2011 Medicare Part D Plan Formulary Information |
Blue Advantage Complete (PPO) (H0104-011-3)
Benefit Details
|
The Blue Advantage Complete (PPO) (H0104-011-3) Formulary Drugs Starting with the Letter T in Covington County, AL: CMS MA Region 10 which includes: AL
|
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 |
TACROLIMUS 0.5 MG ORAL CAPSULE |
1* |
Tier 1 |
$7.00 | $21.00 | P |
TACROLIMUS 1 MG ORAL CAPSULE |
1* |
Tier 1 |
$7.00 | $21.00 | P |
TACROLIMUS 5 MG ORAL CAPSULE |
1* |
Tier 1 |
$7.00 | $21.00 | P |
TAMIFLU 30MG CAPSULE |
3 |
Tier 3 |
$75.00 | $225.00 | None |
TAMIFLU 45MG CAPSULE |
3 |
Tier 3 |
$75.00 | $225.00 | None |
TAMIFLU 75MG CAPSULE UD |
3 |
Tier 3 |
$75.00 | $225.00 | Q:28 /180Days |
TAMIFLU ORAL SUSPENSION |
3 |
Tier 3 |
$75.00 | $225.00 | Q:680 /30Days |
TAMOXIFEN CITRATE 20MG TABLET (30 CT) |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TAMOXIFEN CITRATE TABLETS 10MG 180 BOT |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TAMSULOSIN HCL 0.4 MG CAPSULE |
1* |
Tier 1 |
$7.00 | $21.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAPENTADOL 100 MG ORAL TABLET [NUCYNTA] |
3 |
Tier 3 |
$75.00 | $225.00 | Q:180 /30Days |
TAPENTADOL 50 MG ORAL TABLET [NUCYNTA] |
3 |
Tier 3 |
$75.00 | $225.00 | Q:360 /30Days |
TAPENTADOL 75 MG ORAL TABLET [NUCYNTA] |
3 |
Tier 3 |
$75.00 | $225.00 | Q:240 /30Days |
TARCEVA 100MG TABLET |
4 |
Tier 4 |
30% | 30% | P |
TARCEVA 150MG TABLET |
4 |
Tier 4 |
30% | 30% | P |
TARCEVA 25MG TABLET |
4 |
Tier 4 |
30% | 30% | P |
TARGRETIN 1% GEL 60GM TUBE |
2 |
Tier 2 |
$45.00 | $135.00 | None |
TARGRETIN 75MG (100 CT) |
2 |
Tier 2 |
$45.00 | $135.00 | None |
TARKA 1/240MG TABLET SA |
2 |
Tier 2 |
$45.00 | $135.00 | S Q:30 /30Days |
TARKA 2/180MG TABLET SA |
2 |
Tier 2 |
$45.00 | $135.00 | S Q:30 /30Days |
TARKA 2/240MG TABLET SA |
2 |
Tier 2 |
$45.00 | $135.00 | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TARKA 4/240MG TABLET SA |
2 |
Tier 2 |
$45.00 | $135.00 | S Q:30 /30Days |
TASIGNA 200MG CAPSULE 28 BLPK |
4 |
Tier 4 |
30% | 30% | P Q:120 /30Days |
TASMAR 100MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
TAXOTERE 80MG/2ML VIAL |
4 |
Tier 4 |
30% | 30% | None |
TAZICEF 1GM VIAL |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TAZICEF 2GM ADD-VANTAGE |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TAZICEF 6GM/100ML VIAL |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TAZORAC 0.05% CREAM |
3 |
Tier 3 |
$75.00 | $225.00 | None |
TAZORAC 0.05% GEL |
3 |
Tier 3 |
$75.00 | $225.00 | None |
TAZORAC 0.1% CREAM |
3 |
Tier 3 |
$75.00 | $225.00 | None |
TAZORAC 0.1% GEL |
3 |
Tier 3 |
$75.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TAZTIA XT 240MG CAPSULE SA |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TAZTIA XT 360MG CAPSULE SA |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TEGRETOL XR TABLETS 100MG 100 BOT |
3 |
Tier 3 |
$75.00 | $225.00 | None |
TEGRETOL XR TABLETS 200MG 100 BOT |
3 |
Tier 3 |
$75.00 | $225.00 | None |
TEGRETOL XR TABLETS 400MG 100 BOT |
3 |
Tier 3 |
$75.00 | $225.00 | None |
TEKTURNA 150MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | S Q:30 /30Days |
TEKTURNA 300MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | S Q:30 /30Days |
TEKTURNA HCT 150-12.5MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TEKTURNA HCT 150MG-25MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | S Q:30 /30Days |
TEKTURNA HCT 300-12.5MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | S Q:30 /30Days |
TEKTURNA HCT 300MG-25MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | S Q:30 /30Days |
TERAZOSIN HCL 10MG CAPSULE |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TERAZOSIN HCL 1MG CAPSULE |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TERAZOSIN HCL 2MG CAPSULE |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TERAZOSIN HCL 5MG CAPSULE |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TERBINAFINE HCL 250MG TABLET |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TERBUTALINE SULF 1MG/ML VL |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TERBUTALINE SULF 2.5MG TABLET |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TERBUTALINE SULFATE 5MG TABLET |
1* |
Tier 1 |
$7.00 | $21.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TERCONAZOLE 0.4% CREAM WITH APPLICATOR |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TERCONAZOLE 80MG SUPPOSITORY VAGINAL |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TERCONAZOLE VAGINAL CREAM |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TESTIM 1%(50MG) GEL |
2 |
Tier 2 |
$45.00 | $135.00 | None |
TESTOSTERONE CYPIONATE INJECTION |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TESTOSTERONE ENANTHATE INJECTION |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TETANUS AND DIPHTHERIA TOXOIDS ADSORBED FOR ADULT USE 2 UNT/VIAL |
2 |
Tier 2 |
$45.00 | $135.00 | None |
TETANUS TOXOID ADSORBED VIAL 5LF |
2 |
Tier 2 |
$45.00 | $135.00 | P |
TETRACYCLINE 250 MG ORAL CAPSULE |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TETRACYCLINE 500MG CAPSULE |
1* |
Tier 1 |
$7.00 | $21.00 | None |
THALOMID 100MG CAPSULE 140 BOX |
4 |
Tier 4 |
30% | 30% | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THALOMID 150MG CAPSULE |
4 |
Tier 4 |
30% | 30% | P Q:60 /30Days |
THALOMID 200MG CAPSULE 28 BLPK |
4 |
Tier 4 |
30% | 30% | P Q:60 /30Days |
THALOMID 50MG CAPSULE 280 BOX |
4 |
Tier 4 |
30% | 30% | P Q:30 /30Days |
THEOCHRON 100MG TABLET SA |
1* |
Tier 1 |
$7.00 | $21.00 | None |
THEOCHRON 100MG TABLET SA |
1* |
Tier 1 |
$7.00 | $21.00 | None |
THEOCHRON 200MG TABLET SA 100 EA |
1* |
Tier 1 |
$7.00 | $21.00 | None |
THEOCHRON TABLETS EXTENDED RELEASE 300MG 100 BOT |
1* |
Tier 1 |
$7.00 | $21.00 | None |
THEOPHYLLINE 400MG TABLET SA |
1* |
Tier 1 |
$7.00 | $21.00 | None |
THEOPHYLLINE 600MG TABLET SA |
1* |
Tier 1 |
$7.00 | $21.00 | None |
THEOPHYLLINE ANHYDROUS ER TABLET 200MG (1000 CT) |
1* |
Tier 1 |
$7.00 | $21.00 | None |
THEOPHYLLINE TABLET ER 300MG (100 CT) |
1* |
Tier 1 |
$7.00 | $21.00 | 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* |
Tier 1 |
$7.00 | $21.00 | None |
THERMAZENE 50GM CREAM |
1* |
Tier 1 |
$7.00 | $21.00 | None |
THIOGUANINE TABLET LOID 40MG |
3 |
Tier 3 |
$75.00 | $225.00 | None |
THIORIDAZINE 100MG TABLET |
1* |
Tier 1 |
$7.00 | $21.00 | None |
THIORIDAZINE HCL 10MG TABLET (1000 CT) |
1* |
Tier 1 |
$7.00 | $21.00 | None |
THIORIDAZINE HCL 25MG TABLET (1000 CT) |
1* |
Tier 1 |
$7.00 | $21.00 | None |
THIORIDAZINE HCL 50MG TABLET (1000 CT) |
1* |
Tier 1 |
$7.00 | $21.00 | None |
THIOTEPA POWDER FOR INJECTION 15MG/VIL 1 VIAL SINGLE DOSE CRTN |
1* |
Tier 1 |
$7.00 | $21.00 | None |
THIOTHIXENE 10MG CAPSULE |
1* |
Tier 1 |
$7.00 | $21.00 | None |
THIOTHIXENE 1MG CAPSULE (100 CT) |
1* |
Tier 1 |
$7.00 | $21.00 | None |
THIOTHIXENE 2MG CAPSULE |
1* |
Tier 1 |
$7.00 | $21.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THIOTHIXENE 5MG CAPSULE |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TICLOPIDINE 250 MG ORAL TABLET |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TIKOSYN .125MG CAPSULE |
3 |
Tier 3 |
$75.00 | $225.00 | None |
TIKOSYN .250MG CAPSULE |
3 |
Tier 3 |
$75.00 | $225.00 | None |
TIKOSYN .5MG CAPSULE |
3 |
Tier 3 |
$75.00 | $225.00 | None |
TIMENTIN 3.1GM VIAL |
3 |
Tier 3 |
$75.00 | $225.00 | None |
TIMOLOL 0.0025 MG/MG OPHTHALMIC GEL |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TIMOLOL 0.005 MG/MG OPHTHALMIC GEL |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TIMOLOL MAL SOL 0.25% OP 15ML BOT |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TIMOLOL MAL SOL 0.5% OP 10ML BOT |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TIMOLOL MALEATE 10MG TABLET |
1* |
Tier 1 |
$7.00 | $21.00 | 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 |
$7.00 | $21.00 | None |
TIMOLOL MALEATE 5MG TABLET |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TIS-U-SOL IRRIGATION SOLUTION |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TIZANIDINE HCL 2MG TABLET (150 CT) |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TIZANIDINE HCL 4MG TABLET 150 BOT |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TOBRADEX EYE OINTMENT |
3 |
Tier 3 |
$75.00 | $225.00 | None |
TOBRADEX SUSPENSION OPHTHALMIC 0.1%/0.3% 5ML BOT |
3 |
Tier 3 |
$75.00 | $225.00 | None |
TOBRAMYCIN 10MG/ML VIAL |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TOBRAMYCIN 40MG/ML VIAL |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TOBRAMYCIN OPHTHALMIC SOLUTION 0.3% 5ML BOT |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TOBRAMYCIN-DEXAMETH OPTH SUSP |
1* |
Tier 1 |
$7.00 | $21.00 | None |
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 |
$7.00 | $21.00 | None |
TOLAZAMIDE TABLETS 250MG 100 BOT |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TOLAZAMIDE TABLETS 500MG 100 BOT |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TOLMETIN SODIUM 200MG TABLET |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TOLMETIN SODIUM 400MG CAPSULE |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TOLMETIN SODIUM 600MG TABLET |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TOLVAPTAN 15 MG ORAL TABLET [SAMSCA] |
4 |
Tier 4 |
30% | 30% | None |
TOLVAPTAN 30 MG ORAL TABLET [SAMSCA] |
4 |
Tier 4 |
30% | 30% | None |
TOPAMAX TABLETS 100MG 60 BOT |
3 |
Tier 3 |
$75.00 | $225.00 | None |
TOPAMAX TABLETS 200MG 60 BOT |
3 |
Tier 3 |
$75.00 | $225.00 | None |
TOPAMAX TABLETS 25MG 60 BOT |
3 |
Tier 3 |
$75.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOPAMAX TABLETS 50MG 60 BOT |
3 |
Tier 3 |
$75.00 | $225.00 | None |
TOPIRAMATE 25 MG SPRINKLE CAP |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TOPIRAMATE SPRINKLE CAPSULES 15MG 60 BOT |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TOPIRAMATE TABLETS 100MG 1000 BOT |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TOPIRAMATE TABLETS 200MG 1000 BOT |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TOPIRAMATE TABLETS 25MG 1000 BOT |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TOPIRAMATE TABLETS 50MG 1000 BOT |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TOPOSAR INJECTION 20MG/ML 50ML VIAL MD CRTN |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TOPOTECAN HYDROCHLORIDE FOR INJECTION |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TORISEL SOL 25MG/ML |
4 |
Tier 4 |
30% | 30% | None |
TORSEMIDE 100 MG ORAL TABLET |
1* |
Tier 1 |
$7.00 | $21.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TORSEMIDE 20 MG ORAL TABLET |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TORSEMIDE INJECTION 20MG/2ML |
3 |
Tier 3 |
$75.00 | $225.00 | None |
TORSEMIDE TABLETS 10 MG |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TORSEMIDE TABLETS 5 MG |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TPN ELECTROLYTES VIAL |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TRACLEER 125MG TABLET |
4 |
Tier 4 |
30% | 30% | P |
TRACLEER 62.5MG TABLET |
4 |
Tier 4 |
30% | 30% | P |
TRAMADOL HCL 50 MG TABLET |
1* |
Tier 1 |
$7.00 | $21.00 | Q:240 /30Days |
TRAMADOL HCL-ACETAMINOPHEN 37.5-325MG TABLET (1000 CT) |
1* |
Tier 1 |
$7.00 | $21.00 | Q:240 /30Days |
TRAMADOL HYDROCHLORIDE 100 MG ER TABLET 24 HR |
1* |
Tier 1 |
$7.00 | $21.00 | Q:30 /30Days |
TRAMADOL HYDROCHLORIDE 200 MG ER TABLET 24 HR |
1* |
Tier 1 |
$7.00 | $21.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRANDOLAPRIL 1MG TABLET |
1* |
Tier 1 |
$7.00 | $21.00 | Q:30 /30Days |
TRANDOLAPRIL 2MG TABLET |
1* |
Tier 1 |
$7.00 | $21.00 | Q:30 /30Days |
TRANDOLAPRIL 4MG TABLET |
1* |
Tier 1 |
$7.00 | $21.00 | Q:60 /30Days |
TRANDOLAPRIL AND VERAPAMIL HYDROCHLORIDE TABLETS EXTENDED RELEASE |
1* |
Tier 1 |
$7.00 | $21.00 | Q:30 /30Days |
TRANDOLAPRIL-VERAPAMIL ER 2-180 MG |
1* |
Tier 1 |
$7.00 | $21.00 | Q:30 /30Days |
TRANDOLAPRIL-VERAPAMIL ER 2-240 MG |
1* |
Tier 1 |
$7.00 | $21.00 | Q:30 /30Days |
TRANDOLAPRIL-VERAPAMIL ER 4-240 MG |
1* |
Tier 1 |
$7.00 | $21.00 | Q:30 /30Days |
TRANYLCYPROMINE SULFATE 10MG TABLET |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TRAVASOL 10% SOLUTION VIAFLEX |
3 |
Tier 3 |
$75.00 | $225.00 | P |
TRAVATAN Z 0.04MG DROPS 2.5ML BOT |
2 |
Tier 2 |
$45.00 | $135.00 | None |
TRAZODONE 300MG TABLET |
1* |
Tier 1 |
$7.00 | $21.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRAZODONE HCL TABLET USP 100MG (500 CT) |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TRAZODONE HCL TABLET USP 150MG (100 CT) |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TRAZODONE HCL TABLET USP 50MG (500 CT) |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TREANDA FOR INJECTION 100MG/VIAL |
4 |
Tier 4 |
30% | 30% | P |
TRECATOR 250MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
TRETINOIN 0.01% GEL 45GM TUBE |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TRETINOIN 0.025% GEL 45GM TUBE |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TRETINOIN 0.025% GEL 45GM TUBE |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TRETINOIN 0.05% CREAM 45GM TUBE |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TRETINOIN 0.1% CREAM 45GM TUBE |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TRETINOIN 10MG CAPSULE |
1* |
Tier 1 |
$7.00 | $21.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRETINOIN CREAM |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TRI PREVIFEM TABLETS |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TRI-LEGEST FE 5-7-9-7 TABLET |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TRI-SPRINTEC 7DAYSX3 28 TABLET |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TRIAMCINOLONE 0.1% OINTMENT |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TRIAMCINOLONE 0.1% PASTE |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TRIAMCINOLONE ACETONIDE 0.025% OINTMENT 80GM TUBE |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TRIAMCINOLONE ACETONIDE 0.1% LOTION 60ML BOTPL |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TRIAMCINOLONE ACETONIDE 0.025% CREAM 80GM TUBE |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TRIAMCINOLONE ACETONIDE 0.025% LOTION 2 FL OZ BOT |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TRIAMCINOLONE ACETONIDE 0.05% CREAM 15GM TUBE |
1* |
Tier 1 |
$7.00 | $21.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT |
2 |
Tier 2 |
$45.00 | $135.00 | None |
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TRIAMCINOLONE ACETONIDE 0.1% CREAM 80GM TUBE |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TRIAMTERENE/HCTZ 25/37.5MG CAPSULES (100 CT) |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TRIAMTERENE/HCTZ 37.5/25 TABLET |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TRIAMTERENE/HCTZ 75/50 TABLET |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TRICOR 145MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
TRICOR 48MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
TRIDERM 0.1% CREAM |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TRIDERM 0.1% OINTMENT |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TRIFLUOPERAZINE 1MG TABLET |
1* |
Tier 1 |
$7.00 | $21.00 | 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 |
$7.00 | $21.00 | None |
TRIFLUOPERAZINE HCL 5MG TABLET |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT) |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TRIHEXYPHENIDYL HCL 5MG TABLET (100 CT) |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TRIHEXYPHENIDYL HCL ELIXIR 5%/2 16 FLO BOT |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TRIHEXYPHENIDYL HCL TABLET 2MG (1000 CT) |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TRIHIBIT PRESERVATIVE FREE |
2 |
Tier 2 |
$45.00 | $135.00 | None |
TRILEPTAL 150MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
TRILEPTAL 300MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
TRILEPTAL 300MG/5ML SUSP |
3 |
Tier 3 |
$75.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRILEPTAL 600MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
TRILIPIX CAPSULE DR 45MG |
2 |
Tier 2 |
$45.00 | $135.00 | None |
TRILIPIX DELAYED RELEASE CAPSULES 135MG |
2 |
Tier 2 |
$45.00 | $135.00 | None |
TRIMETHOPRIM TABLETS |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TRINESSA TABLET |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TRIPEDIA PRESERVATIVE FREE 6.7;23.4; UNT/.5 ML; |
2 |
Tier 2 |
$45.00 | $135.00 | None |
TRISENOX 10MG/10ML AMPULE |
3 |
Tier 3 |
$75.00 | $225.00 | None |
TRIVORA-28 TABLET |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TRIZIVIR TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
TROPHAMINE INJECTION SOLUTION |
3 |
Tier 3 |
$75.00 | $225.00 | P |
TROPICAMIDE 0.5% EYE DROPS |
1* |
Tier 1 |
$7.00 | $21.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TROPICAMIDE OPHTHALMIC SOLUTION USP |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TROSPIUM CHLORIDE TABLETS |
1* |
Tier 1 |
$7.00 | $21.00 | None |
TRUSOPT PLUS 2% EYE DROPS 10ML BOT |
3 |
Tier 3 |
$75.00 | $225.00 | None |
TRUVADA TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
TWINRIX TF PF VACCINE 720UNT/20ML 10 X 1ML VIALSD |
2 |
Tier 2 |
$45.00 | $135.00 | None |
TYGACIL 50MG VIAL 10 VILSU BOX |
3 |
Tier 3 |
$75.00 | $225.00 | None |
TYKERB 250MG TABLET |
4 |
Tier 4 |
30% | 30% | P |
TYPHIM VI 25MCG/0.5ML VIAL |
2 |
Tier 2 |
$45.00 | $135.00 | None |
TYSABRI 300MG/15ML VIAL |
4 |
Tier 4 |
30% | 30% | S |
TYZEKA 600MG TABLET (30 CT) |
3 |
Tier 3 |
$75.00 | $225.00 | Q:30 /30Days |
TYZINE 0.1% NOSE DROPS |
2 |
Tier 2 |
$45.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TYZINE PEDIATRIC 0.05% DROP |
2 |
Tier 2 |
$45.00 | $135.00 | None |