Q1GROUP LLC | Q1Medicare.com - a non-government resource for the Medicare community
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

Select your search style and criteria below or use this example to get started

Search by:
State & Plan   ZIP & Plan   PlanID   FormularyID

Search Criteria
PDP     MAPD
Scroll down to see formulary results.

DrMax (HMO-POS) (H4140-001-0)
Tier 1 (742)
Tier 2 (1280)
Tier 3 (338)
Tier 4 (851)
Tier 5 (866)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
Yes No Show either
Cick on the first letter of your drug name to browse the formulary:

A B C D E F G H I J K L 
M N O P Q R S T U V W X Y Z 0-9 
2020 Medicare Part D Plan Formulary Information
DrMax (HMO-POS) (H4140-001-0)
Benefit Details           
The DrMax (HMO-POS) (H4140-001-0)
Formulary Drugs Starting with the Letter T

in Miami-Dade County, FL: CMS MA Region 9 which includes: FL
Plan Monthly Premium: $0.00 Deductible: $0
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 Tier 4 $35.00$105.00None
TABRECTA 150 MG TABLET   5 Tier 5 33%N/AP Q:120
/30Days
TABRECTA 200 MG TABLET   5 Tier 5 33%N/AP Q:120
/30Days
Tacrolimus 0.03% ointment   4 Tier 4 $35.00$105.00P
Tacrolimus 0.1% ointment   4 Tier 4 $35.00$105.00P
TACROLIMUS 0.5 MG CAPSULE   2 Tier 2 $0.00$0.00P
TACROLIMUS 1 MG CAPSULE   2 Tier 2 $0.00$0.00P
TACROLIMUS 5 MG CAPSULE   4 Tier 4 $35.00$105.00P
TADALAFIL 20 MG TABLET [ALYQ]   5 Tier 5 33%N/AP Q:60
/30Days
TADALAFIL 5 MG TABLET [Cialis]   4 Tier 4 $35.00$105.00P Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TAFINLAR 50 MG CAPSULE   5 Tier 5 33%N/AP
TAFINLAR 75 MG CAPSULE   5 Tier 5 33%N/AP
TAGRISSO 40 MG TABLET   5 Tier 5 33%N/AP Q:30
/30Days
TAGRISSO 80 MG TABLET   5 Tier 5 33%N/AP Q:30
/30Days
TALZENNA 0.25 MG CAPSULE   5 Tier 5 33%N/AP
TALZENNA 1 MG CAPSULE   5 Tier 5 33%N/AP
TAMIFLU 6 MG/ML SUSPENSION   4 Tier 4 $35.00$105.00Q:2250
/365Days
TAMOXIFEN 10 MG TABLET [Nolvadex]   2 Tier 2 $0.00$0.00None
TAMOXIFEN 20 MG TABLET [Nolvadex]   2 Tier 2 $0.00$0.00None
TAMSULOSIN HCL 0.4 MG CAPSULE   1 Tier 1 $0.00$0.00None
TARGRETIN 1% GEL   5 Tier 5 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Tarina Fe 1-20 tablet   2 Tier 2 $0.00$0.00None
Tasigna 150mg/1 4 BLISTER PACK per CARTON / 28 CAPSULE per BLISTER PACK   5 Tier 5 33%N/AP
TASIGNA 200 MG CAPSULE   5 Tier 5 33%N/AP
TASIGNA 50 MG CAPSULE   5 Tier 5 33%N/AP
TAVALISSE 100 MG TABLET   5 Tier 5 33%N/AP
TAVALISSE 150 MG TABLET   5 Tier 5 33%N/AP
TAZAROTENE 0.1% CREAM [Tazorac]   4 Tier 4 $35.00$105.00P
TAZICEF 1GM VIAL   3 Tier 3 $0.00$0.00None
TAZICEF 2 GRAM VIAL   3 Tier 3 $0.00$0.00None
TAZICEF 6 GRAM VIAL   3 Tier 3 $0.00$0.00None
TAZORAC 0.05% CREAM (G)   4 Tier 4 $35.00$105.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TAZORAC 0.05% GEL   4 Tier 4 $35.00$105.00P Q:100
/30Days
TAZORAC 0.1% CREAM   4 Tier 4 $35.00$105.00P Q:100
/30Days
TAZORAC 0.1% GEL   4 Tier 4 $35.00$105.00P Q:100
/30Days
TAZTIA XT 120 MG CAPSULE SA 24H [Tiazac]   2 Tier 2 $0.00$0.00None
TAZTIA XT 180 MG CAPSULE   2 Tier 2 $0.00$0.00None
TAZTIA XT 240 MG CAPSULE SA 24H [Tiazac]   2 Tier 2 $0.00$0.00None
TAZTIA XT 300 MG CAPSULE   2 Tier 2 $0.00$0.00None
TAZTIA XT 360 MG CAPSULE SA 24H [Tiazac]   2 Tier 2 $0.00$0.00None
TAZVERIK 200 MG TABLET   5 Tier 5 33%N/AP
TDVAX VIAL   3 Tier 3 $0.00$0.00None
TECFIDERA DR 120 MG CAPSULE   5 Tier 5 33%N/AP Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TECFIDERA DR 240 MG CAPSULE   5 Tier 5 33%N/AP Q:60
/30Days
TECFIDERA STARTER PACK   5 Tier 5 33%N/AP Q:120
/365Days
Teflaro 400mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE   5 Tier 5 33%N/ANone
Teflaro 600mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE   5 Tier 5 33%N/ANone
TEGRETOL SUSPENSION 100MG/5ML 450 ML BOT   4 Tier 4 $35.00$105.00None
TEGRETOL TABLETS 200MG 100 BOT   4 Tier 4 $35.00$105.00None
TEGRETOL XR TABLETS 100MG 100 BOT   4 Tier 4 $35.00$105.00None
TEGRETOL XR TABLETS 200MG 100 BOT   4 Tier 4 $35.00$105.00None
TEGRETOL XR TABLETS 400MG 100 BOT   4 Tier 4 $35.00$105.00None
TEGSEDI 284 MG/1.5 ML SYRINGE   5 Tier 5 33%N/AQ:6
/30Days
TEKTURNA 150 MG TABLET   4 Tier 4 $35.00$105.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TEKTURNA 300 MG TABLET   4 Tier 4 $35.00$105.00None
TEKTURNA HCT 300-25 MG TABLET   4 Tier 4 $35.00$105.00None
TELMISARTAN 20 MG TABLET [Micardis]   1 Tier 1 $0.00$0.00None
TELMISARTAN 40 MG TABLET [Micardis]   1 Tier 1 $0.00$0.00None
TELMISARTAN 80 MG TABLET [Micardis]   1 Tier 1 $0.00$0.00None
Telmisartan-Amlodipine 40-10 MG [Micardis]   2 Tier 2 $0.00$0.00None
Telmisartan-Amlodipine 40-5 MG [Micardis]   2 Tier 2 $0.00$0.00None
Telmisartan-Amlodipine 80-10 MG [Micardis]   2 Tier 2 $0.00$0.00None
Telmisartan-Amlodipine 80-5 MG [Micardis]   2 Tier 2 $0.00$0.00None
TELMISARTAN-HCTZ 40-12.5 MG TABLET [Micardis HCT]   1 Tier 1 $0.00$0.00None
TELMISARTAN-HCTZ 80-12.5 MG TABLET [Micardis HCT]   1 Tier 1 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TELMISARTAN-HCTZ 80-25 MG TABLET [Micardis HCT]   1 Tier 1 $0.00$0.00None
TEMAZEPAM 15 MG CAPSULE [Restoril]   1 Tier 1 $0.00$0.00Q:30
/30Days
TEMAZEPAM 22.5 MG CAPSULE   1 Tier 1 $0.00$0.00Q:30
/30Days
TEMAZEPAM 30 MG CAPSULE   1 Tier 1 $0.00$0.00Q:30
/30Days
Temazepam 7.5mg/1 100 CAPSULE BOTTLE, PLASTIC   1 Tier 1 $0.00$0.00Q:30
/30Days
Tencon 50-325 MG TABLET   4 Tier 4 $35.00$105.00Q:360
/30Days
TENIVAC SYRINGE   3 Tier 3 $0.00$0.00None
TENOFOVIR DISOP FUM 300 MG TABLET [Viread]   3 Tier 3 $0.00$0.00None
TERAZOSIN 1 MG CAPSULE   1 Tier 1 $0.00$0.00None
TERAZOSIN 10 MG CAPSULE [Hytrin]   1 Tier 1 $0.00$0.00None
TERAZOSIN 2 MG CAPSULE   1 Tier 1 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TERAZOSIN 5 MG CAPSULE [Hytrin]   1 Tier 1 $0.00$0.00None
TERBINAFINE HCL 250 MG TABLET [Terbinex]   1 Tier 1 $0.00$0.00Q:84
/180Days
TERBUTALINE SULFATE 2.5 MG TAB   4 Tier 4 $35.00$105.00None
TERBUTALINE SULFATE 5MG TABLET   4 Tier 4 $35.00$105.00None
TERCONAZOLE 0.4% CREAM WITH APPLICATOR   2 Tier 2 $0.00$0.00None
TERCONAZOLE 0.8% CREAM   2 Tier 2 $0.00$0.00None
TERCONAZOLE 80MG SUPPOSITORY VAGINAL   2 Tier 2 $0.00$0.00None
TERIPARATIDE 620 MCG/2.48 ML PEN INJECTOR [Forteo]   5 Tier 5 33%N/AP
TESTOSTERON CYP 2,000 MG/10 ML VIAL [Virilon]   2 Tier 2 $0.00$0.00None
TESTOSTERON ENAN 1,000 MG/5 ML VIAL [Delatestryl]   2 Tier 2 $0.00$0.00None
TESTOSTERONE 1.62% (2.5 G) PKT GEL PACKET [AndroGel]   3 Tier 3 $0.00$0.00None
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 Tier 3 $0.00$0.00None
TESTOSTERONE 1.62%(1.25 G) GEL PACKET [AndroGel]   3 Tier 3 $0.00$0.00None
TESTOSTERONE 12.5 MG/1.25 GRAM GEL MD PMP [Vogelxo]   3 Tier 3 $0.00$0.00None
TESTOSTERONE 25 MG/2.5 GM GEL PACKET [Vogelxo]   3 Tier 3 $0.00$0.00Q:300
/30Days
TESTOSTERONE 50 MG/5 GRAM GEL PACKET [Vogelxo]   3 Tier 3 $0.00$0.00Q:300
/30Days
Testosterone cyp 100 mg/ml   2 Tier 2 $0.00$0.00None
TESTOSTERONE CYP 200 MG/ML   2 Tier 2 $0.00$0.00None
TETRABENAZINE 12.5 MG TABLET [XENAZINE]   5 Tier 5 33%N/AP
TETRABENAZINE 25 MG TABLET [XENAZINE]   5 Tier 5 33%N/AP
TETRACYCLINE 250 MG CAPSULE   2 Tier 2 $0.00$0.00None
TETRACYCLINE 500 MG CAPSULE   2 Tier 2 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
THALOMID 100 MG CAPSULE   5 Tier 5 33%N/AP
THALOMID 150 MG CAPSULE   5 Tier 5 33%N/AP
THALOMID 200 MG CAPSULE   5 Tier 5 33%N/AP
THALOMID 50 MG CAPSULE   5 Tier 5 33%N/AP
THEOPHYLLINE 80 MG/15 ML SOLN   2 Tier 2 $0.00$0.00None
THEOPHYLLINE ER 300 MG TAB   2 Tier 2 $0.00$0.00None
THEOPHYLLINE ER 400 MG TABLET   2 Tier 2 $0.00$0.00None
THEOPHYLLINE ER 600 MG TABLET   2 Tier 2 $0.00$0.00None
THIOLA EC 100 MG TABLET DR   5 Tier 5 33%N/AP Q:180
/30Days
THIOLA EC 300 MG TABLET DR   5 Tier 5 33%N/AP Q:180
/30Days
THIORIDAZINE 10 MG TABLET   1 Tier 1 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
THIORIDAZINE 100MG TABLET   1 Tier 1 $0.00$0.00None
THIORIDAZINE 25 MG TABLET   1 Tier 1 $0.00$0.00None
THIORIDAZINE 50 MG TABLET   1 Tier 1 $0.00$0.00None
THIOTHIXENE 1 MG CAPSULE   2 Tier 2 $0.00$0.00None
THIOTHIXENE 10MG CAPSULE   2 Tier 2 $0.00$0.00None
THIOTHIXENE 2MG CAPSULE   2 Tier 2 $0.00$0.00None
THIOTHIXENE 5MG CAPSULE   2 Tier 2 $0.00$0.00None
TIADYLT ER 120 MG CAPSULE SA 24H [Tiazac]   1 Tier 1 $0.00$0.00None
TIADYLT ER 180 MG CAPSULE SA 24H [Tiazac]   1 Tier 1 $0.00$0.00None
TIADYLT ER 240 MG CAPSULE SA 24H [Tiazac]   1 Tier 1 $0.00$0.00None
TIADYLT ER 300 MG CAPSULE SA 24H [Tiazac]   1 Tier 1 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TIADYLT ER 360 MG CAPSULE SA 24H [Tiazac]   1 Tier 1 $0.00$0.00None
TIADYLT ER 420 MG CAPSULE SA 24H [Tiazac]   1 Tier 1 $0.00$0.00None
TIAGABINE HCL 12 MG TABLET [Gabitril]   4 Tier 4 $35.00$105.00None
TIAGABINE HCL 16 MG TABLET [Gabitril]   4 Tier 4 $35.00$105.00None
TIAGABINE HCL 2 MG TABLET [Gabitril]   4 Tier 4 $35.00$105.00None
TIAGABINE HCL 4 MG TABLET [Gabitril]   4 Tier 4 $35.00$105.00None
TIBSOVO 250 MG TABLET   5 Tier 5 33%N/AP
TIGECYCLINE 50 MG VIAL [Tygacil]   5 Tier 5 33%N/ANone
TIGLUTIK 50 MG/10 ML Oral Suspension   4 Tier 4 $35.00$105.00None
TIMOLOL 0.25% EYE DROPS   1 Tier 1 $0.00$0.00None
TIMOLOL 0.25% GFS GEL-SOLUTION   2 Tier 2 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TIMOLOL 0.5% EYE DROPS   1 Tier 1 $0.00$0.00None
TIMOLOL 0.5% EYE DROPS   4 Tier 4 $35.00$105.00None
TIMOLOL 0.5% GFS GEL-SOLUTION   2 Tier 2 $0.00$0.00None
TIMOLOL MALEATE 10MG TABLET   2 Tier 2 $0.00$0.00None
TIMOLOL MALEATE 20MG TABLET   2 Tier 2 $0.00$0.00None
TIMOLOL MALEATE 5MG TABLET   2 Tier 2 $0.00$0.00None
TIMOPTIC-XE 0.5% GEL-SOLUTION SOL-GEL   4 Tier 4 $35.00$105.00None
TINIDAZOLE 250 MG TABLET   2 Tier 2 $0.00$0.00None
TINIDAZOLE 500 MG TABLET   2 Tier 2 $0.00$0.00None
TIROSINT 100 MCG CAPSULE   4 Tier 4 $35.00$105.00None
TIROSINT 112 MCG CAPSULE   4 Tier 4 $35.00$105.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TIROSINT 125 MCG CAPSULE   4 Tier 4 $35.00$105.00None
TIROSINT 13 MCG CAPSULE   4 Tier 4 $35.00$105.00None
TIROSINT 137 MCG CAPSULE   4 Tier 4 $35.00$105.00None
TIROSINT 150 MCG CAPSULE   4 Tier 4 $35.00$105.00None
TIROSINT 25 MCG CAPSULE   4 Tier 4 $35.00$105.00None
TIROSINT 50 MCG CAPSULE   4 Tier 4 $35.00$105.00None
TIROSINT 75 MCG CAPSULE   4 Tier 4 $35.00$105.00None
TIROSINT 88 MCG CAPSULE   4 Tier 4 $35.00$105.00None
TIROSINT-SOL 100 MCG/ML SOLUTION   4 Tier 4 $35.00$105.00None
TIROSINT-SOL 112 MCG/ML SOLUTION   4 Tier 4 $35.00$105.00None
TIROSINT-SOL 125 MCG/ML SOLUTION   4 Tier 4 $35.00$105.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TIROSINT-SOL 13 MCG/ML SOLUTION   4 Tier 4 $35.00$105.00None
TIROSINT-SOL 137 MCG/ML SOLUTION   4 Tier 4 $35.00$105.00None
TIROSINT-SOL 150 MCG/ML SOLUTION   4 Tier 4 $35.00$105.00None
TIROSINT-SOL 175 MCG/ML SOLUTION   4 Tier 4 $35.00$105.00None
TIROSINT-SOL 200 MCG/ML SOLUTION   4 Tier 4 $35.00$105.00None
TIROSINT-SOL 25 MCG/ML SOLUTION   4 Tier 4 $35.00$105.00None
TIROSINT-SOL 50 MCG/ML SOLUTION   4 Tier 4 $35.00$105.00None
TIROSINT-SOL 75 MCG/ML SOLUTION   4 Tier 4 $35.00$105.00None
TIROSINT-SOL 88 MCG/ML SOLUTION   4 Tier 4 $35.00$105.00None
TIVICAY 10 MG TABLET   3 Tier 3 $0.00$0.00None
TIVICAY 25 MG TABLET   3 Tier 3 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TIVICAY 50 MG TABLET   3 Tier 3 $0.00$0.00None
TIZANIDINE HCL 2 MG TABLET   1 Tier 1 $0.00$0.00None
TIZANIDINE HCL 4 MG TABLET   1 Tier 1 $0.00$0.00None
TOBI PODHALER 28 MG INHALE CAP   5 Tier 5 33%N/AQ:224
/56Days
TOBRADEX EYE OINTMENT   4 Tier 4 $35.00$105.00None
TOBRADEX ST 0.5; 3mg/mL; mg/mL 5 mL in 1 BOTTLE   4 Tier 4 $35.00$105.00None
TOBRAMYCIN 0.3% EYE DROPS [Tobrex]   1 Tier 1 $0.00$0.00None
TOBRAMYCIN 10 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate]   2 Tier 2 $0.00$0.00None
TOBRAMYCIN 300 MG/5 ML AMPULE [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate]   5 Tier 5 33%N/AP
TOBRAMYCIN 40 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate]   2 Tier 2 $0.00$0.00None
TOBRAMYCIN-DEXAMETH OPTH SUSP   2 Tier 2 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TOBREX 0.3% EYE OINTMENT   4 Tier 4 $35.00$105.00None
TOLCAPONE 100 MG TABLET [Tasmar]   5 Tier 5 33%N/ANone
TOLMETIN SODIUM 400 MG CAP   2 Tier 2 $0.00$0.00None
TOLMETIN SODIUM 600MG TABLET   4 Tier 4 $35.00$105.00None
TOLTERODINE TART ER 2 MG CAPSULE ER 24H [Detrol LA]   2 Tier 2 $0.00$0.00None
TOLTERODINE TART ER 4 MG CAPSULE ER 24H [Detrol LA]   2 Tier 2 $0.00$0.00None
TOLTERODINE TARTRATE 1 MG TABLET [Detrol LA]   2 Tier 2 $0.00$0.00None
TOLTERODINE TARTRATE 2 MG TABLET [Detrol]   2 Tier 2 $0.00$0.00None
TOLVAPTAN 15 MG ORAL TABLET [SAMSCA]   5 Tier 5 33%N/AQ:60
/30Days
TOLVAPTAN 30 MG ORAL TABLET [SAMSCA]   5 Tier 5 33%N/AQ:60
/30Days
TOPIRAMATE 100 MG TABLET   1 Tier 1 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TOPIRAMATE 15 MG SPRINKLE CAP   2 Tier 2 $0.00$0.00None
TOPIRAMATE 200 MG TABLET [Topiragen]   1 Tier 1 $0.00$0.00None
TOPIRAMATE 25 MG TABLET   1 Tier 1 $0.00$0.00None
Topiramate 25mg/1   2 Tier 2 $0.00$0.00None
TOPIRAMATE 50 MG TABLET [Topiragen]   1 Tier 1 $0.00$0.00None
TOREMIFENE CITRATE 60 MG TABLET [Fareston]   5 Tier 5 33%N/ANone
TORSEMIDE 10 MG TABLET   1 Tier 1 $0.00$0.00None
TORSEMIDE 100 MG TABLET   1 Tier 1 $0.00$0.00None
TORSEMIDE 20 MG TABLET   1 Tier 1 $0.00$0.00None
TORSEMIDE 5 MG TABLET [Demadex]   1 Tier 1 $0.00$0.00None
TOUJEO MAX SOLOSTAR 300UNIT/ML INSULN PEN   3 Tier 3 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TOUJEO SOLOSTAR 300 UNITS/ML   3 Tier 3 $0.00$0.00None
TOVIAZ TABLETS 4MG EXTENDED RELEASE   4 Tier 4 $35.00$105.00S
TOVIAZ TABLETS 8MG EXTENDED RELEASE   4 Tier 4 $35.00$105.00S
TPN ELECTROLYTES16.5/25.4 VIAL   4 Tier 4 $35.00$105.00None
TRADJENTA 5 MG TABLET   3 Tier 3 $0.00$0.00None
TRAMADOL ER 100 MG TABLET   2 Tier 2 $0.00$0.00None
TRAMADOL ER 200 MG TABLET   2 Tier 2 $0.00$0.00None
TRAMADOL ER 300 MG TABLET TBMP 24HR [Ultram ER]   2 Tier 2 $0.00$0.00None
TRAMADOL HCL 100 MG TABLET   1 Tier 1 $0.00$0.00None
TRAMADOL HCL 50 MG TABLET   1 Tier 1 $0.00$0.00None
TRAMADOL HCL ER 100 MG TABLET   2 Tier 2 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRAMADOL HCL ER 200 MG TABLET   2 Tier 2 $0.00$0.00None
TRAMADOL HCL ER 300 MG Tablet ER 24H [Ultram ER]   2 Tier 2 $0.00$0.00None
TRAMADOL-ACETAMINOPHN 37.5-325   2 Tier 2 $0.00$0.00None
TRANDOLAPRIL 1 MG TABLET   1 Tier 1 $0.00$0.00None
TRANDOLAPRIL 2 MG TABLET   1 Tier 1 $0.00$0.00None
TRANDOLAPRIL 4 MG TABLET   1 Tier 1 $0.00$0.00None
TRANDOLAPRIL-VERAPAMIL ER 1-240 MG   1 Tier 1 $0.00$0.00None
TRANDOLAPRIL-VERAPAMIL ER 2-240 MG   1 Tier 1 $0.00$0.00None
TRANDOLAPRIL-VERAPAMIL ER 4-240 MG   1 Tier 1 $0.00$0.00None
TRANEXAMIC ACID 650 MG TABLET [Lysteda]   1 Tier 1 $0.00$0.00None
TRANSDERM-SCOP 1.5 MG/3 DAY   4 Tier 4 $35.00$105.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRANYLCYPROMINE SULF 10 MG TABLET [Parnate]   4 Tier 4 $35.00$105.00None
TRAVASOL 10% SOLUTION VIAFLEX   4 Tier 4 $35.00$105.00P
TRAVOPROST 0.004% EYE DROPS [Travatan]   1 Tier 1 $0.00$0.00None
TRAZODONE 100 MG TABLET   1 Tier 1 $0.00$0.00None
TRAZODONE 150 MG TABLET [Desyrel]   1 Tier 1 $0.00$0.00None
TRAZODONE 300 MG TABLET [Desyrel]   2 Tier 2 $0.00$0.00None
TRAZODONE 50 MG TABLET   1 Tier 1 $0.00$0.00None
TRECATOR 250MG TABLET   4 Tier 4 $35.00$105.00None
TRELEGY ELLIPTA 100-62.5-25   3 Tier 3 $0.00$0.00Q:60
/30Days
TRELSTAR 11.25 MG SYRINGE   5 Tier 5 33%N/AP Q:1
/84Days
TRELSTAR 3.75 MG SYRINGE   5 Tier 5 33%N/AP Q:1
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRESIBA 100 UNIT/ML VIAL   3 Tier 3 $0.00$0.00None
TRESIBA FLEXTOUCH 100 UNITS/ML   3 Tier 3 $0.00$0.00None
TRESIBA FLEXTOUCH 200 UNITS/ML   3 Tier 3 $0.00$0.00None
Tretinoin 0.0004 MG/MG Topical Gel   4 Tier 4 $35.00$105.00P
Tretinoin 0.001 MG/MG Topical Gel   4 Tier 4 $35.00$105.00P
TRETINOIN 0.01% GEL [Tretin-X]   4 Tier 4 $35.00$105.00P
TRETINOIN 0.025% CREAM   4 Tier 4 $35.00$105.00P
TRETINOIN 0.025% GEL [Tretin-X]   4 Tier 4 $35.00$105.00P
TRETINOIN 0.05% CREAM   4 Tier 4 $35.00$105.00P
TRETINOIN 0.05% GEL [Atralin]   4 Tier 4 $35.00$105.00P
TRETINOIN 0.1% CREAM   4 Tier 4 $35.00$105.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRETINOIN 10MG CAPSULE   5 Tier 5 33%N/ANone
TREXALL 10MG TABLET   4 Tier 4 $35.00$105.00None
TREXALL 15MG TABLET   4 Tier 4 $35.00$105.00None
TREXALL 5MG TABLET   4 Tier 4 $35.00$105.00None
TREXALL 7.5MG TABLET   4 Tier 4 $35.00$105.00None
TRI-LEGEST FE 5-7-9-7 TABLET   2 Tier 2 $0.00$0.00None
TRI-LO-ESTARYLLA TABLET [Trinessa Lo]   2 Tier 2 $0.00$0.00None
TRI-LO-SPRINTEC TABLET   2 Tier 2 $0.00$0.00None
TRI-PREVIFEM TABLET [Trinessa]   2 Tier 2 $0.00$0.00None
TRI-SPRINTEC 7DAYSX3 28 TABLET   2 Tier 2 $0.00$0.00None
TRIAMCINOLONE 0.025% CREAM   1 Tier 1 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRIAMCINOLONE 0.025% LOTION   1 Tier 1 $0.00$0.00None
TRIAMCINOLONE 0.025% OINT   1 Tier 1 $0.00$0.00None
TRIAMCINOLONE 0.05% OINTMENT [Trianex]   1 Tier 1 $0.00$0.00None
TRIAMCINOLONE 0.1% CREAM (g) [Triderm]   1 Tier 1 $0.00$0.00None
TRIAMCINOLONE 0.1% LOTION [Kenalog]   1 Tier 1 $0.00$0.00None
TRIAMCINOLONE 0.1% OINTMENT [Triderm]   1 Tier 1 $0.00$0.00None
TRIAMCINOLONE 0.1% PASTE (G) [Oralone]   2 Tier 2 $0.00$0.00None
Triamcinolone 0.147 MG/G Spray   4 Tier 4 $35.00$105.00None
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE   1 Tier 1 $0.00$0.00None
Triamcinolone Acetonide 1 MG/ML Topical Cream [Triderm]   1 Tier 1 $0.00$0.00None
Triamcinolone Acetonide 5mg/g 1 TUBE per CARTON / 15 g in 1 TUBE   1 Tier 1 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRIAMTERENE 100 MG CAPSULE [Dyrenium]   2 Tier 2 $0.00$0.00None
TRIAMTERENE 50 MG CAPSULE [Dyrenium]   2 Tier 2 $0.00$0.00None
TRIAMTERENE-HCTZ 37.5-25 MG CAPSULE [Dyazide]   1 Tier 1 $0.00$0.00None
TRIAMTERENE-HCTZ 37.5-25 MG TB   1 Tier 1 $0.00$0.00None
TRIAMTERENE-HCTZ 75-50 MG TAB   1 Tier 1 $0.00$0.00None
TRIFLUOPERAZINE 1 MG TABLET   2 Tier 2 $0.00$0.00None
TRIFLUOPERAZINE HCL 2MG TABLET   2 Tier 2 $0.00$0.00None
TRIFLUOPERAZINE HCL 5MG TABLET   2 Tier 2 $0.00$0.00None
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT)   2 Tier 2 $0.00$0.00None
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT   2 Tier 2 $0.00$0.00None
TRIHEXYPHENIDYL 2 MG TABLET   1 Tier 1 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRIHEXYPHENIDYL 5 MG TABLET [Artane]   1 Tier 1 $0.00$0.00None
Trihexyphenidyl Hydrochloride 2mg/5mL 473 mL in 1 BOTTLE   2 Tier 2 $0.00$0.00None
TRIJARDY XR 10-5-1,000 MG TABLET BP 24H   3 Tier 3 $0.00$0.00Q:30
/30Days
TRIJARDY XR 12.5-2.5-1,000 MG TAB BP 24H   3 Tier 3 $0.00$0.00Q:60
/30Days
TRIJARDY XR 25-5-1,000 MG TABLET BP 24H   3 Tier 3 $0.00$0.00Q:30
/30Days
TRIJARDY XR 5-2.5-1,000 MG TABLET BP 24H   3 Tier 3 $0.00$0.00Q:60
/30Days
TRIKAFTA 100/50/75 MG-150 MG TABLET SEQ   5 Tier 5 33%N/AP
TRILYTE WITH FLAVOR PACKETS   2 Tier 2 $0.00$0.00None
TRIMETHOBENZAMIDE 300 MG CAP   2 Tier 2 $0.00$0.00P
TRIMETHOPRIM 100 MG TABLET   1 Tier 1 $0.00$0.00None
TRIMIPRAMINE MALEATE 100 MG CP   4 Tier 4 $35.00$105.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRIMIPRAMINE MALEATE 25 MG CAP   4 Tier 4 $35.00$105.00None
TRIMIPRAMINE MALEATE 50 MG CAP   4 Tier 4 $35.00$105.00None
TRINTELLIX 10 MG TABLET   4 Tier 4 $35.00$105.00S Q:30
/30Days
TRINTELLIX 20 MG TABLET   4 Tier 4 $35.00$105.00S Q:30
/30Days
TRINTELLIX 5 MG TABLET   4 Tier 4 $35.00$105.00S Q:30
/30Days
Triptorelin 11.3 MG/ML Injectable Suspension [Trelstar]   5 Tier 5 33%N/AP Q:1
/168Days
TRIUMEQ TABLET   5 Tier 5 33%N/AQ:30
/30Days
TRIVORA-28 TABLET [Trivora]   2 Tier 2 $0.00$0.00None
TROPHAMINE INJECTION SOLUTION   4 Tier 4 $35.00$105.00P
TROSPIUM CHLORIDE 20 MG TABLET   2 Tier 2 $0.00$0.00None
TROSPIUM CHLORIDE ER 60 MG CAP   2 Tier 2 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRULICITY 0.75 MG/0.5 ML PEN   3 Tier 3 $0.00$0.00Q:2
/28Days
TRULICITY 1.5 MG/0.5 ML PEN   3 Tier 3 $0.00$0.00Q:2
/28Days
TRUMENBA 120 MCG/0.5 ML VACCIN Syringe   3 Tier 3 $0.00$0.00None
TRUVADA 100 MG-150 MG TABLET   5 Tier 5 33%N/AQ:30
/30Days
TRUVADA 133 MG-200 MG TABLET   5 Tier 5 33%N/AQ:30
/30Days
TRUVADA 167 MG-250 MG TABLET   5 Tier 5 33%N/AQ:30
/30Days
TRUVADA 200/300MG TABLET   5 Tier 5 33%N/AQ:30
/30Days
TUKYSA 150 MG TABLET   5 Tier 5 33%N/AP
TUKYSA 50 MG TABLET   5 Tier 5 33%N/AP
TURALIO 200 MG CAPSULE   5 Tier 5 33%N/AP
TWINRIX VACCINE SYRINGE   3 Tier 3 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TYBOST 150 MG TABLET   3 Tier 3 $0.00$0.00None
Tygacil 50mg/5mL 10 VIAL, SINGLE-USE per CARTON / 50 mL in 1 VIAL, SINGLE-USE   5 Tier 5 33%N/ANone
TYKERB 250 MG TABLET   5 Tier 5 33%N/AP
TYPHIM VI 25 MCG/0.5 ML SYRINGE   3 Tier 3 $0.00$0.00None
TYPHIM VI 25MCG/0.5ML VIAL   3 Tier 3 $0.00$0.00None

Chart Legend:

Below are a few notes to help you understand the above 2020 Medicare Part D DrMax (HMO-POS) 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.