2012 Medicare Part D Plan Formulary Information |
Aetna Medicare Rx Premier (PDP) (S5810-189-0)
Benefit Details
|
The Aetna Medicare Rx Premier (PDP) (S5810-189-0) Formulary Drugs Starting with the Letter T in CMS PDP Region 19 which includes: AR
|
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 SCALP SUSPENSION |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | S |
Tacrolimus 0.5mg/1 100 CAPSULE in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | P |
Tacrolimus 1mg/1 100 CAPSULE in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | P |
Tacrolimus 5mg/1 100 CAPSULE in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | P |
TALWIN 30MG/ML VIAL |
5 |
Specialty Tier Drugs |
33% | 33% | P |
Tamiflu 30mg/1 1 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | Q:168 /365Days |
Tamiflu 45mg/1 1 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | Q:84 /365Days |
Tamiflu 6mg/mL 1 BOTTLE, GLASS in 1 CARTON / 6 mL in 1 BOTTLE, GLASS |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | Q:1080 /365Days |
TAMIFLU 75MG CAPSULE UD |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | Q:84 /365Days |
TAMIFLU ORAL SUSPENSION |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | Q:525 /365Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAMOXIFEN CITRATE 20MG TABLET (30 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TAMOXIFEN CITRATE TABLETS 10MG 180 BOT |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TAMSULOSIN HCL 0.4 MG CAPSULE |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | Q:2 /1Days |
TAPAZOLE 10MG TABLET |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
TAPAZOLE 5MG TABLET |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
TARCEVA 100MG TABLET |
5 |
Specialty Tier Drugs |
33% | 33% | P Q:3 /1Days |
TARCEVA 150MG TABLET |
5 |
Specialty Tier Drugs |
33% | 33% | P Q:3 /1Days |
TARCEVA 25MG TABLET |
5 |
Specialty Tier Drugs |
33% | 33% | P Q:2 /1Days |
TARGRETIN 1% GEL 60GM TUBE |
5 |
Specialty Tier Drugs |
33% | 33% | P |
TARGRETIN 75MG (100 CT) |
5 |
Specialty Tier Drugs |
33% | 33% | P |
Tasigna 150mg/1 4 BLISTER PACK in 1 CARTON / 28 CAPSULE in 1 BLISTER PACK |
5 |
Specialty Tier Drugs |
33% | 33% | P Q:4 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TASIGNA 200MG CAPSULE 28 BLPK |
5 |
Specialty Tier Drugs |
33% | 33% | P Q:4 /1Days |
TAXOTERE 80MG/2ML VIAL |
5 |
Specialty Tier Drugs |
33% | 33% | P |
TAXOTERE 80mg/4mL 1 VIAL, GLASS in 1 CARTON / 4 mL in 1 VIAL, GLASS |
5 |
Specialty Tier Drugs |
33% | 33% | P |
TAZICEF 1GM VIAL |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | None |
TAZICEF 2GM ADD-VANTAGE |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | None |
TAZICEF 6GM/100ML VIAL |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | None |
TAZORAC 0.05% CREAM |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
TAZORAC 0.05% GEL |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
TAZORAC 0.1% CREAM |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
TAZORAC 0.1% GEL |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | Q:1 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | Q:3 /1Days |
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TAZTIA XT 240MG CAPSULE SA |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TAZTIA XT 360MG CAPSULE SA |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
Teflaro 400mg/20mL 10 VIAL, SINGLE-DOSE in 1 CARTON / 20 mL in 1 VIAL, SINGLE-DOSE |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
Teflaro 600mg/20mL 10 VIAL, SINGLE-DOSE in 1 CARTON / 20 mL in 1 VIAL, SINGLE-DOSE |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
TEGRETOL XR TABLETS 100MG 100 BOT |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
TEGRETOL XR TABLETS 200MG 100 BOT |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
TEGRETOL XR TABLETS 400MG 100 BOT |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
Tekamlo 150; 10mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
3 |
Preferred Brand Drugs |
$35.00 | $90.00 | Q:1 /1Days |
Tekamlo 150; 5mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
3 |
Preferred Brand Drugs |
$35.00 | $90.00 | Q:1 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Tekamlo 300; 10mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
3 |
Preferred Brand Drugs |
$35.00 | $90.00 | Q:1 /1Days |
Tekamlo 300; 5mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
3 |
Preferred Brand Drugs |
$35.00 | $90.00 | Q:1 /1Days |
TEKTURNA 150MG TABLET |
3 |
Preferred Brand Drugs |
$35.00 | $90.00 | Q:1 /1Days |
TEKTURNA 300MG TABLET |
3 |
Preferred Brand Drugs |
$35.00 | $90.00 | None |
TEKTURNA HCT 150-12.5MG TABLET |
3 |
Preferred Brand Drugs |
$35.00 | $90.00 | Q:1 /1Days |
TEKTURNA HCT 150MG-25MG TABLET |
3 |
Preferred Brand Drugs |
$35.00 | $90.00 | Q:1 /1Days |
TEKTURNA HCT 300-12.5MG TABLET |
3 |
Preferred Brand Drugs |
$35.00 | $90.00 | None |
TEKTURNA HCT 300MG-25MG TABLET |
3 |
Preferred Brand Drugs |
$35.00 | $90.00 | None |
TEMOVATE 0.05% CREAM 60GM TUBE |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
TEMOVATE 0.05% GEL 60GM BOX |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
TEMOVATE 0.05% OINTMENT |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Temovate Scalp Application 0.5mg/mL 50 mL in 1 BOTTLE, PLASTIC |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
TENORETIC 100 TABLET |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
TENORMIN 25MG TABLET |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
TERAZOSIN HCL 10MG CAPSULE |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TERAZOSIN HCL 1MG CAPSULE |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TERAZOSIN HCL 2MG CAPSULE |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TERAZOSIN HCL 5MG CAPSULE |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TERBINAFINE HCL 250MG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | P Q:1 /1Days |
TERBUTALINE SULF 1MG/ML VL |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TERBUTALINE SULF 2.5MG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TERBUTALINE SULFATE 5MG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | 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 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TERCONAZOLE 80MG SUPPOSITORY VAGINAL |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | None |
TERCONAZOLE VAGINAL CREAM |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | None |
Testosterone Cypionate 200mg/mL 1 VIAL, MULTI-DOSE in 1 CARTON / 10 mL in 1 VIAL, MULTI-DOSE |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | None |
TESTOSTERONE CYPIONATE INJECTION |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | None |
TESTOSTERONE ENANTHATE INJECTION |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TESTRED 10MG CAPSULE |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
Tetanus and Diphtheria Toxoids Adsorbed 2.0; 2.0[Lf]/0.5mL; [Lf]/0.5mL 10 VIAL, SINGLE-DOSE in 1 CA |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | None |
TETANUS TOXOID ADSORBED VIAL 5LF |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | P |
TETRACYCLINE 500MG CAPSULE |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | P |
Tetracycline Hydrochloride 250mg/1 100 CAPSULE in 1 BOTTLE |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THALOMID 100MG CAPSULE 140 BOX |
5 |
Specialty Tier Drugs |
33% | 33% | P Q:28 /28Days |
Thalomid 150mg/1 |
5 |
Specialty Tier Drugs |
33% | 33% | P Q:28 /28Days |
Thalomid 200mg/1 |
5 |
Specialty Tier Drugs |
33% | 33% | P Q:28 /28Days |
THALOMID 50MG CAPSULE 280 BOX |
5 |
Specialty Tier Drugs |
33% | 33% | P Q:28 /28Days |
THEO-24 100MG CAPSULE SA |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
THEO-24 200MG CAPSULE SA |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
THEO-24 300MG CAPSULE SA |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
THEO-24 400MG CAPSULE SA |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
THEOCHRON 100MG TABLET SA |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
THEOCHRON TABLETS EXTENDED RELEASE 300MG 100 BOT |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
Theophylline 100mg/1 500 CAPSULE in 1 BOTTLE |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THEOPHYLLINE 400MG TABLET SA |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
THEOPHYLLINE 600MG TABLET SA |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
THEOPHYLLINE ANHYDROUS ER TABLET 200MG (1000 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
THEOPHYLLINE TABLET ER 300MG (100 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
THEOPHYLLINE TABLET ER 450MG (100 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
Thermazene 10mg/g |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
THIOGUANINE TABLET LOID 40MG |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
THIORIDAZINE 100MG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
THIORIDAZINE HCL 10MG TABLET (1000 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
THIORIDAZINE HCL 25MG TABLET (1000 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
THIORIDAZINE HCL 50MG TABLET (1000 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THIOTEPA POWDER FOR INJECTION 15MG/VIL 1 VIAL SINGLE DOSE CRTN |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | P |
THIOTHIXENE 10MG CAPSULE |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
THIOTHIXENE 1MG CAPSULE (100 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
THIOTHIXENE 2MG CAPSULE |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
THIOTHIXENE 5MG CAPSULE |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
THYMOGLOBULIN 25MG VIAL |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | P |
THYROLAR-1 60MG TABLET |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
THYROLAR-1/4 15MG TABLET |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
THYROLAR-2 120MG TABLET |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
THYROLAR-3 180MG TABLET |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
Ticlopidine Hydrochloride 250mg/1 60 TABLET, FILM COATED in 1 BOTTLE |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | Q:2 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIKOSYN .125MG CAPSULE |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
TIKOSYN .250MG CAPSULE |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
TIKOSYN .5MG CAPSULE |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
TIMENTIN 3.1GM VIAL |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
TIMOLOL MAL SOL 0.25% OP 15ML BOT |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TIMOLOL MAL SOL 0.5% OP 10ML BOT |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TIMOLOL MALEATE 10MG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TIMOLOL MALEATE 20MG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
Timolol Maleate 3.4mg/mL 1 BOTTLE, DISPENSING in 1 CARTON / 5 mL in 1 BOTTLE, DISPENSING |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TIMOLOL MALEATE 5MG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
Timolol Maleate 6.8mg/mL 1 BOTTLE, DISPENSING in 1 CARTON / 5 mL in 1 BOTTLE, DISPENSING |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TINIDAZOLE TAB 250MG |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | None |
TINIDAZOLE TAB 500MG |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | None |
TIS-U-SOL IRRIGATION SOLUTION |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | None |
tizanidine 4mg/1 |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TIZANIDINE HCL 2 MG CAPSULE |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TIZANIDINE HCL 2 MG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TIZANIDINE HCL 4 MG CAPSULE |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TIZANIDINE HCL 6 MG CAPSULE |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TOBI 300mg/5mL 56 AMPULE in 1 CARTON / 5 mL in 1 AMPULE |
5 |
Specialty Tier Drugs |
33% | 33% | P Q:10 /1Days |
TOBRADEX ST 0.5; 3mg/mL; mg/mL 5 mL in 1 BOTTLE |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
TOBRAMYCIN 10MG/ML VIAL |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOBRAMYCIN 40MG/ML VIAL |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TOBRAMYCIN 60MG/0.9% NACL |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | None |
TOBRAMYCIN 80MG/0.9% NACL |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | None |
TOBRAMYCIN OPHTHALMIC SOLUTION 0.3% 5ML BOT |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TOBRAMYCIN-DEXAMETH OPTH SUSP |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | None |
TOBRASOL 0.3% EYE DROPS |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TOBREX 0.3% EYE DROPS |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
TOBREX 0.3% EYE OINTMENT |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
TOFRANIL 50MG TABLET (30 CT) |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
TOFRANIL TABLETS 10MG 30 BOT |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
TOFRANIL TABLETS 25MG 30 BOT |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOLAZAMIDE TABLETS 250MG 100 BOT |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | Q:2 /1Days |
TOLAZAMIDE TABLETS 500MG 100 BOT |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | Q:3 /1Days |
TOLBUTAMIDE 500MG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | Q:6 /1Days |
TOLMETIN SODIUM 200MG TABLET |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | None |
TOLMETIN SODIUM 400MG CAPSULE |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TOLMETIN SODIUM 600MG TABLET |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | None |
TOLVAPTAN 15 MG ORAL TABLET [SAMSCA] |
5 |
Specialty Tier Drugs |
33% | 33% | P Q:4 /1Days |
TOLVAPTAN 30 MG ORAL TABLET [SAMSCA] |
5 |
Specialty Tier Drugs |
33% | 33% | P Q:4 /1Days |
Topicort 0.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
Topicort 0.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
Topicort 2.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Topicort 2.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
Topiramate 25mg/1 |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | None |
TOPIRAMATE SPRINKLE CAPSULES 15MG 60 BOT |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | None |
TOPIRAMATE TABLETS 100MG 1000 BOT |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | None |
TOPIRAMATE TABLETS 200MG 1000 BOT |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | None |
TOPIRAMATE TABLETS 25MG 1000 BOT |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | None |
TOPIRAMATE TABLETS 50MG 1000 BOT |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | None |
TOPOSAR INJECTION 20MG/ML 50ML VIAL MD CRTN |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | P |
TOPOTECAN HYDROCHLORIDE FOR INJECTION |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | P |
Torisel 1 KIT in 1 CARTON |
5 |
Specialty Tier Drugs |
33% | 33% | P |
Torsemide 100mg/1 12 BOTTLE in 1 CASE / 100 TABLET in 1 BOTTLE |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TORSEMIDE 20mg/1 100 TABLET in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TORSEMIDE INJECTION 20MG/2ML |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | None |
TORSEMIDE TABLETS |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TORSEMIDE TABLETS |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TPN ELECTROLYTES VIAL |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | None |
TRACLEER 125MG TABLET |
5 |
Specialty Tier Drugs |
33% | 33% | P Q:2 /1Days |
TRACLEER 62.5MG TABLET |
5 |
Specialty Tier Drugs |
33% | 33% | P Q:2 /1Days |
TRADJENTA 5mg/1 90 TABLET, FILM COATED in 1 BOTTLE |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | Q:1 /1Days |
TRAMADOL HCL 50 MG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | Q:8 /1Days |
TRAMADOL HCL-ACETAMINOPHEN 37.5-325MG TABLET (1000 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | Q:8 /1Days |
TRAMADOL HYDROCHLORIDE 100mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | Q:1 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRAMADOL HYDROCHLORIDE 200mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | Q:2 /1Days |
TRANDOLAPRIL 1MG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TRANDOLAPRIL 2MG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TRANDOLAPRIL 4MG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TRANEXAMIC ACID 1,000 MG/10 ML |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | None |
TRANYLCYPROMINE SULFATE 10MG TABLET |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | None |
TRAVATAN Z 0.04MG DROPS 2.5ML BOT |
3 |
Preferred Brand Drugs |
$35.00 | $90.00 | None |
TRAZODONE 300MG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TRAZODONE HCL TABLET USP 100MG (500 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TRAZODONE HCL TABLET USP 150MG (100 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TRAZODONE HCL TABLET USP 50MG (500 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TREANDA FOR INJECTION 100MG/VIAL |
5 |
Specialty Tier Drugs |
33% | 33% | P |
TRECATOR 250MG TABLET |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
Trelstar 22.5mg/2mL 2 mL in 1 VIAL, SINGLE-DOSE |
5 |
Specialty Tier Drugs |
33% | 33% | P |
TRELSTAR DEPOT MIXJET FOR INJECTION 3.75 MG |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | P |
TRELSTAR MIXJET FOR INJECTION 11.25 MG |
5 |
Specialty Tier Drugs |
33% | 33% | P |
Tretinoin 0.1mg/g 1 TUBE in 1 CARTON / 45 g in 1 TUBE |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | P |
Tretinoin 0.25mg/g 1 TUBE in 1 CARTON / 15 g in 1 TUBE |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | P |
Tretinoin 0.25mg/g 1 TUBE in 1 CARTON / 45 g in 1 TUBE |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | P |
Tretinoin 0.5mg/g 1 TUBE in 1 CARTON / 20 g in 1 TUBE |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | P |
TRETINOIN 10MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | P |
Tretinoin 1mg/g 1 TUBE in 1 CARTON / 45 g in 1 TUBE |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TREXALL 10MG TABLET |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | P |
TREXALL 15MG TABLET |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | P |
TREXALL 5MG TABLET |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | P |
TREXALL 7.5MG TABLET |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | P |
TRI PREVIFEM TABLETS |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | Q:28 /28Days |
TRI-LEGEST FE 5-7-9-7 TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TRI-SPRINTEC 7DAYSX3 28 TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | Q:28 /28Days |
TRIAMCINOLONE 0.1% OINTMENT |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TRIAMCINOLONE ACETONIDE 0.025% CREAM 80GM TUBE |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TRIAMCINOLONE ACETONIDE 0.025% LOTION 2 FL OZ BOT |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TRIAMCINOLONE ACETONIDE 0.025% OINTMENT 80GM TUBE |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TRIAMCINOLONE ACETONIDE 0.1% CREAM 80GM TUBE |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TRIAMCINOLONE ACETONIDE 0.1% LOTION 60ML BOTPL |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
Triamcinolone Acetonide 1mg/g 1 TUBE in 1 CARTON / 5 g in 1 TUBE |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
Triamcinolone Acetonide 5mg/g 1 TUBE in 1 CARTON / 15 g in 1 TUBE |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
Triamterene and Hydrochlorothiazide 25; 37.5mg/1; mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TRIAMTERENE/HCTZ 37.5/25 TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TRIAMTERENE/HCTZ 75/50 TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TRICOR 145MG TABLET |
3 |
Preferred Brand Drugs |
$35.00 | $90.00 | None |
Tricor 48mg/1 90 TABLET in 1 BOTTLE |
3 |
Preferred Brand Drugs |
$35.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIDERM 0.1% CREAM |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TRIFLUOPERAZINE 1MG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TRIFLUOPERAZINE HCL 2MG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TRIFLUOPERAZINE HCL 5MG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | None |
TRIHEXYPHENIDYL HYDROCHLORIDE 2mg/1 |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
Trihexyphenidyl Hydrochloride 2mg/5mL 473 mL in 1 BOTTLE |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
Trihexyphenidyl Hydrochloride 5mg/1 100 TABLET in 1 BOTTLE |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TRILIPIX CAPSULE DR 45MG |
3 |
Preferred Brand Drugs |
$35.00 | $90.00 | None |
TRILIPIX DELAYED RELEASE CAPSULES 135MG |
3 |
Preferred Brand Drugs |
$35.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIMETHOBENZAMIDE 100MG/ML |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | P |
TRIMETHOBENZAMIDE HCL 300MG CAPSULE |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | P |
TRIMETHOPRIM TABLETS |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TRIMIPRAMINE MALEATE 100 MG CAP |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | None |
TRIMIPRAMINE MALEATE 25 MG CAP |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | None |
TRIMIPRAMINE MALEATE 50 MG CAP |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | None |
TRINESSA TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | Q:28 /28Days |
TRIPEDIA PRESERVATIVE FREE 6.7;23.4; UNT/.5 ML; |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
TRISENOX 10MG/10ML AMPULE |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
Trivora 6 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TRIZIVIR 300; 150; 300mg/1; mg/1; mg/1 60 TABLET, FILM COATED in 1 BOTTLE |
5 |
Specialty Tier Drugs |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TROPICAMIDE 0.5% EYE DROPS |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TROPICAMIDE OPHTHALMIC SOLUTION USP |
1 |
Preferred Generic Drugs |
$4.00 | $12.00 | None |
TROSPIUM CHLORIDE TABLETS |
2 |
Non-Preferred Generic Drugs |
$25.00 | $60.00 | Q:2 /1Days |
TRUVADA TABLET |
5 |
Specialty Tier Drugs |
33% | 33% | None |
TWINRIX TF PF VACCINE 720UNT/20ML 10 X 1ML VIALSD |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
Tygacil 50mg/5mL 10 VIAL, SINGLE-USE in 1 CARTON / 50 mL in 1 VIAL, SINGLE-USE |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
TYKERB 250MG TABLET |
5 |
Specialty Tier Drugs |
33% | 33% | P Q:6 /1Days |
TYLENOL with Codeine 300; 30mg/1; mg/1 1000 TABLET in 1 BOTTLE |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | Q:13 /1Days |
TYLENOL with Codeine 300; 60mg/1; mg/1 500 TABLET in 1 BOTTLE |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | Q:13 /1Days |
TYLOX CAPSULES |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | Q:8 /1Days |
TYPHIM VI 25MCG/0.5ML VIAL |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TYZEKA 600MG TABLET (30 CT) |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | P Q:1 /1Days |
TYZINE 0.1% NOSE DROPS |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |
TYZINE PEDIATRIC 0.05% DROP |
4 |
Non-Preferred Brand Drugs |
$80.00 | $225.00 | None |