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2018 Medicare Part D Plan Formulary Information
HealthPartners Freedom Ultimate with Enhanced Rx (Cost) (H2462-012-0) Benefit Details
The HealthPartners Freedom Ultimate with Enhanced Rx (Cost) (H2462-012-0) Formulary Drugs Starting with the Letter T in Meeker County, MN: CMS MA Region 19 which includes: MN Plan Monthly Premium: $375.90 Deductible: $115
Drugs Starting with Letter T Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter T Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TABLOID 40 MG TABLET	3	Preferred Brand	$47.00	$94.00	None
TACLONEX SCALP SUSPENSION	5	Specialty Tier	29%	N/A	None
Tacrolimus 0.03% ointment	4	Non-Preferred Drug	50%	50%	None
Tacrolimus 0.1% ointment	4	Non-Preferred Drug	50%	50%	None
TACROLIMUS 0.5 MG CAPSULE	4	Non-Preferred Drug	50%	50%	P
TACROLIMUS 1 MG CAPSULE	4	Non-Preferred Drug	50%	50%	P
TACROLIMUS 5 MG CAPSULE	4	Non-Preferred Drug	50%	50%	P
TAFINLAR 50 MG CAPSULE	5	Specialty Tier	29%	N/A	P
TAFINLAR 75 MG CAPSULE	5	Specialty Tier	29%	N/A	P
TAGRISSO 40 MG TABLET	5	Specialty Tier	29%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TAGRISSO 80 MG TABLET	5	Specialty Tier	29%	N/A	P
TAMIFLU 6 MG/ML SUSPENSION	4	Non-Preferred Drug	50%	50%	None
TAMOXIFEN 10 MG TABLET	2	Generic	$14.00	$28.00	None
TAMOXIFEN CITRATE 20MG TABLET (30 CT)	2	Generic	$14.00	$28.00	None
TAMSULOSIN HCL 0.4 MG CAPSULE	2	Generic	$14.00	$28.00	None
TARCEVA 100MG TABLET	5	Specialty Tier	29%	N/A	None
TARCEVA 150MG TABLET	5	Specialty Tier	29%	N/A	None
TARCEVA 25MG TABLET	5	Specialty Tier	29%	N/A	None
TARGRETIN 1% GEL	5	Specialty Tier	29%	N/A	P
Tarina Fe 1-20 tablet	2	Generic	$14.00	$28.00	None
Tasigna 150mg/1 4 BLISTER PACK per CARTON / 28 CAPSULE per BLISTER PACK	5	Specialty Tier	29%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TASIGNA 200 MG CAPSULE	5	Specialty Tier	29%	N/A	None
TASIGNA 50 MG CAPSULE	5	Specialty Tier	29%	N/A	None
TAZAROTENE 0.1% CREAM [Tazorac]	4	Non-Preferred Drug	50%	50%	None
TAZORAC 0.05% CREAM	4	Non-Preferred Drug	50%	50%	None
TAZORAC 0.05% GEL	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
TAZORAC 0.1% CREAM	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
TAZORAC 0.1% GEL	4	Non-Preferred Drug	50%	50%	Q:30 /30Days
TAZTIA DILTIAZEM HYDROCHLORIDE 120MG ER CAPSULES	3	Preferred Brand	$47.00	$94.00	None
TAZTIA XT 180 MG CAPSULE	3	Preferred Brand	$47.00	$94.00	None
TAZTIA XT 240MG CAPSULE SA	3	Preferred Brand	$47.00	$94.00	None
TAZTIA XT 300 MG CAPSULE	3	Preferred Brand	$47.00	$94.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TAZTIA XT 360MG CAPSULE SA	3	Preferred Brand	$47.00	$94.00	None
TECENTRIQ 1,200 MG/20 ML VIAL	5	Specialty Tier	29%	N/A	P
TECFIDERA DR 120 MG CAPSULE	5	Specialty Tier	29%	N/A	Q:60 /30Days
TECFIDERA DR 240 MG CAPSULE	5	Specialty Tier	29%	N/A	Q:60 /30Days
TECFIDERA STARTER PACK	5	Specialty Tier	29%	N/A	Q:60 /30Days
TECHNIVIE DOSE PACK	5	Specialty Tier	29%	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	5	Specialty Tier	29%	N/A	None
TEKTURNA 150 MG TABLET	4	Non-Preferred Drug	50%	50%	None
TEKTURNA 300 MG TABLET	4	Non-Preferred Drug	50%	50%	None
TEMAZEPAM 15 MG CAPSULE	1	Preferred Generic	$5.00	$10.00	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TEMAZEPAM 30 MG CAPSULE	1	Preferred Generic	$5.00	$10.00	Q:30 /30Days
Tencon 50-325 MG TABLET	4	Non-Preferred Drug	50%	50%	Q:12 /1Days
TENIVAC SYRINGE	3	Preferred Brand	$47.00	$94.00	None
TENOFOVIR DISOP FUM 300 MG TB [Viread]	5	Specialty Tier	29%	N/A	None
TERAZOSIN 1 MG CAPSULE	1	Preferred Generic	$5.00	$10.00	None
TERAZOSIN 10 MG CAPSULE [Hytrin]	1	Preferred Generic	$5.00	$10.00	None
TERAZOSIN 2 MG CAPSULE	1	Preferred Generic	$5.00	$10.00	None
TERAZOSIN 5 MG CAPSULE [Hytrin]	1	Preferred Generic	$5.00	$10.00	None
TERBINAFINE HCL 250 MG TABLET	1	Preferred Generic	$5.00	$10.00	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
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TERCONAZOLE 0.4% CREAM WITH APPLICATOR	3	Preferred Brand	$47.00	$94.00	None
TERCONAZOLE 0.8% CREAM	3	Preferred Brand	$47.00	$94.00	None
TERCONAZOLE 80MG SUPPOSITORY VAGINAL	4	Non-Preferred Drug	50%	50%	None
TESTOSTERONE 10 MG GEL PUMP	3	Preferred Brand	$47.00	$94.00	P
TESTOSTERONE 12.5 MG/1.25 GRAM	3	Preferred Brand	$47.00	$94.00	P
Testosterone 2500 MG 0.01 MG/MG Topical Gel	3	Preferred Brand	$47.00	$94.00	P
Testosterone 5000 MG 0.01 MG/MG Topical Gel	3	Preferred Brand	$47.00	$94.00	P
Testosterone cyp 100 mg/ml	3	Preferred Brand	$47.00	$94.00	P
TESTOSTERONE CYP 200 MG/ML	3	Preferred Brand	$47.00	$94.00	P
TESTOSTERONE ENANTHATE 200MG/ML INJECTION	3	Preferred Brand	$47.00	$94.00	P
TETRABENAZINE 12.5 MG TABLET [XENAZINE]	5	Specialty Tier	29%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TETRABENAZINE 25 MG TABLET [XENAZINE]	5	Specialty Tier	29%	N/A	P
TETRACYCLINE 250 MG CAPSULE	4	Non-Preferred Drug	50%	50%	None
TETRACYCLINE 500 MG CAPSULE	4	Non-Preferred Drug	50%	50%	None
THALOMID 100 MG CAPSULE	5	Specialty Tier	29%	N/A	None
THALOMID 150 MG CAPSULE	5	Specialty Tier	29%	N/A	None
THALOMID 200 MG CAPSULE	5	Specialty Tier	29%	N/A	None
THALOMID 50 MG CAPSULE	5	Specialty Tier	29%	N/A	None
THEOPHYLLINE ER 100 MG TABLET	4	Non-Preferred Drug	50%	50%	None
THEOPHYLLINE ER 200 MG TABLET	4	Non-Preferred Drug	50%	50%	None
THEOPHYLLINE ER 300 MG TAB	4	Non-Preferred Drug	50%	50%	None
THEOPHYLLINE ER 400 MG TABLET	2	Generic	$14.00	$28.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
THEOPHYLLINE ER 600 MG TABLET	2	Generic	$14.00	$28.00	None
THIOLA 100 MG TABLET	5	Specialty Tier	29%	N/A	P
THIORIDAZINE 10 MG TABLET	4	Non-Preferred Drug	50%	50%	None
THIORIDAZINE 100MG TABLET	4	Non-Preferred Drug	50%	50%	None
THIORIDAZINE 25 MG TABLET	4	Non-Preferred Drug	50%	50%	None
THIORIDAZINE 50 MG TABLET	4	Non-Preferred Drug	50%	50%	None
THIOTEPA 15 MG VIAL	4	Non-Preferred Drug	50%	50%	P
THIOTHIXENE 1 MG CAPSULE	4	Non-Preferred Drug	50%	50%	None
THIOTHIXENE 10MG CAPSULE	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
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TIAGABINE HCL 12 MG TABLET [Gabitril]	4	Non-Preferred Drug	50%	50%	None
TIAGABINE HCL 16 MG TABLET [Gabitril]	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	29%	N/A	None
TIMOLOL 0.25% EYE DROPS	1	Preferred Generic	$5.00	$10.00	None
TIMOLOL 0.25% GFS GEL-SOLUTION	4	Non-Preferred Drug	50%	50%	None
TIMOLOL 0.5% EYE DROPS	1	Preferred Generic	$5.00	$10.00	None
TIMOLOL 0.5% EYE DROPS	1	Preferred Generic	$5.00	$10.00	None
TIMOLOL 0.5% GFS GEL-SOLUTION	4	Non-Preferred Drug	50%	50%	None
TIVICAY 10 MG 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
TIVICAY 25 MG TABLET	5	Specialty Tier	29%	N/A	None
TIVICAY 50 MG TABLET	5	Specialty Tier	29%	N/A	None
TIZANIDINE HCL 2 MG TABLET	2	Generic	$14.00	$28.00	None
TIZANIDINE HCL 4 MG TABLET	2	Generic	$14.00	$28.00	None
TOBI PODHALER 28 MG INHALE CAP	5	Specialty Tier	29%	N/A	P Q:224 /30Days
TOBRADEX EYE OINTMENT	3	Preferred Brand	$47.00	$94.00	None
TOBRAMYCIN 0.3% EYE DROPS [Tobrex]	2	Generic	$14.00	$28.00	None
TOBRAMYCIN 10 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate]	4	Non-Preferred Drug	50%	50%	P
TOBRAMYCIN 300 MG/5 ML AMPULE [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate]	5	Specialty Tier	29%	N/A	P Q:280 /30Days
TOBRAMYCIN 40 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate]	4	Non-Preferred Drug	50%	50%	P
TOBRAMYCIN-DEXAMETH OPTH SUSP	4	Non-Preferred Drug	50%	50%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TOBREX 0.3% EYE OINTMENT	3	Preferred Brand	$47.00	$94.00	None
TOLTERODINE TARTRATE 1 MG TAB [Detrol LA]	4	Non-Preferred Drug	50%	50%	None
TOLTERODINE TARTRATE 2 MG TAB [Detrol LA]	4	Non-Preferred Drug	50%	50%	None
Tolterodine Tartrate ER 2 MG CAPSULE [Detrol LA]	4	Non-Preferred Drug	50%	50%	None
TOPIRAMATE 100 MG TABLET	1	Preferred Generic	$5.00	$10.00	None
TOPIRAMATE 15 MG SPRINKLE CAP	4	Non-Preferred Drug	50%	50%	None
TOPIRAMATE 200 MG TABLET	1	Preferred Generic	$5.00	$10.00	None
TOPIRAMATE 25 MG TABLET	1	Preferred Generic	$5.00	$10.00	None
Topiramate 25mg/1	4	Non-Preferred Drug	50%	50%	None
TOPIRAMATE 50 MG TABLET	1	Preferred Generic	$5.00	$10.00	None
Topotecan 4 MG Injection	5	Specialty Tier	29%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Torisel 1 KIT per CARTON	5	Specialty Tier	29%	N/A	P
TORSEMIDE 10 MG TABLET	2	Generic	$14.00	$28.00	None
TORSEMIDE 100 MG TABLET	2	Generic	$14.00	$28.00	None
TORSEMIDE 20 MG TABLET	2	Generic	$14.00	$28.00	None
TORSEMIDE 5 MG TABLET	2	Generic	$14.00	$28.00	None
TRACLEER 125MG TABLET	5	Specialty Tier	29%	N/A	P
TRACLEER 32 MG TABLET FOR SUSP	5	Specialty Tier	29%	N/A	P
TRACLEER 62.5MG TABLET	5	Specialty Tier	29%	N/A	P
TRADJENTA 5 MG TABLET	3	Preferred Brand	$47.00	$94.00	None
TRAMADOL HCL 50 MG TABLET	1	Preferred Generic	$5.00	$10.00	Q:8 /1Days
TRANDOLAPRIL 1 MG TABLET	2	Generic	$14.00	$28.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRANDOLAPRIL 2 MG TABLET	2	Generic	$14.00	$28.00	None
TRANDOLAPRIL 4 MG TABLET	2	Generic	$14.00	$28.00	None
TRANEXAMIC ACID 1,000 MG/10 ML	4	Non-Preferred Drug	50%	50%	P
tranexamic acid 650 mg tablet	3	Preferred Brand	$47.00	$94.00	Q:30 /30Days
TRANSDERM-SCOP 1.5 MG/3 DAY	3	Preferred Brand	$47.00	$94.00	None
TRANYLCYPROMINE SULFATE 10MG TABLET	4	Non-Preferred Drug	50%	50%	None
TRAVATAN Z 0.04MG DROPS 2.5ML BOT	3	Preferred Brand	$47.00	$94.00	None
TRAZODONE 100 MG TABLET	1	Preferred Generic	$5.00	$10.00	None
TRAZODONE 300 MG TABLET	1	Preferred Generic	$5.00	$10.00	None
TRAZODONE 50 MG TABLET	1	Preferred Generic	$5.00	$10.00	None
TRAZODONE HCL TABLET USP 150MG (100 CT)	1	Preferred Generic	$5.00	$10.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TREANDA 25 MG VIAL	5	Specialty Tier	29%	N/A	P
TREANDA FOR INJECTION 100MG/VIAL	5	Specialty Tier	29%	N/A	P
TRECATOR 250MG TABLET	3	Preferred Brand	$47.00	$94.00	None
TRELEGY ELLIPTA 100-62.5-25	3	Preferred Brand	$47.00	$94.00	None
TRELSTAR 11.25 MG SYRINGE	5	Specialty Tier	29%	N/A	P
TRELSTAR 3.75 MG SYRINGE	5	Specialty Tier	29%	N/A	P
TREMFYA 100 MG/ML SYRINGE	5	Specialty Tier	29%	N/A	P
Tretinoin 0.0004 MG/MG Topical Gel	4	Non-Preferred Drug	50%	50%	P
Tretinoin 0.001 MG/MG Topical Gel	4	Non-Preferred Drug	50%	50%	P
TRETINOIN 0.01% GEL	4	Non-Preferred Drug	50%	50%	None
TRETINOIN 0.025% CREAM	4	Non-Preferred Drug	50%	50%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRETINOIN 0.025% GEL	4	Non-Preferred Drug	50%	50%	None
TRETINOIN 0.05% CREAM	4	Non-Preferred Drug	50%	50%	None
TRETINOIN 0.1% CREAM	4	Non-Preferred Drug	50%	50%	None
TRETINOIN 10MG CAPSULE	5	Specialty Tier	29%	N/A	None
TRI PREVIFEM TABLETS	2	Generic	$14.00	$28.00	None
TRI-LEGEST FE 5-7-9-7 TABLET	2	Generic	$14.00	$28.00	None
TRI-LO-ESTARYLLA TABLET [Trinessa Lo]	2	Generic	$14.00	$28.00	None
TRI-LO-SPRINTEC TABLET	2	Generic	$14.00	$28.00	None
TRI-MILI 28 TABLET [Trinessa]	2	Generic	$14.00	$28.00	None
TRI-SPRINTEC 7DAYSX3 28 TABLET	2	Generic	$14.00	$28.00	None
TRI-VYLIBRA 28 TABLET [Trinessa]	2	Generic	$14.00	$28.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRIAMCINOLONE 0.025% CREAM	1	Preferred Generic	$5.00	$10.00	None
TRIAMCINOLONE 0.025% LOTION	3	Preferred Brand	$47.00	$94.00	None
TRIAMCINOLONE 0.025% OINT	2	Generic	$14.00	$28.00	None
TRIAMCINOLONE 0.1% CREAM	1	Preferred Generic	$5.00	$10.00	None
TRIAMCINOLONE 0.1% LOTION [Kenalog]	3	Preferred Brand	$47.00	$94.00	None
TRIAMCINOLONE 0.1% OINTMENT	2	Generic	$14.00	$28.00	None
TRIAMCINOLONE 0.1% PASTE	4	Non-Preferred Drug	50%	50%	None
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE	2	Generic	$14.00	$28.00	None
Triamcinolone Acetonide 1 MG/ML Topical Cream [Triderm]	1	Preferred Generic	$5.00	$10.00	None
Triamcinolone Acetonide 5mg/g 1 TUBE per CARTON / 15 g in 1 TUBE	1	Preferred Generic	$5.00	$10.00	None
TRIAMTERENE-HCTZ 37.5-25 MG CP	1	Preferred Generic	$5.00	$10.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRIAMTERENE-HCTZ 37.5-25 MG TB	1	Preferred Generic	$5.00	$10.00	None
TRIAMTERENE-HCTZ 75-50 MG TAB	1	Preferred Generic	$5.00	$10.00	None
Trianex 0.05% Ointment	2	Generic	$14.00	$28.00	None
TRIDESILON 0.05% CREAM	4	Non-Preferred Drug	50%	50%	None
TRIENTINE HCL 250 MG CAPSULE [Syprine]	5	Specialty Tier	29%	N/A	P
TRIFLUOPERAZINE 1MG TABLET	3	Preferred Brand	$47.00	$94.00	None
TRIFLUOPERAZINE HCL 2MG TABLET	3	Preferred Brand	$47.00	$94.00	None
TRIFLUOPERAZINE HCL 5MG TABLET	3	Preferred Brand	$47.00	$94.00	None
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT)	3	Preferred Brand	$47.00	$94.00	None
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT	4	Non-Preferred Drug	50%	50%	None
TRIHEXYPHENIDYL 2 MG TABLET	2	Generic	$14.00	$28.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRIHEXYPHENIDYL 5 MG TABLET	2	Generic	$14.00	$28.00	None
Trihexyphenidyl Hydrochloride 2mg/5mL 473 mL in 1 BOTTLE	2	Generic	$14.00	$28.00	None
TRILYTE WITH FLAVOR PACKETS	2	Generic	$14.00	$28.00	None
TRIMETHOBENZAMIDE 300 MG CAP	4	Non-Preferred Drug	50%	50%	P
TRIMETHOPRIM 100 MG TABLET	2	Generic	$14.00	$28.00	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
TRINESSA TABLET	2	Generic	$14.00	$28.00	None
TRINTELLIX 10 MG TABLET	4	Non-Preferred Drug	50%	50%	P
TRINTELLIX 20 MG TABLET	4	Non-Preferred Drug	50%	50%	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 Drug	50%	50%	P
Triptorelin 11.3 MG/ML Injectable Suspension [Trelstar]	5	Specialty Tier	29%	N/A	P
TRISENOX 12 MG/6 ML VIAL	5	Specialty Tier	29%	N/A	P
TRIUMEQ TABLET	5	Specialty Tier	29%	N/A	None
Trivora-28 tablet	2	Generic	$14.00	$28.00	None
TROSPIUM CHLORIDE 20 MG TABLET	4	Non-Preferred Drug	50%	50%	None
TRULICITY 0.75 MG/0.5 ML PEN	3	Preferred Brand	$47.00	$94.00	Q:2 /28Days
TRULICITY 1.5 MG/0.5 ML PEN	3	Preferred Brand	$47.00	$94.00	Q:2 /28Days
TRUMENBA 120 MCG/0.5 ML VACCIN Syringe	3	Preferred Brand	$47.00	$94.00	None
TRUVADA 100 MG-150 MG TABLET	5	Specialty Tier	29%	N/A	None
TRUVADA 133 MG-200 MG TABLET	5	Specialty Tier	29%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRUVADA 167 MG-250 MG TABLET	5	Specialty Tier	29%	N/A	None
TRUVADA 200/300MG TABLET	5	Specialty Tier	29%	N/A	None
TWINRIX VACCINE SYRINGE	3	Preferred Brand	$47.00	$94.00	None
TYBOST 150 MG TABLET	3	Preferred Brand	$47.00	$94.00	None
TYKERB 250 MG TABLET	5	Specialty Tier	29%	N/A	None
TYMLOS 80 MCG DOSE PEN INJECTR	5	Specialty Tier	29%	N/A	P
TYPHIM VI 25 MCG/0.5 ML SYRINGE	3	Preferred Brand	$47.00	$94.00	None
TYPHIM VI 25MCG/0.5ML VIAL	3	Preferred Brand	$47.00	$94.00	None
TYSABRI 300 MG/15 ML VIAL	5	Specialty Tier	29%	N/A	P

Chart Legend:

Below are a few notes to help you understand the above 2018 Medicare Part D HealthPartners Freedom Ultimate with Enhanced Rx (Cost) 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). The plan name is followed by the plan type (PDP, HMO, HMO-POS, PPO, PFFS, etc.)
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 $405 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 five (5) tiers 1=Preferred Generics, 2=Generics, 3=Preferred Brands, 4=Non-preferred Brands, 5=Specialty Drugs. *Some Part D plans exclude one or more drug tiers from the deductible. If the drug tier field above is followed by * (example: 2*), then this drug tier is excluded from the plan’s deductible.
- Tier 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 $3750) at a "Preferred" network pharmacy. In most cases, the "Preferred" network network pharmacy cost-sharing is lower than the standard (non-preferred) network pharmacy cost-sharing.
- 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 2018 )

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.