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2015 Medicare Part D Plan Formulary Information
WPS MedicareRx Plan 1 (PDP) (S5753-006-0) Benefit Details
The WPS MedicareRx Plan 1 (PDP) (S5753-006-0) Formulary Drugs Starting with the Letter T in CMS PDP Region 16 which includes: WI Plan Monthly Premium: $60.70 Deductible: $170 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	$45.00	$112.50	None
Tacrolimus 0.03% ointment	2	Non-Preferred Generic	$15.00	$37.50	None
Tacrolimus 0.1% ointment	2	Non-Preferred Generic	$15.00	$37.50	None
Tacrolimus 0.5mg/1 100 CAPSULE BOTTLE	2	Non-Preferred Generic	$15.00	$37.50	P
Tacrolimus 1mg/1 100 CAPSULE BOTTLE	2	Non-Preferred Generic	$15.00	$37.50	P
Tacrolimus 5mg/1 100 CAPSULE BOTTLE	5	Specialty Tier	28%	28%	P
TAFINLAR 50 MG CAPSULE	5	Specialty Tier	28%	28%	P Q:180 /30Days
TAFINLAR 75 MG CAPSULE	5	Specialty Tier	28%	28%	P Q:120 /30Days
TAMIFLU 30mg/1 1 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK	3	Preferred Brand	$45.00	$112.50	Q:84 /180Days
TAMIFLU 45mg/1 1 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK	3	Preferred Brand	$45.00	$112.50	Q:42 /180Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TAMIFLU 6 MG/ML SUSPENSION	3	Preferred Brand	$45.00	$112.50	Q:600 /180Days
TAMIFLU 75MG CAPSULE UD	3	Preferred Brand	$45.00	$112.50	Q:42 /180Days
TAMOXIFEN CITRATE 20MG TABLET (30 CT)	2	Non-Preferred Generic	$15.00	$37.50	None
TAMOXIFEN CITRATE TABLETS 10MG 180 BOT	2	Non-Preferred Generic	$15.00	$37.50	None
TAMSULOSIN HCL 0.4 MG CAPSULE	1	Preferred Generic	$4.00	$10.00	None
TARCEVA 100MG TABLET	5	Specialty Tier	28%	28%	P
TARCEVA 150MG TABLET	5	Specialty Tier	28%	28%	P Q:30 /30Days
TARCEVA 25MG TABLET	5	Specialty Tier	28%	28%	P
TARGRETIN 75 MG CAPSULE	5	Specialty Tier	28%	28%	None
Tarina Fe 1-20 tablet	2	Non-Preferred Generic	$15.00	$37.50	None
Tasigna 150mg/1 4 BLISTER PACK per CARTON / 28 CAPSULE per BLISTER PACK	5	Specialty Tier	28%	28%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TASIGNA 200MG CAPSULE 28 BLPK	5	Specialty Tier	28%	28%	P Q:112 /28Days
TAXOTERE 80mg/4mL 1 VIAL, GLASS per CARTON / 4 mL in 1 VIAL, GLASS	5	Specialty Tier	28%	28%	None
TAZICEF 1GM VIAL	3	Preferred Brand	$45.00	$112.50	None
TAZICEF 2 GM/VIAL INJECTION	3	Preferred Brand	$45.00	$112.50	None
TAZICEF 6 GM/VIAL INJECTION	3	Preferred Brand	$45.00	$112.50	None
TAZORAC 0.05% CREAM	3	Preferred Brand	$45.00	$112.50	P
TAZORAC 0.05% GEL	3	Preferred Brand	$45.00	$112.50	P
TAZORAC 0.1% CREAM	3	Preferred Brand	$45.00	$112.50	P
TAZORAC 0.1% GEL	3	Preferred Brand	$45.00	$112.50	P
TAZTIA DILTIAZEM HYDROCHLORIDE 120MG EXTENDED RELEASE CAPSULES	2	Non-Preferred Generic	$15.00	$37.50	None
TAZTIA DILTIAZEM HYDROCHLORIDE 180MG EXTENDED RELEASE CAPSULES	2	Non-Preferred Generic	$15.00	$37.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TAZTIA DILTIAZEM HYDROCHLORIDE 300MG EXTENDED RELEASE CAPSULES	2	Non-Preferred Generic	$15.00	$37.50	None
TAZTIA XT 240MG CAPSULE SA	2	Non-Preferred Generic	$15.00	$37.50	None
TAZTIA XT 360MG CAPSULE SA	2	Non-Preferred Generic	$15.00	$37.50	None
TECFIDERA DR 120 MG CAPSULE	5	Specialty Tier	28%	28%	P
TECFIDERA DR 240 MG CAPSULE	5	Specialty Tier	28%	28%	P
TECFIDERA STARTER PACK	5	Specialty Tier	28%	28%	P
Teflaro 400mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE	3	Preferred Brand	$45.00	$112.50	None
Teflaro 600mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE	3	Preferred Brand	$45.00	$112.50	None
TEGRETOL XR TABLETS 100MG 100 BOT	3	Preferred Brand	$45.00	$112.50	None
Tekamlo 150; 10mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE	4	Non-Preferred Brand	49%	49%	None
Tekamlo 150; 5mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE	4	Non-Preferred Brand	49%	49%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Tekamlo 300; 10mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE	4	Non-Preferred Brand	49%	49%	None
Tekamlo 300; 5mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE	4	Non-Preferred Brand	49%	49%	None
TEKTURNA 150MG TABLET	4	Non-Preferred Brand	49%	49%	None
TEKTURNA 300MG TABLET	4	Non-Preferred Brand	49%	49%	None
TEKTURNA HCT 150-12.5MG TABLET	4	Non-Preferred Brand	49%	49%	None
TEKTURNA HCT 150MG-25MG TABLET	4	Non-Preferred Brand	49%	49%	None
TEKTURNA HCT 300-12.5MG TABLET	4	Non-Preferred Brand	49%	49%	None
TEKTURNA HCT 300MG-25MG TABLET	4	Non-Preferred Brand	49%	49%	None
Telmisartan 20 MG Tablet [Micardis]	1	Preferred Generic	$4.00	$10.00	None
Telmisartan 40 MG Tablet [Micardis]	1	Preferred Generic	$4.00	$10.00	None
Telmisartan 80 MG Tablet [Micardis]	1	Preferred Generic	$4.00	$10.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Telmisartan-Amlodipine 40-10 MG [Micardis]	2	Non-Preferred Generic	$15.00	$37.50	None
Telmisartan-Amlodipine 40-5 MG [Micardis]	2	Non-Preferred Generic	$15.00	$37.50	None
Telmisartan-Amlodipine 80-10 MG [Micardis]	2	Non-Preferred Generic	$15.00	$37.50	None
Telmisartan-Amlodipine 80-5 MG [Micardis]	2	Non-Preferred Generic	$15.00	$37.50	None
Telmisartan-HCTZ 40-12.5 mg tablet [Micardis HCT]	1	Preferred Generic	$4.00	$10.00	None
Telmisartan-HCTZ 80-12.5 mg tablet [Micardis HCT]	1	Preferred Generic	$4.00	$10.00	None
Telmisartan-HCTZ 80-25 mg tablet [Micardis HCT]	1	Preferred Generic	$4.00	$10.00	None
Temazepam 15mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE per BLISTER PACK	2	Non-Preferred Generic	$15.00	$37.50	P
Temazepam 22.5mg/1 30 CAPSULE BOTTLE, PLASTIC	2	Non-Preferred Generic	$15.00	$37.50	P
TEMAZEPAM 30 MG CAPSULE	2	Non-Preferred Generic	$15.00	$37.50	P
Temazepam 7.5mg/1 100 CAPSULE BOTTLE, PLASTIC	2	Non-Preferred Generic	$15.00	$37.50	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TENIVAC SYRINGE	3	Preferred Brand	$45.00	$112.50	None
TERAZOSIN 1 MG CAPSULE	1	Preferred Generic	$4.00	$10.00	Q:30 /30Days
Terazosin Hydrochloride 10mg/1 100 CAPSULE BOTTLE	1	Preferred Generic	$4.00	$10.00	Q:60 /30Days
Terazosin Hydrochloride 2mg/1 100 CAPSULE BOTTLE	1	Preferred Generic	$4.00	$10.00	Q:30 /30Days
Terazosin Hydrochloride 5mg/1 100 CAPSULE BOTTLE	1	Preferred Generic	$4.00	$10.00	Q:30 /30Days
Terbinafine HCl 250 MG Tablet	2	Non-Preferred Generic	$15.00	$37.50	None
TERBUTALINE SULF 1MG/ML VL	2	Non-Preferred Generic	$15.00	$37.50	None
TERBUTALINE SULF 2.5MG TABLET	2	Non-Preferred Generic	$15.00	$37.50	None
TERBUTALINE SULFATE 5MG TABLET	2	Non-Preferred Generic	$15.00	$37.50	None
TERCONAZOLE 0.4% CREAM WITH APPLICATOR	2	Non-Preferred Generic	$15.00	$37.50	None
TERCONAZOLE 0.8% CREAM	2	Non-Preferred Generic	$15.00	$37.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TERCONAZOLE 80MG SUPPOSITORY VAGINAL	2	Non-Preferred Generic	$15.00	$37.50	None
TESTOSTERONE CYPIONATE 2,000 MG/10 ML	2	Non-Preferred Generic	$15.00	$37.50	None
TESTOSTERONE ENANTHATE 200MG/ML INJECTION	2	Non-Preferred Generic	$15.00	$37.50	None
TETANUS DIPHTHERIA TOXOIDS	3	Preferred Brand	$45.00	$112.50	None
tetanus toxoid adsorbed vial	2	Non-Preferred Generic	$15.00	$37.50	None
THALOMID 100MG CAPSULE 140 BOX	5	Specialty Tier	28%	28%	P
Thalomid 150mg/1	5	Specialty Tier	28%	28%	P
Thalomid 200mg/1	5	Specialty Tier	28%	28%	P
THALOMID 50MG CAPSULE 280 BOX	5	Specialty Tier	28%	28%	P
Theophylline 100mg/1 500 CAPSULE BOTTLE	2	Non-Preferred Generic	$15.00	$37.50	None
Theophylline 200mg/1 500 TABLET, EXTENDED RELEASE in 1 BOTTLE	2	Non-Preferred Generic	$15.00	$37.50	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	$15.00	$37.50	None
THEOPHYLLINE 600MG TABLET SA	2	Non-Preferred Generic	$15.00	$37.50	None
THEOPHYLLINE TABLET ER 300MG (100 CT)	2	Non-Preferred Generic	$15.00	$37.50	None
THEOPHYLLINE TABLET ER 450MG (100 CT)	2	Non-Preferred Generic	$15.00	$37.50	None
THIORIDAZINE 100MG TABLET	2	Non-Preferred Generic	$15.00	$37.50	None
THIORIDAZINE HCL 10MG TABLET (1000 CT)	2	Non-Preferred Generic	$15.00	$37.50	None
THIORIDAZINE HCL 25MG TABLET (1000 CT)	2	Non-Preferred Generic	$15.00	$37.50	None
Thioridazine Hydrochloride 50mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED in 1	2	Non-Preferred Generic	$15.00	$37.50	None
THIOTHIXENE 10MG CAPSULE	1	Preferred Generic	$4.00	$10.00	None
THIOTHIXENE 1MG CAPSULE (100 CT)	1	Preferred Generic	$4.00	$10.00	None
THIOTHIXENE 2MG CAPSULE	1	Preferred Generic	$4.00	$10.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
THIOTHIXENE 5MG CAPSULE	1	Preferred Generic	$4.00	$10.00	None
THYMOGLOBULIN 25MG VIAL	5	Specialty Tier	28%	28%	P
THYROLAR-1 TABLETS	3	Preferred Brand	$45.00	$112.50	None
THYROLAR-1/2 TABLETS	3	Preferred Brand	$45.00	$112.50	None
THYROLAR-1/4 TABLETS	3	Preferred Brand	$45.00	$112.50	None
THYROLAR-2 TABLETS	3	Preferred Brand	$45.00	$112.50	None
THYROLAR-3 TABLETS	3	Preferred Brand	$45.00	$112.50	None
tiagabine hcl 2 mg tablet [Gabitril]	2	Non-Preferred Generic	$15.00	$37.50	None
tiagabine hcl 4 mg tablet [Gabitril]	2	Non-Preferred Generic	$15.00	$37.50	None
TIKOSYN .125MG CAPSULE	3	Preferred Brand	$45.00	$112.50	None
TIKOSYN .250MG CAPSULE	3	Preferred Brand	$45.00	$112.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TIKOSYN .5MG CAPSULE	3	Preferred Brand	$45.00	$112.50	None
TIMOLOL MAL SOL 0.25% OP 15ML BOT	1	Preferred Generic	$4.00	$10.00	None
TIMOLOL MAL SOL 0.5% OP 10ML BOT	1	Preferred Generic	$4.00	$10.00	None
TIMOLOL MALEATE 10MG TABLET	1	Preferred Generic	$4.00	$10.00	None
TIMOLOL MALEATE 20MG TABLET	1	Preferred Generic	$4.00	$10.00	None
Timolol Maleate 3.4mg/mL 1 BOTTLE, DISPENSING per CARTON / 5 mL in 1 BOTTLE, DISPENSING	1	Preferred Generic	$4.00	$10.00	None
TIMOLOL MALEATE 5MG TABLET	1	Preferred Generic	$4.00	$10.00	None
Timolol Maleate 6.8mg/mL 1 BOTTLE, DISPENSING per CARTON / 5 mL in 1 BOTTLE, DISPENSING	1	Preferred Generic	$4.00	$10.00	None
Timoptic 3.4mg/mL 4 POUCH per CARTON / 15 CONTAINER in 1 POUCH / 0.2 mL in 1 CONTAINER [TIMOPTIC]	4	Non-Preferred Brand	49%	49%	None
Timoptic 6.8mg/mL 4 POUCH per CARTON / 15 CONTAINER in 1 POUCH / 0.2 mL in 1 CONTAINER [TIMOPTIC]	4	Non-Preferred Brand	49%	49%	None
tinidazole 250 mg tablet	2	Non-Preferred Generic	$15.00	$37.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
tinidazole 500 mg tablet	2	Non-Preferred Generic	$15.00	$37.50	None
TIVICAY 50 MG TABLET	5	Specialty Tier	28%	28%	None
Tizanidine 4mg/1 1000 TABLET BOTTLE	2	Non-Preferred Generic	$15.00	$37.50	None
TIZANIDINE HCL 2 MG CAPSULE	2	Non-Preferred Generic	$15.00	$37.50	None
TIZANIDINE HCL 2 MG TABLET	2	Non-Preferred Generic	$15.00	$37.50	None
TIZANIDINE HCL 4 MG CAPSULE	2	Non-Preferred Generic	$15.00	$37.50	None
TIZANIDINE HCL 6 MG CAPSULE	2	Non-Preferred Generic	$15.00	$37.50	None
TOBRADEX EYE OINTMENT	4	Non-Preferred Brand	49%	49%	None
TOBRADEX ST 0.5; 3mg/mL; mg/mL 5 mL in 1 BOTTLE	4	Non-Preferred Brand	49%	49%	None
TOBRAMYCIN 10MG/ML VIAL	2	Non-Preferred Generic	$15.00	$37.50	None
TOBRAMYCIN 300 MG/5 ML AMPULE [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate]	5	Specialty Tier	28%	28%	P Q:280 /28Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TOBRAMYCIN 40MG/ML VIAL	2	Non-Preferred Generic	$15.00	$37.50	None
TOBRAMYCIN 80MG/0.9% NACL	2	Non-Preferred Generic	$15.00	$37.50	None
TOBRAMYCIN OPHTHALMIC SOLUTION 0.3% 5ML BOT	1	Preferred Generic	$4.00	$10.00	None
TOBRAMYCIN-DEXAMETH OPTH SUSP	2	Non-Preferred Generic	$15.00	$37.50	None
TOBREX 0.3% EYE OINTMENT	3	Preferred Brand	$45.00	$112.50	None
TOLAZAMIDE TABLETS 250MG 100 BOT	2	Non-Preferred Generic	$15.00	$37.50	Q:120 /30Days
TOLAZAMIDE TABLETS 500MG 100 BOT	2	Non-Preferred Generic	$15.00	$37.50	Q:60 /30Days
TOLBUTAMIDE 500MG TABLET	2	Non-Preferred Generic	$15.00	$37.50	Q:180 /30Days
Tolcapone 100 MG TABLET [Tasmar]	2	Non-Preferred Generic	$15.00	$37.50	None
TOLMETIN SODIUM 200MG TABLET	2	Non-Preferred Generic	$15.00	$37.50	None
TOLMETIN SODIUM 400 MG CAP	2	Non-Preferred Generic	$15.00	$37.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TOLMETIN SODIUM 600MG TABLET	2	Non-Preferred Generic	$15.00	$37.50	None
Tolterodine Tartrate 1 MG TABLET [Detrol LA]	2	Non-Preferred Generic	$15.00	$37.50	None
Tolterodine Tartrate 2 MG TABLET [Detrol LA]	2	Non-Preferred Generic	$15.00	$37.50	None
Tolterodine Tartrate ER 2 MG CAPSULE [Detrol LA]	2	Non-Preferred Generic	$15.00	$37.50	None
Tolterodine Tartrate ER 4 MG Capsule [Detrol LA]	2	Non-Preferred Generic	$15.00	$37.50	None
TOLVAPTAN 15 MG ORAL TABLET [SAMSCA]	5	Specialty Tier	28%	28%	P Q:30 /30Days
TOLVAPTAN 30 MG ORAL TABLET [SAMSCA]	5	Specialty Tier	28%	28%	P Q:60 /30Days
Topiramate 25mg/1	2	Non-Preferred Generic	$15.00	$37.50	P
TOPIRAMATE SPRINKLE CAPSULES 15MG 60 BOT	2	Non-Preferred Generic	$15.00	$37.50	P
TOPIRAMATE TABLETS 100MG 1000 BOT	1	Preferred Generic	$4.00	$10.00	P
TOPIRAMATE TABLETS 200MG 1000 BOT	1	Preferred Generic	$4.00	$10.00	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TOPIRAMATE TABLETS 25MG 1000 BOT	1	Preferred Generic	$4.00	$10.00	P
TOPIRAMATE TABLETS 50MG 1000 BOT	1	Preferred Generic	$4.00	$10.00	P
TOPOSAR INJECTION 20MG/ML 50ML VIAL MD CRTN	2	Non-Preferred Generic	$15.00	$37.50	None
Topotecan Hydrochloride 4mg/4mL 1 VIAL in 1 CARTON / 4 mL in 1 VIAL	5	Specialty Tier	28%	28%	None
Torisel 1 KIT per CARTON	5	Specialty Tier	28%	28%	None
Torsemide 100mg/1 12 BOTTLE CASE / 100 TABLET BOTTLE	1	Preferred Generic	$4.00	$10.00	None
Torsemide 10mg/1 100 TABLET BOTTLE, PLASTIC	1	Preferred Generic	$4.00	$10.00	None
TORSEMIDE 20mg 100 TABLET BOTTLE	1	Preferred Generic	$4.00	$10.00	None
Torsemide 5mg/1 100 TABLET BOTTLE, PLASTIC	1	Preferred Generic	$4.00	$10.00	None
TOUJEO SOLOSTAR 300 UNITS/ML	3	Preferred Brand	$45.00	$112.50	None
TOVIAZ TABLETS 4MG EXTENDED RELEASE	3	Preferred Brand	$45.00	$112.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TOVIAZ TABLETS 8MG EXTENDED RELEASE	3	Preferred Brand	$45.00	$112.50	None
TRACLEER 125MG TABLET	5	Specialty Tier	28%	28%	P
TRACLEER 62.5MG TABLET	5	Specialty Tier	28%	28%	P
TRADJENTA 5mg/1 90 FILM COATED TABLETS in BOTTLE	4	Non-Preferred Brand	49%	49%	Q:30 /30Days
TRAMADOL ER 300 MG TABLET	2	Non-Preferred Generic	$15.00	$37.50	Q:30 /30Days
TRAMADOL HCL 50 MG TABLET	2	Non-Preferred Generic	$15.00	$37.50	Q:240 /30Days
TRAMADOL HCL-ACETAMINOPHEN 37.5-325MG TABLET (1000 CT)	2	Non-Preferred Generic	$15.00	$37.50	Q:240 /30Days
TRAMADOL HYDROCHLORIDE 100mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC	2	Non-Preferred Generic	$15.00	$37.50	Q:30 /30Days
TRAMADOL HYDROCHLORIDE 200mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC	2	Non-Preferred Generic	$15.00	$37.50	Q:30 /30Days
TRANDOLAPRIL 1MG TABLET	1	Preferred Generic	$4.00	$10.00	None
TRANDOLAPRIL 2MG TABLET	1	Preferred Generic	$4.00	$10.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRANDOLAPRIL 4MG TABLET	1	Preferred Generic	$4.00	$10.00	None
TRANDOLAPRIL-VERAPAMIL ER 1-240 MG	1	Preferred Generic	$4.00	$10.00	None
TRANDOLAPRIL-VERAPAMIL ER 2-180 MG	1	Preferred Generic	$4.00	$10.00	None
TRANDOLAPRIL-VERAPAMIL ER 2-240 MG	1	Preferred Generic	$4.00	$10.00	None
TRANDOLAPRIL-VERAPAMIL ER 4-240 MG	1	Preferred Generic	$4.00	$10.00	None
tranexamic acid 650 mg tablet	2	Non-Preferred Generic	$15.00	$37.50	None
TRANSDERM-SCOP 1.5 MG/72HR	3	Preferred Brand	$45.00	$112.50	None
TRANYLCYPROMINE SULFATE 10MG TABLET	2	Non-Preferred Generic	$15.00	$37.50	None
TRAVASOL 10% SOLUTION VIAFLEX	3	Preferred Brand	$45.00	$112.50	P
TRAVATAN Z 0.04MG DROPS 2.5ML BOT	3	Preferred Brand	$45.00	$112.50	None
travoprost 0.004% eye drop [Travatan]	2	Non-Preferred Generic	$15.00	$37.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRAZODONE 300MG TABLET	1	Preferred Generic	$4.00	$10.00	None
TRAZODONE HCL TABLET USP 100MG (500 CT)	1	Preferred Generic	$4.00	$10.00	None
TRAZODONE HCL TABLET USP 150MG (100 CT)	1	Preferred Generic	$4.00	$10.00	None
TRAZODONE HCL TABLET USP 50MG (500 CT)	1	Preferred Generic	$4.00	$10.00	None
TREANDA 45 MG/0.5 ML VIAL	5	Specialty Tier	28%	28%	None
TREANDA FOR INJECTION 100MG/VIAL	5	Specialty Tier	28%	28%	None
TRECATOR 250MG TABLET	3	Preferred Brand	$45.00	$112.50	None
Trelstar 22.5mg/2mL 2 mL in 1 VIAL, SINGLE-DOSE	5	Specialty Tier	28%	28%	None
TRELSTAR DEPOT MIXJET FOR INJECTION 3.75 MG	5	Specialty Tier	28%	28%	None
TRELSTAR MIXJET FOR INJECTION 11.25 MG	5	Specialty Tier	28%	28%	None
Tretinoin 0.1mg/g 1 TUBE per CARTON / 45 g in 1 TUBE	2	Non-Preferred Generic	$15.00	$37.50	P
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	2	Non-Preferred Generic	$15.00	$37.50	P
Tretinoin 0.25mg/g 1 TUBE per CARTON / 45 g in 1 TUBE	2	Non-Preferred Generic	$15.00	$37.50	P
Tretinoin 0.5mg/g 1 TUBE per CARTON / 20 g in 1 TUBE	2	Non-Preferred Generic	$15.00	$37.50	P
TRETINOIN 10MG CAPSULE	5	Specialty Tier	28%	28%	None
Tretinoin 1mg/g 1 TUBE per CARTON / 45 g in 1 TUBE	2	Non-Preferred Generic	$15.00	$37.50	P
TRETINOIN GEL MICRO 0.04% PUMP	2	Non-Preferred Generic	$15.00	$37.50	P
TRETINOIN GEL MICRO 0.1% PUMP	2	Non-Preferred Generic	$15.00	$37.50	P
TRI PREVIFEM TABLETS	2	Non-Preferred Generic	$15.00	$37.50	None
TRI-LEGEST FE 5-7-9-7 TABLET	2	Non-Preferred Generic	$15.00	$37.50	None
TRI-SPRINTEC 7DAYSX3 28 TABLET	2	Non-Preferred Generic	$15.00	$37.50	None
TRIAMCINOLONE 0.1% OINTMENT	2	Non-Preferred Generic	$15.00	$37.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Triamcinolone 0.147 MG/G Spray	2	Non-Preferred Generic	$15.00	$37.50	None
TRIAMCINOLONE ACETONIDE 0.025% CREAM 80GM TUBE	2	Non-Preferred Generic	$15.00	$37.50	None
TRIAMCINOLONE ACETONIDE 0.025% LOTION 2 FL OZ BOT	2	Non-Preferred Generic	$15.00	$37.50	None
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE	2	Non-Preferred Generic	$15.00	$37.50	None
TRIAMCINOLONE ACETONIDE 0.1% CREAM 80GM TUBE	2	Non-Preferred Generic	$15.00	$37.50	None
TRIAMCINOLONE ACETONIDE 0.1% LOTION 60ML BOTPL	2	Non-Preferred Generic	$15.00	$37.50	None
triamcinolone acetonide 0.25mg/g 80 g in 1 TUBE	2	Non-Preferred Generic	$15.00	$37.50	None
Triamcinolone Acetonide 1mg/g 1 TUBE per CARTON / 5 g in 1 TUBE	2	Non-Preferred Generic	$15.00	$37.50	None
Triamcinolone Acetonide 55ug/1 1 BOTTLE, SPRAY per CARTON / 120 SPRAY, METERED in 1 BOTTLE, SPRAY	2	Non-Preferred Generic	$15.00	$37.50	Q:17 /30Days
Triamcinolone Acetonide 5mg/g 1 TUBE per CARTON / 15 g in 1 TUBE	2	Non-Preferred Generic	$15.00	$37.50	None
Triamterene and Hydrochlorothiazide 25; 37.5mg 100 CAPSULE BOTTLE	1	Preferred Generic	$4.00	$10.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRIAMTERENE/HCTZ 37.5/25 TABLET	1	Preferred Generic	$4.00	$10.00	None
TRIAMTERENE/HCTZ 50-25 MG CAP	1	Preferred Generic	$4.00	$10.00	None
TRIAMTERENE/HCTZ 75/50 TABLET	1	Preferred Generic	$4.00	$10.00	None
Trianex 0.05% Ointment	2	Non-Preferred Generic	$15.00	$37.50	None
TRIDERM 0.1% CREAM	2	Non-Preferred Generic	$15.00	$37.50	None
TRIFLUOPERAZINE 1MG TABLET	2	Non-Preferred Generic	$15.00	$37.50	None
TRIFLUOPERAZINE HCL 2MG TABLET	2	Non-Preferred Generic	$15.00	$37.50	None
TRIFLUOPERAZINE HCL 5MG TABLET	2	Non-Preferred Generic	$15.00	$37.50	None
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT)	2	Non-Preferred Generic	$15.00	$37.50	None
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT	2	Non-Preferred Generic	$15.00	$37.50	None
TRILYTE WITH FLAVOR PACKETS	2	Non-Preferred Generic	$15.00	$37.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRIMETHOPRIM 100MG TABLETS	2	Non-Preferred Generic	$15.00	$37.50	None
TRINESSA TABLET	2	Non-Preferred Generic	$15.00	$37.50	None
TRISENOX 10MG/10ML AMPULE	5	Specialty Tier	28%	28%	None
TRIUMEQ TABLET	5	Specialty Tier	28%	28%	None
Trivora 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK	2	Non-Preferred Generic	$15.00	$37.50	None
TROPHAMINE INJECTION SOLUTION	3	Preferred Brand	$45.00	$112.50	P
TROPHAMINE INJECTION SOLUTION 6%	3	Preferred Brand	$45.00	$112.50	P
TROSPIUM CHLORIDE 20MG TABLETS	2	Non-Preferred Generic	$15.00	$37.50	None
TROSPIUM CHLORIDE ER 60 MG CAP	2	Non-Preferred Generic	$15.00	$37.50	None
TRUMENBA 120 MCG/0.5 ML VACCINE	3	Preferred Brand	$45.00	$112.50	None
TRUVADA 200/300MG TABLET	5	Specialty Tier	28%	28%	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	$45.00	$112.50	None
Tygacil 50mg/5mL 10 VIAL, SINGLE-USE per CARTON / 50 mL in 1 VIAL, SINGLE-USE	3	Preferred Brand	$45.00	$112.50	None
TYKERB 250MG TABLET	5	Specialty Tier	28%	28%	P Q:180 /30Days
TYPHIM VI 25 MCG/0.5 ML SYRINGE	3	Preferred Brand	$45.00	$112.50	None
TYPHIM VI 25MCG/0.5ML VIAL	3	Preferred Brand	$45.00	$112.50	None
TYSABRI 300 MG/15 ML VIAL	5	Specialty Tier	28%	28%	P
Tyvaso 1.74mg/2.9mL	5	Specialty Tier	28%	28%	P
TYZEKA 600MG TABLET (30 CT)	5	Specialty Tier	28%	28%	None
TYZINE PEDIATRIC 0.05% DROP	3	Preferred Brand	$45.00	$112.50	None

Chart Legend:

Below are a few notes to help you understand the above 2015 Medicare Part D WPS MedicareRx Plan 1 (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 $2960) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2016 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 2015 )

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.