 |
15% | 15% | None |
TRIAMCINOLONE ACETONIDE 0.05% CREAM 15GM TUBE |
1 |
Tier 1 |
15% | 15% | None |
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT |
1 |
Tier 1 |
15% | 15% | None |
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIAMCINOLONE ACETONIDE 0.1% CREAM 80GM TUBE |
1 |
Tier 1 |
15% | 15% | None |
TRIAMTERENE/HCTZ 25/37.5MG CAPSULES (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
TRIAMTERENE/HCTZ 37.5/25 TABLET |
1 |
Tier 1 |
15% | 15% | None |
TRIAMTERENE/HCTZ 50/25 CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
TRIAMTERENE/HCTZ 75/50 TABLET |
1 |
Tier 1 |
15% | 15% | None |
TRICOR 145MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
TRICOR 48MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
TRIDERM 0.1% CREAM |
1 |
Tier 1 |
15% | 15% | None |
TRIDERM 0.1% OINTMENT |
1 |
Tier 1 |
15% | 15% | None |
TRIFLUOPERAZINE 1MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
TRIFLUOPERAZINE HCL 2MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIFLUOPERAZINE HCL 5MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT |
2 |
Tier 2 |
15% | 15% | None |
TRIHEXYPHENIDYL HCL 5MG TABLET (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
TRIHEXYPHENIDYL HCL ELIXIR 5%/2 16 FLO BOT |
1 |
Tier 1 |
15% | 15% | None |
TRIHEXYPHENIDYL HCL TABLET 2MG (1000 CT) |
1 |
Tier 1 |
15% | 15% | None |
TRIHIBIT PRESERVATIVE FREE |
2 |
Tier 2 |
15% | 15% | None |
TRILIPIX CAPSULE DR 45MG |
2 |
Tier 2 |
15% | 15% | None |
TRILIPIX DELAYED RELEASE CAPSULES 135MG |
2 |
Tier 2 |
15% | 15% | None |
TRIMETHOBENZAMIDE 100MG/ML |
1 |
Tier 1 |
15% | 15% | P |
TRIMETHOBENZAMIDE HCL 300MG CAPSULE |
1 |
Tier 1 |
15% | 15% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIMETHOPRIM 100MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
TRIMIPRAMINE MALEATE 25MG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
TRIMIPRAMINE MALEATE 50MG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
TRIMOX CAP 500MG |
1 |
Tier 1 |
15% | 15% | None |
TRINESSA 28 TABLETS 0.180;0.35MG;MG |
1 |
Tier 1 |
15% | 15% | None |
TRIPEDIA PRESERVATIVE FREE 6.7;23.4; UNT/.5 ML; |
2 |
Tier 2 |
15% | 15% | None |
TRIVORA-28 TABLET |
1 |
Tier 1 |
15% | 15% | None |
TROPICACYL SOL 0.5% OP |
1 |
Tier 1 |
15% | 15% | None |
TROPICACYL SOL 1% OP |
1 |
Tier 1 |
15% | 15% | None |
TROPICAMIDE 0.5% EYE DROPS |
1 |
Tier 1 |
15% | 15% | None |
TROPICAMIDE 1% EYE DROPS |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TWINRIX TF PF VACCINE 720UNT/20ML 10 X 1ML VIALSD |
2 |
Tier 2 |
15% | 15% | None |
TYPHIM VI 25MCG/0.5ML VIAL |
2 |
Tier 2 |
15% | 15% | None |
TYZINE 0.1% NOSE DROPS |
2 |
Tier 2 |
15% | 15% | None |
TYZINE PEDIATRIC 0.05% DROP |
2 |
Tier 2 |
15% | 15% | None |