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BlueMedicare Complete Rx (PDP) (S5904-002-0)
Tier 1 (258)
Tier 2 (1701)
Tier 3 (363)
Tier 4 (1048)
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2019 Medicare Part D Plan Formulary Information
BlueMedicare Complete Rx (PDP) (S5904-002-0)
Benefit Details           
The BlueMedicare Complete Rx (PDP) (S5904-002-0)
Formulary Drugs Starting with the Letter T

in CMS PDP Region 11 which includes: FL
Plan Monthly Premium: $155.90 Deductible: $0 Qualifies for LIS: No
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   4 Non-Preferred Brand $93.00$279.00None
Tacrolimus 0.03% ointment   2 Generic $10.00$30.00P
Tacrolimus 0.1% ointment   2 Generic $10.00$30.00P
TACROLIMUS 0.5 MG CAPSULE   2 Generic $10.00$30.00P
TACROLIMUS 1 MG CAPSULE   2 Generic $10.00$30.00P
TACROLIMUS 5 MG CAPSULE   2 Generic $10.00$30.00P
TADALAFIL 20 MG TABLET [ALYQ]   5 Specialty Tier 33%N/AP Q:60
/30Days
TAFINLAR 50 MG CAPSULE   5 Specialty Tier 33%N/AP Q:120
/30Days
TAFINLAR 75 MG CAPSULE   5 Specialty Tier 33%N/AP Q:120
/30Days
TAGRISSO 40 MG TABLET   5 Specialty Tier 33%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 33%N/AP Q:30
/30Days
TALZENNA 0.25 MG CAPSULE   5 Specialty Tier 33%N/AP Q:90
/30Days
TALZENNA 1 MG CAPSULE   5 Specialty Tier 33%N/AP Q:30
/30Days
TAMIFLU 30 MG 1 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK   4 Non-Preferred Brand $93.00$279.00None
TAMIFLU 45 MG 1 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK   4 Non-Preferred Brand $93.00$279.00None
TAMIFLU 6 MG/ML SUSPENSION   4 Non-Preferred Brand $93.00$279.00None
TAMIFLU 75 MG CAPSULE UD   4 Non-Preferred Brand $93.00$279.00None
TAMOXIFEN 10 MG TABLET   2 Generic $10.00$30.00None
TAMOXIFEN CITRATE 20MG TABLET (30 CT)   2 Generic $10.00$30.00None
TAMSULOSIN HCL 0.4 MG CAPSULE   2 Generic $10.00$30.00Q:60
/30Days
TARCEVA 100MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TARCEVA 150MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
TARCEVA 25MG TABLET   5 Specialty Tier 33%N/AP Q:60
/30Days
TARGRETIN 1% GEL   5 Specialty Tier 33%N/ANone
TARGRETIN 75 MG CAPSULE   5 Specialty Tier 33%N/AP
TARINA 24 FE 1 MG-20 MCG TABLET [Tarina Fe 1/20]   2 Generic $10.00$30.00None
Tarina Fe 1-20 tablet   2 Generic $10.00$30.00None
Tasigna 150mg/1 4 BLISTER PACK per CARTON / 28 CAPSULE per BLISTER PACK   5 Specialty Tier 33%N/AP Q:120
/30Days
TASIGNA 200 MG CAPSULE   5 Specialty Tier 33%N/AP Q:120
/30Days
TASIGNA 50 MG CAPSULE   5 Specialty Tier 33%N/AP Q:120
/30Days
TASMAR 100MG TABLET   5 Specialty Tier 33%N/ANone
TAZAROTENE 0.1% CREAM [Tazorac]   2 Generic $10.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TAZICEF 1GM VIAL   2 Generic $10.00$30.00None
TAZICEF 2 GRAM VIAL   2 Generic $10.00$30.00None
TAZICEF 6 GRAM VIAL   2 Generic $10.00$30.00None
TAZORAC 0.05% CREAM   4 Non-Preferred Brand $93.00$279.00None
TAZORAC 0.05% GEL   4 Non-Preferred Brand $93.00$279.00None
TAZORAC 0.1% GEL   4 Non-Preferred Brand $93.00$279.00None
TAZTIA DILTIAZEM HYDROCHLORIDE 120MG ER CAPSULES   2 Generic $10.00$30.00None
TAZTIA XT 180 MG CAPSULE   2 Generic $10.00$30.00None
TAZTIA XT 240MG CAPSULE SA   2 Generic $10.00$30.00None
TAZTIA XT 300 MG CAPSULE   2 Generic $10.00$30.00None
TAZTIA XT 360MG CAPSULE SA   2 Generic $10.00$30.00None
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/AP Q:60
/30Days
TECFIDERA DR 240 MG CAPSULE   5 Specialty Tier 33%N/AP Q:60
/30Days
TECFIDERA STARTER PACK   5 Specialty Tier 33%N/AP Q:60
/30Days
Teflaro 400mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE   5 Specialty Tier 33%N/ANone
Teflaro 600mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE   5 Specialty Tier 33%N/ANone
TEGRETOL SUSPENSION 100MG/5ML 450 ML BOT   4 Non-Preferred Brand $93.00$279.00None
TEGRETOL TABLETS 200MG 100 BOT   4 Non-Preferred Brand $93.00$279.00None
TEGRETOL XR TABLETS 100MG 100 BOT   4 Non-Preferred Brand $93.00$279.00None
TEGRETOL XR TABLETS 200MG 100 BOT   4 Non-Preferred Brand $93.00$279.00None
TEGRETOL XR TABLETS 400MG 100 BOT   4 Non-Preferred Brand $93.00$279.00None
TEKTURNA 150 MG TABLET   3 Preferred Brand $40.00$120.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TEKTURNA 300 MG TABLET   3 Preferred Brand $40.00$120.00Q:30
/30Days
TEKTURNA HCT 300-25 MG TABLET   3 Preferred Brand $40.00$120.00Q:30
/30Days
TELMISARTAN 20 MG TABLET [Micardis]   2 Generic $10.00$30.00Q:30
/30Days
TELMISARTAN 40 MG TABLET [Micardis]   2 Generic $10.00$30.00Q:30
/30Days
TELMISARTAN 80 MG TABLET [Micardis]   2 Generic $10.00$30.00Q:30
/30Days
Telmisartan-Amlodipine 40-10 MG [Micardis]   2 Generic $10.00$30.00Q:30
/30Days
Telmisartan-Amlodipine 40-5 MG [Micardis]   2 Generic $10.00$30.00Q:30
/30Days
Telmisartan-Amlodipine 80-10 MG [Micardis]   2 Generic $10.00$30.00Q:30
/30Days
Telmisartan-Amlodipine 80-5 MG [Micardis]   2 Generic $10.00$30.00Q:30
/30Days
TELMISARTAN-HCTZ 40-12.5 MG TB [Micardis]   2 Generic $10.00$30.00Q:30
/30Days
TELMISARTAN-HCTZ 80-12.5 MG TAB [Micardis HCT]   2 Generic $10.00$30.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TELMISARTAN-HCTZ 80-25 MG TAB [Micardis HCT]   2 Generic $10.00$30.00Q:30
/30Days
TEMAZEPAM 15 MG CAPSULE   1 Preferred Generic $3.00$9.00Q:30
/30Days
TEMAZEPAM 30 MG CAPSULE   1 Preferred Generic $3.00$9.00Q:30
/30Days
Tencon 50-325 MG TABLET   4 Non-Preferred Brand $93.00$279.00Q:180
/30Days
TENIVAC SYRINGE   3 Preferred Brand $40.00$120.00None
TENOFOVIR DISOP FUM 300 MG TABLET [Viread]   5 Specialty Tier 33%N/AQ:30
/30Days
TENORETIC 100 TABLET   4 Non-Preferred Brand $93.00$279.00None
TENORETIC 50 TABLET   4 Non-Preferred Brand $93.00$279.00None
TENORMIN 100 MG TABLET   4 Non-Preferred Brand $93.00$279.00None
TENORMIN 25 MG TABLET   4 Non-Preferred Brand $93.00$279.00None
TENORMIN 50 MG TABLET   4 Non-Preferred Brand $93.00$279.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TERAZOSIN 1 MG CAPSULE   1 Preferred Generic $3.00$9.00Q:90
/30Days
TERAZOSIN 10 MG CAPSULE [Hytrin]   1 Preferred Generic $3.00$9.00Q:60
/30Days
TERAZOSIN 2 MG CAPSULE   1 Preferred Generic $3.00$9.00Q:60
/30Days
TERAZOSIN 5 MG CAPSULE [Hytrin]   1 Preferred Generic $3.00$9.00Q:60
/30Days
TERBINAFINE HCL 250 MG TABLET   1 Preferred Generic $3.00$9.00None
TERBUTALINE SULFATE 2.5 MG TAB   2 Generic $10.00$30.00None
TERBUTALINE SULFATE 5MG TABLET   2 Generic $10.00$30.00None
TERCONAZOLE 0.4% CREAM WITH APPLICATOR   2 Generic $10.00$30.00None
TERCONAZOLE 0.8% CREAM   2 Generic $10.00$30.00None
TERCONAZOLE 80MG SUPPOSITORY VAGINAL   2 Generic $10.00$30.00None
TESTOSTERONE 1.62% (1.25 G) PKT GEL PACKET [AndroGel]   2 Generic $10.00$30.00P Q:38
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TESTOSTERONE 1.62% (2.5 G) PKT GEL PACKET [AndroGel]   2 Generic $10.00$30.00P Q:150
/30Days
TESTOSTERONE 1.62% GEL PUMP GEL MD PMP [AndroGel]   2 Generic $10.00$30.00P Q:150
/30Days
TESTOSTERONE 12.5 MG/1.25 GRAM   2 Generic $10.00$30.00P Q:300
/30Days
Testosterone 2500 MG 0.01 MG/MG Topical Gel   2 Generic $10.00$30.00P Q:225
/30Days
TESTOSTERONE 30 MG/1.5 ML PUMP   2 Generic $10.00$30.00P Q:180
/30Days
Testosterone 5000 MG 0.01 MG/MG Topical Gel   2 Generic $10.00$30.00P Q:300
/30Days
Testosterone cyp 100 mg/ml   2 Generic $10.00$30.00P
TESTOSTERONE CYP 200 MG/ML   2 Generic $10.00$30.00P
TESTOSTERONE ENANTHATE 200MG/ML INJECTION   2 Generic $10.00$30.00P
TETRABENAZINE 12.5 MG TABLET [XENAZINE]   5 Specialty Tier 33%N/AP Q:240
/30Days
TETRABENAZINE 25 MG TABLET [XENAZINE]   5 Specialty Tier 33%N/AP Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TETRACYCLINE 250 MG CAPSULE   2 Generic $10.00$30.00None
TETRACYCLINE 500 MG CAPSULE   2 Generic $10.00$30.00None
THALOMID 100 MG CAPSULE   5 Specialty Tier 33%N/AP Q:30
/30Days
THALOMID 150 MG CAPSULE   5 Specialty Tier 33%N/AP Q:60
/30Days
THALOMID 200 MG CAPSULE   5 Specialty Tier 33%N/AP Q:60
/30Days
THALOMID 50 MG CAPSULE   5 Specialty Tier 33%N/AP Q:30
/30Days
THEO-24 ER 100 MG CAPSULE   4 Non-Preferred Brand $93.00$279.00None
THEO-24 ER 200 MG CAPSULE   4 Non-Preferred Brand $93.00$279.00None
THEO-24 ER 300 MG CAPSULE   4 Non-Preferred Brand $93.00$279.00None
THEO-24 ER 400 MG CAPSULE   4 Non-Preferred Brand $93.00$279.00None
THEOPHYLLINE ER 100 MG TABLET   2 Generic $10.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
THEOPHYLLINE ER 200 MG TABLET   2 Generic $10.00$30.00None
THEOPHYLLINE ER 300 MG TAB   2 Generic $10.00$30.00None
THEOPHYLLINE ER 400 MG TABLET   2 Generic $10.00$30.00None
THEOPHYLLINE ER 600 MG TABLET   2 Generic $10.00$30.00None
THIORIDAZINE 10 MG TABLET   3 Preferred Brand $40.00$120.00P
THIORIDAZINE 100MG TABLET   3 Preferred Brand $40.00$120.00P
THIORIDAZINE 25 MG TABLET   3 Preferred Brand $40.00$120.00P
THIORIDAZINE 50 MG TABLET   3 Preferred Brand $40.00$120.00P
THIOTHIXENE 1 MG CAPSULE   2 Generic $10.00$30.00P
THIOTHIXENE 10MG CAPSULE   2 Generic $10.00$30.00P
THIOTHIXENE 2MG CAPSULE   2 Generic $10.00$30.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
THIOTHIXENE 5MG CAPSULE   2 Generic $10.00$30.00P
TIAGABINE HCL 12 MG TABLET [Gabitril]   2 Generic $10.00$30.00None
TIAGABINE HCL 16 MG TABLET [Gabitril]   2 Generic $10.00$30.00None
tiagabine hcl 2 mg tablet [Gabitril]   2 Generic $10.00$30.00None
tiagabine hcl 4 mg tablet [Gabitril]   2 Generic $10.00$30.00None
TIAZAC ER 120 MG CAPSULE   4 Non-Preferred Brand $93.00$279.00None
TIAZAC ER 180 MG CAPSULE   4 Non-Preferred Brand $93.00$279.00None
TIAZAC ER 240 MG CAPSULE   4 Non-Preferred Brand $93.00$279.00None
TIAZAC ER 300 MG CAPSULE CAP SA 24H   4 Non-Preferred Brand $93.00$279.00None
TIAZAC ER 360 MG CAPSULE   4 Non-Preferred Brand $93.00$279.00None
TIAZAC ER 420 MG CAPSULE CAP SA 24H   4 Non-Preferred Brand $93.00$279.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TIBSOVO 250 MG TABLET   5 Specialty Tier 33%N/AP Q:60
/30Days
TIGECYCLINE 50 MG VIAL [Tygacil]   5 Specialty Tier 33%N/ANone
TIKOSYN .125MG CAPSULE   4 Non-Preferred Brand $93.00$279.00None
TIKOSYN .250MG CAPSULE   4 Non-Preferred Brand $93.00$279.00None
TIKOSYN .5MG CAPSULE   4 Non-Preferred Brand $93.00$279.00None
TIMOLOL 0.25% EYE DROPS   1 Preferred Generic $3.00$9.00None
TIMOLOL 0.25% GFS GEL-SOLUTION   2 Generic $10.00$30.00None
TIMOLOL 0.5% EYE DROPS   1 Preferred Generic $3.00$9.00None
TIMOLOL 0.5% EYE DROPS   2 Generic $10.00$30.00None
TIMOLOL 0.5% GFS GEL-SOLUTION   2 Generic $10.00$30.00None
TIMOLOL MALEATE 10MG TABLET   3 Preferred Brand $40.00$120.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TIMOLOL MALEATE 20MG TABLET   3 Preferred Brand $40.00$120.00None
TIMOLOL MALEATE 5MG TABLET   2 Generic $10.00$30.00None
TIMOPTIC 0.25% OCUDOSE DROP   4 Non-Preferred Brand $93.00$279.00None
TIMOPTIC 0.5% OCUDOSE DROP   4 Non-Preferred Brand $93.00$279.00None
TIROSINT 100 MCG CAPSULE   4 Non-Preferred Brand $93.00$279.00None
TIROSINT 112 MCG CAPSULE   4 Non-Preferred Brand $93.00$279.00None
TIROSINT 125 MCG CAPSULE   4 Non-Preferred Brand $93.00$279.00None
TIROSINT 13 MCG CAPSULE   4 Non-Preferred Brand $93.00$279.00None
TIROSINT 137 MCG CAPSULE   4 Non-Preferred Brand $93.00$279.00None
TIROSINT 150 MCG CAPSULE   4 Non-Preferred Brand $93.00$279.00None
TIROSINT 175 MCG CAPSULE   4 Non-Preferred Brand $93.00$279.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TIROSINT 200 MCG CAPSULE   4 Non-Preferred Brand $93.00$279.00None
TIROSINT 25 MCG CAPSULE   4 Non-Preferred Brand $93.00$279.00None
TIROSINT 50 MCG CAPSULE   4 Non-Preferred Brand $93.00$279.00None
TIROSINT 75 MCG CAPSULE   4 Non-Preferred Brand $93.00$279.00None
TIROSINT 88 MCG CAPSULE   4 Non-Preferred Brand $93.00$279.00None
TIROSINT-SOL 100 MCG/ML SOLUTION   4 Non-Preferred Brand $93.00$279.00None
TIROSINT-SOL 112 MCG/ML SOLUTION   4 Non-Preferred Brand $93.00$279.00None
TIROSINT-SOL 125 MCG/ML SOLUTION   4 Non-Preferred Brand $93.00$279.00None
TIROSINT-SOL 13 MCG/ML SOLUTION   4 Non-Preferred Brand $93.00$279.00None
TIROSINT-SOL 137 MCG/ML SOLUTION   4 Non-Preferred Brand $93.00$279.00None
TIROSINT-SOL 150 MCG/ML SOLUTION   4 Non-Preferred Brand $93.00$279.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TIROSINT-SOL 175 MCG/ML SOLUTION   4 Non-Preferred Brand $93.00$279.00None
TIROSINT-SOL 200 MCG/ML SOLUTION   4 Non-Preferred Brand $93.00$279.00None
TIROSINT-SOL 25 MCG/ML SOLUTION   4 Non-Preferred Brand $93.00$279.00None
TIROSINT-SOL 50 MCG/ML SOLUTION   4 Non-Preferred Brand $93.00$279.00None
TIROSINT-SOL 75 MCG/ML SOLUTION   4 Non-Preferred Brand $93.00$279.00None
TIROSINT-SOL 88 MCG/ML SOLUTION   4 Non-Preferred Brand $93.00$279.00None
TIVICAY 10 MG TABLET   4 Non-Preferred Brand $93.00$279.00Q:60
/30Days
TIVICAY 25 MG TABLET   5 Specialty Tier 33%N/AQ:60
/30Days
TIVICAY 50 MG TABLET   5 Specialty Tier 33%N/AQ:60
/30Days
TIZANIDINE HCL 2 MG CAPSULE   2 Generic $10.00$30.00None
TIZANIDINE HCL 2 MG TABLET   2 Generic $10.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TIZANIDINE HCL 4 MG CAPSULE   2 Generic $10.00$30.00None
TIZANIDINE HCL 4 MG TABLET   2 Generic $10.00$30.00None
TIZANIDINE HCL 6 MG CAPSULE   2 Generic $10.00$30.00None
TOBRADEX EYE OINTMENT   4 Non-Preferred Brand $93.00$279.00None
TOBRADEX SUSPENSION OPHTHALMIC 0.1%/0.3% 5ML BOT   4 Non-Preferred Brand $93.00$279.00None
TOBRAMYCIN 0.3% EYE DROPS [Tobrex]   2 Generic $10.00$30.00None
TOBRAMYCIN 10 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate]   2 Generic $10.00$30.00None
TOBRAMYCIN 300 MG/5 ML AMPULE [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate]   5 Specialty Tier 33%N/AP
TOBRAMYCIN 40 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate]   3 Preferred Brand $40.00$120.00None
TOBRAMYCIN-DEXAMETH OPTH SUSP   2 Generic $10.00$30.00None
Tolcapone 100 MG TABLET [Tasmar]   5 Specialty Tier 33%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TOLMETIN SODIUM 400 MG CAP   3 Preferred Brand $40.00$120.00Q:120
/30Days
TOLTERODINE TARTRATE 1 MG TAB [Detrol LA]   2 Generic $10.00$30.00Q:60
/30Days
TOLTERODINE TARTRATE 2 MG TABLET [Detrol]   2 Generic $10.00$30.00Q:60
/30Days
Tolterodine Tartrate 24 HR 4 MG Extended Release Oral Capsule [Detrol LA]   2 Generic $10.00$30.00Q:30
/30Days
Tolterodine Tartrate ER 2 MG CAPSULE [Detrol LA]   2 Generic $10.00$30.00Q:30
/30Days
TOLVAPTAN 15 MG ORAL TABLET [SAMSCA]   5 Specialty Tier 33%N/AP
TOLVAPTAN 30 MG ORAL TABLET [SAMSCA]   5 Specialty Tier 33%N/AP
TOPIRAMATE 100 MG TABLET   1 Preferred Generic $3.00$9.00None
TOPIRAMATE 15 MG SPRINKLE CAP   2 Generic $10.00$30.00None
TOPIRAMATE 200 MG TABLET   1 Preferred Generic $3.00$9.00None
TOPIRAMATE 25 MG TABLET   1 Preferred Generic $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Topiramate 25mg/1   2 Generic $10.00$30.00None
TOPIRAMATE 50 MG TABLET   1 Preferred Generic $3.00$9.00None
TOPROL XL 100 MG TABLET ER 24H   4 Non-Preferred Brand $93.00$279.00None
TOPROL XL 200 MG TABLET ER 24H   4 Non-Preferred Brand $93.00$279.00None
TOPROL XL 25 MG TABLET ER 24H   4 Non-Preferred Brand $93.00$279.00None
TOPROL XL 50 MG TABLET ER 24H   4 Non-Preferred Brand $93.00$279.00None
TOREMIFENE CITRATE 60 MG TABLET [Fareston]   5 Specialty Tier 33%N/ANone
TORSEMIDE 10 MG TABLET   1 Preferred Generic $3.00$9.00None
TORSEMIDE 100 MG TABLET   1 Preferred Generic $3.00$9.00None
TORSEMIDE 20 MG TABLET   1 Preferred Generic $3.00$9.00None
TORSEMIDE 5 MG TABLET   1 Preferred Generic $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TOUJEO MAX SOLOSTAR 300UNIT/ML INSULN PEN   3 Preferred Brand $40.00$120.00Q:60
/30Days
TOUJEO SOLOSTAR 300 UNITS/ML   3 Preferred Brand $40.00$120.00Q:60
/30Days
TOVIAZ TABLETS 4MG EXTENDED RELEASE   3 Preferred Brand $40.00$120.00Q:30
/30Days
TOVIAZ TABLETS 8MG EXTENDED RELEASE   3 Preferred Brand $40.00$120.00Q:30
/30Days
TRACLEER 125MG TABLET   5 Specialty Tier 33%N/AP Q:60
/30Days
TRACLEER 32 MG TABLET FOR SUSP   5 Specialty Tier 33%N/AP Q:120
/30Days
TRACLEER 62.5MG TABLET   5 Specialty Tier 33%N/AP Q:60
/30Days
TRADJENTA 5 MG TABLET   4 Non-Preferred Brand $93.00$279.00Q:30
/30Days
TRAMADOL HCL 50 MG TABLET   1 Preferred Generic $3.00$9.00Q:240
/30Days
TRAMADOL HCL ER 100 MG TABLET   2 Generic $10.00$30.00P Q:30
/30Days
TRAMADOL HCL ER 200 MG TABLET   2 Generic $10.00$30.00P Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRAMADOL HCL ER 300 MG Tablet ER 24H [Ultram ER]   2 Generic $10.00$30.00P Q:30
/30Days
TRAMADOL-ACETAMINOPHN 37.5-325   2 Generic $10.00$30.00Q:240
/30Days
TRANDOLAPRIL 1 MG TABLET   2 Generic $10.00$30.00None
TRANDOLAPRIL 2 MG TABLET   2 Generic $10.00$30.00None
TRANDOLAPRIL 4 MG TABLET   2 Generic $10.00$30.00None
tranexamic acid 650 mg tablet   2 Generic $10.00$30.00None
TRANYLCYPROMINE SULF 10 MG TABLET [Parnate]   2 Generic $10.00$30.00None
TRAVATAN Z 0.04MG DROPS 2.5ML BOT   3 Preferred Brand $40.00$120.00None
TRAZODONE 100 MG TABLET   1 Preferred Generic $3.00$9.00None
TRAZODONE 300 MG TABLET   1 Preferred Generic $3.00$9.00None
TRAZODONE 50 MG TABLET   1 Preferred Generic $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRAZODONE HCL TABLET USP 150MG (100 CT)   1 Preferred Generic $3.00$9.00None
TRECATOR 250MG TABLET   4 Non-Preferred Brand $93.00$279.00None
TRELEGY ELLIPTA 100-62.5-25   3 Preferred Brand $40.00$120.00Q:60
/30Days
TRELSTAR 11.25 MG SYRINGE   5 Specialty Tier 33%N/AP
TRELSTAR 3.75 MG SYRINGE   5 Specialty Tier 33%N/AP
TRESIBA 100 UNIT/ML VIAL   3 Preferred Brand $40.00$120.00Q:60
/30Days
TRESIBA FLEXTOUCH 100 UNITS/ML   3 Preferred Brand $40.00$120.00Q:60
/30Days
TRESIBA FLEXTOUCH 200 UNITS/ML   3 Preferred Brand $40.00$120.00Q:60
/30Days
TRETINOIN 0.01% GEL   2 Generic $10.00$30.00None
TRETINOIN 0.025% CREAM   2 Generic $10.00$30.00None
TRETINOIN 0.025% GEL   2 Generic $10.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRETINOIN 0.05% CREAM   2 Generic $10.00$30.00None
TRETINOIN 0.1% CREAM   2 Generic $10.00$30.00None
Tretinoin 0.25 MG/ML Topical Cream [Retin-A]   4 Non-Preferred Brand $93.00$279.00None
Tretinoin 0.5 MG/ML Topical Cream [Retin-A]   4 Non-Preferred Brand $93.00$279.00None
Tretinoin 1 MG/ML Topical Cream [Retin-A]   4 Non-Preferred Brand $93.00$279.00None
TRETINOIN 10MG CAPSULE   5 Specialty Tier 33%N/AP
TRI-ESTARYLLA TABLET [Trinessa]   2 Generic $10.00$30.00None
TRI-LEGEST FE 5-7-9-7 TABLET   2 Generic $10.00$30.00None
TRI-LO-ESTARYLLA TABLET [Trinessa Lo]   2 Generic $10.00$30.00None
TRI-LO-SPRINTEC TABLET   2 Generic $10.00$30.00None
TRI-MILI 28 TABLET [Trinessa]   2 Generic $10.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRI-PREVIFEM TABLET [Trinessa]   2 Generic $10.00$30.00None
TRI-SPRINTEC 7DAYSX3 28 TABLET   2 Generic $10.00$30.00None
TRI-VYLIBRA 28 TABLET [Trinessa]   2 Generic $10.00$30.00None
TRI-VYLIBRA LO TABLET [Trinessa Lo]   2 Generic $10.00$30.00None
TRIAMCINOLONE 0.025% CREAM   2 Generic $10.00$30.00None
TRIAMCINOLONE 0.025% LOTION   2 Generic $10.00$30.00None
TRIAMCINOLONE 0.025% OINT   2 Generic $10.00$30.00None
TRIAMCINOLONE 0.1% CREAM   2 Generic $10.00$30.00None
TRIAMCINOLONE 0.1% LOTION [Kenalog]   2 Generic $10.00$30.00None
TRIAMCINOLONE 0.1% OINTMENT   2 Generic $10.00$30.00None
TRIAMCINOLONE 0.1% PASTE   2 Generic $10.00$30.00None
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$30.00None
Triamcinolone Acetonide 1 MG/ML Topical Cream [Triderm]   2 Generic $10.00$30.00None
Triamcinolone Acetonide 5mg/g 1 TUBE per CARTON / 15 g in 1 TUBE   2 Generic $10.00$30.00None
TRIAMTERENE-HCTZ 37.5-25 MG CP   1 Preferred Generic $3.00$9.00None
TRIAMTERENE-HCTZ 37.5-25 MG TB   1 Preferred Generic $3.00$9.00None
TRIAMTERENE-HCTZ 75-50 MG TAB   1 Preferred Generic $3.00$9.00None
TRIBENZOR 20/5/12.5MG TABLETS   4 Non-Preferred Brand $93.00$279.00Q:30
/30Days
TRIBENZOR 40/10/12.5MG TABLETS   4 Non-Preferred Brand $93.00$279.00Q:30
/30Days
TRIBENZOR 40/10/25MG TABLETS   4 Non-Preferred Brand $93.00$279.00Q:30
/30Days
Tribenzor 5; 12.5; 40mg/1; mg/1; mg/1   4 Non-Preferred Brand $93.00$279.00Q:30
/30Days
Tribenzor 5; 25; 40mg/1; mg/1; mg/1   4 Non-Preferred Brand $93.00$279.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRIENTINE HCL 250 MG CAPSULE [Syprine]   5 Specialty Tier 33%N/AP Q:240
/30Days
TRIFLUOPERAZINE 1 MG TABLET   2 Generic $10.00$30.00P
TRIFLUOPERAZINE HCL 2MG TABLET   2 Generic $10.00$30.00P
TRIFLUOPERAZINE HCL 5MG TABLET   2 Generic $10.00$30.00P
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT)   2 Generic $10.00$30.00P
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT   2 Generic $10.00$30.00None
TRILEPTAL 150MG TABLET   4 Non-Preferred Brand $93.00$279.00None
TRILEPTAL 300MG TABLET   4 Non-Preferred Brand $93.00$279.00None
TRILEPTAL 300MG/5ML SUSP   5 Specialty Tier 33%N/ANone
TRILEPTAL 600MG TABLET   4 Non-Preferred Brand $93.00$279.00None
TRILYTE WITH FLAVOR PACKETS   2 Generic $10.00$30.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRIMETHOPRIM 100 MG TABLET   2 Generic $10.00$30.00None
TRIMIPRAMINE MALEATE 100 MG CP   4 Non-Preferred Brand $93.00$279.00P
TRIMIPRAMINE MALEATE 25 MG CAP   4 Non-Preferred Brand $93.00$279.00P
TRIMIPRAMINE MALEATE 50 MG CAP   4 Non-Preferred Brand $93.00$279.00P
TRINTELLIX 10 MG TABLET   4 Non-Preferred Brand $93.00$279.00Q:30
/30Days
TRINTELLIX 20 MG TABLET   4 Non-Preferred Brand $93.00$279.00Q:30
/30Days
TRINTELLIX 5 MG TABLET   4 Non-Preferred Brand $93.00$279.00Q:30
/30Days
Triptorelin 11.3 MG/ML Injectable Suspension [Trelstar]   5 Specialty Tier 33%N/AP
TRIUMEQ TABLET   5 Specialty Tier 33%N/AQ:30
/30Days
TRIVORA-28 TABLET   2 Generic $10.00$30.00None
TROPHAMINE INJECTION SOLUTION 6%   4 Non-Preferred Brand $93.00$279.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TROSPIUM CHLORIDE 20 MG TABLET   2 Generic $10.00$30.00Q:60
/30Days
TROSPIUM CHLORIDE ER 60 MG CAP   2 Generic $10.00$30.00Q:30
/30Days
TRULICITY 0.75 MG/0.5 ML PEN   4 Non-Preferred Brand $93.00$279.00S Q:2
/28Days
TRULICITY 1.5 MG/0.5 ML PEN   4 Non-Preferred Brand $93.00$279.00S Q:2
/28Days
TRUMENBA 120 MCG/0.5 ML VACCIN Syringe   3 Preferred Brand $40.00$120.00None
TRUSOPT PLUS 2% EYE DROPS 10ML BOT   4 Non-Preferred Brand $93.00$279.00None
TRUVADA 100 MG-150 MG TABLET   5 Specialty Tier 33%N/AQ:30
/30Days
TRUVADA 133 MG-200 MG TABLET   5 Specialty Tier 33%N/AQ:30
/30Days
TRUVADA 167 MG-250 MG TABLET   5 Specialty Tier 33%N/AQ:30
/30Days
TRUVADA 200/300MG TABLET   5 Specialty Tier 33%N/AQ:30
/30Days
TWINRIX VACCINE SYRINGE   3 Preferred Brand $40.00$120.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TYBOST 150 MG TABLET   3 Preferred Brand $40.00$120.00Q:30
/30Days
TYDEMY TABLET   2 Generic $10.00$30.00None
Tygacil 50mg/5mL 10 VIAL, SINGLE-USE per CARTON / 50 mL in 1 VIAL, SINGLE-USE   5 Specialty Tier 33%N/ANone
TYKERB 250 MG TABLET   5 Specialty Tier 33%N/AP Q:180
/30Days
TYMLOS 80 MCG DOSE PEN INJECTR   5 Specialty Tier 33%N/AP
TYPHIM VI 25 MCG/0.5 ML SYRINGE   3 Preferred Brand $40.00$120.00None
TYPHIM VI 25MCG/0.5ML VIAL   3 Preferred Brand $40.00$120.00None

Chart Legend:

Below are a few notes to help you understand the above 2019 Medicare Part D BlueMedicare Complete Rx (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.