2011 Medicare Part D Plan Formulary Information |
Sierra VillageHealth (HMO SNP) (H2931-015-0)
Benefit Details
|
The Sierra VillageHealth (HMO SNP) (H2931-015-0) Formulary Drugs Starting with the Letter T in Clark County, NV: CMS MA Region 22 which includes: NV
|
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 |
4 |
Tier 4 |
$92.00 | N/A | Q:60 /30Days |
TACROLIMUS 0.5 MG ORAL CAPSULE |
3 |
Tier 3 |
$38.00 | $104.00 | P |
TACROLIMUS 1 MG ORAL CAPSULE |
3 |
Tier 3 |
$38.00 | $104.00 | P |
TACROLIMUS 5 MG ORAL CAPSULE |
3 |
Tier 3 |
$38.00 | $104.00 | P |
TALWIN 30MG/ML VIAL |
4 |
Tier 4 |
$92.00 | N/A | S |
TAMIFLU 30MG CAPSULE |
3 |
Tier 3 |
$38.00 | $104.00 | Q:60 /30Days |
TAMIFLU 45MG CAPSULE |
3 |
Tier 3 |
$38.00 | $104.00 | Q:28 /30Days |
TAMIFLU 75MG CAPSULE UD |
3 |
Tier 3 |
$38.00 | $104.00 | Q:28 /30Days |
TAMIFLU ORAL SUSPENSION |
3 |
Tier 3 |
$38.00 | $104.00 | Q:194 /30Days |
TAMOXIFEN CITRATE 20MG TABLET (30 CT) |
2 |
Tier 2 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAMOXIFEN CITRATE TABLETS 10MG 180 BOT |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TAMSULOSIN HCL 0.4 MG CAPSULE |
2 |
Tier 2 |
$10.00 | $20.00 | Q:60 /30Days |
TAPENTADOL 100 MG ORAL TABLET [NUCYNTA] |
4 |
Tier 4 |
$92.00 | N/A | P Q:180 /30Days |
TAPENTADOL 50 MG ORAL TABLET [NUCYNTA] |
4 |
Tier 4 |
$92.00 | N/A | P Q:180 /30Days |
TAPENTADOL 75 MG ORAL TABLET [NUCYNTA] |
4 |
Tier 4 |
$92.00 | N/A | P Q:180 /30Days |
TARCEVA 100MG TABLET |
5 |
Tier 5 |
33% | 33% | P |
TARCEVA 150MG TABLET |
5 |
Tier 5 |
33% | 33% | P |
TARCEVA 25MG TABLET |
5 |
Tier 5 |
33% | 33% | P |
TARGRETIN 1% GEL 60GM TUBE |
3 |
Tier 3 |
$38.00 | $104.00 | P |
TARGRETIN 75MG (100 CT) |
5 |
Tier 5 |
33% | 33% | P |
TARKA 1/240MG TABLET SA |
4 |
Tier 4 |
$92.00 | N/A | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TASIGNA 200MG CAPSULE 28 BLPK |
5 |
Tier 5 |
33% | 33% | P |
TASMAR 100MG TABLET |
5 |
Tier 5 |
33% | 33% | None |
TAZICEF 1GM VIAL |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TAZORAC 0.05% CREAM |
4 |
Tier 4 |
$92.00 | N/A | P |
TAZORAC 0.05% GEL |
4 |
Tier 4 |
$92.00 | N/A | P |
TAZORAC 0.1% CREAM |
4 |
Tier 4 |
$92.00 | N/A | P |
TAZORAC 0.1% GEL |
4 |
Tier 4 |
$92.00 | N/A | P |
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TAZTIA XT 240MG CAPSULE SA |
2 |
Tier 2 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAZTIA XT 360MG CAPSULE SA |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TEGRETOL CHEWABLE TABLETS 100MG 100 BOT |
3 |
Tier 3 |
$38.00 | $104.00 | None |
TEGRETOL SUSPENSION 100MG/5ML 450 ML BOT |
3 |
Tier 3 |
$38.00 | $104.00 | None |
TEGRETOL TABLETS 200MG 100 BOT |
3 |
Tier 3 |
$38.00 | $104.00 | None |
TEGRETOL XR TABLETS 100MG 100 BOT |
4 |
Tier 4 |
$92.00 | N/A | None |
TEKTURNA 150MG TABLET |
4 |
Tier 4 |
$92.00 | N/A | S Q:30 /30Days |
TEKTURNA 300MG TABLET |
4 |
Tier 4 |
$92.00 | N/A | S Q:30 /30Days |
TEKTURNA HCT 150-12.5MG TABLET |
4 |
Tier 4 |
$92.00 | N/A | S Q:30 /30Days |
TEKTURNA HCT 150MG-25MG TABLET |
4 |
Tier 4 |
$92.00 | N/A | S Q:30 /30Days |
TEKTURNA HCT 300-12.5MG TABLET |
4 |
Tier 4 |
$92.00 | N/A | S Q:30 /30Days |
TEKTURNA HCT 300MG-25MG TABLET |
4 |
Tier 4 |
$92.00 | N/A | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TELAVANCIN 15 MG/ML INJECTABLE SOLUTION [VIBATIV] |
5 |
Tier 5 |
33% | 33% | P |
TERAZOSIN HCL 10MG CAPSULE |
2 |
Tier 2 |
$10.00 | $20.00 | Q:60 /30Days |
TERAZOSIN HCL 1MG CAPSULE |
2 |
Tier 2 |
$10.00 | $20.00 | Q:30 /30Days |
TERAZOSIN HCL 2MG CAPSULE |
2 |
Tier 2 |
$10.00 | $20.00 | Q:30 /30Days |
TERAZOSIN HCL 5MG CAPSULE |
2 |
Tier 2 |
$10.00 | $20.00 | Q:30 /30Days |
TERBINAFINE HCL 250MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | Q:90 /365Days |
TERBUTALINE SULF 1MG/ML VL |
3 |
Tier 3 |
$38.00 | $104.00 | None |
TERBUTALINE SULF 2.5MG TABLET |
1 |
Tier 1 |
$8.00 | $16.00 | None |
TERBUTALINE SULFATE 5MG TABLET |
1 |
Tier 1 |
$8.00 | $16.00 | None |
TERCONAZOLE 0.4% CREAM WITH APPLICATOR |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TERCONAZOLE 80MG SUPPOSITORY VAGINAL |
2 |
Tier 2 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TERCONAZOLE VAGINAL CREAM |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TESTIM 1%(50MG) GEL |
4 |
Tier 4 |
$92.00 | N/A | P Q:300 /30Days |
TESTOSTERONE CYPIONATE INJECTION |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TESTOSTERONE ENANTHATE INJECTION |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TESTRED 10MG CAPSULE |
4 |
Tier 4 |
$92.00 | N/A | None |
TETANUS AND DIPHTHERIA TOXOIDS ADSORBED FOR ADULT USE 2 UNT/VIAL |
3 |
Tier 3 |
$38.00 | $104.00 | None |
TETANUS TOXOID ADSORBED VIAL 5LF |
3 |
Tier 3 |
$38.00 | $104.00 | None |
TETRACYCLINE 250 MG ORAL CAPSULE |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TETRACYCLINE 500MG CAPSULE |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TEV-TROPIN 5MG VIAL |
5 |
Tier 5 |
33% | 33% | P |
TEVETEN HCT TABLETS 600;25MG;MG 100 BOT |
4 |
Tier 4 |
$92.00 | N/A | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TEVETEN TABLETS 400MG 100 BOT |
4 |
Tier 4 |
$92.00 | N/A | S |
TEVETEN TABLETS 600;12.5MG;MG 100 BOT |
4 |
Tier 4 |
$92.00 | N/A | S |
TEVETEN TABLETS 600MG 100 BOT |
4 |
Tier 4 |
$92.00 | N/A | S |
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 |
$92.00 | N/A | None |
THEO-24 200MG CAPSULE SA |
4 |
Tier 4 |
$92.00 | N/A | None |
THEO-24 300MG CAPSULE SA |
4 |
Tier 4 |
$92.00 | N/A | None |
THEO-24 400MG CAPSULE SA |
4 |
Tier 4 |
$92.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THEOCHRON 100MG TABLET SA |
2 |
Tier 2 |
$10.00 | $20.00 | None |
THEOCHRON 100MG TABLET SA |
2 |
Tier 2 |
$10.00 | $20.00 | None |
THEOCHRON 200MG TABLET SA 100 EA |
2 |
Tier 2 |
$10.00 | $20.00 | None |
THEOCHRON TABLETS EXTENDED RELEASE 300MG 100 BOT |
2 |
Tier 2 |
$10.00 | $20.00 | None |
THEOPHYLLINE 400MG TABLET SA |
2 |
Tier 2 |
$10.00 | $20.00 | None |
THEOPHYLLINE 600MG TABLET SA |
2 |
Tier 2 |
$10.00 | $20.00 | None |
THEOPHYLLINE ANHYDROUS ER TABLET 200MG (1000 CT) |
2 |
Tier 2 |
$10.00 | $20.00 | None |
THEOPHYLLINE TABLET ER 300MG (100 CT) |
2 |
Tier 2 |
$10.00 | $20.00 | None |
THEOPHYLLINE TABLET ER 450MG (100 CT) |
2 |
Tier 2 |
$10.00 | $20.00 | None |
THERMAZENE 50GM CREAM |
2 |
Tier 2 |
$10.00 | $20.00 | None |
THIOGUANINE TABLET LOID 40MG |
4 |
Tier 4 |
$92.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THIORIDAZINE 100MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
THIORIDAZINE HCL 10MG TABLET (1000 CT) |
1 |
Tier 1 |
$8.00 | $16.00 | None |
THIORIDAZINE HCL 25MG TABLET (1000 CT) |
2 |
Tier 2 |
$10.00 | $20.00 | None |
THIORIDAZINE HCL 50MG TABLET (1000 CT) |
2 |
Tier 2 |
$10.00 | $20.00 | None |
THIOTHIXENE 10MG CAPSULE |
2 |
Tier 2 |
$10.00 | $20.00 | None |
THIOTHIXENE 1MG CAPSULE (100 CT) |
1 |
Tier 1 |
$8.00 | $16.00 | None |
THIOTHIXENE 2MG CAPSULE |
1 |
Tier 1 |
$8.00 | $16.00 | None |
THIOTHIXENE 5MG CAPSULE |
1 |
Tier 1 |
$8.00 | $16.00 | None |
THYMOGLOBULIN 25MG VIAL |
5 |
Tier 5 |
33% | 33% | P |
THYROLAR-1 60MG TABLET |
4 |
Tier 4 |
$92.00 | N/A | None |
THYROLAR-1/4 15MG TABLET |
4 |
Tier 4 |
$92.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THYROLAR-2 120MG TABLET |
4 |
Tier 4 |
$92.00 | N/A | None |
THYROLAR-3 180MG TABLET |
4 |
Tier 4 |
$92.00 | N/A | None |
TICLOPIDINE 250 MG ORAL TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | Q:60 /30Days |
TIKOSYN .125MG CAPSULE |
4 |
Tier 4 |
$92.00 | N/A | None |
TIKOSYN .250MG CAPSULE |
4 |
Tier 4 |
$92.00 | N/A | None |
TIKOSYN .5MG CAPSULE |
4 |
Tier 4 |
$92.00 | N/A | None |
TIMENTIN 3.1GM VIAL |
4 |
Tier 4 |
$92.00 | N/A | P |
TIMOLOL 0.0025 MG/MG OPHTHALMIC GEL |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TIMOLOL 0.005 MG/MG OPHTHALMIC GEL |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TIMOLOL MAL SOL 0.25% OP 15ML BOT |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TIMOLOL MAL SOL 0.5% OP 10ML BOT |
2 |
Tier 2 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIMOLOL MALEATE 10MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TIMOLOL MALEATE 20MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TIMOLOL MALEATE 5MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TIS-U-SOL IRRIGATION SOLUTION |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TIZANIDINE HCL 2MG TABLET (150 CT) |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TIZANIDINE HCL 4MG TABLET 150 BOT |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TOBRADEX EYE OINTMENT |
3 |
Tier 3 |
$38.00 | $104.00 | None |
TOBRAMYCIN INHALATION SOLUTION |
5 |
Tier 5 |
33% | 33% | P |
TOBRAMYCIN OPHTHALMIC SOLUTION 0.3% 5ML BOT |
3 |
Tier 3 |
$38.00 | $104.00 | None |
TOBRAMYCIN-DEXAMETH OPTH SUSP |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TOBRASOL 0.3% EYE DROPS |
2 |
Tier 2 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOBREX 0.3% EYE OINTMENT |
3 |
Tier 3 |
$38.00 | $104.00 | None |
TOLAZAMIDE TABLETS 250MG 100 BOT |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TOLAZAMIDE TABLETS 500MG 100 BOT |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TOLBUTAMIDE 500MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TOLMETIN SODIUM 200MG TABLET |
1 |
Tier 1 |
$8.00 | $16.00 | None |
TOLMETIN SODIUM 400MG CAPSULE |
3 |
Tier 3 |
$38.00 | $104.00 | None |
TOLMETIN SODIUM 600MG TABLET |
3 |
Tier 3 |
$38.00 | $104.00 | None |
TOLVAPTAN 15 MG ORAL TABLET [SAMSCA] |
5 |
Tier 5 |
33% | 33% | P |
TOLVAPTAN 30 MG ORAL TABLET [SAMSCA] |
5 |
Tier 5 |
33% | 33% | P |
TOPICORT LP 0.05% CREAM |
4 |
Tier 4 |
$92.00 | N/A | None |
TOPIRAMATE 25 MG SPRINKLE CAP |
2 |
Tier 2 |
$10.00 | $20.00 | 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 |
$10.00 | $20.00 | None |
TOPIRAMATE TABLETS 100MG 1000 BOT |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TOPIRAMATE TABLETS 200MG 1000 BOT |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TOPIRAMATE TABLETS 25MG 1000 BOT |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TOPIRAMATE TABLETS 50MG 1000 BOT |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TOPOTECAN HYDROCHLORIDE FOR INJECTION |
5 |
Tier 5 |
33% | 33% | None |
TORSEMIDE 100 MG ORAL TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TORSEMIDE 20 MG ORAL TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TORSEMIDE TABLETS 10 MG |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TORSEMIDE TABLETS 5 MG |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TOVIAZ TABLETS 4MG EXTENDED RELEASE |
4 |
Tier 4 |
$92.00 | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOVIAZ TABLETS 8MG EXTENDED RELEASE |
4 |
Tier 4 |
$92.00 | N/A | Q:30 /30Days |
TPN ELECTROLYTES VIAL |
3 |
Tier 3 |
$38.00 | $104.00 | None |
TRACLEER 125MG TABLET |
5 |
Tier 5 |
33% | 33% | P Q:60 /30Days |
TRACLEER 62.5MG TABLET |
5 |
Tier 5 |
33% | 33% | P Q:60 /30Days |
TRAMADOL HCL 50 MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | Q:240 /30Days |
TRAMADOL HCL-ACETAMINOPHEN 37.5-325MG TABLET (1000 CT) |
2 |
Tier 2 |
$10.00 | $20.00 | Q:240 /30Days |
TRAMADOL HYDROCHLORIDE 100 MG ER TABLET 24 HR |
4 |
Tier 4 |
$92.00 | N/A | Q:30 /30Days |
TRAMADOL HYDROCHLORIDE 200 MG ER TABLET 24 HR |
4 |
Tier 4 |
$92.00 | N/A | Q:30 /30Days |
TRANDOLAPRIL 1MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | Q:60 /30Days |
TRANDOLAPRIL 2MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | Q:60 /30Days |
TRANDOLAPRIL 4MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRANDOLAPRIL AND VERAPAMIL HYDROCHLORIDE TABLETS EXTENDED RELEASE |
4 |
Tier 4 |
$92.00 | N/A | Q:60 /30Days |
TRANDOLAPRIL-VERAPAMIL ER 2-180 MG |
4 |
Tier 4 |
$92.00 | N/A | Q:60 /30Days |
TRANDOLAPRIL-VERAPAMIL ER 2-240 MG |
4 |
Tier 4 |
$92.00 | N/A | Q:60 /30Days |
TRANDOLAPRIL-VERAPAMIL ER 4-240 MG |
4 |
Tier 4 |
$92.00 | N/A | Q:60 /30Days |
TRANSDERM-SCOP 1.5MG 24 PKG |
3 |
Tier 3 |
$38.00 | $104.00 | Q:10 /30Days |
TRANYLCYPROMINE SULFATE 10MG TABLET |
3 |
Tier 3 |
$38.00 | $104.00 | None |
TRAVATAN Z 0.04MG DROPS 2.5ML BOT |
3 |
Tier 3 |
$38.00 | $104.00 | Q:5 /30Days |
TRAZODONE 300MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRAZODONE HCL TABLET USP 100MG (500 CT) |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRAZODONE HCL TABLET USP 150MG (100 CT) |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRAZODONE HCL TABLET USP 50MG (500 CT) |
2 |
Tier 2 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRECATOR 250MG TABLET |
4 |
Tier 4 |
$92.00 | N/A | None |
TRETINOIN 0.01% GEL 45GM TUBE |
2 |
Tier 2 |
$10.00 | $20.00 | P Q:45 /60Days |
TRETINOIN 0.025% GEL 45GM TUBE |
2 |
Tier 2 |
$10.00 | $20.00 | P Q:45 /60Days |
TRETINOIN 0.025% GEL 45GM TUBE |
2 |
Tier 2 |
$10.00 | $20.00 | P Q:45 /60Days |
TRETINOIN 0.05% CREAM 45GM TUBE |
2 |
Tier 2 |
$10.00 | $20.00 | P Q:45 /60Days |
TRETINOIN 0.1% CREAM 45GM TUBE |
2 |
Tier 2 |
$10.00 | $20.00 | P Q:45 /60Days |
TRETINOIN 10MG CAPSULE |
5 |
Tier 5 |
33% | 33% | None |
TRETINOIN CREAM |
2 |
Tier 2 |
$10.00 | $20.00 | P Q:45 /60Days |
TREXALL 10MG TABLET |
4 |
Tier 4 |
$92.00 | N/A | None |
TREXALL 15MG TABLET |
4 |
Tier 4 |
$92.00 | N/A | None |
TREXALL 5MG TABLET |
4 |
Tier 4 |
$92.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TREXALL 7.5MG TABLET |
4 |
Tier 4 |
$92.00 | N/A | None |
TREXIMET 500MG TABLET |
4 |
Tier 4 |
$92.00 | N/A | S Q:8 /30Days |
TRI PREVIFEM TABLETS |
2 |
Tier 2 |
$10.00 | $20.00 | Q:28 /28Days |
TRI-LEGEST FE 5-7-9-7 TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | Q:28 /28Days |
TRI-NORINYL 28 TABLET |
4 |
Tier 4 |
$92.00 | N/A | Q:28 /28Days |
TRI-SPRINTEC 7DAYSX3 28 TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | Q:28 /28Days |
TRIAMCINOLONE 0.1% OINTMENT |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRIAMCINOLONE 0.1% PASTE |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRIAMCINOLONE ACETONIDE 0.025% OINTMENT 80GM TUBE |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRIAMCINOLONE ACETONIDE 0.1% LOTION 60ML BOTPL |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRIAMCINOLONE ACETONIDE 0.025% CREAM 80GM TUBE |
2 |
Tier 2 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIAMCINOLONE ACETONIDE 0.025% LOTION 2 FL OZ BOT |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRIAMCINOLONE ACETONIDE 0.05% CREAM 15GM TUBE |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRIAMCINOLONE ACETONIDE 0.1% CREAM 80GM TUBE |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRIAMTERENE/HCTZ 25/37.5MG CAPSULES (100 CT) |
1 |
Tier 1 |
$8.00 | $16.00 | None |
TRIAMTERENE/HCTZ 37.5/25 TABLET |
1 |
Tier 1 |
$8.00 | $16.00 | None |
TRIAMTERENE/HCTZ 75/50 TABLET |
1 |
Tier 1 |
$8.00 | $16.00 | None |
TRIBENZOR TABLETS |
4 |
Tier 4 |
$92.00 | N/A | S Q:30 /30Days |
TRIBENZOR TABLETS |
4 |
Tier 4 |
$92.00 | N/A | S Q:30 /30Days |
TRIBENZOR TABLETS |
4 |
Tier 4 |
$92.00 | N/A | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRICOR 145MG TABLET |
3 |
Tier 3 |
$38.00 | $104.00 | Q:30 /30Days |
TRICOR 48MG TABLET |
3 |
Tier 3 |
$38.00 | $104.00 | Q:60 /30Days |
TRIDERM 0.1% CREAM |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRIDERM 0.1% OINTMENT |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRIFLUOPERAZINE 1MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRIFLUOPERAZINE HCL 2MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRIFLUOPERAZINE HCL 5MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT) |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRIGLIDE 160MG TABLET (30 CT) |
4 |
Tier 4 |
$92.00 | N/A | Q:30 /30Days |
TRIGLIDE 50MG TABLET (30 CT) |
4 |
Tier 4 |
$92.00 | N/A | Q:30 /30Days |
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 |
$8.00 | $16.00 | None |
TRIHEXYPHENIDYL HCL ELIXIR 5%/2 16 FLO BOT |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRIHEXYPHENIDYL HCL TABLET 2MG (1000 CT) |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRIHIBIT PRESERVATIVE FREE |
4 |
Tier 4 |
$92.00 | N/A | None |
TRILIPIX CAPSULE DR 45MG |
4 |
Tier 4 |
$92.00 | N/A | Q:30 /30Days |
TRILIPIX DELAYED RELEASE CAPSULES 135MG |
4 |
Tier 4 |
$92.00 | N/A | Q:30 /30Days |
TRIMETHOBENZAMIDE HCL 300MG CAPSULE |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRIMETHOPRIM TABLETS |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRINESSA TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | Q:28 /28Days |
TRIPEDIA PRESERVATIVE FREE 6.7;23.4; UNT/.5 ML; |
4 |
Tier 4 |
$92.00 | N/A | None |
TRISENOX 10MG/10ML AMPULE |
4 |
Tier 4 |
$92.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIVORA-28 TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | Q:28 /28Days |
TRIZIVIR TABLET |
5 |
Tier 5 |
33% | 33% | None |
TROPICAMIDE 0.5% EYE DROPS |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TROPICAMIDE OPHTHALMIC SOLUTION USP |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TROSPIUM CHLORIDE TABLETS |
4 |
Tier 4 |
$92.00 | N/A | Q:60 /30Days |
TRUVADA TABLET |
5 |
Tier 5 |
33% | 33% | None |
TWINJECT AUTO INJECTOR INJECTION 1% AUTO INJECTOR TWO PACK SYR |
3 |
Tier 3 |
$38.00 | $104.00 | None |
TWINJECT AUTO INJECTOR INJECTION 1% AUTO TWO PACK SYR |
3 |
Tier 3 |
$38.00 | $104.00 | None |
TWINRIX TF PF VACCINE 720UNT/20ML 10 X 1ML VIALSD |
4 |
Tier 4 |
$92.00 | N/A | None |
TYGACIL 50MG VIAL 10 VILSU BOX |
5 |
Tier 5 |
33% | 33% | P |
TYKERB 250MG TABLET |
5 |
Tier 5 |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TYPHIM VI 25MCG/0.5ML VIAL |
3 |
Tier 3 |
$38.00 | $104.00 | None |
TYSABRI 300MG/15ML VIAL |
5 |
Tier 5 |
33% | 33% | P |
TYZEKA 600MG TABLET (30 CT) |
5 |
Tier 5 |
33% | 33% | P Q:30 /30Days |
TYZINE 0.1% NOSE DROPS |
3 |
Tier 3 |
$38.00 | $104.00 | None |