2017 Express Scripts Medicare - Choice (PDP) Formulary



Below is the Formulary, or drug list, for Express Scripts Medicare - Choice (PDP) from Medco Containment Life And Medco Containment Ny This formulary is a list of prescription medications that are covered under Medco Containment Life And Medco Containment Ny's 2017 Part-D Plan. The Express Scripts Medicare - Choice (PDP) plan has a $350 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. Express Scripts Medicare - Choice (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 Express Scripts Medicare - Choice (PDP)





Plan Name:
Express Scripts Medicare - Choice (PDP)
Plan ID:
S5660-181
Provider: Medco Containment Life And Medco Containment Ny
Plan Year:2017
Premium:$91.40
Deductible:$350
Initial Coverage Limit:$3700
Coverage Area:Florida




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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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
3
N N Y 23%N25%NNAN
Tacrolimus 1 Tube In 1 Carton > 30 G In 1 Tube
3
Y N Y 23%N25%NNAN
Tacrolimus 1 Tube In 1 Carton > 30 G In 1 Tube
3
Y N Y 23%N25%NNAN
Tacrolimus .5mg 100 Capsule In 1 Bottle
3
Y N Y 23%N25%NNAN
Tacrolimus 1mg 100 Capsule In 1 Bottle
3
Y N Y 23%N25%NNAN
Tacrolimus 5mg 100 Capsule In 1 Bottle
3
Y N Y 23%N25%NNAN
Tamiflu 75mg 1 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack
3
N N Y 23%N25%NNAN
Tamiflu 45mg 1 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack
3
N N Y 23%N25%NNAN
Tamiflu 30mg 1 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack
3
N N Y 23%N25%NNAN
Tamiflu 6mg/mL 1 Bottle, Glass In 1 Carton > 60 Ml In 1 Bottle, Glass
3
N N Y 23%N25%NNAN
Tamoxifen Citrate 10mg 180 Tablet, Film Coated In 1 Bottle
2
N N N $7N$20NNAN
Tamoxifen Citrate 20mg 30 Tablet In 1 Bottle
2
N N N $7N$20NNAN
Tamsulosin Hydrochloride 100 Capsule In 1 Bottle
1
N N N $2N$10NNAN
Tanzeum 30mg/.5mL 4 Syringe In 1 Carton > .5 Ml In 1 Syringe
4
4 28 N N Y 48%N50%N50%N
Tanzeum 50mg/.5mL 4 Syringe In 1 Carton > .5 Ml In 1 Syringe
4
4 28 N N Y 48%N50%N50%N
Tarceva 25mg 30 Tablet In 1 Bottle
5
Y N Y 26%N26%N26%N
Tarceva 100mg 30 Tablet In 1 Bottle
5
Y N Y 26%N26%N26%N
Tarceva 150mg 30 Tablet In 1 Bottle
5
31 31 Y N Y 26%N26%N26%N
Targretin 60 G In 1 Tube
5
N N Y 26%N26%N26%N
Tarina Fe 1/20 3 Pouch In 1 Carton > 1 Kit In 1 Pouch
2
N N N $7N$20NNAN
Tasigna 200mg 28 Capsule In 1 Blister Pack
5
112 28 Y N Y 26%N26%N26%N
Tasigna 150mg 4 Blister Pack In 1 Carton > 28 Capsule In 1 Blister Pack
5
Y N Y 26%N26%N26%N
Tazorac 1mg/g 1 Tube In 1 Carton > 100 G In 1 Tube
3
Y N Y 23%N25%NNAN
Tazorac .5mg/g 1 Tube In 1 Carton > 100 G In 1 Tube
3
Y N Y 23%N25%NNAN
Tazorac .5mg/g 1 Tube In 1 Carton > 60 G In 1 Tube
3
Y N Y 23%N25%NNAN
Tazorac 1mg/g 1 Tube In 1 Carton > 60 G In 1 Tube
3
Y N Y 23%N25%NNAN
Taztia 120mg 90 Capsule, Extended Release In 1 Bottle, Plastic
2
N N N $7N$20NNAN
Taztia 180mg 90 Capsule, Extended Release In 1 Bottle, Plastic
2
N N N $7N$20NNAN
Taztia 240mg 90 Capsule, Extended Release In 1 Bottle, Plastic
2
N N N $7N$20NNAN
Taztia 300mg 90 Capsule, Extended Release In 1 Bottle, Plastic
2
N N N $7N$20NNAN
Taztia 360mg 90 Capsule, Extended Release In 1 Bottle, Plastic
2
N N N $7N$20NNAN
Tecfidera 120mg 1 Bottle, Plastic In 1 Carton > 14 Capsule In 1 Bottle, Plastic
5
Y N Y 26%N26%N26%N
Tecfidera 240mg 1 Bottle, Plastic In 1 Carton > 60 Capsule In 1 Bottle, Plastic
5
Y N Y 26%N26%N26%N
Tecfidera 1 Kit In 1 Kit * 14 Capsule In 1 Bottle, Plastic * 46 Capsule In 1 Bottle, Plastic
5
Y N Y 26%N26%N26%N
Teflaro 400mg/20mL 10 Vial, Single-dose In 1 Carton
4
N N Y 48%N50%N50%N
Teflaro 600mg/20mL 10 Vial, Single-dose In 1 Carton
4
N N Y 48%N50%N50%N
Tekturna 150mg 30 Tablet, Film Coated In 1 Bottle
3
N N Y 23%N25%NNAN
Tekturna 300mg 30 Tablet, Film Coated In 1 Bottle
3
N N Y 23%N25%NNAN
Tekturna Hct 150; 12.5mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
N N Y 48%N50%N50%N
Tekturna Hct 150; 25mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
N N Y 48%N50%N50%N
Tekturna Hct 300; 12.5mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
N N Y 48%N50%N50%N
Tekturna Hct 300; 25mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
N N Y 48%N50%N50%N
Telmisartan 20mg 3 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
2
N N N $7N$20NNAN
Telmisartan 40mg 3 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
2
N N N $7N$20NNAN
Telmisartan 80mg 3 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
2
N N N $7N$20NNAN
Telmisartan And Amlodipine 5; 40mg/1; mg 30 Tablet In 1 Bottle
2
N N N $7N$20NNAN
Telmisartan And Amlodipine 10; 40mg/1; mg 30 Tablet In 1 Bottle
2
N N N $7N$20NNAN
Telmisartan And Amlodipine 5; 80mg/1; mg 30 Tablet In 1 Bottle
2
N N N $7N$20NNAN
Telmisartan And Amlodipine 10; 80mg/1; mg 30 Tablet In 1 Bottle
2
N N N $7N$20NNAN
Telmisartan And Hydrochlorothiazide 90 Tablet In 1 Bottle
2
N N N $7N$20NNAN
Telmisartan And Hydrochlorothiazide 90 Tablet In 1 Bottle
2
N N N $7N$20NNAN
Telmisartan And Hydrochlorothiazide 90 Tablet In 1 Bottle
2
N N N $7N$20NNAN
Temazepam 7.5mg 100 Capsule In 1 Bottle, Plastic
2
Y N N $7N$20NNAN
Temazepam 22.5mg 30 Capsule In 1 Bottle, Plastic
2
Y N N $7N$20NNAN
Temazepam 15mg 100 Blister Pack In 1 Box, Unit-dose
2
Y N N $7N$20NNAN
Temazepam 30mg 500 Capsule In 1 Bottle
2
Y N N $7N$20NNAN
Tenivac 10 Syringe In 1 Package > .5 Ml In 1 Syringe
3
N N Y 23%N25%NNAN
Terazosin 1mg 100 Capsule In 1 Bottle
1
31 31 N N N $2N$10NNAN
Terazosin Hydrochloride 2mg 100 Capsule In 1 Bottle
1
31 31 N N N $2N$10NNAN
Terazosin Hydrochloride 5mg 100 Capsule In 1 Bottle
1
31 31 N N N $2N$10NNAN
Terazosin Hydrochloride 10mg 100 Capsule In 1 Bottle
1
62 31 N N N $2N$10NNAN
Terbinafine Hydrochloride 90 Tablet In 1 Bottle
2
N N N $7N$20NNAN
Terbutaline Sulfate 2.5mg 100 Tablet In 1 Bottle
2
N N N $7N$20NNAN
Terbutaline Sulfate 5mg 100 Tablet In 1 Bottle
2
N N N $7N$20NNAN
Terbutaline Sulfate 1mg/mL 25 Vial, Single-use In 1 Tray > 1 Ml In 1 Vial, Single-use
5
N N Y 26%N26%N26%N
Terconazole 80mg 1 Blister Pack In 1 Carton > 3 Suppository In 1 Blister Pack
2
N N N $7N$20NNAN
Terconazole 8mg/g 1 Tube, With Applicator In 1 Carton > 20 G In 1 Tube, With Applicator
2
N N N $7N$20NNAN
Terconazole 4mg/g 1 Tube, With Applicator In 1 Carton > 45 G In 1 Tube, With Applicator
2
N N N $7N$20NNAN
Testosterone Cypionate 1 Vial, Multi-dose In 1 Carton > 10 Ml In 1 Vial, Multi-dose
2
N N N $7N$20NNAN
Testosterone Cypionate 1 Vial, Multi-dose In 1 Carton > 10 Ml In 1 Vial, Multi-dose
2
N N N $7N$20NNAN
Testosterone Enanthate 200mg/mL 1 Vial, Multi-dose In 1 Carton > 5 Ml In 1 Vial, Multi-dose
2
N N N $7N$20NNAN
Thalomid 50mg 10 Blister Pack In 1 Box
5
Y N Y 26%N26%N26%N
Thalomid 100mg 5 Blister Pack In 1 Box
5
Y N Y 26%N26%N26%N
Thalomid 150mg 4 Blister Pack In 1 Box
5
Y N Y 26%N26%N26%N
Thalomid 200mg 3 Blister Pack In 1 Box
5
Y N Y 26%N26%N26%N
Theophylline 400mg 100 Tablet, Extended Release In 1 Bottle, Plastic
2
N N N $7N$20NNAN
Theophylline 600mg 100 Tablet, Extended Release In 1 Bottle, Plastic
2
N N N $7N$20NNAN
Theophylline 300mg 100 Tablet, Extended Release In 1 Bottle
2
N N N $7N$20NNAN
Theophylline 200mg 500 Tablet, Extended Release In 1 Bottle
2
N N N $7N$20NNAN
Theophylline 100mg 500 Tablet, Extended Release In 1 Bottle
2
N N N $7N$20NNAN
Theophylline 450mg 100 Tablet, Extended Release In 1 Bottle
2
N N N $7N$20NNAN
Thioridazine Hydrochloride 100mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N N $7N$20NNAN
Thioridazine Hydrochloride 50mg 100 Blister Pack In 1 Box, Unit-dose
2
N N N $7N$20NNAN
Thioridazine Hydrochloride 10mg 1000 Tablet, Film Coated In 1 Bottle, Plastic
2
N N N $7N$20NNAN
Thioridazine Hydrochloride 25mg 1000 Tablet, Film Coated In 1 Bottle, Plastic
2
N N N $7N$20NNAN
Thiothixene 2mg 100 Capsule In 1 Bottle, Plastic
1
N N N $2N$10NNAN
Thiothixene 5mg 100 Capsule In 1 Bottle, Plastic
1
N N N $2N$10NNAN
Thiothixene 10mg 100 Capsule In 1 Bottle, Plastic
1
N N N $2N$10NNAN
Thiothixene 1mg 100 Capsule In 1 Bottle
1
N N N $2N$10NNAN
Tiagabine Hydrochloride 2mg 30 Tablet, Film Coated In 1 Bottle
4
N N Y 48%N50%N50%N
Tiagabine Hydrochloride 4mg 30 Tablet, Film Coated In 1 Bottle
4
N N Y 48%N50%N50%N
Timolol Maleate 5mg 100 Tablet In 1 Bottle, Plastic
2
N N N $7N$20NNAN
Timolol Maleate 10mg 100 Tablet In 1 Bottle, Plastic
2
N N N $7N$20NNAN
Timolol Maleate 20mg 100 Tablet In 1 Bottle, Plastic
2
N N N $7N$20NNAN
Timolol Maleate 3.4mg/mL 1 Bottle, Dispensing In 1 Carton > 5 Ml In 1 Bottle, Dispensing
2
N N N $7N$20NNAN
Timolol Maleate 6.8mg/mL 1 Bottle, Dispensing In 1 Carton > 5 Ml In 1 Bottle, Dispensing
2
N N N $7N$20NNAN
Timolol Maleate 2.5mg/mL 15 Ml In 1 Bottle, Plastic
1
N N N $2N$10NNAN
Timolol Maleate 5mg/mL 10 Ml In 1 Bottle, Plastic
1
N N N $2N$10NNAN
Tinidazole 250mg 40 Tablet In 1 Bottle
2
N N N $7N$20NNAN
Tinidazole 500mg 60 Tablet In 1 Bottle
2
N N N $7N$20NNAN
Tivicay 50mg 30 Tablet, Film Coated In 1 Bottle
5
N N Y 26%N26%N26%N
Tizanidine 2mg 150 Tablet In 1 Bottle, Plastic
2
N N N $7N$20NNAN
Tizanidine 4mg 1000 Tablet In 1 Bottle
2
N N N $7N$20NNAN
Tizanidine Hydrochloride 2mg 150 Capsule, Gelatin Coated In 1 Bottle
4
N N Y 48%N50%N50%N
Tizanidine Hydrochloride 4mg 150 Capsule, Gelatin Coated In 1 Bottle
4
N N Y 48%N50%N50%N
Tizanidine Hydrochloride 6mg 150 Capsule, Gelatin Coated In 1 Bottle
4
N N Y 48%N50%N50%N
Tobramycin 300mg/5mL 56 Ampule In 1 Carton > 5 Ml In 1 Ampule
5
280 28 Y N Y 26%N26%N26%N
Tobramycin 10mg/mL 25 Vial, Multi-dose In 1 Tray > 2 Ml In 1 Vial, Multi-dose
2
N N N $7N$20NNAN
Tobramycin 40mg/mL 25 Vial, Multi-dose In 1 Tray > 2 Ml In 1 Vial, Multi-dose
2
N N N $7N$20NNAN
Tobramycin 3mg/mL 1 Bottle, Dropper In 1 Carton > 5 Ml In 1 Bottle, Dropper
1
N N N $2N$10NNAN
Tobramycin And Dexamethasone 1; 3mg/mL; mg/mL 1 Bottle, Dropper In 1 Carton > 5 Ml In 1 Bottle, Dropper
2
N N N $7N$20NNAN
Tolazamide 250mg 100 Tablet In 1 Bottle, Plastic
2
124 31 N N N $7N$20NNAN
Tolazamide 500mg 100 Tablet In 1 Bottle, Plastic
2
62 31 N N N $7N$20NNAN
Tolbutamide 500mg 500 Tablet In 1 Bottle, Plastic
2
186 31 N N N $7N$20NNAN
Tolmetin Sodium 400mg 100 Capsule In 1 Bottle
2
N N N $7N$20NNAN
Tolmetin Sodium 600mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N N $7N$20NNAN
Tolterodine Tartrate 2mg 30 Capsule, Extended Release In 1 Bottle, Plastic
2
N N N $7N$20NNAN
Tolterodine Tartrate 500 Capsule, Extended Release In 1 Bottle, Plastic
2
N N N $7N$20NNAN
Tolterodine Tartrate 2mg 60 Tablet, Film Coated In 1 Bottle, Plastic
4
N N Y 48%N50%N50%N
Tolterodine Tartrate 1mg 500 Tablet, Film Coated In 1 Bottle
4
N N Y 48%N50%N50%N
Topiramate 15mg 60 Capsule, Coated Pellets In 1 Bottle
3
Y N Y 23%N25%NNAN
Topiramate 25mg 60 Capsule, Coated Pellets In 1 Bottle
3
Y N Y 23%N25%NNAN
Topiramate 25mg 1000 Tablet, Film Coated In 1 Bottle
1
Y N N $2N$10NNAN
Topiramate 100mg 1000 Tablet, Film Coated In 1 Bottle
1
Y N N $2N$10NNAN
Topiramate 200mg 1000 Tablet, Film Coated In 1 Bottle
1
Y N N $2N$10NNAN
Topiramate 50mg 1000 Tablet, Film Coated In 1 Bottle
1
Y N N $2N$10NNAN
Toposar 20mg/mL 1 Vial, Multi-dose In 1 Carton > 50 Ml In 1 Vial, Multi-dose
2
N N N $7N$20NNAN
Torisel 1 Kit In 1 Carton
5
N N Y 26%N26%N26%N
Torsemide 20mg 100 Tablet In 1 Bottle, Plastic
1
N N N $2N$10NNAN
Torsemide 100mg 12 Bottle In 1 Case > 100 Tablet In 1 Bottle
1
N N N $2N$10NNAN
Torsemide 100 Tablet In 1 Bottle
1
N N N $2N$10NNAN
Torsemide 100 Tablet In 1 Bottle
1
N N N $2N$10NNAN
Tracleer 62.5mg 1 Bottle, Plastic In 1 Carton > 60 Tablet, Film Coated In 1 Bottle, Plastic
5
Y N Y 26%N26%N26%N
Tracleer 125mg 1 Bottle, Plastic In 1 Carton > 60 Tablet, Film Coated In 1 Bottle, Plastic
5
Y N Y 26%N26%N26%N
Tradjenta 5mg 90 Tablet, Film Coated In 1 Bottle
3
31 31 N N Y 23%N25%NNAN
Tramadol Hydrochloride 50mg 100 Tablet, Film Coated In 1 Bottle
2
248 31 N N N $7N$20NNAN
Trandolapril 100 Tablet In 1 Bottle
1
N N N $2N$10NNAN
Trandolapril 100 Tablet In 1 Bottle
1
N N N $2N$10NNAN
Trandolapril 100 Tablet In 1 Bottle
1
N N N $2N$10NNAN
Trandolapril And Verapamil Hydrochloride 100 Tablet, Film Coated, Extended Release In 1 Bottle
2
N N N $7N$20NNAN
Trandolapril And Verapamil Hydrochloride 100 Tablet, Film Coated, Extended Release In 1 Bottle
2
N N N $7N$20NNAN
Trandolapril And Verapamil Hydrochloride 100 Tablet, Film Coated, Extended Release In 1 Bottle
2
N N N $7N$20NNAN
Trandolapril And Verapamil Hydrochloride 100 Tablet, Film Coated, Extended Release In 1 Bottle
2
N N N $7N$20NNAN
Tranexamic Acid 650mg 30 Tablet, Film Coated In 1 Bottle, Plastic
3
N N Y 23%N25%NNAN
Transderm Scop 1mg/3d 10 Pouch In 1 Box > 1 Patch In 1 Pouch > 3 D In 1 Patch
4
N N Y 48%N50%N50%N
Tranylcypromine Sulfate 10mg 100 Tablet In 1 Bottle, Plastic
4
N N Y 48%N50%N50%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 48%N50%N50%N
Travatan Z .04mg/mL 2.5 Ml In 1 Bottle
3
N N Y 23%N25%NNAN
Travoprost Ophthalmic Solution 0.004% .04mg/mL 1 Bottle In 1 Carton > 2.5 Ml In 1 Bottle
2
N N N $7N$20NNAN
Trazodone Hydrochloride 300mg 100 Tablet In 1 Bottle
1
N N N $2N$10NNAN
Trazodone Hydrochloride 50mg 500 Tablet In 1 Bottle
1
N N N $2N$10NNAN
Trazodone Hydrochloride 100mg 500 Tablet In 1 Bottle
1
N N N $2N$10NNAN
Trazodone Hydrochloride 150mg 100 Tablet In 1 Bottle
1
N N N $2N$10NNAN
Treanda 100mg/20mL 20 Ml In 1 Vial, Single-use
4
N N Y 48%N50%N50%N
Trecator 250mg 100 Tablet, Film Coated In 1 Bottle
3
N N Y 23%N25%NNAN
Trelstar 22.5mg/2mL 2 Ml In 1 Vial, Single-dose
5
N N Y 26%N26%N26%N
Trelstar 1 Kit In 1 Carton * 2 Ml In 1 Syringe
5
N N Y 26%N26%N26%N
Trelstar 1 Kit In 1 Carton * 2 Ml In 1 Syringe
5
N N Y 26%N26%N26%N
Tretinoin 10mg 100 Capsule In 1 Bottle
3
N N Y 23%N25%NNAN
Tretinoin 1mg/g 1 Tube In 1 Carton > 45 G In 1 Tube
3
Y N Y 23%N25%NNAN
Tretinoin .5mg/g 1 Tube In 1 Carton > 20 G In 1 Tube
3
Y N Y 23%N25%NNAN
Tretinoin .25mg/g 1 Tube In 1 Carton > 45 G In 1 Tube
2
Y N N $7N$20NNAN
Tretinoin .25mg/g 1 Tube In 1 Carton > 45 G In 1 Tube
3
Y N Y 23%N25%NNAN
Tretinoin 1 Tube In 1 Carton > 45 G In 1 Tube
3
Y N Y 23%N25%NNAN
Tretinoin Gel Microsphere 1 Bottle, Pump In 1 Carton > 50 G In 1 Bottle, Pump
4
Y N Y 48%N50%N50%N
Tretinoin Gel Microsphere 1 Bottle, Pump In 1 Carton > 50 G In 1 Bottle, Pump
4
Y N Y 48%N50%N50%N
Tri Previfem 6 Blister Pack In 1 Carton
2
N N N $7N$20NNAN
Tri-legest Fe 5 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
2
N N N $7N$20NNAN
Tri-sprintec 6 Pouch In 1 Carton > 1 Blister Pack In 1 Pouch > 1 Kit In 1 Blister Pack
2
N N N $7N$20NNAN
Triamcinolone Acetonide .25mg/g 80 G In 1 Tube
2
N N N $7N$20NNAN
Triamcinolone Acetonide 1mg/g 80 G In 1 Tube
2
N N N $7N$20NNAN
Triamcinolone Acetonide 1mg/mL 60 Ml In 1 Bottle, Plastic
2
N N N $7N$20NNAN
Triamcinolone Acetonide 5mg/g 1 Tube In 1 Carton > 15 G In 1 Tube
2
N N N $7N$20NNAN
Triamcinolone Acetonide .25mg/g 1 Tube In 1 Carton > 80 G In 1 Tube
2
N N N $7N$20NNAN
Triamcinolone Acetonide 1mg/g 1 Tube In 1 Carton > 80 G In 1 Tube
2
N N N $7N$20NNAN
Triamcinolone Acetonide 5mg/g 1 Tube In 1 Carton > 15 G In 1 Tube
2
N N N $7N$20NNAN
Triamcinolone Acetonide 1mg/g 1 Tube In 1 Carton > 5 G In 1 Tube
2
N N N $7N$20NNAN
Triamcinolone Acetonide .25mg/mL 60 Ml In 1 Bottle, With Applicator
2
N N N $7N$20NNAN
Triamterene And Hydrochlorothiazide 25; 37.5mg/1; mg 100 Capsule In 1 Bottle, Plastic
1
N N N $2N$10NNAN
Triamterene And Hydrochlorothiazide 25; 50mg/1; mg 100 Capsule In 1 Bottle
1
N N N $2N$10NNAN
Triamterene Hydrochlorothiazide 50; 75mg/1; mg 500 Tablet In 1 Bottle
1
N N N $2N$10NNAN
Triamterene Hydrochlorothiazide 25; 37.5mg/1; mg 100 Tablet In 1 Bottle
1
N N N $2N$10NNAN
Tribenzor 5; 12.5; 20mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
N N Y 48%N50%N50%N
Tribenzor 5; 12.5; 40mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
N N Y 48%N50%N50%N
Tribenzor 5; 25; 40mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
N N Y 48%N50%N50%N
Tribenzor 10; 12.5; 40mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
N N Y 48%N50%N50%N
Tribenzor 10; 25; 40mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
N N Y 48%N50%N50%N
Triderm 1mg/g 85.2 G In 1 Tube
2
N N N $7N$20NNAN
Trifluoperazine Hydrochloride 2mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N N $7N$20NNAN
Trifluoperazine Hydrochloride 5mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N N $7N$20NNAN
Trifluoperazine Hydrochloride 10mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N N $7N$20NNAN
Trifluoperazine Hydrochloride 1mg 100 Tablet, Film Coated In 1 Bottle
2
N N N $7N$20NNAN
Trifluridine 10mg/mL 7.5 Ml In 1 Bottle, Plastic
2
N N N $7N$20NNAN
Trihexyphenidyl Hydrochloride 2mg/5mL 473 Ml In 1 Bottle
1
N N N $2N$10NNAN
Trihexyphenidyl Hydrochloride 5mg 100 Tablet In 1 Bottle, Plastic
1
N N N $2N$10NNAN
Trihexyphenidyl Hydrochloride 2mg 100 Blister Pack In 1 Box, Unit-dose
1
N N N $2N$10NNAN
Trilyte 420; 1.48; 5.72; 11.2g/4L; g/4L; g/4L; g/4L 4 L In 1 Bottle
2
N N N $7N$20NNAN
Trimethoprim 100mg 100 Tablet In 1 Bottle, Plastic
2
N N N $7N$20NNAN
Trimipramine Maleate 30 Capsule In 1 Bottle
2
Y N N $7N$20NNAN
Trimipramine Maleate 30 Capsule In 1 Bottle
2
Y N N $7N$20NNAN
Trimipramine Maleate 30 Capsule In 1 Bottle
2
Y N N $7N$20NNAN
Trinessa 1 Dialpack In 1 Carton > 1 Kit In 1 Dialpack
2
N N N $7N$20NNAN
Trisenox 1mg/mL 10 Ampule In 1 Carton
4
N N Y 48%N50%N50%N
Triumeq 30 Tablet, Film Coated In 1 Bottle
5
N N Y 26%N26%N26%N
Trivora 6 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
2
N N N $7N$20NNAN
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
3
Y N Y 23%N25%NNAN
Trophamine .32; .73; .19; .02; .3; .22; .29; .49; .84; .69; .g/100mL; g/100mL; g/100mL; g/100mL; g/100mL; g/100 12 Carton In 1 Case > 1 Container In 1 Carton > 500 Ml In 1 Container
3
Y N Y 23%N25%NNAN
Trospium Chloride 20mg 60 Tablet, Film Coated In 1 Bottle
2
N N N $7N$20NNAN
Trospium Chloride 60mg 30 Capsule, Extended Release In 1 Bottle, Plastic
4
N N Y 48%N50%N50%N
Trulicity 4 Syringe In 1 Carton
4
2 28 N N Y 48%N50%N50%N
Trulicity 4 Syringe In 1 Carton
4
2 28 N N Y 48%N50%N50%N
Truvada 200; 300mg/1; mg 30 Tablet, Film Coated In 1 Bottle, Plastic
5
N N Y 26%N26%N26%N
Twinrix 720; 20[iU]/mL; ug/mL 10 Vial In 1 Carton
3
N N Y 23%N25%NNAN
Tygacil 50mg/5mL 10 Vial, Single-use In 1 Carton
5
N N Y 26%N26%N26%N
Tykerb 250mg 150 Tablet In 1 Bottle
5
186 31 Y N Y 26%N26%N26%N
Typhim Vi 25ug/.5mL 1 Vial, Multi-dose In 1 Package
3
N N Y 23%N25%NNAN
Typhim Vi 1 Syringe In 1 Package
3
N N Y 23%N25%NNAN
Tysabri 300mg/15mL 1 Vial, Single-use In 1 Carton > 15 Ml In 1 Vial, Single-use
5
Y N Y 26%N26%N26%N
Tyvaso 1.74mg/2.9mL 4 Ampule In 1 Box > 2.9 Ml In 1 Ampule
5
Y N Y 26%N26%N26%N
Tyzeka 600mg 30 Tablet, Film Coated In 1 Bottle
5
N N Y 26%N26%N26%N



Medicare Help's Additional Notes:

Coverage Levels for S5660-181

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1.Pre-Deductable: Before you reach the plans deductible of $350. 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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