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Humana Preferred Rx Plan (PDP) (S5884-105-0)
Tier 1 (188)
Tier 2 (713)
Tier 3 (784)
Tier 4 (1241)
Tier 5 (523)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
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2016 Medicare Part D Plan Formulary Information
Humana Preferred Rx Plan (PDP) (S5884-105-0)
Benefit Details           
The Humana Preferred Rx Plan (PDP) (S5884-105-0)
Formulary Drugs Starting with the Letter T

in CMS PDP Region 11 which includes: FL
Plan Monthly Premium: $27.50 Deductible: $360 Qualifies for LIS: Yes
Drugs Starting with Letter T

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
TABLOID 40 MG TABLET   4 Non-Preferred Brand 35%30%None
Tacrolimus 0.5mg/1 100 CAPSULE BOTTLE   3 Preferred Brand 20%15%P
Tacrolimus 1mg/1 100 CAPSULE BOTTLE   3 Preferred Brand 20%15%P
Tacrolimus 5mg/1 100 CAPSULE BOTTLE   3 Preferred Brand 20%15%P
TAFINLAR 50 MG CAPSULE   5 Specialty Tier 25%N/AP Q:180
/30Days
TAFINLAR 75 MG CAPSULE   5 Specialty Tier 25%N/AP Q:120
/30Days
TAGRISSO 40 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
TAGRISSO 80 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
TAMIFLU 30 MG 1 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK   4 Non-Preferred Brand 35%30%Q:112
/365Days
TAMIFLU 45 MG 1 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK   4 Non-Preferred Brand 35%30%Q:56
/365Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TAMIFLU 6 MG/ML SUSPENSION   4 Non-Preferred Brand 35%30%Q:720
/365Days
TAMIFLU 75 MG CAPSULE UD   4 Non-Preferred Brand 35%30%Q:56
/365Days
TAMOXIFEN CITRATE 20MG TABLET (30 CT)   2 Generic $2.00$0.00None
TAMOXIFEN CITRATE TABLETS 10MG 180 BOT   2 Generic $2.00$0.00None
TAMSULOSIN HCL 0.4 MG CAPSULE   2 Generic $2.00$0.00Q:60
/30Days
TARCEVA 100MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
TARCEVA 150MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
TARCEVA 25MG TABLET   5 Specialty Tier 25%N/AP Q:90
/30Days
TARGRETIN 1% GEL   5 Specialty Tier 25%N/AP
TARGRETIN 75 MG CAPSULE   5 Specialty Tier 25%N/AP Q:300
/30Days
Tarina Fe 1-20 tablet   4 Non-Preferred Brand 35%30%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Tasigna 150mg/1 4 BLISTER PACK per CARTON / 28 CAPSULE per BLISTER PACK   5 Specialty Tier 25%N/AP Q:120
/30Days
TASIGNA 200MG CAPSULE 28 BLPK   5 Specialty Tier 25%N/AP Q:120
/30Days
TASMAR 100MG TABLET   4 Non-Preferred Brand 35%30%P
TAXOTERE 80mg/4mL 1 VIAL, GLASS per CARTON / 4 mL in 1 VIAL, GLASS   5 Specialty Tier 25%N/ANone
TAZORAC 0.05% CREAM   4 Non-Preferred Brand 35%30%P
TAZORAC 0.05% GEL   4 Non-Preferred Brand 35%30%P
TAZORAC 0.1% CREAM   4 Non-Preferred Brand 35%30%P
TAZORAC 0.1% GEL   4 Non-Preferred Brand 35%30%P
TAZTIA DILTIAZEM HYDROCHLORIDE 120MG EXTENDED RELEASE CAPSULES   3 Preferred Brand 20%15%Q:60
/30Days
TAZTIA DILTIAZEM HYDROCHLORIDE 180MG EXTENDED RELEASE CAPSULES   3 Preferred Brand 20%15%Q:60
/30Days
TAZTIA DILTIAZEM HYDROCHLORIDE 300MG EXTENDED RELEASE CAPSULES   3 Preferred Brand 20%15%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TAZTIA XT 240MG CAPSULE SA   3 Preferred Brand 20%15%Q:60
/30Days
TAZTIA XT 360MG CAPSULE SA   3 Preferred Brand 20%15%Q:30
/30Days
TECENTRIQ 1,200 MG/20 ML VIAL   5 Specialty Tier 25%N/AP Q:20
/21Days
Teflaro 400mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE   4 Non-Preferred Brand 35%30%None
Teflaro 600mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE   4 Non-Preferred Brand 35%30%None
TEGRETOL XR TABLETS 100MG 100 BOT   4 Non-Preferred Brand 35%30%None
TEKTURNA 150MG TABLET   3 Preferred Brand 20%15%Q:30
/30Days
TEKTURNA 300MG TABLET   3 Preferred Brand 20%15%Q:30
/30Days
Temazepam 15mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE per BLISTER PACK   4 Non-Preferred Brand 35%30%Q:30
/30Days
TEMAZEPAM 30 MG CAPSULE   4 Non-Preferred Brand 35%30%Q:30
/30Days
TENIVAC SYRINGE   4 Non-Preferred Brand 35%30%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TERAZOSIN 1 MG CAPSULE   1 Preferred Generic $1.00$0.00None
Terazosin Hydrochloride 10mg/1 100 CAPSULE BOTTLE   1 Preferred Generic $1.00$0.00None
Terazosin Hydrochloride 2mg/1 100 CAPSULE BOTTLE   1 Preferred Generic $1.00$0.00None
Terazosin Hydrochloride 5mg/1 100 CAPSULE BOTTLE   1 Preferred Generic $1.00$0.00None
Terbinafine HCl 250 MG Tablet   1 Preferred Generic $1.00$0.00Q:90
/365Days
TERBUTALINE SULF 1MG/ML VL   5 Specialty Tier 25%N/ANone
TERBUTALINE SULF 2.5MG TABLET   4 Non-Preferred Brand 35%30%None
TERBUTALINE SULFATE 5MG TABLET   4 Non-Preferred Brand 35%30%None
TERCONAZOLE 0.4% CREAM WITH APPLICATOR   3 Preferred Brand 20%15%None
TERCONAZOLE 0.8% CREAM   3 Preferred Brand 20%15%None
TERCONAZOLE 80MG SUPPOSITORY VAGINAL   3 Preferred Brand 20%15%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Testosterone cyp 100 mg/ml   3 Preferred Brand 20%15%None
Testosterone cyp 200 mg/ml   3 Preferred Brand 20%15%None
TESTOSTERONE ENANTHATE 200MG/ML INJECTION   4 Non-Preferred Brand 35%30%None
TESTRED 10MG CAPSULE   5 Specialty Tier 25%N/ANone
TETANUS DIPHTHERIA TOXOIDS   4 Non-Preferred Brand 35%30%None
TETRABENAZINE 12.5 MG TABLET [XENAZINE]   5 Specialty Tier 25%N/AP Q:240
/30Days
TETRABENAZINE 25 MG TABLET [XENAZINE]   5 Specialty Tier 25%N/AP Q:120
/30Days
TETRACYCLINE 250 MG CAPSULE   3 Preferred Brand 20%15%None
TETRACYCLINE 500 MG CAPSULE   3 Preferred Brand 20%15%None
THALOMID 100MG CAPSULE 140 BOX   5 Specialty Tier 25%N/AP Q:30
/30Days
Thalomid 150mg/1   5 Specialty Tier 25%N/AP Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Thalomid 200mg/1   5 Specialty Tier 25%N/AP Q:30
/30Days
THALOMID 50MG CAPSULE 280 BOX   5 Specialty Tier 25%N/AP Q:30
/30Days
Theophylline 100mg/1 500 CAPSULE BOTTLE   2 Generic $2.00$0.00None
Theophylline 200mg/1 500 TABLET, EXTENDED RELEASE in 1 BOTTLE   2 Generic $2.00$0.00None
THEOPHYLLINE 400MG TABLET SA   2 Generic $2.00$0.00None
THEOPHYLLINE 600MG TABLET SA   2 Generic $2.00$0.00None
THEOPHYLLINE TABLET ER 300MG (100 CT)   2 Generic $2.00$0.00None
THEOPHYLLINE TABLET ER 450MG (100 CT)   2 Generic $2.00$0.00None
THIOLA 100 MG TABLET   5 Specialty Tier 25%N/ANone
THIORIDAZINE 100MG TABLET   2 Generic $2.00$0.00None
THIORIDAZINE HCL 10MG TABLET (1000 CT)   2 Generic $2.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
THIORIDAZINE HCL 25MG TABLET (1000 CT)   2 Generic $2.00$0.00None
Thioridazine Hydrochloride 50mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED in 1   2 Generic $2.00$0.00None
THIOTEPA 15 MG VIAL   2 Generic $2.00$0.00None
THIOTHIXENE 10MG CAPSULE   3 Preferred Brand 20%15%None
THIOTHIXENE 1MG CAPSULE (100 CT)   3 Preferred Brand 20%15%None
THIOTHIXENE 2MG CAPSULE   3 Preferred Brand 20%15%None
THIOTHIXENE 5MG CAPSULE   3 Preferred Brand 20%15%None
THYMOGLOBULIN 25MG VIAL   3 Preferred Brand 20%15%P
THYROLAR-1 TABLETS   2 Generic $2.00$0.00None
THYROLAR-1/2 TABLETS   2 Generic $2.00$0.00None
THYROLAR-1/4 TABLETS   2 Generic $2.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
THYROLAR-2 TABLETS   2 Generic $2.00$0.00None
THYROLAR-3 TABLETS   2 Generic $2.00$0.00None
tiagabine hcl 2 mg tablet [Gabitril]   4 Non-Preferred Brand 35%30%None
tiagabine hcl 4 mg tablet [Gabitril]   4 Non-Preferred Brand 35%30%None
TIKOSYN .125MG CAPSULE   4 Non-Preferred Brand 35%30%Q:240
/30Days
TIKOSYN .250MG CAPSULE   4 Non-Preferred Brand 35%30%Q:120
/30Days
TIKOSYN .5MG CAPSULE   4 Non-Preferred Brand 35%30%Q:60
/30Days
TIMOLOL MAL SOL 0.25% OP 15ML BOT   1 Preferred Generic $1.00$0.00None
TIMOLOL MAL SOL 0.5% OP 10ML BOT   1 Preferred Generic $1.00$0.00None
TIMOLOL MALEATE 10MG TABLET   2 Generic $2.00$0.00None
TIMOLOL MALEATE 20MG TABLET   2 Generic $2.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Timolol Maleate 3.4mg/mL 1 BOTTLE, DISPENSING per CARTON / 5 mL in 1 BOTTLE, DISPENSING   3 Preferred Brand 20%15%None
TIMOLOL MALEATE 5MG TABLET   2 Generic $2.00$0.00None
Timolol Maleate 6.8mg/mL 1 BOTTLE, DISPENSING per CARTON / 5 mL in 1 BOTTLE, DISPENSING   3 Preferred Brand 20%15%None
tinidazole 250 mg tablet   3 Preferred Brand 20%15%None
tinidazole 500 mg tablet   3 Preferred Brand 20%15%None
TIVICAY 10 MG TABLET   4 Non-Preferred Brand 35%30%Q:60
/30Days
TIVICAY 25 MG TABLET   5 Specialty Tier 25%N/AQ:60
/30Days
TIVICAY 50 MG TABLET   5 Specialty Tier 25%N/AQ:60
/30Days
Tizanidine 4mg/1 1000 TABLET BOTTLE   2 Generic $2.00$0.00None
TIZANIDINE HCL 2 MG TABLET   2 Generic $2.00$0.00None
TOBI PODHALER 28 MG INHALE CAP   5 Specialty Tier 25%N/AP Q:224
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TOBRAMYCIN 10MG/ML VIAL   3 Preferred Brand 20%15%None
TOBRAMYCIN 40MG/ML VIAL   3 Preferred Brand 20%15%None
TOBRAMYCIN OPHTHALMIC SOLUTION 0.3% 5ML BOT   1 Preferred Generic $1.00$0.00None
TOBRAMYCIN-DEXAMETH OPTH SUSP   4 Non-Preferred Brand 35%30%None
TOBREX 0.3% EYE OINTMENT   4 Non-Preferred Brand 35%30%None
TOLAK 4% CREAM   4 Non-Preferred Brand 35%30%None
TOLAZAMIDE TABLETS 250MG 100 BOT   4 Non-Preferred Brand 35%30%None
TOLAZAMIDE TABLETS 500MG 100 BOT   4 Non-Preferred Brand 35%30%None
TOLBUTAMIDE 500MG TABLET   4 Non-Preferred Brand 35%30%None
Tolcapone 100 MG TABLET [Tasmar]   4 Non-Preferred Brand 35%30%P
TOLMETIN SODIUM 400 MG CAP   4 Non-Preferred Brand 35%30%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TOLMETIN SODIUM 600MG TABLET   4 Non-Preferred Brand 35%30%None
Tolterodine Tartrate 1 MG TABLET [Detrol LA]   3 Preferred Brand 20%15%Q:60
/30Days
Tolterodine Tartrate 2 MG TABLET [Detrol LA]   3 Preferred Brand 20%15%Q:60
/30Days
Tolterodine Tartrate ER 2 MG CAPSULE [Detrol LA]   2 Generic $2.00$0.00Q:30
/30Days
Tolterodine Tartrate ER 4 MG Capsule [Detrol LA]   2 Generic $2.00$0.00Q:30
/30Days
TOLVAPTAN 15 MG ORAL TABLET [SAMSCA]   5 Specialty Tier 25%N/AQ:60
/30Days
TOLVAPTAN 30 MG ORAL TABLET [SAMSCA]   5 Specialty Tier 25%N/AQ:60
/30Days
Topiramate 25mg/1   2 Generic $2.00$0.00None
TOPIRAMATE SPRINKLE CAPSULES 15MG 60 BOT   2 Generic $2.00$0.00None
TOPIRAMATE TABLETS 100MG 1000 BOT   2 Generic $2.00$0.00Q:120
/30Days
TOPIRAMATE TABLETS 200MG 1000 BOT   2 Generic $2.00$0.00Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TOPIRAMATE TABLETS 25MG 1000 BOT   2 Generic $2.00$0.00Q:90
/30Days
TOPIRAMATE TABLETS 50MG 1000 BOT   2 Generic $2.00$0.00Q:120
/30Days
TOPOSAR INJECTION 20MG/ML 50ML VIAL MD CRTN   4 Non-Preferred Brand 35%30%None
TOPOTECAN HCL 4 MG VIAL   5 Specialty Tier 25%N/ANone
Torisel 1 KIT per CARTON   5 Specialty Tier 25%N/AP Q:8
/28Days
TORSEMIDE 10 MG TABLET   2 Generic $2.00$0.00None
Torsemide 100mg/1 12 BOTTLE CASE / 100 TABLET BOTTLE   2 Generic $2.00$0.00None
TORSEMIDE 20mg 100 TABLET BOTTLE   2 Generic $2.00$0.00None
TORSEMIDE 5 MG TABLET   2 Generic $2.00$0.00None
TOUJEO SOLOSTAR 300 UNITS/ML   3 Preferred Brand 20%15%None
TOVIAZ TABLETS 4MG EXTENDED RELEASE   3 Preferred Brand 20%15%Q:30
/30Days
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 20%15%Q:30
/30Days
TPN ELECTROLYTES16.5/25.4 VIAL   4 Non-Preferred Brand 35%30%None
TRACLEER 125MG TABLET   5 Specialty Tier 25%N/AP Q:60
/30Days
TRACLEER 62.5MG TABLET   5 Specialty Tier 25%N/AP Q:60
/30Days
TRADJENTA 5mg/1 90 FILM COATED TABLETS in BOTTLE   3 Preferred Brand 20%15%Q:30
/30Days
TRAMADOL HCL 50 MG TABLET   2 Generic $2.00$0.00Q:240
/30Days
TRAMADOL HCL-ACETAMINOPHEN 37.5-325MG TABLET (1000 CT)   4 Non-Preferred Brand 35%30%Q:240
/30Days
TRANDOLAPRIL 1 MG TABLET   2 Generic $2.00$0.00None
TRANDOLAPRIL 2 MG TABLET   2 Generic $2.00$0.00None
TRANDOLAPRIL 4 MG TABLET   2 Generic $2.00$0.00None
TRANEXAMIC ACID 1,000 MG/10 ML   3 Preferred Brand 20%15%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
tranexamic acid 650 mg tablet   4 Non-Preferred Brand 35%30%Q:30
/5Days
TRANSDERM-SCOP 1.5 MG/72HR   4 Non-Preferred Brand 35%30%Q:10
/30Days
TRANYLCYPROMINE SULFATE 10MG TABLET   4 Non-Preferred Brand 35%30%None
TRAVASOL 10% SOLUTION VIAFLEX   4 Non-Preferred Brand 35%30%P
TRAVATAN Z 0.04MG DROPS 2.5ML BOT   3 Preferred Brand 20%15%Q:3
/25Days
TRAZODONE 300MG TABLET   2 Generic $2.00$0.00None
TRAZODONE HCL TABLET USP 100MG (500 CT)   1 Preferred Generic $1.00$0.00None
TRAZODONE HCL TABLET USP 150MG (100 CT)   1 Preferred Generic $1.00$0.00None
TRAZODONE HCL TABLET USP 50MG (500 CT)   1 Preferred Generic $1.00$0.00None
TREANDA FOR INJECTION 100MG/VIAL   5 Specialty Tier 25%N/AP
TRECATOR 250MG TABLET   4 Non-Preferred Brand 35%30%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRESIBA FLEXTOUCH 100 UNITS/ML   3 Preferred Brand 20%15%Q:30
/30Days
TRESIBA FLEXTOUCH 200 UNITS/ML   3 Preferred Brand 20%15%Q:27
/30Days
TRETINOIN 0.01% GEL   3 Preferred Brand 20%15%P
Tretinoin 0.25mg/g 1 TUBE per CARTON / 45 g in 1 TUBE   3 Preferred Brand 20%15%P
Tretinoin 0.25mg/g 1 TUBE per CARTON / 45 g in 1 TUBE   3 Preferred Brand 20%15%P
Tretinoin 0.5mg/g 1 TUBE per CARTON / 20 g in 1 TUBE   3 Preferred Brand 20%15%P
TRETINOIN 10MG CAPSULE   5 Specialty Tier 25%N/ANone
Tretinoin 1mg/g 1 TUBE per CARTON / 45 g in 1 TUBE   3 Preferred Brand 20%15%P
TREXALL 10MG TABLET   4 Non-Preferred Brand 35%30%P
TREXALL 15MG TABLET   4 Non-Preferred Brand 35%30%P
TREXALL 5MG TABLET   4 Non-Preferred Brand 35%30%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TREXALL 7.5MG TABLET   4 Non-Preferred Brand 35%30%P
TRI PREVIFEM TABLETS   4 Non-Preferred Brand 35%30%None
TRI-LEGEST FE 5-7-9-7 TABLET   4 Non-Preferred Brand 35%30%None
TRI-LO-ESTARYLLA TABLET   4 Non-Preferred Brand 35%30%None
TRI-LO-SPRINTEC TABLET   4 Non-Preferred Brand 35%30%None
TRI-SPRINTEC 7DAYSX3 28 TABLET   4 Non-Preferred Brand 35%30%None
TRIAMCINOLONE 0.1% OINTMENT   1 Preferred Generic $1.00$0.00None
Triamcinolone 0.147 MG/G Spray   4 Non-Preferred Brand 35%30%None
TRIAMCINOLONE ACETONIDE 0.025% CREAM 80GM TUBE   1 Preferred Generic $1.00$0.00None
TRIAMCINOLONE ACETONIDE 0.025% LOTION 2 FL OZ BOT   3 Preferred Brand 20%15%None
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE   2 Generic $2.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRIAMCINOLONE ACETONIDE 0.1% CREAM 80GM TUBE   1 Preferred Generic $1.00$0.00None
TRIAMCINOLONE ACETONIDE 0.1% LOTION 60ML BOTPL   3 Preferred Brand 20%15%None
triamcinolone acetonide 0.25mg/g 80 g in 1 TUBE   2 Generic $2.00$0.00None
Triamcinolone Acetonide 1mg/g 1 TUBE per CARTON / 5 g in 1 TUBE   3 Preferred Brand 20%15%None
Triamcinolone Acetonide 5mg/g 1 TUBE per CARTON / 15 g in 1 TUBE   1 Preferred Generic $1.00$0.00None
Triamterene and Hydrochlorothiazide 25; 37.5mg 100 CAPSULE BOTTLE   2 Generic $2.00$0.00None
TRIAMTERENE/HCTZ 37.5/25 TABLET   1 Preferred Generic $1.00$0.00None
TRIAMTERENE/HCTZ 50-25 MG CAP   2 Generic $2.00$0.00None
TRIAMTERENE/HCTZ 75/50 TABLET   1 Preferred Generic $1.00$0.00None
TRIBENZOR 20/5/12.5MG TABLETS   3 Preferred Brand 20%15%Q:30
/30Days
TRIBENZOR 40/10/12.5MG TABLETS   3 Preferred Brand 20%15%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRIBENZOR 40/10/25MG TABLETS   3 Preferred Brand 20%15%Q:30
/30Days
Tribenzor 5; 12.5; 40mg/1; mg/1; mg/1   3 Preferred Brand 20%15%Q:30
/30Days
Tribenzor 5; 25; 40mg/1; mg/1; mg/1   3 Preferred Brand 20%15%Q:30
/30Days
TRIDERM 0.1% CREAM   2 Generic $2.00$0.00None
TRIFLUOPERAZINE 1MG TABLET   3 Preferred Brand 20%15%None
TRIFLUOPERAZINE HCL 2MG TABLET   3 Preferred Brand 20%15%None
TRIFLUOPERAZINE HCL 5MG TABLET   3 Preferred Brand 20%15%None
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT)   3 Preferred Brand 20%15%None
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT   4 Non-Preferred Brand 35%30%None
TRIHEXYPHENIDYL 5 MG TABLET   2 Generic $2.00$0.00None
TRIHEXYPHENIDYL HYDROCHLORIDE 2mg/1   1 Preferred Generic $1.00$0.00None
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   2 Generic $2.00$0.00None
TRILYTE WITH FLAVOR PACKETS   2 Generic $2.00$0.00None
TRIMETHOBENZAMIDE HCL 300MG CAPSULE   4 Non-Preferred Brand 35%30%None
TRIMETHOPRIM 100MG TABLETS   2 Generic $2.00$0.00None
TRIMIPRAMINE MALEATE 100 MG CP   4 Non-Preferred Brand 35%30%None
TRIMIPRAMINE MALEATE 25 MG CAP   4 Non-Preferred Brand 35%30%None
TRIMIPRAMINE MALEATE 50 MG CAP   4 Non-Preferred Brand 35%30%None
TRINESSA TABLET   4 Non-Preferred Brand 35%30%None
TRINTELLIX 10 MG TABLET   4 Non-Preferred Brand 35%30%S Q:30
/30Days
TRINTELLIX 20 MG TABLET   4 Non-Preferred Brand 35%30%S Q:30
/30Days
TRINTELLIX 5 MG TABLET   4 Non-Preferred Brand 35%30%S Q:30
/30Days
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 35%30%None
TRIUMEQ TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
Trivora 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK   4 Non-Preferred Brand 35%30%None
TRIZIVIR 300; 150; 300mg/1; mg/1; mg/1 60 FILM COATED TABLETS in BOTTLE   5 Specialty Tier 25%N/AQ:60
/30Days
TROPHAMINE INJECTION SOLUTION   4 Non-Preferred Brand 35%30%P
TROPHAMINE INJECTION SOLUTION 6%   4 Non-Preferred Brand 35%30%P
TROSPIUM CHLORIDE 20MG TABLETS   4 Non-Preferred Brand 35%30%None
TRULICITY 0.75 MG/0.5 ML PEN   3 Preferred Brand 20%15%Q:2
/28Days
TRULICITY 1.5 MG/0.5 ML PEN   3 Preferred Brand 20%15%Q:2
/28Days
TRUMENBA 120 MCG/0.5 ML VACCINE   4 Non-Preferred Brand 35%30%None
TRUVADA 100 MG-150 MG TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRUVADA 133 MG-200 MG TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
TRUVADA 167 MG-250 MG TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
TRUVADA 200/300MG TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
TWINRIX TF PF VACCINE 720UNT/20ML 10 X 1ML VIALSD   4 Non-Preferred Brand 35%30%None
TYBOST 150 MG TABLET   4 Non-Preferred Brand 35%30%Q:30
/30Days
Tygacil 50mg/5mL 10 VIAL, SINGLE-USE per CARTON / 50 mL in 1 VIAL, SINGLE-USE   5 Specialty Tier 25%N/ANone
TYKERB 250MG TABLET   5 Specialty Tier 25%N/AP Q:150
/30Days
TYPHIM VI 25 MCG/0.5 ML SYRINGE   4 Non-Preferred Brand 35%30%None
TYPHIM VI 25MCG/0.5ML VIAL   4 Non-Preferred Brand 35%30%None
TYSABRI 300 MG/15 ML VIAL   5 Specialty Tier 25%N/AP
TYZEKA 600MG TABLET (30 CT)   5 Specialty Tier 25%N/AQ:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TYZINE PEDIATRIC 0.05% DROP   4 Non-Preferred Brand 35%30%None

Chart Legend:

Below are a few notes to help you understand the above 2016 Medicare Part D Humana Preferred Rx Plan (PDP) Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region).

  • Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.

  • Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $360 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 $3310) 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 2016 )

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.







Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.