2017 PacificSource Medicare Essentials Rx 6 (HMO) Formulary



Below is the Formulary, or drug list, for PacificSource Medicare Essentials Rx 6 (HMO) from Pacificsource Community Health Plans This formulary is a list of prescription medications that are covered under Pacificsource Community Health Plans's 2017 Medicare Advantage Plan. The PacificSource Medicare Essentials Rx 6 (HMO) plan has a $150 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. PacificSource Medicare Essentials Rx 6 (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 PacificSource Medicare Essentials Rx 6 (HMO)





Plan Name:
PacificSource Medicare Essentials Rx 6 (HMO)
Plan ID:
H3864-006
Provider: Pacificsource Community Health Plans
Plan Year:2017
Premium:$70.20
Deductible:$150
Initial Coverage Limit:$3700
Coverage Area:Oregon




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
3
N N Y $37N$47N$37N
Tacrolimus 1 Tube In 1 Carton > 30 G In 1 Tube
2
Y N N $12N$17N$12N
Tacrolimus 1 Tube In 1 Carton > 30 G In 1 Tube
2
Y N N $12N$17N$12N
Tacrolimus .5mg 100 Capsule In 1 Bottle
2
Y N N $12N$17N$12N
Tacrolimus 1mg 100 Capsule In 1 Bottle
2
Y N N $12N$17N$12N
Tacrolimus 5mg 100 Capsule In 1 Bottle
4
Y N Y $90N$100N$90N
Talwin 30mg/mL 1 Vial, Multi-dose In 1 Carton > 10 Ml In 1 Vial, Multi-dose
3
360 30 Y N Y $37N$47N$37N
Tamiflu 75mg 1 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack
3
10 90 N N Y $37N$47N$37N
Tamiflu 45mg 1 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack
3
N N Y $37N$47N$37N
Tamiflu 30mg 1 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack
3
N N Y $37N$47N$37N
Tamiflu 6mg/mL 1 Bottle, Glass In 1 Carton > 60 Ml In 1 Bottle, Glass
3
360 90 N N Y $37N$47N$37N
Tamoxifen Citrate 10mg 180 Tablet, Film Coated In 1 Bottle
2
N N N $12N$17N$12N
Tamoxifen Citrate 20mg 30 Tablet In 1 Bottle
2
N N N $12N$17N$12N
Tamsulosin Hydrochloride 100 Capsule In 1 Bottle
2
N N N $12N$17N$12N
Tarceva 25mg 30 Tablet In 1 Bottle
5
30 30 Y N Y 30%N30%N30%N
Tarceva 100mg 30 Tablet In 1 Bottle
5
30 30 Y N Y 30%N30%N30%N
Tarceva 150mg 30 Tablet In 1 Bottle
5
30 30 Y N Y 30%N30%N30%N
Targretin 60 G In 1 Tube
5
Y N Y 30%N30%N30%N
Tarina Fe 1/20 3 Pouch In 1 Carton > 1 Kit In 1 Pouch
2
N N N $12N$17N$12N
Tasigna 200mg 28 Capsule In 1 Blister Pack
5
112 28 Y N Y 30%N30%N30%N
Tasigna 150mg 4 Blister Pack In 1 Carton > 28 Capsule In 1 Blister Pack
5
112 28 Y N Y 30%N30%N30%N
Tazicef 10 Vial In 1 Tray > 1 Injection, Powder, For Solution In 1 Vial
2
N N N $12N$17N$12N
Tazorac 1mg/g 1 Tube In 1 Carton > 100 G In 1 Tube
4
N N Y $90N$100N$90N
Tazorac .5mg/g 1 Tube In 1 Carton > 100 G In 1 Tube
4
N N Y $90N$100N$90N
Tazorac .5mg/g 1 Tube In 1 Carton > 60 G In 1 Tube
4
N N Y $90N$100N$90N
Tazorac 1mg/g 1 Tube In 1 Carton > 60 G In 1 Tube
4
N N Y $90N$100N$90N
Taztia 120mg 90 Capsule, Extended Release In 1 Bottle, Plastic
2
N N N $12N$17N$12N
Taztia 180mg 90 Capsule, Extended Release In 1 Bottle, Plastic
2
N N N $12N$17N$12N
Taztia 240mg 90 Capsule, Extended Release In 1 Bottle, Plastic
2
N N N $12N$17N$12N
Taztia 300mg 90 Capsule, Extended Release In 1 Bottle, Plastic
2
N N N $12N$17N$12N
Taztia 360mg 90 Capsule, Extended Release In 1 Bottle, Plastic
2
N N N $12N$17N$12N
Teflaro 400mg/20mL 10 Vial, Single-dose In 1 Carton
4
N N Y $90N$100N$90N
Teflaro 600mg/20mL 10 Vial, Single-dose In 1 Carton
4
N N Y $90N$100N$90N
Tegretol 100mg 100 Tablet, Extended Release In 1 Bottle
4
N N Y $90N$100N$90N
Tekturna 150mg 30 Tablet, Film Coated In 1 Bottle
4
Y N Y $90N$100N$90N
Tekturna 300mg 30 Tablet, Film Coated In 1 Bottle
4
Y N Y $90N$100N$90N
Tekturna Hct 150; 12.5mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
Y N Y $90N$100N$90N
Tekturna Hct 150; 25mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
Y N Y $90N$100N$90N
Tekturna Hct 300; 12.5mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
Y N Y $90N$100N$90N
Tekturna Hct 300; 25mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
Y N Y $90N$100N$90N
Telmisartan 20mg 3 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
6
N N N $0N$0N$0N
Telmisartan 40mg 3 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
6
N N N $0N$0N$0N
Telmisartan 80mg 3 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
6
N N N $0N$0N$0N
Telmisartan And Amlodipine 5; 40mg/1; mg 30 Tablet In 1 Bottle
6
N N N $0N$0N$0N
Telmisartan And Amlodipine 10; 40mg/1; mg 30 Tablet In 1 Bottle
6
N N N $0N$0N$0N
Telmisartan And Amlodipine 5; 80mg/1; mg 30 Tablet In 1 Bottle
6
N N N $0N$0N$0N
Telmisartan And Amlodipine 10; 80mg/1; mg 30 Tablet In 1 Bottle
6
N N N $0N$0N$0N
Telmisartan And Hydrochlorothiazide 90 Tablet In 1 Bottle
6
N N N $0N$0N$0N
Telmisartan And Hydrochlorothiazide 90 Tablet In 1 Bottle
6
N N N $0N$0N$0N
Telmisartan And Hydrochlorothiazide 90 Tablet In 1 Bottle
6
N N N $0N$0N$0N
Temazepam 7.5mg 100 Capsule In 1 Bottle, Plastic
2
N N N $12N$17N$12N
Temazepam 22.5mg 30 Capsule In 1 Bottle, Plastic
2
N N N $12N$17N$12N
Temazepam 15mg 100 Blister Pack In 1 Box, Unit-dose
2
N N N $12N$17N$12N
Temazepam 30mg 500 Capsule In 1 Bottle
2
N N N $12N$17N$12N
Tenivac 10 Syringe In 1 Package > .5 Ml In 1 Syringe
3
N N Y $37N$47N$37N
Terazosin 1mg 100 Capsule In 1 Bottle
1
N N N $2N$7N$2N
Terazosin Hydrochloride 2mg 100 Capsule In 1 Bottle
1
N N N $2N$7N$2N
Terazosin Hydrochloride 5mg 100 Capsule In 1 Bottle
1
N N N $2N$7N$2N
Terazosin Hydrochloride 10mg 100 Capsule In 1 Bottle
1
N N N $2N$7N$2N
Terbinafine Hydrochloride 90 Tablet In 1 Bottle
2
N N N $12N$17N$12N
Terbutaline Sulfate 2.5mg 100 Tablet In 1 Bottle
2
N N N $12N$17N$12N
Terbutaline Sulfate 5mg 100 Tablet In 1 Bottle
2
N N N $12N$17N$12N
Terbutaline Sulfate 1mg/mL 25 Vial, Single-use In 1 Tray > 1 Ml In 1 Vial, Single-use
2
N N N $12N$17N$12N
Terconazole 80mg 1 Blister Pack In 1 Carton > 3 Suppository In 1 Blister Pack
2
N N N $12N$17N$12N
Terconazole 8mg/g 1 Tube, With Applicator In 1 Carton > 20 G In 1 Tube, With Applicator
2
N N N $12N$17N$12N
Terconazole 4mg/g 1 Tube, With Applicator In 1 Carton > 45 G In 1 Tube, With Applicator
2
N N N $12N$17N$12N
Testosterone 1 Canister In 1 Carton > 60 G In 1 Canister
2
N N N $12N$17N$12N
Testosterone 30 Packet In 1 Carton
2
N N N $12N$17N$12N
Testosterone Cypionate 1 Vial, Multi-dose In 1 Carton > 10 Ml In 1 Vial, Multi-dose
2
N N N $12N$17N$12N
Testosterone Cypionate 1 Vial, Multi-dose In 1 Carton > 10 Ml In 1 Vial, Multi-dose
2
N N N $12N$17N$12N
Testosterone Enanthate 200mg/mL 1 Vial, Multi-dose In 1 Carton > 5 Ml In 1 Vial, Multi-dose
2
N N N $12N$17N$12N
Thalomid 50mg 10 Blister Pack In 1 Box
5
Y N Y 30%N30%N30%N
Thalomid 100mg 5 Blister Pack In 1 Box
5
Y N Y 30%N30%N30%N
Thalomid 150mg 4 Blister Pack In 1 Box
5
Y N Y 30%N30%N30%N
Thalomid 200mg 3 Blister Pack In 1 Box
5
Y N Y 30%N30%N30%N
Theophylline 400mg 100 Tablet, Extended Release In 1 Bottle, Plastic
2
N N N $12N$17N$12N
Theophylline 600mg 100 Tablet, Extended Release In 1 Bottle, Plastic
2
N N N $12N$17N$12N
Theophylline 300mg 100 Tablet, Extended Release In 1 Bottle
2
N N N $12N$17N$12N
Theophylline 200mg 500 Tablet, Extended Release In 1 Bottle
2
N N N $12N$17N$12N
Theophylline 100mg 500 Tablet, Extended Release In 1 Bottle
1
N N N $2N$7N$2N
Theophylline 450mg 100 Tablet, Extended Release In 1 Bottle
2
N N N $12N$17N$12N
Theophylline 80mg/15mL 473 Ml In 1 Bottle, Plastic
2
N N N $12N$17N$12N
Thioridazine Hydrochloride 100mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N N $12N$17N$12N
Thioridazine Hydrochloride 50mg 100 Blister Pack In 1 Box, Unit-dose
2
N N N $12N$17N$12N
Thioridazine Hydrochloride 10mg 1000 Tablet, Film Coated In 1 Bottle, Plastic
2
N N N $12N$17N$12N
Thioridazine Hydrochloride 25mg 1000 Tablet, Film Coated In 1 Bottle, Plastic
2
N N N $12N$17N$12N
Thiothixene 2mg 100 Capsule In 1 Bottle, Plastic
2
N N N $12N$17N$12N
Thiothixene 5mg 100 Capsule In 1 Bottle, Plastic
2
N N N $12N$17N$12N
Thiothixene 10mg 100 Capsule In 1 Bottle, Plastic
2
N N N $12N$17N$12N
Thiothixene 1mg 100 Capsule In 1 Bottle
2
N N N $12N$17N$12N
Thymoglobulin 5mg/mL 5 Ml In 1 Vial, Glass
5
Y N Y 30%N30%N30%N
Tiagabine Hydrochloride 2mg 30 Tablet, Film Coated In 1 Bottle
2
N N N $12N$17N$12N
Tiagabine Hydrochloride 4mg 30 Tablet, Film Coated In 1 Bottle
4
N N Y $90N$100N$90N
Tikosyn .125mg 60 Capsule In 1 Bottle
4
N N Y $90N$100N$90N
Tikosyn .25mg 60 Capsule In 1 Bottle
4
N N Y $90N$100N$90N
Tikosyn .5mg 60 Capsule In 1 Bottle
4
N N Y $90N$100N$90N
Timolol Maleate 5mg 100 Tablet In 1 Bottle, Plastic
2
N N N $12N$17N$12N
Timolol Maleate 10mg 100 Tablet In 1 Bottle, Plastic
2
N N N $12N$17N$12N
Timolol Maleate 20mg 100 Tablet In 1 Bottle, Plastic
2
N N N $12N$17N$12N
Timolol Maleate 3.4mg/mL 1 Bottle, Dispensing In 1 Carton > 5 Ml In 1 Bottle, Dispensing
2
N N N $12N$17N$12N
Timolol Maleate 6.8mg/mL 1 Bottle, Dispensing In 1 Carton > 5 Ml In 1 Bottle, Dispensing
2
N N N $12N$17N$12N
Timolol Maleate 2.5mg/mL 15 Ml In 1 Bottle, Plastic
1
N N N $2N$7N$2N
Timolol Maleate 5mg/mL 10 Ml In 1 Bottle, Plastic
1
N N N $2N$7N$2N
Tirosint 13ug 4 Blister Pack In 1 Carton > 7 Capsule In 1 Blister Pack
4
N N Y $90N$100N$90N
Tirosint 25ug 4 Blister Pack In 1 Carton > 7 Capsule In 1 Blister Pack
4
N N Y $90N$100N$90N
Tirosint 50ug 4 Blister Pack In 1 Carton > 7 Capsule In 1 Blister Pack
4
N N Y $90N$100N$90N
Tirosint 75ug 4 Blister Pack In 1 Carton > 7 Capsule In 1 Blister Pack
4
N N Y $90N$100N$90N
Tirosint 88ug 4 Blister Pack In 1 Carton > 7 Capsule In 1 Blister Pack
4
N N Y $90N$100N$90N
Tirosint 100ug 4 Blister Pack In 1 Carton > 7 Capsule In 1 Blister Pack
4
N N Y $90N$100N$90N
Tirosint 112ug 4 Blister Pack In 1 Carton > 7 Capsule In 1 Blister Pack
4
N N Y $90N$100N$90N
Tirosint 125ug 4 Blister Pack In 1 Carton > 7 Capsule In 1 Blister Pack
4
N N Y $90N$100N$90N
Tirosint 137ug 4 Blister Pack In 1 Carton > 7 Capsule In 1 Blister Pack
4
N N Y $90N$100N$90N
Tirosint 150ug 4 Blister Pack In 1 Carton > 7 Capsule In 1 Blister Pack
4
N N Y $90N$100N$90N
Tivicay 50mg 30 Tablet, Film Coated In 1 Bottle
5
N N Y 30%N30%N30%N
Tizanidine 2mg 150 Tablet In 1 Bottle, Plastic
2
N N N $12N$17N$12N
Tizanidine 4mg 1000 Tablet In 1 Bottle
2
N N N $12N$17N$12N
Tobi Podhaler 28mg 224 Package In 1 Box, Unit-dose
5
Y N Y 30%N30%N30%N
Tobradex 1; 3mg/g; mg/g 3.5 G In 1 Tube
4
N N Y $90N$100N$90N
Tobramycin 300mg/5mL 56 Ampule In 1 Carton > 5 Ml In 1 Ampule
5
Y N Y 30%N30%N30%N
Tobramycin 10mg/mL 25 Vial, Multi-dose In 1 Tray > 2 Ml In 1 Vial, Multi-dose
2
N N N $12N$17N$12N
Tobramycin 40mg/mL 25 Vial, Multi-dose In 1 Tray > 2 Ml In 1 Vial, Multi-dose
2
N N N $12N$17N$12N
Tobramycin 3mg/mL 1 Bottle, Dropper In 1 Carton > 5 Ml In 1 Bottle, Dropper
2
N N N $12N$17N$12N
Tobramycin And Dexamethasone 1; 3mg/mL; mg/mL 1 Bottle, Dropper In 1 Carton > 5 Ml In 1 Bottle, Dropper
2
N N N $12N$17N$12N
Tobrex 3mg/g 3.5 G In 1 Tube
4
N N Y $90N$100N$90N
Tolmetin Sodium 400mg 100 Capsule In 1 Bottle
2
N N N $12N$17N$12N
Tolmetin Sodium 600mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N N $12N$17N$12N
Tolterodine Tartrate 2mg 30 Capsule, Extended Release In 1 Bottle, Plastic
2
N Y N $12N$17N$12N
Tolterodine Tartrate 500 Capsule, Extended Release In 1 Bottle, Plastic
2
N Y N $12N$17N$12N
Tolterodine Tartrate 2mg 60 Tablet, Film Coated In 1 Bottle, Plastic
2
N Y N $12N$17N$12N
Tolterodine Tartrate 1mg 500 Tablet, Film Coated In 1 Bottle
2
N Y N $12N$17N$12N
Topiramate 15mg 60 Capsule, Coated Pellets In 1 Bottle
2
N N N $12N$17N$12N
Topiramate 30 Capsule, Extended Release In 1 Bottle
2
N N N $12N$17N$12N
Topiramate 30 Capsule, Extended Release In 1 Bottle
2
N N N $12N$17N$12N
Topiramate 30 Capsule, Extended Release In 1 Bottle
2
N N N $12N$17N$12N
Topiramate 30 Capsule, Extended Release In 1 Bottle
2
N N N $12N$17N$12N
Topiramate 30 Capsule, Extended Release In 1 Bottle
2
N N N $12N$17N$12N
Topiramate 25mg 60 Capsule, Coated Pellets In 1 Bottle
2
N N N $12N$17N$12N
Topiramate 25mg 1000 Tablet, Film Coated In 1 Bottle
1
N N N $2N$7N$2N
Topiramate 100mg 1000 Tablet, Film Coated In 1 Bottle
2
N N N $12N$17N$12N
Topiramate 200mg 1000 Tablet, Film Coated In 1 Bottle
2
N N N $12N$17N$12N
Topiramate 50mg 1000 Tablet, Film Coated In 1 Bottle
2
N N N $12N$17N$12N
Toposar 20mg/mL 1 Vial, Multi-dose In 1 Carton > 50 Ml In 1 Vial, Multi-dose
3
Y N Y $37N$47N$37N
Torisel 1 Kit In 1 Carton
5
Y N Y 30%N30%N30%N
Torsemide 20mg 100 Tablet In 1 Bottle, Plastic
1
N N N $2N$7N$2N
Torsemide 100mg 12 Bottle In 1 Case > 100 Tablet In 1 Bottle
2
N N N $12N$17N$12N
Torsemide 100 Tablet In 1 Bottle
1
N N N $2N$7N$2N
Torsemide 100 Tablet In 1 Bottle
1
N N N $2N$7N$2N
Toviaz 4mg 30 Tablet, Film Coated, Extended Release In 1 Bottle
3
N Y Y $37N$47N$37N
Toviaz 8mg 30 Tablet, Film Coated, Extended Release In 1 Bottle
3
N Y Y $37N$47N$37N
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
2
Y N N $12N$17N$12N
Tracleer 62.5mg 1 Bottle, Plastic In 1 Carton > 60 Tablet, Film Coated In 1 Bottle, Plastic
5
Y N Y 30%N30%N30%N
Tracleer 125mg 1 Bottle, Plastic In 1 Carton > 60 Tablet, Film Coated In 1 Bottle, Plastic
5
Y N Y 30%N30%N30%N
Tradjenta 5mg 90 Tablet, Film Coated In 1 Bottle
3
30 30 N N Y $37N$47N$37N
Tramadol Hydrochloride 50mg 100 Tablet, Film Coated In 1 Bottle
2
240 30 N N N $12N$17N$12N
Tramadol Hydrochloride 300mg 100 Tablet, Extended Release In 1 Bottle
2
30 30 N N N $12N$17N$12N
Tramadol Hydrochloride 100mg 30 Tablet, Extended Release In 1 Bottle, Plastic
2
90 30 N N N $12N$17N$12N
Tramadol Hydrochloride 200mg 30 Tablet, Extended Release In 1 Bottle, Plastic
2
30 30 N N N $12N$17N$12N
Tramadol Hydrochloride And Acetaminophen 325; 37.5mg/1; mg 1000 Tablet, Film Coated In 1 Bottle
2
240 30 N N N $12N$17N$12N
Trandolapril 100 Tablet In 1 Bottle
6
N N N $0N$0N$0N
Trandolapril 100 Tablet In 1 Bottle
6
N N N $0N$0N$0N
Trandolapril 100 Tablet In 1 Bottle
6
N N N $0N$0N$0N
Tranexamic Acid 650mg 30 Tablet, Film Coated In 1 Bottle, Plastic
2
N N N $12N$17N$12N
Transderm Scop 1mg/3d 10 Pouch In 1 Box > 1 Patch In 1 Pouch > 3 D In 1 Patch
3
10 30 N N Y $37N$47N$37N
Tranylcypromine Sulfate 10mg 100 Tablet In 1 Bottle, Plastic
2
N N N $12N$17N$12N
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 $90N$100N$90N
Travatan Z .04mg/mL 2.5 Ml In 1 Bottle
3
N N Y $37N$47N$37N
Travoprost Ophthalmic Solution 0.004% .04mg/mL 1 Bottle In 1 Carton > 2.5 Ml In 1 Bottle
2
N N N $12N$17N$12N
Trazodone Hydrochloride 300mg 100 Tablet In 1 Bottle
2
N N N $12N$17N$12N
Trazodone Hydrochloride 50mg 500 Tablet In 1 Bottle
1
N N N $2N$7N$2N
Trazodone Hydrochloride 100mg 500 Tablet In 1 Bottle
1
N N N $2N$7N$2N
Trazodone Hydrochloride 150mg 100 Tablet In 1 Bottle
1
N N N $2N$7N$2N
Treanda 100mg/20mL 20 Ml In 1 Vial, Single-use
5
Y N Y 30%N30%N30%N
Trecator 250mg 100 Tablet, Film Coated In 1 Bottle
3
N N Y $37N$47N$37N
Trelstar 22.5mg/2mL 2 Ml In 1 Vial, Single-dose
5
Y N Y 30%N30%N30%N
Trelstar 1 Kit In 1 Carton * 2 Ml In 1 Syringe
5
Y N Y 30%N30%N30%N
Trelstar 1 Kit In 1 Carton * 2 Ml In 1 Syringe
5
Y N Y 30%N30%N30%N
Tretinoin 10mg 100 Capsule In 1 Bottle
5
N N Y 30%N30%N30%N
Tretinoin 1mg/g 1 Tube In 1 Carton > 45 G In 1 Tube
2
N N N $12N$17N$12N
Tretinoin .5mg/g 1 Tube In 1 Carton > 20 G In 1 Tube
2
N N N $12N$17N$12N
Tretinoin .25mg/g 1 Tube In 1 Carton > 45 G In 1 Tube
2
N N N $12N$17N$12N
Tretinoin .25mg/g 1 Tube In 1 Carton > 45 G In 1 Tube
2
N N N $12N$17N$12N
Tretinoin 1 Tube In 1 Carton > 45 G In 1 Tube
2
N N N $12N$17N$12N
Tretinoin Gel Microsphere 1 Bottle, Pump In 1 Carton > 50 G In 1 Bottle, Pump
2
N N N $12N$17N$12N
Tretinoin Gel Microsphere 1 Bottle, Pump In 1 Carton > 50 G In 1 Bottle, Pump
2
N N N $12N$17N$12N
Trexall 5mg 30 Tablet, Film Coated In 1 Bottle
4
Y N Y $90N$100N$90N
Trexall 7.5mg 30 Tablet, Film Coated In 1 Bottle
4
Y N Y $90N$100N$90N
Trexall 10mg 30 Tablet, Film Coated In 1 Bottle
4
Y N Y $90N$100N$90N
Trexall 15mg 30 Tablet, Film Coated In 1 Bottle
4
Y N Y $90N$100N$90N
Tri Previfem 6 Blister Pack In 1 Carton
2
N N N $12N$17N$12N
Tri-legest Fe 5 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
2
N N N $12N$17N$12N
Tri-sprintec 6 Pouch In 1 Carton > 1 Blister Pack In 1 Pouch > 1 Kit In 1 Blister Pack
2
N N N $12N$17N$12N
Triamcinolone Acetonide .25mg/g 80 G In 1 Tube
2
N N N $12N$17N$12N
Triamcinolone Acetonide 1mg/g 80 G In 1 Tube
2
N N N $12N$17N$12N
Triamcinolone Acetonide 1mg/mL 60 Ml In 1 Bottle, Plastic
2
N N N $12N$17N$12N
Triamcinolone Acetonide 5mg/g 1 Tube In 1 Carton > 15 G In 1 Tube
2
N N N $12N$17N$12N
Triamcinolone Acetonide .25mg/g 1 Tube In 1 Carton > 80 G In 1 Tube
2
N N N $12N$17N$12N
Triamcinolone Acetonide 1mg/g 1 Tube In 1 Carton > 80 G In 1 Tube
2
N N N $12N$17N$12N
Triamcinolone Acetonide 5mg/g 1 Tube In 1 Carton > 15 G In 1 Tube
2
N N N $12N$17N$12N
Triamcinolone Acetonide 1mg/g 1 Tube In 1 Carton > 5 G In 1 Tube
2
N N N $12N$17N$12N
Triamcinolone Acetonide .25mg/mL 60 Ml In 1 Bottle, With Applicator
2
N N N $12N$17N$12N
Triamterene And Hydrochlorothiazide 25; 37.5mg/1; mg 100 Capsule In 1 Bottle, Plastic
2
N N N $12N$17N$12N
Triamterene And Hydrochlorothiazide 25; 50mg/1; mg 100 Capsule In 1 Bottle
2
N N N $12N$17N$12N
Triamterene Hydrochlorothiazide 50; 75mg/1; mg 500 Tablet In 1 Bottle
2
N N N $12N$17N$12N
Triamterene Hydrochlorothiazide 25; 37.5mg/1; mg 100 Tablet In 1 Bottle
2
N N N $12N$17N$12N
Triazolam 10 Bottle In 1 Package > 10 Tablet In 1 Bottle
2
120 30 N N N $12N$17N$12N
Triazolam 500 Tablet In 1 Bottle
2
120 30 N N N $12N$17N$12N
Tribenzor 5; 12.5; 20mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle
3
N Y Y $37N$47N$37N
Tribenzor 5; 12.5; 40mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle
3
N Y Y $37N$47N$37N
Tribenzor 5; 25; 40mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle
3
N Y Y $37N$47N$37N
Tribenzor 10; 12.5; 40mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle
3
N Y Y $37N$47N$37N
Tribenzor 10; 25; 40mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle
3
N Y Y $37N$47N$37N
Trifluoperazine Hydrochloride 2mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N N $12N$17N$12N
Trifluoperazine Hydrochloride 5mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N N $12N$17N$12N
Trifluoperazine Hydrochloride 10mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N N $12N$17N$12N
Trifluoperazine Hydrochloride 1mg 100 Tablet, Film Coated In 1 Bottle
2
N N N $12N$17N$12N
Trifluridine 10mg/mL 7.5 Ml In 1 Bottle, Plastic
2
N N N $12N$17N$12N
Trihexyphenidyl Hydrochloride 2mg/5mL 473 Ml In 1 Bottle
2
N N N $12N$17N$12N
Trihexyphenidyl Hydrochloride 5mg 100 Tablet In 1 Bottle, Plastic
1
N N N $2N$7N$2N
Trihexyphenidyl Hydrochloride 2mg 100 Blister Pack In 1 Box, Unit-dose
1
N N N $2N$7N$2N
Trilipix 135mg 90 Capsule, Delayed Release In 1 Bottle
4
N Y Y $90N$100N$90N
Trilipix 45mg 90 Capsule, Delayed Release In 1 Bottle
4
N Y Y $90N$100N$90N
Trilyte 420; 1.48; 5.72; 11.2g/4L; g/4L; g/4L; g/4L 4 L In 1 Bottle
2
N N N $12N$17N$12N
Trimethoprim 100mg 100 Tablet In 1 Bottle, Plastic
2
N N N $12N$17N$12N
Trimipramine Maleate 30 Capsule In 1 Bottle
2
N N N $12N$17N$12N
Trimipramine Maleate 30 Capsule In 1 Bottle
2
N N N $12N$17N$12N
Trimipramine Maleate 30 Capsule In 1 Bottle
2
N N N $12N$17N$12N
Trinessa 1 Dialpack In 1 Carton > 1 Kit In 1 Dialpack
2
N N N $12N$17N$12N
Trisenox 1mg/mL 10 Ampule In 1 Carton
5
Y N Y 30%N30%N30%N
Triumeq 30 Tablet, Film Coated In 1 Bottle
5
N N Y 30%N30%N30%N
Trivora 6 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
2
N N N $12N$17N$12N
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 $90N$100N$90N
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 Y $90N$100N$90N
Trospium Chloride 20mg 60 Tablet, Film Coated In 1 Bottle
2
N N N $12N$17N$12N
Trospium Chloride 60mg 30 Capsule, Extended Release In 1 Bottle, Plastic
2
N Y N $12N$17N$12N
Truvada 200; 300mg/1; mg 30 Tablet, Film Coated In 1 Bottle, Plastic
5
N N Y 30%N30%N30%N
Twinrix 720; 20[iU]/mL; ug/mL 10 Vial In 1 Carton
3
Y N Y $37N$47N$37N
Tybost 30 Tablet, Film Coated In 1 Bottle
3
N N Y $37N$47N$37N
Tygacil 50mg/5mL 10 Vial, Single-use In 1 Carton
5
N N Y 30%N30%N30%N
Tykerb 250mg 150 Tablet In 1 Bottle
5
Y N Y 30%N30%N30%N
Typhim Vi 25ug/.5mL 1 Vial, Multi-dose In 1 Package
3
N N Y $37N$47N$37N
Typhim Vi 1 Syringe In 1 Package
3
N N Y $37N$47N$37N
Tysabri 300mg/15mL 1 Vial, Single-use In 1 Carton > 15 Ml In 1 Vial, Single-use
5
Y N Y 30%N30%N30%N
Tyzeka 600mg 30 Tablet, Film Coated In 1 Bottle
4
N N Y $90N$100N$90N



Medicare Help's Additional Notes:

Coverage Levels for H3864-006

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1.Pre-Deductable: Before you reach the plans deductible of $150. 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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