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2015 Medicare Part D Plan Formulary Information
Anthem Blue MedicareRx Premier (PDP) (S5596-019-0) Benefit Details
The Anthem Blue MedicareRx Premier (PDP) (S5596-019-0) Formulary Drugs Starting with the Letter T in CMS PDP Region 15 which includes: IN KY Plan Monthly Premium: $108.50 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	4	Non-Preferred Brand	38%	38%	None
TACLONEX OINTMENT	5	Specialty Tier	33%	N/A	None
TACLONEX SCALP SUSPENSION	4	Non-Preferred Brand	38%	38%	None
Tacrolimus 0.03% ointment	4	Non-Preferred Brand	38%	38%	P Q:60 /1Days
Tacrolimus 0.1% ointment	4	Non-Preferred Brand	38%	38%	P Q:60 /1Days
Tacrolimus 0.5mg/1 100 CAPSULE BOTTLE	3	Preferred Brand	$40.00	$120.00	P
Tacrolimus 1mg/1 100 CAPSULE BOTTLE	3	Preferred Brand	$40.00	$120.00	P
Tacrolimus 5mg/1 100 CAPSULE BOTTLE	5	Specialty Tier	33%	N/A	P
TAFINLAR 50 MG CAPSULE	5	Specialty Tier	33%	N/A	P
TAFINLAR 75 MG CAPSULE	5	Specialty Tier	33%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TAMIFLU 30mg/1 1 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK	3	Preferred Brand	$40.00	$120.00	Q:84 /1Days
TAMIFLU 45mg/1 1 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK	3	Preferred Brand	$40.00	$120.00	Q:42 /1Days
TAMIFLU 6 MG/ML SUSPENSION	3	Preferred Brand	$40.00	$120.00	Q:360 /180Days
TAMIFLU 75MG CAPSULE UD	3	Preferred Brand	$40.00	$120.00	Q:56 /365Days
TAMOXIFEN CITRATE 20MG TABLET (30 CT)	2	Non-Preferred Generic	$3.00	$6.00	None
TAMOXIFEN CITRATE TABLETS 10MG 180 BOT	2	Non-Preferred Generic	$3.00	$6.00	None
TAMSULOSIN HCL 0.4 MG CAPSULE	2	Non-Preferred Generic	$3.00	$6.00	None
TANZEUM 30 MG PEN INJECT	4	Non-Preferred Brand	38%	38%	Q:4 /28Days
TANZEUM 50 MG PEN INJECT	4	Non-Preferred Brand	38%	38%	Q:4 /28Days
TAPAZOLE 10MG TABLET	4	Non-Preferred Brand	38%	38%	None
TAPAZOLE 5MG TABLET	4	Non-Preferred Brand	38%	38%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TARCEVA 100MG TABLET	5	Specialty Tier	33%	N/A	P
TARCEVA 150MG TABLET	5	Specialty Tier	33%	N/A	P
TARCEVA 25MG TABLET	5	Specialty Tier	33%	N/A	P
TARGRETIN 75 MG CAPSULE	5	Specialty Tier	33%	N/A	P
TARKA 1/240MG TABLET SA	4	Non-Preferred Brand	38%	38%	None
Tarka 2; 240mg/1; mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE	4	Non-Preferred Brand	38%	38%	None
TARKA 2/180MG TABLET SA	4	Non-Preferred Brand	38%	38%	None
Tarka 4; 240mg/1; mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE	4	Non-Preferred Brand	38%	38%	None
Tasigna 150mg/1 4 BLISTER PACK per CARTON / 28 CAPSULE per BLISTER PACK	5	Specialty Tier	33%	N/A	P
TASIGNA 200MG CAPSULE 28 BLPK	5	Specialty Tier	33%	N/A	P
TASMAR 100MG TABLET	5	Specialty Tier	33%	N/A	None
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	38%	38%	P
TAZORAC 0.05% GEL	4	Non-Preferred Brand	38%	38%	P
TAZORAC 0.1% CREAM	4	Non-Preferred Brand	38%	38%	P
TAZORAC 0.1% GEL	4	Non-Preferred Brand	38%	38%	P
TAZTIA DILTIAZEM HYDROCHLORIDE 120MG EXTENDED RELEASE CAPSULES	2	Non-Preferred Generic	$3.00	$6.00	None
TAZTIA DILTIAZEM HYDROCHLORIDE 180MG EXTENDED RELEASE CAPSULES	2	Non-Preferred Generic	$3.00	$6.00	None
TAZTIA DILTIAZEM HYDROCHLORIDE 300MG EXTENDED RELEASE CAPSULES	2	Non-Preferred Generic	$3.00	$6.00	None
TAZTIA XT 240MG CAPSULE SA	2	Non-Preferred Generic	$3.00	$6.00	None
TAZTIA XT 360MG CAPSULE SA	2	Non-Preferred Generic	$3.00	$6.00	None
TECFIDERA DR 120 MG CAPSULE	5	Specialty Tier	33%	N/A	P
TECFIDERA DR 240 MG CAPSULE	5	Specialty Tier	33%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TECFIDERA STARTER PACK	5	Specialty Tier	33%	N/A	P
Teflaro 400mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE	4	Non-Preferred Brand	38%	38%	None
Teflaro 600mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE	4	Non-Preferred Brand	38%	38%	None
TEGRETOL SUSPENSION 100MG/5ML 450 ML BOT	4	Non-Preferred Brand	38%	38%	None
TEGRETOL TABLETS 200MG 100 BOT	4	Non-Preferred Brand	38%	38%	None
TEGRETOL XR TABLETS 100MG 100 BOT	4	Non-Preferred Brand	38%	38%	None
TEGRETOL XR TABLETS 200MG 100 BOT	4	Non-Preferred Brand	38%	38%	None
TEGRETOL XR TABLETS 400MG 100 BOT	4	Non-Preferred Brand	38%	38%	None
TEKTURNA 150MG TABLET	4	Non-Preferred Brand	38%	38%	Q:30 /30Days
TEKTURNA 300MG TABLET	4	Non-Preferred Brand	38%	38%	Q:30 /30Days
TEKTURNA HCT 150-12.5MG TABLET	4	Non-Preferred Brand	38%	38%	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TEKTURNA HCT 150MG-25MG TABLET	4	Non-Preferred Brand	38%	38%	Q:30 /30Days
TEKTURNA HCT 300-12.5MG TABLET	4	Non-Preferred Brand	38%	38%	Q:30 /30Days
TEKTURNA HCT 300MG-25MG TABLET	4	Non-Preferred Brand	38%	38%	Q:30 /30Days
Telmisartan 20 MG Tablet [Micardis]	2	Non-Preferred Generic	$3.00	$6.00	Q:30 /30Days
Telmisartan 40 MG Tablet [Micardis]	2	Non-Preferred Generic	$3.00	$6.00	Q:30 /30Days
Telmisartan 80 MG Tablet [Micardis]	2	Non-Preferred Generic	$3.00	$6.00	Q:60 /30Days
Telmisartan-Amlodipine 40-10 MG [Micardis]	2	Non-Preferred Generic	$3.00	$6.00	Q:30 /30Days
Telmisartan-Amlodipine 40-5 MG [Micardis]	2	Non-Preferred Generic	$3.00	$6.00	Q:30 /30Days
Telmisartan-Amlodipine 80-10 MG [Micardis]	2	Non-Preferred Generic	$3.00	$6.00	Q:30 /30Days
Telmisartan-Amlodipine 80-5 MG [Micardis]	2	Non-Preferred Generic	$3.00	$6.00	Q:30 /30Days
Telmisartan-HCTZ 40-12.5 mg tablet [Micardis HCT]	2	Non-Preferred Generic	$3.00	$6.00	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Telmisartan-HCTZ 80-12.5 mg tablet [Micardis HCT]	2	Non-Preferred Generic	$3.00	$6.00	Q:60 /30Days
Telmisartan-HCTZ 80-25 mg tablet [Micardis HCT]	2	Non-Preferred Generic	$3.00	$6.00	Q:30 /30Days
TENORETIC 100 TABLET	4	Non-Preferred Brand	38%	38%	None
TENORETIC 50 TABLET	4	Non-Preferred Brand	38%	38%	None
TENORMIN 100 MG TABLET	4	Non-Preferred Brand	38%	38%	None
TENORMIN 25 MG TABLET	4	Non-Preferred Brand	38%	38%	None
TENORMIN 50 MG TABLET	4	Non-Preferred Brand	38%	38%	None
TERAZOL 3 CREAM	4	Non-Preferred Brand	38%	38%	None
TERAZOL 7 CREAM	4	Non-Preferred Brand	38%	38%	None
TERAZOSIN 1 MG CAPSULE	1	Preferred Generic	$1.00	$2.00	None
Terazosin Hydrochloride 10mg/1 100 CAPSULE BOTTLE	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
Terazosin Hydrochloride 2mg/1 100 CAPSULE BOTTLE	1	Preferred Generic	$1.00	$2.00	None
Terazosin Hydrochloride 5mg/1 100 CAPSULE BOTTLE	1	Preferred Generic	$1.00	$2.00	None
Terbinafine HCl 250 MG Tablet	2	Non-Preferred Generic	$3.00	$6.00	Q:30 /30Days
TERBUTALINE SULF 1MG/ML VL	4	Non-Preferred Brand	38%	38%	None
TERBUTALINE SULF 2.5MG TABLET	2	Non-Preferred Generic	$3.00	$6.00	None
TERBUTALINE SULFATE 5MG TABLET	2	Non-Preferred Generic	$3.00	$6.00	None
TERCONAZOLE 0.4% CREAM WITH APPLICATOR	2	Non-Preferred Generic	$3.00	$6.00	None
TERCONAZOLE 0.8% CREAM	3	Preferred Brand	$40.00	$120.00	None
TERCONAZOLE 80MG SUPPOSITORY VAGINAL	4	Non-Preferred Brand	38%	38%	None
TESTIM 1%(50MG) GEL	3	Preferred Brand	$40.00	$120.00	P Q:300 /30Days
TESTOSTERONE CYPIONATE 2,000 MG/10 ML	4	Non-Preferred Brand	38%	38%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TESTOSTERONE ENANTHATE 200MG/ML INJECTION	4	Non-Preferred Brand	38%	38%	None
TETANUS DIPHTHERIA TOXOIDS	3	Preferred Brand	$40.00	$120.00	None
tetanus toxoid adsorbed vial	3	Preferred Brand	$40.00	$120.00	None
TETRACYCLINE 250 MG CAPSULE	2	Non-Preferred Generic	$3.00	$6.00	None
TETRACYCLINE 500 MG CAPSULE	2	Non-Preferred Generic	$3.00	$6.00	None
TEVETEN HCT TABLETS 600;25MG;MG 100 BOT	4	Non-Preferred Brand	38%	38%	Q:30 /30Days
TEVETEN TABLETS 600;12.5MG;MG 100 BOT	4	Non-Preferred Brand	38%	38%	Q:30 /30Days
THALOMID 100MG CAPSULE 140 BOX	5	Specialty Tier	33%	N/A	P Q:30 /30Days
Thalomid 150mg/1	5	Specialty Tier	33%	N/A	P Q:60 /30Days
Thalomid 200mg/1	5	Specialty Tier	33%	N/A	P Q:60 /30Days
THALOMID 50MG CAPSULE 280 BOX	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
Theophylline 100mg/1 500 CAPSULE BOTTLE	1	Preferred Generic	$1.00	$2.00	None
Theophylline 200mg/1 500 TABLET, EXTENDED RELEASE in 1 BOTTLE	2	Non-Preferred Generic	$3.00	$6.00	None
THEOPHYLLINE 400MG TABLET SA	2	Non-Preferred Generic	$3.00	$6.00	None
THEOPHYLLINE 600MG TABLET SA	2	Non-Preferred Generic	$3.00	$6.00	None
Theophylline 80mg/15mL 473 mL in 1 BOTTLE, PLASTIC	2	Non-Preferred Generic	$3.00	$6.00	None
THEOPHYLLINE TABLET ER 300MG (100 CT)	2	Non-Preferred Generic	$3.00	$6.00	None
THEOPHYLLINE TABLET ER 450MG (100 CT)	2	Non-Preferred Generic	$3.00	$6.00	None
THIORIDAZINE 100MG TABLET	3	Preferred Brand	$40.00	$120.00	P
THIORIDAZINE HCL 10MG TABLET (1000 CT)	3	Preferred Brand	$40.00	$120.00	P
THIORIDAZINE HCL 25MG TABLET (1000 CT)	3	Preferred Brand	$40.00	$120.00	P
Thioridazine Hydrochloride 50mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED in 1	3	Preferred Brand	$40.00	$120.00	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
THIOTHIXENE 10MG CAPSULE	2	Non-Preferred Generic	$3.00	$6.00	None
THIOTHIXENE 1MG CAPSULE (100 CT)	2	Non-Preferred Generic	$3.00	$6.00	None
THIOTHIXENE 2MG CAPSULE	2	Non-Preferred Generic	$3.00	$6.00	None
THIOTHIXENE 5MG CAPSULE	2	Non-Preferred Generic	$3.00	$6.00	None
THYMOGLOBULIN 25MG VIAL	5	Specialty Tier	33%	N/A	P
tiagabine hcl 2 mg tablet [Gabitril]	4	Non-Preferred Brand	38%	38%	None
tiagabine hcl 4 mg tablet [Gabitril]	4	Non-Preferred Brand	38%	38%	None
TIAZAC ER 120 MG CAPSULE	4	Non-Preferred Brand	38%	38%	None
TIAZAC ER 180 MG CAPSULE	4	Non-Preferred Brand	38%	38%	None
TIAZAC ER 240 MG CAPSULE	4	Non-Preferred Brand	38%	38%	None
TIAZAC ER 300 MG CAPSULE	4	Non-Preferred Brand	38%	38%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TIAZAC ER 360 MG CAPSULE	4	Non-Preferred Brand	38%	38%	None
TIAZAC ER 420 MG CAPSULE	4	Non-Preferred Brand	38%	38%	None
TIKOSYN .125MG CAPSULE	4	Non-Preferred Brand	38%	38%	None
TIKOSYN .250MG CAPSULE	4	Non-Preferred Brand	38%	38%	None
TIKOSYN .5MG CAPSULE	4	Non-Preferred Brand	38%	38%	None
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 10MG TABLET	2	Non-Preferred Generic	$3.00	$6.00	None
TIMOLOL MALEATE 20MG TABLET	2	Non-Preferred Generic	$3.00	$6.00	None
Timolol Maleate 3.4mg/mL 1 BOTTLE, DISPENSING per CARTON / 5 mL in 1 BOTTLE, DISPENSING	2	Non-Preferred Generic	$3.00	$6.00	None
TIMOLOL MALEATE 5MG TABLET	2	Non-Preferred Generic	$3.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Timolol Maleate 6.8mg/mL 1 BOTTLE, DISPENSING per CARTON / 5 mL in 1 BOTTLE, DISPENSING	2	Non-Preferred Generic	$3.00	$6.00	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	38%	38%	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	38%	38%	None
Timoptic-XE 3.4mg/mL 1 BOTTLE, DISPENSING per CARTON / 5 mL in 1 BOTTLE, DISPENSING	4	Non-Preferred Brand	38%	38%	None
Timoptic-XE 6.8mg/mL 1 BOTTLE, DISPENSING per CARTON / 5 mL in 1 BOTTLE, DISPENSING	4	Non-Preferred Brand	38%	38%	None
tinidazole 250 mg tablet	3	Preferred Brand	$40.00	$120.00	None
tinidazole 500 mg tablet	3	Preferred Brand	$40.00	$120.00	None
TIVICAY 50 MG TABLET	5	Specialty Tier	33%	N/A	None
Tizanidine 4mg/1 1000 TABLET BOTTLE	2	Non-Preferred Generic	$3.00	$6.00	None
TIZANIDINE HCL 2 MG CAPSULE	3	Preferred Brand	$40.00	$120.00	None
TIZANIDINE HCL 2 MG TABLET	2	Non-Preferred Generic	$3.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TIZANIDINE HCL 4 MG CAPSULE	3	Preferred Brand	$40.00	$120.00	None
TIZANIDINE HCL 6 MG CAPSULE	4	Non-Preferred Brand	38%	38%	None
TOBRADEX EYE OINTMENT	3	Preferred Brand	$40.00	$120.00	None
TOBRADEX ST 0.5; 3mg/mL; mg/mL 5 mL in 1 BOTTLE	3	Preferred Brand	$40.00	$120.00	None
TOBRADEX SUSPENSION OPHTHALMIC 0.1%/0.3% 5ML BOT	4	Non-Preferred Brand	38%	38%	None
TOBRAMYCIN 10MG/ML VIAL	4	Non-Preferred Brand	38%	38%	None
TOBRAMYCIN 300 MG/5 ML AMPULE [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate]	5	Specialty Tier	33%	N/A	P Q:280 /28Days
TOBRAMYCIN 40MG/ML VIAL	4	Non-Preferred Brand	38%	38%	None
TOBRAMYCIN 80MG/0.9% NACL	4	Non-Preferred Brand	38%	38%	None
TOBRAMYCIN OPHTHALMIC SOLUTION 0.3% 5ML BOT	2	Non-Preferred Generic	$3.00	$6.00	None
TOBRAMYCIN-DEXAMETH OPTH SUSP	3	Preferred Brand	$40.00	$120.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TOBREX 0.3% EYE DROPS	4	Non-Preferred Brand	38%	38%	None
TOBREX 0.3% EYE OINTMENT	4	Non-Preferred Brand	38%	38%	None
TOLAZAMIDE TABLETS 250MG 100 BOT	2	Non-Preferred Generic	$3.00	$6.00	Q:120 /30Days
TOLAZAMIDE TABLETS 500MG 100 BOT	2	Non-Preferred Generic	$3.00	$6.00	Q:60 /30Days
TOLBUTAMIDE 500MG TABLET	2	Non-Preferred Generic	$3.00	$6.00	Q:180 /30Days
Tolcapone 100 MG TABLET [Tasmar]	5	Specialty Tier	33%	N/A	None
TOLMETIN SODIUM 200MG TABLET	2	Non-Preferred Generic	$3.00	$6.00	None
TOLMETIN SODIUM 400 MG CAP	2	Non-Preferred Generic	$3.00	$6.00	None
TOLMETIN SODIUM 600MG TABLET	3	Preferred Brand	$40.00	$120.00	None
Tolterodine Tartrate 1 MG TABLET [Detrol LA]	2	Non-Preferred Generic	$3.00	$6.00	Q:60 /30Days
Tolterodine Tartrate 2 MG TABLET [Detrol LA]	3	Preferred Brand	$40.00	$120.00	Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TOLVAPTAN 15 MG ORAL TABLET [SAMSCA]	5	Specialty Tier	33%	N/A	P Q:120 /30Days
TOLVAPTAN 30 MG ORAL TABLET [SAMSCA]	5	Specialty Tier	33%	N/A	P Q:60 /30Days
TOPAMAX 15 MG SPRINKLE CAP	4	Non-Preferred Brand	38%	38%	P
TOPAMAX 25 MG SPRINKLE CAP	4	Non-Preferred Brand	38%	38%	P
TOPAMAX TABLETS 100MG 60 BOT	4	Non-Preferred Brand	38%	38%	P
TOPAMAX TABLETS 200MG 60 BOT	5	Specialty Tier	33%	N/A	P
TOPAMAX TABLETS 25MG 60 BOT	4	Non-Preferred Brand	38%	38%	P
TOPAMAX TABLETS 50MG 60 BOT	4	Non-Preferred Brand	38%	38%	P
Topicort 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE	4	Non-Preferred Brand	38%	38%	None
Topicort 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE	4	Non-Preferred Brand	38%	38%	None
Topicort 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE	4	Non-Preferred Brand	38%	38%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Topicort 2.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE	4	Non-Preferred Brand	38%	38%	None
Topicort 2.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE	4	Non-Preferred Brand	38%	38%	None
Topiramate 25mg/1	3	Preferred Brand	$40.00	$120.00	P
TOPIRAMATE SPRINKLE CAPSULES 15MG 60 BOT	3	Preferred Brand	$40.00	$120.00	P
TOPIRAMATE TABLETS 100MG 1000 BOT	2	Non-Preferred Generic	$3.00	$6.00	P
TOPIRAMATE TABLETS 200MG 1000 BOT	2	Non-Preferred Generic	$3.00	$6.00	P
TOPIRAMATE TABLETS 25MG 1000 BOT	2	Non-Preferred Generic	$3.00	$6.00	P
TOPIRAMATE TABLETS 50MG 1000 BOT	2	Non-Preferred Generic	$3.00	$6.00	P
TOPOSAR INJECTION 20MG/ML 50ML VIAL MD CRTN	4	Non-Preferred Brand	38%	38%	P
Topotecan Hydrochloride 4mg/4mL 1 VIAL in 1 CARTON / 4 mL in 1 VIAL	5	Specialty Tier	33%	N/A	P
TOPROL XL 100MG TABLET SA	4	Non-Preferred Brand	38%	38%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TOPROL XL 200MG TABLET SA	4	Non-Preferred Brand	38%	38%	None
TOPROL XL 25MG TABLET SA	4	Non-Preferred Brand	38%	38%	None
TOPROL XL 50MG TABLET SA	4	Non-Preferred Brand	38%	38%	None
Torisel 1 KIT per CARTON	5	Specialty Tier	33%	N/A	P
Torsemide 100mg/1 12 BOTTLE CASE / 100 TABLET BOTTLE	2	Non-Preferred Generic	$3.00	$6.00	None
Torsemide 10mg/1 100 TABLET BOTTLE, PLASTIC	2	Non-Preferred Generic	$3.00	$6.00	None
TORSEMIDE 20mg 100 TABLET BOTTLE	2	Non-Preferred Generic	$3.00	$6.00	None
Torsemide 5mg/1 100 TABLET BOTTLE, PLASTIC	2	Non-Preferred Generic	$3.00	$6.00	None
TOUJEO SOLOSTAR 300 UNITS/ML	3	Preferred Brand	$40.00	$120.00	None
TOVIAZ TABLETS 4MG EXTENDED RELEASE	4	Non-Preferred Brand	38%	38%	Q:30 /30Days
TOVIAZ TABLETS 8MG EXTENDED RELEASE	4	Non-Preferred Brand	38%	38%	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TPN ELECTROLYTES16.5/25.4 VIAL	4	Non-Preferred Brand	38%	38%	P
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	4	Non-Preferred Brand	38%	38%	Q:30 /30Days
TRAMADOL HCL 50 MG TABLET	2	Non-Preferred Generic	$3.00	$6.00	Q:240 /30Days
TRAMADOL HCL-ACETAMINOPHEN 37.5-325MG TABLET (1000 CT)	2	Non-Preferred Generic	$3.00	$6.00	Q:240 /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
TRANDOLAPRIL-VERAPAMIL ER 1-240 MG	4	Non-Preferred Brand	38%	38%	None
TRANDOLAPRIL-VERAPAMIL ER 2-180 MG	4	Non-Preferred Brand	38%	38%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRANDOLAPRIL-VERAPAMIL ER 2-240 MG	4	Non-Preferred Brand	38%	38%	None
TRANDOLAPRIL-VERAPAMIL ER 4-240 MG	4	Non-Preferred Brand	38%	38%	None
TRANEXAMIC ACID 1,000 MG/10 ML	3	Preferred Brand	$40.00	$120.00	None
tranexamic acid 650 mg tablet	3	Preferred Brand	$40.00	$120.00	None
TRANYLCYPROMINE SULFATE 10MG TABLET	3	Preferred Brand	$40.00	$120.00	None
TRAVASOL 10% SOLUTION VIAFLEX	4	Non-Preferred Brand	38%	38%	P
TRAVATAN Z 0.04MG DROPS 2.5ML BOT	3	Preferred Brand	$40.00	$120.00	None
travoprost 0.004% eye drop [Travatan]	2	Non-Preferred Generic	$3.00	$6.00	None
TRAZODONE 300MG TABLET	2	Non-Preferred Generic	$3.00	$6.00	None
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
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRAZODONE HCL TABLET USP 50MG (500 CT)	1	Preferred Generic	$1.00	$2.00	None
TREANDA 45 MG/0.5 ML VIAL	5	Specialty Tier	33%	N/A	P
TREANDA FOR INJECTION 100MG/VIAL	5	Specialty Tier	33%	N/A	P
TRECATOR 250MG TABLET	4	Non-Preferred Brand	38%	38%	None
Trelstar 22.5mg/2mL 2 mL in 1 VIAL, SINGLE-DOSE	5	Specialty Tier	33%	N/A	None
TRELSTAR DEPOT MIXJET FOR INJECTION 3.75 MG	5	Specialty Tier	33%	N/A	None
TRELSTAR MIXJET FOR INJECTION 11.25 MG	5	Specialty Tier	33%	N/A	None
Tretinoin 0.1mg/g 1 TUBE per CARTON / 45 g in 1 TUBE	3	Preferred Brand	$40.00	$120.00	Q:45 /30Days
Tretinoin 0.25mg/g 1 TUBE per CARTON / 45 g in 1 TUBE	3	Preferred Brand	$40.00	$120.00	Q:45 /30Days
Tretinoin 0.25mg/g 1 TUBE per CARTON / 45 g in 1 TUBE	3	Preferred Brand	$40.00	$120.00	Q:45 /30Days
Tretinoin 0.5mg/g 1 TUBE per CARTON / 20 g in 1 TUBE	3	Preferred Brand	$40.00	$120.00	Q:45 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRETINOIN 10MG CAPSULE	5	Specialty Tier	33%	N/A	None
Tretinoin 1mg/g 1 TUBE per CARTON / 45 g in 1 TUBE	3	Preferred Brand	$40.00	$120.00	Q:45 /30Days
TREXALL 10MG TABLET	4	Non-Preferred Brand	38%	38%	None
TREXALL 15MG TABLET	4	Non-Preferred Brand	38%	38%	None
TREXALL 5MG TABLET	4	Non-Preferred Brand	38%	38%	None
TREXALL 7.5MG TABLET	4	Non-Preferred Brand	38%	38%	None
TRI PREVIFEM TABLETS	4	Non-Preferred Brand	38%	38%	None
TRI-LEGEST FE 5-7-9-7 TABLET	4	Non-Preferred Brand	38%	38%	None
TRI-SPRINTEC 7DAYSX3 28 TABLET	4	Non-Preferred Brand	38%	38%	None
TRIAMCINOLONE 0.1% OINTMENT	2	Non-Preferred Generic	$3.00	$6.00	None
Triamcinolone 0.147 MG/G Spray	4	Non-Preferred Brand	38%	38%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRIAMCINOLONE ACETONIDE 0.025% CREAM 80GM TUBE	2	Non-Preferred Generic	$3.00	$6.00	None
TRIAMCINOLONE ACETONIDE 0.025% LOTION 2 FL OZ BOT	2	Non-Preferred Generic	$3.00	$6.00	None
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE	2	Non-Preferred Generic	$3.00	$6.00	None
TRIAMCINOLONE ACETONIDE 0.1% CREAM 80GM TUBE	2	Non-Preferred Generic	$3.00	$6.00	None
TRIAMCINOLONE ACETONIDE 0.1% LOTION 60ML BOTPL	2	Non-Preferred Generic	$3.00	$6.00	None
triamcinolone acetonide 0.25mg/g 80 g in 1 TUBE	2	Non-Preferred Generic	$3.00	$6.00	None
Triamcinolone Acetonide 1mg/g 1 TUBE per CARTON / 5 g in 1 TUBE	3	Preferred Brand	$40.00	$120.00	None
Triamcinolone Acetonide 55ug/1 1 BOTTLE, SPRAY per CARTON / 120 SPRAY, METERED in 1 BOTTLE, SPRAY	2	Non-Preferred Generic	$3.00	$6.00	Q:34 /30Days
Triamcinolone Acetonide 5mg/g 1 TUBE per CARTON / 15 g in 1 TUBE	2	Non-Preferred Generic	$3.00	$6.00	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
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRIAMTERENE/HCTZ 75/50 TABLET	1	Preferred Generic	$1.00	$2.00	None
Trianex 0.05% Ointment	2	Non-Preferred Generic	$3.00	$6.00	None
TRIBENZOR 20/5/12.5MG TABLETS	3	Preferred Brand	$40.00	$120.00	Q:30 /30Days
TRIBENZOR 40/10/12.5MG TABLETS	3	Preferred Brand	$40.00	$120.00	Q:30 /30Days
TRIBENZOR 40/10/25MG TABLETS	3	Preferred Brand	$40.00	$120.00	Q:30 /30Days
Tribenzor 5; 12.5; 40mg/1; mg/1; mg/1	3	Preferred Brand	$40.00	$120.00	Q:30 /30Days
Tribenzor 5; 25; 40mg/1; mg/1; mg/1	3	Preferred Brand	$40.00	$120.00	Q:30 /30Days
TRIDERM 0.1% CREAM	2	Non-Preferred Generic	$3.00	$6.00	None
TRIFLUOPERAZINE 1MG TABLET	2	Non-Preferred Generic	$3.00	$6.00	None
TRIFLUOPERAZINE HCL 2MG TABLET	2	Non-Preferred Generic	$3.00	$6.00	None
TRIFLUOPERAZINE HCL 5MG TABLET	2	Non-Preferred Generic	$3.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT)	2	Non-Preferred Generic	$3.00	$6.00	None
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT	3	Preferred Brand	$40.00	$120.00	None
TRILEPTAL 150MG TABLET	4	Non-Preferred Brand	38%	38%	None
TRILEPTAL 300MG TABLET	4	Non-Preferred Brand	38%	38%	None
TRILEPTAL 300MG/5ML SUSP	4	Non-Preferred Brand	38%	38%	None
TRILEPTAL 600MG TABLET	4	Non-Preferred Brand	38%	38%	None
TRILYTE WITH FLAVOR PACKETS	2	Non-Preferred Generic	$3.00	$6.00	None
TRIMETHOPRIM 100MG TABLETS	2	Non-Preferred Generic	$3.00	$6.00	None
TRINESSA TABLET	4	Non-Preferred Brand	38%	38%	None
TRISENOX 10MG/10ML AMPULE	5	Specialty Tier	33%	N/A	P
TRIUMEQ TABLET	5	Specialty Tier	33%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Trivora 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK	4	Non-Preferred Brand	38%	38%	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	38%	38%	P
TROPHAMINE INJECTION SOLUTION 6%	4	Non-Preferred Brand	38%	38%	P
TROSPIUM CHLORIDE 20MG TABLETS	2	Non-Preferred Generic	$3.00	$6.00	Q:60 /30Days
TRULICITY 0.75 MG/0.5 ML PEN	4	Non-Preferred Brand	38%	38%	Q:2 /28Days
TRULICITY 1.5 MG/0.5 ML PEN	4	Non-Preferred Brand	38%	38%	Q:2 /28Days
TRUMENBA 120 MCG/0.5 ML VACCINE	3	Preferred Brand	$40.00	$120.00	None
TRUVADA 200/300MG TABLET	5	Specialty Tier	33%	N/A	None
TWINRIX TF PF VACCINE 720UNT/20ML 10 X 1ML VIALSD	3	Preferred Brand	$40.00	$120.00	None
TYBOST 150 MG TABLET	4	Non-Preferred Brand	38%	38%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Tygacil 50mg/5mL 10 VIAL, SINGLE-USE per CARTON / 50 mL in 1 VIAL, SINGLE-USE	5	Specialty Tier	33%	N/A	None
TYKERB 250MG TABLET	5	Specialty Tier	33%	N/A	P
TYPHIM VI 25 MCG/0.5 ML SYRINGE	3	Preferred Brand	$40.00	$120.00	None
TYPHIM VI 25MCG/0.5ML VIAL	3	Preferred Brand	$40.00	$120.00	None
TYSABRI 300 MG/15 ML VIAL	5	Specialty Tier	33%	N/A	None
Tyvaso 1.74mg/2.9mL	5	Specialty Tier	33%	N/A	P
TYZEKA 600MG TABLET (30 CT)	5	Specialty Tier	33%	N/A	P
TYZINE PEDIATRIC 0.05% DROP	4	Non-Preferred Brand	38%	38%	None

Chart Legend:

Below are a few notes to help you understand the above 2015 Medicare Part D Anthem Blue MedicareRx Premier (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.