Q1Medicare.com 2012 Medicare Part D or Medicare Advantage Plan Formulary Browser

2012 Medicare Part D Plan Formulary Information
Blue MedicareRx Value (PDP) (S5726-013-0) Benefit Details
The Blue MedicareRx Value (PDP) (S5726-013-0) Formulary Drugs Starting with the Letter T in CMS PDP Region 24 which includes: KS
Drugs Starting with Letter T Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter T Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Tacrolimus 0.5mg/1 100 CAPSULE in 1 BOTTLE	2	Non-Preferred Generic Drugs	$7.00	$10.50	P
Tacrolimus 1mg/1 100 CAPSULE in 1 BOTTLE	2	Non-Preferred Generic Drugs	$7.00	$10.50	P
Tacrolimus 5mg/1 100 CAPSULE in 1 BOTTLE	2	Non-Preferred Generic Drugs	$7.00	$10.50	P
TALWIN 30MG/ML VIAL	5	Injectable Drugs	25%	25%	None
Tamiflu 30mg/1 1 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK	3	Preferred Brand Drugs	$33.00	$82.50	Q:84 /1Days
Tamiflu 45mg/1 1 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK	3	Preferred Brand Drugs	$33.00	$82.50	Q:42 /1Days
Tamiflu 6mg/mL 1 BOTTLE, GLASS in 1 CARTON / 6 mL in 1 BOTTLE, GLASS	3	Preferred Brand Drugs	$33.00	$82.50	Q:360 /180Days
TAMIFLU 75MG CAPSULE UD	3	Preferred Brand Drugs	$33.00	$82.50	Q:56 /365Days
TAMIFLU ORAL SUSPENSION	3	Preferred Brand Drugs	$33.00	$82.50	Q:175 /180Days
TAMOXIFEN CITRATE 20MG TABLET (30 CT)	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
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	$10.50	None
TAMSULOSIN HCL 0.4 MG CAPSULE	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
TARCEVA 100MG TABLET	6	Specialty Tier Drugs	25%	N/A	P
TARCEVA 150MG TABLET	6	Specialty Tier Drugs	25%	N/A	P
TARCEVA 25MG TABLET	6	Specialty Tier Drugs	25%	N/A	P
TARGRETIN 1% GEL 60GM TUBE	6	Specialty Tier Drugs	25%	N/A	None
TARGRETIN 75MG (100 CT)	6	Specialty Tier Drugs	25%	N/A	P
Tasigna 150mg/1 4 BLISTER PACK in 1 CARTON / 28 CAPSULE in 1 BLISTER PACK	6	Specialty Tier Drugs	25%	N/A	P
TASIGNA 200MG CAPSULE 28 BLPK	6	Specialty Tier Drugs	25%	N/A	P
TASMAR 100MG TABLET	6	Specialty Tier Drugs	25%	N/A	None
TAXOTERE 80MG/2ML VIAL	6	Specialty Tier Drugs	25%	N/A	P
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	25%	N/A	P
TAZORAC 0.05% CREAM	4	Non-Preferred Brand Drugs	$85.00	$212.50	None
TAZORAC 0.05% GEL	4	Non-Preferred Brand Drugs	$85.00	$212.50	None
TAZORAC 0.1% CREAM	4	Non-Preferred Brand Drugs	$85.00	$212.50	None
TAZORAC 0.1% GEL	4	Non-Preferred Brand Drugs	$85.00	$212.50	None
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
TAZTIA XT 240MG CAPSULE SA	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
TAZTIA XT 360MG CAPSULE SA	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
TEKTURNA 150MG TABLET	3	Preferred Brand Drugs	$33.00	$82.50	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TEKTURNA 300MG TABLET	3	Preferred Brand Drugs	$33.00	$82.50	Q:30 /30Days
TEKTURNA HCT 150-12.5MG TABLET	3	Preferred Brand Drugs	$33.00	$82.50	Q:30 /30Days
TEKTURNA HCT 150MG-25MG TABLET	3	Preferred Brand Drugs	$33.00	$82.50	Q:30 /30Days
TEKTURNA HCT 300-12.5MG TABLET	3	Preferred Brand Drugs	$33.00	$82.50	Q:30 /30Days
TEKTURNA HCT 300MG-25MG TABLET	3	Preferred Brand Drugs	$33.00	$82.50	Q:30 /30Days
TERAZOSIN HCL 10MG CAPSULE	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
TERAZOSIN HCL 1MG CAPSULE	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
TERAZOSIN HCL 2MG CAPSULE	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
TERAZOSIN HCL 5MG CAPSULE	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
TERBINAFINE HCL 250MG TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
TERBUTALINE SULF 1MG/ML VL	5	Injectable Drugs	25%	25%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TERBUTALINE SULF 2.5MG TABLET	1*	Preferred Generic Drugs	$4.00	$6.00	None
TERBUTALINE SULFATE 5MG TABLET	1*	Preferred Generic Drugs	$4.00	$6.00	None
TERCONAZOLE 0.4% CREAM WITH APPLICATOR	1*	Preferred Generic Drugs	$4.00	$6.00	Q:90 /30Days
TERCONAZOLE 80MG SUPPOSITORY VAGINAL	1*	Preferred Generic Drugs	$4.00	$6.00	None
TERCONAZOLE VAGINAL CREAM	1*	Preferred Generic Drugs	$4.00	$6.00	Q:40 /30Days
TESTIM 1%(50MG) GEL	3	Preferred Brand Drugs	$33.00	$82.50	P Q:300 /30Days
Testosterone Cypionate 200mg/mL 1 VIAL, MULTI-DOSE in 1 CARTON / 10 mL in 1 VIAL, MULTI-DOSE	5	Injectable Drugs	25%	25%	None
TESTOSTERONE CYPIONATE INJECTION	5	Injectable Drugs	25%	25%	None
TESTOSTERONE ENANTHATE INJECTION	5	Injectable Drugs	25%	25%	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	$33.00	$82.50	None
TETANUS TOXOID ADSORBED VIAL 5LF	1*	Preferred Generic Drugs	$4.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TETRACYCLINE 500MG CAPSULE	1*	Preferred Generic Drugs	$4.00	$6.00	None
Tetracycline Hydrochloride 250mg/1 100 CAPSULE in 1 BOTTLE	1*	Preferred Generic Drugs	$4.00	$6.00	None
TEV-TROPIN 2 CARTON in 1 BOX / 1 POWDER, FOR SOLUTION in 1 CARTON	5	Injectable Drugs	25%	25%	P
THALITONE 15MG TABLET	3	Preferred Brand Drugs	$33.00	$82.50	None
THALOMID 100MG CAPSULE 140 BOX	6	Specialty Tier Drugs	25%	N/A	P
Thalomid 150mg/1	6	Specialty Tier Drugs	25%	N/A	P
Thalomid 200mg/1	6	Specialty Tier Drugs	25%	N/A	P
THALOMID 50MG CAPSULE 280 BOX	6	Specialty Tier Drugs	25%	N/A	P
THEOCHRON 100MG TABLET SA	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
THEOCHRON TABLETS EXTENDED RELEASE 300MG 100 BOT	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
Theophylline 100mg/1 500 CAPSULE in 1 BOTTLE	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
THEOPHYLLINE 400MG TABLET SA	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
THEOPHYLLINE 600MG TABLET SA	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
THEOPHYLLINE ANHYDROUS ER TABLET 200MG (1000 CT)	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
THEOPHYLLINE TABLET ER 300MG (100 CT)	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
THEOPHYLLINE TABLET ER 450MG (100 CT)	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
Thermazene 10mg/g	1*	Preferred Generic Drugs	$4.00	$6.00	None
THIOGUANINE TABLET LOID 40MG	4	Non-Preferred Brand Drugs	$85.00	$212.50	None
THIORIDAZINE 100MG TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
THIORIDAZINE HCL 10MG TABLET (1000 CT)	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
THIORIDAZINE HCL 25MG TABLET (1000 CT)	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
THIORIDAZINE HCL 50MG TABLET (1000 CT)	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
THIOTEPA POWDER FOR INJECTION 15MG/VIL 1 VIAL SINGLE DOSE CRTN	5	Injectable Drugs	25%	25%	P
THIOTHIXENE 10MG CAPSULE	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
THIOTHIXENE 1MG CAPSULE (100 CT)	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
THIOTHIXENE 2MG CAPSULE	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
THIOTHIXENE 5MG CAPSULE	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
THYMOGLOBULIN 25MG VIAL	6	Specialty Tier Drugs	25%	N/A	P
THYROLAR-1 60MG TABLET	3	Preferred Brand Drugs	$33.00	$82.50	None
THYROLAR-1/4 15MG TABLET	3	Preferred Brand Drugs	$33.00	$82.50	None
THYROLAR-2 120MG TABLET	3	Preferred Brand Drugs	$33.00	$82.50	None
THYROLAR-3 180MG TABLET	3	Preferred Brand Drugs	$33.00	$82.50	None
Ticlopidine Hydrochloride 250mg/1 60 TABLET, FILM COATED in 1 BOTTLE	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TIGAN INJECTION 100MG/ML 20 ML VIALMD	5	Injectable Drugs	25%	25%	None
TIKOSYN .125MG CAPSULE	4	Non-Preferred Brand Drugs	$85.00	$212.50	None
TIKOSYN .250MG CAPSULE	4	Non-Preferred Brand Drugs	$85.00	$212.50	None
TIKOSYN .5MG CAPSULE	4	Non-Preferred Brand Drugs	$85.00	$212.50	None
TIMENTIN 3.1GM VIAL	5	Injectable Drugs	25%	25%	None
TIMOLOL MAL SOL 0.25% OP 15ML BOT	1*	Preferred Generic Drugs	$4.00	$6.00	None
TIMOLOL MAL SOL 0.5% OP 10ML BOT	1*	Preferred Generic Drugs	$4.00	$6.00	None
Timolol Maleate 3.4mg/mL 1 BOTTLE, DISPENSING in 1 CARTON / 5 mL in 1 BOTTLE, DISPENSING	1*	Preferred Generic Drugs	$4.00	$6.00	None
Timolol Maleate 6.8mg/mL 1 BOTTLE, DISPENSING in 1 CARTON / 5 mL in 1 BOTTLE, DISPENSING	1*	Preferred Generic Drugs	$4.00	$6.00	None
TINIDAZOLE TAB 250MG	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
TINIDAZOLE TAB 500MG	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TIS-U-SOL IRRIGATION SOLUTION	5	Injectable Drugs	25%	25%	P
tizanidine 4mg/1	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
TIZANIDINE HCL 2 MG TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
TOBI 300mg/5mL 56 AMPULE in 1 CARTON / 5 mL in 1 AMPULE	6	Specialty Tier Drugs	25%	N/A	P
TOBRADEX EYE OINTMENT	3	Preferred Brand Drugs	$33.00	$82.50	None
TOBRADEX ST 0.5; 3mg/mL; mg/mL 5 mL in 1 BOTTLE	3	Preferred Brand Drugs	$33.00	$82.50	None
TOBRAMYCIN 10MG/ML VIAL	5	Injectable Drugs	25%	25%	None
TOBRAMYCIN 40MG/ML VIAL	5	Injectable Drugs	25%	25%	None
TOBRAMYCIN 60MG/0.9% NACL	5	Injectable Drugs	25%	25%	None
TOBRAMYCIN 80MG/0.9% NACL	5	Injectable Drugs	25%	25%	None
TOBRAMYCIN OPHTHALMIC SOLUTION 0.3% 5ML BOT	1*	Preferred Generic Drugs	$4.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TOBRAMYCIN-DEXAMETH OPTH SUSP	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
TOBRASOL 0.3% EYE DROPS	1*	Preferred Generic Drugs	$4.00	$6.00	None
TOLAZAMIDE TABLETS 250MG 100 BOT	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
TOLAZAMIDE TABLETS 500MG 100 BOT	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
TOLBUTAMIDE 500MG TABLET	1*	Preferred Generic Drugs	$4.00	$6.00	None
TOLVAPTAN 15 MG ORAL TABLET [SAMSCA]	6	Specialty Tier Drugs	25%	N/A	P Q:30 /30Days
TOLVAPTAN 30 MG ORAL TABLET [SAMSCA]	6	Specialty Tier Drugs	25%	N/A	P Q:60 /30Days
Topiramate 25mg/1	2	Non-Preferred Generic Drugs	$7.00	$10.50	P
TOPIRAMATE SPRINKLE CAPSULES 15MG 60 BOT	2	Non-Preferred Generic Drugs	$7.00	$10.50	P
TOPIRAMATE TABLETS 100MG 1000 BOT	2	Non-Preferred Generic Drugs	$7.00	$10.50	P Q:60 /30Days
TOPIRAMATE TABLETS 200MG 1000 BOT	2	Non-Preferred Generic Drugs	$7.00	$10.50	P Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TOPIRAMATE TABLETS 25MG 1000 BOT	2	Non-Preferred Generic Drugs	$7.00	$10.50	P Q:60 /30Days
TOPIRAMATE TABLETS 50MG 1000 BOT	2	Non-Preferred Generic Drugs	$7.00	$10.50	P Q:60 /30Days
TOPOSAR INJECTION 20MG/ML 50ML VIAL MD CRTN	5	Injectable Drugs	25%	25%	P
TOPOTECAN HYDROCHLORIDE FOR INJECTION	6	Specialty Tier Drugs	25%	N/A	P
Torisel 1 KIT in 1 CARTON	6	Specialty Tier Drugs	25%	N/A	P
TORSEMIDE INJECTION 20MG/2ML	5	Injectable Drugs	25%	25%	None
TOVIAZ TABLETS 4MG EXTENDED RELEASE	3	Preferred Brand Drugs	$33.00	$82.50	Q:30 /30Days
TOVIAZ TABLETS 8MG EXTENDED RELEASE	3	Preferred Brand Drugs	$33.00	$82.50	Q:30 /30Days
TPN ELECTROLYTES VIAL	5	Injectable Drugs	25%	25%	None
TRACLEER 125MG TABLET	6	Specialty Tier Drugs	25%	N/A	None
TRACLEER 62.5MG TABLET	6	Specialty Tier Drugs	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRAMADOL HCL 50 MG TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	Q:240 /30Days
TRAMADOL HCL-ACETAMINOPHEN 37.5-325MG TABLET (1000 CT)	2	Non-Preferred Generic Drugs	$7.00	$10.50	Q:240 /30Days
TRAMADOL HYDROCHLORIDE 100mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC	2	Non-Preferred Generic Drugs	$7.00	$10.50	Q:30 /30Days
TRAMADOL HYDROCHLORIDE 200mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC	2	Non-Preferred Generic Drugs	$7.00	$10.50	Q:30 /30Days
TRANDOLAPRIL 1MG TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
TRANDOLAPRIL 2MG TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
TRANDOLAPRIL 4MG TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
TRANEXAMIC ACID 1,000 MG/10 ML	5	Injectable Drugs	25%	25%	None
TRANYLCYPROMINE SULFATE 10MG TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
TRAVASOL 10% SOLUTION VIAFLEX	5	Injectable Drugs	25%	25%	None
TRAVATAN Z 0.04MG DROPS 2.5ML BOT	3	Preferred Brand Drugs	$33.00	$82.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRAZODONE 300MG TABLET	1*	Preferred Generic Drugs	$4.00	$6.00	None
TRAZODONE HCL TABLET USP 100MG (500 CT)	1*	Preferred Generic Drugs	$4.00	$6.00	None
TRAZODONE HCL TABLET USP 150MG (100 CT)	1*	Preferred Generic Drugs	$4.00	$6.00	None
TRAZODONE HCL TABLET USP 50MG (500 CT)	1*	Preferred Generic Drugs	$4.00	$6.00	None
TREANDA FOR INJECTION 100MG/VIAL	6	Specialty Tier Drugs	25%	N/A	P
TRECATOR 250MG TABLET	4	Non-Preferred Brand Drugs	$85.00	$212.50	None
Tretinoin 0.1mg/g 1 TUBE in 1 CARTON / 45 g in 1 TUBE	2	Non-Preferred Generic Drugs	$7.00	$10.50	Q:90 /30Days
Tretinoin 0.25mg/g 1 TUBE in 1 CARTON / 15 g in 1 TUBE	2	Non-Preferred Generic Drugs	$7.00	$10.50	Q:90 /30Days
Tretinoin 0.25mg/g 1 TUBE in 1 CARTON / 45 g in 1 TUBE	2	Non-Preferred Generic Drugs	$7.00	$10.50	Q:90 /30Days
Tretinoin 0.5mg/g 1 TUBE in 1 CARTON / 20 g in 1 TUBE	2	Non-Preferred Generic Drugs	$7.00	$10.50	Q:90 /30Days
TRETINOIN 10MG CAPSULE	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Tretinoin 1mg/g 1 TUBE in 1 CARTON / 45 g in 1 TUBE	2	Non-Preferred Generic Drugs	$7.00	$10.50	Q:90 /30Days
TRI PREVIFEM TABLETS	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
TRI-LEGEST FE 5-7-9-7 TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
TRI-SPRINTEC 7DAYSX3 28 TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
TRIAMCINOLONE 0.1% OINTMENT	1*	Preferred Generic Drugs	$4.00	$6.00	None
TRIAMCINOLONE ACETONIDE 0.025% CREAM 80GM TUBE	1*	Preferred Generic Drugs	$4.00	$6.00	None
TRIAMCINOLONE ACETONIDE 0.025% LOTION 2 FL OZ BOT	1*	Preferred Generic Drugs	$4.00	$6.00	None
TRIAMCINOLONE ACETONIDE 0.025% OINTMENT 80GM TUBE	1*	Preferred Generic Drugs	$4.00	$6.00	None
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT	1*	Preferred Generic Drugs	$4.00	$6.00	None
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE	1*	Preferred Generic Drugs	$4.00	$6.00	None
TRIAMCINOLONE ACETONIDE 0.1% CREAM 80GM TUBE	1*	Preferred Generic Drugs	$4.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRIAMCINOLONE ACETONIDE 0.1% LOTION 60ML BOTPL	1*	Preferred Generic Drugs	$4.00	$6.00	None
Triamcinolone Acetonide 1mg/g 1 TUBE in 1 CARTON / 5 g in 1 TUBE	1*	Preferred Generic Drugs	$4.00	$6.00	None
Triamcinolone Acetonide 5mg/g 1 TUBE in 1 CARTON / 15 g in 1 TUBE	1*	Preferred Generic Drugs	$4.00	$6.00	None
Triamterene and Hydrochlorothiazide 25; 37.5mg/1; mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC	1*	Preferred Generic Drugs	$4.00	$6.00	None
TRIAMTERENE/HCTZ 37.5/25 TABLET	1*	Preferred Generic Drugs	$4.00	$6.00	None
TRIAMTERENE/HCTZ 75/50 TABLET	1*	Preferred Generic Drugs	$4.00	$6.00	None
TRIDERM 0.1% CREAM	1*	Preferred Generic Drugs	$4.00	$6.00	None
TRIFLUOPERAZINE 1MG TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
TRIFLUOPERAZINE HCL 2MG TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
TRIFLUOPERAZINE HCL 5MG TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT)	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
TRIHEXYPHENIDYL HYDROCHLORIDE 2mg/1	1*	Preferred Generic Drugs	$4.00	$6.00	None
Trihexyphenidyl Hydrochloride 2mg/5mL 473 mL in 1 BOTTLE	1*	Preferred Generic Drugs	$4.00	$6.00	None
Trihexyphenidyl Hydrochloride 5mg/1 100 TABLET in 1 BOTTLE	1*	Preferred Generic Drugs	$4.00	$6.00	None
TRIMETHOBENZAMIDE 100MG/ML	5	Injectable Drugs	25%	25%	None
TRIMETHOBENZAMIDE HCL 300MG CAPSULE	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
TRIMETHOPRIM TABLETS	1*	Preferred Generic Drugs	$4.00	$6.00	None
TRIMIPRAMINE MALEATE 100 MG CAP	4	Non-Preferred Brand Drugs	$85.00	$212.50	None
TRIMIPRAMINE MALEATE 25 MG CAP	4	Non-Preferred Brand Drugs	$85.00	$212.50	None
TRIMIPRAMINE MALEATE 50 MG CAP	4	Non-Preferred Brand Drugs	$85.00	$212.50	None
TRINESSA TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRIPEDIA PRESERVATIVE FREE 6.7;23.4; UNT/.5 ML;	3	Preferred Brand Drugs	$33.00	$82.50	None
TRISENOX 10MG/10ML AMPULE	5	Injectable Drugs	25%	25%	P
Trivora 6 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
TRIZIVIR 300; 150; 300mg/1; mg/1; mg/1 60 TABLET, FILM COATED in 1 BOTTLE	6	Specialty Tier Drugs	25%	N/A	None
TROPHAMINE INJECTION SOLUTION	5	Injectable Drugs	25%	25%	None
TROPHAMINE INJECTION SOLUTION 6%	5	Injectable Drugs	25%	25%	None
TROPICAMIDE 0.5% EYE DROPS	1*	Preferred Generic Drugs	$4.00	$6.00	None
TROPICAMIDE OPHTHALMIC SOLUTION USP	1*	Preferred Generic Drugs	$4.00	$6.00	None
TRUVADA TABLET	6	Specialty Tier Drugs	25%	N/A	None
TWINJECT AUTO INJECTOR INJECTION 1% AUTO INJECTOR TWO PACK SYR	5	Injectable Drugs	25%	25%	Q:2 /1Days
TWINJECT AUTO INJECTOR INJECTION 1% AUTO TWO PACK SYR	5	Injectable Drugs	25%	25%	Q:2 /1Days
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	3	Preferred Brand Drugs	$33.00	$82.50	None
Tygacil 50mg/5mL 10 VIAL, SINGLE-USE in 1 CARTON / 50 mL in 1 VIAL, SINGLE-USE	6	Specialty Tier Drugs	25%	N/A	None
TYKERB 250MG TABLET	6	Specialty Tier Drugs	25%	N/A	P
TYPHIM VI 25MCG/0.5ML VIAL	3	Preferred Brand Drugs	$33.00	$82.50	None
TYZEKA 600MG TABLET (30 CT)	6	Specialty Tier Drugs	25%	N/A	P
TYZINE 0.1% NOSE DROPS	3	Preferred Brand Drugs	$33.00	$82.50	None
TYZINE PEDIATRIC 0.05% DROP	4	Non-Preferred Brand Drugs	$85.00	$212.50	None

Chart Legend:

Below are a few notes to help you understand the above 2012 Medicare Part D Blue MedicareRx 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.