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

2014 Medicare Part D Plan Formulary Information
First Health Part D Value Plus (PDP) (S5768-128-0) Benefit Details
The First Health Part D Value Plus (PDP) (S5768-128-0) Formulary Drugs Starting with the Letter T in CMS PDP Region 5 which includes: DC DE MD Plan Monthly Premium: $39.00 Deductible: $0 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	3	Preferred Brand	$37.00	N/A	None
TACLONEX OINTMENT	3	Preferred Brand	$37.00	N/A	Q:400 /28Days
Tacrolimus 0.5mg/1 100 CAPSULE BOTTLE	4	Non-Preferred Brand	$88.00	N/A	P
Tacrolimus 1mg/1 100 CAPSULE BOTTLE	4	Non-Preferred Brand	$88.00	N/A	P
Tacrolimus 5mg/1 100 CAPSULE BOTTLE	4	Non-Preferred Brand	$88.00	N/A	P
TAFINLAR 50 MG CAPSULE	5	Specialty Tier	33%	N/A	P Q:180 /30Days
TAFINLAR 75 MG CAPSULE	5	Specialty Tier	33%	N/A	P Q:120 /30Days
Tamiflu 30mg/1 1 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK	4	Non-Preferred Brand	$88.00	N/A	None
Tamiflu 45mg/1 1 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK	4	Non-Preferred Brand	$88.00	N/A	None
TAMIFLU 6 MG/ML SUSPENSION	4	Non-Preferred Brand	$88.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TAMIFLU 75MG CAPSULE UD	4	Non-Preferred Brand	$88.00	N/A	Q:56 /365Days
TAMOXIFEN CITRATE 20MG TABLET (30 CT)	1	Preferred Generic	$3.00	N/A	None
TAMOXIFEN CITRATE TABLETS 10MG 180 BOT	1	Preferred Generic	$3.00	N/A	None
TAMSULOSIN HCL 0.4 MG CAPSULE	2	Non-Preferred Generic	$11.00	N/A	Q:60 /30Days
TARCEVA 100MG TABLET	5	Specialty Tier	33%	N/A	P Q:30 /30Days
TARCEVA 150MG TABLET	5	Specialty Tier	33%	N/A	P Q:30 /30Days
TARCEVA 25MG TABLET	5	Specialty Tier	33%	N/A	P Q:60 /30Days
TARGRETIN 1% GEL 60GM TUBE	5	Specialty Tier	33%	N/A	P Q:60 /30Days
TARGRETIN 75 MG CAPSULE	5	Specialty Tier	33%	N/A	P
Tasigna 150mg/1 4 BLISTER PACK per CARTON / 28 CAPSULE per BLISTER PACK	5	Specialty Tier	33%	N/A	P Q:120 /30Days
TASIGNA 200MG CAPSULE 28 BLPK	5	Specialty Tier	33%	N/A	P Q:120 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TASMAR 100MG TABLET	4	Non-Preferred Brand	$88.00	N/A	None
TAZORAC 0.05% CREAM	4	Non-Preferred Brand	$88.00	N/A	Q:30 /30Days
TAZORAC 0.05% GEL	4	Non-Preferred Brand	$88.00	N/A	Q:30 /30Days
TAZORAC 0.1% CREAM	4	Non-Preferred Brand	$88.00	N/A	Q:30 /30Days
TAZORAC 0.1% GEL	4	Non-Preferred Brand	$88.00	N/A	Q:30 /30Days
TAZTIA DILTIAZEM HYDROCHLORIDE 120MG EXTENDED RELEASE CAPSULES	1	Preferred Generic	$3.00	N/A	None
TAZTIA DILTIAZEM HYDROCHLORIDE 180MG EXTENDED RELEASE CAPSULES	1	Preferred Generic	$3.00	N/A	None
TAZTIA DILTIAZEM HYDROCHLORIDE 300MG EXTENDED RELEASE CAPSULES	1	Preferred Generic	$3.00	N/A	None
TAZTIA XT 240MG CAPSULE SA	1	Preferred Generic	$3.00	N/A	None
TAZTIA XT 360MG CAPSULE SA	1	Preferred Generic	$3.00	N/A	None
Teflaro 400mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE	4	Non-Preferred Brand	$88.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Teflaro 600mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE	4	Non-Preferred Brand	$88.00	N/A	None
TEGRETOL SUSPENSION 100MG/5ML 450 ML BOT	4	Non-Preferred Brand	$88.00	N/A	None
TEGRETOL TABLETS 200MG 100 BOT	4	Non-Preferred Brand	$88.00	N/A	None
TEGRETOL XR TABLETS 100MG 100 BOT	4	Non-Preferred Brand	$88.00	N/A	None
TEGRETOL XR TABLETS 200MG 100 BOT	4	Non-Preferred Brand	$88.00	N/A	None
TEGRETOL XR TABLETS 400MG 100 BOT	4	Non-Preferred Brand	$88.00	N/A	None
Telmisartan 20 MG Tablet [Micardis]	1	Preferred Generic	$3.00	N/A	Q:30 /30Days
Telmisartan 40 MG Tablet [Micardis]	1	Preferred Generic	$3.00	N/A	Q:30 /30Days
Telmisartan 80 MG Tablet [Micardis]	1	Preferred Generic	$3.00	N/A	Q:30 /30Days
Telmisartan-Amlodipine 40-10 MG [Micardis]	1	Preferred Generic	$3.00	N/A	Q:30 /30Days
Telmisartan-Amlodipine 40-5 MG [Micardis]	1	Preferred Generic	$3.00	N/A	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Telmisartan-Amlodipine 80-10 MG [Micardis]	1	Preferred Generic	$3.00	N/A	Q:30 /30Days
Telmisartan-Amlodipine 80-5 MG [Micardis]	1	Preferred Generic	$3.00	N/A	Q:30 /30Days
Telmisartan-HCTZ 40-12.5 mg tablet [Micardis HCT]	1	Preferred Generic	$3.00	N/A	Q:30 /30Days
Telmisartan-HCTZ 80-12.5 mg tablet [Micardis HCT]	1	Preferred Generic	$3.00	N/A	Q:30 /30Days
Telmisartan-HCTZ 80-25 mg tablet [Micardis HCT]	1	Preferred Generic	$3.00	N/A	Q:30 /30Days
Temazepam 15mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE per BLISTER PACK	2	Non-Preferred Generic	$11.00	N/A	Q:30 /30Days
TEMAZEPAM 30 MG CAPSULE	2	Non-Preferred Generic	$11.00	N/A	Q:30 /30Days
TERAZOSIN 1 MG CAPSULE	1	Preferred Generic	$3.00	N/A	None
Terazosin Hydrochloride 10mg/1 100 CAPSULE BOTTLE	1	Preferred Generic	$3.00	N/A	None
Terazosin Hydrochloride 2mg/1 100 CAPSULE BOTTLE	1	Preferred Generic	$3.00	N/A	None
Terazosin Hydrochloride 5mg/1 100 CAPSULE BOTTLE	1	Preferred Generic	$3.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TERBINAFINE HCL 250 MG TABLET	2	Non-Preferred Generic	$11.00	N/A	Q:30 /30Days
TERBUTALINE SULF 2.5MG TABLET	1	Preferred Generic	$3.00	N/A	None
TERBUTALINE SULFATE 5MG TABLET	1	Preferred Generic	$3.00	N/A	None
TERCONAZOLE 0.4% CREAM WITH APPLICATOR	2	Non-Preferred Generic	$11.00	N/A	None
TERCONAZOLE 0.8% CREAM	2	Non-Preferred Generic	$11.00	N/A	None
TERCONAZOLE 80MG SUPPOSITORY VAGINAL	2	Non-Preferred Generic	$11.00	N/A	None
TESTIM 1%(50MG) GEL	3	Preferred Brand	$37.00	N/A	P Q:300 /30Days
TESTOSTERONE CYPIONATE 100MG/ML INJECTION	2	Non-Preferred Generic	$11.00	N/A	None
Testosterone Cypionate 200mg/mL 1 VIAL, MULTI-DOSE per CARTON / 10 mL in 1 VIAL, MULTI-DOSE	2	Non-Preferred Generic	$11.00	N/A	None
TESTOSTERONE ENANTHATE 200MG/ML INJECTION	2	Non-Preferred Generic	$11.00	N/A	None
TESTRED 10MG CAPSULE	4	Non-Preferred Brand	$88.00	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TETANUS DIPHTHERIA TOXOIDS	3	Preferred Brand	$37.00	N/A	None
tetanus toxoid adsorbed vial	3	Preferred Brand	$37.00	N/A	None
THALOMID 100MG CAPSULE 140 BOX	5	Specialty Tier	33%	N/A	P Q:28 /28Days
Thalomid 150mg/1	5	Specialty Tier	33%	N/A	P Q:28 /28Days
Thalomid 200mg/1	5	Specialty Tier	33%	N/A	P Q:56 /28Days
THALOMID 50MG CAPSULE 280 BOX	5	Specialty Tier	33%	N/A	P Q:28 /28Days
Theophylline 100mg/1 500 CAPSULE BOTTLE	1	Preferred Generic	$3.00	N/A	None
Theophylline 200mg/1 500 TABLET, EXTENDED RELEASE in 1 BOTTLE	1	Preferred Generic	$3.00	N/A	None
THEOPHYLLINE 400MG TABLET SA	1	Preferred Generic	$3.00	N/A	None
THEOPHYLLINE 600MG TABLET SA	1	Preferred Generic	$3.00	N/A	None
THEOPHYLLINE TABLET ER 300MG (100 CT)	1	Preferred Generic	$3.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
THEOPHYLLINE TABLET ER 450MG (100 CT)	1	Preferred Generic	$3.00	N/A	None
Thermazene 10mg/g	2	Non-Preferred Generic	$11.00	N/A	None
THIORIDAZINE 100MG TABLET	1	Preferred Generic	$3.00	N/A	None
THIORIDAZINE HCL 10MG TABLET (1000 CT)	1	Preferred Generic	$3.00	N/A	None
THIORIDAZINE HCL 25MG TABLET (1000 CT)	1	Preferred Generic	$3.00	N/A	None
Thioridazine Hydrochloride 50mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED in 1	1	Preferred Generic	$3.00	N/A	None
THIOTHIXENE 10MG CAPSULE	1	Preferred Generic	$3.00	N/A	None
THIOTHIXENE 1MG CAPSULE (100 CT)	1	Preferred Generic	$3.00	N/A	None
THIOTHIXENE 2MG CAPSULE	1	Preferred Generic	$3.00	N/A	None
THIOTHIXENE 5MG CAPSULE	1	Preferred Generic	$3.00	N/A	None
THYMOGLOBULIN 25MG VIAL	5	Specialty Tier	33%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
THYROLAR-1 TABLETS	4	Non-Preferred Brand	$88.00	N/A	None
THYROLAR-1/2 TABLETS	4	Non-Preferred Brand	$88.00	N/A	None
THYROLAR-1/4 TABLETS	4	Non-Preferred Brand	$88.00	N/A	None
THYROLAR-2 TABLETS	4	Non-Preferred Brand	$88.00	N/A	None
THYROLAR-3 TABLETS	4	Non-Preferred Brand	$88.00	N/A	None
tiagabine hcl 2 mg tablet [Gabitril]	4	Non-Preferred Brand	$88.00	N/A	None
tiagabine hcl 4 mg tablet [Gabitril]	4	Non-Preferred Brand	$88.00	N/A	None
Ticlopidine 250 mg tablet	1	Preferred Generic	$3.00	N/A	None
TIKOSYN .125MG CAPSULE	3	Preferred Brand	$37.00	N/A	None
TIKOSYN .250MG CAPSULE	3	Preferred Brand	$37.00	N/A	None
TIKOSYN .5MG CAPSULE	3	Preferred Brand	$37.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TIMENTIN ADD-VANTAGE 1; 30mg/mL; mg/mL 10 VIAL in 1 TRAY / 50 mL in 1 VIAL	4	Non-Preferred Brand	$88.00	N/A	None
TIMOLOL MAL SOL 0.25% OP 15ML BOT	1	Preferred Generic	$3.00	N/A	None
TIMOLOL MAL SOL 0.5% OP 10ML BOT	1	Preferred Generic	$3.00	N/A	None
TIMOLOL MALEATE 10MG TABLET	2	Non-Preferred Generic	$11.00	N/A	None
TIMOLOL MALEATE 20MG TABLET	2	Non-Preferred Generic	$11.00	N/A	None
Timolol Maleate 3.4mg/mL 1 BOTTLE, DISPENSING per CARTON / 5 mL in 1 BOTTLE, DISPENSING	1	Preferred Generic	$3.00	N/A	None
TIMOLOL MALEATE 5MG TABLET	2	Non-Preferred Generic	$11.00	N/A	None
Timolol Maleate 6.8mg/mL 1 BOTTLE, DISPENSING per CARTON / 5 mL in 1 BOTTLE, DISPENSING	1	Preferred Generic	$3.00	N/A	None
tinidazole 250 mg tablet	4	Non-Preferred Brand	$88.00	N/A	None
tinidazole 500 mg tablet	4	Non-Preferred Brand	$88.00	N/A	None
TIVICAY 50 MG TABLET	5	Specialty Tier	33%	N/A	Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Tizanidine 4mg/1 1000 TABLET BOTTLE	1	Preferred Generic	$3.00	N/A	None
TIZANIDINE HCL 2 MG TABLET	1	Preferred Generic	$3.00	N/A	None
TOBI 300mg/5mL 56 AMPULE per CARTON / 5 mL in 1 AMPULE	5	Specialty Tier	33%	N/A	P Q:280 /28Days
TOBRADEX EYE OINTMENT	4	Non-Preferred Brand	$88.00	N/A	None
TOBRADEX ST 0.5; 3mg/mL; mg/mL 5 mL in 1 BOTTLE	4	Non-Preferred Brand	$88.00	N/A	None
TOBRAMYCIN 10MG/ML VIAL	2	Non-Preferred Generic	$11.00	N/A	None
TOBRAMYCIN 40MG/ML VIAL	2	Non-Preferred Generic	$11.00	N/A	None
TOBRAMYCIN 80MG/0.9% NACL	2	Non-Preferred Generic	$11.00	N/A	None
TOBRAMYCIN OPHTHALMIC SOLUTION 0.3% 5ML BOT	2	Non-Preferred Generic	$11.00	N/A	None
TOBRAMYCIN-DEXAMETH OPTH SUSP	2	Non-Preferred Generic	$11.00	N/A	None
TOBREX 0.3% EYE OINTMENT	3	Preferred Brand	$37.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TOLAZAMIDE TABLETS 250MG 100 BOT	1	Preferred Generic	$3.00	N/A	None
TOLAZAMIDE TABLETS 500MG 100 BOT	1	Preferred Generic	$3.00	N/A	None
TOLBUTAMIDE 500MG TABLET	1	Preferred Generic	$3.00	N/A	None
TOLMETIN SODIUM 200MG TABLET	4	Non-Preferred Brand	$88.00	N/A	None
TOLMETIN SODIUM 400 MG CAP	4	Non-Preferred Brand	$88.00	N/A	None
TOLMETIN SODIUM 600MG TABLET	4	Non-Preferred Brand	$88.00	N/A	None
Tolterodine Tartrate 1 MG TABLET [Detrol LA]	4	Non-Preferred Brand	$88.00	N/A	None
Tolterodine Tartrate 2 MG TABLET [Detrol LA]	4	Non-Preferred Brand	$88.00	N/A	None
Tolterodine Tartrate ER 2 MG CAPSULE [Detrol LA]	4	Non-Preferred Brand	$88.00	N/A	S Q:30 /30Days
Tolterodine Tartrate ER 4 MG CAPSULE [Detrol LA]	4	Non-Preferred Brand	$88.00	N/A	S Q:30 /30Days
TOLVAPTAN 15 MG ORAL TABLET [SAMSCA]	5	Specialty Tier	33%	N/A	P Q:30 /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 Tier	33%	N/A	P Q:60 /30Days
Topiramate 25mg/1	4	Non-Preferred Brand	$88.00	N/A	None
TOPIRAMATE SPRINKLE CAPSULES 15MG 60 BOT	4	Non-Preferred Brand	$88.00	N/A	None
TOPIRAMATE TABLETS 100MG 1000 BOT	4	Non-Preferred Brand	$88.00	N/A	Q:90 /30Days
TOPIRAMATE TABLETS 200MG 1000 BOT	4	Non-Preferred Brand	$88.00	N/A	None
TOPIRAMATE TABLETS 25MG 1000 BOT	4	Non-Preferred Brand	$88.00	N/A	None
TOPIRAMATE TABLETS 50MG 1000 BOT	4	Non-Preferred Brand	$88.00	N/A	Q:90 /30Days
Topotecan hcl 4 mg vial	2	Non-Preferred Generic	$11.00	N/A	P
Torsemide 100mg/1 12 BOTTLE CASE / 100 TABLET BOTTLE	1	Preferred Generic	$3.00	N/A	None
TORSEMIDE 10MG TABLETS	1	Preferred Generic	$3.00	N/A	None
TORSEMIDE 20mg 100 TABLET BOTTLE	1	Preferred Generic	$3.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TORSEMIDE 5MG TABLETS	1	Preferred Generic	$3.00	N/A	None
TPN ELECTROLYTES16.5/25.4 VIAL	4	Non-Preferred Brand	$88.00	N/A	None
TRACLEER 125MG TABLET	5	Specialty Tier	33%	N/A	P Q:60 /30Days
TRACLEER 62.5MG TABLET	5	Specialty Tier	33%	N/A	P Q:60 /30Days
TRADJENTA 5mg/1 90 FILM COATED TABLETS in BOTTLE	3	Preferred Brand	$37.00	N/A	Q:30 /30Days
TRAMADOL HCL 50 MG TABLET	2	Non-Preferred Generic	$11.00	N/A	None
TRAMADOL HCL-ACETAMINOPHEN 37.5-325MG TABLET (1000 CT)	4	Non-Preferred Brand	$88.00	N/A	Q:240 /30Days
TRANDOLAPRIL 1MG TABLET	1	Preferred Generic	$3.00	N/A	None
TRANDOLAPRIL 2MG TABLET	1	Preferred Generic	$3.00	N/A	None
TRANDOLAPRIL 4MG TABLET	1	Preferred Generic	$3.00	N/A	None
TRANYLCYPROMINE SULFATE 10MG TABLET	2	Non-Preferred Generic	$11.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRAVASOL 10% SOLUTION VIAFLEX	4	Non-Preferred Brand	$88.00	N/A	P
travoprost 0.004% eye drop [Travatan]	4	Non-Preferred Brand	$88.00	N/A	Q:5 /30Days
TRAZODONE 300MG TABLET	1	Preferred Generic	$3.00	N/A	None
TRAZODONE HCL TABLET USP 100MG (500 CT)	1	Preferred Generic	$3.00	N/A	None
TRAZODONE HCL TABLET USP 150MG (100 CT)	1	Preferred Generic	$3.00	N/A	None
TRAZODONE HCL TABLET USP 50MG (500 CT)	1	Preferred Generic	$3.00	N/A	None
TRECATOR 250MG TABLET	4	Non-Preferred Brand	$88.00	N/A	None
Trelstar 22.5mg/2mL 2 mL in 1 VIAL, SINGLE-DOSE	5	Specialty Tier	33%	N/A	Q:1 /168Days
TRELSTAR DEPOT MIXJET FOR INJECTION 3.75 MG	5	Specialty Tier	33%	N/A	Q:1 /28Days
TRELSTAR MIXJET FOR INJECTION 11.25 MG	5	Specialty Tier	33%	N/A	Q:1 /84Days
Tretinoin 0.1mg/g 1 TUBE per CARTON / 45 g in 1 TUBE	4	Non-Preferred Brand	$88.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Tretinoin 0.25mg/g 1 TUBE per CARTON / 45 g in 1 TUBE	4	Non-Preferred Brand	$88.00	N/A	None
Tretinoin 0.25mg/g 1 TUBE per CARTON / 45 g in 1 TUBE	4	Non-Preferred Brand	$88.00	N/A	None
Tretinoin 0.5mg/g 1 TUBE per CARTON / 20 g in 1 TUBE	4	Non-Preferred Brand	$88.00	N/A	None
TRETINOIN 10MG CAPSULE	5	Specialty Tier	33%	N/A	P
Tretinoin 1mg/g 1 TUBE per CARTON / 45 g in 1 TUBE	4	Non-Preferred Brand	$88.00	N/A	None
TRI PREVIFEM TABLETS	1	Preferred Generic	$3.00	N/A	None
TRI-LEGEST FE 5-7-9-7 TABLET	4	Non-Preferred Brand	$88.00	N/A	None
TRI-SPRINTEC 7DAYSX3 28 TABLET	1	Preferred Generic	$3.00	N/A	None
TRIAMCINOLONE 0.1% OINTMENT	1	Preferred Generic	$3.00	N/A	None
TRIAMCINOLONE ACETONIDE 0.025% CREAM 80GM TUBE	1	Preferred Generic	$3.00	N/A	None
TRIAMCINOLONE ACETONIDE 0.025% LOTION 2 FL OZ BOT	1	Preferred Generic	$3.00	N/A	None
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	$3.00	N/A	None
TRIAMCINOLONE ACETONIDE 0.1% CREAM 80GM TUBE	1	Preferred Generic	$3.00	N/A	None
TRIAMCINOLONE ACETONIDE 0.1% LOTION 60ML BOTPL	1	Preferred Generic	$3.00	N/A	None
triamcinolone acetonide 0.25mg/g 80 g in 1 TUBE	1	Preferred Generic	$3.00	N/A	None
Triamcinolone Acetonide 1mg/g 1 TUBE per CARTON / 5 g in 1 TUBE	2	Non-Preferred Generic	$11.00	N/A	None
Triamcinolone Acetonide 55ug/1 1 BOTTLE, SPRAY per CARTON / 120 SPRAY, METERED in 1 BOTTLE, SPRAY	4	Non-Preferred Brand	$88.00	N/A	Q:33 /30Days
Triamcinolone Acetonide 5mg/g 1 TUBE per CARTON / 15 g in 1 TUBE	1	Preferred Generic	$3.00	N/A	None
Triamterene and Hydrochlorothiazide 25; 37.5mg 100 CAPSULE BOTTLE	1	Preferred Generic	$3.00	N/A	None
TRIAMTERENE/HCTZ 37.5/25 TABLET	1	Preferred Generic	$3.00	N/A	None
TRIAMTERENE/HCTZ 50-25 MG CAP	1	Preferred Generic	$3.00	N/A	None
TRIAMTERENE/HCTZ 75/50 TABLET	1	Preferred Generic	$3.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Triazolam 0.125mg/1 10 TABLET BOTTLE	2	Non-Preferred Generic	$11.00	N/A	Q:60 /30Days
TRIAZOLAM 0.25 MG TABLET	2	Non-Preferred Generic	$11.00	N/A	Q:60 /30Days
TRIDERM 0.1% CREAM	1	Preferred Generic	$3.00	N/A	None
TRIFLUOPERAZINE 1MG TABLET	1	Preferred Generic	$3.00	N/A	None
TRIFLUOPERAZINE HCL 2MG TABLET	1	Preferred Generic	$3.00	N/A	None
TRIFLUOPERAZINE HCL 5MG TABLET	1	Preferred Generic	$3.00	N/A	None
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT)	1	Preferred Generic	$3.00	N/A	None
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT	2	Non-Preferred Generic	$11.00	N/A	None
TRIGLIDE 160 MG TABLET	4	Non-Preferred Brand	$88.00	N/A	Q:30 /30Days
TRIHEXYPHENIDYL 5 MG TABLET	1	Preferred Generic	$3.00	N/A	None
TRIHEXYPHENIDYL HYDROCHLORIDE 2mg/1	1	Preferred Generic	$3.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Trihexyphenidyl Hydrochloride 2mg/5mL 473 mL in 1 BOTTLE	1	Preferred Generic	$3.00	N/A	None
TRILEPTAL 300MG/5ML SUSP	4	Non-Preferred Brand	$88.00	N/A	None
TRILIPIX CAPSULE DR 45MG	4	Non-Preferred Brand	$88.00	N/A	Q:30 /30Days
TRILIPIX DELAYED RELEASE CAPSULES 135MG	4	Non-Preferred Brand	$88.00	N/A	Q:30 /30Days
TRILYTE WITH FLAVOR PACKETS	2	Non-Preferred Generic	$11.00	N/A	Q:1 /30Days
TRIMETHOBENZAMIDE HCL 300MG CAPSULE	4	Non-Preferred Brand	$88.00	N/A	None
TRIMETHOPRIM 100MG TABLETS	2	Non-Preferred Generic	$11.00	N/A	None
TRIMIPRAMINE MALEATE 100 MG CAP	4	Non-Preferred Brand	$88.00	N/A	None
TRIMIPRAMINE MALEATE 25 MG CAP	4	Non-Preferred Brand	$88.00	N/A	None
TRIMIPRAMINE MALEATE 50 MG CAP	4	Non-Preferred Brand	$88.00	N/A	None
TRINESSA TABLET	1	Preferred Generic	$3.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRISENOX 10MG/10ML AMPULE	4	Non-Preferred Brand	$88.00	N/A	P
Trivora 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK	4	Non-Preferred Brand	$88.00	N/A	None
TRIZIVIR 300; 150; 300mg/1; mg/1; mg/1 60 FILM COATED TABLETS in BOTTLE	5	Specialty Tier	33%	N/A	None
TROPHAMINE INJECTION SOLUTION	4	Non-Preferred Brand	$88.00	N/A	P
TROPHAMINE INJECTION SOLUTION 6%	4	Non-Preferred Brand	$88.00	N/A	P
TROSPIUM CHLORIDE 20MG TABLETS	2	Non-Preferred Generic	$11.00	N/A	Q:60 /30Days
TROSPIUM CHLORIDE ER 60 MG CAP	2	Non-Preferred Generic	$11.00	N/A	Q:30 /30Days
TRUVADA 200/300MG TABLET	5	Specialty Tier	33%	N/A	Q:30 /30Days
TUDORZA PRESSAIR 400 MCG INH	3	Preferred Brand	$37.00	N/A	Q:1 /30Days
TWINRIX TF PF VACCINE 720UNT/20ML 10 X 1ML VIALSD	4	Non-Preferred Brand	$88.00	N/A	None
Twynsta 10; 40mg/1; mg/1 3 BLISTER PACK per CARTON / 10 TABLET, MULTILAYER per BLISTER PACK	4	Non-Preferred Brand	$88.00	N/A	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Twynsta 10; 80mg/1; mg/1 3 BLISTER PACK per CARTON / 10 TABLET, MULTILAYER per BLISTER PACK	4	Non-Preferred Brand	$88.00	N/A	Q:30 /30Days
Twynsta 5; 40mg/1; mg/1 3 BLISTER PACK per CARTON / 10 TABLET, MULTILAYER per BLISTER PACK	4	Non-Preferred Brand	$88.00	N/A	Q:30 /30Days
Twynsta 5; 80mg/1; mg/1 3 BLISTER PACK per CARTON / 10 TABLET, MULTILAYER per BLISTER PACK	4	Non-Preferred Brand	$88.00	N/A	Q:30 /30Days
TYKERB 250MG TABLET	5	Specialty Tier	33%	N/A	P Q:180 /30Days
TYPHIM VI 25MCG/0.5ML VIAL	4	Non-Preferred Brand	$88.00	N/A	None
TYSABRI 300 MG/15 ML VIAL	5	Specialty Tier	33%	N/A	P
TYZEKA 600MG TABLET (30 CT)	4	Non-Preferred Brand	$88.00	N/A	Q:30 /30Days
TYZINE PEDIATRIC 0.05% DROP	3	Preferred Brand	$37.00	N/A	None

Chart Legend:

Below are a few notes to help you understand the above 2014 Medicare Part D First Health Part D Value 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 $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.