2017 BlueAdvantage Diamond (PPO) Formulary



Below is the Formulary, or drug list, for BlueAdvantage Diamond (PPO) from Bluecross Blueshield Of Tennessee, Inc. This formulary is a list of prescription medications that are covered under Bluecross Blueshield Of Tennessee, Inc.'s 2017 Medicare Advantage Plan. The BlueAdvantage Diamond (PPO) plan has a $0 drug deductible. 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. BlueAdvantage Diamond (PPO) 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 BlueAdvantage Diamond (PPO)





Plan Name:
BlueAdvantage Diamond (PPO)
Plan ID:
H7917-010
Provider: Bluecross Blueshield Of Tennessee, Inc.
Plan Year:2017
Premium:$115.80
Deductible:$0
Initial Coverage Limit:$3700
Coverage Area:Tennessee




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
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 NAN$30NNAN
Tacrolimus 1 Tube In 1 Carton > 30 G In 1 Tube
4
Y N NAN$50NNAN
Tacrolimus 1 Tube In 1 Carton > 30 G In 1 Tube
4
Y N NAN$50NNAN
Tacrolimus .5mg 100 Capsule In 1 Bottle
4
Y N NAN$50NNAN
Tacrolimus 1mg 100 Capsule In 1 Bottle
4
Y N NAN$50NNAN
Tacrolimus 5mg 100 Capsule In 1 Bottle
4
Y N NAN$50NNAN
Tamiflu 75mg 1 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack
3
42 180 N N NAN$30NNAN
Tamiflu 45mg 1 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack
3
42 180 N N NAN$30NNAN
Tamiflu 30mg 1 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack
3
84 180 N N NAN$30NNAN
Tamiflu 6mg/mL 1 Bottle, Glass In 1 Carton > 60 Ml In 1 Bottle, Glass
3
600 180 N N NAN$30NNAN
Tamoxifen Citrate 10mg 180 Tablet, Film Coated In 1 Bottle
2
N N NAN$6NNAN
Tamoxifen Citrate 20mg 30 Tablet In 1 Bottle
2
N N NAN$6NNAN
Tamsulosin Hydrochloride 100 Capsule In 1 Bottle
1
N N NAN$3NNAN
Tarceva 25mg 30 Tablet In 1 Bottle
5
Y N NAN33%NNAN
Tarceva 100mg 30 Tablet In 1 Bottle
5
Y N NAN33%NNAN
Tarceva 150mg 30 Tablet In 1 Bottle
5
30 30 Y N NAN33%NNAN
Targretin 60 G In 1 Tube
5
N N NAN33%NNAN
Tasigna 200mg 28 Capsule In 1 Blister Pack
5
112 28 Y N NAN33%NNAN
Tasigna 150mg 4 Blister Pack In 1 Carton > 28 Capsule In 1 Blister Pack
5
112 28 Y N NAN33%NNAN
Tazorac 1mg/g 1 Tube In 1 Carton > 100 G In 1 Tube
3
Y N NAN$30NNAN
Tazorac .5mg/g 1 Tube In 1 Carton > 100 G In 1 Tube
3
Y N NAN$30NNAN
Tazorac .5mg/g 1 Tube In 1 Carton > 60 G In 1 Tube
3
Y N NAN$30NNAN
Tazorac 1mg/g 1 Tube In 1 Carton > 60 G In 1 Tube
3
Y N NAN$30NNAN
Taztia 120mg 90 Capsule, Extended Release In 1 Bottle, Plastic
2
N N NAN$6NNAN
Taztia 180mg 90 Capsule, Extended Release In 1 Bottle, Plastic
2
N N NAN$6NNAN
Taztia 240mg 90 Capsule, Extended Release In 1 Bottle, Plastic
2
N N NAN$6NNAN
Taztia 300mg 90 Capsule, Extended Release In 1 Bottle, Plastic
2
N N NAN$6NNAN
Taztia 360mg 90 Capsule, Extended Release In 1 Bottle, Plastic
2
N N NAN$6NNAN
Tecfidera 120mg 1 Bottle, Plastic In 1 Carton > 14 Capsule In 1 Bottle, Plastic
5
Y N NAN33%NNAN
Tecfidera 240mg 1 Bottle, Plastic In 1 Carton > 60 Capsule In 1 Bottle, Plastic
5
Y N NAN33%NNAN
Tecfidera 1 Kit In 1 Kit * 14 Capsule In 1 Bottle, Plastic * 46 Capsule In 1 Bottle, Plastic
5
Y N NAN33%NNAN
Teflaro 400mg/20mL 10 Vial, Single-dose In 1 Carton
5
N N NAN33%NNAN
Teflaro 600mg/20mL 10 Vial, Single-dose In 1 Carton
5
N N NAN33%NNAN
Tegretol 100mg 100 Tablet, Extended Release In 1 Bottle
3
N N NAN$30NNAN
Telmisartan 20mg 3 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
1
N N NAN$3NNAN
Telmisartan 40mg 3 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
1
N N NAN$3NNAN
Telmisartan 80mg 3 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
1
N N NAN$3NNAN
Telmisartan And Amlodipine 5; 40mg/1; mg 30 Tablet In 1 Bottle
1
N N NAN$3NNAN
Telmisartan And Amlodipine 10; 40mg/1; mg 30 Tablet In 1 Bottle
1
N N NAN$3NNAN
Telmisartan And Amlodipine 5; 80mg/1; mg 30 Tablet In 1 Bottle
1
N N NAN$3NNAN
Telmisartan And Amlodipine 10; 80mg/1; mg 30 Tablet In 1 Bottle
1
N N NAN$3NNAN
Telmisartan And Hydrochlorothiazide 90 Tablet In 1 Bottle
1
N N NAN$3NNAN
Telmisartan And Hydrochlorothiazide 90 Tablet In 1 Bottle
1
N N NAN$3NNAN
Telmisartan And Hydrochlorothiazide 90 Tablet In 1 Bottle
1
N N NAN$3NNAN
Temazepam 7.5mg 100 Capsule In 1 Bottle, Plastic
4
Y N NAN$50NNAN
Temazepam 22.5mg 30 Capsule In 1 Bottle, Plastic
4
Y N NAN$50NNAN
Temazepam 15mg 100 Blister Pack In 1 Box, Unit-dose
4
Y N NAN$50NNAN
Temazepam 30mg 500 Capsule In 1 Bottle
4
Y N NAN$50NNAN
Tenivac 10 Syringe In 1 Package > .5 Ml In 1 Syringe
3
N N NAN$30NNAN
Terazosin 1mg 100 Capsule In 1 Bottle
1
30 30 N N NAN$3NNAN
Terazosin Hydrochloride 2mg 100 Capsule In 1 Bottle
1
30 30 N N NAN$3NNAN
Terazosin Hydrochloride 5mg 100 Capsule In 1 Bottle
1
30 30 N N NAN$3NNAN
Terazosin Hydrochloride 10mg 100 Capsule In 1 Bottle
1
60 30 N N NAN$3NNAN
Terbinafine Hydrochloride 90 Tablet In 1 Bottle
2
N N NAN$6NNAN
Terbutaline Sulfate 2.5mg 100 Tablet In 1 Bottle
2
N N NAN$6NNAN
Terbutaline Sulfate 5mg 100 Tablet In 1 Bottle
2
N N NAN$6NNAN
Terbutaline Sulfate 1mg/mL 25 Vial, Single-use In 1 Tray > 1 Ml In 1 Vial, Single-use
5
N N NAN33%NNAN
Terconazole 80mg 1 Blister Pack In 1 Carton > 3 Suppository In 1 Blister Pack
2
N N NAN$6NNAN
Terconazole 8mg/g 1 Tube, With Applicator In 1 Carton > 20 G In 1 Tube, With Applicator
2
N N NAN$6NNAN
Terconazole 4mg/g 1 Tube, With Applicator In 1 Carton > 45 G In 1 Tube, With Applicator
2
N N NAN$6NNAN
Testosterone Cypionate 1 Vial, Multi-dose In 1 Carton > 10 Ml In 1 Vial, Multi-dose
2
N N NAN$6NNAN
Testosterone Cypionate 1 Vial, Multi-dose In 1 Carton > 10 Ml In 1 Vial, Multi-dose
2
N N NAN$6NNAN
Testosterone Enanthate 200mg/mL 1 Vial, Multi-dose In 1 Carton > 5 Ml In 1 Vial, Multi-dose
2
N N NAN$6NNAN
Tetracycline Hydrochloride 250mg 100 Capsule In 1 Bottle
4
N N NAN$50NNAN
Tetracycline Hydrochloride 500mg 100 Capsule In 1 Bottle
4
N N NAN$50NNAN
Thalomid 50mg 10 Blister Pack In 1 Box
5
Y N NAN33%NNAN
Thalomid 100mg 5 Blister Pack In 1 Box
5
Y N NAN33%NNAN
Thalomid 150mg 4 Blister Pack In 1 Box
5
Y N NAN33%NNAN
Thalomid 200mg 3 Blister Pack In 1 Box
5
Y N NAN33%NNAN
Theophylline 400mg 100 Tablet, Extended Release In 1 Bottle, Plastic
2
N N NAN$6NNAN
Theophylline 600mg 100 Tablet, Extended Release In 1 Bottle, Plastic
2
N N NAN$6NNAN
Theophylline 300mg 100 Tablet, Extended Release In 1 Bottle
2
N N NAN$6NNAN
Theophylline 200mg 500 Tablet, Extended Release In 1 Bottle
2
N N NAN$6NNAN
Theophylline 100mg 500 Tablet, Extended Release In 1 Bottle
2
N N NAN$6NNAN
Theophylline 450mg 100 Tablet, Extended Release In 1 Bottle
2
N N NAN$6NNAN
Theophylline 80mg/15mL 473 Ml In 1 Bottle, Plastic
2
N N NAN$6NNAN
Thiola 100mg 100 Tablet, Sugar Coated In 1 Bottle
5
N N NAN33%NNAN
Thioridazine Hydrochloride 100mg 100 Tablet, Film Coated In 1 Bottle, Plastic
4
Y N NAN$50NNAN
Thioridazine Hydrochloride 50mg 100 Blister Pack In 1 Box, Unit-dose
4
Y N NAN$50NNAN
Thioridazine Hydrochloride 10mg 1000 Tablet, Film Coated In 1 Bottle, Plastic
4
Y N NAN$50NNAN
Thioridazine Hydrochloride 25mg 1000 Tablet, Film Coated In 1 Bottle, Plastic
4
Y N NAN$50NNAN
Thiothixene 2mg 100 Capsule In 1 Bottle, Plastic
2
N N NAN$6NNAN
Thiothixene 5mg 100 Capsule In 1 Bottle, Plastic
2
N N NAN$6NNAN
Thiothixene 10mg 100 Capsule In 1 Bottle, Plastic
2
N N NAN$6NNAN
Thiothixene 1mg 100 Capsule In 1 Bottle
2
N N NAN$6NNAN
Thymoglobulin 5mg/mL 5 Ml In 1 Vial, Glass
5
Y N NAN33%NNAN
Tiagabine Hydrochloride 2mg 30 Tablet, Film Coated In 1 Bottle
4
N N NAN$50NNAN
Tiagabine Hydrochloride 4mg 30 Tablet, Film Coated In 1 Bottle
4
N N NAN$50NNAN
Timolol Maleate 5mg 100 Tablet In 1 Bottle, Plastic
1
N N NAN$3NNAN
Timolol Maleate 10mg 100 Tablet In 1 Bottle, Plastic
1
N N NAN$3NNAN
Timolol Maleate 20mg 100 Tablet In 1 Bottle, Plastic
1
N N NAN$3NNAN
Timolol Maleate 3.4mg/mL 1 Bottle, Dispensing In 1 Carton > 5 Ml In 1 Bottle, Dispensing
2
N N NAN$6NNAN
Timolol Maleate 6.8mg/mL 1 Bottle, Dispensing In 1 Carton > 5 Ml In 1 Bottle, Dispensing
2
N N NAN$6NNAN
Timolol Maleate 2.5mg/mL 15 Ml In 1 Bottle, Plastic
1
N N NAN$3NNAN
Timolol Maleate 5mg/mL 10 Ml In 1 Bottle, Plastic
1
N N NAN$3NNAN
Tinidazole 250mg 40 Tablet In 1 Bottle
2
N N NAN$6NNAN
Tinidazole 500mg 60 Tablet In 1 Bottle
2
N N NAN$6NNAN
Tivicay 50mg 30 Tablet, Film Coated In 1 Bottle
5
N N NAN33%NNAN
Tizanidine 2mg 150 Tablet In 1 Bottle, Plastic
2
N N NAN$6NNAN
Tizanidine 4mg 1000 Tablet In 1 Bottle
2
N N NAN$6NNAN
Tizanidine Hydrochloride 2mg 150 Capsule, Gelatin Coated In 1 Bottle
2
N N NAN$6NNAN
Tizanidine Hydrochloride 4mg 150 Capsule, Gelatin Coated In 1 Bottle
2
N N NAN$6NNAN
Tizanidine Hydrochloride 6mg 150 Capsule, Gelatin Coated In 1 Bottle
2
N N NAN$6NNAN
Tobramycin 300mg/5mL 56 Ampule In 1 Carton > 5 Ml In 1 Ampule
5
280 28 Y N NAN33%NNAN
Tobramycin 10mg/mL 25 Vial, Multi-dose In 1 Tray > 2 Ml In 1 Vial, Multi-dose
2
N N NAN$6NNAN
Tobramycin 40mg/mL 25 Vial, Multi-dose In 1 Tray > 2 Ml In 1 Vial, Multi-dose
2
N N NAN$6NNAN
Tobramycin 3mg/mL 1 Bottle, Dropper In 1 Carton > 5 Ml In 1 Bottle, Dropper
1
N N NAN$3NNAN
Tobramycin And Dexamethasone 1; 3mg/mL; mg/mL 1 Bottle, Dropper In 1 Carton > 5 Ml In 1 Bottle, Dropper
2
N N NAN$6NNAN
Tobrex 3mg/g 3.5 G In 1 Tube
3
N N NAN$30NNAN
Tolazamide 250mg 100 Tablet In 1 Bottle, Plastic
2
120 30 N N NAN$6NNAN
Tolazamide 500mg 100 Tablet In 1 Bottle, Plastic
2
60 30 N N NAN$6NNAN
Tolbutamide 500mg 500 Tablet In 1 Bottle, Plastic
2
180 30 N N NAN$6NNAN
Tolmetin Sodium 400mg 100 Capsule In 1 Bottle
2
N N NAN$6NNAN
Tolmetin Sodium 600mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N NAN$6NNAN
Tolterodine Tartrate 2mg 30 Capsule, Extended Release In 1 Bottle, Plastic
2
N N NAN$6NNAN
Tolterodine Tartrate 500 Capsule, Extended Release In 1 Bottle, Plastic
2
N N NAN$6NNAN
Tolterodine Tartrate 2mg 60 Tablet, Film Coated In 1 Bottle, Plastic
2
N N NAN$6NNAN
Tolterodine Tartrate 1mg 500 Tablet, Film Coated In 1 Bottle
2
N N NAN$6NNAN
Topiramate 15mg 60 Capsule, Coated Pellets In 1 Bottle
4
N N NAN$50NNAN
Topiramate 25mg 60 Capsule, Coated Pellets In 1 Bottle
4
N N NAN$50NNAN
Topiramate 25mg 1000 Tablet, Film Coated In 1 Bottle
2
N N NAN$6NNAN
Topiramate 100mg 1000 Tablet, Film Coated In 1 Bottle
2
N N NAN$6NNAN
Topiramate 200mg 1000 Tablet, Film Coated In 1 Bottle
2
N N NAN$6NNAN
Topiramate 50mg 1000 Tablet, Film Coated In 1 Bottle
2
N N NAN$6NNAN
Toposar 20mg/mL 1 Vial, Multi-dose In 1 Carton > 50 Ml In 1 Vial, Multi-dose
2
Y N NAN$6NNAN
Torisel 1 Kit In 1 Carton
5
Y N NAN33%NNAN
Torsemide 20mg 100 Tablet In 1 Bottle, Plastic
1
N N NAN$3NNAN
Torsemide 100mg 12 Bottle In 1 Case > 100 Tablet In 1 Bottle
1
N N NAN$3NNAN
Torsemide 100 Tablet In 1 Bottle
1
N N NAN$3NNAN
Torsemide 100 Tablet In 1 Bottle
1
N N NAN$3NNAN
Toviaz 4mg 30 Tablet, Film Coated, Extended Release In 1 Bottle
3
N N NAN$30NNAN
Toviaz 8mg 30 Tablet, Film Coated, Extended Release In 1 Bottle
3
N N NAN$30NNAN
Tracleer 62.5mg 1 Bottle, Plastic In 1 Carton > 60 Tablet, Film Coated In 1 Bottle, Plastic
5
Y N NAN33%NNAN
Tracleer 125mg 1 Bottle, Plastic In 1 Carton > 60 Tablet, Film Coated In 1 Bottle, Plastic
5
Y N NAN33%NNAN
Tradjenta 5mg 90 Tablet, Film Coated In 1 Bottle
3
30 30 N N NAN$30NNAN
Tramadol Hydrochloride 50mg 100 Tablet, Film Coated In 1 Bottle
2
240 30 N N NAN$6NNAN
Tramadol Hydrochloride 300mg 100 Tablet, Extended Release In 1 Bottle
2
30 30 N N NAN$6NNAN
Tramadol Hydrochloride 100mg 30 Tablet, Extended Release In 1 Bottle, Plastic
2
30 30 N N NAN$6NNAN
Tramadol Hydrochloride 200mg 30 Tablet, Extended Release In 1 Bottle, Plastic
2
30 30 N N NAN$6NNAN
Tramadol Hydrochloride And Acetaminophen 325; 37.5mg/1; mg 1000 Tablet, Film Coated In 1 Bottle
2
240 30 N N NAN$6NNAN
Trandolapril 100 Tablet In 1 Bottle
1
N N NAN$3NNAN
Trandolapril 100 Tablet In 1 Bottle
1
N N NAN$3NNAN
Trandolapril 100 Tablet In 1 Bottle
1
N N NAN$3NNAN
Trandolapril And Verapamil Hydrochloride 100 Tablet, Film Coated, Extended Release In 1 Bottle
2
N N NAN$6NNAN
Trandolapril And Verapamil Hydrochloride 100 Tablet, Film Coated, Extended Release In 1 Bottle
2
N N NAN$6NNAN
Trandolapril And Verapamil Hydrochloride 100 Tablet, Film Coated, Extended Release In 1 Bottle
2
N N NAN$6NNAN
Trandolapril And Verapamil Hydrochloride 100 Tablet, Film Coated, Extended Release In 1 Bottle
2
N N NAN$6NNAN
Tranexamic Acid 650mg 30 Tablet, Film Coated In 1 Bottle, Plastic
2
N N NAN$6NNAN
Tranexamic Acid 100mg/mL 10 Vial, Single-dose In 1 Package
2
N N NAN$6NNAN
Transderm Scop 1mg/3d 10 Pouch In 1 Box > 1 Patch In 1 Pouch > 3 D In 1 Patch
4
N N NAN$50NNAN
Tranylcypromine Sulfate 10mg 100 Tablet In 1 Bottle, Plastic
4
N N NAN$50NNAN
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 NAN$50NNAN
Travoprost Ophthalmic Solution 0.004% .04mg/mL 1 Bottle In 1 Carton > 2.5 Ml In 1 Bottle
2
N N NAN$6NNAN
Trazodone Hydrochloride 300mg 100 Tablet In 1 Bottle
1
N N NAN$3NNAN
Trazodone Hydrochloride 50mg 500 Tablet In 1 Bottle
1
N N NAN$3NNAN
Trazodone Hydrochloride 100mg 500 Tablet In 1 Bottle
1
N N NAN$3NNAN
Trazodone Hydrochloride 150mg 100 Tablet In 1 Bottle
1
N N NAN$3NNAN
Treanda 100mg/20mL 20 Ml In 1 Vial, Single-use
5
Y N NAN33%NNAN
Trecator 250mg 100 Tablet, Film Coated In 1 Bottle
3
N N NAN$30NNAN
Trelstar 22.5mg/2mL 2 Ml In 1 Vial, Single-dose
5
Y N NAN33%NNAN
Trelstar 1 Kit In 1 Carton * 2 Ml In 1 Syringe
5
N N NAN33%NNAN
Trelstar 1 Kit In 1 Carton * 2 Ml In 1 Syringe
5
N N NAN33%NNAN
Tretinoin 10mg 100 Capsule In 1 Bottle
5
N N NAN33%NNAN
Tretinoin 1mg/g 1 Tube In 1 Carton > 45 G In 1 Tube
2
Y N NAN$6NNAN
Tretinoin .5mg/g 1 Tube In 1 Carton > 20 G In 1 Tube
2
Y N NAN$6NNAN
Tretinoin .25mg/g 1 Tube In 1 Carton > 45 G In 1 Tube
2
Y N NAN$6NNAN
Tretinoin .25mg/g 1 Tube In 1 Carton > 45 G In 1 Tube
2
Y N NAN$6NNAN
Tretinoin 1 Tube In 1 Carton > 45 G In 1 Tube
2
Y N NAN$6NNAN
Tri Previfem 6 Blister Pack In 1 Carton
2
N N NAN$6NNAN
Tri-legest Fe 5 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
2
N N NAN$6NNAN
Tri-sprintec 6 Pouch In 1 Carton > 1 Blister Pack In 1 Pouch > 1 Kit In 1 Blister Pack
2
N N NAN$6NNAN
Triamcinolone Acetonide .25mg/g 80 G In 1 Tube
2
N N NAN$6NNAN
Triamcinolone Acetonide 1mg/g 80 G In 1 Tube
2
N N NAN$6NNAN
Triamcinolone Acetonide 1mg/mL 60 Ml In 1 Bottle, Plastic
2
N N NAN$6NNAN
Triamcinolone Acetonide 5mg/g 1 Tube In 1 Carton > 15 G In 1 Tube
2
N N NAN$6NNAN
Triamcinolone Acetonide .25mg/g 1 Tube In 1 Carton > 80 G In 1 Tube
2
N N NAN$6NNAN
Triamcinolone Acetonide 1mg/g 1 Tube In 1 Carton > 80 G In 1 Tube
2
N N NAN$6NNAN
Triamcinolone Acetonide 5mg/g 1 Tube In 1 Carton > 15 G In 1 Tube
2
N N NAN$6NNAN
Triamcinolone Acetonide 1mg/g 1 Tube In 1 Carton > 5 G In 1 Tube
2
N N NAN$6NNAN
Triamcinolone Acetonide .25mg/mL 60 Ml In 1 Bottle, With Applicator
2
N N NAN$6NNAN
Triamterene And Hydrochlorothiazide 25; 37.5mg/1; mg 100 Capsule In 1 Bottle, Plastic
1
N N NAN$3NNAN
Triamterene And Hydrochlorothiazide 25; 50mg/1; mg 100 Capsule In 1 Bottle
1
N N NAN$3NNAN
Triamterene Hydrochlorothiazide 50; 75mg/1; mg 500 Tablet In 1 Bottle
1
N N NAN$3NNAN
Triamterene Hydrochlorothiazide 25; 37.5mg/1; mg 100 Tablet In 1 Bottle
1
N N NAN$3NNAN
Triderm 1mg/g 85.2 G In 1 Tube
2
N N NAN$6NNAN
Trifluoperazine Hydrochloride 2mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N NAN$6NNAN
Trifluoperazine Hydrochloride 5mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N NAN$6NNAN
Trifluoperazine Hydrochloride 10mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N NAN$6NNAN
Trifluoperazine Hydrochloride 1mg 100 Tablet, Film Coated In 1 Bottle
2
N N NAN$6NNAN
Trifluridine 10mg/mL 7.5 Ml In 1 Bottle, Plastic
2
N N NAN$6NNAN
Trilyte 420; 1.48; 5.72; 11.2g/4L; g/4L; g/4L; g/4L 4 L In 1 Bottle
2
N N NAN$6NNAN
Trimethoprim 100mg 100 Tablet In 1 Bottle, Plastic
1
N N NAN$3NNAN
Trimipramine Maleate 30 Capsule In 1 Bottle
4
Y N NAN$50NNAN
Trimipramine Maleate 30 Capsule In 1 Bottle
4
Y N NAN$50NNAN
Trimipramine Maleate 30 Capsule In 1 Bottle
4
Y N NAN$50NNAN
Trinessa 1 Dialpack In 1 Carton > 1 Kit In 1 Dialpack
2
N N NAN$6NNAN
Trisenox 1mg/mL 10 Ampule In 1 Carton
5
N N NAN33%NNAN
Triumeq 30 Tablet, Film Coated In 1 Bottle
5
N N NAN33%NNAN
Trivora 6 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
2
N N NAN$6NNAN
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 NAN$30NNAN
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 NAN$30NNAN
Trospium Chloride 20mg 60 Tablet, Film Coated In 1 Bottle
2
N N NAN$6NNAN
Trospium Chloride 60mg 30 Capsule, Extended Release In 1 Bottle, Plastic
2
N N NAN$6NNAN
Trulicity 4 Syringe In 1 Carton
3
2 28 Y N NAN$30NNAN
Trulicity 4 Syringe In 1 Carton
3
2 28 Y N NAN$30NNAN
Truvada 200; 300mg/1; mg 30 Tablet, Film Coated In 1 Bottle, Plastic
5
N N NAN33%NNAN
Twinrix 720; 20[iU]/mL; ug/mL 10 Vial In 1 Carton
3
N N NAN$30NNAN
Tygacil 50mg/5mL 10 Vial, Single-use In 1 Carton
5
N N NAN33%NNAN
Tykerb 250mg 150 Tablet In 1 Bottle
5
180 30 Y N NAN33%NNAN
Typhim Vi 25ug/.5mL 1 Vial, Multi-dose In 1 Package
3
N N NAN$30NNAN
Typhim Vi 1 Syringe In 1 Package
3
N N NAN$30NNAN
Tysabri 300mg/15mL 1 Vial, Single-use In 1 Carton > 15 Ml In 1 Vial, Single-use
5
Y N NAN33%NNAN
Tyvaso 1.74mg/2.9mL 4 Ampule In 1 Box > 2.9 Ml In 1 Ampule
5
Y N NAN33%NNAN
Tyzeka 600mg 30 Tablet, Film Coated In 1 Bottle
5
N N NAN33%NNAN



Medicare Help's Additional Notes:

Coverage Levels for H7917-010

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 $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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