2012 Medicare Part D Plan Formulary Information |
First Health Part D Premier (PDP) (S5768-124-0)
Benefit Details
|
The First Health Part D Premier (PDP) (S5768-124-0) Formulary Drugs Starting with the Letter T in CMS PDP Region 33 which includes: HI
|
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 |
Non-Preferred Brand Drugs |
35% | 35% | Q:400 /28Days |
Tacrolimus 0.5mg/1 100 CAPSULE in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
35% | 35% | P |
Tacrolimus 1mg/1 100 CAPSULE in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
35% | 35% | P |
Tacrolimus 5mg/1 100 CAPSULE in 1 BOTTLE |
4 |
Specialty Tier Drugs |
26% | N/A | P |
Tamiflu 30mg/1 1 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
Tamiflu 45mg/1 1 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
Tamiflu 6mg/mL 1 BOTTLE, GLASS in 1 CARTON / 6 mL in 1 BOTTLE, GLASS |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
TAMIFLU 75MG CAPSULE UD |
3 |
Non-Preferred Brand Drugs |
35% | 35% | Q:56 /365Days |
TAMIFLU ORAL SUSPENSION |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
TAMOXIFEN CITRATE 20MG TABLET (30 CT) |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAMOXIFEN CITRATE TABLETS 10MG 180 BOT |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TAMSULOSIN HCL 0.4 MG CAPSULE |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | Q:60 /30Days |
TARCEVA 100MG TABLET |
4 |
Specialty Tier Drugs |
26% | N/A | P Q:30 /30Days |
TARCEVA 150MG TABLET |
4 |
Specialty Tier Drugs |
26% | N/A | P Q:30 /30Days |
TARCEVA 25MG TABLET |
4 |
Specialty Tier Drugs |
26% | N/A | P Q:30 /30Days |
TARGRETIN 1% GEL 60GM TUBE |
4 |
Specialty Tier Drugs |
26% | N/A | P Q:60 /30Days |
TARGRETIN 75MG (100 CT) |
4 |
Specialty Tier Drugs |
26% | N/A | P |
Tasigna 150mg/1 4 BLISTER PACK in 1 CARTON / 28 CAPSULE in 1 BLISTER PACK |
4 |
Specialty Tier Drugs |
26% | N/A | P Q:120 /30Days |
TASIGNA 200MG CAPSULE 28 BLPK |
4 |
Specialty Tier Drugs |
26% | N/A | P Q:120 /30Days |
TASMAR 100MG TABLET |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
TAXOTERE 80MG/2ML VIAL |
4 |
Specialty Tier Drugs |
26% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAXOTERE 80mg/4mL 1 VIAL, GLASS in 1 CARTON / 4 mL in 1 VIAL, GLASS |
4 |
Specialty Tier Drugs |
26% | N/A | None |
TAZORAC 0.05% CREAM |
3 |
Non-Preferred Brand Drugs |
35% | 35% | Q:30 /30Days |
TAZORAC 0.05% GEL |
3 |
Non-Preferred Brand Drugs |
35% | 35% | Q:30 /30Days |
TAZORAC 0.1% CREAM |
3 |
Non-Preferred Brand Drugs |
35% | 35% | Q:30 /30Days |
TAZORAC 0.1% GEL |
3 |
Non-Preferred Brand Drugs |
35% | 35% | Q:30 /30Days |
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TAZTIA XT 240MG CAPSULE SA |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TAZTIA XT 360MG CAPSULE SA |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
Teflaro 400mg/20mL 10 VIAL, SINGLE-DOSE in 1 CARTON / 20 mL in 1 VIAL, SINGLE-DOSE |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Teflaro 600mg/20mL 10 VIAL, SINGLE-DOSE in 1 CARTON / 20 mL in 1 VIAL, SINGLE-DOSE |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
TEGRETOL CHEWABLE TABLETS 100MG 100 BOT |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
TEGRETOL SUSPENSION 100MG/5ML 450 ML BOT |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
TEGRETOL TABLETS 200MG 100 BOT |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
TEGRETOL XR TABLETS 100MG 100 BOT |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
TEGRETOL XR TABLETS 200MG 100 BOT |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
TEGRETOL XR TABLETS 400MG 100 BOT |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
TERAZOSIN HCL 10MG CAPSULE |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TERAZOSIN HCL 1MG CAPSULE |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TERAZOSIN HCL 2MG CAPSULE |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TERAZOSIN HCL 5MG CAPSULE |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TERBINAFINE HCL 250MG TABLET |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | Q:30 /30Days |
TERBUTALINE SULF 2.5MG TABLET |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TERBUTALINE SULFATE 5MG TABLET |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TERCONAZOLE 0.4% CREAM WITH APPLICATOR |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TERCONAZOLE 80MG SUPPOSITORY VAGINAL |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
TERCONAZOLE VAGINAL CREAM |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
Testosterone Cypionate 200mg/mL 1 VIAL, MULTI-DOSE in 1 CARTON / 10 mL in 1 VIAL, MULTI-DOSE |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
TESTOSTERONE CYPIONATE INJECTION |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
TESTOSTERONE ENANTHATE INJECTION |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
TESTRED 10MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
35% | 35% | P |
Tetanus and Diphtheria Toxoids Adsorbed 2.0; 2.0[Lf]/0.5mL; [Lf]/0.5mL 10 VIAL, SINGLE-DOSE in 1 CA |
2 |
Preferred Brand Drugs |
20% | 18% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TETANUS TOXOID ADSORBED VIAL 5LF |
2 |
Preferred Brand Drugs |
20% | 18% | None |
TETRACYCLINE 500MG CAPSULE |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
Tetracycline Hydrochloride 250mg/1 100 CAPSULE in 1 BOTTLE |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
THALITONE 15MG TABLET |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
THALOMID 100MG CAPSULE 140 BOX |
4 |
Specialty Tier Drugs |
26% | N/A | P Q:28 /28Days |
Thalomid 150mg/1 |
4 |
Specialty Tier Drugs |
26% | N/A | P Q:28 /28Days |
Thalomid 200mg/1 |
4 |
Specialty Tier Drugs |
26% | N/A | P Q:28 /28Days |
THALOMID 50MG CAPSULE 280 BOX |
4 |
Specialty Tier Drugs |
26% | N/A | P Q:28 /28Days |
THEO-24 100MG CAPSULE SA |
3 |
Non-Preferred Brand Drugs |
35% | 35% | Q:30 /30Days |
THEO-24 200MG CAPSULE SA |
3 |
Non-Preferred Brand Drugs |
35% | 35% | Q:30 /30Days |
THEO-24 300MG CAPSULE SA |
3 |
Non-Preferred Brand Drugs |
35% | 35% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THEO-24 400MG CAPSULE SA |
3 |
Non-Preferred Brand Drugs |
35% | 35% | Q:30 /30Days |
THEOCHRON 100MG TABLET SA |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
THEOCHRON TABLETS EXTENDED RELEASE 300MG 100 BOT |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
Theophylline 100mg/1 500 CAPSULE in 1 BOTTLE |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
THEOPHYLLINE 400MG TABLET SA |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
THEOPHYLLINE 600MG TABLET SA |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
THEOPHYLLINE ANHYDROUS ER TABLET 200MG (1000 CT) |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
THEOPHYLLINE TABLET ER 300MG (100 CT) |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
THEOPHYLLINE TABLET ER 450MG (100 CT) |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
Thermazene 10mg/g |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
THIOGUANINE TABLET LOID 40MG |
2 |
Preferred Brand Drugs |
20% | 18% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THIORIDAZINE 100MG TABLET |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
THIORIDAZINE HCL 10MG TABLET (1000 CT) |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
THIORIDAZINE HCL 25MG TABLET (1000 CT) |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
THIORIDAZINE HCL 50MG TABLET (1000 CT) |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
THIOTEPA POWDER FOR INJECTION 15MG/VIL 1 VIAL SINGLE DOSE CRTN |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
THIOTHIXENE 10MG CAPSULE |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
THIOTHIXENE 1MG CAPSULE (100 CT) |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
THIOTHIXENE 2MG CAPSULE |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
THIOTHIXENE 5MG CAPSULE |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
THYROLAR-1 60MG TABLET |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
THYROLAR-1/4 15MG TABLET |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THYROLAR-2 120MG TABLET |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
THYROLAR-3 180MG TABLET |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
Ticlopidine Hydrochloride 250mg/1 60 TABLET, FILM COATED in 1 BOTTLE |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TIKOSYN .125MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
TIKOSYN .250MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
TIKOSYN .5MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
TIMENTIN 3.1GM VIAL |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
TIMOLOL MAL SOL 0.25% OP 15ML BOT |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TIMOLOL MAL SOL 0.5% OP 10ML BOT |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TIMOLOL MALEATE 10MG TABLET |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TIMOLOL MALEATE 20MG TABLET |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Timolol Maleate 3.4mg/mL 1 BOTTLE, DISPENSING in 1 CARTON / 5 mL in 1 BOTTLE, DISPENSING |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
TIMOLOL MALEATE 5MG TABLET |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
Timolol Maleate 6.8mg/mL 1 BOTTLE, DISPENSING in 1 CARTON / 5 mL in 1 BOTTLE, DISPENSING |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
TINIDAZOLE TAB 250MG |
3 |
Non-Preferred Brand Drugs |
35% | 35% | Q:20 /30Days |
TINIDAZOLE TAB 500MG |
3 |
Non-Preferred Brand Drugs |
35% | 35% | Q:10 /30Days |
Tirosint 100ug/1 4 BLISTER PACK in 1 CARTON / 7 CAPSULE in 1 BLISTER PACK |
2 |
Preferred Brand Drugs |
20% | 18% | Q:30 /30Days |
Tirosint 112ug/1 4 BLISTER PACK in 1 CARTON / 7 CAPSULE in 1 BLISTER PACK |
2 |
Preferred Brand Drugs |
20% | 18% | Q:30 /30Days |
Tirosint 125ug/1 4 BLISTER PACK in 1 CARTON / 7 CAPSULE in 1 BLISTER PACK |
2 |
Preferred Brand Drugs |
20% | 18% | Q:30 /30Days |
Tirosint 137ug/1 4 BLISTER PACK in 1 CARTON / 7 CAPSULE in 1 BLISTER PACK |
2 |
Preferred Brand Drugs |
20% | 18% | Q:30 /30Days |
Tirosint 13ug/1 4 BLISTER PACK in 1 CARTON / 7 CAPSULE in 1 BLISTER PACK |
2 |
Preferred Brand Drugs |
20% | 18% | Q:30 /30Days |
Tirosint 150ug/1 4 BLISTER PACK in 1 CARTON / 7 CAPSULE in 1 BLISTER PACK |
2 |
Preferred Brand Drugs |
20% | 18% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Tirosint 25ug/1 4 BLISTER PACK in 1 CARTON / 7 CAPSULE in 1 BLISTER PACK |
2 |
Preferred Brand Drugs |
20% | 18% | Q:30 /30Days |
Tirosint 50ug/1 4 BLISTER PACK in 1 CARTON / 7 CAPSULE in 1 BLISTER PACK |
2 |
Preferred Brand Drugs |
20% | 18% | Q:30 /30Days |
Tirosint 75ug/1 4 BLISTER PACK in 1 CARTON / 7 CAPSULE in 1 BLISTER PACK |
2 |
Preferred Brand Drugs |
20% | 18% | Q:30 /30Days |
Tirosint 88ug/1 4 BLISTER PACK in 1 CARTON / 7 CAPSULE in 1 BLISTER PACK |
2 |
Preferred Brand Drugs |
20% | 18% | Q:30 /30Days |
tizanidine 4mg/1 |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TIZANIDINE HCL 2 MG TABLET |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TOBI 300mg/5mL 56 AMPULE in 1 CARTON / 5 mL in 1 AMPULE |
4 |
Specialty Tier Drugs |
26% | N/A | P Q:280 /28Days |
TOBRADEX EYE OINTMENT |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
TOBRADEX ST 0.5; 3mg/mL; mg/mL 5 mL in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
TOBRAMYCIN 10MG/ML VIAL |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
TOBRAMYCIN 40MG/ML VIAL |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOBRAMYCIN 60MG/0.9% NACL |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
TOBRAMYCIN 80MG/0.9% NACL |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
TOBRAMYCIN OPHTHALMIC SOLUTION 0.3% 5ML BOT |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TOBRAMYCIN-DEXAMETH OPTH SUSP |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
TOBRASOL 0.3% EYE DROPS |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TOBREX 0.3% EYE OINTMENT |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
TOLAZAMIDE TABLETS 250MG 100 BOT |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TOLAZAMIDE TABLETS 500MG 100 BOT |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TOLBUTAMIDE 500MG TABLET |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TOLMETIN SODIUM 200MG TABLET |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
TOLMETIN SODIUM 400MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOLMETIN SODIUM 600MG TABLET |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
TOLVAPTAN 15 MG ORAL TABLET [SAMSCA] |
4 |
Specialty Tier Drugs |
26% | N/A | P Q:30 /30Days |
TOLVAPTAN 30 MG ORAL TABLET [SAMSCA] |
4 |
Specialty Tier Drugs |
26% | N/A | P Q:60 /30Days |
Topiramate 25mg/1 |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
TOPIRAMATE SPRINKLE CAPSULES 15MG 60 BOT |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
TOPIRAMATE TABLETS 100MG 1000 BOT |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | Q:90 /30Days |
TOPIRAMATE TABLETS 200MG 1000 BOT |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TOPIRAMATE TABLETS 25MG 1000 BOT |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TOPIRAMATE TABLETS 50MG 1000 BOT |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | Q:90 /30Days |
Torsemide 100mg/1 12 BOTTLE in 1 CASE / 100 TABLET in 1 BOTTLE |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TORSEMIDE 20mg/1 100 TABLET in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TORSEMIDE TABLETS |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TORSEMIDE TABLETS |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TPN ELECTROLYTES VIAL |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
TRACLEER 125MG TABLET |
4 |
Specialty Tier Drugs |
26% | N/A | P Q:60 /30Days |
TRACLEER 62.5MG TABLET |
4 |
Specialty Tier Drugs |
26% | N/A | P Q:60 /30Days |
TRAMADOL HCL 50 MG TABLET |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TRAMADOL HCL-ACETAMINOPHEN 37.5-325MG TABLET (1000 CT) |
3 |
Non-Preferred Brand Drugs |
35% | 35% | Q:240 /30Days |
TRANDOLAPRIL 1MG TABLET |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TRANDOLAPRIL 2MG TABLET |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TRANDOLAPRIL 4MG TABLET |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TRANEXAMIC ACID 1,000 MG/10 ML |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRANYLCYPROMINE SULFATE 10MG TABLET |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TRAVASOL 10% SOLUTION VIAFLEX |
3 |
Non-Preferred Brand Drugs |
35% | 35% | P |
TRAVATAN Z 0.04MG DROPS 2.5ML BOT |
3 |
Non-Preferred Brand Drugs |
35% | 35% | Q:5 /30Days |
TRAZODONE 300MG TABLET |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TRAZODONE HCL TABLET USP 100MG (500 CT) |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TRAZODONE HCL TABLET USP 150MG (100 CT) |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TRAZODONE HCL TABLET USP 50MG (500 CT) |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TRECATOR 250MG TABLET |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
Trelstar 22.5mg/2mL 2 mL in 1 VIAL, SINGLE-DOSE |
4 |
Specialty Tier Drugs |
26% | N/A | Q:1 /180Days |
TRELSTAR DEPOT MIXJET FOR INJECTION 3.75 MG |
4 |
Specialty Tier Drugs |
26% | N/A | Q:1 /30Days |
TRELSTAR MIXJET FOR INJECTION 11.25 MG |
4 |
Specialty Tier Drugs |
26% | N/A | Q:1 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Tretinoin 0.1mg/g 1 TUBE in 1 CARTON / 45 g in 1 TUBE |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
Tretinoin 0.25mg/g 1 TUBE in 1 CARTON / 15 g in 1 TUBE |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
Tretinoin 0.25mg/g 1 TUBE in 1 CARTON / 45 g in 1 TUBE |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
Tretinoin 0.5mg/g 1 TUBE in 1 CARTON / 20 g in 1 TUBE |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TRETINOIN 10MG CAPSULE |
4 |
Specialty Tier Drugs |
26% | N/A | P |
Tretinoin 1mg/g 1 TUBE in 1 CARTON / 45 g in 1 TUBE |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TRI PREVIFEM TABLETS |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | Q:28 /28Days |
TRI-LEGEST FE 5-7-9-7 TABLET |
3 |
Non-Preferred Brand Drugs |
35% | 35% | Q:28 /28Days |
TRI-SPRINTEC 7DAYSX3 28 TABLET |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | Q:28 /28Days |
TRIAMCINOLONE 0.1% OINTMENT |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TRIAMCINOLONE ACETONIDE 0.025% CREAM 80GM TUBE |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | 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 |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TRIAMCINOLONE ACETONIDE 0.025% OINTMENT 80GM TUBE |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TRIAMCINOLONE ACETONIDE 0.1% CREAM 80GM TUBE |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TRIAMCINOLONE ACETONIDE 0.1% LOTION 60ML BOTPL |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
Triamcinolone Acetonide 1mg/g 1 TUBE in 1 CARTON / 5 g in 1 TUBE |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
Triamcinolone Acetonide 55ug/1 1 BOTTLE, SPRAY in 1 CARTON / 120 SPRAY, METERED in 1 BOTTLE, SPRAY |
3 |
Non-Preferred Brand Drugs |
35% | 35% | Q:33 /30Days |
Triamcinolone Acetonide 5mg/g 1 TUBE in 1 CARTON / 15 g in 1 TUBE |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
Triamterene and Hydrochlorothiazide 25; 37.5mg/1; mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TRIAMTERENE/HCTZ 37.5/25 TABLET |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIAMTERENE/HCTZ 75/50 TABLET |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TRICOR 145MG TABLET |
3 |
Non-Preferred Brand Drugs |
35% | 35% | Q:30 /30Days |
Tricor 48mg/1 90 TABLET in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
35% | 35% | Q:30 /30Days |
TRIDERM 0.1% CREAM |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TRIFLUOPERAZINE 1MG TABLET |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TRIFLUOPERAZINE HCL 2MG TABLET |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TRIFLUOPERAZINE HCL 5MG TABLET |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT) |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
TRIGLIDE 160MG TABLET (30 CT) |
3 |
Non-Preferred Brand Drugs |
35% | 35% | Q:30 /30Days |
TRIGLIDE 50MG TABLET (30 CT) |
3 |
Non-Preferred Brand Drugs |
35% | 35% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIHEXYPHENIDYL HYDROCHLORIDE 2mg/1 |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
Trihexyphenidyl Hydrochloride 2mg/5mL 473 mL in 1 BOTTLE |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
Trihexyphenidyl Hydrochloride 5mg/1 100 TABLET in 1 BOTTLE |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TRILIPIX CAPSULE DR 45MG |
3 |
Non-Preferred Brand Drugs |
35% | 35% | Q:30 /30Days |
TRILIPIX DELAYED RELEASE CAPSULES 135MG |
3 |
Non-Preferred Brand Drugs |
35% | 35% | Q:30 /30Days |
TRIMETHOBENZAMIDE HCL 300MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
TRIMETHOPRIM TABLETS |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TRIMIPRAMINE MALEATE 100 MG CAP |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
TRIMIPRAMINE MALEATE 25 MG CAP |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
TRIMIPRAMINE MALEATE 50 MG CAP |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
TRINESSA TABLET |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | Q:28 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIPEDIA PRESERVATIVE FREE 6.7;23.4; UNT/.5 ML; |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
TRISENOX 10MG/10ML AMPULE |
3 |
Non-Preferred Brand Drugs |
35% | 35% | P |
Trivora 6 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK |
3 |
Non-Preferred Brand Drugs |
35% | 35% | Q:28 /28Days |
TRIZIVIR 300; 150; 300mg/1; mg/1; mg/1 60 TABLET, FILM COATED in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
TROPHAMINE INJECTION SOLUTION |
3 |
Non-Preferred Brand Drugs |
35% | 35% | P |
TROPHAMINE INJECTION SOLUTION 6% |
3 |
Non-Preferred Brand Drugs |
35% | 35% | P |
TROPICAMIDE 0.5% EYE DROPS |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TROPICAMIDE OPHTHALMIC SOLUTION USP |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | None |
TROSPIUM CHLORIDE TABLETS |
1 |
Preferred Generic Drugs |
$7.00 | $17.50 | Q:60 /30Days |
TRUVADA TABLET |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
TWINJECT AUTO INJECTOR INJECTION 1% AUTO INJECTOR TWO PACK SYR |
2 |
Preferred Brand Drugs |
20% | 18% | Q:1 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TWINJECT AUTO INJECTOR INJECTION 1% AUTO TWO PACK SYR |
2 |
Preferred Brand Drugs |
20% | 18% | Q:1 /30Days |
TWINRIX TF PF VACCINE 720UNT/20ML 10 X 1ML VIALSD |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
Twynsta 10; 40mg/1; mg/1 3 BLISTER PACK in 1 CARTON / 10 TABLET, MULTILAYER in 1 BLISTER PACK |
3 |
Non-Preferred Brand Drugs |
35% | 35% | Q:30 /30Days |
Twynsta 10; 80mg/1; mg/1 3 BLISTER PACK in 1 CARTON / 10 TABLET, MULTILAYER in 1 BLISTER PACK |
3 |
Non-Preferred Brand Drugs |
35% | 35% | Q:30 /30Days |
Twynsta 5; 40mg/1; mg/1 3 BLISTER PACK in 1 CARTON / 10 TABLET, MULTILAYER in 1 BLISTER PACK |
3 |
Non-Preferred Brand Drugs |
35% | 35% | Q:30 /30Days |
Twynsta 5; 80mg/1; mg/1 3 BLISTER PACK in 1 CARTON / 10 TABLET, MULTILAYER in 1 BLISTER PACK |
3 |
Non-Preferred Brand Drugs |
35% | 35% | Q:30 /30Days |
Tygacil 50mg/5mL 10 VIAL, SINGLE-USE in 1 CARTON / 50 mL in 1 VIAL, SINGLE-USE |
3 |
Non-Preferred Brand Drugs |
35% | 35% | P |
TYKERB 250MG TABLET |
4 |
Specialty Tier Drugs |
26% | N/A | P Q:180 /30Days |
TYPHIM VI 25MCG/0.5ML VIAL |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
TYZEKA 600MG TABLET (30 CT) |
3 |
Non-Preferred Brand Drugs |
35% | 35% | Q:30 /30Days |
TYZINE 0.1% NOSE DROPS |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TYZINE PEDIATRIC 0.05% DROP |
3 |
Non-Preferred Brand Drugs |
35% | 35% | None |