2012 Medicare Part D Plan Formulary Information |
Rite Aid EnvisionRxPlus (PDP) (S7694-072-0)
Benefit Details
|
The Rite Aid EnvisionRxPlus (PDP) (S7694-072-0) Formulary Drugs Starting with the Letter T in CMS PDP Region 01 which includes: ME NH
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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 0.5mg/1 100 CAPSULE in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
20% | 20% | P |
Tacrolimus 1mg/1 100 CAPSULE in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
20% | 20% | P |
Tacrolimus 5mg/1 100 CAPSULE in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
20% | 20% | P |
Tamiflu 30mg/1 1 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
Tamiflu 45mg/1 1 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
Tamiflu 6mg/mL 1 BOTTLE, GLASS in 1 CARTON / 6 mL in 1 BOTTLE, GLASS |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
TAMIFLU 75MG CAPSULE UD |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
TAMOXIFEN CITRATE 20MG TABLET (30 CT) |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
TAMOXIFEN CITRATE TABLETS 10MG 180 BOT |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
TAMSULOSIN HCL 0.4 MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TARCEVA 100MG TABLET |
5 |
Specialty Tier Drugs |
33% | N/A | None |
TARCEVA 150MG TABLET |
5 |
Specialty Tier Drugs |
33% | N/A | None |
TARCEVA 25MG TABLET |
5 |
Specialty Tier Drugs |
33% | N/A | None |
TARGRETIN 1% GEL 60GM TUBE |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
TARGRETIN 75MG (100 CT) |
3 |
Preferred Brand Drugs |
15% | 15% | None |
Tasigna 150mg/1 4 BLISTER PACK in 1 CARTON / 28 CAPSULE in 1 BLISTER PACK |
5 |
Specialty Tier Drugs |
33% | N/A | None |
TASIGNA 200MG CAPSULE 28 BLPK |
5 |
Specialty Tier Drugs |
33% | N/A | None |
TAZORAC 0.05% CREAM |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
TAZORAC 0.05% GEL |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
TAZORAC 0.1% CREAM |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
TAZORAC 0.1% GEL |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
TAZTIA XT 240MG CAPSULE SA |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
TAZTIA XT 360MG CAPSULE SA |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
TEGRETOL XR TABLETS 100MG 100 BOT |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
TEKTURNA 150MG TABLET |
3 |
Preferred Brand Drugs |
15% | 15% | None |
TEKTURNA 300MG TABLET |
3 |
Preferred Brand Drugs |
15% | 15% | None |
TEKTURNA HCT 150-12.5MG TABLET |
3 |
Preferred Brand Drugs |
15% | 15% | None |
TEKTURNA HCT 150MG-25MG TABLET |
3 |
Preferred Brand Drugs |
15% | 15% | None |
TEKTURNA HCT 300-12.5MG TABLET |
3 |
Preferred Brand Drugs |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TEKTURNA HCT 300MG-25MG TABLET |
3 |
Preferred Brand Drugs |
15% | 15% | None |
TERAZOSIN HCL 10MG CAPSULE |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
TERAZOSIN HCL 1MG CAPSULE |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
TERAZOSIN HCL 2MG CAPSULE |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
TERAZOSIN HCL 5MG CAPSULE |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
TERBUTALINE SULF 1MG/ML VL |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
TERCONAZOLE 0.4% CREAM WITH APPLICATOR |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
TERCONAZOLE 80MG SUPPOSITORY VAGINAL |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
TERCONAZOLE VAGINAL CREAM |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
Testosterone Cypionate 200mg/mL 1 VIAL, MULTI-DOSE in 1 CARTON / 10 mL in 1 VIAL, MULTI-DOSE |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
TESTOSTERONE CYPIONATE INJECTION |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TESTOSTERONE ENANTHATE INJECTION |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
Tetanus and Diphtheria Toxoids Adsorbed 2.0; 2.0[Lf]/0.5mL; [Lf]/0.5mL 10 VIAL, SINGLE-DOSE in 1 CA |
4 |
Non-Preferred Brand Drugs |
30% | 30% | P |
TETANUS TOXOID ADSORBED VIAL 5LF |
4 |
Non-Preferred Brand Drugs |
30% | 30% | P |
TETRACYCLINE 500MG CAPSULE |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
Tetracycline Hydrochloride 250mg/1 100 CAPSULE in 1 BOTTLE |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
THALOMID 100MG CAPSULE 140 BOX |
5 |
Specialty Tier Drugs |
33% | N/A | None |
Thalomid 150mg/1 |
5 |
Specialty Tier Drugs |
33% | N/A | None |
Thalomid 200mg/1 |
5 |
Specialty Tier Drugs |
33% | N/A | None |
THALOMID 50MG CAPSULE 280 BOX |
5 |
Specialty Tier Drugs |
33% | N/A | None |
THEOCHRON 100MG TABLET SA |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
THEOCHRON TABLETS EXTENDED RELEASE 300MG 100 BOT |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Theophylline 100mg/1 500 CAPSULE in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
THEOPHYLLINE 600MG TABLET SA |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
THEOPHYLLINE ANHYDROUS ER TABLET 200MG (1000 CT) |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
THEOPHYLLINE TABLET ER 300MG (100 CT) |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
THEOPHYLLINE TABLET ER 450MG (100 CT) |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
Thermazene 10mg/g |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
THIOGUANINE TABLET LOID 40MG |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
THIORIDAZINE 100MG TABLET |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
THIORIDAZINE HCL 10MG TABLET (1000 CT) |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
THIORIDAZINE HCL 25MG TABLET (1000 CT) |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
THIORIDAZINE HCL 50MG TABLET (1000 CT) |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THIOTHIXENE 10MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
THIOTHIXENE 1MG CAPSULE (100 CT) |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
THIOTHIXENE 2MG CAPSULE |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
THIOTHIXENE 5MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
THYMOGLOBULIN 25MG VIAL |
5 |
Specialty Tier Drugs |
33% | N/A | P |
Ticlopidine Hydrochloride 250mg/1 60 TABLET, FILM COATED in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
TIKOSYN .125MG CAPSULE |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
TIKOSYN .250MG CAPSULE |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
TIKOSYN .5MG CAPSULE |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
TIMOLOL MAL SOL 0.25% OP 15ML BOT |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
TIMOLOL MAL SOL 0.5% OP 10ML BOT |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIMOLOL MALEATE 10MG TABLET |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
TIMOLOL MALEATE 20MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
Timolol Maleate 3.4mg/mL 1 BOTTLE, DISPENSING in 1 CARTON / 5 mL in 1 BOTTLE, DISPENSING |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
TIMOLOL MALEATE 5MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
Timolol Maleate 6.8mg/mL 1 BOTTLE, DISPENSING in 1 CARTON / 5 mL in 1 BOTTLE, DISPENSING |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
TIS-U-SOL IRRIGATION SOLUTION |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
tizanidine 4mg/1 |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
TIZANIDINE HCL 2 MG TABLET |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
TOBI 300mg/5mL 56 AMPULE in 1 CARTON / 5 mL in 1 AMPULE |
5 |
Specialty Tier Drugs |
33% | N/A | P |
TOBRAMYCIN 10MG/ML VIAL |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
TOBRAMYCIN 40MG/ML VIAL |
2 |
Non-Preferred Generic Drugs |
20% | 20% | 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 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
TOBRAMYCIN-DEXAMETH OPTH SUSP |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
TOBRASOL 0.3% EYE DROPS |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
TOLMETIN SODIUM 200MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
TOLMETIN SODIUM 400MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
TOLMETIN SODIUM 600MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
TOLVAPTAN 15 MG ORAL TABLET [SAMSCA] |
5 |
Specialty Tier Drugs |
33% | N/A | P |
TOLVAPTAN 30 MG ORAL TABLET [SAMSCA] |
5 |
Specialty Tier Drugs |
33% | N/A | P |
Topiramate 25mg/1 |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
TOPIRAMATE SPRINKLE CAPSULES 15MG 60 BOT |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
TOPIRAMATE TABLETS 100MG 1000 BOT |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOPIRAMATE TABLETS 200MG 1000 BOT |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
TOPIRAMATE TABLETS 25MG 1000 BOT |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
TOPIRAMATE TABLETS 50MG 1000 BOT |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
TOPOTECAN HYDROCHLORIDE FOR INJECTION |
2 |
Non-Preferred Generic Drugs |
20% | 20% | P |
Torsemide 100mg/1 12 BOTTLE in 1 CASE / 100 TABLET in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
TORSEMIDE 20mg/1 100 TABLET in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
TORSEMIDE TABLETS |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
TORSEMIDE TABLETS |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
TPN ELECTROLYTES VIAL |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
TRACLEER 125MG TABLET |
5 |
Specialty Tier Drugs |
33% | N/A | None |
TRACLEER 62.5MG TABLET |
5 |
Specialty Tier Drugs |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRAMADOL HCL 50 MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | Q:240 /30Days |
TRAMADOL HCL-ACETAMINOPHEN 37.5-325MG TABLET (1000 CT) |
2 |
Non-Preferred Generic Drugs |
20% | 20% | Q:240 /30Days |
TRANDOLAPRIL 1MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
TRANDOLAPRIL 2MG TABLET |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
TRANDOLAPRIL 4MG TABLET |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
TRANEXAMIC ACID 1,000 MG/10 ML |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
TRANYLCYPROMINE SULFATE 10MG TABLET |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
TRAVASOL 10% SOLUTION VIAFLEX |
3 |
Preferred Brand Drugs |
15% | 15% | P |
TRAVATAN Z 0.04MG DROPS 2.5ML BOT |
3 |
Preferred Brand Drugs |
15% | 15% | None |
TRAZODONE 300MG TABLET |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
TRAZODONE HCL TABLET USP 100MG (500 CT) |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRAZODONE HCL TABLET USP 150MG (100 CT) |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
TRAZODONE HCL TABLET USP 50MG (500 CT) |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
TRECATOR 250MG TABLET |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
Trelstar 22.5mg/2mL 2 mL in 1 VIAL, SINGLE-DOSE |
5 |
Specialty Tier Drugs |
33% | N/A | None |
TRELSTAR DEPOT MIXJET FOR INJECTION 3.75 MG |
5 |
Specialty Tier Drugs |
33% | N/A | None |
TRELSTAR MIXJET FOR INJECTION 11.25 MG |
5 |
Specialty Tier Drugs |
33% | N/A | None |
TRETINOIN 10MG CAPSULE |
5 |
Specialty Tier Drugs |
33% | N/A | None |
TRIAMCINOLONE 0.1% OINTMENT |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
TRIAMCINOLONE ACETONIDE 0.025% CREAM 80GM TUBE |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
TRIAMCINOLONE ACETONIDE 0.025% LOTION 2 FL OZ BOT |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
TRIAMCINOLONE ACETONIDE 0.025% OINTMENT 80GM TUBE |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
TRIAMCINOLONE ACETONIDE 0.1% CREAM 80GM TUBE |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
TRIAMCINOLONE ACETONIDE 0.1% LOTION 60ML BOTPL |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
Triamcinolone Acetonide 1mg/g 1 TUBE in 1 CARTON / 5 g in 1 TUBE |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
Triamcinolone Acetonide 5mg/g 1 TUBE in 1 CARTON / 15 g in 1 TUBE |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
TRIAMTERENE/HCTZ 37.5/25 TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
TRIAMTERENE/HCTZ 75/50 TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
TRICOR 145MG TABLET |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
Tricor 48mg/1 90 TABLET in 1 BOTTLE |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
TRIDERM 0.1% CREAM |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
TRIFLUOPERAZINE 1MG TABLET |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIFLUOPERAZINE HCL 2MG TABLET |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
TRIFLUOPERAZINE HCL 5MG TABLET |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT) |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
TRIHEXYPHENIDYL HYDROCHLORIDE 2mg/1 |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
Trihexyphenidyl Hydrochloride 2mg/5mL 473 mL in 1 BOTTLE |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
Trihexyphenidyl Hydrochloride 5mg/1 100 TABLET in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
TRIMETHOPRIM TABLETS |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
TRIMIPRAMINE MALEATE 100 MG CAP |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
TRIMIPRAMINE MALEATE 25 MG CAP |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
TRIMIPRAMINE MALEATE 50 MG CAP |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
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; |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
TRISENOX 10MG/10ML AMPULE |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
TRIZIVIR 300; 150; 300mg/1; mg/1; mg/1 60 TABLET, FILM COATED in 1 BOTTLE |
5 |
Specialty Tier Drugs |
33% | N/A | None |
TROPICAMIDE 0.5% EYE DROPS |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
TROPICAMIDE OPHTHALMIC SOLUTION USP |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
TRUVADA TABLET |
5 |
Specialty Tier Drugs |
33% | N/A | None |
TWINRIX TF PF VACCINE 720UNT/20ML 10 X 1ML VIALSD |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
TYKERB 250MG TABLET |
5 |
Specialty Tier Drugs |
33% | N/A | None |
TYPHIM VI 25MCG/0.5ML VIAL |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
TYZEKA 600MG TABLET (30 CT) |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
TYZINE 0.1% NOSE DROPS |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TYZINE PEDIATRIC 0.05% DROP |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |