2010 Medicare Part D Plan Formulary Information |
Sierra Optima Choice Rx (PFFS) (H4449-014-0)
Benefit Details
|
The Sierra Optima Choice Rx (PFFS) (H4449-014-0) Formulary Drugs Starting with the Letter T in Statewide County, UT: CMS MA Region 23 which includes: UT
|
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 |
TACLONEX OINTMENT |
3 |
Tier 3 |
$80.00 | N/A | S Q:60 /30Days |
TAMIFLU 30MG CAPSULE |
2 |
Tier 2 |
$40.00 | $80.00 | Q:28 /30Days |
TAMIFLU 45MG CAPSULE |
2 |
Tier 2 |
$40.00 | $80.00 | Q:28 /30Days |
TAMIFLU 75MG CAPSULE UD |
2 |
Tier 2 |
$40.00 | $80.00 | Q:28 /30Days |
TAMIFLU ORAL SUSPENSION |
2 |
Tier 2 |
$40.00 | $80.00 | Q:100 /60Days |
TAMOXIFEN CITRATE 20MG TABLET (30 CT) |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TAMOXIFEN CITRATE TABLETS 10MG 180 BOT |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TARCEVA 100MG TABLET |
4 |
Tier 4 |
33% | 33% | P |
TARCEVA 150MG TABLET |
4 |
Tier 4 |
33% | 33% | P |
TARCEVA 25MG TABLET |
4 |
Tier 4 |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TARGRETIN 1% GEL 60GM TUBE |
3 |
Tier 3 |
$80.00 | N/A | P |
TARGRETIN 75MG (100 CT) |
4 |
Tier 4 |
33% | 33% | P |
TARKA 1/240MG TABLET SA |
3 |
Tier 3 |
$80.00 | N/A | Q:60 /30Days |
TARKA 2/180MG TABLET SA |
3 |
Tier 3 |
$80.00 | N/A | Q:60 /30Days |
TARKA 2/240MG TABLET SA |
3 |
Tier 3 |
$80.00 | N/A | Q:60 /30Days |
TARKA 4/240MG TABLET SA |
3 |
Tier 3 |
$80.00 | N/A | Q:60 /30Days |
TASIGNA 200MG CAPSULE 28 BLPK |
4 |
Tier 4 |
33% | 33% | P |
TASMAR 100MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | None |
TASMAR 200MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | None |
TAZICEF 1GM VIAL |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TAZORAC 0.05% CREAM |
3 |
Tier 3 |
$80.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAZORAC 0.05% GEL |
3 |
Tier 3 |
$80.00 | N/A | P |
TAZORAC 0.1% CREAM |
3 |
Tier 3 |
$80.00 | N/A | P |
TAZORAC 0.1% GEL |
3 |
Tier 3 |
$80.00 | N/A | P |
TAZTIA XT 120MG CAPSULE SA (500 CT) |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TAZTIA XT 180MG CAPSULE SA (500 CT) |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TAZTIA XT 240MG CAPSULE SA |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TAZTIA XT 300MG CAPSULE SA (500 CT) |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TAZTIA XT 360MG CAPSULE SA |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TEGRETOL CHEWABLE TABLETS 100MG 100 BOT |
2 |
Tier 2 |
$40.00 | $80.00 | None |
TEGRETOL SUSPENSION 100MG/5ML 450 ML BOT |
2 |
Tier 2 |
$40.00 | $80.00 | None |
TEGRETOL TABLETS 200MG 100 BOT |
2 |
Tier 2 |
$40.00 | $80.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TEGRETOL XR TABLETS 100MG 100 BOT |
3 |
Tier 3 |
$80.00 | N/A | None |
TEKTURNA 150MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | Q:30 /30Days |
TEKTURNA 300MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | Q:30 /30Days |
TEKTURNA HCT 150-12.5MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | Q:30 /30Days |
TEKTURNA HCT 150MG-25MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | Q:30 /30Days |
TEKTURNA HCT 300-12.5MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | Q:30 /30Days |
TEKTURNA HCT 300MG-25MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | Q:30 /30Days |
TERAZOSIN HCL 10MG CAPSULE |
1 |
Tier 1 |
$10.00 | $20.00 | Q:60 /30Days |
TERAZOSIN HCL 1MG CAPSULE |
1 |
Tier 1 |
$10.00 | $20.00 | Q:30 /30Days |
TERAZOSIN HCL 2MG CAPSULE |
1 |
Tier 1 |
$10.00 | $20.00 | Q:30 /30Days |
TERAZOSIN HCL 5MG CAPSULE |
1 |
Tier 1 |
$10.00 | $20.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TERBINAFINE HCL 250MG TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | Q:90 /365Days |
TERBUTALINE SULF 2.5MG TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TERBUTALINE SULFATE 5MG TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TERCONAZOLE 0.4% CREAM WITH APPLICATOR |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TERCONAZOLE 0.8% CREAM WITH APPLICATOR |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TESTIM 1%(50MG) GEL |
3 |
Tier 3 |
$80.00 | N/A | P Q:300 /30Days |
TESTOSTERONE CYPIONATE INJECTION |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TESTRED 10MG CAPSULE |
3 |
Tier 3 |
$80.00 | N/A | None |
TETANUS AND DIPHTHERIA TOXOIDS ADSORBED FOR ADULT USE 2 UNT/VIAL |
2 |
Tier 2 |
$40.00 | $80.00 | None |
TETANUS TOXOID ADSORBED VIAL 5LF |
2 |
Tier 2 |
$40.00 | $80.00 | None |
TETRACYCLINE 500MG CAPSULE |
1 |
Tier 1 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TETRACYCLINE HCL CAPSULES 250MG 100 (10 X 10) NS |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TEV-TROPIN 5MG VIAL |
4 |
Tier 4 |
33% | 33% | P |
TEVETEN HCT TABLETS 600;25MG;MG 100 BOT |
3 |
Tier 3 |
$80.00 | N/A | None |
TEVETEN TABLETS 400MG 100 BOT |
3 |
Tier 3 |
$80.00 | N/A | None |
TEVETEN TABLETS 600;12.5MG;MG 100 BOT |
3 |
Tier 3 |
$80.00 | N/A | None |
TEVETEN TABLETS 600MG 100 BOT |
3 |
Tier 3 |
$80.00 | N/A | None |
THALOMID 100MG CAPSULE 140 BOX |
4 |
Tier 4 |
33% | 33% | P |
THALOMID 150MG CAPSULE |
4 |
Tier 4 |
33% | 33% | P |
THALOMID 200MG CAPSULE 28 BLPK |
4 |
Tier 4 |
33% | 33% | P |
THALOMID 50MG CAPSULE 280 BOX |
4 |
Tier 4 |
33% | 33% | P |
THEO-24 100MG CAPSULE SA |
3 |
Tier 3 |
$80.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THEO-24 200MG CAPSULE SA |
3 |
Tier 3 |
$80.00 | N/A | None |
THEO-24 300MG CAPSULE SA |
3 |
Tier 3 |
$80.00 | N/A | None |
THEO-24 400MG CAPSULE SA |
3 |
Tier 3 |
$80.00 | N/A | None |
THEOCHRON 100MG TABLET SA |
1 |
Tier 1 |
$10.00 | $20.00 | None |
THEOCHRON 100MG TABLET SA |
1 |
Tier 1 |
$10.00 | $20.00 | None |
THEOPHYLLINE 200MG TABLET SA |
1 |
Tier 1 |
$10.00 | $20.00 | None |
THEOPHYLLINE 300MG TABLET SA |
1 |
Tier 1 |
$10.00 | $20.00 | None |
THEOPHYLLINE ANHYDROUS ER TABLET 200MG (1000 CT) |
1 |
Tier 1 |
$10.00 | $20.00 | None |
THEOPHYLLINE TABLET ER 300MG (100 CT) |
1 |
Tier 1 |
$10.00 | $20.00 | None |
THEOPHYLLINE TABLET ER 450MG (100 CT) |
1 |
Tier 1 |
$10.00 | $20.00 | None |
THIOGUANINE TABLET LOID 40MG |
3 |
Tier 3 |
$80.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THIOLA 100MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | None |
THIORIDAZINE 100MG TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | None |
THIORIDAZINE HCL 10MG TABLET (1000 CT) |
1 |
Tier 1 |
$10.00 | $20.00 | None |
THIORIDAZINE HCL 25MG TABLET (1000 CT) |
1 |
Tier 1 |
$10.00 | $20.00 | None |
THIORIDAZINE HCL 50MG TABLET (1000 CT) |
1 |
Tier 1 |
$10.00 | $20.00 | None |
THIOTHIXENE 10MG CAPSULE |
1 |
Tier 1 |
$10.00 | $20.00 | None |
THIOTHIXENE 1MG CAPSULE (100 CT) |
1 |
Tier 1 |
$10.00 | $20.00 | None |
THIOTHIXENE 2MG CAPSULE |
1 |
Tier 1 |
$10.00 | $20.00 | None |
THIOTHIXENE 5MG CAPSULE |
1 |
Tier 1 |
$10.00 | $20.00 | None |
THYMOGLOBULIN 25MG VIAL |
4 |
Tier 4 |
33% | 33% | P |
THYROLAR-1 60MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THYROLAR-1/2 30MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | None |
THYROLAR-1/4 15MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | None |
THYROLAR-2 120MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | None |
THYROLAR-3 180MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | None |
TICLOPIDINE HCL 250MG TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | Q:60 /30Days |
TIKOSYN .125MG CAPSULE |
3 |
Tier 3 |
$80.00 | N/A | None |
TIKOSYN .250MG CAPSULE |
3 |
Tier 3 |
$80.00 | N/A | None |
TIKOSYN .5MG CAPSULE |
3 |
Tier 3 |
$80.00 | N/A | None |
TIMOLOL MAL SOL 0.25% OP 15ML BOT |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TIMOLOL MAL SOL 0.5% OP 10ML BOT |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TIMOLOL MALEATE 10MG TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIMOLOL MALEATE 20MG TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TIMOLOL MALEATE 5MG TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TINDAMAX 250MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | None |
TINDAMAX 500MG TABLET (60 CT) |
3 |
Tier 3 |
$80.00 | N/A | None |
TIZANIDINE HCL 2MG TABLET (150 CT) |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TIZANIDINE HCL 4MG TABLET 150 BOT |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TOBRADEX EYE OINTMENT |
2 |
Tier 2 |
$40.00 | $80.00 | None |
TOBRAMYCIN INHALATION SOLUTION |
4 |
Tier 4 |
33% | 33% | P |
TOBRAMYCIN OPHTHALMIC SOLUTION 0.3% 5ML BOT |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TOBRAMYCIN-DEXAMETH OPTH SUSP |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TOBREX 0.3% EYE OINTMENT |
2 |
Tier 2 |
$40.00 | $80.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOFRANIL-PM 100MG CAPSULE |
3 |
Tier 3 |
$80.00 | N/A | None |
TOFRANIL-PM 125MG CAPSULE |
3 |
Tier 3 |
$80.00 | N/A | None |
TOFRANIL-PM 150MG CAPSULE |
3 |
Tier 3 |
$80.00 | N/A | None |
TOFRANIL-PM 75MG CAPSULE |
3 |
Tier 3 |
$80.00 | N/A | None |
TOLMETIN SODIUM 200MG TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TOLMETIN SODIUM 400MG CAPSULE |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TOLMETIN SODIUM 600MG TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TOPICORT LP 0.05% CREAM |
3 |
Tier 3 |
$80.00 | N/A | None |
TOPIRAMATE CAPSULES 25MG 60 CAPS BOT |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TOPIRAMATE SPRINKLE CAPSULES 15MG 60 BOT |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TOPIRAMATE TABLETS 100MG 1000 BOT |
1 |
Tier 1 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOPIRAMATE TABLETS 200MG 1000 BOT |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TOPIRAMATE TABLETS 25MG 1000 BOT |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TOPIRAMATE TABLETS 50MG 1000 BOT |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TORSEMIDE 100MG TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TORSEMIDE 10MG TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TORSEMIDE 20MG TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TORSEMIDE 5MG TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TOVIAZ TABLETS 4MG EXTENDED RELEASE |
2 |
Tier 2 |
$40.00 | $80.00 | Q:30 /30Days |
TOVIAZ TABLETS 8MG EXTENDED RELEASE |
2 |
Tier 2 |
$40.00 | $80.00 | Q:30 /30Days |
TPN ELECTROLYTES VIAL |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TRACLEER 125MG TABLET |
4 |
Tier 4 |
33% | 33% | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRACLEER 62.5MG TABLET |
4 |
Tier 4 |
33% | 33% | P Q:60 /30Days |
TRAMADOL HCL 50MG TABLET (500 CT) |
1 |
Tier 1 |
$10.00 | $20.00 | Q:240 /30Days |
TRAMADOL HCL-ACETAMINOPHEN 37.5-325MG TABLET (1000 CT) |
1 |
Tier 1 |
$10.00 | $20.00 | Q:240 /30Days |
TRANDOLAPRIL 1MG TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | Q:60 /30Days |
TRANDOLAPRIL 2MG TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | Q:60 /30Days |
TRANDOLAPRIL 4MG TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | Q:60 /30Days |
TRANSDERM-SCOP 1.5MG 24 PKG |
2 |
Tier 2 |
$40.00 | $80.00 | Q:10 /30Days |
TRANYLCYPROMINE SULFATE 10MG TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TRAVATAN Z 0.04MG DROPS 2.5ML BOT |
2 |
Tier 2 |
$40.00 | $80.00 | Q:5 /30Days |
TRAZODONE 300MG TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TRAZODONE HCL TABLET USP 100MG (500 CT) |
1 |
Tier 1 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRAZODONE HCL TABLET USP 150MG (100 CT) |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TRAZODONE HCL TABLET USP 50MG (500 CT) |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TRECATOR 250MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | None |
TRETINOIN 0.01% GEL 45GM TUBE |
1 |
Tier 1 |
$10.00 | $20.00 | P Q:45 /60Days |
TRETINOIN 0.025% CREAM |
1 |
Tier 1 |
$10.00 | $20.00 | P Q:45 /60Days |
TRETINOIN 0.025% GEL 45GM TUBE |
1 |
Tier 1 |
$10.00 | $20.00 | P Q:45 /60Days |
TRETINOIN 0.025% GEL 45GM TUBE |
1 |
Tier 1 |
$10.00 | $20.00 | P Q:45 /60Days |
TRETINOIN 0.05% CREAM 45GM TUBE |
1 |
Tier 1 |
$10.00 | $20.00 | P Q:45 /60Days |
TRETINOIN 0.1% CREAM 45GM TUBE |
1 |
Tier 1 |
$10.00 | $20.00 | P Q:45 /60Days |
TRETINOIN 10MG CAPSULE |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TREXALL 10MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TREXALL 15MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | None |
TREXALL 5MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | None |
TREXALL 7.5MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | None |
TRI-NORINYL 28 TABLET |
3 |
Tier 3 |
$80.00 | N/A | Q:28 /28Days |
TRI-SPRINTEC 7DAYSX3 28 TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | Q:28 /28Days |
TRIAMCINOLONE 0.1% OINTMENT |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TRIAMCINOLONE 0.1% PASTE |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TRIAMCINOLONE ACETONIDE 0.025% OINTMENT 80GM TUBE |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TRIAMCINOLONE ACETONIDE 0.1% LOTION 60ML BOTPL |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TRIAMCINOLONE ACETONIDE 0.025% CREAM 80GM TUBE |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TRIAMCINOLONE ACETONIDE 0.025% LOTION 2 FL OZ BOT |
1 |
Tier 1 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIAMCINOLONE ACETONIDE 0.05% CREAM 15GM TUBE |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TRIAMCINOLONE ACETONIDE 0.1% CREAM 80GM TUBE |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TRIAMTERENE/HCTZ 25/37.5MG CAPSULES (100 CT) |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TRIAMTERENE/HCTZ 37.5/25 TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TRIAMTERENE/HCTZ 50/25 CAPSULE |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TRIAMTERENE/HCTZ 75/50 TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TRICOR 145MG TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | Q:30 /30Days |
TRICOR 48MG TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | Q:60 /30Days |
TRIFLUOPERAZINE 1MG TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIFLUOPERAZINE HCL 2MG TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TRIFLUOPERAZINE HCL 5MG TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT) |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TRIGLIDE 160MG TABLET (30 CT) |
3 |
Tier 3 |
$80.00 | N/A | Q:30 /30Days |
TRIGLIDE 50MG TABLET (30 CT) |
3 |
Tier 3 |
$80.00 | N/A | Q:30 /30Days |
TRIHEXYPHENIDYL HCL 5MG TABLET (100 CT) |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TRIHEXYPHENIDYL HCL ELIXIR 5%/2 16 FLO BOT |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TRIHEXYPHENIDYL HCL TABLET 2MG (1000 CT) |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TRIHIBIT PRESERVATIVE FREE |
3 |
Tier 3 |
$80.00 | N/A | None |
TRILEPTAL 300MG/5ML SUSP |
2 |
Tier 2 |
$40.00 | $80.00 | Q:1200 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRILIPIX CAPSULE DR 45MG |
3 |
Tier 3 |
$80.00 | N/A | Q:30 /30Days |
TRILIPIX DELAYED RELEASE CAPSULES 135MG |
3 |
Tier 3 |
$80.00 | N/A | Q:30 /30Days |
TRILYTE WITH FLAVOR PACKETS 5.72GM/11.2GM |
1 |
Tier 1 |
$10.00 | $20.00 | Q:4000 /30Days |
TRIMETHOBENZAMIDE HCL 300MG CAPSULE |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TRIMETHOPRIM 100MG TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TRIMIPRAMINE MALEATE 25MG CAPSULE |
3 |
Tier 3 |
$80.00 | N/A | None |
TRIMIPRAMINE MALEATE 50MG CAPSULE |
3 |
Tier 3 |
$80.00 | N/A | None |
TRINESSA 28 TABLETS 0.180;0.35MG;MG |
1 |
Tier 1 |
$10.00 | $20.00 | Q:28 /28Days |
TRIPEDIA PRESERVATIVE FREE 6.7;23.4; UNT/.5 ML; |
3 |
Tier 3 |
$80.00 | N/A | None |
TRISENOX 10MG/10ML AMPULE |
3 |
Tier 3 |
$80.00 | N/A | P |
TRIVORA-28 TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | Q:28 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIZIVIR TABLET |
4 |
Tier 4 |
33% | 33% | None |
TROPICAMIDE 0.5% EYE DROPS |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TROPICAMIDE 1% EYE DROPS |
1 |
Tier 1 |
$10.00 | $20.00 | None |
TRUVADA TABLET |
4 |
Tier 4 |
33% | 33% | None |
TWINJECT AUTO INJECTOR INJECTION 1% AUTO INJECTOR TWO PACK SYR |
2 |
Tier 2 |
$40.00 | $80.00 | None |
TWINJECT AUTO INJECTOR INJECTION 1% AUTO TWO PACK SYR |
2 |
Tier 2 |
$40.00 | $80.00 | None |
TWINRIX TF PF VACCINE 720UNT/20ML 10 X 1ML VIALSD |
3 |
Tier 3 |
$80.00 | N/A | None |
TYGACIL 50MG VIAL 10 VILSU BOX |
4 |
Tier 4 |
33% | 33% | P |
TYKERB 250MG TABLET |
4 |
Tier 4 |
33% | 33% | P |
TYPHIM VI 25MCG/0.5ML VIAL |
2 |
Tier 2 |
$40.00 | $80.00 | None |
TYZEKA 600MG TABLET (30 CT) |
3 |
Tier 3 |
$80.00 | N/A | 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 |
$40.00 | $80.00 | None |