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Express Scripts Medicare - Value (PDP) (S5660-114-0)
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Tier 2 (808)
Tier 3 (706)
Tier 4 (949)
Tier 5 (455)
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2019 Medicare Part D Plan Formulary Information
Express Scripts Medicare - Value (PDP) (S5660-114-0)
Benefit Details           
The Express Scripts Medicare - Value (PDP) (S5660-114-0)
Formulary Drugs Starting with the Letter T

in CMS PDP Region 12 which includes: AL TN
Plan Monthly Premium: $30.20 Deductible: $415 Qualifies for LIS: Yes
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 $25.00$75.00None
Tacrolimus 0.03% ointment   3 Preferred Brand $25.00$75.00P Q:100
/30Days
Tacrolimus 0.1% ointment   3 Preferred Brand $25.00$75.00P Q:100
/30Days
TACROLIMUS 0.5 MG CAPSULE   3 Preferred Brand $25.00$75.00P
TACROLIMUS 1 MG CAPSULE   3 Preferred Brand $25.00$75.00P
TACROLIMUS 5 MG CAPSULE   3 Preferred Brand $25.00$75.00P
TADALAFIL 20 MG TABLET [ALYQ]   5 Specialty Tier 25%N/AP Q:60
/30Days
TAFINLAR 50 MG CAPSULE   5 Specialty Tier 25%N/AP Q:120
/30Days
TAFINLAR 75 MG CAPSULE   5 Specialty Tier 25%N/AP Q:120
/30Days
TAGRISSO 40 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/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 25%N/AP Q:30
/30Days
TALZENNA 0.25 MG CAPSULE   4 Non-Preferred Drug 41%N/AP
TALZENNA 1 MG CAPSULE   4 Non-Preferred Drug 41%N/AP
TAMOXIFEN 10 MG TABLET   2 Generic $3.00$6.00None
TAMOXIFEN CITRATE 20MG TABLET (30 CT)   2 Generic $3.00$6.00None
TAMSULOSIN HCL 0.4 MG CAPSULE   2 Generic $3.00$6.00Q:60
/30Days
TARCEVA 100MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
TARCEVA 150MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
TARCEVA 25MG TABLET   5 Specialty Tier 25%N/AP Q:60
/30Days
TARGRETIN 1% GEL   5 Specialty Tier 25%N/AP
TARINA 24 FE 1 MG-20 MCG TABLET [Tarina Fe 1/20]   4 Non-Preferred Drug 41%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Tarina Fe 1-20 tablet   4 Non-Preferred Drug 41%N/ANone
Tasigna 150mg/1 4 BLISTER PACK per CARTON / 28 CAPSULE per BLISTER PACK   5 Specialty Tier 25%N/AP Q:112
/28Days
TASIGNA 200 MG CAPSULE   5 Specialty Tier 25%N/AP Q:112
/28Days
TASIGNA 50 MG CAPSULE   5 Specialty Tier 25%N/AP
TAZAROTENE 0.1% CREAM [Tazorac]   3 Preferred Brand $25.00$75.00P
TAZORAC 0.05% CREAM   3 Preferred Brand $25.00$75.00P
TAZORAC 0.05% GEL   3 Preferred Brand $25.00$75.00P
TAZORAC 0.1% GEL   3 Preferred Brand $25.00$75.00P
TECFIDERA DR 120 MG CAPSULE   5 Specialty Tier 25%N/AP
TECFIDERA DR 240 MG CAPSULE   5 Specialty Tier 25%N/AP
TECFIDERA STARTER PACK   5 Specialty Tier 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Teflaro 400mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE   4 Non-Preferred Drug 41%N/ANone
Teflaro 600mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE   4 Non-Preferred Drug 41%N/ANone
Telmisartan-Amlodipine 40-10 MG [Micardis]   2 Generic $3.00$6.00None
Telmisartan-Amlodipine 40-5 MG [Micardis]   2 Generic $3.00$6.00None
Telmisartan-Amlodipine 80-10 MG [Micardis]   2 Generic $3.00$6.00None
Telmisartan-Amlodipine 80-5 MG [Micardis]   2 Generic $3.00$6.00None
TENIVAC SYRINGE   3 Preferred Brand $25.00$75.00None
TENOFOVIR DISOP FUM 300 MG TABLET [Viread]   5 Specialty Tier 25%N/AQ:30
/30Days
TERAZOSIN 1 MG CAPSULE   2 Generic $3.00$6.00Q:30
/30Days
TERAZOSIN 10 MG CAPSULE [Hytrin]   2 Generic $3.00$6.00Q:60
/30Days
TERAZOSIN 2 MG CAPSULE   2 Generic $3.00$6.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TERAZOSIN 5 MG CAPSULE [Hytrin]   2 Generic $3.00$6.00Q:30
/30Days
TERBINAFINE HCL 250 MG TABLET   2 Generic $3.00$6.00None
TERBUTALINE SULFATE 2.5 MG TAB   4 Non-Preferred Drug 41%N/ANone
TERBUTALINE SULFATE 5MG TABLET   4 Non-Preferred Drug 41%N/ANone
TERCONAZOLE 0.4% CREAM WITH APPLICATOR   2 Generic $3.00$6.00None
TERCONAZOLE 0.8% CREAM   2 Generic $3.00$6.00None
TERCONAZOLE 80MG SUPPOSITORY VAGINAL   4 Non-Preferred Drug 41%N/ANone
TESTOSTERONE 1.62% (1.25 G) PKT GEL PACKET [AndroGel]   3 Preferred Brand $25.00$75.00P Q:38
/30Days
TESTOSTERONE 1.62% (2.5 G) PKT GEL PACKET [AndroGel]   3 Preferred Brand $25.00$75.00P Q:150
/30Days
TESTOSTERONE 1.62% GEL PUMP GEL MD PMP [AndroGel]   3 Preferred Brand $25.00$75.00P Q:150
/30Days
Testosterone 2500 MG 0.01 MG/MG Topical Gel   3 Preferred Brand $25.00$75.00P Q:300
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Testosterone cyp 100 mg/ml   2 Generic $3.00$6.00P
TESTOSTERONE CYP 200 MG/ML   2 Generic $3.00$6.00P
TESTOSTERONE ENANTHATE 200MG/ML INJECTION   4 Non-Preferred Drug 41%N/AP
TETRABENAZINE 12.5 MG TABLET [XENAZINE]   5 Specialty Tier 25%N/AP Q:240
/30Days
TETRABENAZINE 25 MG TABLET [XENAZINE]   5 Specialty Tier 25%N/AP Q:120
/30Days
TETRACYCLINE 250 MG CAPSULE   2 Generic $3.00$6.00None
TETRACYCLINE 500 MG CAPSULE   2 Generic $3.00$6.00None
THALOMID 100 MG CAPSULE   5 Specialty Tier 25%N/AP Q:30
/30Days
THALOMID 150 MG CAPSULE   5 Specialty Tier 25%N/AP Q:60
/30Days
THALOMID 200 MG CAPSULE   5 Specialty Tier 25%N/AP Q:60
/30Days
THALOMID 50 MG CAPSULE   5 Specialty Tier 25%N/AP Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
THEOPHYLLINE ER 100 MG TABLET   2 Generic $3.00$6.00None
THEOPHYLLINE ER 200 MG TABLET   2 Generic $3.00$6.00None
THEOPHYLLINE ER 300 MG TAB   2 Generic $3.00$6.00None
THEOPHYLLINE ER 400 MG TABLET   2 Generic $3.00$6.00None
THEOPHYLLINE ER 600 MG TABLET   2 Generic $3.00$6.00None
THIORIDAZINE 10 MG TABLET   4 Non-Preferred Drug 41%N/ANone
THIORIDAZINE 100MG TABLET   4 Non-Preferred Drug 41%N/ANone
THIORIDAZINE 25 MG TABLET   4 Non-Preferred Drug 41%N/ANone
THIORIDAZINE 50 MG TABLET   4 Non-Preferred Drug 41%N/ANone
THIOTHIXENE 1 MG CAPSULE   4 Non-Preferred Drug 41%N/ANone
THIOTHIXENE 10MG CAPSULE   4 Non-Preferred Drug 41%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
THIOTHIXENE 2MG CAPSULE   4 Non-Preferred Drug 41%N/ANone
THIOTHIXENE 5MG CAPSULE   4 Non-Preferred Drug 41%N/ANone
TIAGABINE HCL 12 MG TABLET [Gabitril]   4 Non-Preferred Drug 41%N/ANone
TIAGABINE HCL 16 MG TABLET [Gabitril]   4 Non-Preferred Drug 41%N/ANone
tiagabine hcl 2 mg tablet [Gabitril]   4 Non-Preferred Drug 41%N/ANone
tiagabine hcl 4 mg tablet [Gabitril]   4 Non-Preferred Drug 41%N/ANone
TIBSOVO 250 MG TABLET   5 Specialty Tier 25%N/AP
TIGECYCLINE 50 MG VIAL [Tygacil]   5 Specialty Tier 25%N/ANone
TIMOLOL 0.25% EYE DROPS   1 Preferred Generic $1.00$2.00None
TIMOLOL 0.25% GFS GEL-SOLUTION   2 Generic $3.00$6.00None
TIMOLOL 0.5% EYE DROPS   2 Generic $3.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TIMOLOL 0.5% EYE DROPS   1 Preferred Generic $1.00$2.00None
TIMOLOL 0.5% GFS GEL-SOLUTION   2 Generic $3.00$6.00None
TIMOLOL MALEATE 10MG TABLET   4 Non-Preferred Drug 41%N/ANone
TIMOLOL MALEATE 20MG TABLET   4 Non-Preferred Drug 41%N/ANone
TIMOLOL MALEATE 5MG TABLET   4 Non-Preferred Drug 41%N/ANone
TINIDAZOLE 250 MG TABLET   4 Non-Preferred Drug 41%N/ANone
TINIDAZOLE 500 MG TABLET   4 Non-Preferred Drug 41%N/ANone
TIVICAY 10 MG TABLET   3 Preferred Brand $25.00$75.00Q:60
/30Days
TIVICAY 25 MG TABLET   5 Specialty Tier 25%N/AQ:60
/30Days
TIVICAY 50 MG TABLET   5 Specialty Tier 25%N/AQ:60
/30Days
TIZANIDINE HCL 2 MG TABLET   2 Generic $3.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TIZANIDINE HCL 4 MG TABLET   2 Generic $3.00$6.00None
TOBRAMYCIN 0.3% EYE DROPS [Tobrex]   2 Generic $3.00$6.00None
TOBRAMYCIN 10 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate]   2 Generic $3.00$6.00None
TOBRAMYCIN 300 MG/5 ML AMPULE [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate]   5 Specialty Tier 25%N/AP Q:280
/28Days
TOBRAMYCIN 40 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate]   4 Non-Preferred Drug 41%N/ANone
TOBRAMYCIN-DEXAMETH OPTH SUSP   3 Preferred Brand $25.00$75.00None
TOLAZAMIDE TABLETS 250MG 100 BOT   2 Generic $3.00$6.00Q:120
/30Days
TOLAZAMIDE TABLETS 500MG 100 BOT   2 Generic $3.00$6.00Q:60
/30Days
TOLBUTAMIDE 500 MG TABLET   2 Generic $3.00$6.00Q:180
/30Days
TOLTERODINE TARTRATE 1 MG TAB [Detrol LA]   4 Non-Preferred Drug 41%N/ANone
TOLTERODINE TARTRATE 2 MG TABLET [Detrol]   4 Non-Preferred Drug 41%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Tolterodine Tartrate 24 HR 4 MG Extended Release Oral Capsule [Detrol LA]   4 Non-Preferred Drug 41%N/ANone
Tolterodine Tartrate ER 2 MG CAPSULE [Detrol LA]   4 Non-Preferred Drug 41%N/ANone
TOLVAPTAN 15 MG ORAL TABLET [SAMSCA]   5 Specialty Tier 25%N/AP Q:30
/30Days
TOLVAPTAN 30 MG ORAL TABLET [SAMSCA]   5 Specialty Tier 25%N/AP Q:60
/30Days
TOPIRAMATE 100 MG TABLET   3 Preferred Brand $25.00$75.00P
TOPIRAMATE 15 MG SPRINKLE CAP   3 Preferred Brand $25.00$75.00P
TOPIRAMATE 200 MG TABLET   3 Preferred Brand $25.00$75.00P
TOPIRAMATE 25 MG TABLET   3 Preferred Brand $25.00$75.00P
Topiramate 25mg/1   3 Preferred Brand $25.00$75.00P
TOPIRAMATE 50 MG TABLET   3 Preferred Brand $25.00$75.00P
TOREMIFENE CITRATE 60 MG TABLET [Fareston]   5 Specialty Tier 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TORSEMIDE 10 MG TABLET   2 Generic $3.00$6.00None
TORSEMIDE 100 MG TABLET   2 Generic $3.00$6.00None
TORSEMIDE 20 MG TABLET   2 Generic $3.00$6.00None
TORSEMIDE 5 MG TABLET   2 Generic $3.00$6.00None
TOUJEO MAX SOLOSTAR 300UNIT/ML INSULN PEN   3 Preferred Brand $25.00$75.00None
TOUJEO SOLOSTAR 300 UNITS/ML   3 Preferred Brand $25.00$75.00None
TOVIAZ TABLETS 4MG EXTENDED RELEASE   4 Non-Preferred Drug 41%N/AQ:30
/30Days
TOVIAZ TABLETS 8MG EXTENDED RELEASE   4 Non-Preferred Drug 41%N/AQ:30
/30Days
TRADJENTA 5 MG TABLET   3 Preferred Brand $25.00$75.00Q:30
/30Days
TRAMADOL HCL 50 MG TABLET   2 Generic $3.00$6.00Q:240
/30Days
tranexamic acid 650 mg tablet   3 Preferred Brand $25.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRANYLCYPROMINE SULF 10 MG TABLET [Parnate]   4 Non-Preferred Drug 41%N/ANone
TRAVASOL 10% SOLUTION VIAFLEX   4 Non-Preferred Drug 41%N/AP
TRAVATAN Z 0.04MG DROPS 2.5ML BOT   3 Preferred Brand $25.00$75.00None
TRAZODONE 100 MG TABLET   2 Generic $3.00$6.00None
TRAZODONE 300 MG TABLET   2 Generic $3.00$6.00None
TRAZODONE 50 MG TABLET   2 Generic $3.00$6.00None
TRAZODONE HCL TABLET USP 150MG (100 CT)   2 Generic $3.00$6.00None
TRECATOR 250MG TABLET   3 Preferred Brand $25.00$75.00None
TRELSTAR 11.25 MG SYRINGE   5 Specialty Tier 25%N/AP
TRELSTAR 3.75 MG SYRINGE   5 Specialty Tier 25%N/AP
TRETINOIN 0.01% GEL   3 Preferred Brand $25.00$75.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRETINOIN 0.025% CREAM   3 Preferred Brand $25.00$75.00P
TRETINOIN 0.025% GEL   3 Preferred Brand $25.00$75.00P
TRETINOIN 0.05% CREAM   3 Preferred Brand $25.00$75.00P
TRETINOIN 0.05% GEL [Atralin]   3 Preferred Brand $25.00$75.00P
TRETINOIN 0.1% CREAM   3 Preferred Brand $25.00$75.00P
TRETINOIN 10MG CAPSULE   5 Specialty Tier 25%N/ANone
TRI-LEGEST FE 5-7-9-7 TABLET   4 Non-Preferred Drug 41%N/ANone
TRI-LO-ESTARYLLA TABLET [Trinessa Lo]   4 Non-Preferred Drug 41%N/ANone
TRI-LO-SPRINTEC TABLET   4 Non-Preferred Drug 41%N/ANone
TRI-MILI 28 TABLET [Trinessa]   4 Non-Preferred Drug 41%N/ANone
TRI-PREVIFEM TABLET [Trinessa]   4 Non-Preferred Drug 41%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRI-SPRINTEC 7DAYSX3 28 TABLET   4 Non-Preferred Drug 41%N/ANone
TRI-VYLIBRA 28 TABLET [Trinessa]   4 Non-Preferred Drug 41%N/ANone
TRI-VYLIBRA LO TABLET [Trinessa Lo]   4 Non-Preferred Drug 41%N/ANone
TRIAMCINOLONE 0.025% CREAM   2 Generic $3.00$6.00None
TRIAMCINOLONE 0.025% LOTION   2 Generic $3.00$6.00None
TRIAMCINOLONE 0.025% OINT   2 Generic $3.00$6.00None
TRIAMCINOLONE 0.1% CREAM   2 Generic $3.00$6.00None
TRIAMCINOLONE 0.1% LOTION [Kenalog]   2 Generic $3.00$6.00None
TRIAMCINOLONE 0.1% OINTMENT   2 Generic $3.00$6.00None
TRIAMCINOLONE 0.1% PASTE   4 Non-Preferred Drug 41%N/ANone
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE   2 Generic $3.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Triamcinolone Acetonide 1 MG/ML Topical Cream [Triderm]   2 Generic $3.00$6.00None
Triamcinolone Acetonide 5mg/g 1 TUBE per CARTON / 15 g in 1 TUBE   2 Generic $3.00$6.00None
TRIAMTERENE-HCTZ 37.5-25 MG CP   2 Generic $3.00$6.00None
TRIAMTERENE-HCTZ 37.5-25 MG TB   2 Generic $3.00$6.00None
TRIAMTERENE-HCTZ 75-50 MG TAB   2 Generic $3.00$6.00None
Trianex 0.05% Ointment   4 Non-Preferred Drug 41%N/ANone
TRIENTINE HCL 250 MG CAPSULE [Syprine]   5 Specialty Tier 25%N/AP Q:240
/30Days
TRIFLUOPERAZINE 1 MG TABLET   2 Generic $3.00$6.00None
TRIFLUOPERAZINE HCL 2MG TABLET   2 Generic $3.00$6.00None
TRIFLUOPERAZINE HCL 5MG TABLET   2 Generic $3.00$6.00None
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT)   2 Generic $3.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT   3 Preferred Brand $25.00$75.00None
TRILYTE WITH FLAVOR PACKETS   2 Generic $3.00$6.00None
TRIMETHOPRIM 100 MG TABLET   2 Generic $3.00$6.00None
TRIMIPRAMINE MALEATE 100 MG CP   4 Non-Preferred Drug 41%N/AP
TRIMIPRAMINE MALEATE 25 MG CAP   4 Non-Preferred Drug 41%N/AP
TRIMIPRAMINE MALEATE 50 MG CAP   4 Non-Preferred Drug 41%N/AP
TRINTELLIX 10 MG TABLET   4 Non-Preferred Drug 41%N/AQ:30
/30Days
TRINTELLIX 20 MG TABLET   4 Non-Preferred Drug 41%N/AQ:30
/30Days
TRINTELLIX 5 MG TABLET   4 Non-Preferred Drug 41%N/AQ:30
/30Days
Triptorelin 11.3 MG/ML Injectable Suspension [Trelstar]   5 Specialty Tier 25%N/AP
TRIUMEQ TABLET   4 Non-Preferred Drug 41%N/AQ:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRIVORA-28 TABLET   4 Non-Preferred Drug 41%N/ANone
TROPHAMINE INJECTION SOLUTION   3 Preferred Brand $25.00$75.00P
TROPHAMINE INJECTION SOLUTION 6%   3 Preferred Brand $25.00$75.00P
TRULANCE 3 MG TABLET   4 Non-Preferred Drug 41%N/ANone
TRULICITY 0.75 MG/0.5 ML PEN   4 Non-Preferred Drug 41%N/AP Q:2
/28Days
TRULICITY 1.5 MG/0.5 ML PEN   4 Non-Preferred Drug 41%N/AP Q:2
/28Days
TRUMENBA 120 MCG/0.5 ML VACCIN Syringe   3 Preferred Brand $25.00$75.00None
TRUVADA 100 MG-150 MG TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
TRUVADA 133 MG-200 MG TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
TRUVADA 167 MG-250 MG TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
TRUVADA 200/300MG TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TUDORZA PRESSAIR 400 MCG INH   3 Preferred Brand $25.00$75.00Q:1
/30Days
TUDORZA PRESSAIR 400 MCG INH   3 Preferred Brand $25.00$75.00Q:1
/30Days
TWINRIX VACCINE SYRINGE   3 Preferred Brand $25.00$75.00None
TYDEMY TABLET   4 Non-Preferred Drug 41%N/ANone
TYKERB 250 MG TABLET   5 Specialty Tier 25%N/AP Q:180
/30Days
TYMLOS 80 MCG DOSE PEN INJECTR   5 Specialty Tier 25%N/AP Q:2
/30Days
TYPHIM VI 25 MCG/0.5 ML SYRINGE   3 Preferred Brand $25.00$75.00None
TYPHIM VI 25MCG/0.5ML VIAL   3 Preferred Brand $25.00$75.00None

Chart Legend:

Below are a few notes to help you understand the above 2019 Medicare Part D Express Scripts Medicare - Value (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 $415 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 $3820) at a "Preferred" network pharmacy. In most cases, the "Preferred" 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 2019 )

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.








Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.