Q1Medicare.com 2014 Medicare Part D or Medicare Advantage Plan Formulary Browser

2014 Medicare Part D Plan Formulary Information
MedicareRx Rewards Standard (PDP) (S5960-131-0) Benefit Details
The MedicareRx Rewards Standard (PDP) (S5960-131-0) Formulary Drugs Starting with the Letter T in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY Plan Monthly Premium: $59.30 Deductible: $310 Qualifies for LIS: No
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	$76.00	$228.00	None
Tacrolimus 0.5mg/1 100 CAPSULE BOTTLE	3	Preferred Brand	$24.00	$72.00	P
Tacrolimus 1mg/1 100 CAPSULE BOTTLE	3	Preferred Brand	$24.00	$72.00	P
Tacrolimus 5mg/1 100 CAPSULE BOTTLE	6	Specialty Tier	25%	N/A	P
TAFINLAR 50 MG CAPSULE	6	Specialty Tier	25%	N/A	P
TAFINLAR 75 MG CAPSULE	6	Specialty Tier	25%	N/A	P
Tamiflu 30mg/1 1 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK	3	Preferred Brand	$24.00	$72.00	Q:84 /1Days
Tamiflu 45mg/1 1 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK	3	Preferred Brand	$24.00	$72.00	Q:42 /1Days
TAMIFLU 6 MG/ML SUSPENSION	3	Preferred Brand	$24.00	$72.00	Q:360 /180Days
TAMIFLU 75MG CAPSULE UD	3	Preferred Brand	$24.00	$72.00	Q:56 /365Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TAMOXIFEN CITRATE 20MG TABLET (30 CT)	2	Non-Preferred Generic	$2.00	$4.00	None
TAMOXIFEN CITRATE TABLETS 10MG 180 BOT	2	Non-Preferred Generic	$2.00	$4.00	None
TAMSULOSIN HCL 0.4 MG CAPSULE	2	Non-Preferred Generic	$2.00	$4.00	None
TARCEVA 100MG TABLET	6	Specialty Tier	25%	N/A	P
TARCEVA 150MG TABLET	6	Specialty Tier	25%	N/A	P
TARCEVA 25MG TABLET	6	Specialty Tier	25%	N/A	P
TARGRETIN 1% GEL 60GM TUBE	6	Specialty Tier	25%	N/A	None
TARGRETIN 75 MG CAPSULE	6	Specialty Tier	25%	N/A	P
Tasigna 150mg/1 4 BLISTER PACK per CARTON / 28 CAPSULE per BLISTER PACK	6	Specialty Tier	25%	N/A	P
TASIGNA 200MG CAPSULE 28 BLPK	6	Specialty Tier	25%	N/A	P
TAXOTERE 80mg/4mL 1 VIAL, GLASS per CARTON / 4 mL in 1 VIAL, GLASS	6	Specialty Tier	25%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TAZORAC 0.05% CREAM	4	Non-Preferred Brand	$76.00	$228.00	None
TAZORAC 0.05% GEL	4	Non-Preferred Brand	$76.00	$228.00	None
TAZORAC 0.1% CREAM	4	Non-Preferred Brand	$76.00	$228.00	None
TAZORAC 0.1% GEL	4	Non-Preferred Brand	$76.00	$228.00	None
TAZTIA DILTIAZEM HYDROCHLORIDE 120MG EXTENDED RELEASE CAPSULES	2	Non-Preferred Generic	$2.00	$4.00	None
TAZTIA DILTIAZEM HYDROCHLORIDE 180MG EXTENDED RELEASE CAPSULES	2	Non-Preferred Generic	$2.00	$4.00	None
TAZTIA DILTIAZEM HYDROCHLORIDE 300MG EXTENDED RELEASE CAPSULES	2	Non-Preferred Generic	$2.00	$4.00	None
TAZTIA XT 240MG CAPSULE SA	2	Non-Preferred Generic	$2.00	$4.00	None
TAZTIA XT 360MG CAPSULE SA	2	Non-Preferred Generic	$2.00	$4.00	None
TEKTURNA 150MG TABLET	4	Non-Preferred Brand	$76.00	$228.00	Q:30 /30Days
TEKTURNA 300MG TABLET	4	Non-Preferred Brand	$76.00	$228.00	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TEKTURNA HCT 150-12.5MG TABLET	4	Non-Preferred Brand	$76.00	$228.00	Q:30 /30Days
TEKTURNA HCT 150MG-25MG TABLET	4	Non-Preferred Brand	$76.00	$228.00	Q:30 /30Days
TEKTURNA HCT 300-12.5MG TABLET	4	Non-Preferred Brand	$76.00	$228.00	Q:30 /30Days
TEKTURNA HCT 300MG-25MG TABLET	4	Non-Preferred Brand	$76.00	$228.00	Q:30 /30Days
Telmisartan 20 MG Tablet [Micardis]	3	Preferred Brand	$24.00	$72.00	Q:30 /30Days
Telmisartan 40 MG Tablet [Micardis]	3	Preferred Brand	$24.00	$72.00	Q:30 /30Days
Telmisartan 80 MG Tablet [Micardis]	3	Preferred Brand	$24.00	$72.00	Q:60 /30Days
Telmisartan-Amlodipine 40-10 MG [Micardis]	3	Preferred Brand	$24.00	$72.00	Q:30 /30Days
Telmisartan-Amlodipine 40-5 MG [Micardis]	3	Preferred Brand	$24.00	$72.00	Q:30 /30Days
Telmisartan-Amlodipine 80-10 MG [Micardis]	3	Preferred Brand	$24.00	$72.00	Q:30 /30Days
Telmisartan-Amlodipine 80-5 MG [Micardis]	3	Preferred Brand	$24.00	$72.00	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Telmisartan-HCTZ 40-12.5 mg tablet [Micardis HCT]	2	Non-Preferred Generic	$2.00	$4.00	Q:30 /30Days
Telmisartan-HCTZ 80-12.5 mg tablet [Micardis HCT]	2	Non-Preferred Generic	$2.00	$4.00	Q:60 /30Days
Telmisartan-HCTZ 80-25 mg tablet [Micardis HCT]	2	Non-Preferred Generic	$2.00	$4.00	Q:30 /30Days
TERAZOSIN 1 MG CAPSULE	2	Non-Preferred Generic	$2.00	$4.00	None
Terazosin Hydrochloride 10mg/1 100 CAPSULE BOTTLE	2	Non-Preferred Generic	$2.00	$4.00	None
Terazosin Hydrochloride 2mg/1 100 CAPSULE BOTTLE	2	Non-Preferred Generic	$2.00	$4.00	None
Terazosin Hydrochloride 5mg/1 100 CAPSULE BOTTLE	2	Non-Preferred Generic	$2.00	$4.00	None
TERBINAFINE HCL 250 MG TABLET	3	Preferred Brand	$24.00	$72.00	None
TERBUTALINE SULF 2.5MG TABLET	2	Non-Preferred Generic	$2.00	$4.00	None
TERBUTALINE SULFATE 5MG TABLET	2	Non-Preferred Generic	$2.00	$4.00	None
TERCONAZOLE 0.4% CREAM WITH APPLICATOR	2	Non-Preferred Generic	$2.00	$4.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TERCONAZOLE 0.8% CREAM	2	Non-Preferred Generic	$2.00	$4.00	None
TERCONAZOLE 80MG SUPPOSITORY VAGINAL	2	Non-Preferred Generic	$2.00	$4.00	None
TESTOSTERONE CYPIONATE 100MG/ML INJECTION	5	Injectable Drugs	$95.00	$285.00	None
Testosterone Cypionate 200mg/mL 1 VIAL, MULTI-DOSE per CARTON / 10 mL in 1 VIAL, MULTI-DOSE	5	Injectable Drugs	$95.00	$285.00	None
TESTOSTERONE ENANTHATE 200MG/ML INJECTION	5	Injectable Drugs	$95.00	$285.00	None
TETANUS DIPHTHERIA TOXOIDS	3	Preferred Brand	$24.00	$72.00	None
tetanus toxoid adsorbed vial	3	Preferred Brand	$24.00	$72.00	None
TEV-TROPIN 2 CARTON in 1 BOX / 1 POWDER, FOR SOLUTION per CARTON	5	Injectable Drugs	$95.00	$285.00	P
THALOMID 100MG CAPSULE 140 BOX	6	Specialty Tier	25%	N/A	P
Thalomid 150mg/1	6	Specialty Tier	25%	N/A	P
Thalomid 200mg/1	6	Specialty Tier	25%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
THALOMID 50MG CAPSULE 280 BOX	6	Specialty Tier	25%	N/A	P
Theophylline 100mg/1 500 CAPSULE BOTTLE	2	Non-Preferred Generic	$2.00	$4.00	None
Theophylline 200mg/1 500 TABLET, EXTENDED RELEASE in 1 BOTTLE	2	Non-Preferred Generic	$2.00	$4.00	None
THEOPHYLLINE 400MG TABLET SA	2	Non-Preferred Generic	$2.00	$4.00	None
THEOPHYLLINE 600MG TABLET SA	2	Non-Preferred Generic	$2.00	$4.00	None
THEOPHYLLINE TABLET ER 300MG (100 CT)	2	Non-Preferred Generic	$2.00	$4.00	None
THEOPHYLLINE TABLET ER 450MG (100 CT)	2	Non-Preferred Generic	$2.00	$4.00	None
Thermazene 10mg/g	1*	Preferred Generic	$1.00	$2.00	None
THIORIDAZINE 100MG TABLET	3	Preferred Brand	$24.00	$72.00	P
THIORIDAZINE HCL 10MG TABLET (1000 CT)	3	Preferred Brand	$24.00	$72.00	P
THIORIDAZINE HCL 25MG TABLET (1000 CT)	3	Preferred Brand	$24.00	$72.00	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Thioridazine Hydrochloride 50mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED in 1	3	Preferred Brand	$24.00	$72.00	P
THIOTHIXENE 10MG CAPSULE	2	Non-Preferred Generic	$2.00	$4.00	None
THIOTHIXENE 1MG CAPSULE (100 CT)	2	Non-Preferred Generic	$2.00	$4.00	None
THIOTHIXENE 2MG CAPSULE	2	Non-Preferred Generic	$2.00	$4.00	None
THIOTHIXENE 5MG CAPSULE	2	Non-Preferred Generic	$2.00	$4.00	None
THYMOGLOBULIN 25MG VIAL	6	Specialty Tier	25%	N/A	P
tiagabine hcl 2 mg tablet [Gabitril]	3	Preferred Brand	$24.00	$72.00	None
tiagabine hcl 4 mg tablet [Gabitril]	3	Preferred Brand	$24.00	$72.00	None
TIKOSYN .125MG CAPSULE	4	Non-Preferred Brand	$76.00	$228.00	None
TIKOSYN .250MG CAPSULE	4	Non-Preferred Brand	$76.00	$228.00	None
TIKOSYN .5MG CAPSULE	4	Non-Preferred Brand	$76.00	$228.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TIMOLOL MAL SOL 0.25% OP 15ML BOT	1*	Preferred Generic	$1.00	$2.00	None
TIMOLOL MAL SOL 0.5% OP 10ML BOT	1*	Preferred Generic	$1.00	$2.00	None
Timolol Maleate 3.4mg/mL 1 BOTTLE, DISPENSING per CARTON / 5 mL in 1 BOTTLE, DISPENSING	1*	Preferred Generic	$1.00	$2.00	None
Timolol Maleate 6.8mg/mL 1 BOTTLE, DISPENSING per CARTON / 5 mL in 1 BOTTLE, DISPENSING	1*	Preferred Generic	$1.00	$2.00	None
tinidazole 250 mg tablet	2	Non-Preferred Generic	$2.00	$4.00	None
tinidazole 500 mg tablet	2	Non-Preferred Generic	$2.00	$4.00	None
TIVICAY 50 MG TABLET	6	Specialty Tier	25%	N/A	None
Tizanidine 4mg/1 1000 TABLET BOTTLE	2	Non-Preferred Generic	$2.00	$4.00	None
TIZANIDINE HCL 2 MG TABLET	2	Non-Preferred Generic	$2.00	$4.00	None
TOBI 300mg/5mL 56 AMPULE per CARTON / 5 mL in 1 AMPULE	6	Specialty Tier	25%	N/A	P
TOBRAMYCIN 10MG/ML VIAL	5	Injectable Drugs	$95.00	$285.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TOBRAMYCIN 300 MG/5 ML AMPULE [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate]	6	Specialty Tier	25%	N/A	P
TOBRAMYCIN 40MG/ML VIAL	5	Injectable Drugs	$95.00	$285.00	None
TOBRAMYCIN OPHTHALMIC SOLUTION 0.3% 5ML BOT	1*	Preferred Generic	$1.00	$2.00	None
TOBRAMYCIN-DEXAMETH OPTH SUSP	2	Non-Preferred Generic	$2.00	$4.00	None
TOLAZAMIDE TABLETS 250MG 100 BOT	2	Non-Preferred Generic	$2.00	$4.00	Q:120 /30Days
TOLAZAMIDE TABLETS 500MG 100 BOT	2	Non-Preferred Generic	$2.00	$4.00	Q:60 /30Days
TOLBUTAMIDE 500MG TABLET	2	Non-Preferred Generic	$2.00	$4.00	Q:180 /30Days
Tolterodine Tartrate 1 MG TABLET [Detrol LA]	2	Non-Preferred Generic	$2.00	$4.00	Q:30 /30Days
Tolterodine Tartrate 2 MG TABLET [Detrol LA]	2	Non-Preferred Generic	$2.00	$4.00	Q:60 /30Days
TOLVAPTAN 15 MG ORAL TABLET [SAMSCA]	6	Specialty Tier	25%	N/A	P Q:120 /30Days
TOLVAPTAN 30 MG ORAL TABLET [SAMSCA]	6	Specialty Tier	25%	N/A	P Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Topiramate 25mg/1	2	Non-Preferred Generic	$2.00	$4.00	P
TOPIRAMATE SPRINKLE CAPSULES 15MG 60 BOT	2	Non-Preferred Generic	$2.00	$4.00	P
TOPIRAMATE TABLETS 100MG 1000 BOT	2	Non-Preferred Generic	$2.00	$4.00	P Q:480 /30Days
TOPIRAMATE TABLETS 200MG 1000 BOT	2	Non-Preferred Generic	$2.00	$4.00	P Q:240 /30Days
TOPIRAMATE TABLETS 25MG 1000 BOT	2	Non-Preferred Generic	$2.00	$4.00	P Q:1920 /30Days
TOPIRAMATE TABLETS 50MG 1000 BOT	2	Non-Preferred Generic	$2.00	$4.00	P Q:960 /30Days
TOPOSAR INJECTION 20MG/ML 50ML VIAL MD CRTN	5	Injectable Drugs	$95.00	$285.00	P
Topotecan hcl 4 mg vial	6	Specialty Tier	25%	N/A	P
Torisel 1 KIT per CARTON	6	Specialty Tier	25%	N/A	P
TPN ELECTROLYTES16.5/25.4 VIAL	5	Injectable Drugs	$95.00	$285.00	None
TRACLEER 125MG TABLET	6	Specialty Tier	25%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRACLEER 62.5MG TABLET	6	Specialty Tier	25%	N/A	P
TRAMADOL HCL 50 MG TABLET	2	Non-Preferred Generic	$2.00	$4.00	Q:240 /30Days
TRAMADOL HCL-ACETAMINOPHEN 37.5-325MG TABLET (1000 CT)	2	Non-Preferred Generic	$2.00	$4.00	Q:300 /30Days
TRANDOLAPRIL 1MG TABLET	1*	Preferred Generic	$1.00	$2.00	None
TRANDOLAPRIL 2MG TABLET	1*	Preferred Generic	$1.00	$2.00	None
TRANDOLAPRIL 4MG TABLET	1*	Preferred Generic	$1.00	$2.00	None
TRANEXAMIC ACID 1,000 MG/10 ML	5	Injectable Drugs	$95.00	$285.00	None
TRANYLCYPROMINE SULFATE 10MG TABLET	3	Preferred Brand	$24.00	$72.00	None
TRAVATAN Z 0.04MG DROPS 2.5ML BOT	3	Preferred Brand	$24.00	$72.00	None
travoprost 0.004% eye drop [Travatan]	3	Preferred Brand	$24.00	$72.00	None
TRAZODONE 300MG TABLET	1*	Preferred Generic	$1.00	$2.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRAZODONE HCL TABLET USP 100MG (500 CT)	1*	Preferred Generic	$1.00	$2.00	None
TRAZODONE HCL TABLET USP 150MG (100 CT)	1*	Preferred Generic	$1.00	$2.00	None
TRAZODONE HCL TABLET USP 50MG (500 CT)	1*	Preferred Generic	$1.00	$2.00	None
TREANDA FOR INJECTION 100MG/VIAL	6	Specialty Tier	25%	N/A	P
TRECATOR 250MG TABLET	4	Non-Preferred Brand	$76.00	$228.00	None
Tretinoin 0.1mg/g 1 TUBE per CARTON / 45 g in 1 TUBE	3	Preferred Brand	$24.00	$72.00	Q:90 /30Days
Tretinoin 0.25mg/g 1 TUBE per CARTON / 45 g in 1 TUBE	3	Preferred Brand	$24.00	$72.00	Q:90 /30Days
Tretinoin 0.25mg/g 1 TUBE per CARTON / 45 g in 1 TUBE	3	Preferred Brand	$24.00	$72.00	Q:90 /30Days
Tretinoin 0.5mg/g 1 TUBE per CARTON / 20 g in 1 TUBE	3	Preferred Brand	$24.00	$72.00	Q:90 /30Days
TRETINOIN 10MG CAPSULE	6	Specialty Tier	25%	N/A	None
Tretinoin 1mg/g 1 TUBE per CARTON / 45 g in 1 TUBE	3	Preferred Brand	$24.00	$72.00	Q:90 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRI PREVIFEM TABLETS	3	Preferred Brand	$24.00	$72.00	None
TRI-LEGEST FE 5-7-9-7 TABLET	3	Preferred Brand	$24.00	$72.00	None
TRI-SPRINTEC 7DAYSX3 28 TABLET	3	Preferred Brand	$24.00	$72.00	None
TRIAMCINOLONE 0.1% OINTMENT	2	Non-Preferred Generic	$2.00	$4.00	None
Triamcinolone acet 40mg/ml vl	5	Injectable Drugs	$95.00	$285.00	None
Triamcinolone acet 50mg/5ml vl	5	Injectable Drugs	$95.00	$285.00	None
TRIAMCINOLONE ACETONIDE 0.025% CREAM 80GM TUBE	2	Non-Preferred Generic	$2.00	$4.00	None
TRIAMCINOLONE ACETONIDE 0.025% LOTION 2 FL OZ BOT	2	Non-Preferred Generic	$2.00	$4.00	None
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE	2	Non-Preferred Generic	$2.00	$4.00	None
TRIAMCINOLONE ACETONIDE 0.1% CREAM 80GM TUBE	2	Non-Preferred Generic	$2.00	$4.00	None
TRIAMCINOLONE ACETONIDE 0.1% LOTION 60ML BOTPL	2	Non-Preferred Generic	$2.00	$4.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
triamcinolone acetonide 0.25mg/g 80 g in 1 TUBE	2	Non-Preferred Generic	$2.00	$4.00	None
Triamcinolone Acetonide 1mg/g 1 TUBE per CARTON / 5 g in 1 TUBE	2	Non-Preferred Generic	$2.00	$4.00	None
Triamcinolone Acetonide 5mg/g 1 TUBE per CARTON / 15 g in 1 TUBE	2	Non-Preferred Generic	$2.00	$4.00	None
Triamterene and Hydrochlorothiazide 25; 37.5mg 100 CAPSULE BOTTLE	1*	Preferred Generic	$1.00	$2.00	None
TRIAMTERENE/HCTZ 37.5/25 TABLET	1*	Preferred Generic	$1.00	$2.00	None
TRIAMTERENE/HCTZ 75/50 TABLET	1*	Preferred Generic	$1.00	$2.00	None
TRIDERM 0.1% CREAM	2	Non-Preferred Generic	$2.00	$4.00	None
TRIFLUOPERAZINE 1MG TABLET	2	Non-Preferred Generic	$2.00	$4.00	None
TRIFLUOPERAZINE HCL 2MG TABLET	2	Non-Preferred Generic	$2.00	$4.00	None
TRIFLUOPERAZINE HCL 5MG TABLET	2	Non-Preferred Generic	$2.00	$4.00	None
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT)	2	Non-Preferred Generic	$2.00	$4.00	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	3	Preferred Brand	$24.00	$72.00	None
TRILIPIX CAPSULE DR 45MG	3	Preferred Brand	$24.00	$72.00	None
TRILIPIX DELAYED RELEASE CAPSULES 135MG	3	Preferred Brand	$24.00	$72.00	None
TRILYTE WITH FLAVOR PACKETS	1*	Preferred Generic	$1.00	$2.00	None
TRIMETHOPRIM 100MG TABLETS	1*	Preferred Generic	$1.00	$2.00	None
TRINESSA TABLET	3	Preferred Brand	$24.00	$72.00	None
TRISENOX 10MG/10ML AMPULE	6	Specialty Tier	25%	N/A	P
Trivora 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK	3	Preferred Brand	$24.00	$72.00	None
TRIZIVIR 300; 150; 300mg/1; mg/1; mg/1 60 FILM COATED TABLETS in BOTTLE	6	Specialty Tier	25%	N/A	None
TROSPIUM CHLORIDE 20MG TABLETS	2	Non-Preferred Generic	$2.00	$4.00	Q:60 /30Days
TRUVADA 200/300MG TABLET	6	Specialty Tier	25%	N/A	None
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	$24.00	$72.00	None
Twynsta 10; 40mg/1; mg/1 3 BLISTER PACK per CARTON / 10 TABLET, MULTILAYER per BLISTER PACK	3	Preferred Brand	$24.00	$72.00	Q:30 /30Days
Twynsta 10; 80mg/1; mg/1 3 BLISTER PACK per CARTON / 10 TABLET, MULTILAYER per BLISTER PACK	3	Preferred Brand	$24.00	$72.00	Q:30 /30Days
Twynsta 5; 40mg/1; mg/1 3 BLISTER PACK per CARTON / 10 TABLET, MULTILAYER per BLISTER PACK	3	Preferred Brand	$24.00	$72.00	Q:30 /30Days
Twynsta 5; 80mg/1; mg/1 3 BLISTER PACK per CARTON / 10 TABLET, MULTILAYER per BLISTER PACK	3	Preferred Brand	$24.00	$72.00	Q:30 /30Days
TYKERB 250MG TABLET	6	Specialty Tier	25%	N/A	P
TYPHIM VI 25MCG/0.5ML VIAL	3	Preferred Brand	$24.00	$72.00	None
TYSABRI 300 MG/15 ML VIAL	6	Specialty Tier	25%	N/A	P
TYZEKA 600MG TABLET (30 CT)	6	Specialty Tier	25%	N/A	P

Chart Legend:

Below are a few notes to help you understand the above 2014 Medicare Part D MedicareRx Rewards Standard (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 $310 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 $2850) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2014 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 2014 )

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.