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2018 Medicare Part D Plan Formulary Information
UPMC for Life PPO High Deductible with Rx (PPO) (H5533-003-0) Benefit Details
The UPMC for Life PPO High Deductible with Rx (PPO) (H5533-003-0) Formulary Drugs Starting with the Letter T in Armstrong County, PA: CMS MA Region 6 which includes: PA Plan Monthly Premium: $35.00 Deductible: $0
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	$95.00	N/A	P
Tacrolimus 0.03% ointment	3	Preferred Brand	$42.00	N/A	P
Tacrolimus 0.1% ointment	3	Preferred Brand	$42.00	N/A	P
TACROLIMUS 0.5 MG CAPSULE	2	Generic	$10.00	N/A	P
TACROLIMUS 1 MG CAPSULE	2	Generic	$10.00	N/A	P
TACROLIMUS 5 MG CAPSULE	4	Non-Preferred Drug	$95.00	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
TAGRISSO 40 MG TABLET	5	Specialty Tier	33%	N/A	P
TAGRISSO 80 MG TABLET	5	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	$10.00	N/A	None
TAMOXIFEN CITRATE 20MG TABLET (30 CT)	2	Generic	$10.00	N/A	None
TAMSULOSIN HCL 0.4 MG CAPSULE	2	Generic	$10.00	N/A	None
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 1% GEL	5	Specialty Tier	33%	N/A	None
Tarina Fe 1-20 tablet	2	Generic	$10.00	N/A	None
Tasigna 150mg/1 4 BLISTER PACK per CARTON / 28 CAPSULE per BLISTER PACK	5	Specialty Tier	33%	N/A	P
TASIGNA 200 MG CAPSULE	5	Specialty Tier	33%	N/A	P
TASIGNA 50 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
TAZAROTENE 0.1% CREAM [Tazorac]	4	Non-Preferred Drug	$95.00	N/A	P
TAZORAC 0.05% CREAM	4	Non-Preferred Drug	$95.00	N/A	P
TAZORAC 0.05% GEL	4	Non-Preferred Drug	$95.00	N/A	P
TAZORAC 0.1% CREAM	4	Non-Preferred Drug	$95.00	N/A	P
TAZORAC 0.1% GEL	4	Non-Preferred Drug	$95.00	N/A	P
TAZTIA DILTIAZEM HYDROCHLORIDE 120MG ER CAPSULES	2	Generic	$10.00	N/A	None
TAZTIA XT 180 MG CAPSULE	2	Generic	$10.00	N/A	None
TAZTIA XT 240MG CAPSULE SA	2	Generic	$10.00	N/A	None
TAZTIA XT 300 MG CAPSULE	2	Generic	$10.00	N/A	None
TAZTIA XT 360MG CAPSULE SA	4	Non-Preferred Drug	$95.00	N/A	None
TECENTRIQ 1,200 MG/20 ML VIAL	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 DR 120 MG CAPSULE	5	Specialty Tier	33%	N/A	P Q:60 /30Days
TECFIDERA DR 240 MG CAPSULE	5	Specialty Tier	33%	N/A	P Q:60 /30Days
TECFIDERA STARTER PACK	5	Specialty Tier	33%	N/A	P Q:120 /365Days
Teflaro 400mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE	5	Specialty Tier	33%	N/A	None
Teflaro 600mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE	5	Specialty Tier	33%	N/A	None
TEKTURNA 150 MG TABLET	3	Preferred Brand	$42.00	N/A	S
TEKTURNA 300 MG TABLET	3	Preferred Brand	$42.00	N/A	S
TEKTURNA HCT 300-25 MG TABLET	3	Preferred Brand	$42.00	N/A	S
Telmisartan 20 MG Tablet [Micardis]	2	Generic	$10.00	N/A	None
Telmisartan 40 MG Tablet [Micardis]	2	Generic	$10.00	N/A	None
Telmisartan 80 MG Tablet [Micardis]	2	Generic	$10.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Telmisartan-Amlodipine 40-10 MG [Micardis]	4	Non-Preferred Drug	$95.00	N/A	None
Telmisartan-Amlodipine 40-5 MG [Micardis]	4	Non-Preferred Drug	$95.00	N/A	None
Telmisartan-Amlodipine 80-10 MG [Micardis]	4	Non-Preferred Drug	$95.00	N/A	None
Telmisartan-Amlodipine 80-5 MG [Micardis]	4	Non-Preferred Drug	$95.00	N/A	None
TELMISARTAN-HCTZ 40-12.5 MG TB [Micardis]	4	Non-Preferred Drug	$95.00	N/A	None
TELMISARTAN-HCTZ 80-12.5 MG TAB [Micardis HCT]	4	Non-Preferred Drug	$95.00	N/A	None
TELMISARTAN-HCTZ 80-25 MG TAB [Micardis HCT]	4	Non-Preferred Drug	$95.00	N/A	None
TEMAZEPAM 15 MG CAPSULE	2	Generic	$10.00	N/A	None
TEMAZEPAM 30 MG CAPSULE	2	Generic	$10.00	N/A	None
TENIVAC SYRINGE	3	Preferred Brand	$42.00	N/A	None
TENOFOVIR DISOP FUM 300 MG TB [Viread]	5	Specialty Tier	33%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TERAZOSIN 1 MG CAPSULE	2	Generic	$10.00	N/A	None
TERAZOSIN 10 MG CAPSULE [Hytrin]	2	Generic	$10.00	N/A	None
TERAZOSIN 2 MG CAPSULE	2	Generic	$10.00	N/A	None
TERAZOSIN 5 MG CAPSULE [Hytrin]	2	Generic	$10.00	N/A	None
TERBINAFINE HCL 250 MG TABLET	2	Generic	$10.00	N/A	None
TERBUTALINE SULF 1MG/ML VL	4	Non-Preferred Drug	$95.00	N/A	None
TERBUTALINE SULFATE 2.5 MG TAB	4	Non-Preferred Drug	$95.00	N/A	None
TERBUTALINE SULFATE 5MG TABLET	4	Non-Preferred Drug	$95.00	N/A	None
TERCONAZOLE 0.4% CREAM WITH APPLICATOR	2	Generic	$10.00	N/A	None
TERCONAZOLE 0.8% CREAM	2	Generic	$10.00	N/A	None
TERCONAZOLE 80MG SUPPOSITORY VAGINAL	4	Non-Preferred Drug	$95.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TESTIM 1%(50MG) GEL	4	Non-Preferred Drug	$95.00	N/A	P
TESTOSTERONE 12.5 MG/1.25 GRAM	4	Non-Preferred Drug	$95.00	N/A	P
Testosterone 2500 MG 0.01 MG/MG Topical Gel	4	Non-Preferred Drug	$95.00	N/A	P
Testosterone 5000 MG 0.01 MG/MG Topical Gel	4	Non-Preferred Drug	$95.00	N/A	P
Testosterone cyp 100 mg/ml	2	Generic	$10.00	N/A	P
TESTOSTERONE CYP 200 MG/ML	2	Generic	$10.00	N/A	P
TESTOSTERONE ENANTHATE 200MG/ML INJECTION	2	Generic	$10.00	N/A	P
TETRABENAZINE 12.5 MG TABLET [XENAZINE]	5	Specialty Tier	33%	N/A	P Q:240 /30Days
TETRABENAZINE 25 MG TABLET [XENAZINE]	5	Specialty Tier	33%	N/A	P Q:120 /30Days
TETRACYCLINE 250 MG CAPSULE	4	Non-Preferred Drug	$95.00	N/A	None
TETRACYCLINE 500 MG CAPSULE	4	Non-Preferred Drug	$95.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
THALOMID 100 MG CAPSULE	5	Specialty Tier	33%	N/A	P
THALOMID 150 MG CAPSULE	5	Specialty Tier	33%	N/A	P
THALOMID 200 MG CAPSULE	5	Specialty Tier	33%	N/A	P
THALOMID 50 MG CAPSULE	5	Specialty Tier	33%	N/A	P
THEOPHYLLINE 80 MG/15 ML SOLN	4	Non-Preferred Drug	$95.00	N/A	None
THEOPHYLLINE ER 100 MG TABLET	2	Generic	$10.00	N/A	None
THEOPHYLLINE ER 200 MG TABLET	2	Generic	$10.00	N/A	None
THEOPHYLLINE ER 300 MG TAB	2	Generic	$10.00	N/A	None
THEOPHYLLINE ER 400 MG TABLET	2	Generic	$10.00	N/A	None
THEOPHYLLINE ER 600 MG TABLET	2	Generic	$10.00	N/A	None
THIOLA 100 MG TABLET	5	Specialty Tier	33%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
THIORIDAZINE 10 MG TABLET	2	Generic	$10.00	N/A	None
THIORIDAZINE 100MG TABLET	2	Generic	$10.00	N/A	None
THIORIDAZINE 25 MG TABLET	2	Generic	$10.00	N/A	None
THIORIDAZINE 50 MG TABLET	2	Generic	$10.00	N/A	None
THIOTEPA 15 MG VIAL	5	Specialty Tier	33%	N/A	P
THIOTHIXENE 1 MG CAPSULE	2	Generic	$10.00	N/A	None
THIOTHIXENE 10MG CAPSULE	2	Generic	$10.00	N/A	None
THIOTHIXENE 2MG CAPSULE	2	Generic	$10.00	N/A	None
THIOTHIXENE 5MG CAPSULE	2	Generic	$10.00	N/A	None
THYMOGLOBULIN 25MG VIAL	5	Specialty Tier	33%	N/A	P
TIAGABINE HCL 12 MG TABLET [Gabitril]	4	Non-Preferred Drug	$95.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TIAGABINE HCL 16 MG TABLET [Gabitril]	4	Non-Preferred Drug	$95.00	N/A	None
tiagabine hcl 2 mg tablet [Gabitril]	4	Non-Preferred Drug	$95.00	N/A	None
tiagabine hcl 4 mg tablet [Gabitril]	4	Non-Preferred Drug	$95.00	N/A	None
TIGECYCLINE 50 MG VIAL [Tygacil]	5	Specialty Tier	33%	N/A	None
TIMOLOL 0.25% EYE DROPS	2	Generic	$10.00	N/A	None
TIMOLOL 0.25% GFS GEL-SOLUTION	4	Non-Preferred Drug	$95.00	N/A	None
TIMOLOL 0.5% EYE DROPS	2	Generic	$10.00	N/A	None
TIMOLOL 0.5% GFS GEL-SOLUTION	4	Non-Preferred Drug	$95.00	N/A	None
TIMOLOL MALEATE 10MG TABLET	4	Non-Preferred Drug	$95.00	N/A	None
TIMOLOL MALEATE 20MG TABLET	4	Non-Preferred Drug	$95.00	N/A	None
TIMOLOL MALEATE 5MG TABLET	4	Non-Preferred Drug	$95.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TINIDAZOLE 250 MG TABLET	4	Non-Preferred Drug	$95.00	N/A	None
TINIDAZOLE 500 MG TABLET	4	Non-Preferred Drug	$95.00	N/A	None
TIVICAY 10 MG TABLET	4	Non-Preferred Drug	$95.00	N/A	None
TIVICAY 25 MG TABLET	5	Specialty Tier	33%	N/A	None
TIVICAY 50 MG TABLET	5	Specialty Tier	33%	N/A	None
TIZANIDINE HCL 2 MG TABLET	2	Generic	$10.00	N/A	None
TIZANIDINE HCL 4 MG TABLET	2	Generic	$10.00	N/A	None
TOBI PODHALER 28 MG INHALE CAP	5	Specialty Tier	33%	N/A	Q:224 /56Days
TOBRADEX EYE OINTMENT	4	Non-Preferred Drug	$95.00	N/A	None
TOBRAMYCIN 0.3% EYE DROPS [Tobrex]	2	Generic	$10.00	N/A	None
TOBRAMYCIN 10 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate]	4	Non-Preferred Drug	$95.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TOBRAMYCIN 300 MG/5 ML AMPULE [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate]	5	Specialty Tier	33%	N/A	P Q:280 /56Days
TOBRAMYCIN 40 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate]	4	Non-Preferred Drug	$95.00	N/A	None
TOBRAMYCIN-DEXAMETH OPTH SUSP	4	Non-Preferred Drug	$95.00	N/A	None
TOBREX 0.3% EYE OINTMENT	4	Non-Preferred Drug	$95.00	N/A	None
TOLAZAMIDE TABLETS 250MG 100 BOT	2	Generic	$10.00	N/A	Q:120 /30Days
TOLAZAMIDE TABLETS 500MG 100 BOT	2	Generic	$10.00	N/A	Q:60 /30Days
TOLBUTAMIDE 500 MG TABLET	2	Generic	$10.00	N/A	Q:180 /30Days
TOLMETIN SODIUM 400 MG CAP	4	Non-Preferred Drug	$95.00	N/A	None
TOLMETIN SODIUM 600MG TABLET	4	Non-Preferred Drug	$95.00	N/A	None
TOLTERODINE TARTRATE 1 MG TAB [Detrol LA]	2	Generic	$10.00	N/A	None
TOLTERODINE TARTRATE 2 MG TAB [Detrol LA]	2	Generic	$10.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Tolterodine Tartrate ER 2 MG CAPSULE [Detrol LA]	2	Generic	$10.00	N/A	None
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 100 MG TABLET	2	Generic	$10.00	N/A	None
TOPIRAMATE 15 MG SPRINKLE CAP	4	Non-Preferred Drug	$95.00	N/A	None
TOPIRAMATE 200 MG TABLET	2	Generic	$10.00	N/A	None
TOPIRAMATE 25 MG TABLET	2	Generic	$10.00	N/A	None
Topiramate 25mg/1	4	Non-Preferred Drug	$95.00	N/A	None
TOPIRAMATE 50 MG TABLET	2	Generic	$10.00	N/A	None
TOPOSAR INJECTION 20MG/ML 50ML VIAL MD CRTN	2	Generic	$10.00	N/A	P
Topotecan 4 MG Injection	5	Specialty Tier	33%	N/A	P
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	33%	N/A	P
TORSEMIDE 10 MG TABLET	2	Generic	$10.00	N/A	None
TORSEMIDE 100 MG TABLET	2	Generic	$10.00	N/A	None
TORSEMIDE 20 MG TABLET	2	Generic	$10.00	N/A	None
TORSEMIDE 5 MG TABLET	2	Generic	$10.00	N/A	None
TOUJEO MAX SOLOSTAR 300UNIT/ML INSULN PEN	3	Preferred Brand	$42.00	N/A	Q:18 /30Days
TOUJEO SOLOSTAR 300 UNITS/ML	3	Preferred Brand	$42.00	N/A	Q:9 /30Days
TPN ELECTROLYTES16.5/25.4 VIAL	4	Non-Preferred Drug	$95.00	N/A	None
TRACLEER 125MG TABLET	5	Specialty Tier	33%	N/A	P Q:60 /30Days
TRACLEER 32 MG TABLET FOR SUSP	5	Specialty Tier	33%	N/A	P Q:120 /30Days
TRACLEER 62.5MG TABLET	5	Specialty Tier	33%	N/A	P Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRADJENTA 5 MG TABLET	3	Preferred Brand	$42.00	N/A	Q:30 /30Days
TRAMADOL HCL 50 MG TABLET	2	Generic	$10.00	N/A	Q:240 /30Days
TRAMADOL-ACETAMINOPHN 37.5-325	2	Generic	$10.00	N/A	Q:40 /5Days
TRANDOLAPRIL 1 MG TABLET	1	Preferred Generic	$0.00	N/A	None
TRANDOLAPRIL 2 MG TABLET	1	Preferred Generic	$0.00	N/A	None
TRANDOLAPRIL 4 MG TABLET	1	Preferred Generic	$0.00	N/A	None
TRANEXAMIC ACID 1,000 MG/10 ML	2	Generic	$10.00	N/A	None
tranexamic acid 650 mg tablet	4	Non-Preferred Drug	$95.00	N/A	Q:30 /28Days
TRANYLCYPROMINE SULFATE 10MG TABLET	4	Non-Preferred Drug	$95.00	N/A	None
TRAVASOL 10% SOLUTION VIAFLEX	4	Non-Preferred Drug	$95.00	N/A	P
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 300 MG TABLET	4	Non-Preferred Drug	$95.00	N/A	None
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	Specialty Tier	33%	N/A	P
TREANDA FOR INJECTION 100MG/VIAL	5	Specialty Tier	33%	N/A	P
TRECATOR 250MG TABLET	4	Non-Preferred Drug	$95.00	N/A	None
TRELEGY ELLIPTA 100-62.5-25	3	Preferred Brand	$42.00	N/A	None
TRELSTAR 11.25 MG SYRINGE	5	Specialty Tier	33%	N/A	P Q:1 /84Days
TRELSTAR 3.75 MG SYRINGE	5	Specialty Tier	33%	N/A	P Q:1 /28Days
TREMFYA 100 MG/ML SYRINGE	5	Specialty Tier	33%	N/A	P Q:2 /28Days
TRESIBA FLEXTOUCH 100 UNITS/ML	3	Preferred Brand	$42.00	N/A	Q:45 /30Days
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	$42.00	N/A	Q:27 /30Days
TRETINOIN 0.01% GEL	4	Non-Preferred Drug	$95.00	N/A	P
TRETINOIN 0.025% CREAM	4	Non-Preferred Drug	$95.00	N/A	P
TRETINOIN 0.025% GEL	4	Non-Preferred Drug	$95.00	N/A	P
TRETINOIN 0.05% CREAM	4	Non-Preferred Drug	$95.00	N/A	P
TRETINOIN 0.1% CREAM	4	Non-Preferred Drug	$95.00	N/A	P
TRETINOIN 10MG CAPSULE	5	Specialty Tier	33%	N/A	None
TRI PREVIFEM TABLETS	2	Generic	$10.00	N/A	None
TRI-LEGEST FE 5-7-9-7 TABLET	2	Generic	$10.00	N/A	None
TRI-LO-ESTARYLLA TABLET [Trinessa Lo]	2	Generic	$10.00	N/A	None
TRI-LO-SPRINTEC TABLET	2	Generic	$10.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRI-MILI 28 TABLET [Trinessa]	2	Generic	$10.00	N/A	None
TRI-SPRINTEC 7DAYSX3 28 TABLET	2	Generic	$10.00	N/A	None
TRI-VYLIBRA 28 TABLET [Trinessa]	2	Generic	$10.00	N/A	None
TRIAMCINOLONE 0.025% CREAM	2	Generic	$10.00	N/A	None
TRIAMCINOLONE 0.025% LOTION	2	Generic	$10.00	N/A	None
TRIAMCINOLONE 0.025% OINT	2	Generic	$10.00	N/A	None
TRIAMCINOLONE 0.1% CREAM	2	Generic	$10.00	N/A	None
TRIAMCINOLONE 0.1% LOTION [Kenalog]	2	Generic	$10.00	N/A	None
TRIAMCINOLONE 0.1% OINTMENT	2	Generic	$10.00	N/A	None
TRIAMCINOLONE 0.1% PASTE	2	Generic	$10.00	N/A	None
TRIAMCINOLONE 200 MG/5 ML VIAL [Triesence]	2	Generic	$10.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE	2	Generic	$10.00	N/A	None
Triamcinolone Acetonide 1 MG/ML Topical Cream [Triderm]	2	Generic	$10.00	N/A	None
Triamcinolone Acetonide 5mg/g 1 TUBE per CARTON / 15 g in 1 TUBE	2	Generic	$10.00	N/A	None
TRIAMTERENE-HCTZ 37.5-25 MG CP	1	Preferred Generic	$0.00	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
TRIENTINE HCL 250 MG CAPSULE [Syprine]	5	Specialty Tier	33%	N/A	P
TRIFLUOPERAZINE 1MG TABLET	2	Generic	$10.00	N/A	None
TRIFLUOPERAZINE HCL 2MG TABLET	2	Generic	$10.00	N/A	None
TRIFLUOPERAZINE HCL 5MG TABLET	2	Generic	$10.00	N/A	None
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT)	2	Generic	$10.00	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	$10.00	N/A	None
TRIHEXYPHENIDYL 2 MG TABLET	2	Generic	$10.00	N/A	None
TRIHEXYPHENIDYL 5 MG TABLET	2	Generic	$10.00	N/A	None
Trihexyphenidyl Hydrochloride 2mg/5mL 473 mL in 1 BOTTLE	2	Generic	$10.00	N/A	None
TRILYTE WITH FLAVOR PACKETS	2	Generic	$10.00	N/A	None
TRIMETHOBENZAMIDE 300 MG CAP	4	Non-Preferred Drug	$95.00	N/A	None
TRIMETHOPRIM 100 MG TABLET	2	Generic	$10.00	N/A	None
TRIMIPRAMINE MALEATE 100 MG CP	4	Non-Preferred Drug	$95.00	N/A	P
TRIMIPRAMINE MALEATE 25 MG CAP	4	Non-Preferred Drug	$95.00	N/A	P
TRIMIPRAMINE MALEATE 50 MG CAP	4	Non-Preferred Drug	$95.00	N/A	P
TRINESSA TABLET	2	Generic	$10.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRINTELLIX 10 MG TABLET	4	Non-Preferred Drug	$95.00	N/A	P
TRINTELLIX 20 MG TABLET	4	Non-Preferred Drug	$95.00	N/A	P
TRINTELLIX 5 MG TABLET	4	Non-Preferred Drug	$95.00	N/A	P
Triptorelin 11.3 MG/ML Injectable Suspension [Trelstar]	5	Specialty Tier	33%	N/A	P Q:1 /168Days
TRISENOX 12 MG/6 ML VIAL	5	Specialty Tier	33%	N/A	P
TRIUMEQ TABLET	5	Specialty Tier	33%	N/A	None
Trivora-28 tablet	2	Generic	$10.00	N/A	None
TROPHAMINE INJECTION SOLUTION	4	Non-Preferred Drug	$95.00	N/A	P
TROPHAMINE INJECTION SOLUTION 6%	4	Non-Preferred Drug	$95.00	N/A	P
TROSPIUM CHLORIDE 20 MG TABLET	2	Generic	$10.00	N/A	None
TROSPIUM CHLORIDE ER 60 MG CAP	2	Generic	$10.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRULICITY 0.75 MG/0.5 ML PEN	3	Preferred Brand	$42.00	N/A	Q:2 /28Days
TRULICITY 1.5 MG/0.5 ML PEN	3	Preferred Brand	$42.00	N/A	Q:2 /28Days
TRUMENBA 120 MCG/0.5 ML VACCIN Syringe	3	Preferred Brand	$42.00	N/A	None
TRUVADA 100 MG-150 MG TABLET	5	Specialty Tier	33%	N/A	None
TRUVADA 133 MG-200 MG TABLET	5	Specialty Tier	33%	N/A	None
TRUVADA 167 MG-250 MG TABLET	5	Specialty Tier	33%	N/A	None
TRUVADA 200/300MG TABLET	5	Specialty Tier	33%	N/A	None
TWINRIX VACCINE SYRINGE	3	Preferred Brand	$42.00	N/A	None
TYBOST 150 MG TABLET	3	Preferred Brand	$42.00	N/A	None
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
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TYMLOS 80 MCG DOSE PEN INJECTR	5	Specialty Tier	33%	N/A	P Q:2 /30Days
TYPHIM VI 25 MCG/0.5 ML SYRINGE	3	Preferred Brand	$42.00	N/A	None
TYPHIM VI 25MCG/0.5ML VIAL	3	Preferred Brand	$42.00	N/A	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 2018 Medicare Part D UPMC for Life PPO High Deductible with Rx (PPO) 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.