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2012 Medicare Part D and Medicare Advantage Plan Formulary Browser

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Blue Cross MedicareRx Plus (PDP) (S5596-034-0)
Tier 1 (407)
Tier 2 (1277)
Tier 3 (451)
Tier 4 (270)
Tier 5 (604)
Tier 6 (434)
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2012 Medicare Part D Plan Formulary Information
Blue Cross MedicareRx Plus (PDP) (S5596-034-0)
Benefit Details           
The Blue Cross MedicareRx Plus (PDP) (S5596-034-0)
Formulary Drugs Starting with the Letter T

in CMS PDP Region 32 which includes: CA
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
Tacrolimus 0.5mg/1 100 CAPSULE in 1 BOTTLE   2 Non-Preferred Generic Drugs $7.00$10.50P
Tacrolimus 1mg/1 100 CAPSULE in 1 BOTTLE   2 Non-Preferred Generic Drugs $7.00$10.50P
Tacrolimus 5mg/1 100 CAPSULE in 1 BOTTLE   2 Non-Preferred Generic Drugs $7.00$10.50P
TALWIN 30MG/ML VIAL   5 Injectable Drug 33%33%None
Tamiflu 30mg/1 1 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK   3 Preferred Brand Drugs $45.00$112.50Q:84
/1Days
Tamiflu 45mg/1 1 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK   3 Preferred Brand Drugs $45.00$112.50Q:42
/1Days
Tamiflu 6mg/mL 1 BOTTLE, GLASS in 1 CARTON / 6 mL in 1 BOTTLE, GLASS   3 Preferred Brand Drugs $45.00$112.50Q:360
/180Days
TAMIFLU 75MG CAPSULE UD   3 Preferred Brand Drugs $45.00$112.50Q:56
/365Days
TAMIFLU ORAL SUSPENSION   3 Preferred Brand Drugs $45.00$112.50Q:175
/180Days
TAMOXIFEN CITRATE 20MG TABLET (30 CT)   2 Non-Preferred Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TAMOXIFEN CITRATE TABLETS 10MG 180 BOT   2 Non-Preferred Generic Drugs $7.00$10.50None
TAMSULOSIN HCL 0.4 MG CAPSULE   2 Non-Preferred Generic Drugs $7.00$10.50None
TARCEVA 100MG TABLET   6 Specialty Tier Drugs 33%N/AP
TARCEVA 150MG TABLET   6 Specialty Tier Drugs 33%N/AP
TARCEVA 25MG TABLET   6 Specialty Tier Drugs 33%N/AP
TARGRETIN 1% GEL 60GM TUBE   6 Specialty Tier Drugs 33%N/ANone
TARGRETIN 75MG (100 CT)   6 Specialty Tier Drugs 33%N/AP
Tasigna 150mg/1 4 BLISTER PACK in 1 CARTON / 28 CAPSULE in 1 BLISTER PACK   6 Specialty Tier Drugs 33%N/AP
TASIGNA 200MG CAPSULE 28 BLPK   6 Specialty Tier Drugs 33%N/AP
TASMAR 100MG TABLET   6 Specialty Tier Drugs 33%N/ANone
TAXOTERE 80MG/2ML VIAL   6 Specialty Tier Drugs 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TAXOTERE 80mg/4mL 1 VIAL, GLASS in 1 CARTON / 4 mL in 1 VIAL, GLASS   6 Specialty Tier Drugs 33%N/AP
TAZICEF 1GM VIAL   5 Injectable Drug 33%33%None
TAZICEF 2GM ADD-VANTAGE   5 Injectable Drug 33%33%None
TAZICEF 6GM/100ML VIAL   5 Injectable Drug 33%33%None
TAZORAC 0.05% CREAM   4 Non-Preferred Brand Drugs $90.00$225.00None
TAZORAC 0.05% GEL   4 Non-Preferred Brand Drugs $90.00$225.00None
TAZORAC 0.1% CREAM   4 Non-Preferred Brand Drugs $90.00$225.00None
TAZORAC 0.1% GEL   4 Non-Preferred Brand Drugs $90.00$225.00None
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES   2 Non-Preferred Generic Drugs $7.00$10.50None
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES   2 Non-Preferred Generic Drugs $7.00$10.50None
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES   2 Non-Preferred Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TAZTIA XT 240MG CAPSULE SA   2 Non-Preferred Generic Drugs $7.00$10.50None
TAZTIA XT 360MG CAPSULE SA   2 Non-Preferred Generic Drugs $7.00$10.50None
TEKTURNA 150MG TABLET   3 Preferred Brand Drugs $45.00$112.50Q:30
/30Days
TEKTURNA 300MG TABLET   3 Preferred Brand Drugs $45.00$112.50Q:30
/30Days
TEKTURNA HCT 150-12.5MG TABLET   3 Preferred Brand Drugs $45.00$112.50Q:30
/30Days
TEKTURNA HCT 150MG-25MG TABLET   3 Preferred Brand Drugs $45.00$112.50Q:30
/30Days
TEKTURNA HCT 300-12.5MG TABLET   3 Preferred Brand Drugs $45.00$112.50Q:30
/30Days
TEKTURNA HCT 300MG-25MG TABLET   3 Preferred Brand Drugs $45.00$112.50Q:30
/30Days
TERAZOSIN HCL 10MG CAPSULE   2 Non-Preferred Generic Drugs $7.00$10.50None
TERAZOSIN HCL 1MG CAPSULE   2 Non-Preferred Generic Drugs $7.00$10.50None
TERAZOSIN HCL 2MG CAPSULE   2 Non-Preferred Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TERAZOSIN HCL 5MG CAPSULE   2 Non-Preferred Generic Drugs $7.00$10.50None
TERBINAFINE HCL 250MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
TERBUTALINE SULF 1MG/ML VL   5 Injectable Drug 33%33%None
TERBUTALINE SULF 2.5MG TABLET   1 Preferred Generic Drugs $2.00$3.00None
TERBUTALINE SULFATE 5MG TABLET   1 Preferred Generic Drugs $2.00$3.00None
TERCONAZOLE 0.4% CREAM WITH APPLICATOR   1 Preferred Generic Drugs $2.00$3.00Q:90
/30Days
TERCONAZOLE 80MG SUPPOSITORY VAGINAL   1 Preferred Generic Drugs $2.00$3.00None
TERCONAZOLE VAGINAL CREAM   1 Preferred Generic Drugs $2.00$3.00Q:40
/30Days
TESTIM 1%(50MG) GEL   3 Preferred Brand Drugs $45.00$112.50P Q:300
/30Days
Testosterone Cypionate 200mg/mL 1 VIAL, MULTI-DOSE in 1 CARTON / 10 mL in 1 VIAL, MULTI-DOSE   5 Injectable Drug 33%33%None
TESTOSTERONE CYPIONATE INJECTION   5 Injectable Drug 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TESTOSTERONE ENANTHATE INJECTION   5 Injectable Drug 33%33%None
Tetanus and Diphtheria Toxoids Adsorbed 2.0; 2.0[Lf]/0.5mL; [Lf]/0.5mL 10 VIAL, SINGLE-DOSE in 1 CA   3 Preferred Brand Drugs $45.00$112.50None
TETANUS TOXOID ADSORBED VIAL 5LF   1 Preferred Generic Drugs $2.00$3.00None
TETRACYCLINE 500MG CAPSULE   1 Preferred Generic Drugs $2.00$3.00None
Tetracycline Hydrochloride 250mg/1 100 CAPSULE in 1 BOTTLE   1 Preferred Generic Drugs $2.00$3.00None
TEV-TROPIN 2 CARTON in 1 BOX / 1 POWDER, FOR SOLUTION in 1 CARTON   5 Injectable Drug 33%33%P
THALITONE 15MG TABLET   3 Preferred Brand Drugs $45.00$112.50None
THALOMID 100MG CAPSULE 140 BOX   6 Specialty Tier Drugs 33%N/AP
Thalomid 150mg/1   6 Specialty Tier Drugs 33%N/AP
Thalomid 200mg/1   6 Specialty Tier Drugs 33%N/AP
THALOMID 50MG CAPSULE 280 BOX   6 Specialty Tier Drugs 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
THEOCHRON 100MG TABLET SA   2 Non-Preferred Generic Drugs $7.00$10.50None
THEOCHRON TABLETS EXTENDED RELEASE 300MG 100 BOT   2 Non-Preferred Generic Drugs $7.00$10.50None
Theophylline 100mg/1 500 CAPSULE in 1 BOTTLE   2 Non-Preferred Generic Drugs $7.00$10.50None
THEOPHYLLINE 400MG TABLET SA   2 Non-Preferred Generic Drugs $7.00$10.50None
THEOPHYLLINE 600MG TABLET SA   2 Non-Preferred Generic Drugs $7.00$10.50None
THEOPHYLLINE ANHYDROUS ER TABLET 200MG (1000 CT)   2 Non-Preferred Generic Drugs $7.00$10.50None
THEOPHYLLINE TABLET ER 300MG (100 CT)   2 Non-Preferred Generic Drugs $7.00$10.50None
THEOPHYLLINE TABLET ER 450MG (100 CT)   2 Non-Preferred Generic Drugs $7.00$10.50None
Thermazene 10mg/g   1 Preferred Generic Drugs $2.00$3.00None
THIOGUANINE TABLET LOID 40MG   4 Non-Preferred Brand Drugs $90.00$225.00None
THIORIDAZINE 100MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
THIORIDAZINE HCL 10MG TABLET (1000 CT)   2 Non-Preferred Generic Drugs $7.00$10.50None
THIORIDAZINE HCL 25MG TABLET (1000 CT)   2 Non-Preferred Generic Drugs $7.00$10.50None
THIORIDAZINE HCL 50MG TABLET (1000 CT)   2 Non-Preferred Generic Drugs $7.00$10.50None
THIOTEPA POWDER FOR INJECTION 15MG/VIL 1 VIAL SINGLE DOSE CRTN   5 Injectable Drug 33%33%P
THIOTHIXENE 10MG CAPSULE   2 Non-Preferred Generic Drugs $7.00$10.50None
THIOTHIXENE 1MG CAPSULE (100 CT)   2 Non-Preferred Generic Drugs $7.00$10.50None
THIOTHIXENE 2MG CAPSULE   2 Non-Preferred Generic Drugs $7.00$10.50None
THIOTHIXENE 5MG CAPSULE   2 Non-Preferred Generic Drugs $7.00$10.50None
THYMOGLOBULIN 25MG VIAL   6 Specialty Tier Drugs 33%N/AP
THYROLAR-1 60MG TABLET   3 Preferred Brand Drugs $45.00$112.50None
THYROLAR-1/4 15MG TABLET   3 Preferred Brand Drugs $45.00$112.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
THYROLAR-2 120MG TABLET   3 Preferred Brand Drugs $45.00$112.50None
THYROLAR-3 180MG TABLET   3 Preferred Brand Drugs $45.00$112.50None
Ticlopidine Hydrochloride 250mg/1 60 TABLET, FILM COATED in 1 BOTTLE   2 Non-Preferred Generic Drugs $7.00$10.50None
TIGAN INJECTION 100MG/ML 20 ML VIALMD   5 Injectable Drug 33%33%None
TIKOSYN .125MG CAPSULE   4 Non-Preferred Brand Drugs $90.00$225.00None
TIKOSYN .250MG CAPSULE   4 Non-Preferred Brand Drugs $90.00$225.00None
TIKOSYN .5MG CAPSULE   4 Non-Preferred Brand Drugs $90.00$225.00None
TIMENTIN 3.1GM VIAL   5 Injectable Drug 33%33%None
TIMOLOL MAL SOL 0.25% OP 15ML BOT   1 Preferred Generic Drugs $2.00$3.00None
TIMOLOL MAL SOL 0.5% OP 10ML BOT   1 Preferred Generic Drugs $2.00$3.00None
TIMOLOL MALEATE 10MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TIMOLOL MALEATE 20MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
Timolol Maleate 3.4mg/mL 1 BOTTLE, DISPENSING in 1 CARTON / 5 mL in 1 BOTTLE, DISPENSING   1 Preferred Generic Drugs $2.00$3.00None
TIMOLOL MALEATE 5MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
Timolol Maleate 6.8mg/mL 1 BOTTLE, DISPENSING in 1 CARTON / 5 mL in 1 BOTTLE, DISPENSING   1 Preferred Generic Drugs $2.00$3.00None
TINIDAZOLE TAB 250MG   2 Non-Preferred Generic Drugs $7.00$10.50None
TINIDAZOLE TAB 500MG   2 Non-Preferred Generic Drugs $7.00$10.50None
TIS-U-SOL IRRIGATION SOLUTION   5 Injectable Drug 33%33%P
tizanidine 4mg/1   2 Non-Preferred Generic Drugs $7.00$10.50None
TIZANIDINE HCL 2 MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
TOBI 300mg/5mL 56 AMPULE in 1 CARTON / 5 mL in 1 AMPULE   6 Specialty Tier Drugs 33%N/AP
TOBRADEX EYE OINTMENT   3 Preferred Brand Drugs $45.00$112.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TOBRADEX ST 0.5; 3mg/mL; mg/mL 5 mL in 1 BOTTLE   3 Preferred Brand Drugs $45.00$112.50None
TOBRAMYCIN 10MG/ML VIAL   5 Injectable Drug 33%33%None
TOBRAMYCIN 40MG/ML VIAL   5 Injectable Drug 33%33%None
TOBRAMYCIN 60MG/0.9% NACL   5 Injectable Drug 33%33%None
TOBRAMYCIN 80MG/0.9% NACL   5 Injectable Drug 33%33%None
TOBRAMYCIN OPHTHALMIC SOLUTION 0.3% 5ML BOT   1 Preferred Generic Drugs $2.00$3.00None
TOBRAMYCIN-DEXAMETH OPTH SUSP   2 Non-Preferred Generic Drugs $7.00$10.50None
TOBRASOL 0.3% EYE DROPS   1 Preferred Generic Drugs $2.00$3.00None
TOLAZAMIDE TABLETS 250MG 100 BOT   2 Non-Preferred Generic Drugs $7.00$10.50None
TOLAZAMIDE TABLETS 500MG 100 BOT   2 Non-Preferred Generic Drugs $7.00$10.50None
TOLBUTAMIDE 500MG TABLET   1 Preferred Generic Drugs $2.00$3.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TOLMETIN SODIUM 200MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
TOLMETIN SODIUM 400MG CAPSULE   2 Non-Preferred Generic Drugs $7.00$10.50None
TOLMETIN SODIUM 600MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
TOLVAPTAN 15 MG ORAL TABLET [SAMSCA]   6 Specialty Tier Drugs 33%N/AP Q:30
/30Days
TOLVAPTAN 30 MG ORAL TABLET [SAMSCA]   6 Specialty Tier Drugs 33%N/AP Q:60
/30Days
Topiramate 25mg/1   2 Non-Preferred Generic Drugs $7.00$10.50P
TOPIRAMATE SPRINKLE CAPSULES 15MG 60 BOT   2 Non-Preferred Generic Drugs $7.00$10.50P
TOPIRAMATE TABLETS 100MG 1000 BOT   2 Non-Preferred Generic Drugs $7.00$10.50P Q:60
/30Days
TOPIRAMATE TABLETS 200MG 1000 BOT   2 Non-Preferred Generic Drugs $7.00$10.50P Q:60
/30Days
TOPIRAMATE TABLETS 25MG 1000 BOT   2 Non-Preferred Generic Drugs $7.00$10.50P Q:60
/30Days
TOPIRAMATE TABLETS 50MG 1000 BOT   2 Non-Preferred Generic Drugs $7.00$10.50P Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TOPOSAR INJECTION 20MG/ML 50ML VIAL MD CRTN   5 Injectable Drug 33%33%P
TOPOTECAN HYDROCHLORIDE FOR INJECTION   6 Specialty Tier Drugs 33%N/AP
Torisel 1 KIT in 1 CARTON   6 Specialty Tier Drugs 33%N/AP
Torsemide 100mg/1 12 BOTTLE in 1 CASE / 100 TABLET in 1 BOTTLE   2 Non-Preferred Generic Drugs $7.00$10.50None
TORSEMIDE 20mg/1 100 TABLET in 1 BOTTLE, PLASTIC   2 Non-Preferred Generic Drugs $7.00$10.50None
TORSEMIDE INJECTION 20MG/2ML   5 Injectable Drug 33%33%None
TORSEMIDE TABLETS   2 Non-Preferred Generic Drugs $7.00$10.50None
TORSEMIDE TABLETS   2 Non-Preferred Generic Drugs $7.00$10.50None
TOVIAZ TABLETS 4MG EXTENDED RELEASE   3 Preferred Brand Drugs $45.00$112.50Q:30
/30Days
TOVIAZ TABLETS 8MG EXTENDED RELEASE   3 Preferred Brand Drugs $45.00$112.50Q:30
/30Days
TPN ELECTROLYTES VIAL   5 Injectable Drug 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRACLEER 125MG TABLET   6 Specialty Tier Drugs 33%N/ANone
TRACLEER 62.5MG TABLET   6 Specialty Tier Drugs 33%N/ANone
TRAMADOL HCL 50 MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50Q:240
/30Days
TRAMADOL HCL-ACETAMINOPHEN 37.5-325MG TABLET (1000 CT)   2 Non-Preferred Generic Drugs $7.00$10.50Q:240
/30Days
TRAMADOL HYDROCHLORIDE 100mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC   2 Non-Preferred Generic Drugs $7.00$10.50Q:30
/30Days
TRAMADOL HYDROCHLORIDE 200mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC   2 Non-Preferred Generic Drugs $7.00$10.50Q:30
/30Days
TRANDOLAPRIL 1MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
TRANDOLAPRIL 2MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
TRANDOLAPRIL 4MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
TRANEXAMIC ACID 1,000 MG/10 ML   5 Injectable Drug 33%33%None
TRANYLCYPROMINE SULFATE 10MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRAVASOL 10% SOLUTION VIAFLEX   5 Injectable Drug 33%33%None
TRAVATAN Z 0.04MG DROPS 2.5ML BOT   3 Preferred Brand Drugs $45.00$112.50None
TRAZODONE 300MG TABLET   1 Preferred Generic Drugs $2.00$3.00None
TRAZODONE HCL TABLET USP 100MG (500 CT)   1 Preferred Generic Drugs $2.00$3.00None
TRAZODONE HCL TABLET USP 150MG (100 CT)   1 Preferred Generic Drugs $2.00$3.00None
TRAZODONE HCL TABLET USP 50MG (500 CT)   1 Preferred Generic Drugs $2.00$3.00None
TREANDA FOR INJECTION 100MG/VIAL   6 Specialty Tier Drugs 33%N/AP
TRECATOR 250MG TABLET   4 Non-Preferred Brand Drugs $90.00$225.00None
Tretinoin 0.1mg/g 1 TUBE in 1 CARTON / 45 g in 1 TUBE   2 Non-Preferred Generic Drugs $7.00$10.50Q:90
/30Days
Tretinoin 0.25mg/g 1 TUBE in 1 CARTON / 15 g in 1 TUBE   2 Non-Preferred Generic Drugs $7.00$10.50Q:90
/30Days
Tretinoin 0.25mg/g 1 TUBE in 1 CARTON / 45 g in 1 TUBE   2 Non-Preferred Generic Drugs $7.00$10.50Q:90
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Tretinoin 0.5mg/g 1 TUBE in 1 CARTON / 20 g in 1 TUBE   2 Non-Preferred Generic Drugs $7.00$10.50Q:90
/30Days
TRETINOIN 10MG CAPSULE   2 Non-Preferred Generic Drugs $7.00$10.50None
Tretinoin 1mg/g 1 TUBE in 1 CARTON / 45 g in 1 TUBE   2 Non-Preferred Generic Drugs $7.00$10.50Q:90
/30Days
TRI PREVIFEM TABLETS   2 Non-Preferred Generic Drugs $7.00$10.50None
TRI-LEGEST FE 5-7-9-7 TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
TRI-SPRINTEC 7DAYSX3 28 TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
TRIAMCINOLONE 0.1% OINTMENT   1 Preferred Generic Drugs $2.00$3.00None
TRIAMCINOLONE ACETONIDE 0.025% CREAM 80GM TUBE   1 Preferred Generic Drugs $2.00$3.00None
TRIAMCINOLONE ACETONIDE 0.025% LOTION 2 FL OZ BOT   1 Preferred Generic Drugs $2.00$3.00None
TRIAMCINOLONE ACETONIDE 0.025% OINTMENT 80GM TUBE   1 Preferred Generic Drugs $2.00$3.00None
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT   1 Preferred Generic Drugs $2.00$3.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE   1 Preferred Generic Drugs $2.00$3.00None
TRIAMCINOLONE ACETONIDE 0.1% CREAM 80GM TUBE   1 Preferred Generic Drugs $2.00$3.00None
TRIAMCINOLONE ACETONIDE 0.1% LOTION 60ML BOTPL   1 Preferred Generic Drugs $2.00$3.00None
Triamcinolone Acetonide 1mg/g 1 TUBE in 1 CARTON / 5 g in 1 TUBE   1 Preferred Generic Drugs $2.00$3.00None
Triamcinolone Acetonide 55ug/1 1 BOTTLE, SPRAY in 1 CARTON / 120 SPRAY, METERED in 1 BOTTLE, SPRAY   4 Non-Preferred Brand Drugs $90.00$225.00Q:34
/30Days
Triamcinolone Acetonide 5mg/g 1 TUBE in 1 CARTON / 15 g in 1 TUBE   1 Preferred Generic Drugs $2.00$3.00None
Triamterene and Hydrochlorothiazide 25; 37.5mg/1; mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC   1 Preferred Generic Drugs $2.00$3.00None
TRIAMTERENE/HCTZ 37.5/25 TABLET   1 Preferred Generic Drugs $2.00$3.00None
TRIAMTERENE/HCTZ 75/50 TABLET   1 Preferred Generic Drugs $2.00$3.00None
TRIDERM 0.1% CREAM   1 Preferred Generic Drugs $2.00$3.00None
TRIFLUOPERAZINE 1MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRIFLUOPERAZINE HCL 2MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
TRIFLUOPERAZINE HCL 5MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT)   2 Non-Preferred Generic Drugs $7.00$10.50None
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT   2 Non-Preferred Generic Drugs $7.00$10.50None
TRIHEXYPHENIDYL HYDROCHLORIDE 2mg/1   1 Preferred Generic Drugs $2.00$3.00None
Trihexyphenidyl Hydrochloride 2mg/5mL 473 mL in 1 BOTTLE   1 Preferred Generic Drugs $2.00$3.00None
Trihexyphenidyl Hydrochloride 5mg/1 100 TABLET in 1 BOTTLE   1 Preferred Generic Drugs $2.00$3.00None
TRILIPIX CAPSULE DR 45MG   3 Preferred Brand Drugs $45.00$112.50None
TRILIPIX DELAYED RELEASE CAPSULES 135MG   3 Preferred Brand Drugs $45.00$112.50None
TRIMETHOBENZAMIDE 100MG/ML   5 Injectable Drug 33%33%None
TRIMETHOBENZAMIDE HCL 300MG CAPSULE   2 Non-Preferred Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRIMETHOPRIM TABLETS   1 Preferred Generic Drugs $2.00$3.00None
TRIMIPRAMINE MALEATE 100 MG CAP   4 Non-Preferred Brand Drugs $90.00$225.00None
TRIMIPRAMINE MALEATE 25 MG CAP   4 Non-Preferred Brand Drugs $90.00$225.00None
TRIMIPRAMINE MALEATE 50 MG CAP   4 Non-Preferred Brand Drugs $90.00$225.00None
TRINESSA TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
TRIPEDIA PRESERVATIVE FREE 6.7;23.4; UNT/.5 ML;   3 Preferred Brand Drugs $45.00$112.50None
TRISENOX 10MG/10ML AMPULE   5 Injectable Drug 33%33%P
Trivora 6 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK   2 Non-Preferred Generic Drugs $7.00$10.50None
TRIZIVIR 300; 150; 300mg/1; mg/1; mg/1 60 TABLET, FILM COATED in 1 BOTTLE   6 Specialty Tier Drugs 33%N/ANone
TROPHAMINE INJECTION SOLUTION   5 Injectable Drug 33%33%None
TROPHAMINE INJECTION SOLUTION 6%   5 Injectable Drug 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TROPICAMIDE 0.5% EYE DROPS   1 Preferred Generic Drugs $2.00$3.00None
TROPICAMIDE OPHTHALMIC SOLUTION USP   1 Preferred Generic Drugs $2.00$3.00None
TRUVADA TABLET   6 Specialty Tier Drugs 33%N/ANone
TWINJECT AUTO INJECTOR INJECTION 1% AUTO INJECTOR TWO PACK SYR   5 Injectable Drug 33%33%Q:2
/1Days
TWINJECT AUTO INJECTOR INJECTION 1% AUTO TWO PACK SYR   5 Injectable Drug 33%33%Q:2
/1Days
TWINRIX TF PF VACCINE 720UNT/20ML 10 X 1ML VIALSD   3 Preferred Brand Drugs $45.00$112.50None
Tygacil 50mg/5mL 10 VIAL, SINGLE-USE in 1 CARTON / 50 mL in 1 VIAL, SINGLE-USE   6 Specialty Tier Drugs 33%N/ANone
TYKERB 250MG TABLET   6 Specialty Tier Drugs 33%N/AP
TYPHIM VI 25MCG/0.5ML VIAL   3 Preferred Brand Drugs $45.00$112.50None
TYZEKA 600MG TABLET (30 CT)   6 Specialty Tier Drugs 33%N/AP
TYZINE 0.1% NOSE DROPS   3 Preferred Brand Drugs $45.00$112.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TYZINE PEDIATRIC 0.05% DROP   4 Non-Preferred Brand Drugs $90.00$225.00None

Chart Legend:

Below are a few notes to help you understand the above 2012 Medicare Part D Blue Cross MedicareRx Plus (PDP) 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 $320 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 intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $2930) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2012 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 September 2012 )

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.







Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.