2017 Generations Premier (HMO) Formulary



Below is the Formulary, or drug list, for Generations Premier (HMO) from Globalhealth, Inc. This formulary is a list of prescription medications that are covered under Globalhealth, Inc.'s 2017 Medicare Advantage Plan. The Generations Premier (HMO) 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. Generations Premier (HMO) 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 Generations Premier (HMO)





Plan Name:
Generations Premier (HMO)
Plan ID:
H3706-019
Provider: Globalhealth, Inc.
Plan Year:2017
Premium:$51.50
Deductible:$0
Initial Coverage Limit:$3700
Coverage Area:Oklahoma




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
4
N N 40%N50%N30%N
Taclonex .5; 50mg/g; ug/g 100 Carton In 1 Case > 1 Tube In 1 Carton > 60 G In 1 Tube
5
N N 33%N33%N33%N
Taclonex .5; 50mg/g; ug/g 40 Carton In 1 Case > 1 Bottle In 1 Carton > 60 G In 1 Bottle
5
N N 33%N33%N33%N
Tacrolimus 1 Tube In 1 Carton > 30 G In 1 Tube
2
N N $15N$20N$15N
Tacrolimus 1 Tube In 1 Carton > 30 G In 1 Tube
2
N N $15N$20N$15N
Tacrolimus .5mg 100 Capsule In 1 Bottle
2
Y N $15N$20N$15N
Tacrolimus 1mg 100 Capsule In 1 Bottle
2
Y N $15N$20N$15N
Tacrolimus 5mg 100 Capsule In 1 Bottle
2
Y N $15N$20N$15N
Tamiflu 75mg 1 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack
3
N N $42N$47N$42N
Tamiflu 45mg 1 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack
3
N N $42N$47N$42N
Tamiflu 30mg 1 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack
3
N N $42N$47N$42N
Tamiflu 6mg/mL 1 Bottle, Glass In 1 Carton > 60 Ml In 1 Bottle, Glass
3
N N $42N$47N$42N
Tamoxifen Citrate 10mg 180 Tablet, Film Coated In 1 Bottle
1
N N $5N$10N$5N
Tamoxifen Citrate 20mg 30 Tablet In 1 Bottle
1
N N $5N$10N$5N
Tamsulosin Hydrochloride 100 Capsule In 1 Bottle
2
N N $15N$20N$15N
Tanzeum 30mg/.5mL 4 Syringe In 1 Carton > .5 Ml In 1 Syringe
4
4 28 N N 40%N50%N30%N
Tanzeum 50mg/.5mL 4 Syringe In 1 Carton > .5 Ml In 1 Syringe
4
4 28 N N 40%N50%N30%N
Tapazole 5mg 100 Tablet In 1 Bottle
4
N N 40%N50%N30%N
Tapazole 10mg 100 Tablet In 1 Bottle
4
N N 40%N50%N30%N
Tarceva 25mg 30 Tablet In 1 Bottle
5
Y N 33%N33%N33%N
Tarceva 100mg 30 Tablet In 1 Bottle
5
Y N 33%N33%N33%N
Tarceva 150mg 30 Tablet In 1 Bottle
5
Y N 33%N33%N33%N
Targretin 60 G In 1 Tube
5
Y N 33%N33%N33%N
Targretin 75mg 1 Bottle In 1 Carton > 100 Capsule, Liquid Filled In 1 Bottle
5
Y N 33%N33%N33%N
Tarina Fe 1/20 3 Pouch In 1 Carton > 1 Kit In 1 Pouch
2
N N $15N$20N$15N
Tarka 2; 180mg/1; mg 100 Tablet, Film Coated, Extended Release In 1 Bottle
4
N N 40%N50%N30%N
Tarka 1; 240mg/1; mg 100 Tablet, Film Coated, Extended Release In 1 Bottle
4
N N 40%N50%N30%N
Tarka 2; 240mg/1; mg 100 Tablet, Film Coated, Extended Release In 1 Bottle
4
N N 40%N50%N30%N
Tarka 4; 240mg/1; mg 100 Tablet, Film Coated, Extended Release In 1 Bottle
4
N N 40%N50%N30%N
Tasigna 200mg 28 Capsule In 1 Blister Pack
5
Y N 33%N33%N33%N
Tasigna 150mg 4 Blister Pack In 1 Carton > 28 Capsule In 1 Blister Pack
5
Y N 33%N33%N33%N
Taxotere 80mg/4mL 1 Vial, Glass In 1 Carton > 4 Ml In 1 Vial, Glass
5
Y N 33%N33%N33%N
Tazicef 25 Vial In 1 Tray > 1 Injection, Powder, For Solution In 1 Vial
2
N N $15N$20N$15N
Tazicef 10 Vial In 1 Tray > 1 Injection, Powder, For Solution In 1 Vial
2
N N $15N$20N$15N
Tazicef 10 Vial, Pharmacy Bulk Package In 1 Carton > 1 Injection, Powder, For Solution In 1 Vial, Pharmacy Bulk Package
2
N N $15N$20N$15N
Tazorac 1mg/g 1 Tube In 1 Carton > 100 G In 1 Tube
4
Y N 40%N50%N30%N
Tazorac .5mg/g 1 Tube In 1 Carton > 100 G In 1 Tube
4
Y N 40%N50%N30%N
Tazorac .5mg/g 1 Tube In 1 Carton > 60 G In 1 Tube
4
Y N 40%N50%N30%N
Tazorac 1mg/g 1 Tube In 1 Carton > 60 G In 1 Tube
4
Y N 40%N50%N30%N
Taztia 120mg 90 Capsule, Extended Release In 1 Bottle, Plastic
2
N N $15N$20N$15N
Taztia 180mg 90 Capsule, Extended Release In 1 Bottle, Plastic
2
N N $15N$20N$15N
Taztia 240mg 90 Capsule, Extended Release In 1 Bottle, Plastic
2
N N $15N$20N$15N
Taztia 300mg 90 Capsule, Extended Release In 1 Bottle, Plastic
2
N N $15N$20N$15N
Taztia 360mg 90 Capsule, Extended Release In 1 Bottle, Plastic
2
N N $15N$20N$15N
Tecfidera 120mg 1 Bottle, Plastic In 1 Carton > 14 Capsule In 1 Bottle, Plastic
5
14 7 Y N 33%N33%N33%N
Tecfidera 240mg 1 Bottle, Plastic In 1 Carton > 60 Capsule In 1 Bottle, Plastic
5
60 30 Y N 33%N33%N33%N
Tecfidera 1 Kit In 1 Kit * 14 Capsule In 1 Bottle, Plastic * 46 Capsule In 1 Bottle, Plastic
5
Y N 33%N33%N33%N
Teflaro 400mg/20mL 10 Vial, Single-dose In 1 Carton
5
N N 33%N33%N33%N
Teflaro 600mg/20mL 10 Vial, Single-dose In 1 Carton
5
N N 33%N33%N33%N
Tegretol 100mg/5mL 450 Ml In 1 Bottle
4
N N 40%N50%N30%N
Tegretol 200mg 100 Tablet In 1 Bottle
4
N N 40%N50%N30%N
Tegretol 100mg 100 Tablet, Extended Release In 1 Bottle
4
N N 40%N50%N30%N
Tegretol 200mg 100 Tablet, Extended Release In 1 Bottle
4
N N 40%N50%N30%N
Tegretol 400mg 100 Tablet, Extended Release In 1 Bottle
4
N N 40%N50%N30%N
Tekturna 150mg 30 Tablet, Film Coated In 1 Bottle
4
N N 40%N50%N30%N
Tekturna 300mg 30 Tablet, Film Coated In 1 Bottle
4
N N 40%N50%N30%N
Tekturna Hct 150; 12.5mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
N N 40%N50%N30%N
Tekturna Hct 150; 25mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
N N 40%N50%N30%N
Tekturna Hct 300; 12.5mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
N N 40%N50%N30%N
Tekturna Hct 300; 25mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
N N 40%N50%N30%N
Telmisartan 20mg 3 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
1
N N $5N$10N$5N
Telmisartan 40mg 3 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
1
N N $5N$10N$5N
Telmisartan 80mg 3 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
1
N N $5N$10N$5N
Telmisartan And Amlodipine 5; 40mg/1; mg 30 Tablet In 1 Bottle
1
N N $5N$10N$5N
Telmisartan And Amlodipine 10; 40mg/1; mg 30 Tablet In 1 Bottle
1
N N $5N$10N$5N
Telmisartan And Amlodipine 5; 80mg/1; mg 30 Tablet In 1 Bottle
1
N N $5N$10N$5N
Telmisartan And Amlodipine 10; 80mg/1; mg 30 Tablet In 1 Bottle
1
N N $5N$10N$5N
Telmisartan And Hydrochlorothiazide 90 Tablet In 1 Bottle
1
N N $5N$10N$5N
Telmisartan And Hydrochlorothiazide 90 Tablet In 1 Bottle
1
N N $5N$10N$5N
Telmisartan And Hydrochlorothiazide 90 Tablet In 1 Bottle
1
N N $5N$10N$5N
Temazepam 7.5mg 100 Capsule In 1 Bottle, Plastic
2
30 30 Y N $15N$20N$15N
Temazepam 15mg 100 Blister Pack In 1 Box, Unit-dose
2
60 30 Y N $15N$20N$15N
Tenivac 10 Syringe In 1 Package > .5 Ml In 1 Syringe
3
Y N $42N$47N$42N
Terazol 3 1 Tube, With Applicator In 1 Carton > 20 G In 1 Tube, With Applicator
4
N N 40%N50%N30%N
Terazol 7 1 Tube, With Applicator In 1 Carton > 45 G In 1 Tube, With Applicator
4
N N 40%N50%N30%N
Terazosin 1mg 100 Capsule In 1 Bottle
1
N N $5N$10N$5N
Terazosin Hydrochloride 2mg 100 Capsule In 1 Bottle
1
N N $5N$10N$5N
Terazosin Hydrochloride 5mg 100 Capsule In 1 Bottle
1
N N $5N$10N$5N
Terazosin Hydrochloride 10mg 100 Capsule In 1 Bottle
1
N N $5N$10N$5N
Terbinafine Hydrochloride 90 Tablet In 1 Bottle
1
90 365 N N $5N$10N$5N
Terbutaline Sulfate 2.5mg 100 Tablet In 1 Bottle
2
N N $15N$20N$15N
Terbutaline Sulfate 5mg 100 Tablet In 1 Bottle
2
N N $15N$20N$15N
Terbutaline Sulfate 1mg/mL 25 Vial, Single-use In 1 Tray > 1 Ml In 1 Vial, Single-use
5
N N 33%N33%N33%N
Terconazole 80mg 1 Blister Pack In 1 Carton > 3 Suppository In 1 Blister Pack
2
N N $15N$20N$15N
Terconazole 8mg/g 1 Tube, With Applicator In 1 Carton > 20 G In 1 Tube, With Applicator
2
N N $15N$20N$15N
Terconazole 4mg/g 1 Tube, With Applicator In 1 Carton > 45 G In 1 Tube, With Applicator
2
N N $15N$20N$15N
Testim 50mg/5g 30 Tube In 1 Carton > 5 G In 1 Tube
4
300 30 Y N 40%N50%N30%N
Testosterone 1 Canister In 1 Carton > 60 G In 1 Canister
2
120 30 Y N $15N$20N$15N
Testosterone 30 Packet In 1 Carton
2
300 30 Y N $15N$20N$15N
Testosterone Cypionate 1 Vial, Multi-dose In 1 Carton > 10 Ml In 1 Vial, Multi-dose
2
Y N $15N$20N$15N
Testosterone Cypionate 1 Vial, Multi-dose In 1 Carton > 10 Ml In 1 Vial, Multi-dose
2
Y N $15N$20N$15N
Testosterone Enanthate 200mg/mL 1 Vial, Multi-dose In 1 Carton > 5 Ml In 1 Vial, Multi-dose
2
Y N $15N$20N$15N
Tetracycline Hydrochloride 250mg 100 Capsule In 1 Bottle
2
N N $15N$20N$15N
Tetracycline Hydrochloride 500mg 100 Capsule In 1 Bottle
2
N N $15N$20N$15N
Thalomid 50mg 10 Blister Pack In 1 Box
5
Y N 33%N33%N33%N
Thalomid 100mg 5 Blister Pack In 1 Box
5
Y N 33%N33%N33%N
Thalomid 150mg 4 Blister Pack In 1 Box
5
Y N 33%N33%N33%N
Thalomid 200mg 3 Blister Pack In 1 Box
5
Y N 33%N33%N33%N
Theophylline 400mg 100 Tablet, Extended Release In 1 Bottle, Plastic
2
N N $15N$20N$15N
Theophylline 600mg 100 Tablet, Extended Release In 1 Bottle, Plastic
2
N N $15N$20N$15N
Theophylline 300mg 100 Tablet, Extended Release In 1 Bottle
2
N N $15N$20N$15N
Theophylline 200mg 500 Tablet, Extended Release In 1 Bottle
2
N N $15N$20N$15N
Theophylline 100mg 500 Tablet, Extended Release In 1 Bottle
2
N N $15N$20N$15N
Theophylline 450mg 100 Tablet, Extended Release In 1 Bottle
2
N N $15N$20N$15N
Theophylline 80mg/15mL 473 Ml In 1 Bottle, Plastic
2
N N $15N$20N$15N
Thioridazine Hydrochloride 100mg 100 Tablet, Film Coated In 1 Bottle, Plastic
4
Y N 40%N50%N30%N
Thioridazine Hydrochloride 50mg 100 Blister Pack In 1 Box, Unit-dose
4
Y N 40%N50%N30%N
Thioridazine Hydrochloride 10mg 1000 Tablet, Film Coated In 1 Bottle, Plastic
4
Y N 40%N50%N30%N
Thioridazine Hydrochloride 25mg 1000 Tablet, Film Coated In 1 Bottle, Plastic
4
Y N 40%N50%N30%N
Thiothixene 2mg 100 Capsule In 1 Bottle, Plastic
2
N N $15N$20N$15N
Thiothixene 5mg 100 Capsule In 1 Bottle, Plastic
2
N N $15N$20N$15N
Thiothixene 10mg 100 Capsule In 1 Bottle, Plastic
2
N N $15N$20N$15N
Thiothixene 1mg 100 Capsule In 1 Bottle
2
N N $15N$20N$15N
Thymoglobulin 5mg/mL 5 Ml In 1 Vial, Glass
5
Y N 33%N33%N33%N
Tiagabine Hydrochloride 2mg 30 Tablet, Film Coated In 1 Bottle
2
N N $15N$20N$15N
Tiagabine Hydrochloride 4mg 30 Tablet, Film Coated In 1 Bottle
2
N N $15N$20N$15N
Tiazac 90 Capsule, Extended Release In 1 Bottle, Plastic
4
N N 40%N50%N30%N
Tiazac 90 Capsule, Extended Release In 1 Bottle, Plastic
4
N N 40%N50%N30%N
Tiazac 90 Capsule, Extended Release In 1 Bottle, Plastic
4
N N 40%N50%N30%N
Tiazac 90 Capsule, Extended Release In 1 Bottle, Plastic
4
N N 40%N50%N30%N
Tiazac 90 Capsule, Extended Release In 1 Bottle, Plastic
4
N N 40%N50%N30%N
Tiazac 90 Capsule, Extended Release In 1 Bottle, Plastic
4
N N 40%N50%N30%N
Tikosyn .125mg 60 Capsule In 1 Bottle
4
N N 40%N50%N30%N
Tikosyn .25mg 60 Capsule In 1 Bottle
4
N N 40%N50%N30%N
Tikosyn .5mg 60 Capsule In 1 Bottle
4
N N 40%N50%N30%N
Timolol Maleate 5mg 100 Tablet In 1 Bottle, Plastic
2
N N $15N$20N$15N
Timolol Maleate 10mg 100 Tablet In 1 Bottle, Plastic
2
N N $15N$20N$15N
Timolol Maleate 20mg 100 Tablet In 1 Bottle, Plastic
2
N N $15N$20N$15N
Timolol Maleate 3.4mg/mL 1 Bottle, Dispensing In 1 Carton > 5 Ml In 1 Bottle, Dispensing
2
N N $15N$20N$15N
Timolol Maleate 6.8mg/mL 1 Bottle, Dispensing In 1 Carton > 5 Ml In 1 Bottle, Dispensing
2
N N $15N$20N$15N
Timolol Maleate 2.5mg/mL 15 Ml In 1 Bottle, Plastic
1
N N $5N$10N$5N
Timolol Maleate 5mg/mL 10 Ml In 1 Bottle, Plastic
1
N N $5N$10N$5N
Timoptic-xe 2.5mg/mL 1 Bottle, Dispensing In 1 Carton > 5 Ml In 1 Bottle, Dispensing
4
N N 40%N50%N30%N
Timoptic-xe 5mg/mL 1 Bottle, Dispensing In 1 Carton > 5 Ml In 1 Bottle, Dispensing
4
N N 40%N50%N30%N
Tirosint 13ug 4 Blister Pack In 1 Carton > 7 Capsule In 1 Blister Pack
4
N N 40%N50%N30%N
Tirosint 25ug 4 Blister Pack In 1 Carton > 7 Capsule In 1 Blister Pack
4
N N 40%N50%N30%N
Tirosint 50ug 4 Blister Pack In 1 Carton > 7 Capsule In 1 Blister Pack
4
N N 40%N50%N30%N
Tirosint 75ug 4 Blister Pack In 1 Carton > 7 Capsule In 1 Blister Pack
4
N N 40%N50%N30%N
Tirosint 88ug 4 Blister Pack In 1 Carton > 7 Capsule In 1 Blister Pack
4
N N 40%N50%N30%N
Tirosint 100ug 4 Blister Pack In 1 Carton > 7 Capsule In 1 Blister Pack
4
N N 40%N50%N30%N
Tirosint 112ug 4 Blister Pack In 1 Carton > 7 Capsule In 1 Blister Pack
4
N N 40%N50%N30%N
Tirosint 125ug 4 Blister Pack In 1 Carton > 7 Capsule In 1 Blister Pack
4
N N 40%N50%N30%N
Tirosint 137ug 4 Blister Pack In 1 Carton > 7 Capsule In 1 Blister Pack
4
N N 40%N50%N30%N
Tirosint 150ug 4 Blister Pack In 1 Carton > 7 Capsule In 1 Blister Pack
4
N N 40%N50%N30%N
Tivicay 50mg 30 Tablet, Film Coated In 1 Bottle
5
N N 33%N33%N33%N
Tizanidine 2mg 150 Tablet In 1 Bottle, Plastic
2
N N $15N$20N$15N
Tizanidine 4mg 1000 Tablet In 1 Bottle
2
N N $15N$20N$15N
Tizanidine Hydrochloride 2mg 150 Capsule, Gelatin Coated In 1 Bottle
2
N N $15N$20N$15N
Tizanidine Hydrochloride 4mg 150 Capsule, Gelatin Coated In 1 Bottle
2
N N $15N$20N$15N
Tizanidine Hydrochloride 6mg 150 Capsule, Gelatin Coated In 1 Bottle
2
N N $15N$20N$15N
Tobi 300mg/5mL 56 Pouch In 1 Carton
5
Y N 33%N33%N33%N
Tobi Podhaler 28mg 224 Package In 1 Box, Unit-dose
5
Y N 33%N33%N33%N
Tobradex 1; 3mg/mL; mg/mL 5 Ml In 1 Bottle, Plastic
4
N N 40%N50%N30%N
Tobradex 1; 3mg/g; mg/g 3.5 G In 1 Tube
3
N N $42N$47N$42N
Tobradex St .5; 3mg/mL; mg/mL 5 Ml In 1 Bottle
3
N N $42N$47N$42N
Tobramycin 300mg/5mL 56 Ampule In 1 Carton > 5 Ml In 1 Ampule
5
Y N 33%N33%N33%N
Tobramycin 10mg/mL 25 Vial, Multi-dose In 1 Tray > 2 Ml In 1 Vial, Multi-dose
2
N N $15N$20N$15N
Tobramycin 40mg/mL 25 Vial, Multi-dose In 1 Tray > 2 Ml In 1 Vial, Multi-dose
2
N N $15N$20N$15N
Tobramycin 3mg/mL 1 Bottle, Dropper In 1 Carton > 5 Ml In 1 Bottle, Dropper
1
N N $5N$10N$5N
Tobramycin And Dexamethasone 1; 3mg/mL; mg/mL 1 Bottle, Dropper In 1 Carton > 5 Ml In 1 Bottle, Dropper
2
N N $15N$20N$15N
Tobrex 3mg/mL 5 Ml In 1 Bottle, Plastic
4
N N 40%N50%N30%N
Tobrex 3mg/g 3.5 G In 1 Tube
4
N N 40%N50%N30%N
Tofranil 10mg 30 Tablet, Sugar Coated In 1 Bottle
4
Y N 40%N50%N30%N
Tofranil 25mg 30 Tablet, Sugar Coated In 1 Bottle
4
Y N 40%N50%N30%N
Tofranil 50mg 30 Tablet, Sugar Coated In 1 Bottle
4
Y N 40%N50%N30%N
Tolmetin Sodium 400mg 100 Capsule In 1 Bottle
2
N N $15N$20N$15N
Tolmetin Sodium 600mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N $15N$20N$15N
Tolterodine Tartrate 2mg 30 Capsule, Extended Release In 1 Bottle, Plastic
2
N N $15N$20N$15N
Tolterodine Tartrate 500 Capsule, Extended Release In 1 Bottle, Plastic
2
N N $15N$20N$15N
Tolterodine Tartrate 2mg 60 Tablet, Film Coated In 1 Bottle, Plastic
2
N N $15N$20N$15N
Tolterodine Tartrate 1mg 500 Tablet, Film Coated In 1 Bottle
2
N N $15N$20N$15N
Topamax 25mg 60 Tablet, Coated In 1 Bottle
4
N N 40%N50%N30%N
Topamax 50mg 60 Tablet, Coated In 1 Bottle
4
N N 40%N50%N30%N
Topamax 100mg 60 Tablet, Coated In 1 Bottle
5
N N 33%N33%N33%N
Topamax 200mg 60 Tablet, Coated In 1 Bottle
5
N N 33%N33%N33%N
Topamax 25mg 60 Capsule, Coated Pellets In 1 Bottle
5
N N 33%N33%N33%N
Topamax 15mg 60 Capsule, Coated Pellets In 1 Bottle
4
N N 40%N50%N30%N
Topicort .5mg/g 1 Tube In 1 Carton > 60 G In 1 Tube
4
N N 40%N50%N30%N
Topicort 2.5mg/g 1 Tube In 1 Carton > 60 G In 1 Tube
4
N N 40%N50%N30%N
Topicort 2.5mg/g 1 Tube In 1 Carton > 60 G In 1 Tube
4
N N 40%N50%N30%N
Topicort .5mg/g 1 Tube In 1 Carton > 60 G In 1 Tube
4
N N 40%N50%N30%N
Topicort .5mg/g 1 Tube In 1 Carton > 60 G In 1 Tube
4
N N 40%N50%N30%N
Topicort 2.5mg/mL 1 Bottle In 1 Carton > 100 Ml In 1 Bottle
4
N N 40%N50%N30%N
Topiramate 15mg 60 Capsule, Coated Pellets In 1 Bottle
2
N N $15N$20N$15N
Topiramate 30 Capsule, Extended Release In 1 Bottle
2
N N $15N$20N$15N
Topiramate 30 Capsule, Extended Release In 1 Bottle
2
N N $15N$20N$15N
Topiramate 30 Capsule, Extended Release In 1 Bottle
2
N N $15N$20N$15N
Topiramate 30 Capsule, Extended Release In 1 Bottle
2
N N $15N$20N$15N
Topiramate 30 Capsule, Extended Release In 1 Bottle
2
N N $15N$20N$15N
Topiramate 25mg 60 Capsule, Coated Pellets In 1 Bottle
2
N N $15N$20N$15N
Topiramate 25mg 1000 Tablet, Film Coated In 1 Bottle
1
N N $5N$10N$5N
Topiramate 100mg 1000 Tablet, Film Coated In 1 Bottle
1
N N $5N$10N$5N
Topiramate 200mg 1000 Tablet, Film Coated In 1 Bottle
1
N N $5N$10N$5N
Topiramate 50mg 1000 Tablet, Film Coated In 1 Bottle
1
N N $5N$10N$5N
Toposar 20mg/mL 1 Vial, Multi-dose In 1 Carton > 50 Ml In 1 Vial, Multi-dose
2
Y N $15N$20N$15N
Toprol 25mg 100 Tablet, Extended Release In 1 Bottle
4
N N 40%N50%N30%N
Toprol 50mg 100 Tablet, Extended Release In 1 Bottle
4
N N 40%N50%N30%N
Toprol 100mg 100 Tablet, Extended Release In 1 Bottle
4
N N 40%N50%N30%N
Toprol 200mg 100 Tablet, Extended Release In 1 Bottle
4
N N 40%N50%N30%N
Torisel 1 Kit In 1 Carton
5
Y N 33%N33%N33%N
Torsemide 20mg 100 Tablet In 1 Bottle, Plastic
2
N N $15N$20N$15N
Torsemide 100mg 12 Bottle In 1 Case > 100 Tablet In 1 Bottle
2
N N $15N$20N$15N
Torsemide 100 Tablet In 1 Bottle
2
N N $15N$20N$15N
Torsemide 100 Tablet In 1 Bottle
2
N N $15N$20N$15N
Toviaz 4mg 30 Tablet, Film Coated, Extended Release In 1 Bottle
3
N N $42N$47N$42N
Toviaz 8mg 30 Tablet, Film Coated, Extended Release In 1 Bottle
3
N N $42N$47N$42N
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
4
Y N 40%N50%N30%N
Tracleer 62.5mg 1 Bottle, Plastic In 1 Carton > 60 Tablet, Film Coated In 1 Bottle, Plastic
5
Y N 33%N33%N33%N
Tracleer 125mg 1 Bottle, Plastic In 1 Carton > 60 Tablet, Film Coated In 1 Bottle, Plastic
5
Y N 33%N33%N33%N
Tradjenta 5mg 90 Tablet, Film Coated In 1 Bottle
3
30 30 N N $42N$47N$42N
Tramadol Hydrochloride 50mg 100 Tablet, Film Coated In 1 Bottle
2
240 30 N N $15N$20N$15N
Tramadol Hydrochloride 300mg 100 Tablet, Extended Release In 1 Bottle
2
30 30 N N $15N$20N$15N
Tramadol Hydrochloride 100mg 30 Tablet, Extended Release In 1 Bottle, Plastic
2
90 30 N N $15N$20N$15N
Tramadol Hydrochloride 200mg 30 Tablet, Extended Release In 1 Bottle, Plastic
2
30 30 N N $15N$20N$15N
Tramadol Hydrochloride And Acetaminophen 325; 37.5mg/1; mg 1000 Tablet, Film Coated In 1 Bottle
2
240 30 N N $15N$20N$15N
Trandolapril 100 Tablet In 1 Bottle
1
N N $5N$10N$5N
Trandolapril 100 Tablet In 1 Bottle
1
N N $5N$10N$5N
Trandolapril 100 Tablet In 1 Bottle
1
N N $5N$10N$5N
Trandolapril And Verapamil Hydrochloride 100 Tablet, Film Coated, Extended Release In 1 Bottle
1
N N $5N$10N$5N
Trandolapril And Verapamil Hydrochloride 100 Tablet, Film Coated, Extended Release In 1 Bottle
1
N N $5N$10N$5N
Trandolapril And Verapamil Hydrochloride 100 Tablet, Film Coated, Extended Release In 1 Bottle
1
N N $5N$10N$5N
Trandolapril And Verapamil Hydrochloride 100 Tablet, Film Coated, Extended Release In 1 Bottle
1
N N $5N$10N$5N
Tranexamic Acid 650mg 30 Tablet, Film Coated In 1 Bottle, Plastic
2
N N $15N$20N$15N
Tranexamic Acid 100mg/mL 10 Vial, Single-dose In 1 Package
2
N N $15N$20N$15N
Transderm Scop 1mg/3d 10 Pouch In 1 Box > 1 Patch In 1 Pouch > 3 D In 1 Patch
4
10 30 Y N 40%N50%N30%N
Tranxene 3.75mg 100 Tablet In 1 Bottle
4
120 30 Y N 40%N50%N30%N
Tranxene 7.5mg 100 Tablet In 1 Bottle
4
360 30 Y N 40%N50%N30%N
Tranylcypromine Sulfate 10mg 100 Tablet In 1 Bottle, Plastic
2
N N $15N$20N$15N
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 40%N50%N30%N
Travatan Z .04mg/mL 2.5 Ml In 1 Bottle
3
N N $42N$47N$42N
Trazodone Hydrochloride 300mg 100 Tablet In 1 Bottle
2
N N $15N$20N$15N
Trazodone Hydrochloride 50mg 500 Tablet In 1 Bottle
1
N N $5N$10N$5N
Trazodone Hydrochloride 100mg 500 Tablet In 1 Bottle
1
N N $5N$10N$5N
Trazodone Hydrochloride 150mg 100 Tablet In 1 Bottle
1
N N $5N$10N$5N
Treanda 100mg/20mL 20 Ml In 1 Vial, Single-use
5
Y N 33%N33%N33%N
Trecator 250mg 100 Tablet, Film Coated In 1 Bottle
4
N N 40%N50%N30%N
Trelstar 22.5mg/2mL 2 Ml In 1 Vial, Single-dose
5
Y N 33%N33%N33%N
Trelstar 1 Kit In 1 Carton * 2 Ml In 1 Syringe
5
Y N 33%N33%N33%N
Trelstar 1 Kit In 1 Carton * 2 Ml In 1 Syringe
5
Y N 33%N33%N33%N
Tretin.x 1 Tube In 1 Carton > 35 G In 1 Tube
4
Y N 40%N50%N30%N
Tretinoin 10mg 100 Capsule In 1 Bottle
5
N N 33%N33%N33%N
Tretinoin 1mg/g 1 Tube In 1 Carton > 45 G In 1 Tube
2
Y N $15N$20N$15N
Tretinoin .5mg/g 1 Tube In 1 Carton > 20 G In 1 Tube
2
Y N $15N$20N$15N
Tretinoin .25mg/g 1 Tube In 1 Carton > 45 G In 1 Tube
2
Y N $15N$20N$15N
Tretinoin .25mg/g 1 Tube In 1 Carton > 45 G In 1 Tube
2
Y N $15N$20N$15N
Tretinoin 1 Tube In 1 Carton > 45 G In 1 Tube
2
Y N $15N$20N$15N
Tretinoin Gel Microsphere 1 Bottle, Pump In 1 Carton > 50 G In 1 Bottle, Pump
2
Y N $15N$20N$15N
Tretinoin Gel Microsphere 1 Bottle, Pump In 1 Carton > 50 G In 1 Bottle, Pump
2
Y N $15N$20N$15N
Trexall 5mg 30 Tablet, Film Coated In 1 Bottle
4
Y N 40%N50%N30%N
Trexall 7.5mg 30 Tablet, Film Coated In 1 Bottle
4
Y N 40%N50%N30%N
Trexall 10mg 30 Tablet, Film Coated In 1 Bottle
4
Y N 40%N50%N30%N
Trexall 15mg 30 Tablet, Film Coated In 1 Bottle
4
Y N 40%N50%N30%N
Tri Previfem 6 Blister Pack In 1 Carton
2
N N $15N$20N$15N
Tri-legest Fe 5 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
2
N N $15N$20N$15N
Tri-norinyl 6 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
4
N N 40%N50%N30%N
Tri-sprintec 6 Pouch In 1 Carton > 1 Blister Pack In 1 Pouch > 1 Kit In 1 Blister Pack
2
N N $15N$20N$15N
Triamcinolone Acetonide .25mg/g 80 G In 1 Tube
1
N N $5N$10N$5N
Triamcinolone Acetonide 1mg/g 80 G In 1 Tube
1
N N $5N$10N$5N
Triamcinolone Acetonide 1mg/mL 60 Ml In 1 Bottle, Plastic
2
N N $15N$20N$15N
Triamcinolone Acetonide 5mg/g 1 Tube In 1 Carton > 15 G In 1 Tube
1
N N $5N$10N$5N
Triamcinolone Acetonide .25mg/g 1 Tube In 1 Carton > 80 G In 1 Tube
1
N N $5N$10N$5N
Triamcinolone Acetonide 1mg/g 1 Tube In 1 Carton > 80 G In 1 Tube
1
N N $5N$10N$5N
Triamcinolone Acetonide 5mg/g 1 Tube In 1 Carton > 15 G In 1 Tube
1
N N $5N$10N$5N
Triamcinolone Acetonide 1mg/g 1 Tube In 1 Carton > 5 G In 1 Tube
2
N N $15N$20N$15N
Triamcinolone Acetonide .25mg/mL 60 Ml In 1 Bottle, With Applicator
2
N N $15N$20N$15N
Triamterene And Hydrochlorothiazide 25; 37.5mg/1; mg 100 Capsule In 1 Bottle, Plastic
1
N N $5N$10N$5N
Triamterene And Hydrochlorothiazide 25; 50mg/1; mg 100 Capsule In 1 Bottle
1
N N $5N$10N$5N
Triamterene Hydrochlorothiazide 50; 75mg/1; mg 500 Tablet In 1 Bottle
1
N N $5N$10N$5N
Triamterene Hydrochlorothiazide 25; 37.5mg/1; mg 100 Tablet In 1 Bottle
1
N N $5N$10N$5N
Tribenzor 5; 12.5; 20mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
N N 40%N50%N30%N
Tribenzor 5; 12.5; 40mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
N N 40%N50%N30%N
Tribenzor 5; 25; 40mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
N N 40%N50%N30%N
Tribenzor 10; 12.5; 40mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
N N 40%N50%N30%N
Tribenzor 10; 25; 40mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
N N 40%N50%N30%N
Tricor 48mg 90 Tablet In 1 Bottle
4
N N 40%N50%N30%N
Tricor 145mg 90 Tablet In 1 Bottle
4
N N 40%N50%N30%N
Triderm 1mg/g 85.2 G In 1 Tube
1
N N $5N$10N$5N
Trifluoperazine Hydrochloride 2mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N $15N$20N$15N
Trifluoperazine Hydrochloride 5mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N $15N$20N$15N
Trifluoperazine Hydrochloride 10mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N $15N$20N$15N
Trifluoperazine Hydrochloride 1mg 100 Tablet, Film Coated In 1 Bottle
2
N N $15N$20N$15N
Trifluridine 10mg/mL 7.5 Ml In 1 Bottle, Plastic
2
N N $15N$20N$15N
Triglide 160mg 1 Bottle In 1 Carton > 30 Tablet In 1 Bottle
4
N N 40%N50%N30%N
Trileptal 300mg 100 Tablet, Film Coated In 1 Bottle
4
N N 40%N50%N30%N
Trileptal 60mg/mL 250 Ml In 1 Bottle
4
N N 40%N50%N30%N
Trileptal 150mg 100 Tablet, Film Coated In 1 Bottle
4
N N 40%N50%N30%N
Trileptal 600mg 100 Tablet, Film Coated In 1 Bottle
4
N N 40%N50%N30%N
Trilipix 135mg 90 Capsule, Delayed Release In 1 Bottle
4
N N 40%N50%N30%N
Trilipix 45mg 90 Capsule, Delayed Release In 1 Bottle
4
N N 40%N50%N30%N
Trilyte 420; 1.48; 5.72; 11.2g/4L; g/4L; g/4L; g/4L 4 L In 1 Bottle
2
N N $15N$20N$15N
Trimethoprim 100mg 100 Tablet In 1 Bottle, Plastic
1
N N $5N$10N$5N
Trimipramine Maleate 30 Capsule In 1 Bottle
4
Y N 40%N50%N30%N
Trimipramine Maleate 30 Capsule In 1 Bottle
4
Y N 40%N50%N30%N
Trimipramine Maleate 30 Capsule In 1 Bottle
4
Y N 40%N50%N30%N
Trinessa 1 Dialpack In 1 Carton > 1 Kit In 1 Dialpack
2
N N $15N$20N$15N
Triostat 6 Vial In 1 Carton > 1 Ml In 1 Vial
4
N N 40%N50%N30%N
Trisenox 1mg/mL 10 Ampule In 1 Carton
5
Y N 33%N33%N33%N
Triumeq 30 Tablet, Film Coated In 1 Bottle
5
N N 33%N33%N33%N
Trivora 6 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
2
N N $15N$20N$15N
Trizivir 300; 150; 300mg/1; mg/1; mg 60 Tablet, Film Coated In 1 Bottle
5
N N 33%N33%N33%N
Trokendi Xr 25mg 30 Capsule, Extended Release In 1 Blister Pack
4
N N 40%N50%N30%N
Trokendi Xr 50mg 30 Capsule, Extended Release In 1 Blister Pack
4
N N 40%N50%N30%N
Trokendi Xr 100mg 30 Capsule, Extended Release In 1 Blister Pack
4
N N 40%N50%N30%N
Trokendi Xr 200mg 30 Capsule, Extended Release In 1 Blister Pack
5
N N 33%N33%N33%N
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
4
Y N 40%N50%N30%N
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
4
Y N 40%N50%N30%N
Trospium Chloride 20mg 60 Tablet, Film Coated In 1 Bottle
2
N N $15N$20N$15N
Trospium Chloride 60mg 30 Capsule, Extended Release In 1 Bottle, Plastic
2
N N $15N$20N$15N
Trulicity 4 Syringe In 1 Carton
4
4 28 N N 40%N50%N30%N
Trulicity 4 Syringe In 1 Carton
4
4 28 N N 40%N50%N30%N
Trusopt 20mg/mL 1 Bottle, Dropper In 1 Carton > 10 Ml In 1 Bottle, Dropper
4
N N 40%N50%N30%N
Truvada 200; 300mg/1; mg 30 Tablet, Film Coated In 1 Bottle, Plastic
5
30 30 N N 33%N33%N33%N
Twinrix 720; 20[iU]/mL; ug/mL 10 Vial In 1 Carton
3
N N $42N$47N$42N
Twynsta 5; 40mg/1; mg 3 Blister Pack In 1 Carton > 10 Tablet, Multilayer In 1 Blister Pack
4
N N 40%N50%N30%N
Twynsta 10; 40mg/1; mg 3 Blister Pack In 1 Carton > 10 Tablet, Multilayer In 1 Blister Pack
4
N N 40%N50%N30%N
Twynsta 5; 80mg/1; mg 3 Blister Pack In 1 Carton > 10 Tablet, Multilayer In 1 Blister Pack
4
N N 40%N50%N30%N
Twynsta 10; 80mg/1; mg 3 Blister Pack In 1 Carton > 10 Tablet, Multilayer In 1 Blister Pack
4
N N 40%N50%N30%N
Tybost 30 Tablet, Film Coated In 1 Bottle
3
N N $42N$47N$42N
Tygacil 50mg/5mL 10 Vial, Single-use In 1 Carton
5
N N 33%N33%N33%N
Tykerb 250mg 150 Tablet In 1 Bottle
5
Y N 33%N33%N33%N
Tylenol With Codeine 300; 30mg/1; mg 1000 Tablet In 1 Bottle
4
400 30 N N 40%N50%N30%N
Tylenol With Codeine 300; 60mg/1; mg 500 Tablet In 1 Bottle
4
400 30 N N 40%N50%N30%N
Typhim Vi 25ug/.5mL 1 Vial, Multi-dose In 1 Package
3
N N $42N$47N$42N
Typhim Vi 1 Syringe In 1 Package
3
N N $42N$47N$42N
Tysabri 300mg/15mL 1 Vial, Single-use In 1 Carton > 15 Ml In 1 Vial, Single-use
5
Y N 33%N33%N33%N
Tyvaso 1.74mg/2.9mL 4 Ampule In 1 Box > 2.9 Ml In 1 Ampule
5
Y N 33%N33%N33%N
Tyzeka 600mg 30 Tablet, Film Coated In 1 Bottle
5
N N 33%N33%N33%N



Medicare Help's Additional Notes:

Coverage Levels for H3706-019

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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