2010 Medicare Part D Plan Formulary Information |
Advantage Plan Optimumx (HMO-POS) (H9313-012-1)
Benefit Details
|
The Advantage Plan Optimumx (HMO-POS) (H9313-012-1) Formulary Drugs Starting with the Letter T in Statewide County, OH: CMS MA Region 12 which includes: OH
|
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 |
Tier 3 |
$50.00 | $150.00 | Q:20 /365Days |
TAMIFLU 45MG CAPSULE |
3 |
Tier 3 |
$50.00 | $150.00 | Q:20 /365Days |
TAMIFLU 75MG CAPSULE UD |
3 |
Tier 3 |
$50.00 | $150.00 | Q:56 /365Days |
TAMIFLU ORAL SUSPENSION |
3 |
Tier 3 |
$50.00 | $150.00 | None |
TAMOXIFEN CITRATE 20MG TABLET (30 CT) |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TAMOXIFEN CITRATE TABLETS 10MG 180 BOT |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TARCEVA 100MG TABLET |
5 |
Tier 5 |
33% | 33% | P Q:90 /90Days |
TARCEVA 150MG TABLET |
5 |
Tier 5 |
33% | 33% | P Q:90 /90Days |
TARCEVA 25MG TABLET |
5 |
Tier 5 |
33% | 33% | P Q:180 /90Days |
TARGRETIN 1% GEL 60GM TUBE |
3 |
Tier 3 |
$50.00 | $150.00 | 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 |
$50.00 | $150.00 | None |
TASIGNA 200MG CAPSULE 28 BLPK |
5 |
Tier 5 |
33% | 33% | None |
TASMAR 100MG TABLET |
4 |
Tier 4 |
$90.00 | $270.00 | None |
TASMAR 200MG TABLET |
4 |
Tier 4 |
$90.00 | $270.00 | None |
TAXOTERE 80MG/2ML VIAL |
5 |
Tier 5 |
33% | 33% | None |
TAZICEF 1GM VIAL |
3 |
Tier 3 |
$50.00 | $150.00 | None |
TAZICEF 2GM ADD-VANTAGE |
3 |
Tier 3 |
$50.00 | $150.00 | None |
TAZICEF 6GM/100ML VIAL |
3 |
Tier 3 |
$50.00 | $150.00 | None |
TAZTIA XT 120MG CAPSULE SA (500 CT) |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TAZTIA XT 180MG CAPSULE SA (500 CT) |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TAZTIA XT 240MG CAPSULE SA |
2 |
Tier 2 |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAZTIA XT 300MG CAPSULE SA (500 CT) |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TAZTIA XT 360MG CAPSULE SA |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TEGRETOL XR TABLETS 100MG 100 BOT |
3 |
Tier 3 |
$50.00 | $150.00 | None |
TEKTURNA 150MG TABLET |
3 |
Tier 3 |
$50.00 | $150.00 | Q:90 /90Days |
TEKTURNA 300MG TABLET |
3 |
Tier 3 |
$50.00 | $150.00 | Q:90 /90Days |
TEKTURNA HCT 150-12.5MG TABLET |
3 |
Tier 3 |
$50.00 | $150.00 | Q:90 /90Days |
TEKTURNA HCT 150MG-25MG TABLET |
3 |
Tier 3 |
$50.00 | $150.00 | Q:90 /90Days |
TEKTURNA HCT 300-12.5MG TABLET |
3 |
Tier 3 |
$50.00 | $150.00 | Q:90 /90Days |
TEKTURNA HCT 300MG-25MG TABLET |
3 |
Tier 3 |
$50.00 | $150.00 | Q:90 /90Days |
TERAZOSIN HCL 10MG CAPSULE |
1 |
Tier 1 |
$4.00 | $8.00 | Q:180 /90Days |
TERAZOSIN HCL 1MG CAPSULE |
1 |
Tier 1 |
$4.00 | $8.00 | Q:180 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TERAZOSIN HCL 2MG CAPSULE |
1 |
Tier 1 |
$4.00 | $8.00 | Q:180 /90Days |
TERAZOSIN HCL 5MG CAPSULE |
1 |
Tier 1 |
$4.00 | $8.00 | Q:180 /90Days |
TERBINAFINE HCL 250MG TABLET |
1 |
Tier 1 |
$4.00 | $8.00 | Q:90 /90Days |
TERBUTALINE SULF 1MG/ML VL |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TERBUTALINE SULF 2.5MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TERBUTALINE SULFATE 5MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TERCONAZOLE 0.4% CREAM WITH APPLICATOR |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TERCONAZOLE 0.8% CREAM WITH APPLICATOR |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TERCONAZOLE 80MG SUPPOSITORY VAGINAL |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TESTOSTERONE CYPIONATE INJECTION |
2 |
Tier 2 |
$15.00 | $30.00 | P |
TESTOSTERONE ENANTHATE INJECTION |
2 |
Tier 2 |
$15.00 | $30.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TETANUS AND DIPHTHERIA TOXOIDS ADSORBED FOR ADULT USE 2 UNT/VIAL |
3 |
Tier 3 |
$50.00 | $150.00 | None |
TETANUS TOXOID ADSORBED VIAL 5LF |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TETRACYCLINE 500MG CAPSULE |
1 |
Tier 1 |
$4.00 | $8.00 | None |
TETRACYCLINE HCL CAPSULES 250MG 100 (10 X 10) NS |
1 |
Tier 1 |
$4.00 | $8.00 | None |
TEV-TROPIN 5MG VIAL |
5 |
Tier 5 |
33% | 33% | P |
THALOMID 100MG CAPSULE 140 BOX |
5 |
Tier 5 |
33% | 33% | P |
THALOMID 150MG CAPSULE |
5 |
Tier 5 |
33% | 33% | P |
THALOMID 200MG CAPSULE 28 BLPK |
5 |
Tier 5 |
33% | 33% | P |
THALOMID 50MG CAPSULE 280 BOX |
5 |
Tier 5 |
33% | 33% | P |
THEO-24 100MG CAPSULE SA |
4 |
Tier 4 |
$90.00 | $270.00 | None |
THEO-24 200MG CAPSULE SA |
4 |
Tier 4 |
$90.00 | $270.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THEO-24 300MG CAPSULE SA |
4 |
Tier 4 |
$90.00 | $270.00 | None |
THEO-24 400MG CAPSULE SA |
4 |
Tier 4 |
$90.00 | $270.00 | None |
THEOCHRON 100MG TABLET SA |
2 |
Tier 2 |
$15.00 | $30.00 | None |
THEOCHRON 100MG TABLET SA |
2 |
Tier 2 |
$15.00 | $30.00 | None |
THEOCHRON 200MG TABLET SA 100 EA |
2 |
Tier 2 |
$15.00 | $30.00 | None |
THEOCHRON TABLETS EXTENDED RELEASE 300MG 100 BOT |
2 |
Tier 2 |
$15.00 | $30.00 | None |
THEOPHYLLINE 200MG TABLET SA |
2 |
Tier 2 |
$15.00 | $30.00 | None |
THEOPHYLLINE 300MG TABLET SA |
2 |
Tier 2 |
$15.00 | $30.00 | None |
THEOPHYLLINE 400MG TABLET SA |
2 |
Tier 2 |
$15.00 | $30.00 | None |
THEOPHYLLINE 600MG TABLET SA |
2 |
Tier 2 |
$15.00 | $30.00 | None |
THEOPHYLLINE ANHYDROUS ER TABLET 200MG (1000 CT) |
2 |
Tier 2 |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THEOPHYLLINE TABLET ER 300MG (100 CT) |
2 |
Tier 2 |
$15.00 | $30.00 | None |
THEOPHYLLINE TABLET ER 450MG (100 CT) |
2 |
Tier 2 |
$15.00 | $30.00 | None |
THERMAZENE 50GM CREAM |
2 |
Tier 2 |
$15.00 | $30.00 | None |
THIOGUANINE TABLET LOID 40MG |
3 |
Tier 3 |
$50.00 | $150.00 | None |
THIOLA 100MG TABLET |
3 |
Tier 3 |
$50.00 | $150.00 | None |
THIORIDAZINE 100MG TABLET |
1 |
Tier 1 |
$4.00 | $8.00 | None |
THIORIDAZINE HCL 10MG TABLET (1000 CT) |
1 |
Tier 1 |
$4.00 | $8.00 | None |
THIORIDAZINE HCL 25MG TABLET (1000 CT) |
1 |
Tier 1 |
$4.00 | $8.00 | None |
THIORIDAZINE HCL 50MG TABLET (1000 CT) |
1 |
Tier 1 |
$4.00 | $8.00 | None |
THIOTEPA POWDER FOR INJECTION 15MG/VIL 1 VIAL SINGLE DOSE CRTN |
2 |
Tier 2 |
$15.00 | $30.00 | None |
THIOTHIXENE 10MG CAPSULE |
1 |
Tier 1 |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THIOTHIXENE 1MG CAPSULE (100 CT) |
1 |
Tier 1 |
$4.00 | $8.00 | None |
THIOTHIXENE 2MG CAPSULE |
1 |
Tier 1 |
$4.00 | $8.00 | None |
THIOTHIXENE 5MG CAPSULE |
1 |
Tier 1 |
$4.00 | $8.00 | None |
THYMOGLOBULIN 25MG VIAL |
3 |
Tier 3 |
$50.00 | $150.00 | P |
TICLOPIDINE HCL 250MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | Q:180 /90Days |
TIKOSYN .125MG CAPSULE |
4 |
Tier 4 |
$90.00 | $270.00 | None |
TIKOSYN .250MG CAPSULE |
4 |
Tier 4 |
$90.00 | $270.00 | None |
TIKOSYN .5MG CAPSULE |
4 |
Tier 4 |
$90.00 | $270.00 | None |
TIMOLOL MAL SOL 0.25% OP 15ML BOT |
1 |
Tier 1 |
$4.00 | $8.00 | None |
TIMOLOL MAL SOL 0.5% OP 10ML BOT |
1 |
Tier 1 |
$4.00 | $8.00 | None |
TIMOLOL MALEATE 10MG TABLET |
1 |
Tier 1 |
$4.00 | $8.00 | 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 |
$4.00 | $8.00 | None |
TIMOLOL MALEATE 5MG TABLET |
1 |
Tier 1 |
$4.00 | $8.00 | None |
TIMOPTIC 0.25% OCUDOSE DROP |
3 |
Tier 3 |
$50.00 | $150.00 | None |
TIMOPTIC 0.5% OCUDOSE DROP |
3 |
Tier 3 |
$50.00 | $150.00 | None |
TIZANIDINE HCL 2MG TABLET (150 CT) |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TIZANIDINE HCL 4MG TABLET 150 BOT |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TOBRAMYCIN 10MG/ML VIAL |
1 |
Tier 1 |
$4.00 | $8.00 | None |
TOBRAMYCIN 40MG/ML VIAL |
1 |
Tier 1 |
$4.00 | $8.00 | None |
TOBRAMYCIN 60MG/0.9% NACL |
3 |
Tier 3 |
$50.00 | $150.00 | None |
TOBRAMYCIN 80MG/0.9% NACL |
3 |
Tier 3 |
$50.00 | $150.00 | None |
TOBRAMYCIN INHALATION SOLUTION |
5 |
Tier 5 |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOBRAMYCIN OPHTHALMIC SOLUTION 0.3% 5ML BOT |
1 |
Tier 1 |
$4.00 | $8.00 | None |
TOBRAMYCIN-DEXAMETH OPTH SUSP |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TOBRASOL 0.3% EYE DROPS |
1 |
Tier 1 |
$4.00 | $8.00 | None |
TOBREX 0.3% EYE OINTMENT |
3 |
Tier 3 |
$50.00 | $150.00 | None |
TOLAZAMIDE TABLETS 250MG 100 BOT |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TOLAZAMIDE TABLETS 500MG 100 BOT |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TOLBUTAMIDE 500MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TOLMETIN SODIUM 200MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TOLMETIN SODIUM 400MG CAPSULE |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TOLMETIN SODIUM 600MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TOPIRAMATE CAPSULES 25MG 60 CAPS BOT |
2 |
Tier 2 |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOPIRAMATE SPRINKLE CAPSULES 15MG 60 BOT |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TOPIRAMATE TABLETS 100MG 1000 BOT |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TOPIRAMATE TABLETS 200MG 1000 BOT |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TOPIRAMATE TABLETS 25MG 1000 BOT |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TOPIRAMATE TABLETS 50MG 1000 BOT |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TOPROL XL 100MG TABLET SA |
4 |
Tier 4 |
$90.00 | $270.00 | None |
TOPROL XL 200MG TABLET SA |
4 |
Tier 4 |
$90.00 | $270.00 | None |
TOPROL XL 25MG TABLET SA |
4 |
Tier 4 |
$90.00 | $270.00 | None |
TOPROL XL 50MG TABLET SA |
4 |
Tier 4 |
$90.00 | $270.00 | None |
TORSEMIDE 100MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TORSEMIDE 10MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TORSEMIDE 20MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TORSEMIDE 5MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TRACLEER 125MG TABLET |
5 |
Tier 5 |
33% | 33% | P |
TRACLEER 62.5MG TABLET |
5 |
Tier 5 |
33% | 33% | P |
TRAMADOL HCL 50MG TABLET (500 CT) |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TRANDOLAPRIL 1MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TRANDOLAPRIL 2MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TRANDOLAPRIL 4MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TRANSDERM-SCOP 1.5MG 24 PKG |
4 |
Tier 4 |
$90.00 | $270.00 | None |
TRANYLCYPROMINE SULFATE 10MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TRAVASOL 10% SOLUTION VIAFLEX |
3 |
Tier 3 |
$50.00 | $150.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRAVASOL 5.5% SOLUTION/VIAFLEX |
3 |
Tier 3 |
$50.00 | $150.00 | None |
TRAVASOL 8.5%-ELECTROLYTES |
3 |
Tier 3 |
$50.00 | $150.00 | None |
TRAVASOL 8.5%/DEXTROSE 10% QUICK MIX CONT |
3 |
Tier 3 |
$50.00 | $150.00 | None |
TRAVASOL 8.5%/DEXTROSE 20% QUICK MIX CONT |
3 |
Tier 3 |
$50.00 | $150.00 | None |
TRAVASOL 8.5%/DEXTROSE 50% QUICK MIX CONT |
3 |
Tier 3 |
$50.00 | $150.00 | None |
TRAVATAN Z 0.04MG DROPS 2.5ML BOT |
3 |
Tier 3 |
$50.00 | $150.00 | None |
TRAZODONE 300MG TABLET |
1 |
Tier 1 |
$4.00 | $8.00 | None |
TRAZODONE HCL TABLET USP 100MG (500 CT) |
1 |
Tier 1 |
$4.00 | $8.00 | None |
TRAZODONE HCL TABLET USP 150MG (100 CT) |
1 |
Tier 1 |
$4.00 | $8.00 | None |
TRAZODONE HCL TABLET USP 50MG (500 CT) |
1 |
Tier 1 |
$4.00 | $8.00 | None |
TRECATOR 250MG TABLET |
3 |
Tier 3 |
$50.00 | $150.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRELSTAR DEPOT 3.75MG SUSR |
4 |
Tier 4 |
$90.00 | $270.00 | None |
TRELSTAR LA 11.25MG VIAL |
4 |
Tier 4 |
$90.00 | $270.00 | None |
TRETINOIN 0.01% GEL 45GM TUBE |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TRETINOIN 0.025% CREAM |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TRETINOIN 0.025% GEL 45GM TUBE |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TRETINOIN 0.05% CREAM 45GM TUBE |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TRETINOIN 0.1% CREAM 45GM TUBE |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TRETINOIN 10MG CAPSULE |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TREZIX 16-356-30 CAPSULE |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TRI-LEGEST FE 5-7-9-7 TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TRI-SPRINTEC 7DAYSX3 28 TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIAMCINOLONE 0.1% OINTMENT |
1 |
Tier 1 |
$4.00 | $8.00 | None |
TRIAMCINOLONE 0.1% PASTE |
1 |
Tier 1 |
$4.00 | $8.00 | None |
TRIAMCINOLONE ACETONIDE 0.025% OINTMENT 80GM TUBE |
1 |
Tier 1 |
$4.00 | $8.00 | None |
TRIAMCINOLONE ACETONIDE 0.1% LOTION 60ML BOTPL |
1 |
Tier 1 |
$4.00 | $8.00 | None |
TRIAMCINOLONE ACETONIDE 0.025% CREAM 80GM TUBE |
1 |
Tier 1 |
$4.00 | $8.00 | None |
TRIAMCINOLONE ACETONIDE 0.025% LOTION 2 FL OZ BOT |
1 |
Tier 1 |
$4.00 | $8.00 | None |
TRIAMCINOLONE ACETONIDE 0.05% CREAM 15GM TUBE |
1 |
Tier 1 |
$4.00 | $8.00 | None |
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE |
1 |
Tier 1 |
$4.00 | $8.00 | None |
TRIAMCINOLONE ACETONIDE 0.1% CREAM 80GM TUBE |
1 |
Tier 1 |
$4.00 | $8.00 | None |
TRIAMTERENE/HCTZ 25/37.5MG CAPSULES (100 CT) |
1 |
Tier 1 |
$4.00 | $8.00 | None |
TRIAMTERENE/HCTZ 37.5/25 TABLET |
1 |
Tier 1 |
$4.00 | $8.00 | 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 |
$4.00 | $8.00 | None |
TRIAMTERENE/HCTZ 75/50 TABLET |
1 |
Tier 1 |
$4.00 | $8.00 | None |
TRICOR 145MG TABLET |
3 |
Tier 3 |
$50.00 | $150.00 | None |
TRICOR 48MG TABLET |
3 |
Tier 3 |
$50.00 | $150.00 | None |
TRIDERM 0.1% CREAM |
1 |
Tier 1 |
$4.00 | $8.00 | None |
TRIFLUOPERAZINE 1MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TRIFLUOPERAZINE HCL 2MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TRIFLUOPERAZINE HCL 5MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT) |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TRIHEXYPHENIDYL HCL 5MG TABLET (100 CT) |
1 |
Tier 1 |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIHEXYPHENIDYL HCL ELIXIR 5%/2 16 FLO BOT |
1 |
Tier 1 |
$4.00 | $8.00 | None |
TRIHEXYPHENIDYL HCL TABLET 2MG (1000 CT) |
1 |
Tier 1 |
$4.00 | $8.00 | None |
TRIHIBIT PRESERVATIVE FREE |
3 |
Tier 3 |
$50.00 | $150.00 | None |
TRILEPTAL 300MG/5ML SUSP |
3 |
Tier 3 |
$50.00 | $150.00 | None |
TRILIPIX CAPSULE DR 45MG |
3 |
Tier 3 |
$50.00 | $150.00 | None |
TRILIPIX DELAYED RELEASE CAPSULES 135MG |
3 |
Tier 3 |
$50.00 | $150.00 | None |
TRIMETHOPRIM 100MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TRIMIPRAMINE MALEATE 25MG CAPSULE |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TRIMIPRAMINE MALEATE 50MG CAPSULE |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TRINESSA 28 TABLETS 0.180;0.35MG;MG |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TRIPEDIA PRESERVATIVE FREE 6.7;23.4; UNT/.5 ML; |
3 |
Tier 3 |
$50.00 | $150.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIPLE THERAPY PREVPAC KIT 30;500;500MG;MG;MG; 14 PKGCOM |
4 |
Tier 4 |
$90.00 | $270.00 | None |
TRISENOX 10MG/10ML AMPULE |
3 |
Tier 3 |
$50.00 | $150.00 | None |
TRIVORA-28 TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
TRIZIVIR TABLET |
5 |
Tier 5 |
33% | 33% | None |
TROPHAMINE INJECTION SOLUTION |
3 |
Tier 3 |
$50.00 | $150.00 | None |
TROPHAMINE INJECTION SOLUTION 6% |
3 |
Tier 3 |
$50.00 | $150.00 | None |
TROPICACYL SOL 0.5% OP |
1 |
Tier 1 |
$4.00 | $8.00 | None |
TROPICACYL SOL 1% OP |
1 |
Tier 1 |
$4.00 | $8.00 | None |
TROPICAMIDE 0.5% EYE DROPS |
1 |
Tier 1 |
$4.00 | $8.00 | None |
TROPICAMIDE 1% EYE DROPS |
1 |
Tier 1 |
$4.00 | $8.00 | None |
TRUVADA TABLET |
5 |
Tier 5 |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TWINJECT AUTO INJECTOR INJECTION 1% AUTO INJECTOR TWO PACK SYR |
3 |
Tier 3 |
$50.00 | $150.00 | None |
TWINJECT AUTO INJECTOR INJECTION 1% AUTO TWO PACK SYR |
3 |
Tier 3 |
$50.00 | $150.00 | None |
TWINRIX TF PF VACCINE 720UNT/20ML 10 X 1ML VIALSD |
3 |
Tier 3 |
$50.00 | $150.00 | P |
TYGACIL 50MG VIAL 10 VILSU BOX |
3 |
Tier 3 |
$50.00 | $150.00 | None |
TYKERB 250MG TABLET |
5 |
Tier 5 |
33% | 33% | Q:450 /90Days |
TYPHIM VI 25MCG/0.5ML VIAL |
3 |
Tier 3 |
$50.00 | $150.00 | None |
TYZEKA 600MG TABLET (30 CT) |
5 |
Tier 5 |
33% | 33% | None |
TYZINE 0.1% NOSE DROPS |
3 |
Tier 3 |
$50.00 | $150.00 | None |
TYZINE PEDIATRIC 0.05% DROP |
3 |
Tier 3 |
$50.00 | $150.00 | None |