2011 Medicare Part D Plan Formulary Information |
Geisinger Gold Secure 3 (HMO SNP) (H3954-134-0)
Benefit Details
|
The Geisinger Gold Secure 3 (HMO SNP) (H3954-134-0) Formulary Drugs Starting with the Letter T in Montour County, PA: CMS MA Region 6 which includes: PA
|
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 |
TAMOXIFEN CITRATE 20MG TABLET (30 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TAMOXIFEN CITRATE TABLETS 10MG 180 BOT |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TAMSULOSIN HCL 0.4 MG CAPSULE |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TARCEVA 100MG TABLET |
4 |
Tier 4 |
33% | 33% | P |
TARCEVA 150MG TABLET |
4 |
Tier 4 |
33% | 33% | P |
TARCEVA 25MG TABLET |
4 |
Tier 4 |
33% | 33% | P |
TARGRETIN 1% GEL 60GM TUBE |
3 |
Tier 3 |
$69.00 | $172.50 | None |
TARGRETIN 75MG (100 CT) |
3 |
Tier 3 |
$69.00 | $172.50 | None |
TARKA 1/240MG TABLET SA |
3 |
Tier 3 |
$69.00 | $172.50 | None |
TARKA 2/180MG TABLET SA |
3 |
Tier 3 |
$69.00 | $172.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TARKA 2/240MG TABLET SA |
3 |
Tier 3 |
$69.00 | $172.50 | None |
TARKA 4/240MG TABLET SA |
3 |
Tier 3 |
$69.00 | $172.50 | None |
TASIGNA 200MG CAPSULE 28 BLPK |
4 |
Tier 4 |
33% | 33% | P |
TAZORAC 0.05% CREAM |
3 |
Tier 3 |
$69.00 | $172.50 | None |
TAZORAC 0.05% GEL |
3 |
Tier 3 |
$69.00 | $172.50 | None |
TAZORAC 0.1% CREAM |
3 |
Tier 3 |
$69.00 | $172.50 | None |
TAZORAC 0.1% GEL |
3 |
Tier 3 |
$69.00 | $172.50 | None |
TEGRETOL XR TABLETS 100MG 100 BOT |
2 |
Tier 2 |
$39.00 | $97.50 | None |
TEGRETOL XR TABLETS 200MG 100 BOT |
2 |
Tier 2 |
$39.00 | $97.50 | None |
TEGRETOL XR TABLETS 400MG 100 BOT |
2 |
Tier 2 |
$39.00 | $97.50 | None |
TEKTURNA 150MG TABLET |
3 |
Tier 3 |
$69.00 | $172.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TEKTURNA 300MG TABLET |
3 |
Tier 3 |
$69.00 | $172.50 | None |
TERAZOSIN HCL 10MG CAPSULE |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TERAZOSIN HCL 1MG CAPSULE |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TERAZOSIN HCL 2MG CAPSULE |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TERAZOSIN HCL 5MG CAPSULE |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TERBINAFINE HCL 250MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TERCONAZOLE 0.4% CREAM WITH APPLICATOR |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TESTOSTERONE CYPIONATE INJECTION |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TESTOSTERONE ENANTHATE INJECTION |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TETANUS AND DIPHTHERIA TOXOIDS ADSORBED FOR ADULT USE 2 UNT/VIAL |
2 |
Tier 2 |
$39.00 | $97.50 | None |
TETANUS TOXOID ADSORBED VIAL 5LF |
1 |
Tier 1 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TETRACYCLINE 250 MG ORAL CAPSULE |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TEVETEN HCT TABLETS 600;25MG;MG 100 BOT |
3 |
Tier 3 |
$69.00 | $172.50 | None |
TEVETEN TABLETS 400MG 100 BOT |
3 |
Tier 3 |
$69.00 | $172.50 | None |
TEVETEN TABLETS 600;12.5MG;MG 100 BOT |
3 |
Tier 3 |
$69.00 | $172.50 | None |
TEVETEN TABLETS 600MG 100 BOT |
3 |
Tier 3 |
$69.00 | $172.50 | None |
THALOMID 100MG CAPSULE 140 BOX |
4 |
Tier 4 |
33% | 33% | None |
THALOMID 200MG CAPSULE 28 BLPK |
4 |
Tier 4 |
33% | 33% | None |
THALOMID 50MG CAPSULE 280 BOX |
4 |
Tier 4 |
33% | 33% | None |
THEOCHRON 100MG TABLET SA |
1 |
Tier 1 |
$6.00 | $15.00 | None |
THEOPHYLLINE 400MG TABLET SA |
1 |
Tier 1 |
$6.00 | $15.00 | None |
THEOPHYLLINE ANHYDROUS ER TABLET 200MG (1000 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THEOPHYLLINE TABLET ER 300MG (100 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
THEOPHYLLINE TABLET ER 450MG (100 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
THIOGUANINE TABLET LOID 40MG |
2 |
Tier 2 |
$39.00 | $97.50 | None |
THIORIDAZINE 100MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
THIORIDAZINE HCL 10MG TABLET (1000 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
THIORIDAZINE HCL 25MG TABLET (1000 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
THIORIDAZINE HCL 50MG TABLET (1000 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
THIOTHIXENE 10MG CAPSULE |
1 |
Tier 1 |
$6.00 | $15.00 | None |
THIOTHIXENE 1MG CAPSULE (100 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
THIOTHIXENE 2MG CAPSULE |
1 |
Tier 1 |
$6.00 | $15.00 | None |
THIOTHIXENE 5MG CAPSULE |
1 |
Tier 1 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THYMOGLOBULIN 25MG VIAL |
2 |
Tier 2 |
$39.00 | $97.50 | None |
TICLOPIDINE 250 MG ORAL TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TIKOSYN .125MG CAPSULE |
2 |
Tier 2 |
$39.00 | $97.50 | None |
TIKOSYN .250MG CAPSULE |
2 |
Tier 2 |
$39.00 | $97.50 | None |
TIKOSYN .5MG CAPSULE |
2 |
Tier 2 |
$39.00 | $97.50 | None |
TIMENTIN 3.1GM VIAL |
2 |
Tier 2 |
$39.00 | $97.50 | None |
TIMOLOL MAL SOL 0.25% OP 15ML BOT |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TIMOLOL MAL SOL 0.5% OP 10ML BOT |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TIMOLOL MALEATE 10MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TIMOLOL MALEATE 20MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TIMOLOL MALEATE 5MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIZANIDINE HCL 2MG TABLET (150 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TIZANIDINE HCL 4MG TABLET 150 BOT |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TOBRADEX EYE OINTMENT |
2 |
Tier 2 |
$39.00 | $97.50 | None |
TOBRAMYCIN 10MG/ML VIAL |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TOBRAMYCIN 40MG/ML VIAL |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TOBRAMYCIN OPHTHALMIC SOLUTION 0.3% 5ML BOT |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TOBRAMYCIN-DEXAMETH OPTH SUSP |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TOLAZAMIDE TABLETS 250MG 100 BOT |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TOLAZAMIDE TABLETS 500MG 100 BOT |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TOLBUTAMIDE 500MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TOPAMAX 15 MG SPRINKLE CAP |
2 |
Tier 2 |
$39.00 | $97.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOPAMAX 25 MG SPRINKLE CAP |
2 |
Tier 2 |
$39.00 | $97.50 | None |
TOPAMAX TABLETS 100MG 60 BOT |
3 |
Tier 3 |
$69.00 | $172.50 | None |
TOPAMAX TABLETS 200MG 60 BOT |
3 |
Tier 3 |
$69.00 | $172.50 | None |
TOPAMAX TABLETS 25MG 60 BOT |
3 |
Tier 3 |
$69.00 | $172.50 | None |
TOPAMAX TABLETS 50MG 60 BOT |
3 |
Tier 3 |
$69.00 | $172.50 | None |
TOPROL XL 100MG TABLET SA |
3 |
Tier 3 |
$69.00 | $172.50 | None |
TOPROL XL 200MG TABLET SA |
3 |
Tier 3 |
$69.00 | $172.50 | None |
TOPROL XL 25MG TABLET SA |
3 |
Tier 3 |
$69.00 | $172.50 | None |
TOPROL XL 50MG TABLET SA |
3 |
Tier 3 |
$69.00 | $172.50 | None |
TORSEMIDE 100 MG ORAL TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TORSEMIDE 20 MG ORAL TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TORSEMIDE TABLETS 10 MG |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TORSEMIDE TABLETS 5 MG |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TPN ELECTROLYTES VIAL |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TRACLEER 125MG TABLET |
4 |
Tier 4 |
33% | 33% | P |
TRACLEER 62.5MG TABLET |
4 |
Tier 4 |
33% | 33% | P |
TRAMADOL HCL 50 MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TRAMADOL HCL-ACETAMINOPHEN 37.5-325MG TABLET (1000 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TRANDOLAPRIL 1MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TRANDOLAPRIL 2MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TRANDOLAPRIL 4MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TRANYLCYPROMINE SULFATE 10MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRAVATAN Z 0.04MG DROPS 2.5ML BOT |
2 |
Tier 2 |
$39.00 | $97.50 | None |
TRAZODONE 300MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TRAZODONE HCL TABLET USP 100MG (500 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TRAZODONE HCL TABLET USP 150MG (100 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TRAZODONE HCL TABLET USP 50MG (500 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TRECATOR 250MG TABLET |
3 |
Tier 3 |
$69.00 | $172.50 | None |
TRETINOIN 0.01% GEL 45GM TUBE |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TRETINOIN 0.025% GEL 45GM TUBE |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TRETINOIN 0.05% CREAM 45GM TUBE |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TRETINOIN 0.1% CREAM 45GM TUBE |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TRETINOIN 10MG CAPSULE |
4 |
Tier 4 |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRETINOIN CREAM |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TRI-NORINYL 28 TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TRI-SPRINTEC 7DAYSX3 28 TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TRIAMCINOLONE 0.1% OINTMENT |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TRIAMCINOLONE 0.1% PASTE |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TRIAMCINOLONE ACETONIDE 0.025% OINTMENT 80GM TUBE |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TRIAMCINOLONE ACETONIDE 0.1% LOTION 60ML BOTPL |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TRIAMCINOLONE ACETONIDE 0.025% CREAM 80GM TUBE |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TRIAMCINOLONE ACETONIDE 0.025% LOTION 2 FL OZ BOT |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TRIAMCINOLONE ACETONIDE 0.05% CREAM 15GM TUBE |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE |
1 |
Tier 1 |
$6.00 | $15.00 | 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 |
$6.00 | $15.00 | None |
TRIAMTERENE/HCTZ 37.5/25 TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TRIAMTERENE/HCTZ 75/50 TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TRICOR 145MG TABLET |
2 |
Tier 2 |
$39.00 | $97.50 | None |
TRICOR 48MG TABLET |
2 |
Tier 2 |
$39.00 | $97.50 | None |
TRIFLUOPERAZINE 1MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TRIFLUOPERAZINE HCL 2MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TRIFLUOPERAZINE HCL 5MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TRIHEXYPHENIDYL HCL 5MG TABLET (100 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TRIHEXYPHENIDYL HCL ELIXIR 5%/2 16 FLO BOT |
1 |
Tier 1 |
$6.00 | $15.00 | 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 |
Tier 1 |
$6.00 | $15.00 | None |
TRIHIBIT PRESERVATIVE FREE |
2 |
Tier 2 |
$39.00 | $97.50 | None |
TRILEPTAL 300MG/5ML SUSP |
3 |
Tier 3 |
$69.00 | $172.50 | None |
TRILIPIX CAPSULE DR 45MG |
2 |
Tier 2 |
$39.00 | $97.50 | None |
TRILIPIX DELAYED RELEASE CAPSULES 135MG |
2 |
Tier 2 |
$39.00 | $97.50 | None |
TRIMETHOBENZAMIDE 100MG/ML |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TRIMETHOBENZAMIDE HCL 300MG CAPSULE |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TRIMETHOPRIM TABLETS |
1 |
Tier 1 |
$6.00 | $15.00 | None |
TRIPEDIA PRESERVATIVE FREE 6.7;23.4; UNT/.5 ML; |
2 |
Tier 2 |
$39.00 | $97.50 | None |
TRISENOX 10MG/10ML AMPULE |
2 |
Tier 2 |
$39.00 | $97.50 | None |
TRIZIVIR TABLET |
4 |
Tier 4 |
33% | 33% | 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 | $97.50 | None |
TRUVADA TABLET |
4 |
Tier 4 |
33% | 33% | None |
TWINJECT AUTO INJECTOR INJECTION 1% AUTO INJECTOR TWO PACK SYR |
3 |
Tier 3 |
$69.00 | $172.50 | Q:2 /15Days |
TWINJECT AUTO INJECTOR INJECTION 1% AUTO TWO PACK SYR |
3 |
Tier 3 |
$69.00 | $172.50 | Q:2 /15Days |
TWINRIX TF PF VACCINE 720UNT/20ML 10 X 1ML VIALSD |
2 |
Tier 2 |
$39.00 | $97.50 | None |
TYGACIL 50MG VIAL 10 VILSU BOX |
4 |
Tier 4 |
33% | 33% | None |
TYKERB 250MG TABLET |
4 |
Tier 4 |
33% | 33% | P |
TYPHIM VI 25MCG/0.5ML VIAL |
2 |
Tier 2 |
$39.00 | $97.50 | None |
TYSABRI 300MG/15ML VIAL |
3 |
Tier 3 |
$69.00 | $172.50 | P |
TYZEKA 600MG TABLET (30 CT) |
3 |
Tier 3 |
$69.00 | $172.50 | None |
TYZINE 0.1% NOSE DROPS |
2 |
Tier 2 |
$39.00 | $97.50 | None |