2009 Medicare Part D Plan Formulary Information |
SierraRx Basic (S5917-010-0)
Benefit Details
|
The SierraRx Basic (S5917-010-0) Formulary Drugs Starting with the Letter T in CMS PDP Region 5 which includes: DC DE MD
|
Drugs Starting with Letter T
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
TAMIFLU 30MG CAPSULE |
2 |
Tier 2 |
25% | 25% | Q:28 /30Days |
TAMIFLU 45MG CAPSULE |
2 |
Tier 2 |
25% | 25% | Q:14 /30Days |
TAMIFLU 75MG CAPSULE UD |
2 |
Tier 2 |
25% | 25% | Q:28 /30Days |
TAMIFLU ORAL SUSPENSION |
2 |
Tier 2 |
25% | 25% | Q:100 /60Days |
TAMOXIFEN CITRATE 10MG TABLET (180 CT) |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
TAMOXIFEN CITRATE 20MG TABLET (30 CT) |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
TARCEVA 100MG TABLET |
3 |
Tier 3 |
25% | 25% | P |
TARCEVA 150MG TABLET |
3 |
Tier 3 |
25% | 25% | P |
TARCEVA 25MG TABLET |
3 |
Tier 3 |
25% | 25% | P |
TARGRETIN 1% GEL 60GM TUBE |
2 |
Tier 2 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TARGRETIN 75MG (100 CT) |
3 |
Tier 3 |
25% | 25% | P |
TASIGNA 200MG CAPSULE 28 BLPK |
3 |
Tier 3 |
25% | 25% | P |
TAZICEF 1GM ADD-VANTAGE |
1 |
Tier 1 |
25% | 25% | Q:84 /60Days |
TAZICEF 1GM VIAL |
1 |
Tier 1 |
25% | 25% | Q:84 /60Days |
TAZICEF 2GM ADD-VANTAGE |
1 |
Tier 1 |
25% | 25% | Q:42 /60Days |
TAZICEF 2GM VIAL |
1 |
Tier 1 |
25% | 25% | Q:42 /60Days |
TAZICEF 6GM/100ML VIAL |
1 |
Tier 1 |
25% | 25% | Q:14 /60Days |
TAZTIA XT 120MG CAPSULE SA (500 CT) |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
TAZTIA XT 180MG CAPSULE SA (500 CT) |
1 |
Tier 1 |
25% | 25% | Q:90 /30Days |
TAZTIA XT 240MG CAPSULE SA |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
TAZTIA XT 300MG CAPSULE SA (500 CT) |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAZTIA XT 360MG CAPSULE SA |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
TEGRETOL 100MG TABLET CHEW |
2 |
Tier 2 |
25% | 25% | None |
TEGRETOL 100MG/5ML SUSP |
2 |
Tier 2 |
25% | 25% | None |
TEGRETOL 200MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
TEGRETOL XR 100MG SA TABLET |
2 |
Tier 2 |
25% | 25% | Q:120 /30Days |
TEGRETOL XR 200MG SA TABLET |
2 |
Tier 2 |
25% | 25% | Q:120 /30Days |
TEGRETOL XR 400MG SA TABLET |
2 |
Tier 2 |
25% | 25% | Q:120 /30Days |
TEKTURNA 150MG TABLET |
2 |
Tier 2 |
25% | 25% | S Q:30 /30Days |
TEKTURNA 300MG TABLET |
2 |
Tier 2 |
25% | 25% | S Q:30 /30Days |
TEKTURNA HCT 150-12.5MG TABLET |
2 |
Tier 2 |
25% | 25% | S Q:30 /30Days |
TEKTURNA HCT 150MG-25MG TABLET |
2 |
Tier 2 |
25% | 25% | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TEKTURNA HCT 300-12.5MG TABLET |
2 |
Tier 2 |
25% | 25% | S Q:30 /30Days |
TEKTURNA HCT 300MG-25MG TABLET |
2 |
Tier 2 |
25% | 25% | S Q:30 /30Days |
TERAZOSIN HCL 10MG CAPSULE |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
TERAZOSIN HCL 1MG CAPSULE |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
TERAZOSIN HCL 2MG CAPSULE |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
TERAZOSIN HCL 5MG CAPSULE |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
TERBINAFINE HCL 250MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:90 /365Days |
TERBUTALINE SULF 2.5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
TERBUTALINE SULFATE 5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
TERCONAZOLE 0.4% CREAM WITH APPLICATOR |
1 |
Tier 1 |
25% | 25% | None |
TERCONAZOLE 0.8% CREAM WITH APPLICATOR |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TESTOSTERONE CYPIONATE INJECTION |
1 |
Tier 1 |
25% | 25% | None |
TESTOSTERONE CYPIONATE INJECTION 200MG 1 X 10ML VIALMD |
1 |
Tier 1 |
25% | 25% | None |
TETANUS AND DIPHTHERIA TOXOIDS ADSORBED FOR ADULT USE 2 UNT/VIAL |
2 |
Tier 2 |
25% | 25% | None |
TETANUS TOXOID ADSORBED VIAL 5LF |
2 |
Tier 2 |
25% | 25% | None |
TETRACYCLINE 500MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
TETRACYCLINE HCL 250MG CAPSULE (1000 CT) |
1 |
Tier 1 |
25% | 25% | None |
TEV-TROPIN 5MG VIAL |
3 |
Tier 3 |
25% | 25% | P |
THALOMID 100MG CAPSULE 140 BOX |
3 |
Tier 3 |
25% | 25% | P |
THALOMID 150MG CAPSULE |
3 |
Tier 3 |
25% | 25% | P |
THALOMID 200MG CAPSULE 28 BLPK |
3 |
Tier 3 |
25% | 25% | P |
THALOMID 50MG CAPSULE 280 BOX |
3 |
Tier 3 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THEOCHRON 100MG TABLET SA |
1 |
Tier 1 |
25% | 25% | None |
THEOCHRON 100MG TABLET SA |
1 |
Tier 1 |
25% | 25% | None |
THEOCHRON 200MG TABLET SA |
1 |
Tier 1 |
25% | 25% | None |
THEOCHRON 300MG TABLET SA |
1 |
Tier 1 |
25% | 25% | None |
THEOCHRON 450MG TABLET SA |
1 |
Tier 1 |
25% | 25% | None |
THEOPHYLLINE 100MG TABLET SA |
1 |
Tier 1 |
25% | 25% | None |
THEOPHYLLINE 100MG TABLET SA |
1 |
Tier 1 |
25% | 25% | None |
THEOPHYLLINE 200MG TABLET SA |
1 |
Tier 1 |
25% | 25% | None |
THEOPHYLLINE 200MG TABLET SA U.D. |
1 |
Tier 1 |
25% | 25% | None |
THEOPHYLLINE 300MG TABLET SA |
1 |
Tier 1 |
25% | 25% | None |
THEOPHYLLINE 300MG TABLET SA U.D. |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THEOPHYLLINE ANHYDROUS ER TABLET 200MG (1000 CT) |
1 |
Tier 1 |
25% | 25% | None |
THEOPHYLLINE TABLET ER 300MG (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
THEOPHYLLINE TABLET ER 450MG (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
THERMAZENE 50GM CREAM |
1 |
Tier 1 |
25% | 25% | None |
THIOGUANINE TABLET LOID 40MG |
2 |
Tier 2 |
25% | 25% | P |
THIORIDAZINE 100MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
THIORIDAZINE HCL 10MG TABLET (1000 CT) |
1 |
Tier 1 |
25% | 25% | None |
THIORIDAZINE HCL 25MG TABLET (1000 CT) |
1 |
Tier 1 |
25% | 25% | None |
THIORIDAZINE HCL 50MG TABLET (1000 CT) |
1 |
Tier 1 |
25% | 25% | None |
THIOTHIXENE 10MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
THIOTHIXENE 1MG CAPSULE (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THIOTHIXENE 2MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
THIOTHIXENE 5MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
THYMOGLOBULIN 25MG VIAL |
3 |
Tier 3 |
25% | 25% | P |
TICLOPIDINE HCL 250MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
TIKOSYN .125MG CAPSULE |
2 |
Tier 2 |
25% | 25% | Q:60 /30Days |
TIKOSYN .250MG CAPSULE |
2 |
Tier 2 |
25% | 25% | Q:60 /30Days |
TIKOSYN .5MG CAPSULE |
2 |
Tier 2 |
25% | 25% | Q:60 /30Days |
TIMOLOL 0.25% GEL/SOLUTION |
1 |
Tier 1 |
25% | 25% | None |
TIMOLOL 0.5% GEL/SOLUTION |
1 |
Tier 1 |
25% | 25% | None |
TIMOLOL MAL SOL 0.25% OP 15ML BOT |
1 |
Tier 1 |
25% | 25% | None |
TIMOLOL MAL SOL 0.5% OP 10ML BOT |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIMOLOL MALEATE 10MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:90 /30Days |
TIMOLOL MALEATE 20MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:90 /30Days |
TIMOLOL MALEATE 5MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:90 /30Days |
TIZANIDINE HCL 2MG TABLET (150 CT) |
1 |
Tier 1 |
25% | 25% | None |
TIZANIDINE HCL 4MG TABLET 150 BOT |
1 |
Tier 1 |
25% | 25% | None |
TOBRAMYCIN 10MG/ML VIAL |
1 |
Tier 1 |
25% | 25% | Q:280 /30Days |
TOBRAMYCIN 40MG/ML VIAL |
1 |
Tier 1 |
25% | 25% | Q:280 /30Days |
TOBRAMYCIN INHALATION SOLUTION |
3 |
Tier 3 |
25% | 25% | P |
TOBRAMYCIN INJECTION SOLUTION 40MG 10 X 30ML VIAL |
1 |
Tier 1 |
25% | 25% | Q:280 /30Days |
TOBRAMYCIN OPHTHALMIC SOLUTION 0.3% 5ML BOT |
1 |
Tier 1 |
25% | 25% | None |
TOBRAMYCIN SULFATE |
1 |
Tier 1 |
25% | 25% | Q:280 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOBRASOL 0.3% EYE DROPS |
1 |
Tier 1 |
25% | 25% | None |
TOBREX 0.3% EYE OINTMENT |
2 |
Tier 2 |
25% | 25% | Q:3 /30Days |
TOLMETIN SODIUM 200MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:90 /30Days |
TOLMETIN SODIUM 400MG CAPSULE |
1 |
Tier 1 |
25% | 25% | Q:120 /30Days |
TOLMETIN SODIUM 600MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:90 /30Days |
TOPAMAX 100MG TABLET |
2 |
Tier 2 |
25% | 25% | P Q:90 /30Days |
TOPAMAX 15MG SPRINKLE CAP |
2 |
Tier 2 |
25% | 25% | P |
TOPAMAX 200MG TABLET |
2 |
Tier 2 |
25% | 25% | P Q:90 /30Days |
TOPAMAX 25MG SPRINKLE CAP |
2 |
Tier 2 |
25% | 25% | P |
TOPAMAX 25MG TABLET |
2 |
Tier 2 |
25% | 25% | P Q:90 /30Days |
TOPAMAX 50MG TABLET |
2 |
Tier 2 |
25% | 25% | P Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOPROL XL 100MG TABLET SA |
2 |
Tier 2 |
25% | 25% | None |
TOPROL XL 200MG TABLET SA |
2 |
Tier 2 |
25% | 25% | None |
TOPROL XL 25MG TABLET SA |
2 |
Tier 2 |
25% | 25% | None |
TOPROL XL 50MG TABLET SA |
2 |
Tier 2 |
25% | 25% | None |
TORSEMIDE 100MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
TORSEMIDE 10MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
TORSEMIDE 20MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
TORSEMIDE 5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
TPN ELECTROLYTES VIAL |
1 |
Tier 1 |
25% | 25% | None |
TRACLEER 125MG TABLET |
3 |
Tier 3 |
25% | 25% | P Q:60 /30Days |
TRACLEER 62.5MG TABLET |
3 |
Tier 3 |
25% | 25% | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRAMADOL HCL 50MG TABLET (500 CT) |
1 |
Tier 1 |
25% | 25% | Q:240 /30Days |
TRANDOLAPRIL 1MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
TRANDOLAPRIL 2MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
TRANDOLAPRIL 4MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
TRANSDERM-SCOP 1.5MG 24 PKG |
2 |
Tier 2 |
25% | 25% | Q:10 /30Days |
TRANYLCYPROMINE SULFATE 10MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
TRAVATAN 0.004% EYE DROP 2.5ML BOT |
2 |
Tier 2 |
25% | 25% | Q:5 /30Days |
TRAVATAN Z 0.04MG DROPS 2.5ML BOT |
2 |
Tier 2 |
25% | 25% | Q:5 /30Days |
TRAZODONE 300MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
TRAZODONE HCL TABLET USP 100MG (500 CT) |
1 |
Tier 1 |
25% | 25% | None |
TRAZODONE HCL TABLET USP 150MG (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRAZODONE HCL TABLET USP 50MG (500 CT) |
1 |
Tier 1 |
25% | 25% | None |
TRETINOIN 0.01% GEL 45GM TUBE |
1 |
Tier 1 |
25% | 25% | P Q:45 /30Days |
TRETINOIN 0.025% CREAM |
1 |
Tier 1 |
25% | 25% | P Q:45 /30Days |
TRETINOIN 0.025% GEL 45GM TUBE |
1 |
Tier 1 |
25% | 25% | P Q:45 /30Days |
TRETINOIN 0.025% GEL 45GM TUBE |
1 |
Tier 1 |
25% | 25% | P Q:45 /30Days |
TRETINOIN 0.05% CREAM 45GM TUBE |
1 |
Tier 1 |
25% | 25% | P Q:45 /30Days |
TRETINOIN 0.1% CREAM 45GM TUBE |
1 |
Tier 1 |
25% | 25% | P Q:45 /30Days |
TRETINOIN 10MG CAPSULE |
3 |
Tier 3 |
25% | 25% | None |
TRI-PREVIFEM 7DAYSX3 28 168 CRTN |
1 |
Tier 1 |
25% | 25% | Q:28 /28Days |
TRI-SPRINTEC 7DAYSX3 28 TABLET |
1 |
Tier 1 |
25% | 25% | Q:28 /28Days |
TRIAMCINOLONE 0.1% OINTMENT |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIAMCINOLONE 0.1% PASTE |
1 |
Tier 1 |
25% | 25% | None |
TRIAMCINOLONE ACETONIDE 0.025% OINTMENT 80GM TUBE |
1 |
Tier 1 |
25% | 25% | None |
TRIAMCINOLONE ACETONIDE 0.1% LOTION 60ML BOTPL |
1 |
Tier 1 |
25% | 25% | None |
TRIAMCINOLONE ACETONIDE 0.025% CREAM 80GM TUBE |
1 |
Tier 1 |
25% | 25% | None |
TRIAMCINOLONE ACETONIDE 0.025% LOTION 2 FL OZ BOT |
1 |
Tier 1 |
25% | 25% | None |
TRIAMCINOLONE ACETONIDE 0.05% CREAM 15GM TUBE |
1 |
Tier 1 |
25% | 25% | None |
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT |
1 |
Tier 1 |
25% | 25% | None |
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE |
1 |
Tier 1 |
25% | 25% | None |
TRIAMCINOLONE ACETONIDE 0.1% CREAM 80GM TUBE |
1 |
Tier 1 |
25% | 25% | None |
TRIAMTERENE/HCTZ 25/37.5MG CAPSULES (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
TRIAMTERENE/HCTZ 37.5/25 TABLET |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIAMTERENE/HCTZ 50/25 CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
TRIAMTERENE/HCTZ 75/50 TABLET |
1 |
Tier 1 |
25% | 25% | None |
TRICOR 145MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
TRICOR 48MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:60 /30Days |
TRIDERM 0.1% CREAM |
1 |
Tier 1 |
25% | 25% | None |
TRIDERM 0.1% OINTMENT |
1 |
Tier 1 |
25% | 25% | None |
TRIFLUOPERAZINE 1MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
TRIFLUOPERAZINE HCL 2MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
TRIFLUOPERAZINE HCL 5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIHEXYPHENIDYL HCL 5MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
TRIHEXYPHENIDYL HCL ELIXIR 5%/2 16 FLO BOT |
1 |
Tier 1 |
25% | 25% | None |
TRIHEXYPHENIDYL HCL TABLET 2MG (1000 CT) |
1 |
Tier 1 |
25% | 25% | None |
TRIHIBIT PRESERVATIVE FREE |
2 |
Tier 2 |
25% | 25% | None |
TRILEPTAL 150MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:60 /30Days |
TRILEPTAL 300MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:90 /30Days |
TRILEPTAL 300MG/5ML SUSP |
2 |
Tier 2 |
25% | 25% | Q:1200 /30Days |
TRILEPTAL 600MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:120 /30Days |
TRILYTE WITH FLAVOR PACKETS 5.72GM/11.2GM |
1 |
Tier 1 |
25% | 25% | Q:4000 /30Days |
TRIMETHOBENZAMIDE HCL 300MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
TRIMETHOPRIM 100MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIMIPRAMINE MALEATE 25MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
TRIMIPRAMINE MALEATE 50MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
TRIMOX CAP 500MG |
1 |
Tier 1 |
25% | 25% | None |
TRINESSA 7DAYSX3 28 TABLET |
1 |
Tier 1 |
25% | 25% | Q:28 /28Days |
TRIPEDIA PRESERVATIVE FREE 6.7;23.4; UNT/.5 ML; |
2 |
Tier 2 |
25% | 25% | None |
TRIPLE ANTIBIOTIC EYE OINT |
1 |
Tier 1 |
25% | 25% | Q:3 /30Days |
TRISENOX 10MG/10ML AMPULE |
3 |
Tier 3 |
25% | 25% | P |
TRIVORA-28 TABLET |
1 |
Tier 1 |
25% | 25% | Q:28 /28Days |
TRIZIVIR TABLET |
3 |
Tier 3 |
25% | 25% | Q:60 /30Days |
TROPICACYL SOL 0.5% OP |
1 |
Tier 1 |
25% | 25% | None |
TROPICACYL SOL 1% OP |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TROPICAMIDE 0.5% EYE DROPS |
1 |
Tier 1 |
25% | 25% | None |
TROPICAMIDE 1% EYE DROPS |
1 |
Tier 1 |
25% | 25% | None |
TRUSOPT PLUS 2% EYE DROPS 10ML BOT |
2 |
Tier 2 |
25% | 25% | Q:10 /30Days |
TRUVADA TABLET |
3 |
Tier 3 |
25% | 25% | Q:30 /30Days |
TWINJECT 0.15MG AUTO-INJECTOR |
2 |
Tier 2 |
25% | 25% | None |
TWINJECT 0.3MG AUTO-INJECTOR |
2 |
Tier 2 |
25% | 25% | None |
TWINRIX TF PF VACCINE 720UNT/20ML 10 X 1ML VIALSD |
2 |
Tier 2 |
25% | 25% | None |
TYGACIL 50MG VIAL 10 VILSU BOX |
3 |
Tier 3 |
25% | 25% | P Q:28 /30Days |
TYKERB 250MG TABLET |
3 |
Tier 3 |
25% | 25% | P |
TYPHIM VI 25MCG/0.5ML VIAL |
2 |
Tier 2 |
25% | 25% | None |
TYZEKA 600MG TABLET (30 CT) |
2 |
Tier 2 |
25% | 25% | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TYZINE 0.1% NOSE DROPS |
2 |
Tier 2 |
25% | 25% | None |