MedicarePartD.guide

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2026 HealthSpring Assurance Rx (PDP) formulary (drug list)

Contract S5617, plan 113 · Oklahoma · 3,188 drugs on file · formulary ID 00026089. Each drug links to its cost in every CMS PDP Region 23 plan.

Hide drugs on tiers

219 drugs starting with T.

Drug nameTier30-day preferred pharmacy90-day mail orderUsage management
TABLOID 40 mg TabletThioguanine4Non-Preferred Drug29%29%None
TABRECTA 150 mg Tablet, Film CoatedCapmatinib5Specialty Tier25%N/A
  • PA
TABRECTA 200 mg Tablet, Film CoatedCapmatinib5Specialty Tier25%N/A
  • PA
TACROLIMUS .3 mg/g Ointment4Non-Preferred Drug29%29%
  • PA
  • QL 1 per 30 days
TACROLIMUS .5 mg Capsule4Non-Preferred Drug29%29%
  • PA
TACROLIMUS 1 mg Capsule4Non-Preferred Drug29%29%
  • PA
TACROLIMUS 1 mg/g Ointment4Non-Preferred Drug29%29%
  • PA
  • QL 1 per 30 days
TACROLIMUS 5 mg Capsule4Non-Preferred Drug29%29%
  • PA
TADALAFIL 2.5 mg Tablet, Film Coated4Non-Preferred Drug29%29%
  • PA
  • QL 6 per 30 days
TADALAFIL 5 mg Tablet4Non-Preferred Drug29%29%
  • PA
  • QL 3 per 30 days
TAFINLAR 10 mg Tablet, For SuspensionDabrafenib5Specialty Tier25%N/A
  • PA
  • QL 84 per 28 days
TAFINLAR 50 mg CapsuleDabrafenib5Specialty Tier25%N/A
  • PA
  • QL 12 per 30 days
TAFINLAR 75 mg CapsuleDabrafenib5Specialty Tier25%N/A
  • PA
  • QL 12 per 30 days
TAGRISSO 40 mg Tablet, Film CoatedOsimertinib5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
TAGRISSO 80 mg Tablet, Film CoatedOsimertinib5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
TALICIA 10/250/12.5 mg Capsule, Delayed ReleaseOmeprazole Magnesium, Amoxicillin And Rifabutin4Non-Preferred Drug29%29%
  • QL 168 per 180 days
TALZENNA .1 mg Capsule, Liquid FilledTalazoparib5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
TALZENNA .25 mg Capsule, Liquid FilledTalazoparib5Specialty Tier25%N/A
  • PA
  • QL 9 per 30 days
TALZENNA .35 mg Capsule, Liquid FilledTalazoparib5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
TALZENNA .5 mg Capsule, Liquid FilledTalazoparib5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
TALZENNA .75 mg Capsule, Liquid FilledTalazoparib5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
TALZENNA 1 mg Capsule, Liquid FilledTalazoparib5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
TAMOXIFEN CITRATE 10 mg Tablet, Film Coated2Generic$2.00$2.00None
TAMOXIFEN CITRATE 20 mg Tablet, Film Coated2Generic$2.00$2.00None
TAMSULOSIN HYDROCHLORIDE .4 mg Capsule2Generic$2.00$2.00
  • QL 6 per 30 days
TARINA 24 FE KitNorethindrone Acetate And Ethinyl Estradiol And Ferrous Fumarate4Non-Preferred Drug29%29%None
TARINA FE 1/20 EQ KitNorethindrone Acetate And Ethinyl Estradiol And Ferrous Fumarate4Non-Preferred Drug29%29%None
TASIMELTEON 20 mg Capsule, Gelatin Coated5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
TAZAROTENE .5 mg/g Cream3Preferred Brand20%20%
  • PA
TAZAROTENE .5 mg/g Gel4Non-Preferred Drug29%29%
  • PA
TAZAROTENE 1 mg/g Cream3Preferred Brand20%20%
  • PA
TAZAROTENE 1 mg/g Gel4Non-Preferred Drug29%29%
  • PA
TAZICEF 1 g Injection, Powder, For SolutionCeftazidime4Non-Preferred Drug29%29%
  • PA
TAZICEF 2 g Injection, Powder, For SolutionCeftazidime4Non-Preferred Drug29%29%
  • PA
TAZICEF 6 g Injection, Powder, For SolutionCeftazidime4Non-Preferred Drug29%29%
  • PA
TAZVERIK 200 mg Tablet, Film CoatedTazemetostat5Specialty Tier25%N/A
  • PA
TEFLARO 400 mg/20mL Powder, For SolutionCeftaroline Fosamil5Specialty Tier25%N/A
  • PA
TEFLARO 600 mg/20mL Powder, For SolutionCeftaroline Fosamil5Specialty Tier25%N/A
  • PA
TELMISARTAN 20 mg Tablet1Preferred Generic$0.00$0.00None
TELMISARTAN 40 mg Tablet1Preferred Generic$0.00$0.00None
TELMISARTAN 80 mg Tablet1Preferred Generic$0.00$0.00None
TENOFOVIR DISOPROXIL FUMARATE 300 mg Tablet, Film Coated4Non-Preferred Drug29%29%
  • QL 3 per 30 days
TEPMETKO 225 mg TabletTepotinib Hydrochloride5Specialty Tier25%N/A
  • PA
  • QL 6 per 30 days
TERAZOSIN 1 mg CapsuleTerazosin Hydrochloride1Preferred Generic$0.00$0.00
  • QL 3 per 30 days
TERAZOSIN 10 mg CapsuleTerazosin Hydrochloride1Preferred Generic$0.00$0.00
  • QL 6 per 30 days
TERAZOSIN 2 mg CapsuleTerazosin Hydrochloride1Preferred Generic$0.00$0.00
  • QL 3 per 30 days
TERAZOSIN 5 mg CapsuleTerazosin Hydrochloride1Preferred Generic$0.00$0.00
  • QL 3 per 30 days
TERBINAFINE 250 mg TabletTerbinafine Hydrochloride2Generic$2.00$2.00None
TERBUTALINE SULFATE 2.5 mg Tablet4Non-Preferred Drug29%29%None
TERBUTALINE SULFATE 5 mg Tablet4Non-Preferred Drug29%29%None
TERCONAZOLE 4 mg/g Cream4Non-Preferred Drug29%29%None
TERCONAZOLE 8 mg/g Cream4Non-Preferred Drug29%29%None
TERCONAZOLE 80 mg Suppository4Non-Preferred Drug29%29%None
TERIFLUNOMIDE 14 mg Tablet, Film Coated5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
TERIFLUNOMIDE 7 mg Tablet, Film Coated5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
TERIPARATIDE 250 ug/mL Injection5Specialty Tier25%N/A
  • PA
  • QL 2.48 per 28 days
TESTOSTERONE 10 mg/g Gel4Non-Preferred Drug29%29%
  • PA
  • QL 3 per 30 days
TESTOSTERONE 10 mg/g Gel4Non-Preferred Drug29%29%
  • PA
  • QL 3 per 30 days
TESTOSTERONE 16.2 mg/g Gel4Non-Preferred Drug29%29%
  • QL 15 per 30 days
TESTOSTERONE CYPIONATE 100 mg/mL Injection, Solution3Preferred Brand20%20%None
TESTOSTERONE CYPIONATE 200 mg/mL Injection3Preferred Brand20%20%None
TESTOSTERONE CYPIONATE 200 mg/mL Injection, Solution3Preferred Brand20%20%None
TESTOSTERONE ENANTHATE 200 mg/mL Injection, Solution4Non-Preferred Drug29%29%None
TESTOSTERONE GEL, 1% 10 mg/g Gel4Non-Preferred Drug29%29%
  • PA
  • QL 3 per 30 days
TETRABENAZINE 12.5 mg Tablet4Non-Preferred Drug29%29%
  • PA
  • QL 24 per 30 days
TETRABENAZINE 25 mg Tablet5Specialty Tier25%N/A
  • PA
  • QL 12 per 30 days
TETRACYCLINE HYDROCHLORIDE 250 mg Capsule4Non-Preferred Drug29%29%None
TETRACYCLINE HYDROCHLORIDE 500 mg Capsule4Non-Preferred Drug29%29%None
THEOPHYLLINE 300 mg Tablet, Extended Release4Non-Preferred Drug29%29%None
THEOPHYLLINE 400 mg Tablet, Extended Release2Generic$2.00$2.00None
THEOPHYLLINE 450 mg Tablet, Extended Release2Generic$2.00$2.00None
THEOPHYLLINE 600 mg Tablet, Extended Release3Preferred Brand20%20%None
THIORIDAZINE HYDROCHLORIDE 10 mg Tablet, Film Coated4Non-Preferred Drug29%29%None
THIORIDAZINE HYDROCHLORIDE 100 mg Tablet, Film Coated4Non-Preferred Drug29%29%None
THIORIDAZINE HYDROCHLORIDE 25 mg Tablet, Film Coated4Non-Preferred Drug29%29%None
THIORIDAZINE HYDROCHLORIDE 50 mg Tablet, Film Coated4Non-Preferred Drug29%29%None
THIOTHIXENE 1 mg Capsule4Non-Preferred Drug29%29%None
THIOTHIXENE 10 mg Capsule4Non-Preferred Drug29%29%None
THIOTHIXENE 2 mg Capsule4Non-Preferred Drug29%29%None
THIOTHIXENE 5 mg Capsule4Non-Preferred Drug29%29%None
TIADYLT ER 120 mg Capsule, Extended ReleaseDiltiazem Hydrochloride3Preferred Brand20%20%None
TIADYLT ER 180 mg Capsule, Extended ReleaseDiltiazem Hydrochloride3Preferred Brand20%20%None
TIADYLT ER 240 mg Capsule, Extended ReleaseDiltiazem Hydrochloride3Preferred Brand20%20%None
TIADYLT ER 300 mg Capsule, Extended ReleaseDiltiazem Hydrochloride3Preferred Brand20%20%None
TIADYLT ER 360 mg Capsule, Extended ReleaseDiltiazem Hydrochloride3Preferred Brand20%20%None
TIADYLT ER 420 mg Capsule, Extended ReleaseDiltiazem Hydrochloride3Preferred Brand20%20%None
TIAGABINE HYDROCHLORIDE 12 mg Tablet, Film Coated4Non-Preferred Drug29%29%None
TIAGABINE HYDROCHLORIDE 16 mg Tablet, Film Coated4Non-Preferred Drug29%29%None
TIAGABINE HYDROCHLORIDE 2 mg Tablet4Non-Preferred Drug29%29%None
TIAGABINE HYDROCHLORIDE 4 mg Tablet4Non-Preferred Drug29%29%None
TIBSOVO 250 mg Tablet, Film CoatedIvosidenib5Specialty Tier25%N/A
  • PA
TICAGRELOR 60 mg Tablet, Film Coated4Non-Preferred Drug29%29%
  • QL 6 per 30 days
TICAGRELOR 90 mg Tablet4Non-Preferred Drug29%29%
  • QL 6 per 30 days
TICOVAC 1.2 ug/.25mL InjectionTick-Borne Encephalitis Vaccine3Preferred Brand20%20%None
TICOVAC 2.4 ug/.5mL InjectionTick-Borne Encephalitis Vaccine3Preferred Brand20%20%None
TIGECYCLINE 50 mg Injection, Powder, Lyophilized, For Solution4Non-Preferred Drug29%29%
  • PA
TILIA FE KitNdac And Ee Tablets And Ferrous Fumarate Tablets4Non-Preferred Drug29%29%None
TIMOLOL MALEATE 10 mg Tablet4Non-Preferred Drug29%29%None
TIMOLOL MALEATE 2.5 mg/mL Solution/ Drops1Preferred Generic$0.00$0.00None
TIMOLOL MALEATE 5 mg/mL Solution/ Drops1Preferred Generic$0.00$0.00None
TIMOLOL MALEATE OPHTHALMIC GEL FORMING SOLUTION, 0.25% 2.5 mg/mL Solution/ Drops4Non-Preferred Drug29%29%None
TIMOLOL MALEATE OPHTHALMIC GEL FORMING SOLUTION, 0.5% 5 mg/mL Solution/ Drops4Non-Preferred Drug29%29%None
TINDAZOLE 250 mg Tablet, Film CoatedTinidazole4Non-Preferred Drug29%29%None
TINIDAZOLE 500 mg Tablet4Non-Preferred Drug29%29%None
TIVICAY 50 mg Tablet, Film CoatedDolutegravir Sodium5Specialty Tier25%N/A
  • QL 6 per 30 days
TIVICAY PD 5 mg Tablet, For SuspensionDolutegravir Sodium4Non-Preferred Drug29%29%
  • QL 18 per 30 days
TIZANIDINE 2 mg Tablet2Generic$2.00$2.00None
TIZANIDINE 4 mg Tablet2Generic$2.00$2.00None
TOBRAMYCIN 10 mg/mL Injection, SolutionTobramycin Sulfate4Non-Preferred Drug29%29%
  • PA
TOBRAMYCIN 3 mg/mL Solution/ Drops2Generic$2.00$2.00None
TOBRAMYCIN 300 mg/5mL Solution5Specialty Tier25%N/A
  • PA
  • QL 28 per 28 days
TOBRAMYCIN 40 mg/mL Injection, SolutionTobramycin Sulfate4Non-Preferred Drug29%29%
  • PA
TOBRAMYCIN AND DEXAMETHASONE 3/1 mg/mL Suspension/ Drops3Preferred Brand20%20%None
TOLTERODINE TARTRATE 1 mg Tablet, Film Coated4Non-Preferred Drug29%29%None
TOLTERODINE TARTRATE 2 mg Capsule, Extended Release4Non-Preferred Drug29%29%None
TOLTERODINE TARTRATE 2 mg Tablet, Film Coated4Non-Preferred Drug29%29%None
TOLTERODINE TARTRATE 4 mg Capsule, Extended Release4Non-Preferred Drug29%29%None
TOLVAPTAN 15 mg Tablet5Specialty Tier25%N/A
  • PA
  • QL 12 per 30 days
TOLVAPTAN 15 mg Tablet5Specialty Tier25%N/A
  • PA
TOLVAPTAN 30 mg Tablet5Specialty Tier25%N/A
  • PA
  • QL 6 per 30 days
TOLVAPTAN 30 mg Tablet5Specialty Tier25%N/A
  • PA
TOPIRAMATE 100 mg Tablet, Film Coated2Generic$2.00$2.00
  • PA
TOPIRAMATE 15 mg Capsule, Coated Pellets3Preferred Brand20%20%
  • PA
TOPIRAMATE 200 mg Tablet2Generic$2.00$2.00
  • PA
TOPIRAMATE 25 mg Capsule, Coated Pellets3Preferred Brand20%20%
  • PA
TOPIRAMATE 25 mg Tablet, Film Coated2Generic$2.00$2.00
  • PA
TOPIRAMATE 25 mg/mL Solution4Non-Preferred Drug29%29%
  • PA
TOPIRAMATE 50 mg Capsule, Coated Pellets3Preferred Brand20%20%
  • PA
TOPIRAMATE 50 mg Tablet, Film Coated2Generic$2.00$2.00
  • PA
TOREMIFENE CITRATE 60 mg Tablet4Non-Preferred Drug29%29%None
TORSEMIDE 10 mg Tablet2Generic$2.00$2.00None
TORSEMIDE 100 mg Tablet2Generic$2.00$2.00None
TORSEMIDE 20 mg Tablet2Generic$2.00$2.00None
TORSEMIDE 5 mg Tablet2Generic$2.00$2.00None
TOUJEO 300 U/mL Injection, SolutionInsulin Glargine3Preferred Brand20%20%None
TOUJEO MAX 300 U/mL Injection, SolutionInsulin Glargine3Preferred Brand20%20%None
TRADJENTA 5 mg Tablet, Film CoatedLinagliptin3Preferred Brand20%20%
  • QL 3 per 30 days
TRAMADOL HYDROCHLORIDE 50 mg Tablet, Coated2Generic$2.00$2.00
  • QL 24 per 30 days
TRAMADOL HYDROCHLORIDE AND ACETAMINOPHEN 37.5/325 mg Tablet2Generic$2.00$2.00
  • QL 24 per 30 days
TRANDOLAPRIL 1 mg Tablet1Preferred Generic$0.00$0.00None
TRANDOLAPRIL 2 mg Tablet1Preferred Generic$0.00$0.00None
TRANDOLAPRIL 4 mg Tablet1Preferred Generic$0.00$0.00None
TRANEXAMIC ACID 650 mg Tablet3Preferred Brand20%20%None
TRANYLCYPROMINE 10 mg Tablet4Non-Preferred Drug29%29%None
TRAVASOL 730/560/580/400/600/580/480/420/180/2.07/1.03/1.15/680/40/500 mg/100mL/g/100mL InjectionLeucine, Phenylalanine, Lysine Hydrochloride, Methionine, Isoleucine, Valine, Histidine, Threonine, Tryptophan, Alanine, Glycine, Arginine, Proline, Tyrosine, Serine4Non-Preferred Drug29%29%
  • PA
TRAZODONE HYDROCHLORIDE 100 mg Tablet2Generic$2.00$2.00None
TRAZODONE HYDROCHLORIDE 150 mg Tablet2Generic$2.00$2.00None
TRAZODONE HYDROCHLORIDE 300 mg Tablet2Generic$2.00$2.00None
TRAZODONE HYDROCHLORIDE 50 mg Tablet2Generic$2.00$2.00None
TRELEGY ELLIPTA 100/62.5/25 ug PowderFluticasone Furoate, Umeclidinium Bromide And Vilanterol Trifenatate3Preferred Brand20%20%
  • QL 6 per 30 days
TRELEGY ELLIPTA 200/62.5/25 ug PowderFluticasone Furoate, Umeclidinium Bromide And Vilanterol Trifenatate3Preferred Brand20%20%
  • QL 6 per 30 days
TREMFYA 100 mg/mL InjectionGuselkumab5Specialty Tier25%N/A
  • PA
  • QL 2 per 28 days
TREMFYA 100 mg/mL InjectionGuselkumab5Specialty Tier25%N/A
  • PA
  • QL 2 per 28 days
TREMFYA 200 mg/2mL InjectionGuselkumab5Specialty Tier25%N/A
  • PA
  • QL 2 per 28 days
TREMFYA 200 mg/2mL InjectionGuselkumab5Specialty Tier25%N/A
  • PA
  • QL 24 per 365 days
TREMFYA 200 mg/2mL InjectionGuselkumab5Specialty Tier25%N/A
  • PA
  • QL 2 per 28 days
TRETINOIN .05 g/100g Gel4Non-Preferred Drug29%29%
  • PA
TRETINOIN .1 mg/g Gel3Preferred Brand20%20%
  • PA
TRETINOIN .25 mg/g Cream4Non-Preferred Drug29%29%
  • PA
TRETINOIN .25 mg/g Gel4Non-Preferred Drug29%29%
  • PA
TRETINOIN .5 mg/g Cream4Non-Preferred Drug29%29%
  • PA
TRETINOIN 1 mg/g Cream4Non-Preferred Drug29%29%
  • PA
TRETINOIN 1 mg/g Gel4Non-Preferred Drug29%29%
  • PA
TRETINOIN 10 mg Capsule5Specialty Tier25%N/ANone
TRI-ESTARYLLA KitNorgestimate And Ethinyl Estradiol4Non-Preferred Drug29%29%None
TRI-LEGEST FE 28 DAY KitNorethindrone Acetate And Ethinyl Estradiol4Non-Preferred Drug29%29%None
TRI-LO- ESTARYLLA KitNorgestimate And Ethinyl Estradiol4Non-Preferred Drug29%29%None
TRI-LO-SPRINTEC KitNorgestimate And Ethinyl Estradiol4Non-Preferred Drug29%29%None
TRI-MILI KitNorgestimate And Ethinyl Estradiol4Non-Preferred Drug29%29%None
TRI-SPRINTEC KitNorgestimate And Ethinyl Estradiol4Non-Preferred Drug29%29%None
TRI-VYLIBRA KitNorgestimate And Ethinyl Estradiol4Non-Preferred Drug29%29%None
TRI-VYLIBRA LO KitNorgestimate And Ethinyl Estradiol4Non-Preferred Drug29%29%None
TRIAMCINOLONE ACETONIDE .25 mg/g Cream2Generic$2.00$2.00None
TRIAMCINOLONE ACETONIDE .25 mg/g Ointment2Generic$2.00$2.00None
TRIAMCINOLONE ACETONIDE .25 mg/mL Lotion3Preferred Brand20%20%None
TRIAMCINOLONE ACETONIDE 1 mg/g Cream2Generic$2.00$2.00None
TRIAMCINOLONE ACETONIDE 1 mg/g Ointment2Generic$2.00$2.00None
TRIAMCINOLONE ACETONIDE 1 mg/g Paste4Non-Preferred Drug29%29%None
TRIAMCINOLONE ACETONIDE 1 mg/mL Lotion3Preferred Brand20%20%None
TRIAMCINOLONE ACETONIDE 5 mg/g Cream2Generic$2.00$2.00None
TRIAMCINOLONE ACETONIDE 5 mg/g Ointment2Generic$2.00$2.00None
TRIAMTERENE AND HYDROCHLOROTHIAZIDE 37.5/25 mg Tablet1Preferred Generic$0.00$0.00None
TRIAMTERENE AND HYDROCHLOROTHIAZIDE 75/50 mg Tablet1Preferred Generic$0.00$0.00None
TRIENTINE HYDROCHLORIDE 250 mg Capsule5Specialty Tier25%N/A
  • PA
  • QL 24 per 30 days
TRIFLUOPERAZINE HYDROCHLORIDE 1 mg Tablet, Film Coated3Preferred Brand20%20%None
TRIFLUOPERAZINE HYDROCHLORIDE 10 mg Tablet, Film Coated4Non-Preferred Drug29%29%None
TRIFLUOPERAZINE HYDROCHLORIDE 2 mg Tablet, Film Coated4Non-Preferred Drug29%29%None
TRIFLUOPERAZINE HYDROCHLORIDE 5 mg Tablet, Film Coated4Non-Preferred Drug29%29%None
TRIFLURIDINE 10 mg/mL Solution3Preferred Brand20%20%None
TRIKAFTA KitElexacaftor, Tezacaftor, And Ivacaftor5Specialty Tier25%N/A
  • PA
  • QL 84 per 28 days
TRIKAFTA KitElexacaftor, Tezacaftor, And Ivacaftor5Specialty Tier25%N/A
  • PA
  • QL 84 per 28 days
TRIKAFTA KitElexacaftor, Tezacaftor, And Ivacaftor5Specialty Tier25%N/A
  • PA
  • QL 56 per 28 days
TRIKAFTA KitElexacaftor, Tezacaftor, And Ivacaftor5Specialty Tier25%N/A
  • PA
  • QL 56 per 28 days
TRIMETHOPRIM 100 mg Tablet2Generic$2.00$2.00None
TRIMIPRAMINE 100 mg Capsule4Non-Preferred Drug29%29%None
TRIMIPRAMINE 25 mg Capsule4Non-Preferred Drug29%29%None
TRIMIPRAMINE 50 mg Capsule4Non-Preferred Drug29%29%None
TRINTELLIX 10 mg Tablet, Film CoatedVortioxetine4Non-Preferred Drug29%29%
  • ST
  • QL 3 per 30 days
TRINTELLIX 20 mg Tablet, Film CoatedVortioxetine4Non-Preferred Drug29%29%
  • ST
  • QL 3 per 30 days
TRINTELLIX 5 mg Tablet, Film CoatedVortioxetine4Non-Preferred Drug29%29%
  • ST
  • QL 3 per 30 days
TRIUMEQ 600/50/300 mg Tablet, Film CoatedAbacavir Sulfate, Dolutegravir Sodium, Lamivudine5Specialty Tier25%N/A
  • QL 3 per 30 days
TRIUMEQ PD KitAbacavir Sulfate, Dolutegravir Sodium, Lamivudine4Non-Preferred Drug29%29%
  • QL 3 per 30 days
TROPHAMINE .82/1.4/1.2/.34/.48/.42/.2/.78/.024/.48/.044/.24/.54/1.2/.68/.38/.36/.32/.5/.025 g/100mL SolutionIsoleucine, Leucine, Lysine Acetate, Methionine, Phenylalanine, Threonine, Tryptophan, Valine, Cysteine Hydrochloride, Histidine, Tyrosine, N-Acetyl-Tyrosine, Alanine, Arginine, Proline, Serine, Glycine, Aspartic Acid, Glutamic Acid, And Taurine4Non-Preferred Drug29%29%
  • PA
TRULICITY .75 mg/.5mL Injection, SolutionDulaglutide3Preferred Brand20%20%
  • PA
  • QL 2 per 28 days
TRULICITY 1.5 mg/.5mL Injection, SolutionDulaglutide3Preferred Brand20%20%
  • PA
  • QL 2 per 28 days
TRULICITY 3 mg/.5mL Injection, SolutionDulaglutide3Preferred Brand20%20%
  • PA
  • QL 2 per 28 days
TRULICITY 4.5 mg/.5mL Injection, SolutionDulaglutide3Preferred Brand20%20%
  • PA
  • QL 2 per 28 days
TRUMENBA 60/60 ug/.5mL Injection, SuspensionMeningococcal Group B Vaccine3Preferred Brand20%20%None
TRUQAP 200 mg Tablet, Film CoatedCapivasertib5Specialty Tier25%N/A
  • PA
  • QL 64 per 28 days
TUKYSA 150 mg TabletTucatinib5Specialty Tier25%N/A
  • PA
  • QL 12 per 30 days
TUKYSA 50 mg TabletTucatinib5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
TURALIO 125 mg CapsulePexidartinib Hydrochloride5Specialty Tier25%N/A
  • PA
  • QL 12 per 30 days
TURQOZ KitNorgestrel And Ethinyl Estradiol4Non-Preferred Drug29%29%None
TWINRIX 720/20 [iU]/mL/ug/mL Injection, SuspensionHepatitis A And Hepatitis B (Recombinant) Vaccine3Preferred Brand20%20%None
TYDEMY KitDrospirenone, Ethinyl Estradiol And Levomefolate Calcium And Levomefolate Calcium4Non-Preferred Drug29%29%None
TYENNE 162 mg/.9mL Injection, SolutionTocilizumab-Aazg5Specialty Tier25%N/A
  • PA
  • QL 3.6 per 28 days
TYENNE 162 mg/.9mL Injection, SolutionTocilizumab-Aazg5Specialty Tier25%N/A
  • PA
  • QL 3.6 per 28 days
TYPHIM VI 25 ug/.5mL Injection, SolutionSalmonella Typhi Ty2 Vi Polysaccharide Antigen3Preferred Brand20%20%None
TYPHIM VI 25 ug/.5mL Injection, SolutionSalmonella Typhi Ty2 Vi Polysaccharide Antigen3Preferred Brand20%20%None

PA = prior authorization, ST = step therapy, QL = quantity limit. Costs are the plan’s initial-coverage cost-sharing from the CMS 2026 formulary files; a drug not listed here is not on this plan’s formulary, though a formulary exception may still be possible.