2017 EnvisionRxPlus (PDP) Formulary



Below is the Formulary, or drug list, for EnvisionRxPlus (PDP) from Envision Insurance Company This formulary is a list of prescription medications that are covered under Envision Insurance Company's 2017 Part-D Plan. The EnvisionRxPlus (PDP) plan has a $270 drug deductible. This 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 $3700. 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 $3700 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 45% 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" be clicking the "Coverage Gap" link on the left above the chart. In 2017 if you have spent $4700 in expenditures you enter the Catastrophic Phase. During the Catastrophic Period you will begin to receive significant coverage. EnvisionRxPlus (PDP) 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 on the left above the chart.

See More on EnvisionRxPlus (PDP)





Plan Name:
EnvisionRxPlus (PDP)
Plan ID:
S7694-005
Provider: Envision Insurance Company
Plan Year:2017
Premium:$14.60
Deductible:$270
Initial Coverage Limit:$3700
Coverage Area:Mid-Atlantic (Delaware, District of Columbia and Maryland)




Current Table info:


Coverage Level:
Initial Coverage
Days Supply:
30 Days
Drugs Starting With Letter: T

Change Table Options:


Drugs Starting Letter:
A  B  C  D  E  F  G  H  I  J  K  L  M  N  O  P  Q  R  S  U  V  W  X  Y  Z 
Coverage Level:
Drug Days Pricing:60 Day
90 Day











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(Click the Drug Name to Compare every Plans Price)

Drug Name Drug Strength Units in Package Tier Level Amount Limit Days Limit Prior Authorization
Y/N
Step Therapy
Y/N
Does the Deduct Apply Cost Preferred Max Cost Non Preferred Max Cost Mail Max
Tabloid 40mg 1 Bottle In 1 Carton > 25 Tablet In 1 Bottle
4
Y N Y 25%N39%N25%N
Tacrolimus .5mg 100 Capsule In 1 Bottle
2
Y N N $15N$20N$15N
Tacrolimus 1mg 100 Capsule In 1 Bottle
4
Y N Y 25%N39%N25%N
Tacrolimus 5mg 100 Capsule In 1 Bottle
4
Y N Y 25%N39%N25%N
Tamiflu 75mg 1 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack
4
56 365 N N Y 25%N39%N25%N
Tamiflu 45mg 1 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack
4
N N Y 25%N39%N25%N
Tamiflu 30mg 1 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack
4
N N Y 25%N39%N25%N
Tamiflu 6mg/mL 1 Bottle, Glass In 1 Carton > 60 Ml In 1 Bottle, Glass
4
540 30 N N Y 25%N39%N25%N
Tamoxifen Citrate 10mg 180 Tablet, Film Coated In 1 Bottle
2
N N N $15N$20N$15N
Tamoxifen Citrate 20mg 30 Tablet In 1 Bottle
2
N N N $15N$20N$15N
Tamsulosin Hydrochloride 100 Capsule In 1 Bottle
4
60 30 N N Y 25%N39%N25%N
Tarceva 25mg 30 Tablet In 1 Bottle
5
90 30 Y N Y 27%N27%N27%N
Tarceva 100mg 30 Tablet In 1 Bottle
5
30 30 Y N Y 27%N27%N27%N
Tarceva 150mg 30 Tablet In 1 Bottle
5
30 30 Y N Y 27%N27%N27%N
Targretin 60 G In 1 Tube
5
Y N Y 27%N27%N27%N
Tarina Fe 1/20 3 Pouch In 1 Carton > 1 Kit In 1 Pouch
4
N N Y 25%N39%N25%N
Tasigna 200mg 28 Capsule In 1 Blister Pack
5
120 30 Y N Y 27%N27%N27%N
Tasigna 150mg 4 Blister Pack In 1 Carton > 28 Capsule In 1 Blister Pack
5
120 30 Y N Y 27%N27%N27%N
Tazorac 1mg/g 1 Tube In 1 Carton > 100 G In 1 Tube
4
Y N Y 25%N39%N25%N
Tazorac .5mg/g 1 Tube In 1 Carton > 100 G In 1 Tube
4
Y N Y 25%N39%N25%N
Tazorac .5mg/g 1 Tube In 1 Carton > 60 G In 1 Tube
4
Y N Y 25%N39%N25%N
Tazorac 1mg/g 1 Tube In 1 Carton > 60 G In 1 Tube
4
Y N Y 25%N39%N25%N
Taztia 120mg 90 Capsule, Extended Release In 1 Bottle, Plastic
3
60 30 N N Y 10%N20%N10%N
Taztia 180mg 90 Capsule, Extended Release In 1 Bottle, Plastic
3
60 30 N N Y 10%N20%N10%N
Taztia 240mg 90 Capsule, Extended Release In 1 Bottle, Plastic
3
60 30 N N Y 10%N20%N10%N
Taztia 300mg 90 Capsule, Extended Release In 1 Bottle, Plastic
3
30 30 N N Y 10%N20%N10%N
Taztia 360mg 90 Capsule, Extended Release In 1 Bottle, Plastic
3
30 30 N N Y 10%N20%N10%N
Tecfidera 120mg 1 Bottle, Plastic In 1 Carton > 14 Capsule In 1 Bottle, Plastic
5
60 30 Y N Y 27%N27%N27%N
Tecfidera 240mg 1 Bottle, Plastic In 1 Carton > 60 Capsule In 1 Bottle, Plastic
5
60 30 Y N Y 27%N27%N27%N
Tecfidera 1 Kit In 1 Kit * 14 Capsule In 1 Bottle, Plastic * 46 Capsule In 1 Bottle, Plastic
5
60 30 Y N Y 27%N27%N27%N
Teflaro 400mg/20mL 10 Vial, Single-dose In 1 Carton
5
N N Y 27%N27%N27%N
Teflaro 600mg/20mL 10 Vial, Single-dose In 1 Carton
5
N N Y 27%N27%N27%N
Tegretol 100mg 100 Tablet, Extended Release In 1 Bottle
4
N N Y 25%N39%N25%N
Telmisartan 20mg 3 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
2
30 30 N N N $15N$20N$15N
Telmisartan 40mg 3 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
2
30 30 N N N $15N$20N$15N
Telmisartan 80mg 3 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
2
30 30 N N N $15N$20N$15N
Telmisartan And Hydrochlorothiazide 90 Tablet In 1 Bottle
4
30 30 N N Y 25%N39%N25%N
Telmisartan And Hydrochlorothiazide 90 Tablet In 1 Bottle
4
30 30 N N Y 25%N39%N25%N
Telmisartan And Hydrochlorothiazide 90 Tablet In 1 Bottle
4
30 30 N N Y 25%N39%N25%N
Temazepam 7.5mg 100 Capsule In 1 Bottle, Plastic
4
120 30 N N Y 25%N39%N25%N
Temazepam 15mg 100 Blister Pack In 1 Box, Unit-dose
4
30 30 N N Y 25%N39%N25%N
Tenivac 10 Syringe In 1 Package > .5 Ml In 1 Syringe
3
Y N Y 10%N20%N10%N
Terazosin 1mg 100 Capsule In 1 Bottle
2
N N N $15N$20N$15N
Terazosin Hydrochloride 2mg 100 Capsule In 1 Bottle
1
N N N $1N$14.9N$1N
Terazosin Hydrochloride 5mg 100 Capsule In 1 Bottle
1
N N N $1N$14.9N$1N
Terazosin Hydrochloride 10mg 100 Capsule In 1 Bottle
2
N N N $15N$20N$15N
Terbinafine Hydrochloride 90 Tablet In 1 Bottle
1
90 365 N N N $1N$14.9N$1N
Terbutaline Sulfate 2.5mg 100 Tablet In 1 Bottle
4
N N Y 25%N39%N25%N
Terbutaline Sulfate 5mg 100 Tablet In 1 Bottle
4
N N Y 25%N39%N25%N
Terconazole 80mg 1 Blister Pack In 1 Carton > 3 Suppository In 1 Blister Pack
2
N N N $15N$20N$15N
Terconazole 8mg/g 1 Tube, With Applicator In 1 Carton > 20 G In 1 Tube, With Applicator
4
N N Y 25%N39%N25%N
Terconazole 4mg/g 1 Tube, With Applicator In 1 Carton > 45 G In 1 Tube, With Applicator
2
N N N $15N$20N$15N
Testosterone Cypionate 1 Vial, Multi-dose In 1 Carton > 10 Ml In 1 Vial, Multi-dose
4
N N Y 25%N39%N25%N
Testosterone Cypionate 1 Vial, Multi-dose In 1 Carton > 10 Ml In 1 Vial, Multi-dose
4
N N Y 25%N39%N25%N
Testosterone Enanthate 200mg/mL 1 Vial, Multi-dose In 1 Carton > 5 Ml In 1 Vial, Multi-dose
4
N N Y 25%N39%N25%N
Thalomid 50mg 10 Blister Pack In 1 Box
5
30 30 Y N Y 27%N27%N27%N
Thalomid 100mg 5 Blister Pack In 1 Box
5
30 30 Y N Y 27%N27%N27%N
Thalomid 150mg 4 Blister Pack In 1 Box
5
60 30 Y N Y 27%N27%N27%N
Thalomid 200mg 3 Blister Pack In 1 Box
5
30 30 Y N Y 27%N27%N27%N
Theophylline 400mg 100 Tablet, Extended Release In 1 Bottle, Plastic
3
N N Y 10%N20%N10%N
Theophylline 600mg 100 Tablet, Extended Release In 1 Bottle, Plastic
2
N N N $15N$20N$15N
Theophylline 300mg 100 Tablet, Extended Release In 1 Bottle
2
N N N $15N$20N$15N
Theophylline 200mg 500 Tablet, Extended Release In 1 Bottle
2
N N N $15N$20N$15N
Theophylline 100mg 500 Tablet, Extended Release In 1 Bottle
2
N N N $15N$20N$15N
Theophylline 450mg 100 Tablet, Extended Release In 1 Bottle
2
N N N $15N$20N$15N
Theophylline 80mg/15mL 473 Ml In 1 Bottle, Plastic
4
N N Y 25%N39%N25%N
Thioridazine Hydrochloride 100mg 100 Tablet, Film Coated In 1 Bottle, Plastic
4
Y N Y 25%N39%N25%N
Thioridazine Hydrochloride 50mg 100 Blister Pack In 1 Box, Unit-dose
4
Y N Y 25%N39%N25%N
Thioridazine Hydrochloride 10mg 1000 Tablet, Film Coated In 1 Bottle, Plastic
4
Y N Y 25%N39%N25%N
Thioridazine Hydrochloride 25mg 1000 Tablet, Film Coated In 1 Bottle, Plastic
2
Y N N $15N$20N$15N
Thiothixene 2mg 100 Capsule In 1 Bottle, Plastic
2
N N N $15N$20N$15N
Thiothixene 5mg 100 Capsule In 1 Bottle, Plastic
2
N N N $15N$20N$15N
Thiothixene 10mg 100 Capsule In 1 Bottle, Plastic
4
N N Y 25%N39%N25%N
Thiothixene 1mg 100 Capsule In 1 Bottle
4
N N Y 25%N39%N25%N
Tiagabine Hydrochloride 2mg 30 Tablet, Film Coated In 1 Bottle
4
N N Y 25%N39%N25%N
Tiagabine Hydrochloride 4mg 30 Tablet, Film Coated In 1 Bottle
4
N N Y 25%N39%N25%N
Timolol Maleate 5mg 100 Tablet In 1 Bottle, Plastic
2
N N N $15N$20N$15N
Timolol Maleate 10mg 100 Tablet In 1 Bottle, Plastic
2
N N N $15N$20N$15N
Timolol Maleate 20mg 100 Tablet In 1 Bottle, Plastic
2
N N N $15N$20N$15N
Timolol Maleate 3.4mg/mL 1 Bottle, Dispensing In 1 Carton > 5 Ml In 1 Bottle, Dispensing
4
N N Y 25%N39%N25%N
Timolol Maleate 6.8mg/mL 1 Bottle, Dispensing In 1 Carton > 5 Ml In 1 Bottle, Dispensing
4
N N Y 25%N39%N25%N
Timolol Maleate 2.5mg/mL 15 Ml In 1 Bottle, Plastic
1
N N N $1N$14.9N$1N
Timolol Maleate 5mg/mL 10 Ml In 1 Bottle, Plastic
1
N N N $1N$14.9N$1N
Tivicay 50mg 30 Tablet, Film Coated In 1 Bottle
5
60 30 N N Y 27%N27%N27%N
Tizanidine 2mg 150 Tablet In 1 Bottle, Plastic
2
N N N $15N$20N$15N
Tizanidine 4mg 1000 Tablet In 1 Bottle
2
N N N $15N$20N$15N
Tobi Podhaler 28mg 224 Package In 1 Box, Unit-dose
5
Y N Y 27%N27%N27%N
Tobramycin 300mg/5mL 56 Ampule In 1 Carton > 5 Ml In 1 Ampule
5
Y N Y 27%N27%N27%N
Tobramycin 10mg/mL 25 Vial, Multi-dose In 1 Tray > 2 Ml In 1 Vial, Multi-dose
4
N N Y 25%N39%N25%N
Tobramycin 40mg/mL 25 Vial, Multi-dose In 1 Tray > 2 Ml In 1 Vial, Multi-dose
4
N N Y 25%N39%N25%N
Tobramycin 3mg/mL 1 Bottle, Dropper In 1 Carton > 5 Ml In 1 Bottle, Dropper
2
N N N $15N$20N$15N
Tobramycin And Dexamethasone 1; 3mg/mL; mg/mL 1 Bottle, Dropper In 1 Carton > 5 Ml In 1 Bottle, Dropper
4
N N Y 25%N39%N25%N
Tolterodine Tartrate 2mg 30 Capsule, Extended Release In 1 Bottle, Plastic
4
30 30 N N Y 25%N39%N25%N
Tolterodine Tartrate 500 Capsule, Extended Release In 1 Bottle, Plastic
4
30 30 N N Y 25%N39%N25%N
Tolterodine Tartrate 2mg 60 Tablet, Film Coated In 1 Bottle, Plastic
4
60 30 N N Y 25%N39%N25%N
Tolterodine Tartrate 1mg 500 Tablet, Film Coated In 1 Bottle
4
60 30 N N Y 25%N39%N25%N
Topiramate 15mg 60 Capsule, Coated Pellets In 1 Bottle
2
N N N $15N$20N$15N
Topiramate 25mg 60 Capsule, Coated Pellets In 1 Bottle
2
N N N $15N$20N$15N
Topiramate 25mg 1000 Tablet, Film Coated In 1 Bottle
2
N N N $15N$20N$15N
Topiramate 100mg 1000 Tablet, Film Coated In 1 Bottle
2
N N N $15N$20N$15N
Topiramate 200mg 1000 Tablet, Film Coated In 1 Bottle
2
N N N $15N$20N$15N
Topiramate 50mg 1000 Tablet, Film Coated In 1 Bottle
2
N N N $15N$20N$15N
Toposar 20mg/mL 1 Vial, Multi-dose In 1 Carton > 50 Ml In 1 Vial, Multi-dose
2
N N N $15N$20N$15N
Torsemide 20mg 100 Tablet In 1 Bottle, Plastic
2
N N N $15N$20N$15N
Torsemide 100mg 12 Bottle In 1 Case > 100 Tablet In 1 Bottle
2
N N N $15N$20N$15N
Torsemide 100 Tablet In 1 Bottle
2
N N N $15N$20N$15N
Torsemide 100 Tablet In 1 Bottle
2
N N N $15N$20N$15N
Tpn Electrolytes 331; 508; 1491; 2420; 321mg/20mL; mg/20mL; mg/20mL; mg/20mL; mg/20mL 25 Vial, Single-dose In 1 Tray > 20 Ml In 1 Vial, Single-dose
4
N N Y 25%N39%N25%N
Tracleer 62.5mg 1 Bottle, Plastic In 1 Carton > 60 Tablet, Film Coated In 1 Bottle, Plastic
5
60 30 Y N Y 27%N27%N27%N
Tracleer 125mg 1 Bottle, Plastic In 1 Carton > 60 Tablet, Film Coated In 1 Bottle, Plastic
5
60 30 Y N Y 27%N27%N27%N
Tramadol Hydrochloride 50mg 100 Tablet, Film Coated In 1 Bottle
2
240 30 N N N $15N$20N$15N
Tramadol Hydrochloride And Acetaminophen 325; 37.5mg/1; mg 1000 Tablet, Film Coated In 1 Bottle
3
370 30 N N Y 10%N20%N10%N
Trandolapril 100 Tablet In 1 Bottle
2
N N N $15N$20N$15N
Trandolapril 100 Tablet In 1 Bottle
2
N N N $15N$20N$15N
Trandolapril 100 Tablet In 1 Bottle
2
N N N $15N$20N$15N
Tranexamic Acid 650mg 30 Tablet, Film Coated In 1 Bottle, Plastic
2
N N N $15N$20N$15N
Tranexamic Acid 100mg/mL 10 Vial, Single-dose In 1 Package
3
N N Y 10%N20%N10%N
Transderm Scop 1mg/3d 10 Pouch In 1 Box > 1 Patch In 1 Pouch > 3 D In 1 Patch
4
4 12 N N Y 25%N39%N25%N
Tranylcypromine Sulfate 10mg 100 Tablet In 1 Bottle, Plastic
4
N N Y 25%N39%N25%N
Travasol 2.07; 1.15; 1.03; 480; 600; 730; 580; 400; 560; 68g/100mL; g/100mL; g/100mL; mg/100mL; mg/100mL; mg 2000 Ml In 1 Bag
4
Y N Y 25%N39%N25%N
Trazodone Hydrochloride 300mg 100 Tablet In 1 Bottle
4
N N Y 25%N39%N25%N
Trazodone Hydrochloride 50mg 500 Tablet In 1 Bottle
1
N N N $1N$14.9N$1N
Trazodone Hydrochloride 100mg 500 Tablet In 1 Bottle
1
N N N $1N$14.9N$1N
Trazodone Hydrochloride 150mg 100 Tablet In 1 Bottle
1
N N N $1N$14.9N$1N
Treanda 100mg/20mL 20 Ml In 1 Vial, Single-use
5
Y N Y 27%N27%N27%N
Trecator 250mg 100 Tablet, Film Coated In 1 Bottle
4
N N Y 25%N39%N25%N
Trelstar 1 Kit In 1 Carton * 2 Ml In 1 Syringe
5
Y N Y 27%N27%N27%N
Trelstar 1 Kit In 1 Carton * 2 Ml In 1 Syringe
5
Y N Y 27%N27%N27%N
Tretinoin 10mg 100 Capsule In 1 Bottle
5
N N Y 27%N27%N27%N
Tri Previfem 6 Blister Pack In 1 Carton
4
N N Y 25%N39%N25%N
Tri-legest Fe 5 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
4
N N Y 25%N39%N25%N
Tri-sprintec 6 Pouch In 1 Carton > 1 Blister Pack In 1 Pouch > 1 Kit In 1 Blister Pack
4
N N Y 25%N39%N25%N
Triamcinolone Acetonide .25mg/g 80 G In 1 Tube
2
N N N $15N$20N$15N
Triamcinolone Acetonide 1mg/g 80 G In 1 Tube
2
N N N $15N$20N$15N
Triamcinolone Acetonide 1mg/mL 60 Ml In 1 Bottle, Plastic
4
N N Y 25%N39%N25%N
Triamcinolone Acetonide 5mg/g 1 Tube In 1 Carton > 15 G In 1 Tube
2
N N N $15N$20N$15N
Triamcinolone Acetonide .25mg/g 1 Tube In 1 Carton > 80 G In 1 Tube
2
N N N $15N$20N$15N
Triamcinolone Acetonide 1mg/g 1 Tube In 1 Carton > 80 G In 1 Tube
2
N N N $15N$20N$15N
Triamcinolone Acetonide 5mg/g 1 Tube In 1 Carton > 15 G In 1 Tube
2
N N N $15N$20N$15N
Triamcinolone Acetonide 1mg/g 1 Tube In 1 Carton > 5 G In 1 Tube
4
N N Y 25%N39%N25%N
Triamcinolone Acetonide .25mg/mL 60 Ml In 1 Bottle, With Applicator
2
N N N $15N$20N$15N
Triamterene And Hydrochlorothiazide 25; 37.5mg/1; mg 100 Capsule In 1 Bottle, Plastic
1
N N N $1N$14.9N$1N
Triamterene And Hydrochlorothiazide 25; 50mg/1; mg 100 Capsule In 1 Bottle
2
N N N $15N$20N$15N
Triamterene Hydrochlorothiazide 50; 75mg/1; mg 500 Tablet In 1 Bottle
1
N N N $1N$14.9N$1N
Triamterene Hydrochlorothiazide 25; 37.5mg/1; mg 100 Tablet In 1 Bottle
1
N N N $1N$14.9N$1N
Tribenzor 5; 12.5; 20mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle
3
30 30 N N Y 10%N20%N10%N
Tribenzor 5; 12.5; 40mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle
3
30 30 N N Y 10%N20%N10%N
Tribenzor 5; 25; 40mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle
3
30 30 N N Y 10%N20%N10%N
Tribenzor 10; 12.5; 40mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle
3
30 30 N N Y 10%N20%N10%N
Tribenzor 10; 25; 40mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle
3
30 30 N N Y 10%N20%N10%N
Triderm 1mg/g 85.2 G In 1 Tube
2
N N N $15N$20N$15N
Trifluoperazine Hydrochloride 2mg 100 Tablet, Film Coated In 1 Bottle, Plastic
4
N N Y 25%N39%N25%N
Trifluoperazine Hydrochloride 5mg 100 Tablet, Film Coated In 1 Bottle, Plastic
4
N N Y 25%N39%N25%N
Trifluoperazine Hydrochloride 10mg 100 Tablet, Film Coated In 1 Bottle, Plastic
4
N N Y 25%N39%N25%N
Trifluoperazine Hydrochloride 1mg 100 Tablet, Film Coated In 1 Bottle
4
N N Y 25%N39%N25%N
Trifluridine 10mg/mL 7.5 Ml In 1 Bottle, Plastic
4
N N Y 25%N39%N25%N
Trihexyphenidyl Hydrochloride 2mg/5mL 473 Ml In 1 Bottle
4
Y N Y 25%N39%N25%N
Trihexyphenidyl Hydrochloride 5mg 100 Tablet In 1 Bottle, Plastic
2
Y N N $15N$20N$15N
Trihexyphenidyl Hydrochloride 2mg 100 Blister Pack In 1 Box, Unit-dose
2
Y N N $15N$20N$15N
Trilyte 420; 1.48; 5.72; 11.2g/4L; g/4L; g/4L; g/4L 4 L In 1 Bottle
2
N N N $15N$20N$15N
Trimethoprim 100mg 100 Tablet In 1 Bottle, Plastic
2
N N N $15N$20N$15N
Trimipramine Maleate 30 Capsule In 1 Bottle
4
N N Y 25%N39%N25%N
Trimipramine Maleate 30 Capsule In 1 Bottle
4
N N Y 25%N39%N25%N
Trimipramine Maleate 30 Capsule In 1 Bottle
4
N N Y 25%N39%N25%N
Trinessa 1 Dialpack In 1 Carton > 1 Kit In 1 Dialpack
4
N N Y 25%N39%N25%N
Trisenox 1mg/mL 10 Ampule In 1 Carton
5
Y N Y 27%N27%N27%N
Triumeq 30 Tablet, Film Coated In 1 Bottle
5
30 30 N N Y 27%N27%N27%N
Trivora 6 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
4
N N Y 25%N39%N25%N
Trophamine .54; 1.2; .32; .024; .5; .36; .48; .82; 1.4; 1.2; g/100mL; g/100mL; g/100mL; g/100mL; g/100mL; g/100 6 Carton In 1 Case > 1 Container In 1 Carton > 500 Ml In 1 Container
4
Y N Y 25%N39%N25%N
Truvada 200; 300mg/1; mg 30 Tablet, Film Coated In 1 Bottle, Plastic
5
30 30 N N Y 27%N27%N27%N
Twinrix 720; 20[iU]/mL; ug/mL 10 Vial In 1 Carton
4
N N Y 25%N39%N25%N
Tybost 30 Tablet, Film Coated In 1 Bottle
3
30 30 N N Y 10%N20%N10%N
Tygacil 50mg/5mL 10 Vial, Single-use In 1 Carton
5
N N Y 27%N27%N27%N
Tykerb 250mg 150 Tablet In 1 Bottle
5
180 30 Y N Y 27%N27%N27%N
Typhim Vi 25ug/.5mL 1 Vial, Multi-dose In 1 Package
4
N N Y 25%N39%N25%N
Typhim Vi 1 Syringe In 1 Package
4
N N Y 25%N39%N25%N
Tysabri 300mg/15mL 1 Vial, Single-use In 1 Carton > 15 Ml In 1 Vial, Single-use
5
15 28 Y N Y 27%N27%N27%N
Tyzeka 600mg 30 Tablet, Film Coated In 1 Bottle
3
N N Y 10%N20%N10%N



Medicare Help's Additional Notes:

Coverage Levels for S7694-005

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1.Pre-Deductable: Before you reach the plans deductible of $270. 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 $3700
3.Coverage Gap: (AKA Donut Hole) After you reach the plans ICL but before the Catastrophic of $4950 in 2017.
4.Catastrophic: Anything over $4950 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 2017 is $320. 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 in order 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 Prefered: Your Cost for the Drug at the Providers In Network Prefered Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Non Pref: Your Cost for the Prescription Drug at a Non-Prefered 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 plans 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.

Source:CMS Formulary Data Oct. 2016
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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