Tufts Medicare Preferred HMO Prime Rx Plus (HMO) Formulary



Below is the 2023 Formulary, or prescription drug list, from Tufts Medicare Preferred HMO Prime Rx Plus (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 Prime Rx Plus (HMO)(H2256-001) plan has a $0 drug deductible. 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 Prime Rx Plus
Plan ID: H2256-001
Provider: Tufts Associated Health Maintenance Organization
Plan Year:2023
Premium:$100.00
Deductible:$0
Initial Coverage Limit:$4660
Coverage Area:Massachusetts
Similar Plan:H2256-015


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
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
Tabloid
3NA$30NANN
Tabrecta
5NA33%NAYN
Tacrolimus
3NA$30NANN
Tadalafil
3NA$30NA30/30YN
Tafinlar
5NA33%NAYN
Tagrisso
5NA33%NAYN
Takhzyro
5NA33%NAYN
Taltz
5NA33%NA4/28YN
Talzenna
5NA33%NAYN
Tamoxifen Citrate
2NA$4NANN
Tamsulosin Hydrochloride
2NA$4NANN
Targretin
5NA33%NAYN
Tarina Fe 1/20 Eq
2NA$4NANN
Tasigna
5NA33%NAYN
Tavalisse
5NA33%NA60/30NN
Tavneos
5NA33%NAYN
Tazarotene
4NA$80NAYN
Tazorac
4NA$80NAYN
Tazverik
5NA33%NAYN
Tdvax
6NA$0NANN
Teflaro
3NA$30NANN
Tegsedi
5NA33%NA6/30YN
Telmisartan And Amlodipine
1NA$2NANN
Temazepam
2NA$4NANN
Tenofovir Disproxil Fumarate
3NA$30NANN
Terazosin
2NA$4NANN
Terbutaline Sulfate
2NA$4NANN
Terconazole
2NA$4NANN
Teriparatide
5NA33%NAYN
Testosterone
3NA$30NANN
Testosterone Cypionate
2NA$4NANN
Testosterone Enanthate
2NA$4NANN
Tetracycline Hydrochloride
3NA$30NANN
Theophylline
2NA$4NANN
Thiola Ec
5NA33%NANN
Thioridazine Hydrochloride
1NA$2NAYN
Thiothixene
3NA$30NANN
Thyquidity
4NA$80NANN
Tiagabine Hydrochloride
4NA$80NANN
Tibsovo
5NA33%NAYN
Ticovac
6NA$0NANN
Tigecycline
2NA$4NANN
Timolol Maleate
3NA$30NANN
Timolol Maleate Ophthalmic Gel Forming Solution, 0
3NA$30NANN
Tindazole
2NA$4NANN
Tinidazole
2NA$4NANN
Tiopronin
5NA33%NANN
Tivicay
5NA33%NANN
Tivicay Pd
4NA$80NANN
Tizanidine Hydrochloride
3NA$30NANN
Tobi Podhaler
5NA33%NANN
Tobradex
3NA$30NANN
Tobramycin
2NA$4NANN
Tobramycin And Dexamethasone
3NA$30NANN
Tobramycin Inhalation
5NA33%NAYN
Tolcapone
5NA33%NANN
Tolterodine Tartrate
3NA$30NANN
Topiramate
1NA$2NANN
Toremifene Citrate
3NA$30NANN
Torsemide
2NA$4NANN
Tovet (emollient Formulation)
4NA$80NA200/30NN
Tpn Electrolytes
2NA$4NAYN
Tradjenta
3NA$30NANN
Tramadol Hydrochloride
2NA$4NA30/30NN
Tramadol Hydrochloride And Acetaminophen
2NA$4NA240/30NN
Trandolapril
1NA$2NANN
Trandolapril And Verapamil Hydrochloride
1NA$2NANN
Tranexamic Acid
2NA$4NANN
Tranylcypromine Sulfate
2NA$4NANN
Travoprost Ophthalmic Solution
3NA$30NANN
Trazodone Hydrochloride
1NA$2NANN
Trecator
4NA$80NANN
Trelegy Ellipta
3NA$30NA180/90NN
Trelstar
5NA33%NANN
Tresiba
3NA$30NANN
Tretinoin
4NA$80NAYN
Trexall
4NA$80NAYN
Tri-sprintec
2NA$4NANN
Triamcinolone Acetonide
3NA$30NANN
Trianex 0.05%
3NA$30NANN
Triazolam
2NA$4NANN
Triderm
2NA$4NANN
Trientine Hydrochloride
5NA33%NANN
Trifluoperazine Hydrochloride
2NA$4NANN
Trifluridine
2NA$4NANN
Trihexyphenidyl Hydrochloride
1NA$2NAYN
Trikafta
5NA33%NA84/28YN
Trimethoprim
1NA$2NANN
Trimipramine Maleate
2NA$4NAYN
Tritocin
3NA$30NANN
Triumeq
5NA33%NANN
Trivora
2NA$4NANN
Trizivir
5NA33%NANN
Trophamine
3NA$30NAYN
Trospium Chloride
3NA$30NANN
Truseltiq
5NA33%NAYN
Tukysa
5NA33%NAYN
Turalio
5NA33%NAYN
Twinrix
6NA$0NANN
Tybost
3NA$30NANN
Tymlos
5NA33%NAYN
Typhim Vi
6NA$0NANN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H2256-001

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