Tufts Medicare Preferred HMO Value Rx (HMO) Formulary



Below is the 2023 Formulary, or prescription drug list, from Tufts Medicare Preferred HMO Value 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 Value Rx (HMO)(H2256-034) 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 Value Rx
Plan ID: H2256-034
Provider: Tufts Associated Health Maintenance Organization
Plan Year:2023
Premium:$62.00
Deductible:$0
Initial Coverage Limit:$4660
Coverage Area:Massachusetts
Similar Plan:H2256-036


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
3$47$47NANN
Tabrecta
533%33%NAYN
Tacrolimus
3$47$47NANN
Tadalafil
3$47$47NA30/30YN
Tafinlar
533%33%NAYN
Tagrisso
533%33%NAYN
Takhzyro
533%33%NAYN
Taltz
533%33%NA4/28YN
Talzenna
533%33%NAYN
Tamoxifen Citrate
2$4$19NANN
Tamsulosin Hydrochloride
2$4$19NANN
Targretin
533%33%NAYN
Tarina Fe 1/20 Eq
2$4$19NANN
Tasigna
533%33%NAYN
Tavalisse
533%33%NA60/30NN
Tavneos
533%33%NAYN
Tazarotene
4$100$100NAYN
Tazorac
4$100$100NAYN
Tazverik
533%33%NAYN
Tdvax
6$0$0NANN
Teflaro
3$47$47NANN
Tegsedi
533%33%NA6/30YN
Telmisartan And Amlodipine
1$0$14NANN
Temazepam
2$4$19NANN
Tenofovir Disproxil Fumarate
3$47$47NANN
Terazosin
2$4$19NANN
Terbutaline Sulfate
2$4$19NANN
Terconazole
2$4$19NANN
Teriparatide
533%33%NAYN
Testosterone
3$47$47NANN
Testosterone Cypionate
2$4$19NANN
Testosterone Enanthate
2$4$19NANN
Tetracycline Hydrochloride
3$47$47NANN
Theophylline
2$4$19NANN
Thiola Ec
533%33%NANN
Thioridazine Hydrochloride
1$0$14NAYN
Thiothixene
3$47$47NANN
Thyquidity
4$100$100NANN
Tiagabine Hydrochloride
4$100$100NANN
Tibsovo
533%33%NAYN
Ticovac
6$0$0NANN
Tigecycline
2$4$19NANN
Timolol Maleate
3$47$47NANN
Timolol Maleate Ophthalmic Gel Forming Solution, 0
3$47$47NANN
Tindazole
2$4$19NANN
Tinidazole
2$4$19NANN
Tiopronin
533%33%NANN
Tivicay
533%33%NANN
Tivicay Pd
4$100$100NANN
Tizanidine Hydrochloride
3$47$47NANN
Tobi Podhaler
533%33%NANN
Tobradex
3$47$47NANN
Tobramycin
2$4$19NANN
Tobramycin And Dexamethasone
3$47$47NANN
Tobramycin Inhalation
533%33%NAYN
Tolcapone
533%33%NANN
Tolterodine Tartrate
3$47$47NANN
Topiramate
1$0$14NANN
Toremifene Citrate
3$47$47NANN
Torsemide
2$4$19NANN
Tovet (emollient Formulation)
4$100$100NA200/30NN
Tpn Electrolytes
2$4$19NAYN
Tradjenta
3$47$47NANN
Tramadol Hydrochloride
2$4$19NA30/30NN
Tramadol Hydrochloride And Acetaminophen
2$4$19NA240/30NN
Trandolapril
1$0$14NANN
Trandolapril And Verapamil Hydrochloride
1$0$14NANN
Tranexamic Acid
2$4$19NANN
Tranylcypromine Sulfate
2$4$19NANN
Travoprost Ophthalmic Solution
3$47$47NANN
Trazodone Hydrochloride
1$0$14NANN
Trecator
4$100$100NANN
Trelegy Ellipta
3$47$47NA180/90NN
Trelstar
533%33%NANN
Tresiba
3$47$47NANN
Tretinoin
4$100$100NAYN
Trexall
4$100$100NAYN
Tri-sprintec
2$4$19NANN
Triamcinolone Acetonide
3$47$47NANN
Trianex 0.05%
3$47$47NANN
Triazolam
2$4$19NANN
Triderm
2$4$19NANN
Trientine Hydrochloride
533%33%NANN
Trifluoperazine Hydrochloride
2$4$19NANN
Trifluridine
2$4$19NANN
Trihexyphenidyl Hydrochloride
1$0$14NAYN
Trikafta
533%33%NA84/28YN
Trimethoprim
1$0$14NANN
Trimipramine Maleate
2$4$19NAYN
Tritocin
3$47$47NANN
Triumeq
533%33%NANN
Trivora
2$4$19NANN
Trizivir
533%33%NANN
Trophamine
3$47$47NAYN
Trospium Chloride
3$47$47NANN
Truseltiq
533%33%NAYN
Tukysa
533%33%NAYN
Turalio
533%33%NAYN
Twinrix
6$0$0NANN
Tybost
3$47$47NANN
Tymlos
533%33%NAYN
Typhim Vi
6$0$0NANN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H2256-034

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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