MedicarePartD.guide

A non-government resource built from CMS public data

2026 Blue Rx PDP Plus (PDP) formulary (drug list)

Contract S5593, plan 002 · Pennsylvania · 3,788 drugs on file · formulary ID 00026017. Each drug links to its cost in every CMS PDP Region 06 plan.

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297 drugs starting with T.

Drug nameTier30-day preferred pharmacy90-day mail orderUsage management
TABLOID 40 mg TabletThioguanine4Non-Preferred Drug25%25%None
TABRECTA 150 mg Tablet, Film CoatedCapmatinib5Specialty Tier25%25%
  • PA
  • QL 124 per 31 days
TABRECTA 200 mg Tablet, Film CoatedCapmatinib5Specialty Tier25%25%
  • PA
  • QL 124 per 31 days
TACROLIMUS .3 mg/g Ointment2Generic25%25%
  • QL 1 per 28 days
TACROLIMUS .5 mg Capsule2Generic25%25%
  • PA
TACROLIMUS 1 mg Capsule2Generic25%25%
  • PA
TACROLIMUS 1 mg/g Ointment2Generic25%25%
  • QL 1 per 28 days
TACROLIMUS 5 mg Capsule2Generic25%25%
  • PA
TADALAFIL 2.5 mg Tablet, Film Coated4Non-Preferred Drug25%25%
  • PA
  • QL 62 per 31 days
TADALAFIL 20 mg Tablet, Film Coated5Specialty Tier25%25%
  • PA
  • QL 62 per 31 days
TADALAFIL 5 mg Tablet4Non-Preferred Drug25%25%
  • PA
  • QL 31 per 31 days
TAFINLAR 10 mg Tablet, For SuspensionDabrafenib5Specialty Tier25%25%
  • PA
  • QL 93 per 31 days
TAFINLAR 50 mg CapsuleDabrafenib5Specialty Tier25%25%
  • PA
  • QL 124 per 31 days
TAFINLAR 75 mg CapsuleDabrafenib5Specialty Tier25%25%
  • PA
  • QL 124 per 31 days
TAFLUPROST .0045 mg/.3mL Solution/ DropsTafluprost Opthalmic4Non-Preferred Drug25%25%None
TAGRISSO 40 mg Tablet, Film CoatedOsimertinib5Specialty Tier25%25%
  • PA
  • QL 31 per 31 days
TAGRISSO 80 mg Tablet, Film CoatedOsimertinib5Specialty Tier25%25%
  • PA
  • QL 31 per 31 days
TALZENNA .1 mg Capsule, Liquid FilledTalazoparib5Specialty Tier25%25%
  • PA
  • QL 31 per 31 days
TALZENNA .25 mg Capsule, Liquid FilledTalazoparib5Specialty Tier25%25%
  • PA
  • QL 31 per 31 days
TALZENNA .35 mg Capsule, Liquid FilledTalazoparib5Specialty Tier25%25%
  • PA
  • QL 31 per 31 days
TALZENNA .5 mg Capsule, Liquid FilledTalazoparib5Specialty Tier25%25%
  • PA
  • QL 31 per 31 days
TALZENNA .75 mg Capsule, Liquid FilledTalazoparib5Specialty Tier25%25%
  • PA
  • QL 31 per 31 days
TALZENNA 1 mg Capsule, Liquid FilledTalazoparib5Specialty Tier25%25%
  • PA
  • QL 31 per 31 days
TAMOXIFEN CITRATE 10 mg Tablet, Film Coated1Preferred Generic25%25%None
TAMOXIFEN CITRATE 20 mg Tablet, Film Coated1Preferred Generic25%25%None
TAMSULOSIN HYDROCHLORIDE .4 mg Capsule1Preferred Generic25%25%None
TASCENSO ODT .25 mg Tablet, Orally DisintegratingFingolimod Lauryl Sulfate5Specialty Tier25%25%
  • PA
  • QL 31 per 31 days
TASCENSO ODT .5 mg Tablet, Orally DisintegratingFingolimod Lauryl Sulfate5Specialty Tier25%25%
  • PA
  • QL 31 per 31 days
TASIMELTEON 20 mg Capsule, Gelatin Coated5Specialty Tier25%25%
  • PA
  • QL 31 per 31 days
TAVALISSE 100 mg TabletFostamatinib5Specialty Tier25%25%
  • PA
  • QL 62 per 31 days
TAVALISSE 150 mg TabletFostamatinib5Specialty Tier25%25%
  • PA
  • QL 62 per 31 days
TAZAROTENE .5 mg/g Cream4Non-Preferred Drug25%25%
  • PA
  • QL 6 per 28 days
TAZAROTENE 1 mg/g Cream4Non-Preferred Drug25%25%
  • PA
  • QL 6 per 28 days
TAZAROTENE 1 mg/g Gel4Non-Preferred Drug25%25%
  • PA
  • QL 1 per 28 days
TAZVERIK 200 mg Tablet, Film CoatedTazemetostat5Specialty Tier25%25%
  • PA
  • QL 248 per 31 days
TELMISARTAN 20 mg Tablet1Preferred Generic25%25%None
TELMISARTAN 40 mg Tablet1Preferred Generic25%25%None
TELMISARTAN 80 mg Tablet1Preferred Generic25%25%None
TELMISARTAN AND AMLODIPINE 40/10 mg Tablet2Generic25%25%None
TELMISARTAN AND AMLODIPINE 40/5 mg Tablet2Generic25%25%None
TELMISARTAN AND AMLODIPINE 80/10 mg Tablet2Generic25%25%None
TELMISARTAN AND AMLODIPINE 80/5 mg Tablet2Generic25%25%None
TELMISARTAN AND HYDROCHLOROTHIAZIDE 40/12.5 mg Tablet1Preferred Generic25%25%None
TELMISARTAN AND HYDROCHLOROTHIAZIDE 80/12.5 mg Tablet1Preferred Generic25%25%None
TELMISARTAN AND HYDROCHLOROTHIAZIDE 80/25 mg Tablet1Preferred Generic25%25%None
TEMAZEPAM 15 mg Capsule2Generic25%25%
  • PA
  • QL 31 per 31 days
TEMAZEPAM 22.5 mg Capsule2Generic25%25%
  • PA
  • QL 31 per 31 days
TEMAZEPAM 30 mg Capsule2Generic25%25%
  • PA
  • QL 31 per 31 days
TEMAZEPAM 7.5 mg Capsule2Generic25%25%
  • PA
  • QL 31 per 31 days
TENCON 50/325 mg TabletButalbital And Acetaminophen2Generic25%25%
  • QL 372 per 31 days
TENOFOVIR DISOPROXIL FUMARATE 300 mg Tablet, Film Coated3Preferred Brand25%25%None
TEPMETKO 225 mg TabletTepotinib Hydrochloride5Specialty Tier25%25%
  • PA
  • QL 62 per 31 days
TERAZOSIN 1 mg CapsuleTerazosin Hydrochloride1Preferred Generic25%25%None
TERAZOSIN 10 mg CapsuleTerazosin Hydrochloride1Preferred Generic25%25%None
TERAZOSIN 2 mg CapsuleTerazosin Hydrochloride1Preferred Generic25%25%None
TERAZOSIN 5 mg CapsuleTerazosin Hydrochloride1Preferred Generic25%25%None
TERBINAFINE 250 mg TabletTerbinafine Hydrochloride1Preferred Generic25%25%
  • QL 9 per 180 days
TERBUTALINE SULFATE 2.5 mg Tablet4Non-Preferred Drug25%25%None
TERBUTALINE SULFATE 5 mg Tablet4Non-Preferred Drug25%25%None
TERCONAZOLE 4 mg/g Cream2Generic25%25%None
TERCONAZOLE 8 mg/g Cream2Generic25%25%None
TERCONAZOLE 80 mg Suppository2Generic25%25%None
TERIFLUNOMIDE 14 mg Tablet, Film Coated5Specialty Tier25%25%
  • PA
  • QL 31 per 31 days
TERIFLUNOMIDE 7 mg Tablet, Film Coated5Specialty Tier25%25%
  • PA
  • QL 31 per 31 days
TERIPARATIDE 250 ug/mL Injection5Specialty Tier25%25%
  • PA
  • QL 2.48 per 28 days
TESTOSTERONE 16.2 mg/g Gel4Non-Preferred Drug25%25%
  • PA
TESTOSTERONE 30 mg/1.5mL Solution4Non-Preferred Drug25%25%
  • PA
TESTOSTERONE CYPIONATE 100 mg/mL Injection, Solution2Generic25%25%
  • PA
TESTOSTERONE CYPIONATE 200 mg/mL Injection2Generic25%25%
  • PA
TESTOSTERONE CYPIONATE 200 mg/mL Injection, Solution2Generic25%25%
  • PA
TESTOSTERONE ENANTHATE 200 mg/mL Injection, Solution2Generic25%25%
  • PA
TETRABENAZINE 12.5 mg Tablet5Specialty Tier25%25%
  • PA
  • QL 93 per 31 days
TETRABENAZINE 25 mg Tablet5Specialty Tier25%25%
  • PA
  • QL 124 per 31 days
TETRACYCLINE HYDROCHLORIDE 250 mg Capsule4Non-Preferred Drug25%25%None
TETRACYCLINE HYDROCHLORIDE 500 mg Capsule4Non-Preferred Drug25%25%None
THEO-24 100 mg Capsule, Extended ReleaseTheophylline Anhydrous3Preferred Brand25%25%None
THEO-24 200 mg Capsule, Extended ReleaseTheophylline Anhydrous3Preferred Brand25%25%None
THEO-24 300 mg Capsule, Extended ReleaseTheophylline Anhydrous3Preferred Brand25%25%None
THEO-24 400 mg Capsule, Extended ReleaseTheophylline Anhydrous3Preferred Brand25%25%None
THEOPHYLLINE 300 mg Tablet, Extended Release2Generic25%25%None
THEOPHYLLINE 400 mg Tablet, Extended Release2Generic25%25%None
THEOPHYLLINE 450 mg Tablet, Extended Release2Generic25%25%None
THEOPHYLLINE 600 mg Tablet, Extended Release2Generic25%25%None
THEOPHYLLINE 80 mg/15mL Solution2Generic25%25%None
THIORIDAZINE HYDROCHLORIDE 10 mg Tablet, Film Coated2Generic25%25%None
THIORIDAZINE HYDROCHLORIDE 100 mg Tablet, Film Coated2Generic25%25%None
THIORIDAZINE HYDROCHLORIDE 25 mg Tablet, Film Coated2Generic25%25%None
THIORIDAZINE HYDROCHLORIDE 50 mg Tablet, Film Coated2Generic25%25%None
THIOTHIXENE 1 mg Capsule1Preferred Generic25%25%None
THIOTHIXENE 10 mg Capsule1Preferred Generic25%25%None
THIOTHIXENE 2 mg Capsule1Preferred Generic25%25%None
THIOTHIXENE 5 mg Capsule1Preferred Generic25%25%None
TIADYLT ER 120 mg Capsule, Extended ReleaseDiltiazem Hydrochloride2Generic25%25%None
TIADYLT ER 180 mg Capsule, Extended ReleaseDiltiazem Hydrochloride2Generic25%25%None
TIADYLT ER 240 mg Capsule, Extended ReleaseDiltiazem Hydrochloride2Generic25%25%None
TIADYLT ER 300 mg Capsule, Extended ReleaseDiltiazem Hydrochloride2Generic25%25%None
TIADYLT ER 360 mg Capsule, Extended ReleaseDiltiazem Hydrochloride2Generic25%25%None
TIADYLT ER 420 mg Capsule, Extended ReleaseDiltiazem Hydrochloride2Generic25%25%None
TIAGABINE HYDROCHLORIDE 12 mg Tablet, Film Coated3Preferred Brand25%25%None
TIAGABINE HYDROCHLORIDE 16 mg Tablet, Film Coated3Preferred Brand25%25%None
TIAGABINE HYDROCHLORIDE 2 mg Tablet4Non-Preferred Drug25%25%None
TIAGABINE HYDROCHLORIDE 4 mg Tablet4Non-Preferred Drug25%25%None
TIBSOVO 250 mg Tablet, Film CoatedIvosidenib5Specialty Tier25%25%
  • PA
  • QL 62 per 31 days
TICAGRELOR 60 mg Tablet, Film Coated2Generic25%25%None
TICAGRELOR 90 mg Tablet2Generic25%25%None
TICOVAC 1.2 ug/.25mL InjectionTick-Borne Encephalitis Vaccine3Preferred Brand25%25%None
TICOVAC 2.4 ug/.5mL InjectionTick-Borne Encephalitis Vaccine3Preferred Brand25%25%None
TIGECYCLINE 50 mg Injection, Powder, Lyophilized, For Solution4Non-Preferred Drug25%25%None
TIMOLOL HEMIHYDRATE 5 mg/mL Solution/ Drops4Non-Preferred Drug25%25%None
TIMOLOL MALEATE 10 mg Tablet1Preferred Generic25%25%None
TIMOLOL MALEATE 2.5 mg/mL Solution/ Drops1Preferred Generic25%25%None
TIMOLOL MALEATE 5 mg/mL Solution/ Drops1Preferred Generic25%25%None
TIMOLOL MALEATE OPHTHALMIC GEL FORMING SOLUTION, 0.25% 2.5 mg/mL Solution/ Drops2Generic25%25%None
TIMOLOL MALEATE OPHTHALMIC GEL FORMING SOLUTION, 0.5% 5 mg/mL Solution/ Drops2Generic25%25%None
TINDAZOLE 250 mg Tablet, Film CoatedTinidazole2Generic25%25%None
TINIDAZOLE 500 mg Tablet2Generic25%25%None
TIROSINT 100 ug CapsuleLevothyroxine Sodium4Non-Preferred Drug25%25%None
TIROSINT 112 ug CapsuleLevothyroxine Sodium4Non-Preferred Drug25%25%None
TIROSINT 125 ug CapsuleLevothyroxine Sodium4Non-Preferred Drug25%25%None
TIROSINT 13 ug CapsuleLevothyroxine Sodium4Non-Preferred Drug25%25%None
TIROSINT 137 ug CapsuleLevothyroxine Sodium4Non-Preferred Drug25%25%None
TIROSINT 150 ug CapsuleLevothyroxine Sodium4Non-Preferred Drug25%25%None
TIROSINT 175 ug CapsuleLevothyroxine Sodium4Non-Preferred Drug25%25%None
TIROSINT 200 ug CapsuleLevothyroxine Sodium4Non-Preferred Drug25%25%None
TIROSINT 25 ug CapsuleLevothyroxine Sodium4Non-Preferred Drug25%25%None
TIROSINT 37.5 ug CapsuleLevothyroxine Sodium4Non-Preferred Drug25%25%None
TIROSINT 44 ug CapsuleLevothyroxine Sodium4Non-Preferred Drug25%25%None
TIROSINT 50 ug CapsuleLevothyroxine Sodium4Non-Preferred Drug25%25%None
TIROSINT 62.5 ug CapsuleLevothyroxine Sodium4Non-Preferred Drug25%25%None
TIROSINT 75 ug CapsuleLevothyroxine Sodium4Non-Preferred Drug25%25%None
TIROSINT 88 ug CapsuleLevothyroxine Sodium4Non-Preferred Drug25%25%None
TIROSINT SOL 100 ug/mL SolutionLevothyroxine Sodium4Non-Preferred Drug25%25%None
TIROSINT SOL 112 ug/mL SolutionLevothyroxine Sodium4Non-Preferred Drug25%25%None
TIROSINT SOL 125 ug/mL SolutionLevothyroxine Sodium4Non-Preferred Drug25%25%None
TIROSINT SOL 13 ug/mL SolutionLevothyroxine Sodium4Non-Preferred Drug25%25%None
TIROSINT SOL 137 ug/mL SolutionLevothyroxine Sodium4Non-Preferred Drug25%25%None
TIROSINT SOL 150 ug/mL SolutionLevothyroxine Sodium4Non-Preferred Drug25%25%None
TIROSINT SOL 175 ug/mL SolutionLevothyroxine Sodium4Non-Preferred Drug25%25%None
TIROSINT SOL 200 ug/mL SolutionLevothyroxine Sodium4Non-Preferred Drug25%25%None
TIROSINT SOL 25 ug/mL SolutionLevothyroxine Sodium4Non-Preferred Drug25%25%None
TIROSINT SOL 37.5 ug/mL SolutionLevothyroxine Sodium4Non-Preferred Drug25%25%None
TIROSINT SOL 44 ug/mL SolutionLevothyroxine Sodium4Non-Preferred Drug25%25%None
TIROSINT SOL 50 ug/mL SolutionLevothyroxine Sodium4Non-Preferred Drug25%25%None
TIROSINT SOL 62.5 ug/mL SolutionLevothyroxine Sodium4Non-Preferred Drug25%25%None
TIROSINT SOL 75 ug/mL SolutionLevothyroxine Sodium4Non-Preferred Drug25%25%None
TIROSINT SOL 88 ug/mL SolutionLevothyroxine Sodium4Non-Preferred Drug25%25%None
TIVICAY 50 mg Tablet, Film CoatedDolutegravir Sodium5Specialty Tier25%25%None
TIVICAY PD 5 mg Tablet, For SuspensionDolutegravir Sodium5Specialty Tier25%25%None
TIZANIDINE 2 mg Tablet2Generic25%25%None
TIZANIDINE 4 mg Tablet2Generic25%25%None
TIZANIDINE HYDROCHLORIDE 2 mg Capsule2Generic25%25%None
TIZANIDINE HYDROCHLORIDE 4 mg Capsule2Generic25%25%None
TIZANIDINE HYDROCHLORIDE 6 mg Capsule2Generic25%25%None
TOBI PODHALER 28 mg CapsuleTobramycin5Specialty Tier25%25%
  • PA
  • QL 224 per 56 days
TOBRADEX 3/1 mg/g OintmentTobramycin And Dexamethasone3Preferred Brand25%25%None
TOBRADEX ST 3/.5 mg/mL Suspension/ DropsTobramycin / Dexamethasone3Preferred Brand25%25%None
TOBRAMYCIN 10 mg/mL Injection, SolutionTobramycin Sulfate1Preferred Generic25%25%None
TOBRAMYCIN 3 mg/mL Solution/ Drops1Preferred Generic25%25%None
TOBRAMYCIN 300 mg/4mL Solution5Specialty Tier25%25%
  • PA
TOBRAMYCIN 300 mg/5mL Solution5Specialty Tier25%25%
  • PA
TOBRAMYCIN 40 mg/mL Injection, SolutionTobramycin Sulfate1Preferred Generic25%25%None
TOBRAMYCIN AND DEXAMETHASONE 3/1 mg/mL Suspension/ Drops2Generic25%25%None
TOBREX 3 mg/g OintmentTobramycin3Preferred Brand25%25%None
TOLCAPONE 100 mg Tablet5Specialty Tier25%25%None
TOLTERODINE TARTRATE 1 mg Tablet, Film Coated3Preferred Brand25%25%
  • QL 62 per 31 days
TOLTERODINE TARTRATE 2 mg Capsule, Extended Release3Preferred Brand25%25%
  • QL 31 per 31 days
TOLTERODINE TARTRATE 2 mg Tablet, Film Coated3Preferred Brand25%25%
  • QL 62 per 31 days
TOLTERODINE TARTRATE 4 mg Capsule, Extended Release3Preferred Brand25%25%
  • QL 31 per 31 days
TOLVAPTAN 15 mg Tablet5Specialty Tier25%25%
  • PA
TOLVAPTAN 15 mg Tablet5Specialty Tier25%25%
  • PA
  • QL 112 per 28 days
TOLVAPTAN 30 mg Tablet5Specialty Tier25%25%
  • PA
TOLVAPTAN 30 mg Tablet5Specialty Tier25%25%
  • PA
  • QL 112 per 28 days
TOLVAPTAN Kit5Specialty Tier25%25%
  • PA
  • QL 56 per 28 days
TOLVAPTAN Kit5Specialty Tier25%25%
  • PA
  • QL 56 per 28 days
TOLVAPTAN Kit5Specialty Tier25%25%
  • PA
  • QL 56 per 28 days
TOLVAPTAN Kit5Specialty Tier25%25%
  • PA
  • QL 56 per 28 days
TOLVAPTAN Kit5Specialty Tier25%25%
  • PA
  • QL 56 per 28 days
TOPIRAMATE 100 mg Capsule, Extended Release4Non-Preferred Drug25%25%None
TOPIRAMATE 100 mg Tablet, Film Coated2Generic25%25%None
TOPIRAMATE 15 mg Capsule, Coated Pellets2Generic25%25%None
TOPIRAMATE 200 mg Capsule, Extended Release5Specialty Tier25%25%None
TOPIRAMATE 200 mg Tablet2Generic25%25%None
TOPIRAMATE 25 mg Capsule, Coated Pellets2Generic25%25%None
TOPIRAMATE 25 mg Capsule, Extended Release4Non-Preferred Drug25%25%None
TOPIRAMATE 25 mg Tablet, Film Coated2Generic25%25%None
TOPIRAMATE 25 mg/mL Solution4Non-Preferred Drug25%25%
  • PA
  • QL 496 per 31 days
TOPIRAMATE 50 mg Capsule, Extended Release4Non-Preferred Drug25%25%None
TOPIRAMATE 50 mg Tablet, Film Coated2Generic25%25%None
TOREMIFENE CITRATE 60 mg Tablet4Non-Preferred Drug25%25%None
TORSEMIDE 10 mg Tablet1Preferred Generic25%25%None
TORSEMIDE 100 mg Tablet1Preferred Generic25%25%None
TORSEMIDE 20 mg Tablet1Preferred Generic25%25%None
TORSEMIDE 5 mg Tablet1Preferred Generic25%25%None
TOUJEO 300 U/mL Injection, SolutionInsulin Glargine3Preferred Brand25%25%None
TOUJEO MAX 300 U/mL Injection, SolutionInsulin Glargine3Preferred Brand25%25%None
TOVET (EMOLLIENT FORMULATION) .5 mg/g Aerosol, FoamClobetasol Propionate3Preferred Brand25%25%
  • QL 1 per 28 days
TRADJENTA 5 mg Tablet, Film CoatedLinagliptin3Preferred Brand25%25%
  • QL 31 per 31 days
TRAMADOL HYDROCHLORIDE 100 mg Tablet, Coated4Non-Preferred Drug25%25%
  • PA
  • QL 124 per 31 days
TRAMADOL HYDROCHLORIDE 25 mg Tablet, Coated4Non-Preferred Drug25%25%
  • PA
  • QL 496 per 31 days
TRAMADOL HYDROCHLORIDE 50 mg Tablet, Coated2Generic25%25%
  • PA
  • QL 24 per 30 days
TRAMADOL HYDROCHLORIDE 75 mg Tablet, Coated4Non-Preferred Drug25%25%
  • PA
  • QL 155 per 31 days
TRAMADOL HYDROCHLORIDE AND ACETAMINOPHEN 37.5/325 mg Tablet2Generic25%25%
  • PA
  • QL 372 per 31 days
TRANDOLAPRIL 1 mg Tablet1Preferred Generic25%25%None
TRANDOLAPRIL 2 mg Tablet1Preferred Generic25%25%None
TRANDOLAPRIL 4 mg Tablet1Preferred Generic25%25%None
TRANEXAMIC ACID 650 mg Tablet2Generic25%25%None
TRANYLCYPROMINE 10 mg Tablet2Generic25%25%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 Drug25%25%
  • PA
TRAVOPROST OPHTHALMIC .04 mg/mL SolutionTravoprost Ophthalmic Solution3Preferred Brand25%25%None
TRAZODONE HYDROCHLORIDE 100 mg Tablet1Preferred Generic25%25%None
TRAZODONE HYDROCHLORIDE 150 mg Tablet1Preferred Generic25%25%None
TRAZODONE HYDROCHLORIDE 300 mg Tablet2Generic25%25%None
TRAZODONE HYDROCHLORIDE 50 mg Tablet1Preferred Generic25%25%None
TRELEGY ELLIPTA 100/62.5/25 ug PowderFluticasone Furoate, Umeclidinium Bromide And Vilanterol Trifenatate3Preferred Brand25%25%
  • QL 6 per 30 days
TRELEGY ELLIPTA 200/62.5/25 ug PowderFluticasone Furoate, Umeclidinium Bromide And Vilanterol Trifenatate3Preferred Brand25%25%
  • QL 6 per 30 days
TRELSTAR KitTriptorelin Pamoate4Non-Preferred Drug25%25%
  • ST
  • QL 1 per 28 days
TRELSTAR KitTriptorelin Pamoate4Non-Preferred Drug25%25%
  • ST
  • QL 1 per 84 days
TRELSTAR KitTriptorelin Pamoate4Non-Preferred Drug25%25%
  • ST
  • QL 1 per 168 days
TRESIBA 100 U/mL Injection, SolutionInsulin Degludec3Preferred Brand25%25%None
TRESIBA 100 U/mL Injection, SolutionInsulin Degludec3Preferred Brand25%25%None
TRESIBA 200 U/mL Injection, SolutionInsulin Degludec3Preferred Brand25%25%None
TRETINOIN .05 g/100g Gel3Preferred Brand25%25%
  • PA
  • QL 45 per 28 days
TRETINOIN .1 mg/g Gel2Generic25%25%
  • PA
  • QL 45 per 28 days
TRETINOIN .25 mg/g Cream2Generic25%25%
  • PA
  • QL 45 per 28 days
TRETINOIN .25 mg/g Gel2Generic25%25%
  • PA
  • QL 45 per 28 days
TRETINOIN .5 mg/g Cream2Generic25%25%
  • PA
  • QL 45 per 28 days
TRETINOIN 1 mg/g Cream2Generic25%25%
  • PA
  • QL 45 per 28 days
TRETINOIN 10 mg Capsule5Specialty Tier25%25%None
TREXALL 10 mg Tablet, Film CoatedMethotrexate3Preferred Brand25%25%
  • PA
TREXALL 15 mg Tablet, Film CoatedMethotrexate3Preferred Brand25%25%
  • PA
TREXALL 5 mg Tablet, Film CoatedMethotrexate3Preferred Brand25%25%
  • PA
TREXALL 7.5 mg Tablet, Film CoatedMethotrexate3Preferred Brand25%25%
  • PA
TRI-ESTARYLLA KitNorgestimate And Ethinyl Estradiol2Generic25%25%None
TRI-MILI KitNorgestimate And Ethinyl Estradiol2Generic25%25%None
TRI-SPRINTEC KitNorgestimate And Ethinyl Estradiol2Generic25%25%None
TRI-VYLIBRA KitNorgestimate And Ethinyl Estradiol2Generic25%25%None
TRIAMCINOLONE ACETONIDE .25 mg/g Cream1Preferred Generic25%25%None
TRIAMCINOLONE ACETONIDE .25 mg/g Ointment1Preferred Generic25%25%None
TRIAMCINOLONE ACETONIDE .25 mg/mL Lotion1Preferred Generic25%25%None
TRIAMCINOLONE ACETONIDE .5 mg/g Ointment4Non-Preferred Drug25%25%None
TRIAMCINOLONE ACETONIDE 1 mg/g Cream1Preferred Generic25%25%None
TRIAMCINOLONE ACETONIDE 1 mg/g Ointment1Preferred Generic25%25%None
TRIAMCINOLONE ACETONIDE 1 mg/g Paste2Generic25%25%None
TRIAMCINOLONE ACETONIDE 1 mg/mL Lotion1Preferred Generic25%25%None
TRIAMCINOLONE ACETONIDE 5 mg/g Cream1Preferred Generic25%25%None
TRIAMCINOLONE ACETONIDE 5 mg/g Ointment1Preferred Generic25%25%None
TRIAMTERENE 100 mg Capsule4Non-Preferred Drug25%25%None
TRIAMTERENE 50 mg Capsule4Non-Preferred Drug25%25%None
TRIAMTERENE AND HYDROCHLOROTHIAZIDE 37.5/25 mg Tablet1Preferred Generic25%25%None
TRIAMTERENE AND HYDROCHLOROTHIAZIDE 75/50 mg Tablet1Preferred Generic25%25%None
TRIAZOLAM .125 mg Tablet4Non-Preferred Drug25%25%
  • PA
TRIAZOLAM .25 mg Tablet4Non-Preferred Drug25%25%
  • PA
TRIDERM 5 mg/g CreamTriamcinolone Acetonide1Preferred Generic25%25%None
TRIENTINE HYDROCHLORIDE 250 mg Capsule5Specialty Tier25%25%
  • QL 248 per 31 days
TRIFLUOPERAZINE HYDROCHLORIDE 1 mg Tablet, Film Coated2Generic25%25%None
TRIFLUOPERAZINE HYDROCHLORIDE 10 mg Tablet, Film Coated2Generic25%25%None
TRIFLUOPERAZINE HYDROCHLORIDE 2 mg Tablet, Film Coated2Generic25%25%None
TRIFLUOPERAZINE HYDROCHLORIDE 5 mg Tablet, Film Coated2Generic25%25%None
TRIFLURIDINE 10 mg/mL Solution2Generic25%25%None
TRIHEXYPHENIDYL HYDROCHLORIDE 2 mg Tablet2Generic25%25%None
TRIHEXYPHENIDYL HYDROCHLORIDE 2 mg/5mL Solution2Generic25%25%None
TRIHEXYPHENIDYL HYDROCHLORIDE 5 mg Tablet2Generic25%25%None
TRIJARDY XR 10/5/1000 mg Tablet, Extended ReleaseEmpagliflozin, Linagliptin, Metformin Hydrochloride3Preferred Brand25%25%
  • QL 31 per 31 days
TRIJARDY XR 12.5/2.5/1000 mg Tablet, Extended ReleaseEmpagliflozin, Linagliptin, Metformin Hydrochloride3Preferred Brand25%25%
  • QL 62 per 31 days
TRIJARDY XR 25/5/1000 mg Tablet, Extended ReleaseEmpagliflozin, Linagliptin, Metformin Hydrochloride3Preferred Brand25%25%
  • QL 31 per 31 days
TRIJARDY XR 5/2.5/1000 mg Tablet, Extended ReleaseEmpagliflozin, Linagliptin, Metformin Hydrochloride3Preferred Brand25%25%
  • QL 62 per 31 days
TRIKAFTA KitElexacaftor, Tezacaftor, And Ivacaftor5Specialty Tier25%25%
  • PA
  • QL 84 per 28 days
TRIKAFTA KitElexacaftor, Tezacaftor, And Ivacaftor5Specialty Tier25%25%
  • PA
  • QL 84 per 28 days
TRIKAFTA KitElexacaftor, Tezacaftor, And Ivacaftor5Specialty Tier25%25%
  • PA
  • QL 56 per 28 days
TRIKAFTA KitElexacaftor, Tezacaftor, And Ivacaftor5Specialty Tier25%25%
  • PA
  • QL 56 per 28 days
TRIMETHOPRIM 100 mg Tablet2Generic25%25%None
TRIMIPRAMINE 100 mg Capsule3Preferred Brand25%25%
  • PA
TRIMIPRAMINE 25 mg Capsule3Preferred Brand25%25%
  • PA
TRIMIPRAMINE 50 mg Capsule3Preferred Brand25%25%
  • PA
TRINTELLIX 10 mg Tablet, Film CoatedVortioxetine3Preferred Brand25%25%
  • PA
TRINTELLIX 20 mg Tablet, Film CoatedVortioxetine3Preferred Brand25%25%
  • PA
TRINTELLIX 5 mg Tablet, Film CoatedVortioxetine3Preferred Brand25%25%
  • PA
TRIUMEQ 600/50/300 mg Tablet, Film CoatedAbacavir Sulfate, Dolutegravir Sodium, Lamivudine5Specialty Tier25%25%None
TRIUMEQ PD KitAbacavir Sulfate, Dolutegravir Sodium, Lamivudine4Non-Preferred Drug25%25%
  • QL 186 per 31 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 Drug25%25%
  • PA
TROSPIUM CHLORIDE 20 mg Tablet, Film Coated2Generic25%25%
  • QL 93 per 31 days
TROSPIUM CHLORIDE 60 mg Capsule, Extended Release4Non-Preferred Drug25%25%
  • QL 31 per 31 days
TRULICITY .75 mg/.5mL Injection, SolutionDulaglutide3Preferred Brand25%25%
  • PA
  • QL 2 per 28 days
TRULICITY 1.5 mg/.5mL Injection, SolutionDulaglutide3Preferred Brand25%25%
  • PA
  • QL 2 per 28 days
TRULICITY 3 mg/.5mL Injection, SolutionDulaglutide3Preferred Brand25%25%
  • PA
  • QL 2 per 28 days
TRULICITY 4.5 mg/.5mL Injection, SolutionDulaglutide3Preferred Brand25%25%
  • PA
  • QL 2 per 28 days
TRUMENBA 60/60 ug/.5mL Injection, SuspensionMeningococcal Group B Vaccine3Preferred Brand25%25%None
TRUQAP 200 mg Tablet, Film CoatedCapivasertib5Specialty Tier25%25%
  • PA
  • QL 64 per 28 days
TUKYSA 150 mg TabletTucatinib5Specialty Tier25%25%
  • PA
  • QL 124 per 31 days
TUKYSA 50 mg TabletTucatinib5Specialty Tier25%25%
  • PA
  • QL 248 per 31 days
TURALIO 125 mg CapsulePexidartinib Hydrochloride5Specialty Tier25%25%
  • PA
  • QL 124 per 31 days
TURQOZ KitNorgestrel And Ethinyl Estradiol2Generic25%25%None
TWINRIX 720/20 [iU]/mL/ug/mL Injection, SuspensionHepatitis A And Hepatitis B (Recombinant) Vaccine3Preferred Brand25%25%None
TYBOST 150 mg Tablet, Film CoatedCobicistat3Preferred Brand25%25%None
TYMLOS 3.12 mg/1.56mL Injection, SolutionAbaloparatide5Specialty Tier25%25%
  • PA
  • QL 1.56 per 30 days
TYPHIM VI 25 ug/.5mL Injection, SolutionSalmonella Typhi Ty2 Vi Polysaccharide Antigen3Preferred Brand25%25%None
TYPHIM VI 25 ug/.5mL Injection, SolutionSalmonella Typhi Ty2 Vi Polysaccharide Antigen3Preferred Brand25%25%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.