2017 Provider Partners Maryland Advantage Plan (HMO SNP) Formulary



Below is the Formulary, or drug list, for Provider Partners Maryland Advantage Plan (HMO SNP) from Provider Partners Health Plan, Inc. This formulary is a list of prescription medications that are covered under Provider Partners Health Plan, Inc.'s 2017 Medicare Advantage Plan. The Provider Partners Maryland Advantage Plan (HMO SNP) plan has a $400 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. Provider Partners Maryland Advantage Plan (HMO SNP) 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 Provider Partners Maryland Advantage Plan (HMO SNP)





Plan Name:
Provider Partners Maryland Advantage Plan (HMO SNP)
Plan ID:
H8067-001
Provider: Provider Partners Health Plan, Inc.
Plan Year:2017
Premium:$33.20
Deductible:$400
Initial Coverage Limit:$3700
Coverage Area: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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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
1
N N Y NAN25%NNAN
Tacrolimus .5mg 100 Capsule In 1 Bottle
1
Y N Y NAN25%NNAN
Tacrolimus 1mg 100 Capsule In 1 Bottle
1
Y N Y NAN25%NNAN
Tacrolimus 5mg 100 Capsule In 1 Bottle
1
Y N Y NAN25%NNAN
Tamiflu 75mg 1 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack
1
N N Y NAN25%NNAN
Tamiflu 45mg 1 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack
1
N N Y NAN25%NNAN
Tamiflu 30mg 1 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack
1
N N Y NAN25%NNAN
Tamiflu 6mg/mL 1 Bottle, Glass In 1 Carton > 60 Ml In 1 Bottle, Glass
1
N N Y NAN25%NNAN
Tamoxifen Citrate 10mg 180 Tablet, Film Coated In 1 Bottle
1
N N Y NAN25%NNAN
Tamoxifen Citrate 20mg 30 Tablet In 1 Bottle
1
N N Y NAN25%NNAN
Tamsulosin Hydrochloride 100 Capsule In 1 Bottle
1
N N Y NAN25%NNAN
Tarceva 25mg 30 Tablet In 1 Bottle
1
N N Y NAN25%NNAN
Tarceva 100mg 30 Tablet In 1 Bottle
1
N N Y NAN25%NNAN
Tarceva 150mg 30 Tablet In 1 Bottle
1
N N Y NAN25%NNAN
Targretin 60 G In 1 Tube
1
N N Y NAN25%NNAN
Tarina Fe 1/20 3 Pouch In 1 Carton > 1 Kit In 1 Pouch
1
N N Y NAN25%NNAN
Tasigna 200mg 28 Capsule In 1 Blister Pack
1
N N Y NAN25%NNAN
Tasigna 150mg 4 Blister Pack In 1 Carton > 28 Capsule In 1 Blister Pack
1
N N Y NAN25%NNAN
Tazicef 10 Vial In 1 Tray > 1 Injection, Powder, For Solution In 1 Vial
1
Y N Y NAN25%NNAN
Tazorac 1mg/g 1 Tube In 1 Carton > 100 G In 1 Tube
1
N N Y NAN25%NNAN
Tazorac .5mg/g 1 Tube In 1 Carton > 100 G In 1 Tube
1
N N Y NAN25%NNAN
Tazorac .5mg/g 1 Tube In 1 Carton > 60 G In 1 Tube
1
N N Y NAN25%NNAN
Tazorac 1mg/g 1 Tube In 1 Carton > 60 G In 1 Tube
1
N N Y NAN25%NNAN
Taztia 120mg 90 Capsule, Extended Release In 1 Bottle, Plastic
1
N N Y NAN25%NNAN
Taztia 180mg 90 Capsule, Extended Release In 1 Bottle, Plastic
1
N N Y NAN25%NNAN
Taztia 240mg 90 Capsule, Extended Release In 1 Bottle, Plastic
1
N N Y NAN25%NNAN
Taztia 300mg 90 Capsule, Extended Release In 1 Bottle, Plastic
1
N N Y NAN25%NNAN
Taztia 360mg 90 Capsule, Extended Release In 1 Bottle, Plastic
1
N N Y NAN25%NNAN
Tecfidera 120mg 1 Bottle, Plastic In 1 Carton > 14 Capsule In 1 Bottle, Plastic
1
Y N Y NAN25%NNAN
Tecfidera 240mg 1 Bottle, Plastic In 1 Carton > 60 Capsule In 1 Bottle, Plastic
1
Y N Y NAN25%NNAN
Tecfidera 1 Kit In 1 Kit * 14 Capsule In 1 Bottle, Plastic * 46 Capsule In 1 Bottle, Plastic
1
Y N Y NAN25%NNAN
Teflaro 400mg/20mL 10 Vial, Single-dose In 1 Carton
1
N N Y NAN25%NNAN
Teflaro 600mg/20mL 10 Vial, Single-dose In 1 Carton
1
N N Y NAN25%NNAN
Telmisartan 20mg 3 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
1
N N Y NAN25%NNAN
Telmisartan 40mg 3 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
1
N N Y NAN25%NNAN
Telmisartan 80mg 3 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
1
N N Y NAN25%NNAN
Telmisartan And Amlodipine 5; 40mg/1; mg 30 Tablet In 1 Bottle
1
N N Y NAN25%NNAN
Telmisartan And Amlodipine 10; 40mg/1; mg 30 Tablet In 1 Bottle
1
N N Y NAN25%NNAN
Telmisartan And Amlodipine 5; 80mg/1; mg 30 Tablet In 1 Bottle
1
N N Y NAN25%NNAN
Telmisartan And Amlodipine 10; 80mg/1; mg 30 Tablet In 1 Bottle
1
N N Y NAN25%NNAN
Telmisartan And Hydrochlorothiazide 90 Tablet In 1 Bottle
1
N N Y NAN25%NNAN
Telmisartan And Hydrochlorothiazide 90 Tablet In 1 Bottle
1
N N Y NAN25%NNAN
Telmisartan And Hydrochlorothiazide 90 Tablet In 1 Bottle
1
N N Y NAN25%NNAN
Temazepam 7.5mg 100 Capsule In 1 Bottle, Plastic
1
120 30 N N Y NAN25%NNAN
Temazepam 22.5mg 30 Capsule In 1 Bottle, Plastic
1
30 30 N N Y NAN25%NNAN
Temazepam 15mg 100 Blister Pack In 1 Box, Unit-dose
1
30 30 N N Y NAN25%NNAN
Temazepam 30mg 500 Capsule In 1 Bottle
1
30 30 N N Y NAN25%NNAN
Tencon 100 Tablet In 1 Bottle, Plastic
1
180 30 Y N Y NAN25%NNAN
Tenivac 10 Syringe In 1 Package > .5 Ml In 1 Syringe
1
N N Y NAN25%NNAN
Terazosin 1mg 100 Capsule In 1 Bottle
1
N N Y NAN25%NNAN
Terazosin Hydrochloride 2mg 100 Capsule In 1 Bottle
1
N N Y NAN25%NNAN
Terazosin Hydrochloride 5mg 100 Capsule In 1 Bottle
1
N N Y NAN25%NNAN
Terazosin Hydrochloride 10mg 100 Capsule In 1 Bottle
1
N N Y NAN25%NNAN
Terbutaline Sulfate 1mg/mL 25 Vial, Single-use In 1 Tray > 1 Ml In 1 Vial, Single-use
1
N N Y NAN25%NNAN
Terconazole 80mg 1 Blister Pack In 1 Carton > 3 Suppository In 1 Blister Pack
1
N N Y NAN25%NNAN
Terconazole 4mg/g 1 Tube, With Applicator In 1 Carton > 45 G In 1 Tube, With Applicator
1
N N Y NAN25%NNAN
Testosterone Cypionate 1 Vial, Multi-dose In 1 Carton > 10 Ml In 1 Vial, Multi-dose
1
N N Y NAN25%NNAN
Testosterone Cypionate 1 Vial, Multi-dose In 1 Carton > 10 Ml In 1 Vial, Multi-dose
1
N N Y NAN25%NNAN
Testosterone Enanthate 200mg/mL 1 Vial, Multi-dose In 1 Carton > 5 Ml In 1 Vial, Multi-dose
1
N N Y NAN25%NNAN
Thalomid 50mg 10 Blister Pack In 1 Box
1
N N Y NAN25%NNAN
Thalomid 100mg 5 Blister Pack In 1 Box
1
N N Y NAN25%NNAN
Thalomid 150mg 4 Blister Pack In 1 Box
1
N N Y NAN25%NNAN
Thalomid 200mg 3 Blister Pack In 1 Box
1
N N Y NAN25%NNAN
Theophylline 600mg 100 Tablet, Extended Release In 1 Bottle, Plastic
1
N N Y NAN25%NNAN
Theophylline 300mg 100 Tablet, Extended Release In 1 Bottle
1
N N Y NAN25%NNAN
Theophylline 200mg 500 Tablet, Extended Release In 1 Bottle
1
N N Y NAN25%NNAN
Theophylline 100mg 500 Tablet, Extended Release In 1 Bottle
1
N N Y NAN25%NNAN
Theophylline 450mg 100 Tablet, Extended Release In 1 Bottle
1
N N Y NAN25%NNAN
Thioridazine Hydrochloride 100mg 100 Tablet, Film Coated In 1 Bottle, Plastic
1
Y N Y NAN25%NNAN
Thioridazine Hydrochloride 50mg 100 Blister Pack In 1 Box, Unit-dose
1
Y N Y NAN25%NNAN
Thioridazine Hydrochloride 10mg 1000 Tablet, Film Coated In 1 Bottle, Plastic
1
Y N Y NAN25%NNAN
Thioridazine Hydrochloride 25mg 1000 Tablet, Film Coated In 1 Bottle, Plastic
1
Y N Y NAN25%NNAN
Thiothixene 2mg 100 Capsule In 1 Bottle, Plastic
1
N N Y NAN25%NNAN
Thiothixene 5mg 100 Capsule In 1 Bottle, Plastic
1
N N Y NAN25%NNAN
Thiothixene 10mg 100 Capsule In 1 Bottle, Plastic
1
N N Y NAN25%NNAN
Thiothixene 1mg 100 Capsule In 1 Bottle
1
N N Y NAN25%NNAN
Thymoglobulin 5mg/mL 5 Ml In 1 Vial, Glass
1
Y N Y NAN25%NNAN
Tiagabine Hydrochloride 2mg 30 Tablet, Film Coated In 1 Bottle
1
N N Y NAN25%NNAN
Tiagabine Hydrochloride 4mg 30 Tablet, Film Coated In 1 Bottle
1
N N Y NAN25%NNAN
Timolol Maleate 5mg 100 Tablet In 1 Bottle, Plastic
1
N N Y NAN25%NNAN
Timolol Maleate 10mg 100 Tablet In 1 Bottle, Plastic
1
N N Y NAN25%NNAN
Timolol Maleate 20mg 100 Tablet In 1 Bottle, Plastic
1
N N Y NAN25%NNAN
Timolol Maleate 3.4mg/mL 1 Bottle, Dispensing In 1 Carton > 5 Ml In 1 Bottle, Dispensing
1
N N Y NAN25%NNAN
Timolol Maleate 6.8mg/mL 1 Bottle, Dispensing In 1 Carton > 5 Ml In 1 Bottle, Dispensing
1
N N Y NAN25%NNAN
Timolol Maleate 2.5mg/mL 15 Ml In 1 Bottle, Plastic
1
N N Y NAN25%NNAN
Timolol Maleate 5mg/mL 10 Ml In 1 Bottle, Plastic
1
N N Y NAN25%NNAN
Tivicay 50mg 30 Tablet, Film Coated In 1 Bottle
1
N N Y NAN25%NNAN
Tizanidine 2mg 150 Tablet In 1 Bottle, Plastic
1
N N Y NAN25%NNAN
Tizanidine 4mg 1000 Tablet In 1 Bottle
1
N N Y NAN25%NNAN
Tobi Podhaler 28mg 224 Package In 1 Box, Unit-dose
1
224 56 Y N Y NAN25%NNAN
Tobradex 1; 3mg/mL; mg/mL 5 Ml In 1 Bottle, Plastic
1
N N Y NAN25%NNAN
Tobradex 1; 3mg/g; mg/g 3.5 G In 1 Tube
1
N N Y NAN25%NNAN
Tobradex St .5; 3mg/mL; mg/mL 5 Ml In 1 Bottle
1
N N Y NAN25%NNAN
Tobramycin 300mg/5mL 56 Ampule In 1 Carton > 5 Ml In 1 Ampule
1
Y N Y NAN25%NNAN
Tobramycin 10mg/mL 25 Vial, Multi-dose In 1 Tray > 2 Ml In 1 Vial, Multi-dose
1
N N Y NAN25%NNAN
Tobramycin 40mg/mL 25 Vial, Multi-dose In 1 Tray > 2 Ml In 1 Vial, Multi-dose
1
N N Y NAN25%NNAN
Tobramycin 3mg/mL 1 Bottle, Dropper In 1 Carton > 5 Ml In 1 Bottle, Dropper
1
N N Y NAN25%NNAN
Tobramycin And Dexamethasone 1; 3mg/mL; mg/mL 1 Bottle, Dropper In 1 Carton > 5 Ml In 1 Bottle, Dropper
1
N N Y NAN25%NNAN
Tolazamide 250mg 100 Tablet In 1 Bottle, Plastic
1
N N Y NAN25%NNAN
Tolazamide 500mg 100 Tablet In 1 Bottle, Plastic
1
N N Y NAN25%NNAN
Tolbutamide 500mg 500 Tablet In 1 Bottle, Plastic
1
N N Y NAN25%NNAN
Tolmetin Sodium 400mg 100 Capsule In 1 Bottle
1
N N Y NAN25%NNAN
Tolmetin Sodium 600mg 100 Tablet, Film Coated In 1 Bottle, Plastic
1
N N Y NAN25%NNAN
Tolterodine Tartrate 2mg 30 Capsule, Extended Release In 1 Bottle, Plastic
1
N N Y NAN25%NNAN
Tolterodine Tartrate 500 Capsule, Extended Release In 1 Bottle, Plastic
1
N N Y NAN25%NNAN
Tolterodine Tartrate 2mg 60 Tablet, Film Coated In 1 Bottle, Plastic
1
N N Y NAN25%NNAN
Tolterodine Tartrate 1mg 500 Tablet, Film Coated In 1 Bottle
1
N N Y NAN25%NNAN
Topiramate 15mg 60 Capsule, Coated Pellets In 1 Bottle
1
N N Y NAN25%NNAN
Topiramate 30 Capsule, Extended Release In 1 Bottle
1
N N Y NAN25%NNAN
Topiramate 30 Capsule, Extended Release In 1 Bottle
1
N N Y NAN25%NNAN
Topiramate 30 Capsule, Extended Release In 1 Bottle
1
N N Y NAN25%NNAN
Topiramate 30 Capsule, Extended Release In 1 Bottle
1
N N Y NAN25%NNAN
Topiramate 30 Capsule, Extended Release In 1 Bottle
1
N N Y NAN25%NNAN
Topiramate 25mg 60 Capsule, Coated Pellets In 1 Bottle
1
N N Y NAN25%NNAN
Topiramate 25mg 1000 Tablet, Film Coated In 1 Bottle
1
N N Y NAN25%NNAN
Topiramate 100mg 1000 Tablet, Film Coated In 1 Bottle
1
N N Y NAN25%NNAN
Topiramate 200mg 1000 Tablet, Film Coated In 1 Bottle
1
N N Y NAN25%NNAN
Topiramate 50mg 1000 Tablet, Film Coated In 1 Bottle
1
N N Y NAN25%NNAN
Torisel 1 Kit In 1 Carton
1
Y N Y NAN25%NNAN
Torsemide 20mg 100 Tablet In 1 Bottle, Plastic
1
N N Y NAN25%NNAN
Torsemide 100mg 12 Bottle In 1 Case > 100 Tablet In 1 Bottle
1
N N Y NAN25%NNAN
Torsemide 100 Tablet In 1 Bottle
1
N N Y NAN25%NNAN
Torsemide 100 Tablet In 1 Bottle
1
N N Y NAN25%NNAN
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
1
N N Y NAN25%NNAN
Tracleer 62.5mg 1 Bottle, Plastic In 1 Carton > 60 Tablet, Film Coated In 1 Bottle, Plastic
1
N N Y NAN25%NNAN
Tracleer 125mg 1 Bottle, Plastic In 1 Carton > 60 Tablet, Film Coated In 1 Bottle, Plastic
1
N N Y NAN25%NNAN
Tradjenta 5mg 90 Tablet, Film Coated In 1 Bottle
1
N N Y NAN25%NNAN
Tramadol Hydrochloride 50mg 100 Tablet, Film Coated In 1 Bottle
1
240 30 N N Y NAN25%NNAN
Tramadol Hydrochloride And Acetaminophen 325; 37.5mg/1; mg 1000 Tablet, Film Coated In 1 Bottle
1
240 30 N N Y NAN25%NNAN
Trandolapril 100 Tablet In 1 Bottle
1
N N Y NAN25%NNAN
Trandolapril 100 Tablet In 1 Bottle
1
N N Y NAN25%NNAN
Trandolapril 100 Tablet In 1 Bottle
1
N N Y NAN25%NNAN
Tranexamic Acid 650mg 30 Tablet, Film Coated In 1 Bottle, Plastic
1
N N Y NAN25%NNAN
Tranexamic Acid 100mg/mL 10 Vial, Single-dose In 1 Package
1
N N Y NAN25%NNAN
Transderm Scop 1mg/3d 10 Pouch In 1 Box > 1 Patch In 1 Pouch > 3 D In 1 Patch
1
N N Y NAN25%NNAN
Tranylcypromine Sulfate 10mg 100 Tablet In 1 Bottle, Plastic
1
N N Y NAN25%NNAN
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
1
Y N Y NAN25%NNAN
Travatan Z .04mg/mL 2.5 Ml In 1 Bottle
1
N N Y NAN25%NNAN
Travoprost Ophthalmic Solution 0.004% .04mg/mL 1 Bottle In 1 Carton > 2.5 Ml In 1 Bottle
1
N N Y NAN25%NNAN
Trazodone Hydrochloride 300mg 100 Tablet In 1 Bottle
1
N N Y NAN25%NNAN
Trazodone Hydrochloride 50mg 500 Tablet In 1 Bottle
1
N N Y NAN25%NNAN
Trazodone Hydrochloride 100mg 500 Tablet In 1 Bottle
1
N N Y NAN25%NNAN
Trazodone Hydrochloride 150mg 100 Tablet In 1 Bottle
1
N N Y NAN25%NNAN
Treanda 100mg/20mL 20 Ml In 1 Vial, Single-use
1
Y N Y NAN25%NNAN
Trecator 250mg 100 Tablet, Film Coated In 1 Bottle
1
N N Y NAN25%NNAN
Trelstar 22.5mg/2mL 2 Ml In 1 Vial, Single-dose
1
Y N Y NAN25%NNAN
Trelstar 1 Kit In 1 Carton * 2 Ml In 1 Syringe
1
Y N Y NAN25%NNAN
Trelstar 1 Kit In 1 Carton * 2 Ml In 1 Syringe
1
Y N Y NAN25%NNAN
Tretinoin 10mg 100 Capsule In 1 Bottle
1
N N Y NAN25%NNAN
Trexall 5mg 30 Tablet, Film Coated In 1 Bottle
1
Y N Y NAN25%NNAN
Trexall 7.5mg 30 Tablet, Film Coated In 1 Bottle
1
Y N Y NAN25%NNAN
Trexall 10mg 30 Tablet, Film Coated In 1 Bottle
1
Y N Y NAN25%NNAN
Trexall 15mg 30 Tablet, Film Coated In 1 Bottle
1
Y N Y NAN25%NNAN
Tri Previfem 6 Blister Pack In 1 Carton
1
N N Y NAN25%NNAN
Tri-sprintec 6 Pouch In 1 Carton > 1 Blister Pack In 1 Pouch > 1 Kit In 1 Blister Pack
1
N N Y NAN25%NNAN
Triamcinolone Acetonide .25mg/g 80 G In 1 Tube
1
N N Y NAN25%NNAN
Triamcinolone Acetonide 1mg/g 80 G In 1 Tube
1
N N Y NAN25%NNAN
Triamcinolone Acetonide 1mg/mL 60 Ml In 1 Bottle, Plastic
1
N N Y NAN25%NNAN
Triamcinolone Acetonide 5mg/g 1 Tube In 1 Carton > 15 G In 1 Tube
1
N N Y NAN25%NNAN
Triamcinolone Acetonide .25mg/g 1 Tube In 1 Carton > 80 G In 1 Tube
1
N N Y NAN25%NNAN
Triamcinolone Acetonide 1mg/g 1 Tube In 1 Carton > 80 G In 1 Tube
1
N N Y NAN25%NNAN
Triamcinolone Acetonide 5mg/g 1 Tube In 1 Carton > 15 G In 1 Tube
1
N N Y NAN25%NNAN
Triamcinolone Acetonide 1mg/g 1 Tube In 1 Carton > 5 G In 1 Tube
1
N N Y NAN25%NNAN
Triamcinolone Acetonide .25mg/mL 60 Ml In 1 Bottle, With Applicator
1
N N Y NAN25%NNAN
Triamterene And Hydrochlorothiazide 25; 37.5mg/1; mg 100 Capsule In 1 Bottle, Plastic
1
N N Y NAN25%NNAN
Triamterene And Hydrochlorothiazide 25; 50mg/1; mg 100 Capsule In 1 Bottle
1
N N Y NAN25%NNAN
Triamterene Hydrochlorothiazide 50; 75mg/1; mg 500 Tablet In 1 Bottle
1
N N Y NAN25%NNAN
Triamterene Hydrochlorothiazide 25; 37.5mg/1; mg 100 Tablet In 1 Bottle
1
N N Y NAN25%NNAN
Triazolam 10 Bottle In 1 Package > 10 Tablet In 1 Bottle
1
30 30 N N Y NAN25%NNAN
Triazolam 500 Tablet In 1 Bottle
1
60 30 N N Y NAN25%NNAN
Tribenzor 5; 12.5; 20mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle
1
N N Y NAN25%NNAN
Tribenzor 5; 12.5; 40mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle
1
N N Y NAN25%NNAN
Tribenzor 5; 25; 40mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle
1
N N Y NAN25%NNAN
Tribenzor 10; 12.5; 40mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle
1
N N Y NAN25%NNAN
Tribenzor 10; 25; 40mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle
1
N N Y NAN25%NNAN
Trifluoperazine Hydrochloride 2mg 100 Tablet, Film Coated In 1 Bottle, Plastic
1
N N Y NAN25%NNAN
Trifluoperazine Hydrochloride 5mg 100 Tablet, Film Coated In 1 Bottle, Plastic
1
N N Y NAN25%NNAN
Trifluoperazine Hydrochloride 10mg 100 Tablet, Film Coated In 1 Bottle, Plastic
1
N N Y NAN25%NNAN
Trifluoperazine Hydrochloride 1mg 100 Tablet, Film Coated In 1 Bottle
1
N N Y NAN25%NNAN
Trifluridine 10mg/mL 7.5 Ml In 1 Bottle, Plastic
1
N N Y NAN25%NNAN
Trihexyphenidyl Hydrochloride 2mg/5mL 473 Ml In 1 Bottle
1
Y N Y NAN25%NNAN
Trihexyphenidyl Hydrochloride 5mg 100 Tablet In 1 Bottle, Plastic
1
Y N Y NAN25%NNAN
Trihexyphenidyl Hydrochloride 2mg 100 Blister Pack In 1 Box, Unit-dose
1
Y N Y NAN25%NNAN
Trimethoprim 100mg 100 Tablet In 1 Bottle, Plastic
1
N N Y NAN25%NNAN
Trimipramine Maleate 30 Capsule In 1 Bottle
1
Y N Y NAN25%NNAN
Trimipramine Maleate 30 Capsule In 1 Bottle
1
Y N Y NAN25%NNAN
Trimipramine Maleate 30 Capsule In 1 Bottle
1
Y N Y NAN25%NNAN
Trinessa 1 Dialpack In 1 Carton > 1 Kit In 1 Dialpack
1
N N Y NAN25%NNAN
Trisenox 1mg/mL 10 Ampule In 1 Carton
1
Y N Y NAN25%NNAN
Triumeq 30 Tablet, Film Coated In 1 Bottle
1
N N Y NAN25%NNAN
Trivora 6 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
1
N N Y NAN25%NNAN
Trokendi Xr 25mg 30 Capsule, Extended Release In 1 Blister Pack
1
N N Y NAN25%NNAN
Trokendi Xr 50mg 30 Capsule, Extended Release In 1 Blister Pack
1
N N Y NAN25%NNAN
Trokendi Xr 100mg 30 Capsule, Extended Release In 1 Blister Pack
1
N N Y NAN25%NNAN
Trokendi Xr 200mg 30 Capsule, Extended Release In 1 Blister Pack
1
N N Y NAN25%NNAN
Truvada 200; 300mg/1; mg 30 Tablet, Film Coated In 1 Bottle, Plastic
1
N N Y NAN25%NNAN
Twinrix 720; 20[iU]/mL; ug/mL 10 Vial In 1 Carton
1
N N Y NAN25%NNAN
Tybost 30 Tablet, Film Coated In 1 Bottle
1
N N Y NAN25%NNAN
Tygacil 50mg/5mL 10 Vial, Single-use In 1 Carton
1
N N Y NAN25%NNAN
Tykerb 250mg 150 Tablet In 1 Bottle
1
N N Y NAN25%NNAN
Typhim Vi 25ug/.5mL 1 Vial, Multi-dose In 1 Package
1
N N Y NAN25%NNAN
Typhim Vi 1 Syringe In 1 Package
1
N N Y NAN25%NNAN
Tysabri 300mg/15mL 1 Vial, Single-use In 1 Carton > 15 Ml In 1 Vial, Single-use
1
Y N Y NAN25%NNAN
Tyzeka 600mg 30 Tablet, Film Coated In 1 Bottle
1
N N Y NAN25%NNAN



Medicare Help's Additional Notes:

Coverage Levels for H8067-001

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1.Pre-Deductable: Before you reach the plans deductible of $400. 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.