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2013 Medicare Part D Plan Formulary Information
Humana Walmart-Preferred Rx Plan (PDP) (S5884-145-0) Benefit Details
The Humana Walmart-Preferred Rx Plan (PDP) (S5884-145-0) Formulary Drugs Starting with the Letter T in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY
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
TABLOID 40 MG TABLET	4	Non-Preferred Brand	35%	35%	None
Tacrolimus 0.5mg/1 100 CAPSULE in 1 BOTTLE	2	Non-Preferred Generics	$4.00	$0.00	P
Tacrolimus 1mg/1 100 CAPSULE in 1 BOTTLE	2	Non-Preferred Generics	$4.00	$0.00	P
Tacrolimus 5mg/1 100 CAPSULE in 1 BOTTLE	2	Non-Preferred Generics	$4.00	$0.00	P
Tamiflu 30mg/1 1 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK	4	Non-Preferred Brand	35%	35%	Q:112 /365Days
Tamiflu 45mg/1 1 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK	4	Non-Preferred Brand	35%	35%	Q:56 /365Days
Tamiflu 6mg/mL 1 BOTTLE, GLASS in 1 CARTON / 6 mL in 1 BOTTLE, GLASS	4	Non-Preferred Brand	35%	35%	Q:720 /365Days
TAMIFLU 75MG CAPSULE UD	4	Non-Preferred Brand	35%	35%	Q:56 /365Days
TAMOXIFEN CITRATE 20MG TABLET (30 CT)	1	Preferred Generics	$1.00	$0.00	None
TAMOXIFEN CITRATE TABLETS 10MG 180 BOT	1	Preferred Generics	$1.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TAMSULOSIN HCL 0.4 MG CAPSULE	2	Non-Preferred Generics	$4.00	$0.00	Q:60 /30Days
TARCEVA 100MG TABLET	5	Specialty	25%	N/A	P Q:30 /30Days
TARCEVA 150MG TABLET	5	Specialty	25%	N/A	P Q:30 /30Days
TARCEVA 25MG TABLET	5	Specialty	25%	N/A	P Q:90 /30Days
TARGRETIN 1% GEL 60GM TUBE	5	Specialty	25%	N/A	P
TARGRETIN 75MG (100 CT)	5	Specialty	25%	N/A	P Q:300 /30Days
Tasigna 150mg/1 4 BLISTER PACK in 1 CARTON / 28 CAPSULE in 1 BLISTER PACK	5	Specialty	25%	N/A	P Q:120 /30Days
TASIGNA 200MG CAPSULE 28 BLPK	5	Specialty	25%	N/A	P Q:120 /30Days
TASMAR 100MG TABLET	4	Non-Preferred Brand	35%	35%	P
TAXOTERE 80mg/4mL 1 VIAL, GLASS in 1 CARTON / 4 mL in 1 VIAL, GLASS	5	Specialty	25%	N/A	P
TAZORAC 0.05% CREAM	4	Non-Preferred Brand	35%	35%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TAZORAC 0.05% GEL	4	Non-Preferred Brand	35%	35%	None
TAZORAC 0.1% CREAM	4	Non-Preferred Brand	35%	35%	None
TAZORAC 0.1% GEL	4	Non-Preferred Brand	35%	35%	None
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES	3	Preferred Brand	20%	20%	Q:60 /30Days
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES	3	Preferred Brand	20%	20%	Q:60 /30Days
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES	3	Preferred Brand	20%	20%	Q:30 /30Days
TAZTIA XT 240MG CAPSULE SA	3	Preferred Brand	20%	20%	Q:60 /30Days
TAZTIA XT 360MG CAPSULE SA	3	Preferred Brand	20%	20%	Q:30 /30Days
Teflaro 400mg/20mL 10 VIAL, SINGLE-DOSE in 1 CARTON / 20 mL in 1 VIAL, SINGLE-DOSE	4	Non-Preferred Brand	35%	35%	None
Teflaro 600mg/20mL 10 VIAL, SINGLE-DOSE in 1 CARTON / 20 mL in 1 VIAL, SINGLE-DOSE	4	Non-Preferred Brand	35%	35%	None
TEGRETOL XR TABLETS 100MG 100 BOT	4	Non-Preferred Brand	35%	35%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Tekamlo 150; 10mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE	3	Preferred Brand	20%	20%	Q:30 /30Days
Tekamlo 150; 5mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE	3	Preferred Brand	20%	20%	Q:30 /30Days
Tekamlo 300; 10mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE	3	Preferred Brand	20%	20%	Q:30 /30Days
Tekamlo 300; 5mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE	3	Preferred Brand	20%	20%	Q:30 /30Days
TEKTURNA 150MG TABLET	3	Preferred Brand	20%	20%	Q:30 /30Days
TEKTURNA 300MG TABLET	3	Preferred Brand	20%	20%	Q:30 /30Days
TEKTURNA HCT 150-12.5MG TABLET	3	Preferred Brand	20%	20%	Q:30 /30Days
TEKTURNA HCT 150MG-25MG TABLET	3	Preferred Brand	20%	20%	Q:30 /30Days
TEKTURNA HCT 300-12.5MG TABLET	3	Preferred Brand	20%	20%	Q:30 /30Days
TEKTURNA HCT 300MG-25MG TABLET	3	Preferred Brand	20%	20%	Q:30 /30Days
Temazepam 15mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE in 1 BLISTER PACK	4	Non-Preferred Brand	35%	35%	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Temazepam 22.5mg/1 30 CAPSULE in 1 BOTTLE, PLASTIC	4	Non-Preferred Brand	35%	35%	None
TEMAZEPAM 30 MG CAPSULE	4	Non-Preferred Brand	35%	35%	Q:30 /30Days
Temazepam 7.5mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC	4	Non-Preferred Brand	35%	35%	None
Terazosin Hydrochloride 10mg/1 100 CAPSULE in 1 BOTTLE	1	Preferred Generics	$1.00	$0.00	None
Terazosin hydrochloride 1mg/1 500 CAPSULE in 1 BOTTLE	1	Preferred Generics	$1.00	$0.00	None
Terazosin Hydrochloride 2mg/1 100 CAPSULE in 1 BOTTLE	1	Preferred Generics	$1.00	$0.00	None
Terazosin Hydrochloride 5mg/1 100 CAPSULE in 1 BOTTLE	1	Preferred Generics	$1.00	$0.00	None
TERBINAFINE HCL 250MG TABLET	1	Preferred Generics	$1.00	$0.00	Q:90 /365Days
TERBUTALINE SULF 1MG/ML VL	5	Specialty	25%	N/A	None
TERBUTALINE SULF 2.5MG TABLET	3	Preferred Brand	20%	20%	None
TERBUTALINE SULFATE 5MG TABLET	3	Preferred Brand	20%	20%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TERCONAZOLE 0.4% CREAM WITH APPLICATOR	2	Non-Preferred Generics	$4.00	$0.00	None
TERCONAZOLE 0.8% CREAM	2	Non-Preferred Generics	$4.00	$0.00	None
TERCONAZOLE 80MG SUPPOSITORY VAGINAL	2	Non-Preferred Generics	$4.00	$0.00	None
Testosterone Cypionate 200mg/mL 1 VIAL, MULTI-DOSE in 1 CARTON / 10 mL in 1 VIAL, MULTI-DOSE	3	Preferred Brand	20%	20%	None
TESTOSTERONE CYPIONATE INJECTION	2	Non-Preferred Generics	$4.00	$0.00	None
TESTOSTERONE ENANTHATE INJECTION	3	Preferred Brand	20%	20%	None
TESTRED 10MG CAPSULE	4	Non-Preferred Brand	35%	35%	None
Tetanus and Diphtheria Toxoids Adsorbed 2.0; 2.0[Lf]/0.5mL; [Lf]/0.5mL 10 VIAL, SINGLE-DOSE in 1 CA	4	Non-Preferred Brand	35%	35%	None
tetanus toxoid adsorbed vial	4	Non-Preferred Brand	35%	35%	P
Tetracycline Hydrochloride 250mg/1 1000 CAPSULE in 1 BOTTLE, PLASTIC	1	Preferred Generics	$1.00	$0.00	None
Tetracycline Hydrochloride 500mg/1 1000 CAPSULE in 1 BOTTLE, PLASTIC	1	Preferred Generics	$1.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
THALOMID 100MG CAPSULE 140 BOX	3	Preferred Brand	20%	20%	P Q:30 /30Days
Thalomid 150mg/1	5	Specialty	25%	N/A	P Q:60 /30Days
Thalomid 200mg/1	5	Specialty	25%	N/A	P Q:30 /30Days
THALOMID 50MG CAPSULE 280 BOX	3	Preferred Brand	20%	20%	P Q:30 /30Days
Theophylline 100mg/1 500 CAPSULE in 1 BOTTLE	2	Non-Preferred Generics	$4.00	$0.00	None
Theophylline 200mg/1 500 TABLET, EXTENDED RELEASE in 1 BOTTLE	2	Non-Preferred Generics	$4.00	$0.00	None
THEOPHYLLINE 400MG TABLET SA	2	Non-Preferred Generics	$4.00	$0.00	None
THEOPHYLLINE 600MG TABLET SA	2	Non-Preferred Generics	$4.00	$0.00	None
THEOPHYLLINE TABLET ER 300MG (100 CT)	2	Non-Preferred Generics	$4.00	$0.00	None
THEOPHYLLINE TABLET ER 450MG (100 CT)	2	Non-Preferred Generics	$4.00	$0.00	None
Thermazene 10mg/g	1	Preferred Generics	$1.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
THIORIDAZINE 100MG TABLET	2	Non-Preferred Generics	$4.00	$0.00	P
THIORIDAZINE HCL 10MG TABLET (1000 CT)	2	Non-Preferred Generics	$4.00	$0.00	P
THIORIDAZINE HCL 25MG TABLET (1000 CT)	2	Non-Preferred Generics	$4.00	$0.00	P
Thioridazine Hydrochloride 50mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED in 1	2	Non-Preferred Generics	$4.00	$0.00	P
THIOTEPA POWDER FOR INJECTION 15MG/VIL 1 VIAL SINGLE DOSE CRTN	2	Non-Preferred Generics	$4.00	$0.00	P
THIOTHIXENE 10MG CAPSULE	2	Non-Preferred Generics	$4.00	$0.00	None
THIOTHIXENE 1MG CAPSULE (100 CT)	2	Non-Preferred Generics	$4.00	$0.00	None
THIOTHIXENE 2MG CAPSULE	1	Preferred Generics	$1.00	$0.00	None
THIOTHIXENE 5MG CAPSULE	2	Non-Preferred Generics	$4.00	$0.00	None
THYMOGLOBULIN 25MG VIAL	3	Preferred Brand	20%	20%	P
tiagabine hcl 2 mg tablet	4	Non-Preferred Brand	35%	35%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
tiagabine hcl 4 mg tablet	4	Non-Preferred Brand	35%	35%	None
TICLOPIDINE 250 MG TABLET	3	Preferred Brand	20%	20%	P
TIKOSYN .125MG CAPSULE	4	Non-Preferred Brand	35%	35%	Q:240 /30Days
TIKOSYN .250MG CAPSULE	4	Non-Preferred Brand	35%	35%	Q:120 /30Days
TIKOSYN .5MG CAPSULE	4	Non-Preferred Brand	35%	35%	Q:60 /30Days
TIMENTIN ADD-VANTAGE 1; 30mg/mL; mg/mL 10 VIAL in 1 TRAY / 50 mL in 1 VIAL	4	Non-Preferred Brand	35%	35%	None
TIMOLOL MAL SOL 0.25% OP 15ML BOT	1	Preferred Generics	$1.00	$0.00	None
TIMOLOL MAL SOL 0.5% OP 10ML BOT	1	Preferred Generics	$1.00	$0.00	None
TIMOLOL MALEATE 10MG TABLET	2	Non-Preferred Generics	$4.00	$0.00	None
TIMOLOL MALEATE 20MG TABLET	2	Non-Preferred Generics	$4.00	$0.00	None
Timolol Maleate 3.4mg/mL 1 BOTTLE, DISPENSING in 1 CARTON / 5 mL in 1 BOTTLE, DISPENSING	3	Preferred Brand	20%	20%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TIMOLOL MALEATE 5MG TABLET	2	Non-Preferred Generics	$4.00	$0.00	None
Timolol Maleate 6.8mg/mL 1 BOTTLE, DISPENSING in 1 CARTON / 5 mL in 1 BOTTLE, DISPENSING	3	Preferred Brand	20%	20%	None
Timoptic 3.4mg/mL 4 POUCH in 1 CARTON / 15 CONTAINER in 1 POUCH / 0.2 mL in 1 CONTAINER	4	Non-Preferred Brand	35%	35%	None
Timoptic 6.8mg/mL 4 POUCH in 1 CARTON / 15 CONTAINER in 1 POUCH / 0.2 mL in 1 CONTAINER	4	Non-Preferred Brand	35%	35%	None
tinidazole 250 mg tablet	3	Preferred Brand	20%	20%	None
tinidazole 500 mg tablet	3	Preferred Brand	20%	20%	None
Tizanidine 4mg/1 1000 TABLET BOTTLE	2	Non-Preferred Generics	$4.00	$0.00	None
TIZANIDINE HCL 2 MG TABLET	2	Non-Preferred Generics	$4.00	$0.00	None
TOBI 300mg/5mL 56 AMPULE in 1 CARTON / 5 mL in 1 AMPULE	5	Specialty	25%	N/A	P Q:280 /28Days
TOBI PODHALER 28 MG INHALE CAP	5	Specialty	25%	N/A	P Q:224 /28Days
TOBRADEX EYE OINTMENT	4	Non-Preferred Brand	35%	35%	None
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	4	Non-Preferred Brand	35%	35%	None
TOBRAMYCIN 10MG/ML VIAL	2	Non-Preferred Generics	$4.00	$0.00	None
TOBRAMYCIN 40MG/ML VIAL	2	Non-Preferred Generics	$4.00	$0.00	None
TOBRAMYCIN 60MG/0.9% NACL	2	Non-Preferred Generics	$4.00	$0.00	None
TOBRAMYCIN 80MG/0.9% NACL	2	Non-Preferred Generics	$4.00	$0.00	None
TOBRAMYCIN OPHTHALMIC SOLUTION 0.3% 5ML BOT	1	Preferred Generics	$1.00	$0.00	None
TOBRAMYCIN-DEXAMETH OPTH SUSP	3	Preferred Brand	20%	20%	None
TOBREX 0.3% EYE OINTMENT	4	Non-Preferred Brand	35%	35%	None
TOFRANIL 50MG TABLET (30 CT)	4	Non-Preferred Brand	35%	35%	P
TOFRANIL TABLETS 10MG 30 BOT	4	Non-Preferred Brand	35%	35%	P
TOFRANIL TABLETS 25MG 30 BOT	4	Non-Preferred Brand	35%	35%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TOFRANIL-PM 100MG CAPSULE	4	Non-Preferred Brand	35%	35%	P
TOFRANIL-PM 125MG CAPSULE	4	Non-Preferred Brand	35%	35%	P
TOFRANIL-PM 150MG CAPSULE	4	Non-Preferred Brand	35%	35%	P
TOFRANIL-PM 75MG CAPSULE	4	Non-Preferred Brand	35%	35%	P
TOLAZAMIDE TABLETS 250MG 100 BOT	3	Preferred Brand	20%	20%	None
TOLAZAMIDE TABLETS 500MG 100 BOT	3	Preferred Brand	20%	20%	None
TOLBUTAMIDE 500MG TABLET	3	Preferred Brand	20%	20%	None
TOLMETIN SODIUM 200MG TABLET	3	Preferred Brand	20%	20%	None
TOLMETIN SODIUM 400 MG CAP	3	Preferred Brand	20%	20%	None
TOLMETIN SODIUM 600MG TABLET	3	Preferred Brand	20%	20%	None
TOLVAPTAN 15 MG ORAL TABLET [SAMSCA]	5	Specialty	25%	N/A	Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TOLVAPTAN 30 MG ORAL TABLET [SAMSCA]	5	Specialty	25%	N/A	Q:60 /30Days
Topiramate 25mg/1	2	Non-Preferred Generics	$4.00	$0.00	None
TOPIRAMATE SPRINKLE CAPSULES 15MG 60 BOT	2	Non-Preferred Generics	$4.00	$0.00	None
TOPIRAMATE TABLETS 100MG 1000 BOT	2	Non-Preferred Generics	$4.00	$0.00	Q:120 /30Days
TOPIRAMATE TABLETS 200MG 1000 BOT	2	Non-Preferred Generics	$4.00	$0.00	Q:120 /30Days
TOPIRAMATE TABLETS 25MG 1000 BOT	2	Non-Preferred Generics	$4.00	$0.00	Q:90 /30Days
TOPIRAMATE TABLETS 50MG 1000 BOT	2	Non-Preferred Generics	$4.00	$0.00	Q:120 /30Days
TOPOSAR INJECTION 20MG/ML 50ML VIAL MD CRTN	4	Non-Preferred Brand	35%	35%	P
TOPOTECAN HYDROCHLORIDE FOR INJECTION	5	Specialty	25%	N/A	P
Torisel 1 KIT in 1 CARTON	5	Specialty	25%	N/A	P Q:100 /28Days
Torsemide 100mg/1 12 BOTTLE CASE / 100 TABLET BOTTLE	2	Non-Preferred Generics	$4.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TORSEMIDE 20mg 100 TABLET BOTTLE	2	Non-Preferred Generics	$4.00	$0.00	None
TORSEMIDE INJECTION 20MG/2ML	2	Non-Preferred Generics	$4.00	$0.00	None
TORSEMIDE TABLETS	2	Non-Preferred Generics	$4.00	$0.00	None
TORSEMIDE TABLETS	2	Non-Preferred Generics	$4.00	$0.00	None
TPN ELECTROLYTES VIAL	4	Non-Preferred Brand	35%	35%	None
TRACLEER 125MG TABLET	5	Specialty	25%	N/A	P Q:60 /30Days
TRACLEER 62.5MG TABLET	5	Specialty	25%	N/A	P Q:60 /30Days
TRADJENTA 5mg/1 90 FILM COATED TABLETS in BOTTLE	4	Non-Preferred Brand	35%	35%	S Q:30 /30Days
TRAMADOL HCL 50 MG TABLET	1	Preferred Generics	$1.00	$0.00	Q:240 /30Days
TRAMADOL HCL-ACETAMINOPHEN 37.5-325MG TABLET (1000 CT)	3	Preferred Brand	20%	20%	Q:240 /30Days
TRANDOLAPRIL 1MG TABLET	2	Non-Preferred Generics	$4.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRANDOLAPRIL 2MG TABLET	2	Non-Preferred Generics	$4.00	$0.00	None
TRANDOLAPRIL 4MG TABLET	2	Non-Preferred Generics	$4.00	$0.00	None
TRANEXAMIC ACID 1,000 MG/10 ML	3	Preferred Brand	20%	20%	None
TRANYLCYPROMINE SULFATE 10MG TABLET	4	Non-Preferred Brand	35%	35%	None
TRAVASOL 10% SOLUTION VIAFLEX	4	Non-Preferred Brand	35%	35%	P
TRAVATAN Z 0.04MG DROPS 2.5ML BOT	3	Preferred Brand	20%	20%	Q:3 /25Days
TRAZODONE 300MG TABLET	2	Non-Preferred Generics	$4.00	$0.00	None
TRAZODONE HCL TABLET USP 100MG (500 CT)	1	Preferred Generics	$1.00	$0.00	None
TRAZODONE HCL TABLET USP 150MG (100 CT)	1	Preferred Generics	$1.00	$0.00	None
TRAZODONE HCL TABLET USP 50MG (500 CT)	1	Preferred Generics	$1.00	$0.00	None
TREANDA FOR INJECTION 100MG/VIAL	5	Specialty	25%	N/A	P Q:600 /21Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRECATOR 250MG TABLET	4	Non-Preferred Brand	35%	35%	None
Trelstar 22.5mg/2mL 2 mL in 1 VIAL, SINGLE-DOSE	4	Non-Preferred Brand	35%	35%	P
TRELSTAR DEPOT MIXJET FOR INJECTION 3.75 MG	4	Non-Preferred Brand	35%	35%	P
TRELSTAR MIXJET FOR INJECTION 11.25 MG	4	Non-Preferred Brand	35%	35%	P
Tretinoin 0.1mg/g 1 TUBE in 1 CARTON / 45 g in 1 TUBE	3	Preferred Brand	20%	20%	P
Tretinoin 0.25mg/g 1 TUBE in 1 CARTON / 45 g in 1 TUBE	3	Preferred Brand	20%	20%	P
Tretinoin 0.25mg/g 1 TUBE in 1 CARTON / 45 g in 1 TUBE	3	Preferred Brand	20%	20%	P
Tretinoin 0.5mg/g 1 TUBE in 1 CARTON / 20 g in 1 TUBE	3	Preferred Brand	20%	20%	P
TRETINOIN 10MG CAPSULE	3	Preferred Brand	20%	20%	None
Tretinoin 1mg/g 1 TUBE in 1 CARTON / 45 g in 1 TUBE	3	Preferred Brand	20%	20%	P
TREXALL 10MG TABLET	4	Non-Preferred Brand	35%	35%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TREXALL 15MG TABLET	4	Non-Preferred Brand	35%	35%	P
TREXALL 5MG TABLET	4	Non-Preferred Brand	35%	35%	P
TREXALL 7.5MG TABLET	4	Non-Preferred Brand	35%	35%	P
TRI PREVIFEM TABLETS	4	Non-Preferred Brand	35%	35%	None
TRI-LEGEST FE 5-7-9-7 TABLET	4	Non-Preferred Brand	35%	35%	None
TRI-SPRINTEC 7DAYSX3 28 TABLET	4	Non-Preferred Brand	35%	35%	None
TRIAMCINOLONE 0.1% OINTMENT	1	Preferred Generics	$1.00	$0.00	None
TRIAMCINOLONE ACETONIDE 0.025% CREAM 80GM TUBE	1	Preferred Generics	$1.00	$0.00	None
TRIAMCINOLONE ACETONIDE 0.025% LOTION 2 FL OZ BOT	2	Non-Preferred Generics	$4.00	$0.00	None
TRIAMCINOLONE ACETONIDE 0.025% OINTMENT 80GM TUBE	2	Non-Preferred Generics	$4.00	$0.00	None
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE	2	Non-Preferred Generics	$4.00	$0.00	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	Preferred Generics	$1.00	$0.00	None
TRIAMCINOLONE ACETONIDE 0.1% LOTION 60ML BOTPL	2	Non-Preferred Generics	$4.00	$0.00	None
Triamcinolone Acetonide 1mg/g 1 TUBE in 1 CARTON / 5 g in 1 TUBE	2	Non-Preferred Generics	$4.00	$0.00	None
Triamcinolone Acetonide 5mg/g 1 TUBE in 1 CARTON / 15 g in 1 TUBE	1	Preferred Generics	$1.00	$0.00	None
Triamterene and Hydrochlorothiazide 25; 37.5mg 100 CAPSULE BOTTLE	1	Preferred Generics	$1.00	$0.00	None
TRIAMTERENE/HCTZ 37.5/25 TABLET	1	Preferred Generics	$1.00	$0.00	None
TRIAMTERENE/HCTZ 75/50 TABLET	1	Preferred Generics	$1.00	$0.00	None
TRICOR 145MG TABLET	3	Preferred Brand	20%	20%	Q:30 /30Days
Tricor 48mg/1 90 TABLET BOTTLE	3	Preferred Brand	20%	20%	Q:60 /30Days
TRIDERM 0.1% CREAM	2	Non-Preferred Generics	$4.00	$0.00	None
TRIFLUOPERAZINE 1MG TABLET	2	Non-Preferred Generics	$4.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRIFLUOPERAZINE HCL 2MG TABLET	2	Non-Preferred Generics	$4.00	$0.00	None
TRIFLUOPERAZINE HCL 5MG TABLET	2	Non-Preferred Generics	$4.00	$0.00	None
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT)	2	Non-Preferred Generics	$4.00	$0.00	None
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT	4	Non-Preferred Brand	35%	35%	None
TRIHEXYPHENIDYL HYDROCHLORIDE 2mg/1	1	Preferred Generics	$1.00	$0.00	P
Trihexyphenidyl Hydrochloride 2mg/5mL 473 mL in 1 BOTTLE	2	Non-Preferred Generics	$4.00	$0.00	P
Trihexyphenidyl Hydrochloride 5mg/1 100 TABLET BOTTLE	2	Non-Preferred Generics	$4.00	$0.00	P
TRILEPTAL 300MG/5ML SUSP	4	Non-Preferred Brand	35%	35%	None
TRIMETHOBENZAMIDE HCL 300MG CAPSULE	3	Preferred Brand	20%	20%	P
TRIMETHOPRIM TABLETS	2	Non-Preferred Generics	$4.00	$0.00	None
TRIMIPRAMINE MALEATE 100 MG CAP	4	Non-Preferred Brand	35%	35%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRIMIPRAMINE MALEATE 25 MG CAP	4	Non-Preferred Brand	35%	35%	P
TRIMIPRAMINE MALEATE 50 MG CAP	4	Non-Preferred Brand	35%	35%	P
TRINESSA TABLET	4	Non-Preferred Brand	35%	35%	None
TRISENOX 10MG/10ML AMPULE	4	Non-Preferred Brand	35%	35%	P
Trivora 6 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK	4	Non-Preferred Brand	35%	35%	None
TRIZIVIR 300; 150; 300mg/1; mg/1; mg/1 60 FILM COATED TABLETS in BOTTLE	3	Preferred Brand	20%	20%	Q:60 /30Days
TROPHAMINE INJECTION SOLUTION	4	Non-Preferred Brand	35%	35%	P
TROPHAMINE INJECTION SOLUTION 6%	4	Non-Preferred Brand	35%	35%	P
TROSPIUM CHLORIDE TABLETS	4	Non-Preferred Brand	35%	35%	None
TRUVADA TABLET	5	Specialty	25%	N/A	Q:30 /30Days
TWINJECT AUTO INJECTOR INJECTION 1% AUTO INJECTOR TWO PACK SYR	4	Non-Preferred Brand	35%	35%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TWINJECT AUTO INJECTOR INJECTION 1% AUTO TWO PACK SYR	4	Non-Preferred Brand	35%	35%	None
TWINRIX TF PF VACCINE 720UNT/20ML 10 X 1ML VIALSD	4	Non-Preferred Brand	35%	35%	None
Tygacil 50mg/5mL 10 VIAL, SINGLE-USE in 1 CARTON / 50 mL in 1 VIAL, SINGLE-USE	4	Non-Preferred Brand	35%	35%	None
TYKERB 250MG TABLET	3	Preferred Brand	20%	20%	P Q:150 /30Days
TYPHIM VI 25MCG/0.5ML VIAL	4	Non-Preferred Brand	35%	35%	None
TYZEKA 600MG TABLET (30 CT)	4	Non-Preferred Brand	35%	35%	Q:30 /30Days
TYZINE 0.1% NOSE DROPS	3	Preferred Brand	20%	20%	None
TYZINE PEDIATRIC 0.05% DROP	3	Preferred Brand	20%	20%	None

Chart Legend:

Below are a few notes to help you understand the above 2013 Medicare Part D Humana Walmart-Preferred Rx Plan (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 $325 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 $2970) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2013 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 October 2013 )

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.