2017 Medica Prime Solution Enhanced w/Rx (Cost) Formulary



Below is the Formulary, or drug list, for Medica Prime Solution Enhanced w/Rx (Cost) from Medica Insurance Company This formulary is a list of prescription medications that are covered under Medica Insurance Company's 2017 Medicare Advantage Plan. The Medica Prime Solution Enhanced w/Rx (Cost) plan has a $200 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. Medica Prime Solution Enhanced w/Rx (Cost) 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 Medica Prime Solution Enhanced w/Rx (Cost)





Plan Name:
Medica Prime Solution Enhanced w/Rx (Cost)
Plan ID:
H2450-017
Provider: Medica Insurance Company
Plan Year:2017
Premium:$28.40
Deductible:$200
Initial Coverage Limit:$3700
Coverage Area:Minnesota




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
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
4
N N Y NAN50%NNAN
Tacrolimus 1 Tube In 1 Carton > 30 G In 1 Tube
4
N N Y NAN50%NNAN
Tacrolimus 1 Tube In 1 Carton > 30 G In 1 Tube
4
N N Y NAN50%NNAN
Tacrolimus .5mg 100 Capsule In 1 Bottle
4
Y N Y NAN50%NNAN
Tacrolimus 1mg 100 Capsule In 1 Bottle
4
Y N Y NAN50%NNAN
Tacrolimus 5mg 100 Capsule In 1 Bottle
4
Y N Y NAN50%NNAN
Tamiflu 75mg 1 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack
3
N N Y NAN$27NNAN
Tamiflu 45mg 1 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack
3
N N Y NAN$27NNAN
Tamiflu 30mg 1 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack
3
N N Y NAN$27NNAN
Tamiflu 6mg/mL 1 Bottle, Glass In 1 Carton > 60 Ml In 1 Bottle, Glass
3
N N Y NAN$27NNAN
Tamoxifen Citrate 10mg 180 Tablet, Film Coated In 1 Bottle
1
N N Y NAN$3NNAN
Tamoxifen Citrate 20mg 30 Tablet In 1 Bottle
1
N N Y NAN$3NNAN
Tamsulosin Hydrochloride 100 Capsule In 1 Bottle
3
N N Y NAN$27NNAN
Tarceva 25mg 30 Tablet In 1 Bottle
5
Y N Y NAN28%NNAN
Tarceva 100mg 30 Tablet In 1 Bottle
5
Y N Y NAN28%NNAN
Tarceva 150mg 30 Tablet In 1 Bottle
5
Y N Y NAN28%NNAN
Targretin 60 G In 1 Tube
5
Y N Y NAN28%NNAN
Tarina Fe 1/20 3 Pouch In 1 Carton > 1 Kit In 1 Pouch
2
N N Y NAN$13NNAN
Tasigna 200mg 28 Capsule In 1 Blister Pack
5
Y N Y NAN28%NNAN
Tasigna 150mg 4 Blister Pack In 1 Carton > 28 Capsule In 1 Blister Pack
5
Y N Y NAN28%NNAN
Tazicef 25 Vial In 1 Tray > 1 Injection, Powder, For Solution In 1 Vial
4
N N Y NAN50%NNAN
Tazicef 10 Vial In 1 Tray > 1 Injection, Powder, For Solution In 1 Vial
4
N N Y NAN50%NNAN
Tazicef 10 Vial, Pharmacy Bulk Package In 1 Carton > 1 Injection, Powder, For Solution In 1 Vial, Pharmacy Bulk Package
4
N N Y NAN50%NNAN
Tazorac .5mg/g 1 Tube In 1 Carton > 60 G In 1 Tube
4
Y N Y NAN50%NNAN
Tazorac 1mg/g 1 Tube In 1 Carton > 60 G In 1 Tube
4
Y N Y NAN50%NNAN
Taztia 120mg 90 Capsule, Extended Release In 1 Bottle, Plastic
3
N N Y NAN$27NNAN
Taztia 180mg 90 Capsule, Extended Release In 1 Bottle, Plastic
3
N N Y NAN$27NNAN
Taztia 240mg 90 Capsule, Extended Release In 1 Bottle, Plastic
3
N N Y NAN$27NNAN
Taztia 300mg 90 Capsule, Extended Release In 1 Bottle, Plastic
3
N N Y NAN$27NNAN
Taztia 360mg 90 Capsule, Extended Release In 1 Bottle, Plastic
3
N N Y NAN$27NNAN
Teflaro 400mg/20mL 10 Vial, Single-dose In 1 Carton
5
N N Y NAN28%NNAN
Teflaro 600mg/20mL 10 Vial, Single-dose In 1 Carton
5
N N Y NAN28%NNAN
Tegretol 100mg/5mL 450 Ml In 1 Bottle
4
N N Y NAN50%NNAN
Tegretol 200mg 100 Tablet In 1 Bottle
4
N N Y NAN50%NNAN
Tegretol 100mg 100 Tablet, Extended Release In 1 Bottle
4
N N Y NAN50%NNAN
Tegretol 200mg 100 Tablet, Extended Release In 1 Bottle
4
N N Y NAN50%NNAN
Tegretol 400mg 100 Tablet, Extended Release In 1 Bottle
4
N N Y NAN50%NNAN
Temazepam 7.5mg 100 Capsule In 1 Bottle, Plastic
2
30 30 Y N Y NAN$13NNAN
Temazepam 15mg 100 Blister Pack In 1 Box, Unit-dose
2
60 30 Y N Y NAN$13NNAN
Tenivac 10 Syringe In 1 Package > .5 Ml In 1 Syringe
3
Y N Y NAN$27NNAN
Terazosin 1mg 100 Capsule In 1 Bottle
1
N N Y NAN$3NNAN
Terazosin Hydrochloride 2mg 100 Capsule In 1 Bottle
1
N N Y NAN$3NNAN
Terazosin Hydrochloride 5mg 100 Capsule In 1 Bottle
1
N N Y NAN$3NNAN
Terazosin Hydrochloride 10mg 100 Capsule In 1 Bottle
1
N N Y NAN$3NNAN
Terbinafine Hydrochloride 90 Tablet In 1 Bottle
2
90 365 N N Y NAN$13NNAN
Terbutaline Sulfate 2.5mg 100 Tablet In 1 Bottle
4
N N Y NAN50%NNAN
Terbutaline Sulfate 5mg 100 Tablet In 1 Bottle
4
N N Y NAN50%NNAN
Terbutaline Sulfate 1mg/mL 25 Vial, Single-use In 1 Tray > 1 Ml In 1 Vial, Single-use
5
N N Y NAN28%NNAN
Terconazole 80mg 1 Blister Pack In 1 Carton > 3 Suppository In 1 Blister Pack
4
N N Y NAN50%NNAN
Terconazole 8mg/g 1 Tube, With Applicator In 1 Carton > 20 G In 1 Tube, With Applicator
3
N N Y NAN$27NNAN
Terconazole 4mg/g 1 Tube, With Applicator In 1 Carton > 45 G In 1 Tube, With Applicator
3
N N Y NAN$27NNAN
Testosterone Cypionate 1 Vial, Multi-dose In 1 Carton > 10 Ml In 1 Vial, Multi-dose
3
Y N Y NAN$27NNAN
Testosterone Cypionate 1 Vial, Multi-dose In 1 Carton > 10 Ml In 1 Vial, Multi-dose
3
Y N Y NAN$27NNAN
Testosterone Enanthate 200mg/mL 1 Vial, Multi-dose In 1 Carton > 5 Ml In 1 Vial, Multi-dose
3
Y N Y NAN$27NNAN
Thalomid 50mg 10 Blister Pack In 1 Box
5
Y N Y NAN28%NNAN
Thalomid 100mg 5 Blister Pack In 1 Box
5
Y N Y NAN28%NNAN
Thalomid 150mg 4 Blister Pack In 1 Box
5
Y N Y NAN28%NNAN
Thalomid 200mg 3 Blister Pack In 1 Box
5
Y N Y NAN28%NNAN
Theophylline 400mg 100 Tablet, Extended Release In 1 Bottle, Plastic
3
N N Y NAN$27NNAN
Theophylline 600mg 100 Tablet, Extended Release In 1 Bottle, Plastic
3
N N Y NAN$27NNAN
Theophylline 300mg 100 Tablet, Extended Release In 1 Bottle
3
N N Y NAN$27NNAN
Theophylline 200mg 500 Tablet, Extended Release In 1 Bottle
3
N N Y NAN$27NNAN
Theophylline 100mg 500 Tablet, Extended Release In 1 Bottle
3
N N Y NAN$27NNAN
Theophylline 450mg 100 Tablet, Extended Release In 1 Bottle
3
N N Y NAN$27NNAN
Theophylline 80mg/15mL 473 Ml In 1 Bottle, Plastic
4
N N Y NAN50%NNAN
Thioridazine Hydrochloride 100mg 100 Tablet, Film Coated In 1 Bottle, Plastic
4
Y N Y NAN50%NNAN
Thioridazine Hydrochloride 50mg 100 Blister Pack In 1 Box, Unit-dose
4
Y N Y NAN50%NNAN
Thioridazine Hydrochloride 10mg 1000 Tablet, Film Coated In 1 Bottle, Plastic
4
Y N Y NAN50%NNAN
Thioridazine Hydrochloride 25mg 1000 Tablet, Film Coated In 1 Bottle, Plastic
4
Y N Y NAN50%NNAN
Thiothixene 2mg 100 Capsule In 1 Bottle, Plastic
4
N N Y NAN50%NNAN
Thiothixene 5mg 100 Capsule In 1 Bottle, Plastic
4
N N Y NAN50%NNAN
Thiothixene 10mg 100 Capsule In 1 Bottle, Plastic
4
N N Y NAN50%NNAN
Thiothixene 1mg 100 Capsule In 1 Bottle
4
N N Y NAN50%NNAN
Tiagabine Hydrochloride 2mg 30 Tablet, Film Coated In 1 Bottle
4
N N Y NAN50%NNAN
Tiagabine Hydrochloride 4mg 30 Tablet, Film Coated In 1 Bottle
4
N N Y NAN50%NNAN
Timolol Maleate 5mg 100 Tablet In 1 Bottle, Plastic
4
N N Y NAN50%NNAN
Timolol Maleate 10mg 100 Tablet In 1 Bottle, Plastic
4
N N Y NAN50%NNAN
Timolol Maleate 20mg 100 Tablet In 1 Bottle, Plastic
4
N N Y NAN50%NNAN
Timolol Maleate 3.4mg/mL 1 Bottle, Dispensing In 1 Carton > 5 Ml In 1 Bottle, Dispensing
4
N N Y NAN50%NNAN
Timolol Maleate 6.8mg/mL 1 Bottle, Dispensing In 1 Carton > 5 Ml In 1 Bottle, Dispensing
4
N N Y NAN50%NNAN
Timolol Maleate 2.5mg/mL 15 Ml In 1 Bottle, Plastic
1
N N Y NAN$3NNAN
Timolol Maleate 5mg/mL 10 Ml In 1 Bottle, Plastic
1
N N Y NAN$3NNAN
Tivicay 50mg 30 Tablet, Film Coated In 1 Bottle
5
N N Y NAN28%NNAN
Tizanidine 2mg 150 Tablet In 1 Bottle, Plastic
2
N N Y NAN$13NNAN
Tizanidine 4mg 1000 Tablet In 1 Bottle
2
N N Y NAN$13NNAN
Tobradex 1; 3mg/g; mg/g 3.5 G In 1 Tube
3
N N Y NAN$27NNAN
Tobradex St .5; 3mg/mL; mg/mL 5 Ml In 1 Bottle
3
N N Y NAN$27NNAN
Tobramycin 300mg/5mL 56 Ampule In 1 Carton > 5 Ml In 1 Ampule
5
Y N Y NAN28%NNAN
Tobramycin 10mg/mL 25 Vial, Multi-dose In 1 Tray > 2 Ml In 1 Vial, Multi-dose
3
N N Y NAN$27NNAN
Tobramycin 40mg/mL 25 Vial, Multi-dose In 1 Tray > 2 Ml In 1 Vial, Multi-dose
3
N N Y NAN$27NNAN
Tobramycin 3mg/mL 1 Bottle, Dropper In 1 Carton > 5 Ml In 1 Bottle, Dropper
2
N N Y NAN$13NNAN
Tobramycin And Dexamethasone 1; 3mg/mL; mg/mL 1 Bottle, Dropper In 1 Carton > 5 Ml In 1 Bottle, Dropper
4
N N Y NAN50%NNAN
Tobrex 3mg/g 3.5 G In 1 Tube
4
N N Y NAN50%NNAN
Tolterodine Tartrate 2mg 30 Capsule, Extended Release In 1 Bottle, Plastic
4
30 30 N N Y NAN50%NNAN
Tolterodine Tartrate 500 Capsule, Extended Release In 1 Bottle, Plastic
4
30 30 N N Y NAN50%NNAN
Tolterodine Tartrate 2mg 60 Tablet, Film Coated In 1 Bottle, Plastic
4
N N Y NAN50%NNAN
Tolterodine Tartrate 1mg 500 Tablet, Film Coated In 1 Bottle
4
N N Y NAN50%NNAN
Topiramate 15mg 60 Capsule, Coated Pellets In 1 Bottle
4
N N Y NAN50%NNAN
Topiramate 25mg 60 Capsule, Coated Pellets In 1 Bottle
4
N N Y NAN50%NNAN
Topiramate 25mg 1000 Tablet, Film Coated In 1 Bottle
2
N N Y NAN$13NNAN
Topiramate 100mg 1000 Tablet, Film Coated In 1 Bottle
2
N N Y NAN$13NNAN
Topiramate 200mg 1000 Tablet, Film Coated In 1 Bottle
2
N N Y NAN$13NNAN
Topiramate 50mg 1000 Tablet, Film Coated In 1 Bottle
2
N N Y NAN$13NNAN
Toposar 20mg/mL 1 Vial, Multi-dose In 1 Carton > 50 Ml In 1 Vial, Multi-dose
3
Y N Y NAN$27NNAN
Torsemide 20mg 100 Tablet In 1 Bottle, Plastic
2
N N Y NAN$13NNAN
Torsemide 100mg 12 Bottle In 1 Case > 100 Tablet In 1 Bottle
2
N N Y NAN$13NNAN
Torsemide 100 Tablet In 1 Bottle
2
N N Y NAN$13NNAN
Torsemide 100 Tablet In 1 Bottle
2
N N Y NAN$13NNAN
Toviaz 4mg 30 Tablet, Film Coated, Extended Release In 1 Bottle
3
30 30 N N Y NAN$27NNAN
Toviaz 8mg 30 Tablet, Film Coated, Extended Release In 1 Bottle
3
30 30 N N Y NAN$27NNAN
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 Y NAN50%NNAN
Tradjenta 5mg 90 Tablet, Film Coated In 1 Bottle
3
30 30 N N Y NAN$27NNAN
Tramadol Hydrochloride 50mg 100 Tablet, Film Coated In 1 Bottle
2
240 30 N N Y NAN$13NNAN
Tramadol Hydrochloride And Acetaminophen 325; 37.5mg/1; mg 1000 Tablet, Film Coated In 1 Bottle
3
240 30 N N Y NAN$27NNAN
Trandolapril 100 Tablet In 1 Bottle
1
N N Y NAN$3NNAN
Trandolapril 100 Tablet In 1 Bottle
1
N N Y NAN$3NNAN
Trandolapril 100 Tablet In 1 Bottle
1
N N Y NAN$3NNAN
Tranexamic Acid 650mg 30 Tablet, Film Coated In 1 Bottle, Plastic
4
N N Y NAN50%NNAN
Tranexamic Acid 100mg/mL 10 Vial, Single-dose In 1 Package
3
N N Y NAN$27NNAN
Transderm Scop 1mg/3d 10 Pouch In 1 Box > 1 Patch In 1 Pouch > 3 D In 1 Patch
4
10 30 Y N Y NAN50%NNAN
Tranylcypromine Sulfate 10mg 100 Tablet In 1 Bottle, Plastic
4
N N Y NAN50%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
4
Y N Y NAN50%NNAN
Travatan Z .04mg/mL 2.5 Ml In 1 Bottle
3
N N Y NAN$27NNAN
Trazodone Hydrochloride 50mg 500 Tablet In 1 Bottle
1
N N Y NAN$3NNAN
Trazodone Hydrochloride 100mg 500 Tablet In 1 Bottle
1
N N Y NAN$3NNAN
Trazodone Hydrochloride 150mg 100 Tablet In 1 Bottle
1
N N Y NAN$3NNAN
Treanda 100mg/20mL 20 Ml In 1 Vial, Single-use
5
Y N Y NAN28%NNAN
Trecator 250mg 100 Tablet, Film Coated In 1 Bottle
4
N N Y NAN50%NNAN
Trelstar 1 Kit In 1 Carton * 2 Ml In 1 Syringe
5
Y N Y NAN28%NNAN
Trelstar 1 Kit In 1 Carton * 2 Ml In 1 Syringe
5
Y N Y NAN28%NNAN
Tretinoin 10mg 100 Capsule In 1 Bottle
5
N N Y NAN28%NNAN
Tretinoin 1mg/g 1 Tube In 1 Carton > 45 G In 1 Tube
4
Y N Y NAN50%NNAN
Tretinoin .5mg/g 1 Tube In 1 Carton > 20 G In 1 Tube
4
Y N Y NAN50%NNAN
Tretinoin .25mg/g 1 Tube In 1 Carton > 45 G In 1 Tube
4
Y N Y NAN50%NNAN
Tretinoin .25mg/g 1 Tube In 1 Carton > 45 G In 1 Tube
4
Y N Y NAN50%NNAN
Tretinoin 1 Tube In 1 Carton > 45 G In 1 Tube
4
Y N Y NAN50%NNAN
Tri Previfem 6 Blister Pack In 1 Carton
2
N N Y NAN$13NNAN
Tri-legest Fe 5 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
3
N N Y NAN$27NNAN
Tri-sprintec 6 Pouch In 1 Carton > 1 Blister Pack In 1 Pouch > 1 Kit In 1 Blister Pack
2
N N Y NAN$13NNAN
Triamcinolone Acetonide .25mg/g 80 G In 1 Tube
2
N N Y NAN$13NNAN
Triamcinolone Acetonide 1mg/g 80 G In 1 Tube
2
N N Y NAN$13NNAN
Triamcinolone Acetonide 1mg/mL 60 Ml In 1 Bottle, Plastic
3
N N Y NAN$27NNAN
Triamcinolone Acetonide 5mg/g 1 Tube In 1 Carton > 15 G In 1 Tube
2
N N Y NAN$13NNAN
Triamcinolone Acetonide .25mg/g 1 Tube In 1 Carton > 80 G In 1 Tube
2
N N Y NAN$13NNAN
Triamcinolone Acetonide 1mg/g 1 Tube In 1 Carton > 80 G In 1 Tube
2
N N Y NAN$13NNAN
Triamcinolone Acetonide 5mg/g 1 Tube In 1 Carton > 15 G In 1 Tube
2
N N Y NAN$13NNAN
Triamcinolone Acetonide 1mg/g 1 Tube In 1 Carton > 5 G In 1 Tube
3
N N Y NAN$27NNAN
Triamcinolone Acetonide .25mg/mL 60 Ml In 1 Bottle, With Applicator
3
N N Y NAN$27NNAN
Triamterene And Hydrochlorothiazide 25; 37.5mg/1; mg 100 Capsule In 1 Bottle, Plastic
1
N N Y NAN$3NNAN
Triamterene Hydrochlorothiazide 50; 75mg/1; mg 500 Tablet In 1 Bottle
1
N N Y NAN$3NNAN
Triamterene Hydrochlorothiazide 25; 37.5mg/1; mg 100 Tablet In 1 Bottle
1
N N Y NAN$3NNAN
Triderm 1mg/g 85.2 G In 1 Tube
2
N N Y NAN$13NNAN
Trifluoperazine Hydrochloride 2mg 100 Tablet, Film Coated In 1 Bottle, Plastic
4
N N Y NAN50%NNAN
Trifluoperazine Hydrochloride 5mg 100 Tablet, Film Coated In 1 Bottle, Plastic
4
N N Y NAN50%NNAN
Trifluoperazine Hydrochloride 10mg 100 Tablet, Film Coated In 1 Bottle, Plastic
4
N N Y NAN50%NNAN
Trifluoperazine Hydrochloride 1mg 100 Tablet, Film Coated In 1 Bottle
4
N N Y NAN50%NNAN
Trifluridine 10mg/mL 7.5 Ml In 1 Bottle, Plastic
4
N N Y NAN50%NNAN
Trilyte 420; 1.48; 5.72; 11.2g/4L; g/4L; g/4L; g/4L 4 L In 1 Bottle
2
N N Y NAN$13NNAN
Trimethoprim 100mg 100 Tablet In 1 Bottle, Plastic
2
N N Y NAN$13NNAN
Trimipramine Maleate 30 Capsule In 1 Bottle
4
240 30 Y N Y NAN50%NNAN
Trimipramine Maleate 30 Capsule In 1 Bottle
4
120 30 Y N Y NAN50%NNAN
Trimipramine Maleate 30 Capsule In 1 Bottle
4
60 30 Y N Y NAN50%NNAN
Trinessa 1 Dialpack In 1 Carton > 1 Kit In 1 Dialpack
2
N N Y NAN$13NNAN
Trisenox 1mg/mL 10 Ampule In 1 Carton
5
Y N Y NAN28%NNAN
Triumeq 30 Tablet, Film Coated In 1 Bottle
5
N N Y NAN28%NNAN
Trivora 6 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
2
N N Y NAN$13NNAN
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 Y NAN50%NNAN
Trospium Chloride 20mg 60 Tablet, Film Coated In 1 Bottle
4
60 30 N N Y NAN50%NNAN
Trulicity 4 Syringe In 1 Carton
4
4 28 N N Y NAN50%NNAN
Trulicity 4 Syringe In 1 Carton
4
4 28 N N Y NAN50%NNAN
Truvada 200; 300mg/1; mg 30 Tablet, Film Coated In 1 Bottle, Plastic
5
30 30 N N Y NAN28%NNAN
Twinrix 720; 20[iU]/mL; ug/mL 10 Vial In 1 Carton
3
N N Y NAN$27NNAN
Tybost 30 Tablet, Film Coated In 1 Bottle
3
N N Y NAN$27NNAN
Tygacil 50mg/5mL 10 Vial, Single-use In 1 Carton
5
N N Y NAN28%NNAN
Tykerb 250mg 150 Tablet In 1 Bottle
5
Y N Y NAN28%NNAN
Typhim Vi 25ug/.5mL 1 Vial, Multi-dose In 1 Package
3
N N Y NAN$27NNAN
Typhim Vi 1 Syringe In 1 Package
3
N N Y NAN$27NNAN
Tysabri 300mg/15mL 1 Vial, Single-use In 1 Carton > 15 Ml In 1 Vial, Single-use
5
Y N Y NAN28%NNAN
Tyzeka 600mg 30 Tablet, Film Coated In 1 Bottle
5
N N Y NAN28%NNAN



Medicare Help's Additional Notes:

Coverage Levels for H2450-017

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1.Pre-Deductable: Before you reach the plans deductible of $200. 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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