Tufts Medicare Preferred HMO Saver Rx (HMO) Formulary



Below is the 2023 Formulary, or prescription drug list, from Tufts Medicare Preferred HMO Saver Rx (HMO) by Tufts Associated Health Maintenance Organization. A formulary is a continually updated list of available medications and prescription drug cost information. Examining a plans formulary can help you find a Massachusetts Medicare Part-C plan that covers your prescriptions. It also helps you compare costs among Medicare Part D and Medicare Advantage plans available to you. You’ll want to make sure the medicines you are currently taking are covered under any plans you are considering enrolling in.

This Tufts Medicare Preferred HMO Saver Rx (HMO)(H2256-028) plan has a $250 drug deductible. A deductible is the amount of expenses that must be paid out of pocket before the Initial Coverage period begins. However, some drugs do not require that the deductible is met before you receive coverage. You can see if the deductible is required below in the "Does the Deductible Apply" column. The Initial Coverage Limit (ICL) for this plan is $4660. The Initial Coverage Period is the period after the Deductible has been met but before the Coverage Gap phase. Once you and your plan provider have spent $4660 on covered drugs. (Combined amount plus your deductible) You will enter the coverage gap. (AKA "donut hole") Once you reach the coverage gap you will be required to pay 25% of the plan's cost for covered brand-name prescription drugs unless your plan offers additional coverage. You can see if this plan offers coverage in the "donut hole" by clicking the "Coverage Gap" link above the chart.

In 2023 if you have spent $7400 in expenditures you enter the Catastrophic Phase. During the Catastrophic Period you will begin to receive significant coverage. Tufts Associated Health Maintenance Organization will begin paying approximately 95% of your covered medication expenses. You can see if this plan covers your drugs in the Catastrophic Phase by clicking the "Catastrophic" link above the chart.



Plan Overview

Plan Name:Tufts Medicare Preferred HMO Saver Rx
Plan ID: H2256-028
Provider: Tufts Associated Health Maintenance Organization
Plan Year:2023
Premium:$0.00
Deductible:$250
Initial Coverage Limit:$4660
Coverage Area:Massachusetts
Similar Plan:H2256-033


Change Table Options:

Drugs Starting Letter:
Coverage Phase:

*Tip Click the Drug name to Compare Coverage and Retail Cost for Every Plan In Your Area
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Drug
Name⇅
Tier
Level
Deductible
Apply
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
Tabloid
3Y$47$47NANN
Tabrecta
529%29%NAYN
Tacrolimus
3Y$47$47NANN
Tadalafil
3Y$47$47NA30/30YN
Tafinlar
529%29%NAYN
Tagrisso
529%29%NAYN
Takhzyro
529%29%NAYN
Taltz
529%29%NA4/28YN
Talzenna
529%29%NAYN
Tamoxifen Citrate
2N$4$19NANN
Tamsulosin Hydrochloride
2N$4$19NANN
Targretin
529%29%NAYN
Tarina Fe 1/20 Eq
2N$4$19NANN
Tasigna
529%29%NAYN
Tavalisse
529%29%NA60/30NN
Tavneos
529%29%NAYN
Tazarotene
4Y$100$100NAYN
Tazorac
4Y$100$100NAYN
Tazverik
529%29%NAYN
Tdvax
6N$0$0NANN
Teflaro
3Y$47$47NANN
Tegsedi
529%29%NA6/30YN
Telmisartan And Amlodipine
1N$0$14NANN
Temazepam
2N$4$19NANN
Tenofovir Disproxil Fumarate
3Y$47$47NANN
Terazosin
2N$4$19NANN
Terbutaline Sulfate
2N$4$19NANN
Terconazole
2N$4$19NANN
Teriparatide
529%29%NAYN
Testosterone
3Y$47$47NANN
Testosterone Cypionate
2N$4$19NANN
Testosterone Enanthate
2N$4$19NANN
Tetracycline Hydrochloride
3Y$47$47NANN
Theophylline
2N$4$19NANN
Thiola Ec
529%29%NANN
Thioridazine Hydrochloride
1N$0$14NAYN
Thiothixene
3Y$47$47NANN
Thyquidity
4Y$100$100NANN
Tiagabine Hydrochloride
4Y$100$100NANN
Tibsovo
529%29%NAYN
Ticovac
6N$0$0NANN
Tigecycline
2N$4$19NANN
Timolol Maleate
3Y$47$47NANN
Timolol Maleate Ophthalmic Gel Forming Solution, 0
3Y$47$47NANN
Tindazole
2N$4$19NANN
Tinidazole
2N$4$19NANN
Tiopronin
529%29%NANN
Tivicay
529%29%NANN
Tivicay Pd
4Y$100$100NANN
Tizanidine Hydrochloride
3Y$47$47NANN
Tobi Podhaler
529%29%NANN
Tobradex
3Y$47$47NANN
Tobramycin
2N$4$19NANN
Tobramycin And Dexamethasone
3Y$47$47NANN
Tobramycin Inhalation
529%29%NAYN
Tolcapone
529%29%NANN
Tolterodine Tartrate
3Y$47$47NANN
Topiramate
1N$0$14NANN
Toremifene Citrate
3Y$47$47NANN
Torsemide
2N$4$19NANN
Tovet (emollient Formulation)
4Y$100$100NA200/30NN
Tpn Electrolytes
2N$4$19NAYN
Tradjenta
3Y$47$47NANN
Tramadol Hydrochloride
2N$4$19NA30/30NN
Tramadol Hydrochloride And Acetaminophen
2N$4$19NA240/30NN
Trandolapril
1N$0$14NANN
Trandolapril And Verapamil Hydrochloride
1N$0$14NANN
Tranexamic Acid
2N$4$19NANN
Tranylcypromine Sulfate
2N$4$19NANN
Travoprost Ophthalmic Solution
3Y$47$47NANN
Trazodone Hydrochloride
1N$0$14NANN
Trecator
4Y$100$100NANN
Trelegy Ellipta
3Y$47$47NA180/90NN
Trelstar
529%29%NANN
Tresiba
3Y$47$47NANN
Tretinoin
4Y$100$100NAYN
Trexall
4Y$100$100NAYN
Tri-sprintec
2N$4$19NANN
Triamcinolone Acetonide
3Y$47$47NANN
Trianex 0.05%
3Y$47$47NANN
Triazolam
2N$4$19NANN
Triderm
2N$4$19NANN
Trientine Hydrochloride
529%29%NANN
Trifluoperazine Hydrochloride
2N$4$19NANN
Trifluridine
2N$4$19NANN
Trihexyphenidyl Hydrochloride
1N$0$14NAYN
Trikafta
529%29%NA84/28YN
Trimethoprim
1N$0$14NANN
Trimipramine Maleate
2N$4$19NAYN
Tritocin
3Y$47$47NANN
Triumeq
529%29%NANN
Trivora
2N$4$19NANN
Trizivir
529%29%NANN
Trophamine
3Y$47$47NAYN
Trospium Chloride
3Y$47$47NANN
Truseltiq
529%29%NAYN
Tukysa
529%29%NAYN
Turalio
529%29%NAYN
Twinrix
6N$0$0NANN
Tybost
3Y$47$47NANN
Tymlos
529%29%NAYN
Typhim Vi
6N$0$0NANN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H2256-028

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $250. Some plans offer select Pre-deductible drug Coverage
2. Initial Coverage: (ICL) After you reach the plans deductible but before the Initial Coverage limit of $4660
3. Coverage Gap: (AKA Donut Hole) After you reach the plans ICL but before the Catastrophic of $7400 in 2023.
4. Catastrophic: Anything over $7400 you will receive a significant increase in coverage.

Definitions:

Premium: A monthly flat fee that varies by plan.
Deductible: The amount you must pay each year for your prescriptions before your plan begins to pay its share of your covered drugs. The max in 2023 is $505. Some plans have a $0 Deductible.
Tier Level: Medicare drug plans place drugs into different "tiers" on their formularies. Drugs in each tier have a different cost. A drug in a lower tier will generally cost you less.
Quantity Limit Amount/Days: Certain drugs have a Quantity Limit. That means the plan will only cover the drug up to a designated quantity or amount. If your prescribing doctor feels it is necessary to exceed the set limit, he or she must get prior approval before the higher quantity will be covered.
Prior Authorization: Certain Drugs require you or your doctor to get prior authorization to be covered. Usually just an additional form. If you dont get approval, the plan may not cover the drug.
Does the Deduct Apply: Some drugs do not require that the deductible is met before you receive coverage.
Step Therapy: Means you must first try one drug to treat your medical condition before the plan will cover another drug for the same condition. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.
Cost Preferred: Your Cost for the Drug at the Providers In-Network Preferred Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Non-Preferred: Your Cost for the Prescription Drug at a Non-Preferred Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Mail: Your Cost for Prescription Drugs through a Mail Order Pharmacy. As a Percent of the total drug cost or a flat rate.


What if a drug I need is not listed?

Please check the formulary for different brand and generic names. If you still cannot locate your drugs, your plan may not offer coverage. Talk to your doctor first about changing your prescription to a drug on your plan's formulary. If this is not an option, you can request an exception to have the plan review its coverage decision based on your individual circumstances.

Last updated on

Source:CMS Formulary Data Q4 2022
Source:NDC Directory by FDA.gov

**We make every attempt to keep our information accurate. But please check with the plan providers to verify all information.

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