2011 Medicare Part D Plan Formulary Information |
Patriot Plus (PFFS) (H4268-002-0)
Benefit Details
|
The Patriot Plus (PFFS) (H4268-002-0) Formulary Drugs Starting with the Letter T in Iredell County, NC: CMS MA Region 7 which includes: NC
|
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 75MG CAPSULE UD |
2 |
Tier 2 |
$39.00 | $78.00 | Q:28 /180Days |
TAMIFLU ORAL SUSPENSION |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TAMOXIFEN CITRATE 20MG TABLET (30 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TAMOXIFEN CITRATE TABLETS 10MG 180 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TAMSULOSIN HCL 0.4 MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
TARCEVA 100MG TABLET |
4 |
Tier 4 |
33% | 33% | P Q:30 /30Days |
TARCEVA 150MG TABLET |
4 |
Tier 4 |
33% | 33% | P Q:30 /30Days |
TARCEVA 25MG TABLET |
4 |
Tier 4 |
33% | 33% | P Q:30 /30Days |
TARGRETIN 1% GEL 60GM TUBE |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TARGRETIN 75MG (100 CT) |
2 |
Tier 2 |
$39.00 | $78.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TASIGNA 200MG CAPSULE 28 BLPK |
4 |
Tier 4 |
33% | 33% | None |
TASMAR 100MG TABLET |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TAXOTERE 80MG/2ML VIAL |
4 |
Tier 4 |
33% | 33% | P |
TAZORAC 0.05% CREAM |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TAZORAC 0.05% GEL |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TAZORAC 0.1% CREAM |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TAZORAC 0.1% GEL |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
TAZTIA XT 240MG CAPSULE SA |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAZTIA XT 360MG CAPSULE SA |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
TEGRETOL XR TABLETS 100MG 100 BOT |
3 |
Tier 3 |
$69.00 | $138.00 | None |
TEGRETOL XR TABLETS 200MG 100 BOT |
3 |
Tier 3 |
$69.00 | $138.00 | Q:90 /30Days |
TEGRETOL XR TABLETS 400MG 100 BOT |
3 |
Tier 3 |
$69.00 | $138.00 | Q:120 /30Days |
TEKTURNA 150MG TABLET |
3 |
Tier 3 |
$69.00 | $138.00 | S Q:30 /30Days |
TEKTURNA 300MG TABLET |
3 |
Tier 3 |
$69.00 | $138.00 | S Q:30 /30Days |
TEKTURNA HCT 150-12.5MG TABLET |
3 |
Tier 3 |
$69.00 | $138.00 | S Q:30 /30Days |
TEKTURNA HCT 150MG-25MG TABLET |
3 |
Tier 3 |
$69.00 | $138.00 | S Q:30 /30Days |
TEKTURNA HCT 300-12.5MG TABLET |
3 |
Tier 3 |
$69.00 | $138.00 | S Q:30 /30Days |
TEKTURNA HCT 300MG-25MG TABLET |
3 |
Tier 3 |
$69.00 | $138.00 | S Q:30 /30Days |
TERAZOSIN HCL 10MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TERAZOSIN HCL 1MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
TERAZOSIN HCL 2MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
TERAZOSIN HCL 5MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
TERBINAFINE HCL 250MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
TERBUTALINE SULF 2.5MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TERBUTALINE SULFATE 5MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TERCONAZOLE 80MG SUPPOSITORY VAGINAL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TESTOSTERONE CYPIONATE INJECTION |
1 |
Tier 1 |
$0.00 | $0.00 | P |
TESTOSTERONE ENANTHATE INJECTION |
1 |
Tier 1 |
$0.00 | $0.00 | P |
TETANUS AND DIPHTHERIA TOXOIDS ADSORBED FOR ADULT USE 2 UNT/VIAL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TETANUS TOXOID ADSORBED VIAL 5LF |
1 |
Tier 1 |
$0.00 | $0.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TETRACYCLINE 250 MG ORAL CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TETRACYCLINE 500MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
THALOMID 100MG CAPSULE 140 BOX |
4 |
Tier 4 |
33% | 33% | None |
THALOMID 150MG CAPSULE |
4 |
Tier 4 |
33% | 33% | None |
THALOMID 200MG CAPSULE 28 BLPK |
4 |
Tier 4 |
33% | 33% | None |
THALOMID 50MG CAPSULE 280 BOX |
4 |
Tier 4 |
33% | 33% | None |
THEO-24 100MG CAPSULE SA |
3 |
Tier 3 |
$69.00 | $138.00 | Q:30 /30Days |
THEO-24 200MG CAPSULE SA |
3 |
Tier 3 |
$69.00 | $138.00 | Q:30 /30Days |
THEO-24 300MG CAPSULE SA |
3 |
Tier 3 |
$69.00 | $138.00 | Q:30 /30Days |
THEO-24 400MG CAPSULE SA |
3 |
Tier 3 |
$69.00 | $138.00 | Q:30 /30Days |
THEOCHRON 100MG TABLET SA |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THEOPHYLLINE 400MG TABLET SA |
1 |
Tier 1 |
$0.00 | $0.00 | None |
THEOPHYLLINE 600MG TABLET SA |
1 |
Tier 1 |
$0.00 | $0.00 | None |
THEOPHYLLINE ANHYDROUS ER TABLET 200MG (1000 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
THEOPHYLLINE TABLET ER 300MG (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
THEOPHYLLINE TABLET ER 450MG (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
THIOGUANINE TABLET LOID 40MG |
2 |
Tier 2 |
$39.00 | $78.00 | None |
THIORIDAZINE 100MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
THIORIDAZINE HCL 10MG TABLET (1000 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
THIORIDAZINE HCL 25MG TABLET (1000 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
THIORIDAZINE HCL 50MG TABLET (1000 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
THIOTEPA POWDER FOR INJECTION 15MG/VIL 1 VIAL SINGLE DOSE CRTN |
1 |
Tier 1 |
$0.00 | $0.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THIOTHIXENE 10MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
THIOTHIXENE 1MG CAPSULE (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
THIOTHIXENE 2MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
THIOTHIXENE 5MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
THYMOGLOBULIN 25MG VIAL |
2 |
Tier 2 |
$39.00 | $78.00 | None |
THYROLAR-1 60MG TABLET |
2 |
Tier 2 |
$39.00 | $78.00 | None |
THYROLAR-1/4 15MG TABLET |
2 |
Tier 2 |
$39.00 | $78.00 | None |
THYROLAR-2 120MG TABLET |
2 |
Tier 2 |
$39.00 | $78.00 | None |
THYROLAR-3 180MG TABLET |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TIAZAC 120MG E.R. CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
TIAZAC 180MG E.R. CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIAZAC 240MG E.R. CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
TIAZAC 300MG E.R. CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
TIAZAC 360MG E.R. CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
TIAZAC 420MG CAPSULE SA |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
TICLOPIDINE 250 MG ORAL TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TIKOSYN .125MG CAPSULE |
3 |
Tier 3 |
$69.00 | $138.00 | None |
TIKOSYN .250MG CAPSULE |
3 |
Tier 3 |
$69.00 | $138.00 | None |
TIKOSYN .5MG CAPSULE |
3 |
Tier 3 |
$69.00 | $138.00 | None |
TIMENTIN 3.1GM VIAL |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TIMOLOL 0.0025 MG/MG OPHTHALMIC GEL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TIMOLOL 0.005 MG/MG OPHTHALMIC GEL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIMOLOL MAL SOL 0.25% OP 15ML BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TIMOLOL MAL SOL 0.5% OP 10ML BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TIMOLOL MALEATE 10MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TIMOLOL MALEATE 20MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TIMOLOL MALEATE 5MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TIZANIDINE HCL 2MG TABLET (150 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TIZANIDINE HCL 4MG TABLET 150 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TOBRADEX EYE OINTMENT |
3 |
Tier 3 |
$69.00 | $138.00 | None |
TOBRADEX SUSPENSION OPHTHALMIC 0.1%/0.3% 5ML BOT |
3 |
Tier 3 |
$69.00 | $138.00 | None |
TOBRAMYCIN 10MG/ML VIAL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TOBRAMYCIN 40MG/ML VIAL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
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 |
$0.00 | $0.00 | None |
TOBREX 0.3% EYE OINTMENT |
3 |
Tier 3 |
$69.00 | $138.00 | None |
TOLAZAMIDE TABLETS 250MG 100 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TOLAZAMIDE TABLETS 500MG 100 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TOLBUTAMIDE 500MG TABLET |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TOLMETIN SODIUM 200MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TOLMETIN SODIUM 400MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TOLMETIN SODIUM 600MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TOPAMAX 15 MG SPRINKLE CAP |
3 |
Tier 3 |
$69.00 | $138.00 | None |
TOPAMAX 25 MG SPRINKLE CAP |
3 |
Tier 3 |
$69.00 | $138.00 | None |
TOPAMAX TABLETS 100MG 60 BOT |
3 |
Tier 3 |
$69.00 | $138.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOPAMAX TABLETS 200MG 60 BOT |
3 |
Tier 3 |
$69.00 | $138.00 | None |
TOPAMAX TABLETS 25MG 60 BOT |
3 |
Tier 3 |
$69.00 | $138.00 | None |
TOPAMAX TABLETS 50MG 60 BOT |
3 |
Tier 3 |
$69.00 | $138.00 | None |
TOPIRAMATE 25 MG SPRINKLE CAP |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TOPIRAMATE SPRINKLE CAPSULES 15MG 60 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TOPIRAMATE TABLETS 100MG 1000 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TOPIRAMATE TABLETS 200MG 1000 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TOPIRAMATE TABLETS 25MG 1000 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TOPIRAMATE TABLETS 50MG 1000 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TOPOSAR INJECTION 20MG/ML 50ML VIAL MD CRTN |
1 |
Tier 1 |
$0.00 | $0.00 | P |
TORISEL SOL 25MG/ML |
4 |
Tier 4 |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TORSEMIDE 100 MG ORAL TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TORSEMIDE 20 MG ORAL TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TORSEMIDE INJECTION 20MG/2ML |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TORSEMIDE TABLETS 10 MG |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TORSEMIDE TABLETS 5 MG |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TOVIAZ TABLETS 4MG EXTENDED RELEASE |
2 |
Tier 2 |
$39.00 | $78.00 | Q:30 /30Days |
TOVIAZ TABLETS 8MG EXTENDED RELEASE |
2 |
Tier 2 |
$39.00 | $78.00 | Q:30 /30Days |
TPN ELECTROLYTES VIAL |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TRACLEER 125MG TABLET |
4 |
Tier 4 |
33% | 33% | P |
TRACLEER 62.5MG TABLET |
4 |
Tier 4 |
33% | 33% | P |
TRAMADOL HCL 50 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:240 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRANDOLAPRIL 1MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
TRANDOLAPRIL 2MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
TRANDOLAPRIL 4MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
TRANYLCYPROMINE SULFATE 10MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRAVATAN Z 0.04MG DROPS 2.5ML BOT |
2 |
Tier 2 |
$39.00 | $78.00 | Q:3 /25Days |
TRAZODONE 300MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRAZODONE HCL TABLET USP 100MG (500 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRAZODONE HCL TABLET USP 150MG (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRAZODONE HCL TABLET USP 50MG (500 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TREANDA FOR INJECTION 100MG/VIAL |
4 |
Tier 4 |
33% | 33% | P |
TRECATOR 250MG TABLET |
3 |
Tier 3 |
$69.00 | $138.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRELSTAR DEPOT MIXJET FOR INJECTION 3.75 MG |
3 |
Tier 3 |
$69.00 | $138.00 | P |
TRELSTAR MIXJET FOR INJECTION 11.25 MG |
3 |
Tier 3 |
$69.00 | $138.00 | P |
TRETINOIN 0.01% GEL 45GM TUBE |
1 |
Tier 1 |
$0.00 | $0.00 | P |
TRETINOIN 0.025% GEL 45GM TUBE |
1 |
Tier 1 |
$0.00 | $0.00 | P |
TRETINOIN 0.05% CREAM 45GM TUBE |
1 |
Tier 1 |
$0.00 | $0.00 | P |
TRETINOIN 0.1% CREAM 45GM TUBE |
1 |
Tier 1 |
$0.00 | $0.00 | P |
TRETINOIN 10MG CAPSULE |
3 |
Tier 3 |
$69.00 | $138.00 | None |
TRETINOIN CREAM |
1 |
Tier 1 |
$0.00 | $0.00 | P |
TREXALL 10MG TABLET |
3 |
Tier 3 |
$69.00 | $138.00 | P |
TREXALL 15MG TABLET |
3 |
Tier 3 |
$69.00 | $138.00 | P |
TREXALL 5MG TABLET |
3 |
Tier 3 |
$69.00 | $138.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TREXALL 7.5MG TABLET |
3 |
Tier 3 |
$69.00 | $138.00 | P |
TRI PREVIFEM TABLETS |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRIAMCINOLONE 0.1% OINTMENT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRIAMCINOLONE 0.1% PASTE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRIAMCINOLONE ACETONIDE 0.025% OINTMENT 80GM TUBE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRIAMCINOLONE ACETONIDE 0.1% LOTION 60ML BOTPL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRIAMCINOLONE ACETONIDE 0.025% CREAM 80GM TUBE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRIAMCINOLONE ACETONIDE 0.025% LOTION 2 FL OZ BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRIAMCINOLONE ACETONIDE 0.05% CREAM 15GM TUBE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIAMCINOLONE ACETONIDE 0.1% CREAM 80GM TUBE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRIAMTERENE/HCTZ 25/37.5MG CAPSULES (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRIAMTERENE/HCTZ 37.5/25 TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRIAMTERENE/HCTZ 75/50 TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRICOR 145MG TABLET |
3 |
Tier 3 |
$69.00 | $138.00 | None |
TRICOR 48MG TABLET |
3 |
Tier 3 |
$69.00 | $138.00 | None |
TRIFLUOPERAZINE 1MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRIFLUOPERAZINE HCL 2MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRIFLUOPERAZINE HCL 5MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
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 |
$0.00 | $0.00 | None |
TRIHEXYPHENIDYL HCL ELIXIR 5%/2 16 FLO BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRIHEXYPHENIDYL HCL TABLET 2MG (1000 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRIHIBIT PRESERVATIVE FREE |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TRILEPTAL 300MG/5ML SUSP |
3 |
Tier 3 |
$69.00 | $138.00 | None |
TRIMETHOBENZAMIDE 100MG/ML |
1 |
Tier 1 |
$0.00 | $0.00 | P |
TRIMETHOBENZAMIDE HCL 300MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRIMETHOPRIM TABLETS |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRIPEDIA PRESERVATIVE FREE 6.7;23.4; UNT/.5 ML; |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TRISENOX 10MG/10ML AMPULE |
3 |
Tier 3 |
$69.00 | $138.00 | P |
TRIZIVIR TABLET |
4 |
Tier 4 |
33% | 33% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRUSOPT PLUS 2% EYE DROPS 10ML BOT |
3 |
Tier 3 |
$69.00 | $138.00 | None |
TRUVADA TABLET |
4 |
Tier 4 |
33% | 33% | Q:30 /30Days |
TWINRIX TF PF VACCINE 720UNT/20ML 10 X 1ML VIALSD |
2 |
Tier 2 |
$39.00 | $78.00 | P |
TYGACIL 50MG VIAL 10 VILSU BOX |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TYKERB 250MG TABLET |
4 |
Tier 4 |
33% | 33% | Q:150 /30Days |
TYPHIM VI 25MCG/0.5ML VIAL |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TYSABRI 300MG/15ML VIAL |
4 |
Tier 4 |
33% | 33% | None |
TYZEKA 600MG TABLET (30 CT) |
2 |
Tier 2 |
$39.00 | $78.00 | None |
TYZINE 0.1% NOSE DROPS |
2 |
Tier 2 |
$39.00 | $78.00 | None |