2017 VIVA Medicare Plus (HMO) Formulary



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





Plan Name:
VIVA Medicare Plus (HMO)
Plan ID:
H0154-015
Provider: Viva Health, Inc.
Plan Year:2017
Premium:$0.00
Deductible:$200
Initial Coverage Limit:$3700
Coverage Area:Alabama




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 50%N50%N50%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 Y 29%N29%NNAN
Tacrolimus 1 Tube In 1 Carton > 30 G In 1 Tube
2
N N Y $15N$15N$12.5N
Tacrolimus 1 Tube In 1 Carton > 30 G In 1 Tube
2
N N Y $15N$15N$12.5N
Tacrolimus .5mg 100 Capsule In 1 Bottle
2
Y N Y $15N$15N$12.5N
Tacrolimus 1mg 100 Capsule In 1 Bottle
2
Y N Y $15N$15N$12.5N
Tacrolimus 5mg 100 Capsule In 1 Bottle
2
Y N Y $15N$15N$12.5N
Tamiflu 75mg 1 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack
3
N N Y $47N$47N$39.5N
Tamiflu 45mg 1 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack
3
N N Y $47N$47N$39.5N
Tamiflu 30mg 1 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack
3
N N Y $47N$47N$39.5N
Tamiflu 6mg/mL 1 Bottle, Glass In 1 Carton > 60 Ml In 1 Bottle, Glass
3
N N Y $47N$47N$39.5N
Tamoxifen Citrate 10mg 180 Tablet, Film Coated In 1 Bottle
1
N N N $0N$4N$0N
Tamoxifen Citrate 20mg 30 Tablet In 1 Bottle
1
N N N $0N$4N$0N
Tamsulosin Hydrochloride 100 Capsule In 1 Bottle
2
N N Y $15N$15N$12.5N
Tanzeum 30mg/.5mL 4 Syringe In 1 Carton > .5 Ml In 1 Syringe
4
4 28 N N Y 50%N50%N50%N
Tanzeum 50mg/.5mL 4 Syringe In 1 Carton > .5 Ml In 1 Syringe
4
4 28 N N Y 50%N50%N50%N
Tarceva 25mg 30 Tablet In 1 Bottle
5
Y N Y 29%N29%NNAN
Tarceva 100mg 30 Tablet In 1 Bottle
5
Y N Y 29%N29%NNAN
Tarceva 150mg 30 Tablet In 1 Bottle
5
Y N Y 29%N29%NNAN
Targretin 60 G In 1 Tube
5
Y N Y 29%N29%NNAN
Tarina Fe 1/20 3 Pouch In 1 Carton > 1 Kit In 1 Pouch
2
N N Y $15N$15N$12.5N
Tasigna 200mg 28 Capsule In 1 Blister Pack
5
Y N Y 29%N29%NNAN
Tasigna 150mg 4 Blister Pack In 1 Carton > 28 Capsule In 1 Blister Pack
5
Y N Y 29%N29%NNAN
Tazicef 25 Vial In 1 Tray > 1 Injection, Powder, For Solution In 1 Vial
2
N N Y $15N$15N$12.5N
Tazicef 10 Vial In 1 Tray > 1 Injection, Powder, For Solution In 1 Vial
2
N N Y $15N$15N$12.5N
Tazicef 10 Vial, Pharmacy Bulk Package In 1 Carton > 1 Injection, Powder, For Solution In 1 Vial, Pharmacy Bulk Package
2
N N Y $15N$15N$12.5N
Tazorac 1mg/g 1 Tube In 1 Carton > 100 G In 1 Tube
4
Y N Y 50%N50%N50%N
Tazorac .5mg/g 1 Tube In 1 Carton > 100 G In 1 Tube
4
Y N Y 50%N50%N50%N
Tazorac .5mg/g 1 Tube In 1 Carton > 60 G In 1 Tube
4
Y N Y 50%N50%N50%N
Tazorac 1mg/g 1 Tube In 1 Carton > 60 G In 1 Tube
4
Y N Y 50%N50%N50%N
Taztia 120mg 90 Capsule, Extended Release In 1 Bottle, Plastic
2
N N Y $15N$15N$12.5N
Taztia 180mg 90 Capsule, Extended Release In 1 Bottle, Plastic
2
N N Y $15N$15N$12.5N
Taztia 240mg 90 Capsule, Extended Release In 1 Bottle, Plastic
2
N N Y $15N$15N$12.5N
Taztia 300mg 90 Capsule, Extended Release In 1 Bottle, Plastic
2
N N Y $15N$15N$12.5N
Taztia 360mg 90 Capsule, Extended Release In 1 Bottle, Plastic
2
N N Y $15N$15N$12.5N
Teflaro 400mg/20mL 10 Vial, Single-dose In 1 Carton
5
N N Y 29%N29%NNAN
Teflaro 600mg/20mL 10 Vial, Single-dose In 1 Carton
5
N N Y 29%N29%NNAN
Tegretol 100mg/5mL 450 Ml In 1 Bottle
4
N N Y 50%N50%N50%N
Tegretol 200mg 100 Tablet In 1 Bottle
4
N N Y 50%N50%N50%N
Tegretol 100mg 100 Tablet, Extended Release In 1 Bottle
4
N N Y 50%N50%N50%N
Tegretol 200mg 100 Tablet, Extended Release In 1 Bottle
4
N N Y 50%N50%N50%N
Tegretol 400mg 100 Tablet, Extended Release In 1 Bottle
4
N N Y 50%N50%N50%N
Tekturna 150mg 30 Tablet, Film Coated In 1 Bottle
4
N N Y 50%N50%N50%N
Tekturna 300mg 30 Tablet, Film Coated In 1 Bottle
4
N N Y 50%N50%N50%N
Tekturna Hct 150; 12.5mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
N N Y 50%N50%N50%N
Tekturna Hct 150; 25mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
N N Y 50%N50%N50%N
Tekturna Hct 300; 12.5mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
N N Y 50%N50%N50%N
Tekturna Hct 300; 25mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
N N Y 50%N50%N50%N
Telmisartan 20mg 3 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
1
N N N $0N$4N$0N
Telmisartan 40mg 3 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
1
N N N $0N$4N$0N
Telmisartan 80mg 3 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
1
N N N $0N$4N$0N
Telmisartan And Amlodipine 5; 40mg/1; mg 30 Tablet In 1 Bottle
1
N N N $0N$4N$0N
Telmisartan And Amlodipine 10; 40mg/1; mg 30 Tablet In 1 Bottle
1
N N N $0N$4N$0N
Telmisartan And Amlodipine 5; 80mg/1; mg 30 Tablet In 1 Bottle
1
N N N $0N$4N$0N
Telmisartan And Amlodipine 10; 80mg/1; mg 30 Tablet In 1 Bottle
1
N N N $0N$4N$0N
Telmisartan And Hydrochlorothiazide 90 Tablet In 1 Bottle
1
N N N $0N$4N$0N
Telmisartan And Hydrochlorothiazide 90 Tablet In 1 Bottle
1
N N N $0N$4N$0N
Telmisartan And Hydrochlorothiazide 90 Tablet In 1 Bottle
1
N N N $0N$4N$0N
Temazepam 7.5mg 100 Capsule In 1 Bottle, Plastic
2
30 30 Y N Y $15N$15N$12.5N
Temazepam 15mg 100 Blister Pack In 1 Box, Unit-dose
2
60 30 Y N Y $15N$15N$12.5N
Tenivac 10 Syringe In 1 Package > .5 Ml In 1 Syringe
3
Y N Y $47N$47N$39.5N
Terazosin 1mg 100 Capsule In 1 Bottle
1
N N N $0N$4N$0N
Terazosin Hydrochloride 2mg 100 Capsule In 1 Bottle
1
N N N $0N$4N$0N
Terazosin Hydrochloride 5mg 100 Capsule In 1 Bottle
1
N N N $0N$4N$0N
Terazosin Hydrochloride 10mg 100 Capsule In 1 Bottle
1
N N N $0N$4N$0N
Terbinafine Hydrochloride 90 Tablet In 1 Bottle
1
90 365 N N N $0N$4N$0N
Terbutaline Sulfate 2.5mg 100 Tablet In 1 Bottle
2
N N Y $15N$15N$12.5N
Terbutaline Sulfate 5mg 100 Tablet In 1 Bottle
2
N N Y $15N$15N$12.5N
Terbutaline Sulfate 1mg/mL 25 Vial, Single-use In 1 Tray > 1 Ml In 1 Vial, Single-use
5
N N Y 29%N29%NNAN
Terconazole 80mg 1 Blister Pack In 1 Carton > 3 Suppository In 1 Blister Pack
2
N N Y $15N$15N$12.5N
Terconazole 8mg/g 1 Tube, With Applicator In 1 Carton > 20 G In 1 Tube, With Applicator
2
N N Y $15N$15N$12.5N
Terconazole 4mg/g 1 Tube, With Applicator In 1 Carton > 45 G In 1 Tube, With Applicator
2
N N Y $15N$15N$12.5N
Testosterone 1 Canister In 1 Carton > 60 G In 1 Canister
2
120 30 Y N Y $15N$15N$12.5N
Testosterone 30 Packet In 1 Carton
2
300 30 Y N Y $15N$15N$12.5N
Testosterone Cypionate 1 Vial, Multi-dose In 1 Carton > 10 Ml In 1 Vial, Multi-dose
2
Y N Y $15N$15N$12.5N
Testosterone Cypionate 1 Vial, Multi-dose In 1 Carton > 10 Ml In 1 Vial, Multi-dose
2
Y N Y $15N$15N$12.5N
Testosterone Enanthate 200mg/mL 1 Vial, Multi-dose In 1 Carton > 5 Ml In 1 Vial, Multi-dose
2
Y N Y $15N$15N$12.5N
Tetracycline Hydrochloride 250mg 100 Capsule In 1 Bottle
2
N N Y $15N$15N$12.5N
Tetracycline Hydrochloride 500mg 100 Capsule In 1 Bottle
2
N N Y $15N$15N$12.5N
Thalomid 50mg 10 Blister Pack In 1 Box
5
Y N Y 29%N29%NNAN
Thalomid 100mg 5 Blister Pack In 1 Box
5
Y N Y 29%N29%NNAN
Thalomid 150mg 4 Blister Pack In 1 Box
5
Y N Y 29%N29%NNAN
Thalomid 200mg 3 Blister Pack In 1 Box
5
Y N Y 29%N29%NNAN
Theophylline 400mg 100 Tablet, Extended Release In 1 Bottle, Plastic
2
N N Y $15N$15N$12.5N
Theophylline 600mg 100 Tablet, Extended Release In 1 Bottle, Plastic
2
N N Y $15N$15N$12.5N
Theophylline 300mg 100 Tablet, Extended Release In 1 Bottle
2
N N Y $15N$15N$12.5N
Theophylline 200mg 500 Tablet, Extended Release In 1 Bottle
2
N N Y $15N$15N$12.5N
Theophylline 100mg 500 Tablet, Extended Release In 1 Bottle
2
N N Y $15N$15N$12.5N
Theophylline 450mg 100 Tablet, Extended Release In 1 Bottle
2
N N Y $15N$15N$12.5N
Theophylline 80mg/15mL 473 Ml In 1 Bottle, Plastic
2
N N Y $15N$15N$12.5N
Thioridazine Hydrochloride 100mg 100 Tablet, Film Coated In 1 Bottle, Plastic
4
Y N Y 50%N50%N50%N
Thioridazine Hydrochloride 50mg 100 Blister Pack In 1 Box, Unit-dose
4
Y N Y 50%N50%N50%N
Thioridazine Hydrochloride 10mg 1000 Tablet, Film Coated In 1 Bottle, Plastic
4
Y N Y 50%N50%N50%N
Thioridazine Hydrochloride 25mg 1000 Tablet, Film Coated In 1 Bottle, Plastic
4
Y N Y 50%N50%N50%N
Thiothixene 2mg 100 Capsule In 1 Bottle, Plastic
2
N N Y $15N$15N$12.5N
Thiothixene 5mg 100 Capsule In 1 Bottle, Plastic
2
N N Y $15N$15N$12.5N
Thiothixene 10mg 100 Capsule In 1 Bottle, Plastic
2
N N Y $15N$15N$12.5N
Thiothixene 1mg 100 Capsule In 1 Bottle
2
N N Y $15N$15N$12.5N
Thymoglobulin 5mg/mL 5 Ml In 1 Vial, Glass
5
Y N Y 29%N29%NNAN
Tiagabine Hydrochloride 2mg 30 Tablet, Film Coated In 1 Bottle
2
N N Y $15N$15N$12.5N
Tiagabine Hydrochloride 4mg 30 Tablet, Film Coated In 1 Bottle
2
N N Y $15N$15N$12.5N
Timolol Maleate 5mg 100 Tablet In 1 Bottle, Plastic
2
N N Y $15N$15N$12.5N
Timolol Maleate 10mg 100 Tablet In 1 Bottle, Plastic
2
N N Y $15N$15N$12.5N
Timolol Maleate 20mg 100 Tablet In 1 Bottle, Plastic
2
N N Y $15N$15N$12.5N
Timolol Maleate 3.4mg/mL 1 Bottle, Dispensing In 1 Carton > 5 Ml In 1 Bottle, Dispensing
2
N N Y $15N$15N$12.5N
Timolol Maleate 6.8mg/mL 1 Bottle, Dispensing In 1 Carton > 5 Ml In 1 Bottle, Dispensing
2
N N Y $15N$15N$12.5N
Timolol Maleate 2.5mg/mL 15 Ml In 1 Bottle, Plastic
1
N N N $0N$4N$0N
Timolol Maleate 5mg/mL 10 Ml In 1 Bottle, Plastic
1
N N N $0N$4N$0N
Tirosint 13ug 4 Blister Pack In 1 Carton > 7 Capsule In 1 Blister Pack
4
N N Y 50%N50%N50%N
Tirosint 25ug 4 Blister Pack In 1 Carton > 7 Capsule In 1 Blister Pack
4
N N Y 50%N50%N50%N
Tirosint 50ug 4 Blister Pack In 1 Carton > 7 Capsule In 1 Blister Pack
4
N N Y 50%N50%N50%N
Tirosint 75ug 4 Blister Pack In 1 Carton > 7 Capsule In 1 Blister Pack
4
N N Y 50%N50%N50%N
Tirosint 88ug 4 Blister Pack In 1 Carton > 7 Capsule In 1 Blister Pack
4
N N Y 50%N50%N50%N
Tirosint 100ug 4 Blister Pack In 1 Carton > 7 Capsule In 1 Blister Pack
4
N N Y 50%N50%N50%N
Tirosint 112ug 4 Blister Pack In 1 Carton > 7 Capsule In 1 Blister Pack
4
N N Y 50%N50%N50%N
Tirosint 125ug 4 Blister Pack In 1 Carton > 7 Capsule In 1 Blister Pack
4
N N Y 50%N50%N50%N
Tirosint 137ug 4 Blister Pack In 1 Carton > 7 Capsule In 1 Blister Pack
4
N N Y 50%N50%N50%N
Tirosint 150ug 4 Blister Pack In 1 Carton > 7 Capsule In 1 Blister Pack
4
N N Y 50%N50%N50%N
Tivicay 50mg 30 Tablet, Film Coated In 1 Bottle
5
N N Y 29%N29%NNAN
Tizanidine 2mg 150 Tablet In 1 Bottle, Plastic
2
N N Y $15N$15N$12.5N
Tizanidine 4mg 1000 Tablet In 1 Bottle
2
N N Y $15N$15N$12.5N
Tizanidine Hydrochloride 2mg 150 Capsule, Gelatin Coated In 1 Bottle
2
N N Y $15N$15N$12.5N
Tizanidine Hydrochloride 4mg 150 Capsule, Gelatin Coated In 1 Bottle
2
N N Y $15N$15N$12.5N
Tizanidine Hydrochloride 6mg 150 Capsule, Gelatin Coated In 1 Bottle
2
N N Y $15N$15N$12.5N
Tobi Podhaler 28mg 224 Package In 1 Box, Unit-dose
5
Y N Y 29%N29%NNAN
Tobradex 1; 3mg/g; mg/g 3.5 G In 1 Tube
3
N N Y $47N$47N$39.5N
Tobradex St .5; 3mg/mL; mg/mL 5 Ml In 1 Bottle
3
N N Y $47N$47N$39.5N
Tobramycin 300mg/5mL 56 Ampule In 1 Carton > 5 Ml In 1 Ampule
5
Y N Y 29%N29%NNAN
Tobramycin 10mg/mL 25 Vial, Multi-dose In 1 Tray > 2 Ml In 1 Vial, Multi-dose
2
N N Y $15N$15N$12.5N
Tobramycin 40mg/mL 25 Vial, Multi-dose In 1 Tray > 2 Ml In 1 Vial, Multi-dose
2
N N Y $15N$15N$12.5N
Tobramycin 3mg/mL 1 Bottle, Dropper In 1 Carton > 5 Ml In 1 Bottle, Dropper
1
N N N $0N$4N$0N
Tobramycin And Dexamethasone 1; 3mg/mL; mg/mL 1 Bottle, Dropper In 1 Carton > 5 Ml In 1 Bottle, Dropper
2
N N Y $15N$15N$12.5N
Tobrex 3mg/g 3.5 G In 1 Tube
4
N N Y 50%N50%N50%N
Tolmetin Sodium 400mg 100 Capsule In 1 Bottle
2
N N Y $15N$15N$12.5N
Tolmetin Sodium 600mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N Y $15N$15N$12.5N
Tolterodine Tartrate 2mg 30 Capsule, Extended Release In 1 Bottle, Plastic
2
N N Y $15N$15N$12.5N
Tolterodine Tartrate 500 Capsule, Extended Release In 1 Bottle, Plastic
2
N N Y $15N$15N$12.5N
Tolterodine Tartrate 2mg 60 Tablet, Film Coated In 1 Bottle, Plastic
2
N N Y $15N$15N$12.5N
Tolterodine Tartrate 1mg 500 Tablet, Film Coated In 1 Bottle
2
N N Y $15N$15N$12.5N
Topicort 2.5mg/mL 1 Bottle In 1 Carton > 100 Ml In 1 Bottle
4
N N Y 50%N50%N50%N
Topiramate 15mg 60 Capsule, Coated Pellets In 1 Bottle
2
N N Y $15N$15N$12.5N
Topiramate 30 Capsule, Extended Release In 1 Bottle
2
N N Y $15N$15N$12.5N
Topiramate 30 Capsule, Extended Release In 1 Bottle
2
N N Y $15N$15N$12.5N
Topiramate 30 Capsule, Extended Release In 1 Bottle
2
N N Y $15N$15N$12.5N
Topiramate 30 Capsule, Extended Release In 1 Bottle
2
N N Y $15N$15N$12.5N
Topiramate 30 Capsule, Extended Release In 1 Bottle
2
N N Y $15N$15N$12.5N
Topiramate 25mg 60 Capsule, Coated Pellets In 1 Bottle
2
N N Y $15N$15N$12.5N
Topiramate 25mg 1000 Tablet, Film Coated In 1 Bottle
1
N N N $0N$4N$0N
Topiramate 100mg 1000 Tablet, Film Coated In 1 Bottle
1
N N N $0N$4N$0N
Topiramate 200mg 1000 Tablet, Film Coated In 1 Bottle
1
N N N $0N$4N$0N
Topiramate 50mg 1000 Tablet, Film Coated In 1 Bottle
1
N N N $0N$4N$0N
Toposar 20mg/mL 1 Vial, Multi-dose In 1 Carton > 50 Ml In 1 Vial, Multi-dose
2
Y N Y $15N$15N$12.5N
Torisel 1 Kit In 1 Carton
5
Y N Y 29%N29%NNAN
Torsemide 20mg 100 Tablet In 1 Bottle, Plastic
2
N N Y $15N$15N$12.5N
Torsemide 100mg 12 Bottle In 1 Case > 100 Tablet In 1 Bottle
2
N N Y $15N$15N$12.5N
Torsemide 100 Tablet In 1 Bottle
2
N N Y $15N$15N$12.5N
Torsemide 100 Tablet In 1 Bottle
2
N N Y $15N$15N$12.5N
Toviaz 4mg 30 Tablet, Film Coated, Extended Release In 1 Bottle
3
N N Y $47N$47N$39.5N
Toviaz 8mg 30 Tablet, Film Coated, Extended Release In 1 Bottle
3
N N Y $47N$47N$39.5N
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 50%N50%N50%N
Tracleer 62.5mg 1 Bottle, Plastic In 1 Carton > 60 Tablet, Film Coated In 1 Bottle, Plastic
5
Y N Y 29%N29%NNAN
Tracleer 125mg 1 Bottle, Plastic In 1 Carton > 60 Tablet, Film Coated In 1 Bottle, Plastic
5
Y N Y 29%N29%NNAN
Tradjenta 5mg 90 Tablet, Film Coated In 1 Bottle
3
30 30 N N Y $47N$47N$39.5N
Tramadol Hydrochloride 50mg 100 Tablet, Film Coated In 1 Bottle
2
240 30 N N Y $15N$15N$12.5N
Tramadol Hydrochloride 300mg 100 Tablet, Extended Release In 1 Bottle
2
30 30 N N Y $15N$15N$12.5N
Tramadol Hydrochloride 100mg 30 Tablet, Extended Release In 1 Bottle, Plastic
2
90 30 N N Y $15N$15N$12.5N
Tramadol Hydrochloride 200mg 30 Tablet, Extended Release In 1 Bottle, Plastic
2
30 30 N N Y $15N$15N$12.5N
Tramadol Hydrochloride And Acetaminophen 325; 37.5mg/1; mg 1000 Tablet, Film Coated In 1 Bottle
2
240 30 N N Y $15N$15N$12.5N
Trandolapril 100 Tablet In 1 Bottle
1
N N N $0N$4N$0N
Trandolapril 100 Tablet In 1 Bottle
1
N N N $0N$4N$0N
Trandolapril 100 Tablet In 1 Bottle
1
N N N $0N$4N$0N
Trandolapril And Verapamil Hydrochloride 100 Tablet, Film Coated, Extended Release In 1 Bottle
1
N N N $0N$4N$0N
Trandolapril And Verapamil Hydrochloride 100 Tablet, Film Coated, Extended Release In 1 Bottle
1
N N N $0N$4N$0N
Trandolapril And Verapamil Hydrochloride 100 Tablet, Film Coated, Extended Release In 1 Bottle
1
N N N $0N$4N$0N
Trandolapril And Verapamil Hydrochloride 100 Tablet, Film Coated, Extended Release In 1 Bottle
1
N N N $0N$4N$0N
Tranexamic Acid 650mg 30 Tablet, Film Coated In 1 Bottle, Plastic
2
N N Y $15N$15N$12.5N
Tranexamic Acid 100mg/mL 10 Vial, Single-dose In 1 Package
2
N N Y $15N$15N$12.5N
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 50%N50%N50%N
Tranylcypromine Sulfate 10mg 100 Tablet In 1 Bottle, Plastic
2
N N Y $15N$15N$12.5N
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 50%N50%N50%N
Travatan Z .04mg/mL 2.5 Ml In 1 Bottle
3
N N Y $47N$47N$39.5N
Trazodone Hydrochloride 300mg 100 Tablet In 1 Bottle
2
N N Y $15N$15N$12.5N
Trazodone Hydrochloride 50mg 500 Tablet In 1 Bottle
1
N N N $0N$4N$0N
Trazodone Hydrochloride 100mg 500 Tablet In 1 Bottle
1
N N N $0N$4N$0N
Trazodone Hydrochloride 150mg 100 Tablet In 1 Bottle
1
N N N $0N$4N$0N
Treanda 100mg/20mL 20 Ml In 1 Vial, Single-use
5
Y N Y 29%N29%NNAN
Trecator 250mg 100 Tablet, Film Coated In 1 Bottle
4
N N Y 50%N50%N50%N
Trelstar 22.5mg/2mL 2 Ml In 1 Vial, Single-dose
5
Y N Y 29%N29%NNAN
Trelstar 1 Kit In 1 Carton * 2 Ml In 1 Syringe
5
Y N Y 29%N29%NNAN
Trelstar 1 Kit In 1 Carton * 2 Ml In 1 Syringe
5
Y N Y 29%N29%NNAN
Tretin.x 1 Tube In 1 Carton > 35 G In 1 Tube
4
Y N Y 50%N50%N50%N
Tretinoin 10mg 100 Capsule In 1 Bottle
5
N N Y 29%N29%NNAN
Tretinoin 1mg/g 1 Tube In 1 Carton > 45 G In 1 Tube
2
Y N Y $15N$15N$12.5N
Tretinoin .5mg/g 1 Tube In 1 Carton > 20 G In 1 Tube
2
Y N Y $15N$15N$12.5N
Tretinoin .25mg/g 1 Tube In 1 Carton > 45 G In 1 Tube
2
Y N Y $15N$15N$12.5N
Tretinoin .25mg/g 1 Tube In 1 Carton > 45 G In 1 Tube
2
Y N Y $15N$15N$12.5N
Tretinoin 1 Tube In 1 Carton > 45 G In 1 Tube
2
Y N Y $15N$15N$12.5N
Tretinoin Gel Microsphere 1 Bottle, Pump In 1 Carton > 50 G In 1 Bottle, Pump
2
Y N Y $15N$15N$12.5N
Tretinoin Gel Microsphere 1 Bottle, Pump In 1 Carton > 50 G In 1 Bottle, Pump
2
Y N Y $15N$15N$12.5N
Trexall 5mg 30 Tablet, Film Coated In 1 Bottle
4
Y N Y 50%N50%N50%N
Trexall 7.5mg 30 Tablet, Film Coated In 1 Bottle
4
Y N Y 50%N50%N50%N
Trexall 10mg 30 Tablet, Film Coated In 1 Bottle
4
Y N Y 50%N50%N50%N
Trexall 15mg 30 Tablet, Film Coated In 1 Bottle
4
Y N Y 50%N50%N50%N
Tri Previfem 6 Blister Pack In 1 Carton
2
N N Y $15N$15N$12.5N
Tri-legest Fe 5 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
2
N N Y $15N$15N$12.5N
Tri-sprintec 6 Pouch In 1 Carton > 1 Blister Pack In 1 Pouch > 1 Kit In 1 Blister Pack
2
N N Y $15N$15N$12.5N
Triamcinolone Acetonide .25mg/g 80 G In 1 Tube
1
N N N $0N$4N$0N
Triamcinolone Acetonide 1mg/g 80 G In 1 Tube
1
N N N $0N$4N$0N
Triamcinolone Acetonide 1mg/mL 60 Ml In 1 Bottle, Plastic
2
N N Y $15N$15N$12.5N
Triamcinolone Acetonide 5mg/g 1 Tube In 1 Carton > 15 G In 1 Tube
1
N N N $0N$4N$0N
Triamcinolone Acetonide .25mg/g 1 Tube In 1 Carton > 80 G In 1 Tube
1
N N N $0N$4N$0N
Triamcinolone Acetonide 1mg/g 1 Tube In 1 Carton > 80 G In 1 Tube
1
N N N $0N$4N$0N
Triamcinolone Acetonide 5mg/g 1 Tube In 1 Carton > 15 G In 1 Tube
1
N N N $0N$4N$0N
Triamcinolone Acetonide 1mg/g 1 Tube In 1 Carton > 5 G In 1 Tube
2
N N Y $15N$15N$12.5N
Triamcinolone Acetonide .25mg/mL 60 Ml In 1 Bottle, With Applicator
2
N N Y $15N$15N$12.5N
Triamterene And Hydrochlorothiazide 25; 37.5mg/1; mg 100 Capsule In 1 Bottle, Plastic
1
N N N $0N$4N$0N
Triamterene And Hydrochlorothiazide 25; 50mg/1; mg 100 Capsule In 1 Bottle
1
N N N $0N$4N$0N
Triamterene Hydrochlorothiazide 50; 75mg/1; mg 500 Tablet In 1 Bottle
1
N N N $0N$4N$0N
Triamterene Hydrochlorothiazide 25; 37.5mg/1; mg 100 Tablet In 1 Bottle
1
N N N $0N$4N$0N
Tribenzor 5; 12.5; 20mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
N N Y 50%N50%N50%N
Tribenzor 5; 12.5; 40mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
N N Y 50%N50%N50%N
Tribenzor 5; 25; 40mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
N N Y 50%N50%N50%N
Tribenzor 10; 12.5; 40mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
N N Y 50%N50%N50%N
Tribenzor 10; 25; 40mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
N N Y 50%N50%N50%N
Triderm 1mg/g 85.2 G In 1 Tube
1
N N N $0N$4N$0N
Trifluoperazine Hydrochloride 2mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N Y $15N$15N$12.5N
Trifluoperazine Hydrochloride 5mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N Y $15N$15N$12.5N
Trifluoperazine Hydrochloride 10mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N Y $15N$15N$12.5N
Trifluoperazine Hydrochloride 1mg 100 Tablet, Film Coated In 1 Bottle
2
N N Y $15N$15N$12.5N
Trifluridine 10mg/mL 7.5 Ml In 1 Bottle, Plastic
2
N N Y $15N$15N$12.5N
Triglide 160mg 1 Bottle In 1 Carton > 30 Tablet In 1 Bottle
4
N N Y 50%N50%N50%N
Trilyte 420; 1.48; 5.72; 11.2g/4L; g/4L; g/4L; g/4L 4 L In 1 Bottle
2
N N Y $15N$15N$12.5N
Trimethoprim 100mg 100 Tablet In 1 Bottle, Plastic
1
N N N $0N$4N$0N
Trimipramine Maleate 30 Capsule In 1 Bottle
4
Y N Y 50%N50%N50%N
Trimipramine Maleate 30 Capsule In 1 Bottle
4
Y N Y 50%N50%N50%N
Trimipramine Maleate 30 Capsule In 1 Bottle
4
Y N Y 50%N50%N50%N
Trinessa 1 Dialpack In 1 Carton > 1 Kit In 1 Dialpack
2
N N Y $15N$15N$12.5N
Trisenox 1mg/mL 10 Ampule In 1 Carton
5
Y N Y 29%N29%NNAN
Triumeq 30 Tablet, Film Coated In 1 Bottle
5
N N Y 29%N29%NNAN
Trivora 6 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
2
N N Y $15N$15N$12.5N
Trokendi Xr 25mg 30 Capsule, Extended Release In 1 Blister Pack
4
N N Y 50%N50%N50%N
Trokendi Xr 50mg 30 Capsule, Extended Release In 1 Blister Pack
4
N N Y 50%N50%N50%N
Trokendi Xr 100mg 30 Capsule, Extended Release In 1 Blister Pack
4
N N Y 50%N50%N50%N
Trokendi Xr 200mg 30 Capsule, Extended Release In 1 Blister Pack
5
N N Y 29%N29%NNAN
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 50%N50%N50%N
Trospium Chloride 20mg 60 Tablet, Film Coated In 1 Bottle
2
N N Y $15N$15N$12.5N
Trospium Chloride 60mg 30 Capsule, Extended Release In 1 Bottle, Plastic
2
N N Y $15N$15N$12.5N
Trulicity 4 Syringe In 1 Carton
4
4 28 N N Y 50%N50%N50%N
Trulicity 4 Syringe In 1 Carton
4
4 28 N N Y 50%N50%N50%N
Truvada 200; 300mg/1; mg 30 Tablet, Film Coated In 1 Bottle, Plastic
5
30 30 N N Y 29%N29%NNAN
Twinrix 720; 20[iU]/mL; ug/mL 10 Vial In 1 Carton
3
N N Y $47N$47N$39.5N
Tybost 30 Tablet, Film Coated In 1 Bottle
3
N N Y $47N$47N$39.5N
Tygacil 50mg/5mL 10 Vial, Single-use In 1 Carton
5
N N Y 29%N29%NNAN
Tykerb 250mg 150 Tablet In 1 Bottle
5
Y N Y 29%N29%NNAN
Typhim Vi 25ug/.5mL 1 Vial, Multi-dose In 1 Package
3
N N Y $47N$47N$39.5N
Typhim Vi 1 Syringe In 1 Package
3
N N Y $47N$47N$39.5N
Tysabri 300mg/15mL 1 Vial, Single-use In 1 Carton > 15 Ml In 1 Vial, Single-use
5
Y N Y 29%N29%NNAN
Tyvaso 1.74mg/2.9mL 4 Ampule In 1 Box > 2.9 Ml In 1 Ampule
5
Y N Y 29%N29%NNAN
Tyzeka 600mg 30 Tablet, Film Coated In 1 Bottle
5
N N Y 29%N29%NNAN



Medicare Help's Additional Notes:

Coverage Levels for H0154-015

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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