2009 Medicare Part D Plan Formulary Information |
First Health Part D-Premier (S5768-048-0)
Benefit Details
|
The First Health Part D-Premier (S5768-048-0) Formulary Drugs Starting with the Letter T in CMS PDP Region 26 which includes: NM
|
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 |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | Q:10 /5Days |
TAMIFLU 45MG CAPSULE |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | Q:10 /5Days |
TAMIFLU 75MG CAPSULE UD |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | Q:56 /365Days |
TAMIFLU ORAL SUSPENSION |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | None |
TAMOXIFEN CITRATE 10MG TABLET (180 CT) |
1 |
Preferred Generic |
$7.00 | N/A | None |
TAMOXIFEN CITRATE 20MG TABLET (30 CT) |
1 |
Preferred Generic |
$7.00 | N/A | None |
TARCEVA 100MG TABLET |
4 |
Specialty-Generic and Brand |
33% | N/A | P Q:30 /30Days |
TARCEVA 150MG TABLET |
4 |
Specialty-Generic and Brand |
33% | N/A | P Q:30 /30Days |
TARCEVA 25MG TABLET |
4 |
Specialty-Generic and Brand |
33% | N/A | P Q:30 /30Days |
TARGRETIN 1% GEL 60GM TUBE |
4 |
Specialty-Generic and Brand |
33% | N/A | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TARGRETIN 75MG (100 CT) |
4 |
Specialty-Generic and Brand |
33% | N/A | P |
TARKA 1/240MG TABLET SA |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | Q:60 /30Days |
TARKA 2/180MG TABLET SA |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | Q:60 /30Days |
TARKA 2/240MG TABLET SA |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | Q:60 /30Days |
TARKA 4/240MG TABLET SA |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | Q:60 /30Days |
TASIGNA 200MG CAPSULE 28 BLPK |
4 |
Specialty-Generic and Brand |
33% | N/A | P Q:120 /30Days |
TASMAR 100MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | None |
TASMAR 200MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | None |
TAXOTERE 20MG/0.5ML VIAL |
4 |
Specialty-Generic and Brand |
33% | N/A | P |
TAXOTERE 80MG/2ML VIAL |
4 |
Specialty-Generic and Brand |
33% | N/A | P |
TAZORAC 0.05% CREAM |
2 |
Preferred Brand |
$29.00 | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAZORAC 0.05% GEL |
2 |
Preferred Brand |
$29.00 | N/A | Q:30 /30Days |
TAZORAC 0.1% CREAM |
2 |
Preferred Brand |
$29.00 | N/A | Q:30 /30Days |
TAZORAC 0.1% GEL |
2 |
Preferred Brand |
$29.00 | N/A | Q:30 /30Days |
TAZTIA XT 120MG CAPSULE SA (500 CT) |
1 |
Preferred Generic |
$7.00 | N/A | None |
TAZTIA XT 180MG CAPSULE SA (500 CT) |
1 |
Preferred Generic |
$7.00 | N/A | None |
TAZTIA XT 240MG CAPSULE SA |
1 |
Preferred Generic |
$7.00 | N/A | None |
TAZTIA XT 300MG CAPSULE SA (500 CT) |
1 |
Preferred Generic |
$7.00 | N/A | None |
TAZTIA XT 360MG CAPSULE SA |
1 |
Preferred Generic |
$7.00 | N/A | None |
TEGRETOL 100MG TABLET CHEW |
2 |
Preferred Brand |
$29.00 | N/A | None |
TEGRETOL 100MG/5ML SUSP |
2 |
Preferred Brand |
$29.00 | N/A | None |
TEGRETOL 200MG TABLET |
2 |
Preferred Brand |
$29.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TEGRETOL XR 100MG SA TABLET |
2 |
Preferred Brand |
$29.00 | N/A | None |
TEGRETOL XR 200MG SA TABLET |
2 |
Preferred Brand |
$29.00 | N/A | None |
TEGRETOL XR 400MG SA TABLET |
2 |
Preferred Brand |
$29.00 | N/A | None |
TERAZOSIN HCL 10MG CAPSULE |
1 |
Preferred Generic |
$7.00 | N/A | None |
TERAZOSIN HCL 1MG CAPSULE |
1 |
Preferred Generic |
$7.00 | N/A | None |
TERAZOSIN HCL 2MG CAPSULE |
1 |
Preferred Generic |
$7.00 | N/A | None |
TERAZOSIN HCL 5MG CAPSULE |
1 |
Preferred Generic |
$7.00 | N/A | None |
TERBINAFINE HCL 250MG TABLET |
1 |
Preferred Generic |
$7.00 | N/A | None |
TERBUTALINE SULF 2.5MG TABLET |
1 |
Preferred Generic |
$7.00 | N/A | None |
TERBUTALINE SULFATE 5MG TABLET |
1 |
Preferred Generic |
$7.00 | N/A | None |
TERCONAZOLE 0.4% CREAM WITH APPLICATOR |
1 |
Preferred Generic |
$7.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TERCONAZOLE 0.8% CREAM WITH APPLICATOR |
1 |
Preferred Generic |
$7.00 | N/A | None |
TERCONAZOLE 80MG SUPPOSITORY VAGINAL |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | None |
TESTOSTERONE CYPIONATE INJECTION |
1 |
Preferred Generic |
$7.00 | N/A | None |
TESTOSTERONE CYPIONATE INJECTION 200MG 1 X 10ML VIALMD |
1 |
Preferred Generic |
$7.00 | N/A | None |
TESTOSTERONE ENANTHATE INJECTION |
1 |
Preferred Generic |
$7.00 | N/A | None |
TESTRED 10MG CAPSULE |
2 |
Preferred Brand |
$29.00 | N/A | P |
TETANUS AND DIPHTHERIA TOXOIDS ADSORBED FOR ADULT USE 2 UNT/VIAL |
2 |
Preferred Brand |
$29.00 | N/A | None |
TETANUS TOXOID ADSORBED VIAL 5LF |
2 |
Preferred Brand |
$29.00 | N/A | None |
TETRACYCLINE 500MG CAPSULE |
1 |
Preferred Generic |
$7.00 | N/A | None |
TETRACYCLINE HCL 250MG CAPSULE (1000 CT) |
1 |
Preferred Generic |
$7.00 | N/A | None |
TEV-TROPIN 5MG VIAL |
4 |
Specialty-Generic and Brand |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TEVETEN 400MG TILTAB |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | Q:60 /30Days |
TEVETEN 600MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | Q:30 /30Days |
TEVETEN HCT 600-12.5MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | Q:30 /30Days |
TEVETEN HCT 600-25MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | Q:30 /30Days |
TEXACORT 2.5% SOLUTION NON-ORAL |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | None |
THALITONE 15MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | None |
THALOMID 100MG CAPSULE 140 BOX |
4 |
Specialty-Generic and Brand |
33% | N/A | P Q:28 /28Days |
THALOMID 150MG CAPSULE |
4 |
Specialty-Generic and Brand |
33% | N/A | P Q:28 /28Days |
THALOMID 200MG CAPSULE 28 BLPK |
4 |
Specialty-Generic and Brand |
33% | N/A | P Q:28 /28Days |
THALOMID 50MG CAPSULE 280 BOX |
4 |
Specialty-Generic and Brand |
33% | N/A | P Q:28 /28Days |
THEO-24 100MG CAPSULE SA |
2 |
Preferred Brand |
$29.00 | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THEO-24 200MG CAPSULE SA |
2 |
Preferred Brand |
$29.00 | N/A | Q:30 /30Days |
THEO-24 300MG CAPSULE SA |
2 |
Preferred Brand |
$29.00 | N/A | Q:60 /30Days |
THEO-24 400MG CAPSULE SA |
2 |
Preferred Brand |
$29.00 | N/A | Q:30 /30Days |
THEOCHRON 100MG TABLET SA |
1 |
Preferred Generic |
$7.00 | N/A | None |
THEOPHYLLINE 100MG TABLET SA |
1 |
Preferred Generic |
$7.00 | N/A | None |
THEOPHYLLINE 200MG TABLET SA |
1 |
Preferred Generic |
$7.00 | N/A | None |
THEOPHYLLINE 300MG TABLET SA |
1 |
Preferred Generic |
$7.00 | N/A | None |
THEOPHYLLINE 400MG TABLET SA |
1 |
Preferred Generic |
$7.00 | N/A | None |
THEOPHYLLINE 600MG TABLET SA |
1 |
Preferred Generic |
$7.00 | N/A | None |
THEOPHYLLINE ANHYDROUS ER TABLET 200MG (1000 CT) |
1 |
Preferred Generic |
$7.00 | N/A | None |
THEOPHYLLINE TABLET ER 300MG (100 CT) |
1 |
Preferred Generic |
$7.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THEOPHYLLINE TABLET ER 450MG (100 CT) |
1 |
Preferred Generic |
$7.00 | N/A | None |
THIOGUANINE TABLET LOID 40MG |
2 |
Preferred Brand |
$29.00 | N/A | None |
THIOLA 100MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | None |
THIORIDAZINE 100MG TABLET |
1 |
Preferred Generic |
$7.00 | N/A | None |
THIORIDAZINE HCL 10MG TABLET (1000 CT) |
1 |
Preferred Generic |
$7.00 | N/A | None |
THIORIDAZINE HCL 25MG TABLET (1000 CT) |
1 |
Preferred Generic |
$7.00 | N/A | None |
THIORIDAZINE HCL 50MG TABLET (1000 CT) |
1 |
Preferred Generic |
$7.00 | N/A | None |
THIOTEPA 15MG VIAL |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | P |
THIOTHIXENE 10MG CAPSULE |
1 |
Preferred Generic |
$7.00 | N/A | None |
THIOTHIXENE 1MG CAPSULE (100 CT) |
1 |
Preferred Generic |
$7.00 | N/A | None |
THIOTHIXENE 2MG CAPSULE |
1 |
Preferred Generic |
$7.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THIOTHIXENE 5MG CAPSULE |
1 |
Preferred Generic |
$7.00 | N/A | None |
THYMOGLOBULIN 25MG VIAL |
4 |
Specialty-Generic and Brand |
33% | N/A | P |
THYROLAR-1 60MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | None |
THYROLAR-1/2 30MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | None |
THYROLAR-1/4 15MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | None |
THYROLAR-2 120MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | None |
THYROLAR-3 180MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | None |
TICLOPIDINE HCL 250MG TABLET |
1 |
Preferred Generic |
$7.00 | N/A | None |
TIKOSYN .125MG CAPSULE |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | None |
TIKOSYN .250MG CAPSULE |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | None |
TIKOSYN .5MG CAPSULE |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIMOLIDE 10/25 TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | None |
TIMOLOL 0.25% GEL/SOLUTION |
1 |
Preferred Generic |
$7.00 | N/A | None |
TIMOLOL 0.5% GEL/SOLUTION |
1 |
Preferred Generic |
$7.00 | N/A | None |
TIMOLOL MAL SOL 0.25% OP 15ML BOT |
1 |
Preferred Generic |
$7.00 | N/A | None |
TIMOLOL MAL SOL 0.5% OP 10ML BOT |
1 |
Preferred Generic |
$7.00 | N/A | None |
TIMOLOL MALEATE 10MG TABLET |
1 |
Preferred Generic |
$7.00 | N/A | None |
TIMOLOL MALEATE 20MG TABLET |
1 |
Preferred Generic |
$7.00 | N/A | None |
TIMOLOL MALEATE 5MG TABLET |
1 |
Preferred Generic |
$7.00 | N/A | None |
TINDAMAX 250MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | None |
TINDAMAX 500MG TABLET (60 CT) |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | None |
TIZANIDINE HCL 2MG TABLET (150 CT) |
1 |
Preferred Generic |
$7.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIZANIDINE HCL 4MG TABLET 150 BOT |
1 |
Preferred Generic |
$7.00 | N/A | None |
TOBRADEX EYE OINTMENT |
2 |
Preferred Brand |
$29.00 | N/A | None |
TOBRADEX SUSPENSION OPHTHALMIC 0.1%/0.3% 5ML BOT |
2 |
Preferred Brand |
$29.00 | N/A | None |
TOBRAMYCIN 10MG/ML VIAL |
1 |
Preferred Generic |
$7.00 | N/A | None |
TOBRAMYCIN 10MG/ML VIAL |
1 |
Preferred Generic |
$7.00 | N/A | None |
TOBRAMYCIN FOR INJECTION 1.2MG/VIAL |
1 |
Preferred Generic |
$7.00 | N/A | None |
TOBRAMYCIN INHALATION SOLUTION |
4 |
Specialty-Generic and Brand |
33% | N/A | P Q:280 /28Days |
TOBRAMYCIN INJECTION SOLUTION 40MG 10 X 30ML VIAL |
1 |
Preferred Generic |
$7.00 | N/A | None |
TOBRAMYCIN OPHTHALMIC SOLUTION 0.3% 5ML BOT |
1 |
Preferred Generic |
$7.00 | N/A | None |
TOBRAMYCIN-DEXAMETH OPTH SUSP |
1 |
Preferred Generic |
$7.00 | N/A | None |
TOBRASOL 0.3% EYE DROPS |
1 |
Preferred Generic |
$7.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOBREX 0.3% EYE OINTMENT |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | None |
TOLAZAMIDE 250MG TABLET |
1 |
Preferred Generic |
$7.00 | N/A | None |
TOLAZAMIDE 500MG TABLET |
1 |
Preferred Generic |
$7.00 | N/A | None |
TOLBUTAMIDE 500MG TABLET |
1 |
Preferred Generic |
$7.00 | N/A | None |
TOLMETIN SODIUM 200MG TABLET |
1 |
Preferred Generic |
$7.00 | N/A | None |
TOLMETIN SODIUM 400MG CAPSULE |
1 |
Preferred Generic |
$7.00 | N/A | None |
TOLMETIN SODIUM 600MG TABLET |
1 |
Preferred Generic |
$7.00 | N/A | None |
TOPAMAX 100MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | P Q:90 /30Days |
TOPAMAX 15MG SPRINKLE CAP |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | P |
TOPAMAX 200MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | P Q:60 /30Days |
TOPAMAX 25MG SPRINKLE CAP |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOPAMAX 25MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | P Q:90 /30Days |
TOPAMAX 50MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | P Q:90 /30Days |
TOPIRAMATE TABLETS 100MG 1000 BOT |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | Q:90 /30Days |
TOPIRAMATE TABLETS 200MG 1000 BOT |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | Q:60 /30Days |
TOPIRAMATE TABLETS 25MG 1000 BOT |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | Q:90 /30Days |
TOPIRAMATE TABLETS 50MG 1000 BOT |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | Q:90 /30Days |
TOPROL XL 100MG TABLET SA |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | None |
TOPROL XL 200MG TABLET SA |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | None |
TOPROL XL 25MG TABLET SA |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | None |
TOPROL XL 50MG TABLET SA |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | None |
TORISEL SOL 25MG/ML |
4 |
Specialty-Generic and Brand |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TORSEMIDE 100MG TABLET |
1 |
Preferred Generic |
$7.00 | N/A | None |
TORSEMIDE 10MG TABLET |
1 |
Preferred Generic |
$7.00 | N/A | None |
TORSEMIDE 20MG TABLET |
1 |
Preferred Generic |
$7.00 | N/A | None |
TORSEMIDE 5MG TABLET |
1 |
Preferred Generic |
$7.00 | N/A | None |
TPN ELECTROLYTES VIAL |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | None |
TRACLEER 125MG TABLET |
4 |
Specialty-Generic and Brand |
33% | N/A | P Q:60 /30Days |
TRACLEER 62.5MG TABLET |
4 |
Specialty-Generic and Brand |
33% | N/A | P Q:60 /30Days |
TRAMADOL HCL 50MG TABLET (500 CT) |
1 |
Preferred Generic |
$7.00 | N/A | None |
TRAMADOL HCL-ACETAMINOPHEN 37.5-325MG TABLET (1000 CT) |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | None |
TRANDOLAPRIL 1MG TABLET |
1 |
Preferred Generic |
$7.00 | N/A | None |
TRANDOLAPRIL 2MG TABLET |
1 |
Preferred Generic |
$7.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRANDOLAPRIL 4MG TABLET |
1 |
Preferred Generic |
$7.00 | N/A | None |
TRANYLCYPROMINE SULFATE 10MG TABLET |
1 |
Preferred Generic |
$7.00 | N/A | None |
TRAVATAN 0.004% EYE DROP 2.5ML BOT |
2 |
Preferred Brand |
$29.00 | N/A | Q:5 /30Days |
TRAVATAN Z 0.04MG DROPS 2.5ML BOT |
2 |
Preferred Brand |
$29.00 | N/A | Q:5 /30Days |
TRAZODONE 300MG TABLET |
1 |
Preferred Generic |
$7.00 | N/A | None |
TRAZODONE HCL TABLET USP 100MG (500 CT) |
1 |
Preferred Generic |
$7.00 | N/A | None |
TRAZODONE HCL TABLET USP 150MG (100 CT) |
1 |
Preferred Generic |
$7.00 | N/A | None |
TRAZODONE HCL TABLET USP 50MG (500 CT) |
1 |
Preferred Generic |
$7.00 | N/A | None |
TREANDA FOR INJECTION 100MG/VIAL |
4 |
Specialty-Generic and Brand |
33% | N/A | P |
TRECATOR 250MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | None |
TRETINOIN 0.01% GEL 45GM TUBE |
1 |
Preferred Generic |
$7.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRETINOIN 0.025% CREAM |
1 |
Preferred Generic |
$7.00 | N/A | None |
TRETINOIN 0.025% GEL 45GM TUBE |
1 |
Preferred Generic |
$7.00 | N/A | None |
TRETINOIN 0.05% CREAM 45GM TUBE |
1 |
Preferred Generic |
$7.00 | N/A | None |
TRETINOIN 0.1% CREAM 45GM TUBE |
1 |
Preferred Generic |
$7.00 | N/A | None |
TRETINOIN 10MG CAPSULE |
4 |
Specialty-Generic and Brand |
33% | N/A | P |
TRI-LEGEST FE 5-7-9-7 TABLET |
1 |
Preferred Generic |
$7.00 | N/A | None |
TRI-PREVIFEM 7DAYSX3 28 168 CRTN |
1 |
Preferred Generic |
$7.00 | N/A | None |
TRI-SPRINTEC 7DAYSX3 28 TABLET |
1 |
Preferred Generic |
$7.00 | N/A | None |
TRIAMCINOLONE 0.1% OINTMENT |
1 |
Preferred Generic |
$7.00 | N/A | None |
TRIAMCINOLONE 0.1% PASTE |
1 |
Preferred Generic |
$7.00 | N/A | None |
TRIAMCINOLONE ACETONIDE 0.025% OINTMENT 80GM TUBE |
1 |
Preferred Generic |
$7.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIAMCINOLONE ACETONIDE 0.1% LOTION 60ML BOTPL |
1 |
Preferred Generic |
$7.00 | N/A | None |
TRIAMCINOLONE ACETONIDE 0.025% CREAM 80GM TUBE |
1 |
Preferred Generic |
$7.00 | N/A | None |
TRIAMCINOLONE ACETONIDE 0.025% LOTION 2 FL OZ BOT |
1 |
Preferred Generic |
$7.00 | N/A | None |
TRIAMCINOLONE ACETONIDE 0.05% CREAM 15GM TUBE |
1 |
Preferred Generic |
$7.00 | N/A | None |
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT |
1 |
Preferred Generic |
$7.00 | N/A | None |
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE |
1 |
Preferred Generic |
$7.00 | N/A | None |
TRIAMCINOLONE ACETONIDE 0.1% CREAM 80GM TUBE |
1 |
Preferred Generic |
$7.00 | N/A | None |
TRIAMTERENE/HCTZ 25/37.5MG CAPSULES (100 CT) |
1 |
Preferred Generic |
$7.00 | N/A | None |
TRIAMTERENE/HCTZ 37.5/25 TABLET |
1 |
Preferred Generic |
$7.00 | N/A | None |
TRIAMTERENE/HCTZ 50/25 CAPSULE |
1 |
Preferred Generic |
$7.00 | N/A | None |
TRIAMTERENE/HCTZ 75/50 TABLET |
1 |
Preferred Generic |
$7.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRICOR 145MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | Q:30 /30Days |
TRICOR 48MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | Q:30 /30Days |
TRIFLUOPERAZINE 1MG TABLET |
1 |
Preferred Generic |
$7.00 | N/A | None |
TRIFLUOPERAZINE HCL 2MG TABLET |
1 |
Preferred Generic |
$7.00 | N/A | None |
TRIFLUOPERAZINE HCL 5MG TABLET |
1 |
Preferred Generic |
$7.00 | N/A | None |
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT) |
1 |
Preferred Generic |
$7.00 | N/A | None |
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT |
1 |
Preferred Generic |
$7.00 | N/A | None |
TRIGLIDE 160MG TABLET (30 CT) |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | Q:30 /30Days |
TRIGLIDE 50MG TABLET (30 CT) |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | Q:30 /30Days |
TRIHEXYPHENIDYL HCL 5MG TABLET (100 CT) |
1 |
Preferred Generic |
$7.00 | N/A | None |
TRIHEXYPHENIDYL HCL ELIXIR 5%/2 16 FLO BOT |
1 |
Preferred Generic |
$7.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIHEXYPHENIDYL HCL TABLET 2MG (1000 CT) |
1 |
Preferred Generic |
$7.00 | N/A | None |
TRIHIBIT PRESERVATIVE FREE |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | None |
TRILEPTAL 300MG/5ML SUSP |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | Q:1200 /30Days |
TRILYTE WITH FLAVOR PACKETS 5.72GM/11.2GM |
1 |
Preferred Generic |
$7.00 | N/A | None |
TRIMETHOBENZAMIDE HCL 300MG CAPSULE |
1 |
Preferred Generic |
$7.00 | N/A | None |
TRIMETHOPRIM 100MG TABLET |
1 |
Preferred Generic |
$7.00 | N/A | None |
TRIMIPRAMINE MALEATE 25MG CAPSULE |
1 |
Preferred Generic |
$7.00 | N/A | None |
TRIMIPRAMINE MALEATE 50MG CAPSULE |
1 |
Preferred Generic |
$7.00 | N/A | None |
TRIMOX CAP 500MG |
1 |
Preferred Generic |
$7.00 | N/A | None |
TRINESSA 7DAYSX3 28 TABLET |
1 |
Preferred Generic |
$7.00 | N/A | None |
TRIPLE ANTIBIOTIC EYE OINT |
1 |
Preferred Generic |
$7.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRISENOX 10MG/10ML AMPULE |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | P |
TRIVORA-28 TABLET |
1 |
Preferred Generic |
$7.00 | N/A | None |
TRIZIVIR TABLET |
2 |
Preferred Brand |
$29.00 | N/A | None |
TROPICAMIDE 0.5% EYE DROPS |
1 |
Preferred Generic |
$7.00 | N/A | None |
TROPICAMIDE 1% EYE DROPS |
1 |
Preferred Generic |
$7.00 | N/A | None |
TRUSOPT PLUS 2% EYE DROPS 10ML BOT |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | None |
TRUVADA TABLET |
4 |
Specialty-Generic and Brand |
33% | N/A | Q:30 /30Days |
TWINJECT 0.15MG AUTO-INJECTOR |
2 |
Preferred Brand |
$29.00 | N/A | Q:1 /30Days |
TWINJECT 0.3MG AUTO-INJECTOR |
2 |
Preferred Brand |
$29.00 | N/A | Q:1 /30Days |
TWINRIX TF PF VACCINE 720UNT/20ML 10 X 1ML VIALSD |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | None |
TYGACIL 50MG VIAL 10 VILSU BOX |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TYKERB 250MG TABLET |
4 |
Specialty-Generic and Brand |
33% | N/A | P Q:150 /30Days |
TYPHIM VI 25MCG/0.5ML VIAL |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | None |
TYSABRI 300MG/15ML VIAL |
4 |
Specialty-Generic and Brand |
33% | N/A | P |
TYZEKA 600MG TABLET (30 CT) |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | Q:30 /30Days |
TYZINE 0.1% NOSE DROPS |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | None |
TYZINE PEDIATRIC 0.05% DROP |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$59.00 | N/A | None |