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CVS Caremark Value (PDP) (S5601-064-0)
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M N O P Q R S T U V W X Y Z 0-9 
2012 Medicare Part D Plan Formulary Information
CVS Caremark Value (PDP) (S5601-064-0)
Benefit Details           
The CVS Caremark Value (PDP) (S5601-064-0)
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
TACLONEX OINTMENT   2 Preferred Brand Drugs $45.00$101.25None
TACLONEX SCALP SUSPENSION   2 Preferred Brand Drugs $45.00$101.25None
Tacrolimus 0.5mg/1 100 CAPSULE in 1 BOTTLE   1 Generic Drugs $7.00$10.50P
Tacrolimus 1mg/1 100 CAPSULE in 1 BOTTLE   1 Generic Drugs $7.00$10.50P
Tacrolimus 5mg/1 100 CAPSULE in 1 BOTTLE   4 Specialty Tier Drugs 25%N/AP
Tamiflu 30mg/1 1 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK   2 Preferred Brand Drugs $45.00$101.25Q:84
/180Days
Tamiflu 45mg/1 1 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK   2 Preferred Brand Drugs $45.00$101.25Q:42
/180Days
Tamiflu 6mg/mL 1 BOTTLE, GLASS in 1 CARTON / 6 mL in 1 BOTTLE, GLASS   2 Preferred Brand Drugs $45.00$101.25Q:540
/180Days
TAMIFLU 75MG CAPSULE UD   2 Preferred Brand Drugs $45.00$101.25Q:42
/180Days
TAMIFLU ORAL SUSPENSION   2 Preferred Brand Drugs $45.00$101.25Q:263
/180Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TAMOXIFEN CITRATE 20MG TABLET (30 CT)   1 Generic Drugs $7.00$10.50None
TAMOXIFEN CITRATE TABLETS 10MG 180 BOT   1 Generic Drugs $7.00$10.50None
TAMSULOSIN HCL 0.4 MG CAPSULE   1 Generic Drugs $7.00$10.50None
TARCEVA 100MG TABLET   4 Specialty Tier Drugs 25%N/AP
TARCEVA 150MG TABLET   4 Specialty Tier Drugs 25%N/AP
TARCEVA 25MG TABLET   4 Specialty Tier Drugs 25%N/AP
TARGRETIN 1% GEL 60GM TUBE   4 Specialty Tier Drugs 25%N/ANone
TARGRETIN 75MG (100 CT)   4 Specialty Tier Drugs 25%N/AP
Tasigna 150mg/1 4 BLISTER PACK in 1 CARTON / 28 CAPSULE in 1 BLISTER PACK   4 Specialty Tier Drugs 25%N/AP
TASIGNA 200MG CAPSULE 28 BLPK   4 Specialty Tier Drugs 25%N/AP
TAXOTERE 80MG/2ML VIAL   4 Specialty Tier Drugs 25%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   4 Specialty Tier Drugs 25%N/AP
TAZORAC 0.05% CREAM   3 Non-Preferred Brand Drugs $95.00$261.25P
TAZORAC 0.05% GEL   3 Non-Preferred Brand Drugs $95.00$261.25P
TAZORAC 0.1% CREAM   3 Non-Preferred Brand Drugs $95.00$261.25P
TAZORAC 0.1% GEL   3 Non-Preferred Brand Drugs $95.00$261.25P
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES   1 Generic Drugs $7.00$10.50None
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES   1 Generic Drugs $7.00$10.50None
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES   1 Generic Drugs $7.00$10.50None
TAZTIA XT 240MG CAPSULE SA   1 Generic Drugs $7.00$10.50None
TAZTIA XT 360MG CAPSULE SA   1 Generic Drugs $7.00$10.50None
TEGRETOL XR TABLETS 100MG 100 BOT   2 Preferred Brand Drugs $45.00$101.25None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Tekamlo 150; 10mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   2 Preferred Brand Drugs $45.00$101.25None
Tekamlo 150; 5mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   2 Preferred Brand Drugs $45.00$101.25None
Tekamlo 300; 10mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   2 Preferred Brand Drugs $45.00$101.25None
Tekamlo 300; 5mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   2 Preferred Brand Drugs $45.00$101.25None
TEKTURNA 150MG TABLET   2 Preferred Brand Drugs $45.00$101.25Q:45
/30Days
TEKTURNA 300MG TABLET   2 Preferred Brand Drugs $45.00$101.25None
TEKTURNA HCT 150-12.5MG TABLET   2 Preferred Brand Drugs $45.00$101.25None
TEKTURNA HCT 150MG-25MG TABLET   2 Preferred Brand Drugs $45.00$101.25None
TEKTURNA HCT 300-12.5MG TABLET   2 Preferred Brand Drugs $45.00$101.25None
TEKTURNA HCT 300MG-25MG TABLET   2 Preferred Brand Drugs $45.00$101.25None
TERAZOSIN HCL 10MG CAPSULE   1 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 1MG CAPSULE   1 Generic Drugs $7.00$10.50None
TERAZOSIN HCL 2MG CAPSULE   1 Generic Drugs $7.00$10.50None
TERAZOSIN HCL 5MG CAPSULE   1 Generic Drugs $7.00$10.50None
TERBINAFINE HCL 250MG TABLET   1 Generic Drugs $7.00$10.50Q:90
/365Days
TERBUTALINE SULF 1MG/ML VL   1 Generic Drugs $7.00$10.50None
TERBUTALINE SULF 2.5MG TABLET   1 Generic Drugs $7.00$10.50None
TERBUTALINE SULFATE 5MG TABLET   1 Generic Drugs $7.00$10.50None
TERCONAZOLE 0.4% CREAM WITH APPLICATOR   1 Generic Drugs $7.00$10.50None
TERCONAZOLE 80MG SUPPOSITORY VAGINAL   1 Generic Drugs $7.00$10.50None
TERCONAZOLE VAGINAL CREAM   1 Generic Drugs $7.00$10.50None
TESTIM 1%(50MG) GEL   3 Non-Preferred Brand Drugs $95.00$261.25P Q:300
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Testosterone Cypionate 200mg/mL 1 VIAL, MULTI-DOSE in 1 CARTON / 10 mL in 1 VIAL, MULTI-DOSE   1 Generic Drugs $7.00$10.50None
TESTOSTERONE CYPIONATE INJECTION   1 Generic Drugs $7.00$10.50None
TESTOSTERONE ENANTHATE INJECTION   1 Generic Drugs $7.00$10.50None
Tetanus and Diphtheria Toxoids Adsorbed 2.0; 2.0[Lf]/0.5mL; [Lf]/0.5mL 10 VIAL, SINGLE-DOSE in 1 CA   2 Preferred Brand Drugs $45.00$101.25P
TETANUS TOXOID ADSORBED VIAL 5LF   2 Preferred Brand Drugs $45.00$101.25P
TETRACYCLINE 500MG CAPSULE   1 Generic Drugs $7.00$10.50None
Tetracycline Hydrochloride 250mg/1 100 CAPSULE in 1 BOTTLE   1 Generic Drugs $7.00$10.50None
THALOMID 100MG CAPSULE 140 BOX   4 Specialty Tier Drugs 25%N/AP
Thalomid 150mg/1   4 Specialty Tier Drugs 25%N/AP
Thalomid 200mg/1   4 Specialty Tier Drugs 25%N/AP
THALOMID 50MG CAPSULE 280 BOX   4 Specialty Tier Drugs 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
THEO-24 100MG CAPSULE SA   2 Preferred Brand Drugs $45.00$101.25None
THEO-24 200MG CAPSULE SA   2 Preferred Brand Drugs $45.00$101.25None
THEO-24 300MG CAPSULE SA   2 Preferred Brand Drugs $45.00$101.25None
THEO-24 400MG CAPSULE SA   2 Preferred Brand Drugs $45.00$101.25None
THEOCHRON 100MG TABLET SA   1 Generic Drugs $7.00$10.50None
THEOCHRON TABLETS EXTENDED RELEASE 300MG 100 BOT   1 Generic Drugs $7.00$10.50None
Theophylline 100mg/1 500 CAPSULE in 1 BOTTLE   1 Generic Drugs $7.00$10.50None
THEOPHYLLINE 400MG TABLET SA   1 Generic Drugs $7.00$10.50None
THEOPHYLLINE 600MG TABLET SA   1 Generic Drugs $7.00$10.50None
THEOPHYLLINE ANHYDROUS ER TABLET 200MG (1000 CT)   1 Generic Drugs $7.00$10.50None
THEOPHYLLINE TABLET ER 300MG (100 CT)   1 Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
THEOPHYLLINE TABLET ER 450MG (100 CT)   1 Generic Drugs $7.00$10.50None
Thermazene 10mg/g   1 Generic Drugs $7.00$10.50None
THIOGUANINE TABLET LOID 40MG   2 Preferred Brand Drugs $45.00$101.25None
THIORIDAZINE 100MG TABLET   1 Generic Drugs $7.00$10.50P
THIORIDAZINE HCL 10MG TABLET (1000 CT)   1 Generic Drugs $7.00$10.50P
THIORIDAZINE HCL 25MG TABLET (1000 CT)   1 Generic Drugs $7.00$10.50P
THIORIDAZINE HCL 50MG TABLET (1000 CT)   1 Generic Drugs $7.00$10.50P
THIOTHIXENE 10MG CAPSULE   1 Generic Drugs $7.00$10.50None
THIOTHIXENE 1MG CAPSULE (100 CT)   1 Generic Drugs $7.00$10.50None
THIOTHIXENE 2MG CAPSULE   1 Generic Drugs $7.00$10.50None
THIOTHIXENE 5MG CAPSULE   1 Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TIKOSYN .125MG CAPSULE   2 Preferred Brand Drugs $45.00$101.25None
TIKOSYN .250MG CAPSULE   2 Preferred Brand Drugs $45.00$101.25None
TIKOSYN .5MG CAPSULE   2 Preferred Brand Drugs $45.00$101.25None
TIMOLOL MAL SOL 0.25% OP 15ML BOT   1 Generic Drugs $7.00$10.50None
TIMOLOL MAL SOL 0.5% OP 10ML BOT   1 Generic Drugs $7.00$10.50None
Timolol Maleate 3.4mg/mL 1 BOTTLE, DISPENSING in 1 CARTON / 5 mL in 1 BOTTLE, DISPENSING   1 Generic Drugs $7.00$10.50None
Timolol Maleate 6.8mg/mL 1 BOTTLE, DISPENSING in 1 CARTON / 5 mL in 1 BOTTLE, DISPENSING   1 Generic Drugs $7.00$10.50None
tizanidine 4mg/1   1 Generic Drugs $7.00$10.50None
TIZANIDINE HCL 2 MG TABLET   1 Generic Drugs $7.00$10.50None
TOBI 300mg/5mL 56 AMPULE in 1 CARTON / 5 mL in 1 AMPULE   4 Specialty Tier Drugs 25%N/AP
TOBRADEX EYE OINTMENT   3 Non-Preferred Brand Drugs $95.00$261.25None
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 Non-Preferred Brand Drugs $95.00$261.25None
TOBRAMYCIN 10MG/ML VIAL   1 Generic Drugs $7.00$10.50None
TOBRAMYCIN 40MG/ML VIAL   1 Generic Drugs $7.00$10.50None
TOBRAMYCIN OPHTHALMIC SOLUTION 0.3% 5ML BOT   1 Generic Drugs $7.00$10.50None
TOBRAMYCIN-DEXAMETH OPTH SUSP   1 Generic Drugs $7.00$10.50None
TOBRASOL 0.3% EYE DROPS   1 Generic Drugs $7.00$10.50None
TOBREX 0.3% EYE OINTMENT   2 Preferred Brand Drugs $45.00$101.25None
TOLMETIN SODIUM 200MG TABLET   1 Generic Drugs $7.00$10.50None
TOLMETIN SODIUM 400MG CAPSULE   1 Generic Drugs $7.00$10.50None
TOLMETIN SODIUM 600MG TABLET   1 Generic Drugs $7.00$10.50None
Topiramate 25mg/1   1 Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TOPIRAMATE SPRINKLE CAPSULES 15MG 60 BOT   1 Generic Drugs $7.00$10.50None
TOPIRAMATE TABLETS 100MG 1000 BOT   1 Generic Drugs $7.00$10.50None
TOPIRAMATE TABLETS 200MG 1000 BOT   1 Generic Drugs $7.00$10.50None
TOPIRAMATE TABLETS 25MG 1000 BOT   1 Generic Drugs $7.00$10.50None
TOPIRAMATE TABLETS 50MG 1000 BOT   1 Generic Drugs $7.00$10.50None
TOPOSAR INJECTION 20MG/ML 50ML VIAL MD CRTN   1 Generic Drugs $7.00$10.50P
TOPOTECAN HYDROCHLORIDE FOR INJECTION   4 Specialty Tier Drugs 25%N/AP
Torsemide 100mg/1 12 BOTTLE in 1 CASE / 100 TABLET in 1 BOTTLE   1 Generic Drugs $7.00$10.50None
TORSEMIDE 20mg/1 100 TABLET in 1 BOTTLE, PLASTIC   1 Generic Drugs $7.00$10.50None
TORSEMIDE INJECTION 20MG/2ML   2 Preferred Brand Drugs $45.00$101.25None
TORSEMIDE TABLETS   1 Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TORSEMIDE TABLETS   1 Generic Drugs $7.00$10.50None
TPN ELECTROLYTES VIAL   1 Generic Drugs $7.00$10.50P
TRACLEER 125MG TABLET   4 Specialty Tier Drugs 25%N/AP
TRACLEER 62.5MG TABLET   4 Specialty Tier Drugs 25%N/AP
TRAMADOL HCL 50 MG TABLET   1 Generic Drugs $7.00$10.50Q:240
/30Days
TRAMADOL HCL-ACETAMINOPHEN 37.5-325MG TABLET (1000 CT)   1 Generic Drugs $7.00$10.50Q:240
/30Days
TRANDOLAPRIL 1MG TABLET   1 Generic Drugs $7.00$10.50None
TRANDOLAPRIL 2MG TABLET   1 Generic Drugs $7.00$10.50None
TRANDOLAPRIL 4MG TABLET   1 Generic Drugs $7.00$10.50None
TRANEXAMIC ACID 1,000 MG/10 ML   1 Generic Drugs $7.00$10.50None
TRANSDERM-SCOP 1.5MG 24 PKG   2 Preferred Brand Drugs $45.00$101.25P Q:24
/365Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRANYLCYPROMINE SULFATE 10MG TABLET   1 Generic Drugs $7.00$10.50None
TRAVASOL 10% SOLUTION VIAFLEX   2 Preferred Brand Drugs $45.00$101.25P
TRAVATAN Z 0.04MG DROPS 2.5ML BOT   2 Preferred Brand Drugs $45.00$101.25Q:3
/30Days
TRAZODONE 300MG TABLET   1 Generic Drugs $7.00$10.50None
TRAZODONE HCL TABLET USP 100MG (500 CT)   1 Generic Drugs $7.00$10.50None
TRAZODONE HCL TABLET USP 150MG (100 CT)   1 Generic Drugs $7.00$10.50None
TRAZODONE HCL TABLET USP 50MG (500 CT)   1 Generic Drugs $7.00$10.50None
TREANDA FOR INJECTION 100MG/VIAL   4 Specialty Tier Drugs 25%N/AP
TRECATOR 250MG TABLET   3 Non-Preferred Brand Drugs $95.00$261.25None
Trelstar 22.5mg/2mL 2 mL in 1 VIAL, SINGLE-DOSE   4 Specialty Tier Drugs 25%N/AP
TRELSTAR DEPOT MIXJET FOR INJECTION 3.75 MG   2 Preferred Brand Drugs $45.00$101.25P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRELSTAR MIXJET FOR INJECTION 11.25 MG   2 Preferred Brand Drugs $45.00$101.25P
Tretinoin 0.1mg/g 1 TUBE in 1 CARTON / 45 g in 1 TUBE   1 Generic Drugs $7.00$10.50None
Tretinoin 0.25mg/g 1 TUBE in 1 CARTON / 15 g in 1 TUBE   1 Generic Drugs $7.00$10.50None
Tretinoin 0.25mg/g 1 TUBE in 1 CARTON / 45 g in 1 TUBE   1 Generic Drugs $7.00$10.50None
Tretinoin 0.5mg/g 1 TUBE in 1 CARTON / 20 g in 1 TUBE   1 Generic Drugs $7.00$10.50None
TRETINOIN 10MG CAPSULE   4 Specialty Tier Drugs 25%N/ANone
Tretinoin 1mg/g 1 TUBE in 1 CARTON / 45 g in 1 TUBE   1 Generic Drugs $7.00$10.50None
TRI PREVIFEM TABLETS   1 Generic Drugs $7.00$10.50None
TRI-LEGEST FE 5-7-9-7 TABLET   1 Generic Drugs $7.00$10.50None
TRI-SPRINTEC 7DAYSX3 28 TABLET   1 Generic Drugs $7.00$10.50None
TRIAMCINOLONE 0.1% OINTMENT   1 Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRIAMCINOLONE ACETONIDE 0.025% CREAM 80GM TUBE   1 Generic Drugs $7.00$10.50None
TRIAMCINOLONE ACETONIDE 0.025% LOTION 2 FL OZ BOT   1 Generic Drugs $7.00$10.50None
TRIAMCINOLONE ACETONIDE 0.025% OINTMENT 80GM TUBE   1 Generic Drugs $7.00$10.50None
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE   1 Generic Drugs $7.00$10.50None
TRIAMCINOLONE ACETONIDE 0.1% CREAM 80GM TUBE   1 Generic Drugs $7.00$10.50None
TRIAMCINOLONE ACETONIDE 0.1% LOTION 60ML BOTPL   1 Generic Drugs $7.00$10.50None
Triamcinolone Acetonide 1mg/g 1 TUBE in 1 CARTON / 5 g in 1 TUBE   1 Generic Drugs $7.00$10.50None
Triamcinolone Acetonide 55ug/1 1 BOTTLE, SPRAY in 1 CARTON / 120 SPRAY, METERED in 1 BOTTLE, SPRAY   1 Generic Drugs $7.00$10.50Q:17
/30Days
Triamcinolone Acetonide 5mg/g 1 TUBE in 1 CARTON / 15 g in 1 TUBE   1 Generic Drugs $7.00$10.50None
Triamterene and Hydrochlorothiazide 25; 37.5mg/1; mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC   1 Generic Drugs $7.00$10.50None
TRIAMTERENE/HCTZ 37.5/25 TABLET   1 Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRIAMTERENE/HCTZ 75/50 TABLET   1 Generic Drugs $7.00$10.50None
Tribenzor 5; 12.5; 40mg/1; mg/1; mg/1   2 Preferred Brand Drugs $45.00$101.25None
Tribenzor 5; 25; 40mg/1; mg/1; mg/1   2 Preferred Brand Drugs $45.00$101.25None
TRIBENZOR TABLETS   2 Preferred Brand Drugs $45.00$101.25None
TRIBENZOR TABLETS   2 Preferred Brand Drugs $45.00$101.25None
TRIBENZOR TABLETS   2 Preferred Brand Drugs $45.00$101.25None
TRICOR 145MG TABLET   2 Preferred Brand Drugs $45.00$101.25None
Tricor 48mg/1 90 TABLET in 1 BOTTLE   2 Preferred Brand Drugs $45.00$101.25None
TRIDERM 0.1% CREAM   1 Generic Drugs $7.00$10.50None
TRIFLUOPERAZINE 1MG TABLET   1 Generic Drugs $7.00$10.50None
TRIFLUOPERAZINE HCL 2MG TABLET   1 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 5MG TABLET   1 Generic Drugs $7.00$10.50None
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT)   1 Generic Drugs $7.00$10.50None
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT   1 Generic Drugs $7.00$10.50None
TRIHEXYPHENIDYL HYDROCHLORIDE 2mg/1   1 Generic Drugs $7.00$10.50None
Trihexyphenidyl Hydrochloride 2mg/5mL 473 mL in 1 BOTTLE   1 Generic Drugs $7.00$10.50None
Trihexyphenidyl Hydrochloride 5mg/1 100 TABLET in 1 BOTTLE   1 Generic Drugs $7.00$10.50None
TRILIPIX CAPSULE DR 45MG   2 Preferred Brand Drugs $45.00$101.25None
TRILIPIX DELAYED RELEASE CAPSULES 135MG   2 Preferred Brand Drugs $45.00$101.25None
TRIMETHOBENZAMIDE 100MG/ML   1 Generic Drugs $7.00$10.50P
TRIMETHOBENZAMIDE HCL 300MG CAPSULE   1 Generic Drugs $7.00$10.50P
TRIMETHOPRIM TABLETS   1 Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRIMIPRAMINE MALEATE 100 MG CAP   1 Generic Drugs $7.00$10.50None
TRIMIPRAMINE MALEATE 25 MG CAP   1 Generic Drugs $7.00$10.50None
TRIMIPRAMINE MALEATE 50 MG CAP   1 Generic Drugs $7.00$10.50None
TRINESSA TABLET   1 Generic Drugs $7.00$10.50None
TRIPEDIA PRESERVATIVE FREE 6.7;23.4; UNT/.5 ML;   2 Preferred Brand Drugs $45.00$101.25None
TRISENOX 10MG/10ML AMPULE   2 Preferred Brand Drugs $45.00$101.25P
Trivora 6 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK   1 Generic Drugs $7.00$10.50None
TRIZIVIR 300; 150; 300mg/1; mg/1; mg/1 60 TABLET, FILM COATED in 1 BOTTLE   2 Preferred Brand Drugs $45.00$101.25None
TROPHAMINE INJECTION SOLUTION   2 Preferred Brand Drugs $45.00$101.25P
TROPHAMINE INJECTION SOLUTION 6%   2 Preferred Brand Drugs $45.00$101.25P
TROPICAMIDE 0.5% EYE DROPS   1 Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TROPICAMIDE OPHTHALMIC SOLUTION USP   1 Generic Drugs $7.00$10.50None
TROSPIUM CHLORIDE TABLETS   1 Generic Drugs $7.00$10.50None
TRUVADA TABLET   2 Preferred Brand Drugs $45.00$101.25None
TWINRIX TF PF VACCINE 720UNT/20ML 10 X 1ML VIALSD   2 Preferred Brand Drugs $45.00$101.25None
Tygacil 50mg/5mL 10 VIAL, SINGLE-USE in 1 CARTON / 50 mL in 1 VIAL, SINGLE-USE   3 Non-Preferred Brand Drugs $95.00$261.25None
TYKERB 250MG TABLET   4 Specialty Tier Drugs 25%N/AP
TYPHIM VI 25MCG/0.5ML VIAL   2 Preferred Brand Drugs $45.00$101.25None
TYZEKA 600MG TABLET (30 CT)   4 Specialty Tier Drugs 25%N/AP

Chart Legend:

Below are a few notes to help you understand the above 2012 Medicare Part D CVS Caremark Value (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.