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2018 Medicare Part D Plan Formulary Information
Anthem Blue MedicareRx Premier (PDP) (S5596-003-0) Benefit Details
The Anthem Blue MedicareRx Premier (PDP) (S5596-003-0) Formulary Drugs Starting with the Letter T in CMS PDP Region 01 which includes: ME NH Plan Monthly Premium: $148.80 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	35%	N/A	None
TACLONEX SCALP SUSPENSION	5	Specialty Tier	33%	N/A	None
Tacrolimus 0.03% ointment	4	Non-Preferred Drug	35%	N/A	P Q:100 /90Days
Tacrolimus 0.1% ointment	4	Non-Preferred Drug	35%	N/A	P Q:100 /90Days
TACROLIMUS 0.5 MG CAPSULE	3	Preferred Brand	$28.00	N/A	P
TACROLIMUS 1 MG CAPSULE	4	Non-Preferred Drug	35%	N/A	P
TACROLIMUS 5 MG CAPSULE	4	Non-Preferred Drug	35%	N/A	P
TAFINLAR 50 MG CAPSULE	5	Specialty Tier	33%	N/A	P Q:120 /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:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
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	3	Preferred Brand	$28.00	N/A	None
TAMIFLU 45 MG 1 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK	3	Preferred Brand	$28.00	N/A	None
TAMIFLU 6 MG/ML SUSPENSION	3	Preferred Brand	$28.00	N/A	None
TAMIFLU 75 MG CAPSULE UD	3	Preferred Brand	$28.00	N/A	None
TAMOXIFEN 10 MG TABLET	1	Preferred Generic	$1.00	N/A	None
TAMOXIFEN CITRATE 20MG TABLET (30 CT)	2	Generic	$3.00	N/A	None
TAMSULOSIN HCL 0.4 MG CAPSULE	2	Generic	$3.00	N/A	None
TANZEUM 30 MG PEN INJECT	4	Non-Preferred Drug	35%	N/A	Q:4 /28Days
TANZEUM 50 MG PEN INJECT	4	Non-Preferred Drug	35%	N/A	Q:4 /28Days
TAPAZOLE 10MG TABLET	3	Preferred Brand	$28.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TAPAZOLE 5MG TABLET	3	Preferred Brand	$28.00	N/A	None
TARCEVA 100MG TABLET	5	Specialty Tier	33%	N/A	P Q:30 /30Days
TARCEVA 150MG TABLET	5	Specialty Tier	33%	N/A	P Q:30 /30Days
TARCEVA 25MG TABLET	5	Specialty Tier	33%	N/A	P Q:90 /30Days
TARGRETIN 1% GEL	5	Specialty Tier	33%	N/A	P Q:60 /30Days
Tasigna 150mg/1 4 BLISTER PACK per CARTON / 28 CAPSULE per BLISTER PACK	5	Specialty Tier	33%	N/A	P Q:112 /28Days
TASIGNA 200 MG CAPSULE	5	Specialty Tier	33%	N/A	P Q:112 /28Days
TASIGNA 50 MG CAPSULE	5	Specialty Tier	33%	N/A	P Q:56 /28Days
TAZAROTENE 0.1% CREAM [Tazorac]	4	Non-Preferred Drug	35%	N/A	P
TAZORAC 0.05% CREAM	4	Non-Preferred Drug	35%	N/A	P
TAZORAC 0.05% GEL	4	Non-Preferred Drug	35%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TAZORAC 0.1% CREAM	4	Non-Preferred Drug	35%	N/A	P
TAZORAC 0.1% GEL	4	Non-Preferred Drug	35%	N/A	P
TAZTIA DILTIAZEM HYDROCHLORIDE 120MG ER CAPSULES	2	Generic	$3.00	N/A	None
TAZTIA XT 180 MG CAPSULE	2	Generic	$3.00	N/A	None
TAZTIA XT 240MG CAPSULE SA	2	Generic	$3.00	N/A	None
TAZTIA XT 300 MG CAPSULE	2	Generic	$3.00	N/A	None
TAZTIA XT 360MG CAPSULE SA	2	Generic	$3.00	N/A	None
TECENTRIQ 1,200 MG/20 ML VIAL	5	Specialty Tier	33%	N/A	P Q:20 /21Days
TECFIDERA DR 120 MG CAPSULE	5	Specialty Tier	33%	N/A	P
TECFIDERA DR 240 MG CAPSULE	5	Specialty Tier	33%	N/A	P
TECFIDERA STARTER PACK	5	Specialty Tier	33%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TECHNIVIE DOSE PACK	5	Specialty Tier	33%	N/A	P Q:56 /28Days
Teflaro 400mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE	4	Non-Preferred Drug	35%	N/A	None
Teflaro 600mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE	4	Non-Preferred Drug	35%	N/A	None
TEGRETOL SUSPENSION 100MG/5ML 450 ML BOT	4	Non-Preferred Drug	35%	N/A	None
TEGRETOL TABLETS 200MG 100 BOT	4	Non-Preferred Drug	35%	N/A	S
TEGRETOL XR TABLETS 100MG 100 BOT	4	Non-Preferred Drug	35%	N/A	S
TEGRETOL XR TABLETS 200MG 100 BOT	4	Non-Preferred Drug	35%	N/A	S
TEGRETOL XR TABLETS 400MG 100 BOT	4	Non-Preferred Drug	35%	N/A	S
TEKTURNA 150 MG TABLET	4	Non-Preferred Drug	35%	N/A	None
TEKTURNA 300 MG TABLET	4	Non-Preferred Drug	35%	N/A	None
TEKTURNA HCT 300-25 MG TABLET	4	Non-Preferred Drug	35%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Telmisartan 20 MG Tablet [Micardis]	2	Generic	$3.00	N/A	None
Telmisartan 40 MG Tablet [Micardis]	2	Generic	$3.00	N/A	None
Telmisartan 80 MG Tablet [Micardis]	2	Generic	$3.00	N/A	None
Telmisartan-Amlodipine 40-10 MG [Micardis]	2	Generic	$3.00	N/A	None
Telmisartan-Amlodipine 40-5 MG [Micardis]	2	Generic	$3.00	N/A	None
Telmisartan-Amlodipine 80-10 MG [Micardis]	2	Generic	$3.00	N/A	None
Telmisartan-Amlodipine 80-5 MG [Micardis]	2	Generic	$3.00	N/A	None
TELMISARTAN-HCTZ 40-12.5 MG TB [Micardis]	2	Generic	$3.00	N/A	None
TELMISARTAN-HCTZ 80-12.5 MG TAB [Micardis HCT]	2	Generic	$3.00	N/A	None
TELMISARTAN-HCTZ 80-25 MG TAB [Micardis HCT]	2	Generic	$3.00	N/A	None
TEMAZEPAM 15 MG CAPSULE	4	Non-Preferred Drug	35%	N/A	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TEMAZEPAM 30 MG CAPSULE	4	Non-Preferred Drug	35%	N/A	Q:30 /30Days
TENIVAC SYRINGE	3	Preferred Brand	$28.00	N/A	None
TENOFOVIR DISOP FUM 300 MG TB [Viread]	5	Specialty Tier	33%	N/A	Q:30 /30Days
TERAZOSIN 1 MG CAPSULE	1	Preferred Generic	$1.00	N/A	None
TERAZOSIN 10 MG CAPSULE [Hytrin]	1	Preferred Generic	$1.00	N/A	None
TERAZOSIN 2 MG CAPSULE	1	Preferred Generic	$1.00	N/A	None
TERAZOSIN 5 MG CAPSULE [Hytrin]	1	Preferred Generic	$1.00	N/A	None
TERBINAFINE HCL 250 MG TABLET	1	Preferred Generic	$1.00	N/A	None
TERBUTALINE SULF 1MG/ML VL	4	Non-Preferred Drug	35%	N/A	None
TERBUTALINE SULFATE 2.5 MG TAB	4	Non-Preferred Drug	35%	N/A	None
TERBUTALINE SULFATE 5MG TABLET	4	Non-Preferred Drug	35%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TERCONAZOLE 0.4% CREAM WITH APPLICATOR	2	Generic	$3.00	N/A	None
TERCONAZOLE 0.8% CREAM	2	Generic	$3.00	N/A	None
TERCONAZOLE 80MG SUPPOSITORY VAGINAL	3	Preferred Brand	$28.00	N/A	None
Testosterone 2500 MG 0.01 MG/MG Topical Gel	3	Preferred Brand	$28.00	N/A	P Q:300 /30Days
Testosterone 5000 MG 0.01 MG/MG Topical Gel	3	Preferred Brand	$28.00	N/A	P Q:300 /30Days
Testosterone cyp 100 mg/ml	4	Non-Preferred Drug	35%	N/A	P
TESTOSTERONE CYP 200 MG/ML	4	Non-Preferred Drug	35%	N/A	P
TESTOSTERONE ENANTHATE 200MG/ML INJECTION	4	Non-Preferred Drug	35%	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	35%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TETRACYCLINE 500 MG CAPSULE	4	Non-Preferred Drug	35%	N/A	None
THALOMID 100 MG CAPSULE	5	Specialty Tier	33%	N/A	P Q:30 /30Days
THALOMID 150 MG CAPSULE	5	Specialty Tier	33%	N/A	P Q:60 /30Days
THALOMID 200 MG CAPSULE	5	Specialty Tier	33%	N/A	P Q:60 /30Days
THALOMID 50 MG CAPSULE	5	Specialty Tier	33%	N/A	P Q:30 /30Days
THEOPHYLLINE 80 MG/15 ML SOLN	3	Preferred Brand	$28.00	N/A	None
THEOPHYLLINE ER 100 MG TABLET	2	Generic	$3.00	N/A	None
THEOPHYLLINE ER 200 MG TABLET	2	Generic	$3.00	N/A	None
THEOPHYLLINE ER 300 MG TAB	2	Generic	$3.00	N/A	None
THEOPHYLLINE ER 400 MG TABLET	2	Generic	$3.00	N/A	None
THEOPHYLLINE ER 600 MG TABLET	2	Generic	$3.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
THIORIDAZINE 10 MG TABLET	2	Generic	$3.00	N/A	S
THIORIDAZINE 100MG TABLET	2	Generic	$3.00	N/A	S
THIORIDAZINE 25 MG TABLET	2	Generic	$3.00	N/A	S
THIORIDAZINE 50 MG TABLET	2	Generic	$3.00	N/A	S
THIOTEPA 15 MG VIAL	4	Non-Preferred Drug	35%	N/A	P
THIOTHIXENE 1 MG CAPSULE	2	Generic	$3.00	N/A	None
THIOTHIXENE 10MG CAPSULE	2	Generic	$3.00	N/A	None
THIOTHIXENE 2MG CAPSULE	2	Generic	$3.00	N/A	None
THIOTHIXENE 5MG CAPSULE	2	Generic	$3.00	N/A	None
THYMOGLOBULIN 25MG VIAL	5	Specialty Tier	33%	N/A	P
TIAGABINE HCL 12 MG TABLET [Gabitril]	4	Non-Preferred Drug	35%	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	35%	N/A	None
tiagabine hcl 2 mg tablet [Gabitril]	4	Non-Preferred Drug	35%	N/A	None
tiagabine hcl 4 mg tablet [Gabitril]	4	Non-Preferred Drug	35%	N/A	None
TIAZAC ER 120 MG CAPSULE	3	Preferred Brand	$28.00	N/A	None
TIAZAC ER 180 MG CAPSULE	3	Preferred Brand	$28.00	N/A	None
TIAZAC ER 240 MG CAPSULE	3	Preferred Brand	$28.00	N/A	None
TIAZAC ER 300 MG CAPSULE CAP SA 24H	3	Preferred Brand	$28.00	N/A	None
TIAZAC ER 360 MG CAPSULE	3	Preferred Brand	$28.00	N/A	None
TIAZAC ER 420 MG CAPSULE CAP SA 24H	3	Preferred Brand	$28.00	N/A	None
TIGECYCLINE 50 MG VIAL [Tygacil]	5	Specialty Tier	33%	N/A	None
TIMOLOL 0.25% EYE DROPS	1	Preferred Generic	$1.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TIMOLOL 0.25% GFS GEL-SOLUTION	2	Generic	$3.00	N/A	None
TIMOLOL 0.5% EYE DROPS	4	Non-Preferred Drug	35%	N/A	None
TIMOLOL 0.5% EYE DROPS	1	Preferred Generic	$1.00	N/A	None
TIMOLOL 0.5% GFS GEL-SOLUTION	2	Generic	$3.00	N/A	None
TIMOLOL MALEATE 10MG TABLET	2	Generic	$3.00	N/A	None
TIMOLOL MALEATE 20MG TABLET	2	Generic	$3.00	N/A	None
TIMOLOL MALEATE 5MG TABLET	2	Generic	$3.00	N/A	None
TIMOPTIC 0.25% OCUDOSE DROP	4	Non-Preferred Drug	35%	N/A	None
TIMOPTIC-XE 0.25% EYE GEL-SOLN SOL-GEL	3	Preferred Brand	$28.00	N/A	None
TINIDAZOLE 250 MG TABLET	2	Generic	$3.00	N/A	None
TINIDAZOLE 500 MG TABLET	3	Preferred Brand	$28.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TIVICAY 10 MG TABLET	4	Non-Preferred Drug	35%	N/A	Q:60 /30Days
TIVICAY 25 MG TABLET	5	Specialty Tier	33%	N/A	Q:60 /30Days
TIVICAY 50 MG TABLET	5	Specialty Tier	33%	N/A	Q:60 /30Days
TIZANIDINE HCL 2 MG CAPSULE	4	Non-Preferred Drug	35%	N/A	None
TIZANIDINE HCL 2 MG TABLET	2	Generic	$3.00	N/A	None
TIZANIDINE HCL 4 MG CAPSULE	4	Non-Preferred Drug	35%	N/A	None
TIZANIDINE HCL 4 MG TABLET	2	Generic	$3.00	N/A	None
TIZANIDINE HCL 6 MG CAPSULE	4	Non-Preferred Drug	35%	N/A	None
TOBRADEX EYE OINTMENT	3	Preferred Brand	$28.00	N/A	None
TOBRADEX ST 0.5; 3mg/mL; mg/mL 5 mL in 1 BOTTLE	3	Preferred Brand	$28.00	N/A	None
TOBRAMYCIN 0.3% EYE DROPS [Tobrex]	2	Generic	$3.00	N/A	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	35%	N/A	None
TOBRAMYCIN 300 MG/5 ML AMPULE [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate]	5	Specialty Tier	33%	N/A	P Q:280 /28Days
TOBRAMYCIN 40 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate]	4	Non-Preferred Drug	35%	N/A	None
TOBRAMYCIN-DEXAMETH OPTH SUSP	3	Preferred Brand	$28.00	N/A	None
TOLAZAMIDE TABLETS 250MG 100 BOT	2	Generic	$3.00	N/A	Q:120 /30Days
TOLAZAMIDE TABLETS 500MG 100 BOT	2	Generic	$3.00	N/A	Q:60 /30Days
TOLBUTAMIDE 500 MG TABLET	2	Generic	$3.00	N/A	Q:180 /30Days
Tolcapone 100 MG TABLET [Tasmar]	5	Specialty Tier	33%	N/A	P Q:180 /30Days
TOLMETIN SODIUM 400 MG CAP	2	Generic	$3.00	N/A	None
TOLMETIN SODIUM 600MG TABLET	4	Non-Preferred Drug	35%	N/A	None
TOLTERODINE TARTRATE 1 MG TAB [Detrol LA]	2	Generic	$3.00	N/A	Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TOLTERODINE TARTRATE 2 MG TAB [Detrol LA]	3	Preferred Brand	$28.00	N/A	Q:60 /30Days
Tolterodine Tartrate ER 2 MG CAPSULE [Detrol LA]	3	Preferred Brand	$28.00	N/A	Q:30 /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 100 MG TABLET	2	Generic	$3.00	N/A	P Q:480 /30Days
TOPIRAMATE 15 MG SPRINKLE CAP	2	Generic	$3.00	N/A	P
TOPIRAMATE 200 MG TABLET	2	Generic	$3.00	N/A	P Q:240 /30Days
TOPIRAMATE 25 MG TABLET	2	Generic	$3.00	N/A	P Q:1920 /30Days
Topiramate 25mg/1	4	Non-Preferred Drug	35%	N/A	P
TOPIRAMATE 50 MG TABLET	2	Generic	$3.00	N/A	P Q:960 /30Days
TOPOSAR INJECTION 20MG/ML 50ML VIAL MD CRTN	4	Non-Preferred Drug	35%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Topotecan 4 MG Injection	5	Specialty Tier	33%	N/A	P
Torisel 1 KIT per CARTON	5	Specialty Tier	33%	N/A	P
TORSEMIDE 10 MG TABLET	1	Preferred Generic	$1.00	N/A	None
TORSEMIDE 100 MG TABLET	2	Generic	$3.00	N/A	None
TORSEMIDE 20 MG TABLET	2	Generic	$3.00	N/A	None
TORSEMIDE 5 MG TABLET	2	Generic	$3.00	N/A	None
TOUJEO MAX SOLOSTAR 300UNIT/ML INSULN PEN	3	Preferred Brand	$28.00	N/A	None
TOUJEO SOLOSTAR 300 UNITS/ML	3	Preferred Brand	$28.00	N/A	None
TOVIAZ TABLETS 4MG EXTENDED RELEASE	4	Non-Preferred Drug	35%	N/A	Q:30 /30Days
TOVIAZ TABLETS 8MG EXTENDED RELEASE	4	Non-Preferred Drug	35%	N/A	Q:30 /30Days
TPN ELECTROLYTES16.5/25.4 VIAL	4	Non-Preferred Drug	35%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
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
TRADJENTA 5 MG TABLET	3	Preferred Brand	$28.00	N/A	Q:30 /30Days
TRAMADOL HCL 50 MG TABLET	2	Generic	$3.00	N/A	Q:240 /30Days
TRAMADOL HCL ER 100 MG TABLET	2	Generic	$3.00	N/A	P Q:30 /30Days
TRAMADOL HCL ER 200 MG TABLET	2	Generic	$3.00	N/A	P Q:30 /30Days
TRAMADOL-ACETAMINOPHN 37.5-325	2	Generic	$3.00	N/A	Q:40 /30Days
TRANDOLAPRIL 1 MG TABLET	2	Generic	$3.00	N/A	None
TRANDOLAPRIL 2 MG TABLET	2	Generic	$3.00	N/A	None
TRANDOLAPRIL 4 MG TABLET	2	Generic	$3.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRANDOLAPRIL-VERAPAMIL ER 1-240 MG	4	Non-Preferred Drug	35%	N/A	None
TRANDOLAPRIL-VERAPAMIL ER 2-180 MG	4	Non-Preferred Drug	35%	N/A	None
TRANDOLAPRIL-VERAPAMIL ER 2-240 MG	4	Non-Preferred Drug	35%	N/A	None
TRANDOLAPRIL-VERAPAMIL ER 4-240 MG	4	Non-Preferred Drug	35%	N/A	None
TRANEXAMIC ACID 1,000 MG/10 ML	3	Preferred Brand	$28.00	N/A	None
tranexamic acid 650 mg tablet	4	Non-Preferred Drug	35%	N/A	None
TRANSDERM-SCOP 1.5 MG/3 DAY	4	Non-Preferred Drug	35%	N/A	Q:10 /30Days
TRANYLCYPROMINE SULFATE 10MG TABLET	4	Non-Preferred Drug	35%	N/A	None
TRAVASOL 10% SOLUTION VIAFLEX	4	Non-Preferred Drug	35%	N/A	P
TRAVATAN Z 0.04MG DROPS 2.5ML BOT	3	Preferred Brand	$28.00	N/A	None
TRAZODONE 100 MG TABLET	1	Preferred Generic	$1.00	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	35%	N/A	None
TRAZODONE 50 MG TABLET	1	Preferred Generic	$1.00	N/A	None
TRAZODONE HCL TABLET USP 150MG (100 CT)	1	Preferred Generic	$1.00	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	35%	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
TRETINOIN 0.01% GEL	2	Generic	$3.00	N/A	P Q:45 /30Days
TRETINOIN 0.025% CREAM	2	Generic	$3.00	N/A	P Q:45 /30Days
TRETINOIN 0.025% GEL	2	Generic	$3.00	N/A	P Q:45 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRETINOIN 0.05% CREAM	2	Generic	$3.00	N/A	P Q:45 /30Days
TRETINOIN 0.1% CREAM	4	Non-Preferred Drug	35%	N/A	P Q:45 /30Days
TRETINOIN 10MG CAPSULE	5	Specialty Tier	33%	N/A	None
TREXALL 10MG TABLET	4	Non-Preferred Drug	35%	N/A	None
TREXALL 15MG TABLET	4	Non-Preferred Drug	35%	N/A	None
TREXALL 5MG TABLET	4	Non-Preferred Drug	35%	N/A	None
TREXALL 7.5MG TABLET	4	Non-Preferred Drug	35%	N/A	None
TRI PREVIFEM TABLETS	3	Preferred Brand	$28.00	N/A	None
TRI-LEGEST FE 5-7-9-7 TABLET	3	Preferred Brand	$28.00	N/A	None
TRI-SPRINTEC 7DAYSX3 28 TABLET	3	Preferred Brand	$28.00	N/A	None
TRIAMCINOLONE 0.025% CREAM	2	Generic	$3.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRIAMCINOLONE 0.025% LOTION	2	Generic	$3.00	N/A	None
TRIAMCINOLONE 0.025% OINT	1	Preferred Generic	$1.00	N/A	None
TRIAMCINOLONE 0.1% CREAM	2	Generic	$3.00	N/A	None
TRIAMCINOLONE 0.1% LOTION [Kenalog]	3	Preferred Brand	$28.00	N/A	None
TRIAMCINOLONE 0.1% OINTMENT	2	Generic	$3.00	N/A	None
TRIAMCINOLONE 0.1% PASTE	2	Generic	$3.00	N/A	None
Triamcinolone 0.147 MG/G Spray	4	Non-Preferred Drug	35%	N/A	None
TRIAMCINOLONE 200 MG/5 ML VIAL [Triesence]	4	Non-Preferred Drug	35%	N/A	None
Triamcinolone 55 mcg nasal spr	2	Generic	$3.00	N/A	Q:34 /30Days
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE	2	Generic	$3.00	N/A	None
Triamcinolone Acetonide 1 MG/ML Topical Cream [Triderm]	2	Generic	$3.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Triamcinolone Acetonide 5mg/g 1 TUBE per CARTON / 15 g in 1 TUBE	2	Generic	$3.00	N/A	None
TRIAMTERENE-HCTZ 37.5-25 MG CP	1	Preferred Generic	$1.00	N/A	None
TRIAMTERENE-HCTZ 37.5-25 MG TB	1	Preferred Generic	$1.00	N/A	None
TRIAMTERENE-HCTZ 75-50 MG TAB	1	Preferred Generic	$1.00	N/A	None
TRICOR 48 MG TABLET	3	Preferred Brand	$28.00	N/A	None
TRIENTINE HCL 250 MG CAPSULE [Syprine]	5	Specialty Tier	33%	N/A	None
TRIFLUOPERAZINE 1MG TABLET	2	Generic	$3.00	N/A	None
TRIFLUOPERAZINE HCL 2MG TABLET	2	Generic	$3.00	N/A	None
TRIFLUOPERAZINE HCL 5MG TABLET	2	Generic	$3.00	N/A	None
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT)	3	Preferred Brand	$28.00	N/A	None
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT	3	Preferred Brand	$28.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRIHEXYPHENIDYL 2 MG TABLET	2	Generic	$3.00	N/A	P
TRIHEXYPHENIDYL 5 MG TABLET	2	Generic	$3.00	N/A	P
Trihexyphenidyl Hydrochloride 2mg/5mL 473 mL in 1 BOTTLE	2	Generic	$3.00	N/A	P
TRILIPIX DR 45 MG CAPSULE	3	Preferred Brand	$28.00	N/A	None
TRILYTE WITH FLAVOR PACKETS	2	Generic	$3.00	N/A	None
TRIMETHOPRIM 100 MG TABLET	2	Generic	$3.00	N/A	None
TRIMIPRAMINE MALEATE 100 MG CP	4	Non-Preferred Drug	35%	N/A	P
TRIMIPRAMINE MALEATE 25 MG CAP	4	Non-Preferred Drug	35%	N/A	P
TRIMIPRAMINE MALEATE 50 MG CAP	4	Non-Preferred Drug	35%	N/A	P
TRINESSA TABLET	3	Preferred Brand	$28.00	N/A	None
TRINTELLIX 10 MG TABLET	4	Non-Preferred Drug	35%	N/A	S Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRINTELLIX 20 MG TABLET	4	Non-Preferred Drug	35%	N/A	S Q:30 /30Days
TRINTELLIX 5 MG TABLET	4	Non-Preferred Drug	35%	N/A	S Q:120 /30Days
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	Q:30 /30Days
Trivora-28 tablet	3	Preferred Brand	$28.00	N/A	None
TROPHAMINE INJECTION SOLUTION	4	Non-Preferred Drug	35%	N/A	P
TROPHAMINE INJECTION SOLUTION 6%	4	Non-Preferred Drug	35%	N/A	P
TROSPIUM CHLORIDE 20 MG TABLET	3	Preferred Brand	$28.00	N/A	Q:60 /30Days
TRULICITY 0.75 MG/0.5 ML PEN	4	Non-Preferred Drug	35%	N/A	Q:2 /28Days
TRULICITY 1.5 MG/0.5 ML PEN	4	Non-Preferred Drug	35%	N/A	Q:2 /28Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRUMENBA 120 MCG/0.5 ML VACCIN Syringe	3	Preferred Brand	$28.00	N/A	None
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 VACCINE SYRINGE	3	Preferred Brand	$28.00	N/A	None
Twynsta 10; 40mg/1; mg/1 3 BLISTER PACK per CARTON / 10 TABLET, MULTILAYER per BLISTER PACK	4	Non-Preferred Drug	35%	N/A	S
Twynsta 5; 40mg/1; mg/1 3 BLISTER PACK per CARTON / 10 TABLET, MULTILAYER per BLISTER PACK	4	Non-Preferred Drug	35%	N/A	S
Twynsta 5; 80mg/1; mg/1 3 BLISTER PACK per CARTON / 10 TABLET, MULTILAYER per BLISTER PACK	4	Non-Preferred Drug	35%	N/A	S
TYBOST 150 MG TABLET	3	Preferred Brand	$28.00	N/A	Q:30 /30Days
TYKERB 250 MG TABLET	5	Specialty Tier	33%	N/A	P Q:180 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TYPHIM VI 25 MCG/0.5 ML SYRINGE	3	Preferred Brand	$28.00	N/A	None
TYPHIM VI 25MCG/0.5ML VIAL	3	Preferred Brand	$28.00	N/A	None
TYSABRI 300 MG/15 ML VIAL	5	Specialty Tier	33%	N/A	P

Chart Legend:

Below are a few notes to help you understand the above 2018 Medicare Part D Anthem Blue MedicareRx Premier (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). 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.