2018 Medicare Part D Plan Formulary Information |
FHCP's Premier Plan (HMO) (H1035-010-0)
Benefit Details
|
The FHCP's Premier Plan (HMO) (H1035-010-0) Formulary Drugs Starting with the Letter T in Seminole County, FL: CMS MA Region 9 which includes: FL Plan Monthly Premium: $0.00 Deductible: $0 |
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 |
3 |
Preferred Brand |
$42.00 | N/A | None |
Tacrolimus 0.03% ointment |
2 |
Generic |
$7.00 | N/A | Q:30 /30Days |
Tacrolimus 0.1% ointment |
2 |
Generic |
$7.00 | N/A | Q:30 /30Days |
TACROLIMUS 0.5 MG CAPSULE |
2 |
Generic |
$7.00 | N/A | P |
TACROLIMUS 1 MG CAPSULE |
2 |
Generic |
$7.00 | N/A | P |
TACROLIMUS 5 MG CAPSULE |
2 |
Generic |
$7.00 | N/A | P |
TAFINLAR 50 MG CAPSULE |
6 |
Specialty Tier |
33% | N/A | P |
TAFINLAR 75 MG CAPSULE |
6 |
Specialty Tier |
33% | N/A | P |
TAGRISSO 40 MG TABLET |
6 |
Specialty Tier |
33% | N/A | P |
TAGRISSO 80 MG TABLET |
6 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAMOXIFEN 10 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
TAMOXIFEN CITRATE 20MG TABLET (30 CT) |
2 |
Generic |
$7.00 | N/A | None |
TAMSULOSIN HCL 0.4 MG CAPSULE |
2 |
Generic |
$7.00 | N/A | None |
TANZEUM 30 MG PEN INJECT |
3 |
Preferred Brand |
$42.00 | N/A | S |
TANZEUM 50 MG PEN INJECT |
3 |
Preferred Brand |
$42.00 | N/A | S |
TARCEVA 100MG TABLET |
6 |
Specialty Tier |
33% | N/A | None |
TARCEVA 150MG TABLET |
6 |
Specialty Tier |
33% | N/A | None |
TARCEVA 25MG TABLET |
6 |
Specialty Tier |
33% | N/A | None |
TARGRETIN 1% GEL |
6 |
Specialty Tier |
33% | N/A | Q:60 /30Days |
Tasigna 150mg/1 4 BLISTER PACK per CARTON / 28 CAPSULE per BLISTER PACK |
6 |
Specialty Tier |
33% | N/A | P |
TASIGNA 200 MG CAPSULE |
6 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TASIGNA 50 MG CAPSULE |
6 |
Specialty Tier |
33% | N/A | P |
TAZAROTENE 0.1% CREAM [Tazorac] |
4 |
Non-Preferred Brand |
$90.00 | N/A | P Q:30 /30Days |
TAZORAC 0.05% CREAM |
4 |
Non-Preferred Brand |
$90.00 | N/A | P Q:30 /30Days |
TAZORAC 0.05% GEL |
4 |
Non-Preferred Brand |
$90.00 | N/A | P Q:30 /30Days |
TAZORAC 0.1% GEL |
4 |
Non-Preferred Brand |
$90.00 | N/A | P Q:30 /30Days |
TECENTRIQ 1,200 MG/20 ML VIAL |
5 |
Injectable Drugs |
25% | N/A | P |
TECFIDERA DR 120 MG CAPSULE |
6 |
Specialty Tier |
33% | N/A | P |
TECFIDERA DR 240 MG CAPSULE |
6 |
Specialty Tier |
33% | N/A | P |
TECFIDERA STARTER PACK |
6 |
Specialty Tier |
33% | N/A | P |
Teflaro 400mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE |
5 |
Injectable Drugs |
25% | N/A | P |
Teflaro 600mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE |
5 |
Injectable Drugs |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TEKTURNA 150 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | N/A | S |
TEKTURNA 300 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | N/A | S |
Telmisartan 20 MG Tablet [Micardis] |
1 |
Preferred Generic |
$0.00 | N/A | None |
Telmisartan 40 MG Tablet [Micardis] |
1 |
Preferred Generic |
$0.00 | N/A | None |
Telmisartan 80 MG Tablet [Micardis] |
1 |
Preferred Generic |
$0.00 | N/A | None |
TEMAZEPAM 15 MG CAPSULE |
2 |
Generic |
$7.00 | N/A | None |
TEMAZEPAM 30 MG CAPSULE |
2 |
Generic |
$7.00 | N/A | None |
TENIVAC SYRINGE |
5 |
Injectable Drugs |
25% | N/A | P |
TENOFOVIR DISOP FUM 300 MG TB [Viread] |
2 |
Generic |
$7.00 | N/A | None |
TERAZOSIN 1 MG CAPSULE |
1 |
Preferred Generic |
$0.00 | N/A | None |
TERAZOSIN 10 MG CAPSULE [Hytrin] |
1 |
Preferred Generic |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TERAZOSIN 2 MG CAPSULE |
1 |
Preferred Generic |
$0.00 | N/A | None |
TERAZOSIN 5 MG CAPSULE [Hytrin] |
1 |
Preferred Generic |
$0.00 | N/A | None |
TERBINAFINE HCL 250 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
TERBUTALINE SULF 1MG/ML VL |
5 |
Injectable Drugs |
25% | N/A | None |
TERBUTALINE SULFATE 2.5 MG TAB |
2 |
Generic |
$7.00 | N/A | None |
TERBUTALINE SULFATE 5MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
TERCONAZOLE 0.4% CREAM WITH APPLICATOR |
2 |
Generic |
$7.00 | N/A | None |
TERCONAZOLE 0.8% CREAM |
2 |
Generic |
$7.00 | N/A | None |
TERCONAZOLE 80MG SUPPOSITORY VAGINAL |
2 |
Generic |
$7.00 | N/A | None |
Testosterone cyp 100 mg/ml |
2 |
Generic |
$7.00 | N/A | None |
TESTOSTERONE CYP 200 MG/ML |
2 |
Generic |
$7.00 | N/A | 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 |
$90.00 | N/A | None |
TETRABENAZINE 12.5 MG TABLET [XENAZINE] |
6 |
Specialty Tier |
33% | N/A | None |
TETRABENAZINE 25 MG TABLET [XENAZINE] |
6 |
Specialty Tier |
33% | N/A | None |
THALOMID 100 MG CAPSULE |
6 |
Specialty Tier |
33% | N/A | P |
THALOMID 150 MG CAPSULE |
6 |
Specialty Tier |
33% | N/A | P |
THALOMID 200 MG CAPSULE |
6 |
Specialty Tier |
33% | N/A | P |
THALOMID 50 MG CAPSULE |
6 |
Specialty Tier |
33% | N/A | P |
THEOPHYLLINE 80 MG/15 ML SOLN |
2 |
Generic |
$7.00 | N/A | None |
THEOPHYLLINE ER 400 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
THEOPHYLLINE ER 600 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
THIORIDAZINE 10 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THIORIDAZINE 100MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
THIORIDAZINE 25 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
THIORIDAZINE 50 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
THIOTEPA 15 MG VIAL |
6 |
Specialty Tier |
33% | N/A | P |
THIOTHIXENE 1 MG CAPSULE |
2 |
Generic |
$7.00 | N/A | None |
THIOTHIXENE 10MG CAPSULE |
2 |
Generic |
$7.00 | N/A | None |
THIOTHIXENE 2MG CAPSULE |
2 |
Generic |
$7.00 | N/A | None |
THIOTHIXENE 5MG CAPSULE |
2 |
Generic |
$7.00 | N/A | None |
TIAGABINE HCL 12 MG TABLET [Gabitril] |
2 |
Generic |
$7.00 | N/A | None |
TIAGABINE HCL 16 MG TABLET [Gabitril] |
2 |
Generic |
$7.00 | N/A | None |
tiagabine hcl 2 mg tablet [Gabitril] |
2 |
Generic |
$7.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
tiagabine hcl 4 mg tablet [Gabitril] |
2 |
Generic |
$7.00 | N/A | None |
TIGAN 100 MG/ML VIAL |
5 |
Injectable Drugs |
25% | N/A | None |
TIGECYCLINE 50 MG VIAL [Tygacil] |
5 |
Injectable Drugs |
25% | N/A | P |
TIMOLOL 0.25% EYE DROPS |
1 |
Preferred Generic |
$0.00 | N/A | None |
TIMOLOL 0.5% EYE DROPS |
1 |
Preferred Generic |
$0.00 | N/A | None |
TIVICAY 10 MG TABLET |
3 |
Preferred Brand |
$42.00 | N/A | None |
TIVICAY 25 MG TABLET |
3 |
Preferred Brand |
$42.00 | N/A | None |
TIVICAY 50 MG TABLET |
3 |
Preferred Brand |
$42.00 | N/A | None |
TIZANIDINE HCL 2 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
TIZANIDINE HCL 4 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
TOBI PODHALER 28 MG INHALE CAP |
6 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOBRADEX EYE OINTMENT |
3 |
Preferred Brand |
$42.00 | N/A | None |
TOBRAMYCIN 0.3% EYE DROPS [Tobrex] |
2 |
Generic |
$7.00 | N/A | None |
TOBRAMYCIN 10 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate] |
5 |
Injectable Drugs |
25% | N/A | None |
TOBRAMYCIN 300 MG/5 ML AMPULE [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate] |
6 |
Specialty Tier |
33% | N/A | P |
TOBRAMYCIN 40 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate] |
5 |
Injectable Drugs |
25% | N/A | None |
TOBRAMYCIN-DEXAMETH OPTH SUSP |
2 |
Generic |
$7.00 | N/A | None |
TOBREX 0.3% EYE OINTMENT |
3 |
Preferred Brand |
$42.00 | N/A | None |
TOLAZAMIDE TABLETS 250MG 100 BOT |
2 |
Generic |
$7.00 | N/A | None |
TOLAZAMIDE TABLETS 500MG 100 BOT |
2 |
Generic |
$7.00 | N/A | None |
TOLBUTAMIDE 500 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
Tolcapone 100 MG TABLET [Tasmar] |
6 |
Specialty Tier |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOPIRAMATE 100 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
TOPIRAMATE 15 MG SPRINKLE CAP |
2 |
Generic |
$7.00 | N/A | None |
TOPIRAMATE 200 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
TOPIRAMATE 25 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
Topiramate 25mg/1 |
2 |
Generic |
$7.00 | N/A | None |
TOPIRAMATE 50 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
Topotecan 4 MG Injection |
5 |
Injectable Drugs |
25% | N/A | P |
TOVIAZ TABLETS 4MG EXTENDED RELEASE |
3 |
Preferred Brand |
$42.00 | N/A | None |
TOVIAZ TABLETS 8MG EXTENDED RELEASE |
3 |
Preferred Brand |
$42.00 | N/A | None |
TPN ELECTROLYTES16.5/25.4 VIAL |
5 |
Injectable Drugs |
25% | N/A | None |
TRACLEER 125MG TABLET |
6 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRACLEER 32 MG TABLET FOR SUSP |
6 |
Specialty Tier |
33% | N/A | P |
TRACLEER 62.5MG TABLET |
6 |
Specialty Tier |
33% | N/A | P |
TRADJENTA 5 MG TABLET |
3 |
Preferred Brand |
$42.00 | N/A | S |
TRAMADOL HCL 50 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
TRANEXAMIC ACID 1,000 MG/10 ML |
5 |
Injectable Drugs |
25% | N/A | P |
tranexamic acid 650 mg tablet |
2 |
Generic |
$7.00 | N/A | None |
TRANSDERM-SCOP 1.5 MG/3 DAY |
4 |
Non-Preferred Brand |
$90.00 | N/A | P |
TRANYLCYPROMINE SULFATE 10MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
TRAVASOL 10% SOLUTION VIAFLEX |
5 |
Injectable Drugs |
25% | N/A | P |
TRAVATAN Z 0.04MG DROPS 2.5ML BOT |
3 |
Preferred Brand |
$42.00 | N/A | None |
TRAZODONE 100 MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRAZODONE 50 MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
TRAZODONE HCL TABLET USP 150MG (100 CT) |
1 |
Preferred Generic |
$0.00 | N/A | None |
TREANDA 25 MG VIAL |
5 |
Injectable Drugs |
25% | N/A | P |
TREANDA FOR INJECTION 100MG/VIAL |
5 |
Injectable Drugs |
25% | N/A | P |
TRECATOR 250MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | N/A | None |
TRELEGY ELLIPTA 100-62.5-25 |
3 |
Preferred Brand |
$42.00 | N/A | S |
TRELSTAR 11.25 MG SYRINGE |
5 |
Injectable Drugs |
25% | N/A | None |
TRELSTAR 3.75 MG SYRINGE |
5 |
Injectable Drugs |
25% | N/A | None |
TRESIBA FLEXTOUCH 100 UNITS/ML |
3 |
Preferred Brand |
$42.00 | N/A | None |
TRESIBA FLEXTOUCH 200 UNITS/ML |
3 |
Preferred Brand |
$42.00 | N/A | None |
TRETINOIN 0.01% GEL |
2 |
Generic |
$7.00 | N/A | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRETINOIN 0.025% CREAM |
2 |
Generic |
$7.00 | N/A | P Q:30 /30Days |
TRETINOIN 0.025% GEL |
2 |
Generic |
$7.00 | N/A | P Q:30 /30Days |
TRETINOIN 0.05% CREAM |
2 |
Generic |
$7.00 | N/A | P Q:30 /30Days |
TRETINOIN 0.1% CREAM |
2 |
Generic |
$7.00 | N/A | P Q:30 /30Days |
TRETINOIN 10MG CAPSULE |
6 |
Specialty Tier |
33% | N/A | P |
TRIAMCINOLONE 0.025% CREAM |
2 |
Generic |
$7.00 | N/A | Q:120 /30Days |
TRIAMCINOLONE 0.025% LOTION |
2 |
Generic |
$7.00 | N/A | Q:60 /30Days |
TRIAMCINOLONE 0.025% OINT |
2 |
Generic |
$7.00 | N/A | Q:120 /30Days |
TRIAMCINOLONE 0.1% CREAM |
2 |
Generic |
$7.00 | N/A | None |
TRIAMCINOLONE 0.1% LOTION [Kenalog] |
2 |
Generic |
$7.00 | N/A | Q:60 /30Days |
TRIAMCINOLONE 0.1% OINTMENT |
2 |
Generic |
$7.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIAMCINOLONE 0.1% PASTE |
2 |
Generic |
$7.00 | N/A | None |
TRIAMCINOLONE 200 MG/5 ML VIAL [Triesence] |
5 |
Injectable Drugs |
25% | N/A | None |
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE |
2 |
Generic |
$7.00 | N/A | Q:120 /30Days |
Triamcinolone Acetonide 5mg/g 1 TUBE per CARTON / 15 g in 1 TUBE |
2 |
Generic |
$7.00 | N/A | Q:120 /30Days |
TRIAMTERENE-HCTZ 37.5-25 MG CP |
2 |
Generic |
$7.00 | N/A | None |
TRIAMTERENE-HCTZ 37.5-25 MG TB |
1 |
Preferred Generic |
$0.00 | N/A | None |
TRIAMTERENE-HCTZ 75-50 MG TAB |
1 |
Preferred Generic |
$0.00 | N/A | None |
TRIFLUOPERAZINE 1MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
TRIFLUOPERAZINE HCL 2MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
TRIFLUOPERAZINE HCL 5MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT) |
2 |
Generic |
$7.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT |
2 |
Generic |
$7.00 | N/A | None |
TRIHEXYPHENIDYL 2 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
TRIHEXYPHENIDYL 5 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
Trihexyphenidyl Hydrochloride 2mg/5mL 473 mL in 1 BOTTLE |
2 |
Generic |
$7.00 | N/A | None |
TRIMETHOBENZAMIDE 300 MG CAP |
2 |
Generic |
$7.00 | N/A | None |
TRIMETHOPRIM 100 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
TRIMIPRAMINE MALEATE 100 MG CP |
2 |
Generic |
$7.00 | N/A | None |
TRIMIPRAMINE MALEATE 25 MG CAP |
2 |
Generic |
$7.00 | N/A | None |
TRIMIPRAMINE MALEATE 50 MG CAP |
2 |
Generic |
$7.00 | N/A | None |
TRINTELLIX 10 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | N/A | P |
TRINTELLIX 20 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRINTELLIX 5 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | N/A | P |
Triptorelin 11.3 MG/ML Injectable Suspension [Trelstar] |
5 |
Injectable Drugs |
25% | N/A | None |
TRISENOX 12 MG/6 ML VIAL |
5 |
Injectable Drugs |
25% | N/A | P |
TRIUMEQ TABLET |
3 |
Preferred Brand |
$42.00 | N/A | None |
TRUMENBA 120 MCG/0.5 ML VACCIN Syringe |
5 |
Injectable Drugs |
25% | N/A | None |
TRUVADA 100 MG-150 MG TABLET |
3 |
Preferred Brand |
$42.00 | N/A | None |
TRUVADA 133 MG-200 MG TABLET |
3 |
Preferred Brand |
$42.00 | N/A | None |
TRUVADA 167 MG-250 MG TABLET |
3 |
Preferred Brand |
$42.00 | N/A | None |
TRUVADA 200/300MG TABLET |
3 |
Preferred Brand |
$42.00 | N/A | None |
TWINRIX VACCINE SYRINGE |
5 |
Injectable Drugs |
25% | N/A | None |
TYBOST 150 MG TABLET |
3 |
Preferred Brand |
$42.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TYKERB 250 MG TABLET |
6 |
Specialty Tier |
33% | N/A | P |
TYPHIM VI 25 MCG/0.5 ML SYRINGE |
5 |
Injectable Drugs |
25% | N/A | None |
TYPHIM VI 25MCG/0.5ML VIAL |
5 |
Injectable Drugs |
25% | N/A | None |
TYSABRI 300 MG/15 ML VIAL |
5 |
Injectable Drugs |
25% | N/A | P |