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SOLIS SPF 002 (HMO D-SNP) (H0982-002-0)
Tier 1 (702)
Tier 2 (1750)
Tier 3 (467)
Tier 4 (435)
Tier 5 (566)
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2021 Medicare Part D Plan Formulary Information
SOLIS SPF 002 (HMO D-SNP) (H0982-002-0)
Benefits & Contact Info           
The SOLIS SPF 002 (HMO D-SNP) (H0982-002-0)
Formulary Drugs Starting with the Letter T

in Miami-Dade County, FL: CMS MA Region 9 which includes: FL
Plan Monthly Premium: $30.80 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   3 Preferred Brand 0%N/ANone
TABRECTA 150 MG TABLET   5 Specialty Tier 25%N/AP Q:120
/30Days
TABRECTA 200 MG TABLET   5 Specialty Tier 25%N/AP Q:120
/30Days
TACLONEX SCALP SUSPENSION   4 Non-Preferred Brand 25%N/AP Q:420
/30Days
TACROLIMUS 0.03% OINTMENT [Protopic]   2 Generic 0%0%Q:100
/30Days
TACROLIMUS 0.1% OINTMENT [Protopic]   2 Generic 0%0%Q:100
/30Days
TACROLIMUS 0.5 MG CAPSULE   1 Preferred Generic 0%0%P
TACROLIMUS 1 MG CAPSULE   1 Preferred Generic 0%0%P
TACROLIMUS 5 MG CAPSULE   1 Preferred Generic 0%0%P
TADALAFIL 20 MG TABLET [ALYQ]   1 Preferred Generic 0%0%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
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
TAGRISSO 80 MG TABLET   5 Specialty Tier 25%N/AP
TAKHZYRO 300 MG/2 ML VIAL   5 Specialty Tier 25%N/AP Q:4
/28Days
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]   1 Preferred Generic 0%0%None
TAMOXIFEN 20 MG TABLET [Nolvadex]   1 Preferred Generic 0%0%None
TAMSULOSIN HCL 0.4 MG CAPSULE [Flomax]   1 Preferred Generic 0%0%None
TARGRETIN 1% GEL   5 Specialty Tier 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TARINA 24 FE 1 MG-20 MCG TABLET   2 Generic 0%0%None
TARINA FE 1-20 EQ TABLET   2 Generic 0%0%None
Tasigna 150mg/1 4 BLISTER PACK per CARTON / 28 CAPSULE per BLISTER PACK   5 Specialty Tier 25%N/AP
TASIGNA 200 MG CAPSULE   5 Specialty Tier 25%N/AP
TASIGNA 50 MG CAPSULE   5 Specialty Tier 25%N/AP
TAVALISSE 100 MG TABLET   5 Specialty Tier 25%N/AP Q:60
/30Days
TAVALISSE 150 MG TABLET   5 Specialty Tier 25%N/AP Q:60
/30Days
TAZAROTENE 0.1% CREAM [Tazorac]   2 Generic 0%0%None
TAZICEF 1GM VIAL   2 Generic 0%0%None
TAZICEF 2 GRAM VIAL   2 Generic 0%0%None
TAZICEF 6 GRAM VIAL   2 Generic 0%0%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TAZORAC 0.05% CREAM (G)   4 Non-Preferred Brand 25%N/ANone
TAZORAC 0.05% GEL   4 Non-Preferred Brand 25%N/ANone
TAZORAC 0.1% GEL   4 Non-Preferred Brand 25%N/ANone
TAZTIA XT 120 MG CAPSULE SA 24H [Tiazac]   2 Generic 0%0%None
TAZTIA XT 180 MG CAPSULE   2 Generic 0%0%None
TAZTIA XT 240 MG CAPSULE SA 24H [Tiazac]   2 Generic 0%0%None
TAZTIA XT 300 MG CAPSULE   2 Generic 0%0%None
TAZTIA XT 360 MG CAPSULE SA 24H [Tiazac]   2 Generic 0%0%None
TAZVERIK 200 MG TABLET   5 Specialty Tier 25%N/AP Q:240
/30Days
TDVAX VIAL   3 Preferred Brand 0%N/AP
TECFIDERA DR 120 MG CAPSULE   5 Specialty Tier 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TECFIDERA DR 240 MG CAPSULE   5 Specialty Tier 25%N/ANone
TECFIDERA STARTER PACK   5 Specialty Tier 25%N/ANone
Teflaro 400mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE   5 Specialty Tier 25%N/ANone
Teflaro 600mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE   5 Specialty Tier 25%N/ANone
TEGSEDI 284 MG/1.5 ML SYRINGE   5 Specialty Tier 25%N/AP Q:6
/28Days
TEKTURNA HCT 300-25 MG TABLET   4 Non-Preferred Brand 25%N/ANone
TELMISARTAN 20 MG TABLET [Micardis]   2 Generic 0%0%None
TELMISARTAN 40 MG TABLET [Micardis]   2 Generic 0%0%None
TELMISARTAN 80 MG TABLET [Micardis]   2 Generic 0%0%None
TEMAZEPAM 15 MG CAPSULE [Restoril]   1 Preferred Generic 0%0%None
TEMAZEPAM 22.5 MG CAPSULE   2 Generic 0%0%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TEMAZEPAM 30 MG CAPSULE [Restoril]   1 Preferred Generic 0%0%None
TEMAZEPAM 7.5 MG CAPSULE [Restoril]   2 Generic 0%0%None
TENIVAC SYRINGE   3 Preferred Brand 0%N/AP
TENOFOVIR DISOP FUM 300 MG TABLET [Viread]   2 Generic 0%0%None
TERAZOSIN 1 MG CAPSULE   1 Preferred Generic 0%0%None
TERAZOSIN 10 MG CAPSULE [Hytrin]   1 Preferred Generic 0%0%None
TERAZOSIN 2 MG CAPSULE   1 Preferred Generic 0%0%None
TERAZOSIN 5 MG CAPSULE [Hytrin]   1 Preferred Generic 0%0%None
TERBINAFINE HCL 250 MG TABLET [Terbinex]   1 Preferred Generic 0%0%None
TERBUTALINE SULFATE 2.5 MG TAB   2 Generic 0%0%None
TERBUTALINE SULFATE 5MG TABLET   2 Generic 0%0%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TERCONAZOLE 0.4% CREAM WITH APPLICATOR   2 Generic 0%0%None
TERCONAZOLE 0.8% CREAM   2 Generic 0%0%None
TERCONAZOLE 80MG SUPPOSITORY VAGINAL   2 Generic 0%0%None
TESTOSTERON CYP 2,000 MG/10 ML VIAL [Virilon]   2 Generic 0%0%None
TESTOSTERON ENAN 1,000 MG/5 ML VIAL [Delatestryl]   2 Generic 0%0%None
TESTOSTERONE 1.62% (2.5 G) PKT GEL PACKET [AndroGel]   2 Generic 0%0%P Q:150
/30Days
TESTOSTERONE 1.62% GEL PUMP GEL MD PMP [AndroGel]   2 Generic 0%0%P Q:150
/30Days
TESTOSTERONE 1.62%(1.25 G) GEL PACKET [AndroGel]   2 Generic 0%0%P Q:75
/30Days
TESTOSTERONE 12.5 MG/1.25 GRAM GEL MD PMP [Vogelxo]   4 Non-Preferred Brand 25%N/AP Q:300
/30Days
TESTOSTERONE 25 MG/2.5 GM GEL PACKET [Vogelxo]   2 Generic 0%0%P Q:300
/30Days
TESTOSTERONE 50 MG/5 GRAM GEL PACKET [Vogelxo]   2 Generic 0%0%P 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 0%0%None
TESTOSTERONE CYP 200 MG/ML   2 Generic 0%0%None
TETRABENAZINE 12.5 MG TABLET [XENAZINE]   2 Generic 0%0%P
TETRABENAZINE 25 MG TABLET [XENAZINE]   2 Generic 0%0%P
TETRACYCLINE 250 MG CAPSULE   2 Generic 0%0%None
TETRACYCLINE 500 MG CAPSULE [Sumycin]   2 Generic 0%0%None
THALOMID 100 MG CAPSULE   5 Specialty Tier 25%N/AP
THALOMID 150 MG CAPSULE   5 Specialty Tier 25%N/AP
THALOMID 200 MG CAPSULE   5 Specialty Tier 25%N/AP
THALOMID 50 MG CAPSULE   5 Specialty Tier 25%N/AP
THEO-24 ER 100 MG CAPSULE   4 Non-Preferred Brand 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
THEO-24 ER 200 MG CAPSULE   4 Non-Preferred Brand 25%N/ANone
THEO-24 ER 300 MG CAPSULE   4 Non-Preferred Brand 25%N/ANone
THEO-24 ER 400 MG CAPSULE   4 Non-Preferred Brand 25%N/ANone
THEOPHYLLINE 80 MG/15 ML SOLUTION   2 Generic 0%0%None
THEOPHYLLINE ER 300 MG TAB   3 Preferred Brand 0%N/ANone
THEOPHYLLINE ER 400 MG TABLET   1 Preferred Generic 0%0%None
THEOPHYLLINE ER 600 MG TABLET   1 Preferred Generic 0%0%None
THIOLA 100 MG TABLET   4 Non-Preferred Brand 25%N/ANone
THIOLA EC 100 MG TABLET DR   4 Non-Preferred Brand 25%N/ANone
THIOLA EC 300 MG TABLET DR   4 Non-Preferred Brand 25%N/ANone
THIORIDAZINE 10 MG TABLET   2 Generic 0%0%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
THIORIDAZINE 100MG TABLET   2 Generic 0%0%None
THIORIDAZINE 25 MG TABLET   2 Generic 0%0%None
THIORIDAZINE 50 MG TABLET   2 Generic 0%0%None
THIOTHIXENE 1 MG CAPSULE [Navane]   2 Generic 0%0%None
THIOTHIXENE 10 MG CAPSULE [Navane]   2 Generic 0%0%None
THIOTHIXENE 2 MG CAPSULE [Navane]   2 Generic 0%0%None
THIOTHIXENE 5MG CAPSULE   2 Generic 0%0%None
TIADYLT ER 120 MG CAPSULE SA 24H [Tiazac]   2 Generic 0%0%None
TIADYLT ER 180 MG CAPSULE SA 24H [Tiazac]   2 Generic 0%0%None
TIADYLT ER 240 MG CAPSULE SA 24H [Tiazac]   2 Generic 0%0%None
TIADYLT ER 300 MG CAPSULE SA 24H [Tiazac]   2 Generic 0%0%None
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]   2 Generic 0%0%None
TIADYLT ER 420 MG CAPSULE SA 24H [Tiazac]   2 Generic 0%0%None
TIAGABINE HCL 12 MG TABLET [Gabitril]   2 Generic 0%0%None
TIAGABINE HCL 16 MG TABLET [Gabitril]   2 Generic 0%0%None
TIAGABINE HCL 2 MG TABLET [Gabitril]   2 Generic 0%0%None
TIAGABINE HCL 4 MG TABLET [Gabitril]   2 Generic 0%0%None
TIBSOVO 250 MG TABLET   5 Specialty Tier 25%N/AP Q:60
/30Days
TIGECYCLINE 50 MG VIAL [Tygacil]   5 Specialty Tier 25%N/ANone
TIMOLOL 0.25% EYE DROPS   1 Preferred Generic 0%0%None
TIMOLOL 0.25% GFS GEL-SOLUTION   3 Preferred Brand 0%N/ANone
TIMOLOL 0.5% EYE DROPS   2 Generic 0%0%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TIMOLOL 0.5% GFS GEL-SOLUTION   3 Preferred Brand 0%N/ANone
TIMOLOL MALEATE 0.5% EYE DROPS [Timoptic Ocumeter]   1 Preferred Generic 0%0%None
TIMOLOL MALEATE 10MG TABLET   2 Generic 0%0%None
TIMOLOL MALEATE 20MG TABLET   2 Generic 0%0%None
TIMOLOL MALEATE 5MG TABLET   2 Generic 0%0%None
TIMOPTIC 0.25% OCUDOSE DROP   4 Non-Preferred Brand 25%N/ANone
TIMOPTIC 0.5% OCUDOSE DROP   4 Non-Preferred Brand 25%N/ANone
TIMOPTIC-XE 0.25% EYE GEL-SOLUTION SOL-GEL   3 Preferred Brand 0%N/ANone
TIMOPTIC-XE 0.5% GEL-SOLUTION SOL-GEL   3 Preferred Brand 0%N/ANone
TINIDAZOLE 250 MG TABLET   2 Generic 0%0%None
TINIDAZOLE 500 MG TABLET   2 Generic 0%0%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TIVICAY 10 MG TABLET   4 Non-Preferred Brand 25%N/ANone
TIVICAY 25 MG TABLET   4 Non-Preferred Brand 25%N/ANone
TIVICAY 50 MG TABLET   5 Specialty Tier 25%N/ANone
TIVICAY PD 5 MG TABLET FOR SUSPENSION   3 Preferred Brand 0%N/ANone
TIZANIDINE HCL 2 MG TABLET   2 Generic 0%0%None
TIZANIDINE HCL 4 MG TABLET   2 Generic 0%0%None
TIZANIDINE HCL 6 MG CAPSULE   2 Generic 0%0%None
TOBRADEX EYE OINTMENT   3 Preferred Brand 0%N/ANone
TOBRADEX ST 0.5; 3mg/mL; mg/mL 5 mL in 1 BOTTLE   4 Non-Preferred Brand 25%N/ANone
TOBRAMYCIN 0.3% EYE DROPS [Tobrex]   2 Generic 0%0%Q:60
/30Days
TOBRAMYCIN 10 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate]   2 Generic 0%0%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TOBRAMYCIN 300 MG/5 ML AMPULE [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate]   5 Specialty Tier 25%N/AP Q:300
/30Days
TOBRAMYCIN 40 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate]   2 Generic 0%0%None
TOBRAMYCIN-DEXAMETH OPTH SUSP   2 Generic 0%0%None
TOBREX 0.3% EYE OINTMENT   4 Non-Preferred Brand 25%N/AQ:7
/7Days
TOLCAPONE 100 MG TABLET [Tasmar]   2 Generic 0%0%None
TOLMETIN SODIUM 400 MG CAP   4 Non-Preferred Brand 25%N/ANone
TOLMETIN SODIUM 600MG TABLET   4 Non-Preferred Brand 25%N/ANone
TOLTERODINE TART ER 2 MG CAPSULE ER 24H [Detrol LA]   2 Generic 0%0%None
TOLTERODINE TART ER 4 MG CAPSULE ER 24H [Detrol LA]   2 Generic 0%0%None
TOLTERODINE TARTRATE 1 MG TABLET [Detrol LA]   2 Generic 0%0%None
TOLTERODINE TARTRATE 2 MG TABLET [Detrol]   2 Generic 0%0%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TOPIRAMATE 100 MG TABLET   1 Preferred Generic 0%0%None
TOPIRAMATE 15 MG SPRINKLE CAP   2 Generic 0%0%None
TOPIRAMATE 200 MG TABLET [Topiragen]   1 Preferred Generic 0%0%None
TOPIRAMATE 25 MG TABLET   1 Preferred Generic 0%0%None
Topiramate 25mg/1   2 Generic 0%0%None
TOPIRAMATE 50 MG TABLET [Topiragen]   1 Preferred Generic 0%0%None
TOPIRAMATE ER 100 MG CAPSULE   4 Non-Preferred Brand 25%N/AP
TOPIRAMATE ER 150 MG CAPSULE   4 Non-Preferred Brand 25%N/AP
TOPIRAMATE ER 200 MG CAPSULE   4 Non-Preferred Brand 25%N/AP
TOPIRAMATE ER 25 MG CAPSULE   4 Non-Preferred Brand 25%N/AP
TOPIRAMATE ER 50 MG CAPSULE   4 Non-Preferred Brand 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TOREMIFENE CITRATE 60 MG TABLET [Fareston]   2 Generic 0%0%None
TORSEMIDE 10 MG TABLET   1 Preferred Generic 0%0%None
TORSEMIDE 100 MG TABLET   1 Preferred Generic 0%0%None
TORSEMIDE 20 MG TABLET   1 Preferred Generic 0%0%None
TORSEMIDE 5 MG TABLET [Demadex]   1 Preferred Generic 0%0%None
TOUJEO MAX SOLOSTAR 300UNIT/ML INSULN PEN   3 Preferred Brand 0%N/ANone
TOUJEO SOLOSTAR 300 UNITS/ML   3 Preferred Brand 0%N/ANone
TPN ELECTROLYTES16.5/25.4 VIAL   2 Generic 0%0%P
TRACLEER 32 MG TABLET FOR SUSP   5 Specialty Tier 25%N/AP Q:120
/30Days
TRADJENTA 5 MG TABLET   3 Preferred Brand 0%N/AQ:30
/30Days
TRAMADOL HCL 50 MG TABLET [Ultram]   2 Generic 0%0%Q:240
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRAMADOL HCL ER 200 MG TABLET   2 Generic 0%0%Q:60
/30Days
TRAMADOL HCL ER 300 MG Tablet ER 24H [Ultram ER]   2 Generic 0%0%Q:60
/30Days
TRAMADOL-ACETAMINOPHN 37.5-325   2 Generic 0%0%Q:360
/30Days
TRANDOLAPRIL 1 MG TABLET   1 Preferred Generic 0%0%None
TRANDOLAPRIL 2 MG TABLET   1 Preferred Generic 0%0%None
TRANDOLAPRIL 4 MG TABLET   1 Preferred Generic 0%0%None
TRANDOLAPRIL-VERAPAMIL ER 1-240 MG   4 Non-Preferred Brand 25%N/ANone
TRANDOLAPRIL-VERAPAMIL ER 2-180 MG   2 Generic 0%0%None
TRANDOLAPRIL-VERAPAMIL ER 2-240 MG   2 Generic 0%0%None
TRANDOLAPRIL-VERAPAMIL ER 4-240 MG   2 Generic 0%0%None
TRANEXAMIC ACID 650 MG TABLET [Lysteda]   2 Generic 0%0%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRANYLCYPROMINE SULF 10 MG TABLET [Parnate]   2 Generic 0%0%None
TRAVASOL 10% SOLUTION VIAFLEX   4 Non-Preferred Brand 25%N/AP
TRAVOPROST 0.004% EYE DROPS [Travatan]   2 Generic 0%0%Q:5
/30Days
TRAZODONE 100 MG TABLET   1 Preferred Generic 0%0%None
TRAZODONE 150 MG TABLET [Desyrel]   1 Preferred Generic 0%0%None
TRAZODONE 300 MG TABLET [Desyrel]   2 Generic 0%0%None
TRAZODONE 50 MG TABLET   1 Preferred Generic 0%0%None
TRECATOR 250MG TABLET   4 Non-Preferred Brand 25%N/ANone
TRELEGY ELLIPTA 100-62.5-25   3 Preferred Brand 0%N/AQ:60
/30Days
TRELSTAR 11.25 MG SYRINGE   5 Specialty Tier 25%N/ANone
TRELSTAR 3.75 MG SYRINGE   5 Specialty Tier 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRESIBA 100 UNIT/ML VIAL   3 Preferred Brand 0%N/ANone
TRESIBA FLEXTOUCH 100 UNITS/ML   3 Preferred Brand 0%N/ANone
TRESIBA FLEXTOUCH 200 UNITS/ML   3 Preferred Brand 0%N/ANone
Tretinoin 0.0004 MG/MG Topical Gel   2 Generic 0%0%P
Tretinoin 0.001 MG/MG Topical Gel   2 Generic 0%0%P
TRETINOIN 0.01% GEL [Tretin-X]   2 Generic 0%0%P
TRETINOIN 0.025% CREAM (G) [Tretin-X]   2 Generic 0%0%P
TRETINOIN 0.025% GEL [Tretin-X]   2 Generic 0%0%P
TRETINOIN 0.05% CREAM   2 Generic 0%0%P
TRETINOIN 0.05% GEL [Atralin]   2 Generic 0%0%P
TRETINOIN 0.1% CREAM   2 Generic 0%0%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRETINOIN 10MG CAPSULE   1 Preferred Generic 0%0%None
TRI-ESTARYLLA TABLET [Trinessa]   2 Generic 0%0%None
TRI-LEGEST FE 5-7-9-7 TABLET   2 Generic 0%0%None
TRI-LO-ESTARYLLA TABLET [Trinessa Lo]   2 Generic 0%0%None
TRI-LO-SPRINTEC TABLET   2 Generic 0%0%None
TRI-MILI 28 TABLET [Trinessa]   2 Generic 0%0%None
TRI-PREVIFEM TABLET [Trinessa]   2 Generic 0%0%None
TRI-SPRINTEC 7DAYSX3 28 TABLET   2 Generic 0%0%None
TRI-VYLIBRA 28 TABLET [Trinessa]   2 Generic 0%0%None
TRI-VYLIBRA LO TABLET [Trinessa Lo]   2 Generic 0%0%None
TRIAMCINOLONE 0.025% CREAM   2 Generic 0%0%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRIAMCINOLONE 0.025% LOTION   2 Generic 0%0%None
TRIAMCINOLONE 0.025% OINT   2 Generic 0%0%None
TRIAMCINOLONE 0.1% CREAM (g) [Triderm]   2 Generic 0%0%None
TRIAMCINOLONE 0.1% LOTION [Kenalog]   2 Generic 0%0%None
TRIAMCINOLONE 0.1% OINTMENT [Triderm]   2 Generic 0%0%None
TRIAMCINOLONE 0.1% PASTE PASTE (G) [Oralone]   2 Generic 0%0%None
Triamcinolone 0.147 MG/G Spray   2 Generic 0%0%None
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE   2 Generic 0%0%None
Triamcinolone Acetonide 1 MG/ML Topical Cream [Triderm]   2 Generic 0%0%None
Triamcinolone Acetonide 5mg/g 1 TUBE per CARTON / 15 g in 1 TUBE   2 Generic 0%0%None
TRIAMTERENE 100 MG CAPSULE [Dyrenium]   2 Generic 0%0%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRIAMTERENE 50 MG CAPSULE [Dyrenium]   2 Generic 0%0%None
TRIAMTERENE-HCTZ 37.5-25 MG CAPSULE [Dyazide]   1 Preferred Generic 0%0%None
TRIAMTERENE-HCTZ 37.5-25 MG TABLET [Maxzide]   1 Preferred Generic 0%0%None
TRIAMTERENE-HCTZ 75-50 MG TAB   1 Preferred Generic 0%0%None
TRIAZOLAM 0.125 MG TABLET [Halcion]   2 Generic 0%0%None
TRIAZOLAM 0.25 MG TABLET [Halcion]   2 Generic 0%0%None
TRIENTINE HCL 250 MG CAPSULE [Syprine]   2 Generic 0%0%P
TRIFLUOPERAZINE 1 MG TABLET   2 Generic 0%0%None
TRIFLUOPERAZINE HCL 2MG TABLET   2 Generic 0%0%None
TRIFLUOPERAZINE HCL 5MG TABLET   2 Generic 0%0%None
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT)   2 Generic 0%0%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT   2 Generic 0%0%Q:15
/7Days
TRIHEXYPHENIDYL 2 MG TABLET   1 Preferred Generic 0%0%None
TRIHEXYPHENIDYL 5 MG TABLET [Artane]   1 Preferred Generic 0%0%None
Trihexyphenidyl Hydrochloride 2mg/5mL 473 mL in 1 BOTTLE   2 Generic 0%0%None
TRIJARDY XR 10-5-1,000 MG TABLET BP 24H   3 Preferred Brand 0%N/AQ:30
/30Days
TRIJARDY XR 12.5-2.5-1,000 MG TAB BP 24H   3 Preferred Brand 0%N/AQ:60
/30Days
TRIJARDY XR 25-5-1,000 MG TABLET BP 24H   3 Preferred Brand 0%N/AQ:30
/30Days
TRIJARDY XR 5-2.5-1,000 MG TABLET BP 24H   3 Preferred Brand 0%N/AQ:60
/30Days
TRIKAFTA 100/50/75 MG-150 MG TABLET SEQ   5 Specialty Tier 25%N/AP Q:90
/30Days
TRILYTE WITH FLAVOR PACKETS   1 Preferred Generic 0%0%None
TRIMETHOBENZAMIDE 300 MG CAP   2 Generic 0%0%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRIMETHOPRIM 100 MG TABLET   1 Preferred Generic 0%0%None
TRIMIPRAMINE MALEATE 100 MG CP   2 Generic 0%0%None
TRIMIPRAMINE MALEATE 25 MG CAP   2 Generic 0%0%None
TRIMIPRAMINE MALEATE 50 MG CAP   2 Generic 0%0%None
TRINTELLIX 10 MG TABLET   3 Preferred Brand 0%N/AS Q:30
/30Days
TRINTELLIX 20 MG TABLET   3 Preferred Brand 0%N/AS Q:30
/30Days
TRINTELLIX 5 MG TABLET   3 Preferred Brand 0%N/AS Q:30
/30Days
Triptorelin 11.3 MG/ML Injectable Suspension [Trelstar]   5 Specialty Tier 25%N/ANone
TRIUMEQ TABLET   5 Specialty Tier 25%N/ANone
TRIVORA-28 TABLET [Trivora]   2 Generic 0%0%None
TROKENDI XR 100 MG CAPSULE ER 24H   4 Non-Preferred Brand 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TROKENDI XR 200 MG CAPSULE ER 24H   4 Non-Preferred Brand 25%N/AP
TROKENDI XR 25 MG CAPSULE ER 24H   4 Non-Preferred Brand 25%N/AP
TROKENDI XR 50 MG CAPSULE   4 Non-Preferred Brand 25%N/AP
TROPHAMINE INJECTION SOLUTION   4 Non-Preferred Brand 25%N/AP
TROSPIUM CHLORIDE 20 MG TABLET [Sanctura]   2 Generic 0%0%None
TROSPIUM CHLORIDE ER 60 MG CAP   2 Generic 0%0%None
TRULANCE 3 MG TABLET   3 Preferred Brand 0%N/AP
TRULICITY 0.75 MG/0.5 ML PEN   3 Preferred Brand 0%N/AQ:2
/28Days
TRULICITY 1.5 MG/0.5 ML PEN   3 Preferred Brand 0%N/AQ:2
/28Days
TRUMENBA 120 MCG/0.5 ML VACCIN Syringe   3 Preferred Brand 0%N/ANone
TRUVADA 100 MG-150 MG TABLET   5 Specialty Tier 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRUVADA 133 MG-200 MG TABLET   5 Specialty Tier 25%N/ANone
TRUVADA 167 MG-250 MG TABLET   5 Specialty Tier 25%N/ANone
TRUVADA 200/300MG TABLET   5 Specialty Tier 25%N/ANone
TUKYSA 150 MG TABLET   5 Specialty Tier 25%N/AP Q:120
/30Days
TUKYSA 50 MG TABLET   5 Specialty Tier 25%N/AP Q:120
/30Days
TURALIO 200 MG CAPSULE   5 Specialty Tier 25%N/AP Q:120
/30Days
TWINRIX VACCINE SYRINGE   3 Preferred Brand 0%N/ANone
TYBOST 150 MG TABLET   3 Preferred Brand 0%N/ANone
TYDEMY TABLET   2 Generic 0%0%None
TYKERB 250 MG TABLET   5 Specialty Tier 25%N/AP
TYMLOS 80 MCG DOSE PEN INJECTR   5 Specialty Tier 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TYPHIM VI 25 MCG/0.5 ML SYRINGE   3 Preferred Brand 0%N/ANone
TYPHIM VI 25MCG/0.5ML VIAL   3 Preferred Brand 0%N/ANone

Chart Legend:

Below are a few notes to help you understand the above 2021 Medicare Part D SOLIS SPF 002 (HMO D-SNP) 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 $445 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 $4130) 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.

      * When the text "$35 or less" appears, this Part D plan may offer this particular insulin as part of the Senior Savings Model.  The Senior Savings Model stipulates that the insulin will cost no more than $35 in the deductible, initial coverage, and coverage gap phases of your Part D plan. Please contact the drug plan for more details.

    • 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 January 2021 )

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.








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.