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Express Scripts Medicare - Saver (PDP) (S5660-236-0)
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2020 Medicare Part D Plan Formulary Information
Express Scripts Medicare - Saver (PDP) (S5660-236-0)
Benefit Details           
The Express Scripts Medicare - Saver (PDP) (S5660-236-0)
Formulary Drugs Starting with the Letter T

in CMS PDP Region 20 which includes: MS
Plan Monthly Premium: $24.70 Deductible: $435 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 Drug 41%N/ANone
TABRECTA 150 MG TABLET   4 Non-Preferred Drug 41%N/AP
TABRECTA 200 MG TABLET   4 Non-Preferred Drug 41%N/AP
Tacrolimus 0.03% ointment   3 Preferred Brand $30.00$90.00P Q:100
/30Days
Tacrolimus 0.1% ointment   3 Preferred Brand $30.00$90.00P Q:100
/30Days
TACROLIMUS 0.5 MG CAPSULE   3 Preferred Brand $30.00$90.00P
TACROLIMUS 1 MG CAPSULE   3 Preferred Brand $30.00$90.00P
TACROLIMUS 5 MG CAPSULE   3 Preferred Brand $30.00$90.00P
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
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
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
TAGRISSO 80 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
TALZENNA 0.25 MG CAPSULE   5 Specialty Tier 25%N/AP Q:90
/30Days
TALZENNA 1 MG CAPSULE   5 Specialty Tier 25%N/AP Q:30
/30Days
TAMOXIFEN 10 MG TABLET [Nolvadex]   2* Generic $4.00$8.00None
TAMOXIFEN 20 MG TABLET [Nolvadex]   2* Generic $4.00$8.00None
TAMSULOSIN HCL 0.4 MG CAPSULE   2* Generic $4.00$8.00Q:60
/30Days
TARGRETIN 1% GEL   5 Specialty Tier 25%N/AP
TARINA 24 FE 1 MG-20 MCG 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
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
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 $30.00$90.00P
TAZICEF 1GM VIAL   4 Non-Preferred Drug 41%N/ANone
TAZICEF 2 GRAM VIAL   4 Non-Preferred Drug 41%N/ANone
TAZICEF 6 GRAM VIAL   4 Non-Preferred Drug 41%N/ANone
TAZORAC 0.05% CREAM (G)   3 Preferred Brand $30.00$90.00P
TAZVERIK 200 MG TABLET   4 Non-Preferred Drug 41%N/AP
TDVAX VIAL   3 Preferred Brand $30.00$90.00None
TECFIDERA DR 120 MG CAPSULE   5 Specialty Tier 25%N/AP
TECFIDERA DR 240 MG CAPSULE   5 Specialty Tier 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TECFIDERA STARTER PACK   5 Specialty Tier 25%N/AP
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 20 MG TABLET [Micardis]   2* Generic $4.00$8.00None
TELMISARTAN 40 MG TABLET [Micardis]   2* Generic $4.00$8.00None
TELMISARTAN 80 MG TABLET [Micardis]   2* Generic $4.00$8.00None
TENIVAC SYRINGE   3 Preferred Brand $30.00$90.00None
TENOFOVIR DISOP FUM 300 MG TABLET [Viread]   3 Preferred Brand $30.00$90.00Q:30
/30Days
TERAZOSIN 1 MG CAPSULE   2* Generic $4.00$8.00Q:30
/30Days
TERAZOSIN 10 MG CAPSULE [Hytrin]   2* Generic $4.00$8.00Q:60
/30Days
TERAZOSIN 2 MG CAPSULE   2* Generic $4.00$8.00Q: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 $4.00$8.00Q:30
/30Days
TERBINAFINE HCL 250 MG TABLET [Terbinex]   2* Generic $4.00$8.00None
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   3 Preferred Brand $30.00$90.00None
TERCONAZOLE 0.8% CREAM   3 Preferred Brand $30.00$90.00None
TERCONAZOLE 80MG SUPPOSITORY VAGINAL   4 Non-Preferred Drug 41%N/ANone
TERIPARATIDE 620 MCG/2.48 ML PEN INJECTOR [Forteo]   5 Specialty Tier 25%N/AP Q:2
/28Days
TESTOSTERON CYP 2,000 MG/10 ML VIAL [Virilon]   3 Preferred Brand $30.00$90.00P
TESTOSTERON ENAN 1,000 MG/5 ML VIAL [Delatestryl]   4 Non-Preferred Drug 41%N/AP
TESTOSTERONE 1.62% (2.5 G) PKT GEL PACKET [AndroGel]   3 Preferred Brand $30.00$90.00P Q:150
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TESTOSTERONE 1.62% GEL PUMP GEL MD PMP [AndroGel]   3 Preferred Brand $30.00$90.00P Q:150
/30Days
TESTOSTERONE 1.62%(1.25 G) GEL PACKET [AndroGel]   3 Preferred Brand $30.00$90.00P Q:38
/30Days
TESTOSTERONE 25 MG/2.5 GM GEL PACKET [Vogelxo]   3 Preferred Brand $30.00$90.00P Q:300
/30Days
Testosterone cyp 100 mg/ml   3 Preferred Brand $30.00$90.00P
TESTOSTERONE CYP 200 MG/ML   3 Preferred Brand $30.00$90.00P
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   4 Non-Preferred Drug 41%N/ANone
TETRACYCLINE 500 MG CAPSULE   4 Non-Preferred Drug 41%N/ANone
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
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
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
THEOPHYLLINE ER 300 MG TAB   2* Generic $4.00$8.00None
THEOPHYLLINE ER 400 MG TABLET   2* Generic $4.00$8.00None
THEOPHYLLINE ER 600 MG TABLET   2* Generic $4.00$8.00None
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$0.00None
TIMOLOL 0.25% GFS GEL-SOLUTION   2* Generic $4.00$8.00None
TIMOLOL 0.5% EYE DROPS   2* Generic $4.00$8.00None
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$0.00None
TIMOLOL 0.5% GFS GEL-SOLUTION   2* Generic $4.00$8.00None
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
TIVICAY 10 MG TABLET   3 Preferred Brand $30.00$90.00Q: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 $4.00$8.00None
TIZANIDINE HCL 4 MG TABLET   2* Generic $4.00$8.00None
TOBRAMYCIN 0.3% EYE DROPS [Tobrex]   2* Generic $4.00$8.00None
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]   2* Generic $4.00$8.00None
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 $30.00$90.00None
TOLTERODINE TART ER 2 MG CAPSULE ER 24H [Detrol LA]   3 Preferred Brand $30.00$90.00None
TOLTERODINE TART ER 4 MG CAPSULE ER 24H [Detrol LA]   3 Preferred Brand $30.00$90.00None
TOLTERODINE TARTRATE 1 MG TABLET [Detrol LA]   4 Non-Preferred Drug 41%N/ANone
TOLTERODINE TARTRATE 2 MG TABLET [Detrol]   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   2* Generic $4.00$8.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TOPIRAMATE 15 MG SPRINKLE CAP   2* Generic $4.00$8.00P
TOPIRAMATE 200 MG TABLET [Topiragen]   2* Generic $4.00$8.00P
TOPIRAMATE 25 MG TABLET   2* Generic $4.00$8.00P
Topiramate 25mg/1   2* Generic $4.00$8.00P
TOPIRAMATE 50 MG TABLET [Topiragen]   2* Generic $4.00$8.00P
TOREMIFENE CITRATE 60 MG TABLET [Fareston]   5 Specialty Tier 25%N/ANone
TORSEMIDE 10 MG TABLET   2* Generic $4.00$8.00None
TORSEMIDE 100 MG TABLET   2* Generic $4.00$8.00None
TORSEMIDE 20 MG TABLET   2* Generic $4.00$8.00None
TORSEMIDE 5 MG TABLET [Demadex]   2* Generic $4.00$8.00None
TOUJEO MAX SOLOSTAR 300UNIT/ML INSULN PEN   3 Preferred Brand $30.00$90.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TOUJEO SOLOSTAR 300 UNITS/ML   3 Preferred Brand $30.00$90.00None
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
TRACLEER 125MG TABLET   5 Specialty Tier 25%N/AP
TRACLEER 32 MG TABLET FOR SUSP   5 Specialty Tier 25%N/AP
TRACLEER 62.5MG TABLET   5 Specialty Tier 25%N/AP
TRADJENTA 5 MG TABLET   3 Preferred Brand $30.00$90.00Q:30
/30Days
TRAMADOL HCL 100 MG TABLET   3 Preferred Brand $30.00$90.00Q:120
/30Days
TRAMADOL HCL 50 MG TABLET   2* Generic $4.00$8.00Q:240
/30Days
TRANEXAMIC ACID 650 MG TABLET [Lysteda]   3 Preferred Brand $30.00$90.00None
TRANYLCYPROMINE SULF 10 MG TABLET [Parnate]   4 Non-Preferred Drug 41%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRAVASOL 10% SOLUTION VIAFLEX   4 Non-Preferred Drug 41%N/AP
TRAVOPROST 0.004% EYE DROPS [Travatan]   3 Preferred Brand $30.00$90.00None
TRAZODONE 100 MG TABLET   2* Generic $4.00$8.00None
TRAZODONE 150 MG TABLET [Desyrel]   2* Generic $4.00$8.00None
TRAZODONE 300 MG TABLET [Desyrel]   2* Generic $4.00$8.00None
TRAZODONE 50 MG TABLET   2* Generic $4.00$8.00None
TRECATOR 250MG TABLET   4 Non-Preferred Drug 41%N/ANone
TRELEGY ELLIPTA 100-62.5-25   3 Preferred Brand $30.00$90.00Q:60
/30Days
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 [Tretin-X]   3 Preferred Brand $30.00$90.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRETINOIN 0.025% CREAM   4 Non-Preferred Drug 41%N/AP
TRETINOIN 0.025% GEL [Tretin-X]   4 Non-Preferred Drug 41%N/AP
TRETINOIN 0.05% CREAM   4 Non-Preferred Drug 41%N/AP
TRETINOIN 0.05% GEL [Atralin]   4 Non-Preferred Drug 41%N/AP
TRETINOIN 0.1% CREAM   4 Non-Preferred Drug 41%N/AP
TRETINOIN 10MG CAPSULE   5 Specialty Tier 25%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-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
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRIAMCINOLONE 0.025% CREAM   2* Generic $4.00$8.00None
TRIAMCINOLONE 0.025% LOTION   3 Preferred Brand $30.00$90.00None
TRIAMCINOLONE 0.025% OINT   2* Generic $4.00$8.00None
TRIAMCINOLONE 0.05% OINTMENT [Trianex]   2* Generic $4.00$8.00None
TRIAMCINOLONE 0.1% CREAM (g) [Triderm]   2* Generic $4.00$8.00None
TRIAMCINOLONE 0.1% LOTION [Kenalog]   3 Preferred Brand $30.00$90.00None
TRIAMCINOLONE 0.1% OINTMENT [Triderm]   2* Generic $4.00$8.00None
TRIAMCINOLONE 0.1% PASTE (G) [Oralone]   4 Non-Preferred Drug 41%N/ANone
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE   2* Generic $4.00$8.00None
Triamcinolone Acetonide 1 MG/ML Topical Cream [Triderm]   2* Generic $4.00$8.00None
Triamcinolone Acetonide 5mg/g 1 TUBE per CARTON / 15 g in 1 TUBE   2* Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRIAMTERENE 100 MG CAPSULE [Dyrenium]   3 Preferred Brand $30.00$90.00None
TRIAMTERENE 50 MG CAPSULE [Dyrenium]   3 Preferred Brand $30.00$90.00None
TRIAMTERENE-HCTZ 37.5-25 MG CAPSULE [Dyazide]   2* Generic $4.00$8.00None
TRIAMTERENE-HCTZ 37.5-25 MG TB   2* Generic $4.00$8.00None
TRIAMTERENE-HCTZ 75-50 MG TAB   2* Generic $4.00$8.00None
TRIENTINE HCL 250 MG CAPSULE [Syprine]   5 Specialty Tier 25%N/AP Q:240
/30Days
TRIFLUOPERAZINE 1 MG TABLET   3 Preferred Brand $30.00$90.00None
TRIFLUOPERAZINE HCL 2MG TABLET   3 Preferred Brand $30.00$90.00None
TRIFLUOPERAZINE HCL 5MG TABLET   3 Preferred Brand $30.00$90.00None
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT)   3 Preferred Brand $30.00$90.00None
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT   3 Preferred Brand $30.00$90.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRIJARDY XR 10-5-1,000 MG TABLET BP 24H   4 Non-Preferred Drug 41%N/AQ:30
/30Days
TRIJARDY XR 12.5-2.5-1,000 MG TAB BP 24H   4 Non-Preferred Drug 41%N/AQ:60
/30Days
TRIJARDY XR 25-5-1,000 MG TABLET BP 24H   4 Non-Preferred Drug 41%N/AQ:30
/30Days
TRIJARDY XR 5-2.5-1,000 MG TABLET BP 24H   4 Non-Preferred Drug 41%N/AQ:60
/30Days
TRILYTE WITH FLAVOR PACKETS   2* Generic $4.00$8.00None
TRIMETHOPRIM 100 MG TABLET   2* Generic $4.00$8.00None
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
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRINTELLIX 5 MG TABLET   4 Non-Preferred Drug 41%N/AQ:30
/30Days
Triptorelin 11.3 MG/ML Injectable Suspension [Trelstar]   5 Specialty Tier 25%N/AP
TRIUMEQ TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
TROPHAMINE INJECTION SOLUTION   3 Preferred Brand $30.00$90.00P
TRULANCE 3 MG TABLET   4 Non-Preferred Drug 41%N/ANone
TRULICITY 0.75 MG/0.5 ML PEN   3 Preferred Brand $30.00$90.00P Q:2
/28Days
TRULICITY 1.5 MG/0.5 ML PEN   3 Preferred Brand $30.00$90.00P Q:2
/28Days
TRUMENBA 120 MCG/0.5 ML VACCIN Syringe   3 Preferred Brand $30.00$90.00None
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
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRUVADA 200/300MG TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
TUKYSA 150 MG TABLET   4 Non-Preferred Drug 41%N/AP Q:120
/30Days
TUKYSA 50 MG TABLET   4 Non-Preferred Drug 41%N/AP
TWINRIX VACCINE SYRINGE   3 Preferred Brand $30.00$90.00None
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 $30.00$90.00None
TYPHIM VI 25MCG/0.5ML VIAL   3 Preferred Brand $30.00$90.00None

Chart Legend:

Below are a few notes to help you understand the above 2020 Medicare Part D Express Scripts Medicare - Saver (PDP) Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug or Medicare Advantage 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 $435 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.
    • Tier Number* - Some Part D drug plans exclude one or more drug tiers from the plan’s 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 - This is what you will pay for formulary drugs in 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 initial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $4020) 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 2020 )

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 Medicare plan provider.