Q1Medicare.com 2017 Medicare Part D or Medicare Advantage Plan Formulary Browser

2017 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: $39.10 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 Drug	50%	50%	None
Tacrolimus 0.5mg/1 100 CAPSULE BOTTLE	4	Non-Preferred Drug	50%	50%	P
Tacrolimus 1mg/1 100 CAPSULE BOTTLE	4	Non-Preferred Drug	50%	50%	P
Tacrolimus 5mg/1 100 CAPSULE BOTTLE	4	Non-Preferred Drug	50%	50%	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
TAGRISSO 40 MG TABLET	5	Specialty Tier	33%	N/A	P Q:30 /30Days
TAGRISSO 80 MG TABLET	5	Specialty Tier	33%	N/A	P Q:30 /30Days
TAMIFLU 30 MG 1 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK	4	Non-Preferred Drug	50%	50%	Q:170 /365Days
TAMIFLU 45 MG 1 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK	4	Non-Preferred Drug	50%	50%	Q:90 /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 Drug	50%	50%	Q:1080 /365Days
TAMIFLU 75 MG CAPSULE UD	4	Non-Preferred Drug	50%	50%	Q:90 /365Days
TAMOXIFEN 10 MG TABLET	2	Generic	$5.00	$15.00	None
TAMOXIFEN CITRATE 20MG TABLET (30 CT)	2	Generic	$5.00	$15.00	None
TAMSULOSIN HCL 0.4 MG CAPSULE	2	Generic	$5.00	$15.00	None
TANZEUM 30 MG PEN INJECT	4	Non-Preferred Drug	50%	50%	None
TANZEUM 50 MG PEN INJECT	4	Non-Preferred Drug	50%	50%	None
TARCEVA 100MG TABLET	5	Specialty Tier	33%	N/A	P Q:90 /30Days
TARCEVA 150MG TABLET	5	Specialty Tier	33%	N/A	P Q:90 /30Days
TARCEVA 25MG TABLET	5	Specialty Tier	33%	N/A	P Q:60 /30Days
TARGRETIN 1% GEL	5	Specialty Tier	33%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Tarina Fe 1-20 tablet	2	Generic	$5.00	$15.00	None
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
Tazarotene 0.1% Cream [Tazorac]	4	Non-Preferred Drug	50%	50%	None
TAZICEF 1GM VIAL	2	Generic	$5.00	$15.00	None
TAZICEF 2 GRAM VIAL	2	Generic	$5.00	$15.00	None
TAZICEF 6 GRAM VIAL	2	Generic	$5.00	$15.00	None
TAZORAC 0.05% CREAM	4	Non-Preferred Drug	50%	50%	None
TAZORAC 0.05% GEL	4	Non-Preferred Drug	50%	50%	None
TAZORAC 0.1% CREAM	4	Non-Preferred Drug	50%	50%	None
TAZORAC 0.1% GEL	4	Non-Preferred Drug	50%	50%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TAZTIA DILTIAZEM HYDROCHLORIDE 120MG EXTENDED RELEASE CAPSULES	2	Generic	$5.00	$15.00	None
TAZTIA DILTIAZEM HYDROCHLORIDE 180MG EXTENDED RELEASE CAPSULES	2	Generic	$5.00	$15.00	None
TAZTIA DILTIAZEM HYDROCHLORIDE 300MG EXTENDED RELEASE CAPSULES	2	Generic	$5.00	$15.00	None
TAZTIA XT 240MG CAPSULE SA	2	Generic	$5.00	$15.00	None
TAZTIA XT 360MG CAPSULE SA	2	Generic	$5.00	$15.00	None
TECENTRIQ 1,200 MG/20 ML VIAL	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 Drug	50%	50%	None
Teflaro 600mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE	4	Non-Preferred Drug	50%	50%	None
TEKTURNA 150 MG TABLET	3	Preferred Brand	$47.00	$141.00	Q:30 /30Days
TEKTURNA 300 MG TABLET	3	Preferred Brand	$47.00	$141.00	Q:30 /30Days
TEKTURNA HCT 300-25 MG TABLET	3	Preferred Brand	$47.00	$141.00	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Telmisartan 20 MG Tablet [Micardis]	2	Generic	$5.00	$15.00	Q:30 /30Days
Telmisartan 40 MG Tablet [Micardis]	2	Generic	$5.00	$15.00	Q:30 /30Days
Telmisartan 80 MG Tablet [Micardis]	2	Generic	$5.00	$15.00	Q:30 /30Days
Telmisartan-Amlodipine 40-10 MG [Micardis]	1	Preferred Generic	$2.00	$6.00	Q:30 /30Days
Telmisartan-Amlodipine 40-5 MG [Micardis]	1	Preferred Generic	$2.00	$6.00	Q:30 /30Days
Telmisartan-Amlodipine 80-10 MG [Micardis]	1	Preferred Generic	$2.00	$6.00	Q:30 /30Days
Telmisartan-Amlodipine 80-5 MG [Micardis]	1	Preferred Generic	$2.00	$6.00	Q:30 /30Days
TELMISARTAN-HCTZ 40-12.5 MG TB [Micardis]	3	Preferred Brand	$47.00	$141.00	Q:30 /30Days
Telmisartan-hctz 80-12.5 mg tb [Micardis]	3	Preferred Brand	$47.00	$141.00	Q:30 /30Days
TELMISARTAN-HCTZ 80-25 MG TAB [Micardis]	3	Preferred Brand	$47.00	$141.00	Q:30 /30Days
TENIVAC SYRINGE	4	Non-Preferred Drug	50%	50%	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	$2.00	$6.00	None
Terazosin Hydrochloride 10mg/1 100 CAPSULE BOTTLE	1	Preferred Generic	$2.00	$6.00	None
Terazosin Hydrochloride 2mg/1 100 CAPSULE BOTTLE	1	Preferred Generic	$2.00	$6.00	None
Terazosin Hydrochloride 5mg/1 100 CAPSULE BOTTLE	1	Preferred Generic	$2.00	$6.00	None
Terbinafine HCl 250 MG Tablet	2	Generic	$5.00	$15.00	None
TERBUTALINE SULFATE 2.5 MG TAB	4	Non-Preferred Drug	50%	50%	None
TERBUTALINE SULFATE 5MG TABLET	4	Non-Preferred Drug	50%	50%	None
TERCONAZOLE 0.4% CREAM WITH APPLICATOR	3	Preferred Brand	$47.00	$141.00	None
TERCONAZOLE 0.8% CREAM	3	Preferred Brand	$47.00	$141.00	None
TERCONAZOLE 80MG SUPPOSITORY VAGINAL	4	Non-Preferred Drug	50%	50%	None
TESTOSTERONE 25 MG/2.5 GM PKT	3	Preferred Brand	$47.00	$141.00	P Q:300 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TESTOSTERONE 50 MG/5 GRAM PKT	3	Preferred Brand	$47.00	$141.00	P Q:300 /30Days
Testosterone cyp 100 mg/ml	4	Non-Preferred Drug	50%	50%	None
Testosterone cyp 200 mg/ml	4	Non-Preferred Drug	50%	50%	None
TESTOSTERONE ENANTHATE 200MG/ML INJECTION	4	Non-Preferred Drug	50%	50%	None
TETANUS DIPHTHERIA TOXOIDS	2	Generic	$5.00	$15.00	None
TETRABENAZINE 12.5 MG TABLET [XENAZINE]	5	Specialty Tier	33%	N/A	P Q:90 /30Days
TETRABENAZINE 25 MG TABLET [XENAZINE]	5	Specialty Tier	33%	N/A	P Q:120 /30Days
TETRACYCLINE 250 MG CAPSULE	2	Generic	$5.00	$15.00	None
TETRACYCLINE 500 MG CAPSULE	2	Generic	$5.00	$15.00	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
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
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	3	Preferred Brand	$47.00	$141.00	None
Theophylline 200mg/1 500 TABLET, EXTENDED RELEASE in 1 BOTTLE	3	Preferred Brand	$47.00	$141.00	None
Theophylline 80mg/15mL 473 mL in 1 BOTTLE, PLASTIC	3	Preferred Brand	$47.00	$141.00	None
Theophylline er 400 mg tablet	3	Preferred Brand	$47.00	$141.00	None
Theophylline er 600 mg tablet	3	Preferred Brand	$47.00	$141.00	None
THEOPHYLLINE TABLET ER 300MG (100 CT)	3	Preferred Brand	$47.00	$141.00	None
THEOPHYLLINE TABLET ER 450MG (100 CT)	3	Preferred Brand	$47.00	$141.00	None
THIOLA 100 MG TABLET	3	Preferred Brand	$47.00	$141.00	None
THIORIDAZINE 100MG TABLET	3	Preferred Brand	$47.00	$141.00	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
THIORIDAZINE HCL 10MG TABLET (1000 CT)	3	Preferred Brand	$47.00	$141.00	P
THIORIDAZINE HCL 25MG TABLET (1000 CT)	3	Preferred Brand	$47.00	$141.00	P
Thioridazine Hydrochloride 50mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED in 1	3	Preferred Brand	$47.00	$141.00	P
THIOTEPA 15 MG VIAL	5	Specialty Tier	33%	N/A	None
THIOTHIXENE 10MG CAPSULE	4	Non-Preferred Drug	50%	50%	None
THIOTHIXENE 1MG CAPSULE (100 CT)	4	Non-Preferred Drug	50%	50%	None
THIOTHIXENE 2MG CAPSULE	4	Non-Preferred Drug	50%	50%	None
THIOTHIXENE 5MG CAPSULE	4	Non-Preferred Drug	50%	50%	None
THYMOGLOBULIN 25MG VIAL	5	Specialty Tier	33%	N/A	P
THYROLAR-1 TABLETS	4	Non-Preferred Drug	50%	50%	None
THYROLAR-1/2 TABLETS	4	Non-Preferred Drug	50%	50%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
THYROLAR-1/4 TABLETS	4	Non-Preferred Drug	50%	50%	None
THYROLAR-2 TABLETS	4	Non-Preferred Drug	50%	50%	None
THYROLAR-3 TABLETS	4	Non-Preferred Drug	50%	50%	None
tiagabine hcl 2 mg tablet [Gabitril]	4	Non-Preferred Drug	50%	50%	None
tiagabine hcl 4 mg tablet [Gabitril]	4	Non-Preferred Drug	50%	50%	None
TIGECYCLINE 50 MG VIAL [Tygacil]	5	Specialty Tier	33%	N/A	None
TIMOLOL 0.25% GFS GEL-SOLUTION	4	Non-Preferred Drug	50%	50%	None
TIMOLOL MAL SOL 0.25% OP 15ML BOT	1	Preferred Generic	$2.00	$6.00	None
TIMOLOL MAL SOL 0.5% OP 10ML BOT	1	Preferred Generic	$2.00	$6.00	None
TIMOLOL MALEATE 10MG TABLET	1	Preferred Generic	$2.00	$6.00	None
TIMOLOL MALEATE 20MG TABLET	1	Preferred Generic	$2.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TIMOLOL MALEATE 5MG TABLET	1	Preferred Generic	$2.00	$6.00	None
Timolol Maleate 6.8mg/mL 1 BOTTLE, DISPENSING per CARTON / 5 mL in 1 BOTTLE, DISPENSING	4	Non-Preferred Drug	50%	50%	None
tinidazole 250 mg tablet	3	Preferred Brand	$47.00	$141.00	None
tinidazole 500 mg tablet	3	Preferred Brand	$47.00	$141.00	None
TIVICAY 10 MG TABLET	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
TIVICAY 25 MG TABLET	5	Specialty Tier	33%	N/A	Q:30 /30Days
TIVICAY 50 MG TABLET	5	Specialty Tier	33%	N/A	Q:60 /30Days
Tizanidine 4mg/1 1000 TABLET BOTTLE	2	Generic	$5.00	$15.00	None
TIZANIDINE HCL 2 MG TABLET	2	Generic	$5.00	$15.00	None
TOBI PODHALER 28 MG INHALE CAP	5	Specialty Tier	33%	N/A	Q:224 /42Days
TOBRADEX ST 0.5; 3mg/mL; mg/mL 5 mL in 1 BOTTLE	4	Non-Preferred Drug	50%	50%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TOBRAMYCIN 10 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate]	4	Non-Preferred Drug	50%	50%	None
TOBRAMYCIN 300 MG/5 ML AMPULE [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate]	3	Preferred Brand	$47.00	$141.00	P Q:280 /56Days
TOBRAMYCIN 40MG/ML VIAL	4	Non-Preferred Drug	50%	50%	None
TOBRAMYCIN OPHTHALMIC SOLUTION 0.3% 5ML BOT	2	Generic	$5.00	$15.00	None
TOBRAMYCIN-DEXAMETH OPTH SUSP	4	Non-Preferred Drug	50%	50%	None
TOBREX 0.3% EYE OINTMENT	4	Non-Preferred Drug	50%	50%	None
TOLAZAMIDE TABLETS 250MG 100 BOT	3	Preferred Brand	$47.00	$141.00	None
TOLAZAMIDE TABLETS 500MG 100 BOT	3	Preferred Brand	$47.00	$141.00	None
TOLBUTAMIDE 500MG TABLET	2	Generic	$5.00	$15.00	None
TOLMETIN SODIUM 400 MG CAP	4	Non-Preferred Drug	50%	50%	None
TOLMETIN SODIUM 600MG TABLET	2	Generic	$5.00	$15.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Tolterodine Tartrate 1 MG Oral Tablet [Detrol LA]	4	Non-Preferred Drug	50%	50%	Q:60 /30Days
Tolterodine Tartrate 2 MG TABLET [Detrol LA]	4	Non-Preferred Drug	50%	50%	Q:60 /30Days
TOLVAPTAN 15 MG ORAL TABLET [SAMSCA]	5	Specialty Tier	33%	N/A	P Q:30 /30Days
TOLVAPTAN 30 MG ORAL TABLET [SAMSCA]	5	Specialty Tier	33%	N/A	P Q:60 /30Days
Topiramate 25mg/1	2	Generic	$5.00	$15.00	None
TOPIRAMATE SPRINKLE CAPSULES 15MG 60 BOT	2	Generic	$5.00	$15.00	None
TOPIRAMATE TABLETS 100MG 1000 BOT	2	Generic	$5.00	$15.00	None
TOPIRAMATE TABLETS 200MG 1000 BOT	2	Generic	$5.00	$15.00	None
TOPIRAMATE TABLETS 25MG 1000 BOT	2	Generic	$5.00	$15.00	None
TOPIRAMATE TABLETS 50MG 1000 BOT	2	Generic	$5.00	$15.00	None
TOPOSAR INJECTION 20MG/ML 50ML VIAL MD CRTN	3	Preferred Brand	$47.00	$141.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TOPOTECAN HCL 4 MG VIAL	5	Specialty Tier	33%	N/A	None
Torisel 1 KIT per CARTON	5	Specialty Tier	33%	N/A	None
TORSEMIDE 10 MG TABLET	2	Generic	$5.00	$15.00	None
Torsemide 100mg/1 12 BOTTLE CASE / 100 TABLET BOTTLE	2	Generic	$5.00	$15.00	None
TORSEMIDE 20mg 100 TABLET BOTTLE	2	Generic	$5.00	$15.00	None
TORSEMIDE 5 MG TABLET	2	Generic	$5.00	$15.00	None
TPN ELECTROLYTES16.5/25.4 VIAL	2	Generic	$5.00	$15.00	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	$47.00	$141.00	None
TRAMADOL HCL 50 MG TABLET	2	Generic	$5.00	$15.00	Q:240 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRAMADOL HCL-ACETAMINOPHEN 37.5-325MG TABLET (1000 CT)	3	Preferred Brand	$47.00	$141.00	Q:240 /30Days
TRANDOLAPRIL 1 MG TABLET	1	Preferred Generic	$2.00	$6.00	None
TRANDOLAPRIL 2 MG TABLET	1	Preferred Generic	$2.00	$6.00	None
TRANDOLAPRIL 4 MG TABLET	1	Preferred Generic	$2.00	$6.00	None
TRANDOLAPRIL-VERAPAMIL ER 1-240 MG	1	Preferred Generic	$2.00	$6.00	None
TRANDOLAPRIL-VERAPAMIL ER 2-180 MG	1	Preferred Generic	$2.00	$6.00	None
TRANDOLAPRIL-VERAPAMIL ER 2-240 MG	1	Preferred Generic	$2.00	$6.00	None
TRANDOLAPRIL-VERAPAMIL ER 4-240 MG	1	Preferred Generic	$2.00	$6.00	None
TRANEXAMIC ACID 1,000 MG/10 ML	2	Generic	$5.00	$15.00	None
tranexamic acid 650 mg tablet	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
TRANSDERM-SCOP 1.5 MG/3 DAY	4	Non-Preferred Drug	50%	50%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRANYLCYPROMINE SULFATE 10MG TABLET	4	Non-Preferred Drug	50%	50%	None
TRAVATAN Z 0.04MG DROPS 2.5ML BOT	4	Non-Preferred Drug	50%	50%	None
TRAZODONE 300MG TABLET	2	Generic	$5.00	$15.00	None
TRAZODONE HCL TABLET USP 100MG (500 CT)	2	Generic	$5.00	$15.00	None
TRAZODONE HCL TABLET USP 150MG (100 CT)	2	Generic	$5.00	$15.00	None
TRAZODONE HCL TABLET USP 50MG (500 CT)	2	Generic	$5.00	$15.00	None
TREANDA FOR INJECTION 100MG/VIAL	5	Specialty Tier	33%	N/A	None
TRECATOR 250MG TABLET	4	Non-Preferred Drug	50%	50%	None
TRELSTAR 11.25 MG SYRINGE	5	Specialty Tier	33%	N/A	P
TRELSTAR 3.75 MG SYRINGE	5	Specialty Tier	33%	N/A	P
TRESIBA FLEXTOUCH 100 UNITS/ML	3	Preferred Brand	$47.00	$141.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRESIBA FLEXTOUCH 200 UNITS/ML	3	Preferred Brand	$47.00	$141.00	None
Tretinoin 0.0005 MG/MG Topical Gel	4	Non-Preferred Drug	50%	50%	P
TRETINOIN 0.01% GEL	4	Non-Preferred Drug	50%	50%	P
TRETINOIN 0.025% CREAM	4	Non-Preferred Drug	50%	50%	P
TRETINOIN 0.05% CREAM	4	Non-Preferred Drug	50%	50%	P
TRETINOIN 0.1% CREAM	4	Non-Preferred Drug	50%	50%	P
Tretinoin 0.25mg/g 1 TUBE per CARTON / 45 g in 1 TUBE	4	Non-Preferred Drug	50%	50%	P
TRETINOIN 10MG CAPSULE	3	Preferred Brand	$47.00	$141.00	None
TRETINOIN GEL MICRO 0.04% PUMP	4	Non-Preferred Drug	50%	50%	P
TRETINOIN GEL MICRO 0.1% PUMP	4	Non-Preferred Drug	50%	50%	P
TRI PREVIFEM TABLETS	2	Generic	$5.00	$15.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRI-LEGEST FE 5-7-9-7 TABLET	2	Generic	$5.00	$15.00	None
TRI-LO-ESTARYLLA TABLET	2	Generic	$5.00	$15.00	None
TRI-LO-SPRINTEC TABLET	2	Generic	$5.00	$15.00	None
TRI-SPRINTEC 7DAYSX3 28 TABLET	2	Generic	$5.00	$15.00	None
TRIAMCINOLONE 0.1% OINTMENT	2	Generic	$5.00	$15.00	None
Triamcinolone 0.147 MG/G Spray	4	Non-Preferred Drug	50%	50%	None
Triamcinolone 55 mcg nasal spr	4	Non-Preferred Drug	50%	50%	None
TRIAMCINOLONE ACETONIDE 0.025% CREAM 80GM TUBE	2	Generic	$5.00	$15.00	None
TRIAMCINOLONE ACETONIDE 0.025% LOTION 2 FL OZ BOT	3	Preferred Brand	$47.00	$141.00	None
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE	2	Generic	$5.00	$15.00	None
TRIAMCINOLONE ACETONIDE 0.1% CREAM 80GM TUBE	2	Generic	$5.00	$15.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRIAMCINOLONE ACETONIDE 0.1% LOTION 60ML BOTPL	3	Preferred Brand	$47.00	$141.00	None
triamcinolone acetonide 0.25mg/g 80 g in 1 TUBE	2	Generic	$5.00	$15.00	None
Triamcinolone Acetonide 1mg/g 1 TUBE per CARTON / 5 g in 1 TUBE	4	Non-Preferred Drug	50%	50%	None
Triamcinolone Acetonide 5mg/g 1 TUBE per CARTON / 15 g in 1 TUBE	2	Generic	$5.00	$15.00	None
Triamterene and Hydrochlorothiazide 25; 37.5mg 100 CAPSULE BOTTLE	1	Preferred Generic	$2.00	$6.00	None
TRIAMTERENE-HCTZ 37.5-25 MG TB	1	Preferred Generic	$2.00	$6.00	None
TRIAMTERENE/HCTZ 50-25 MG CAP	1	Preferred Generic	$2.00	$6.00	None
TRIAMTERENE/HCTZ 75/50 TABLET	1	Preferred Generic	$2.00	$6.00	None
TRIDERM 0.1% CREAM	2	Generic	$5.00	$15.00	None
TRIFLUOPERAZINE 1MG TABLET	4	Non-Preferred Drug	50%	50%	None
TRIFLUOPERAZINE HCL 2MG TABLET	4	Non-Preferred Drug	50%	50%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRIFLUOPERAZINE HCL 5MG TABLET	4	Non-Preferred Drug	50%	50%	None
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT)	4	Non-Preferred Drug	50%	50%	None
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT	4	Non-Preferred Drug	50%	50%	None
Trihexyphenidyl 2 mg tablet	2	Generic	$5.00	$15.00	P
Trihexyphenidyl 5 mg tablet	2	Generic	$5.00	$15.00	P
Trihexyphenidyl Hydrochloride 2mg/5mL 473 mL in 1 BOTTLE	2	Generic	$5.00	$15.00	P
TRILYTE WITH FLAVOR PACKETS	2	Generic	$5.00	$15.00	None
TRIMETHOPRIM 100MG TABLETS	1	Preferred Generic	$2.00	$6.00	None
TRIMIPRAMINE MALEATE 100 MG CP	4	Non-Preferred Drug	50%	50%	P
TRIMIPRAMINE MALEATE 25 MG CAP	4	Non-Preferred Drug	50%	50%	P
TRIMIPRAMINE MALEATE 50 MG CAP	4	Non-Preferred Drug	50%	50%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRINESSA TABLET	2	Generic	$5.00	$15.00	None
TRINTELLIX 10 MG TABLET	4	Non-Preferred Drug	50%	50%	S Q:30 /30Days
TRINTELLIX 20 MG TABLET	4	Non-Preferred Drug	50%	50%	S Q:30 /30Days
TRINTELLIX 5 MG TABLET	4	Non-Preferred Drug	50%	50%	S Q:30 /30Days
Triptorelin 11.3 MG/ML Injectable Suspension [Trelstar]	5	Specialty Tier	33%	N/A	P
TRISENOX 10MG/10ML AMPULE	4	Non-Preferred Drug	50%	50%	P
TRIUMEQ TABLET	5	Specialty Tier	33%	N/A	Q:30 /30Days
Trivora-28 tablet	2	Generic	$5.00	$15.00	None
TRULICITY 0.75 MG/0.5 ML PEN	3	Preferred Brand	$47.00	$141.00	Q:2 /28Days
TRULICITY 1.5 MG/0.5 ML PEN	3	Preferred Brand	$47.00	$141.00	Q:2 /28Days
TRUMENBA 120 MCG/0.5 ML VACCINE	4	Non-Preferred Drug	50%	50%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRUVADA 100 MG-150 MG TABLET	5	Specialty Tier	33%	N/A	Q:30 /30Days
TRUVADA 133 MG-200 MG TABLET	5	Specialty Tier	33%	N/A	Q:30 /30Days
TRUVADA 167 MG-250 MG TABLET	5	Specialty Tier	33%	N/A	Q:30 /30Days
TRUVADA 200/300MG TABLET	5	Specialty Tier	33%	N/A	Q:30 /30Days
TWINRIX TF PF VACCINE 720UNT/20ML 10 X 1ML VIALSD	4	Non-Preferred Drug	50%	50%	None
TYBOST 150 MG TABLET	3	Preferred Brand	$47.00	$141.00	Q:30 /30Days
Tygacil 50mg/5mL 10 VIAL, SINGLE-USE per CARTON / 50 mL in 1 VIAL, SINGLE-USE	5	Specialty Tier	33%	N/A	None
TYKERB 250 MG TABLET	5	Specialty Tier	33%	N/A	P Q:180 /30Days
TYPHIM VI 25 MCG/0.5 ML SYRINGE	4	Non-Preferred Drug	50%	50%	None
TYPHIM VI 25MCG/0.5ML VIAL	4	Non-Preferred Drug	50%	50%	None
TYSABRI 300 MG/15 ML VIAL	5	Specialty Tier	33%	N/A	P Q:15 /28Days

Chart Legend:

Below are a few notes to help you understand the above 2017 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 $400 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 $3700) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2017 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 2017 )

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.