2013 Medicare Part D Plan Formulary Information |
MCS Classicare Premium Health (HMO) (H4006-007-0)
Benefit Details
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The MCS Classicare Premium Health (HMO) (H4006-007-0) Formulary Drugs Starting with the Letter T in COMERIO County, PR: CMS MA Region 30 which includes: PR
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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 |
TABLOID 40 MG TABLET |
1 |
Generic |
$5.00 | $10.00 | None |
Tacrolimus 0.5mg/1 100 CAPSULE in 1 BOTTLE |
1 |
Generic |
$5.00 | $10.00 | P |
Tacrolimus 1mg/1 100 CAPSULE in 1 BOTTLE |
1 |
Generic |
$5.00 | $10.00 | P |
Tacrolimus 5mg/1 100 CAPSULE in 1 BOTTLE |
1 |
Generic |
$5.00 | $10.00 | P |
Tamiflu 30mg/1 1 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK |
2 |
Preferred Brand |
$25.00 | $50.00 | Q:84 /180Days |
Tamiflu 45mg/1 1 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK |
2 |
Preferred Brand |
$25.00 | $50.00 | Q:28 /180Days |
Tamiflu 6mg/mL 1 BOTTLE, GLASS in 1 CARTON / 6 mL in 1 BOTTLE, GLASS |
2 |
Preferred Brand |
$25.00 | $50.00 | Q:550 /90Days |
TAMIFLU 75MG CAPSULE UD |
2 |
Preferred Brand |
$25.00 | $50.00 | Q:28 /180Days |
TAMOXIFEN CITRATE 20MG TABLET (30 CT) |
1 |
Generic |
$5.00 | $10.00 | None |
TAMOXIFEN CITRATE TABLETS 10MG 180 BOT |
1 |
Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAMSULOSIN HCL 0.4 MG CAPSULE |
1 |
Generic |
$5.00 | $10.00 | Q:60 /30Days |
TARCEVA 100MG TABLET |
4 |
Specialty Tier |
33% | N/A | P |
TARCEVA 150MG TABLET |
4 |
Specialty Tier |
33% | N/A | P |
TARCEVA 25MG TABLET |
4 |
Specialty Tier |
33% | N/A | P |
TARGRETIN 1% GEL 60GM TUBE |
4 |
Specialty Tier |
33% | N/A | None |
TARGRETIN 75MG (100 CT) |
4 |
Specialty Tier |
33% | N/A | None |
Tasigna 150mg/1 4 BLISTER PACK in 1 CARTON / 28 CAPSULE in 1 BLISTER PACK |
4 |
Specialty Tier |
33% | N/A | P |
TASIGNA 200MG CAPSULE 28 BLPK |
4 |
Specialty Tier |
33% | N/A | P |
TASMAR 100MG TABLET |
4 |
Specialty Tier |
33% | N/A | P |
TAZORAC 0.05% CREAM |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | None |
TAZORAC 0.05% GEL |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAZORAC 0.1% CREAM |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | None |
TAZORAC 0.1% GEL |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | None |
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES |
1 |
Generic |
$5.00 | $10.00 | None |
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES |
1 |
Generic |
$5.00 | $10.00 | None |
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES |
1 |
Generic |
$5.00 | $10.00 | None |
TAZTIA XT 240MG CAPSULE SA |
1 |
Generic |
$5.00 | $10.00 | None |
TAZTIA XT 360MG CAPSULE SA |
1 |
Generic |
$5.00 | $10.00 | None |
TECFIDERA DR 120 MG CAPSULE |
4 |
Specialty Tier |
33% | N/A | P Q:14 /365Days |
TECFIDERA DR 240 MG CAPSULE |
4 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
TECFIDERA STARTER PACK |
4 |
Specialty Tier |
33% | N/A | P Q:60 /365Days |
Teflaro 400mg/20mL 10 VIAL, SINGLE-DOSE in 1 CARTON / 20 mL in 1 VIAL, SINGLE-DOSE |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | P |
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 |
$50.00 | $100.00 | P |
TEGRETOL XR TABLETS 100MG 100 BOT |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | None |
Tekamlo 150; 10mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | S Q:30 /30Days |
Tekamlo 150; 5mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | S Q:30 /30Days |
Tekamlo 300; 10mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | S Q:30 /30Days |
Tekamlo 300; 5mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | S Q:30 /30Days |
TEKTURNA 150MG TABLET |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | S Q:30 /30Days |
TEKTURNA 300MG TABLET |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | S Q:30 /30Days |
TEKTURNA HCT 150-12.5MG TABLET |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | S Q:30 /30Days |
TEKTURNA HCT 150MG-25MG TABLET |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | S Q:30 /30Days |
TEKTURNA HCT 300-12.5MG TABLET |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TEKTURNA HCT 300MG-25MG TABLET |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | S Q:30 /30Days |
Terazosin Hydrochloride 10mg/1 100 CAPSULE in 1 BOTTLE |
1 |
Generic |
$5.00 | $10.00 | Q:60 /30Days |
Terazosin hydrochloride 1mg/1 500 CAPSULE in 1 BOTTLE |
1 |
Generic |
$5.00 | $10.00 | Q:60 /30Days |
Terazosin Hydrochloride 2mg/1 100 CAPSULE in 1 BOTTLE |
1 |
Generic |
$5.00 | $10.00 | Q:60 /30Days |
Terazosin Hydrochloride 5mg/1 100 CAPSULE in 1 BOTTLE |
1 |
Generic |
$5.00 | $10.00 | Q:60 /30Days |
TERBINAFINE HCL 250MG TABLET |
1 |
Generic |
$5.00 | $10.00 | P Q:30 /30Days |
TERBUTALINE SULF 1MG/ML VL |
1 |
Generic |
$5.00 | $10.00 | None |
TERBUTALINE SULF 2.5MG TABLET |
1 |
Generic |
$5.00 | $10.00 | None |
TERBUTALINE SULFATE 5MG TABLET |
1 |
Generic |
$5.00 | $10.00 | None |
TERCONAZOLE 0.4% CREAM WITH APPLICATOR |
1 |
Generic |
$5.00 | $10.00 | None |
TERCONAZOLE 0.8% CREAM |
1 |
Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TERCONAZOLE 80MG SUPPOSITORY VAGINAL |
1 |
Generic |
$5.00 | $10.00 | None |
TESTIM 1%(50MG) GEL |
2 |
Preferred Brand |
$25.00 | $50.00 | P Q:300 /30Days |
Testosterone Cypionate 200mg/mL 1 VIAL, MULTI-DOSE in 1 CARTON / 10 mL in 1 VIAL, MULTI-DOSE |
1 |
Generic |
$5.00 | $10.00 | P |
TESTOSTERONE CYPIONATE INJECTION |
1 |
Generic |
$5.00 | $10.00 | P |
TESTOSTERONE ENANTHATE INJECTION |
1 |
Generic |
$5.00 | $10.00 | 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 |
$25.00 | $50.00 | None |
tetanus toxoid adsorbed vial |
2 |
Preferred Brand |
$25.00 | $50.00 | None |
Tetracycline Hydrochloride 250mg/1 1000 CAPSULE in 1 BOTTLE, PLASTIC |
1 |
Generic |
$5.00 | $10.00 | None |
Tetracycline Hydrochloride 500mg/1 1000 CAPSULE in 1 BOTTLE, PLASTIC |
1 |
Generic |
$5.00 | $10.00 | None |
THALOMID 100MG CAPSULE 140 BOX |
4 |
Specialty Tier |
33% | N/A | P |
Thalomid 150mg/1 |
4 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Thalomid 200mg/1 |
4 |
Specialty Tier |
33% | N/A | P |
THALOMID 50MG CAPSULE 280 BOX |
4 |
Specialty Tier |
33% | N/A | P |
Theophylline 100mg/1 500 CAPSULE in 1 BOTTLE |
1 |
Generic |
$5.00 | $10.00 | None |
Theophylline 200mg/1 500 TABLET, EXTENDED RELEASE in 1 BOTTLE |
1 |
Generic |
$5.00 | $10.00 | None |
THEOPHYLLINE 400MG TABLET SA |
1 |
Generic |
$5.00 | $10.00 | None |
THEOPHYLLINE 600MG TABLET SA |
1 |
Generic |
$5.00 | $10.00 | None |
THEOPHYLLINE TABLET ER 300MG (100 CT) |
1 |
Generic |
$5.00 | $10.00 | None |
THEOPHYLLINE TABLET ER 450MG (100 CT) |
1 |
Generic |
$5.00 | $10.00 | None |
Thermazene 10mg/g |
1 |
Generic |
$5.00 | $10.00 | None |
THIORIDAZINE 100MG TABLET |
1 |
Generic |
$5.00 | $10.00 | P |
THIORIDAZINE HCL 10MG TABLET (1000 CT) |
1 |
Generic |
$5.00 | $10.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THIORIDAZINE HCL 25MG TABLET (1000 CT) |
1 |
Generic |
$5.00 | $10.00 | P |
Thioridazine Hydrochloride 50mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED in 1 |
1 |
Generic |
$5.00 | $10.00 | P |
THIOTEPA POWDER FOR INJECTION 15MG/VIL 1 VIAL SINGLE DOSE CRTN |
1 |
Generic |
$5.00 | $10.00 | None |
THIOTHIXENE 10MG CAPSULE |
1 |
Generic |
$5.00 | $10.00 | None |
THIOTHIXENE 1MG CAPSULE (100 CT) |
1 |
Generic |
$5.00 | $10.00 | None |
THIOTHIXENE 2MG CAPSULE |
1 |
Generic |
$5.00 | $10.00 | None |
THIOTHIXENE 5MG CAPSULE |
1 |
Generic |
$5.00 | $10.00 | None |
tiagabine hcl 2 mg tablet |
1 |
Generic |
$5.00 | $10.00 | Q:124 /31Days |
tiagabine hcl 4 mg tablet |
1 |
Generic |
$5.00 | $10.00 | Q:420 /30Days |
TICLOPIDINE 250 MG TABLET |
1 |
Generic |
$5.00 | $10.00 | Q:60 /30Days |
TIKOSYN .125MG CAPSULE |
2 |
Preferred Brand |
$25.00 | $50.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIKOSYN .250MG CAPSULE |
2 |
Preferred Brand |
$25.00 | $50.00 | None |
TIKOSYN .5MG CAPSULE |
2 |
Preferred Brand |
$25.00 | $50.00 | None |
TIMENTIN ADD-VANTAGE 1; 30mg/mL; mg/mL 10 VIAL in 1 TRAY / 50 mL in 1 VIAL |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | P |
TIMOLOL MAL SOL 0.25% OP 15ML BOT |
1 |
Generic |
$5.00 | $10.00 | Q:10 /25Days |
TIMOLOL MAL SOL 0.5% OP 10ML BOT |
1 |
Generic |
$5.00 | $10.00 | Q:10 /25Days |
TIMOLOL MALEATE 10MG TABLET |
1 |
Generic |
$5.00 | $10.00 | None |
TIMOLOL MALEATE 20MG TABLET |
1 |
Generic |
$5.00 | $10.00 | None |
Timolol Maleate 3.4mg/mL 1 BOTTLE, DISPENSING in 1 CARTON / 5 mL in 1 BOTTLE, DISPENSING |
1 |
Generic |
$5.00 | $10.00 | None |
TIMOLOL MALEATE 5MG TABLET |
1 |
Generic |
$5.00 | $10.00 | None |
Timolol Maleate 6.8mg/mL 1 BOTTLE, DISPENSING in 1 CARTON / 5 mL in 1 BOTTLE, DISPENSING |
1 |
Generic |
$5.00 | $10.00 | None |
tinidazole 250 mg tablet |
1 |
Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
tinidazole 500 mg tablet |
1 |
Generic |
$5.00 | $10.00 | None |
Tirosint 100ug/1 4 BLISTER PACK in 1 CARTON / 7 CAPSULE in 1 BLISTER PACK |
2 |
Preferred Brand |
$25.00 | $50.00 | None |
Tirosint 112ug/1 4 BLISTER PACK in 1 CARTON / 7 CAPSULE in 1 BLISTER PACK |
2 |
Preferred Brand |
$25.00 | $50.00 | None |
Tirosint 125ug/1 4 BLISTER PACK in 1 CARTON / 7 CAPSULE in 1 BLISTER PACK |
2 |
Preferred Brand |
$25.00 | $50.00 | None |
Tirosint 137ug/1 4 BLISTER PACK in 1 CARTON / 7 CAPSULE in 1 BLISTER PACK |
2 |
Preferred Brand |
$25.00 | $50.00 | None |
Tirosint 13ug/1 4 BLISTER PACK in 1 CARTON / 7 CAPSULE in 1 BLISTER PACK |
2 |
Preferred Brand |
$25.00 | $50.00 | None |
Tirosint 150ug/1 4 BLISTER PACK in 1 CARTON / 7 CAPSULE in 1 BLISTER PACK |
2 |
Preferred Brand |
$25.00 | $50.00 | None |
Tirosint 25ug/1 4 BLISTER PACK in 1 CARTON / 7 CAPSULE in 1 BLISTER PACK |
2 |
Preferred Brand |
$25.00 | $50.00 | None |
Tirosint 50ug/1 4 BLISTER PACK in 1 CARTON / 7 CAPSULE in 1 BLISTER PACK |
2 |
Preferred Brand |
$25.00 | $50.00 | None |
Tirosint 75ug/1 4 BLISTER PACK in 1 CARTON / 7 CAPSULE in 1 BLISTER PACK |
2 |
Preferred Brand |
$25.00 | $50.00 | None |
Tirosint 88ug/1 4 BLISTER PACK in 1 CARTON / 7 CAPSULE in 1 BLISTER PACK |
2 |
Preferred Brand |
$25.00 | $50.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Tizanidine 4mg/1 1000 TABLET BOTTLE |
1 |
Generic |
$5.00 | $10.00 | None |
TIZANIDINE HCL 2 MG CAPSULE |
1 |
Generic |
$5.00 | $10.00 | None |
TIZANIDINE HCL 2 MG TABLET |
1 |
Generic |
$5.00 | $10.00 | None |
TIZANIDINE HCL 4 MG CAPSULE |
1 |
Generic |
$5.00 | $10.00 | None |
TIZANIDINE HCL 6 MG CAPSULE |
1 |
Generic |
$5.00 | $10.00 | None |
TOBI 300mg/5mL 56 AMPULE in 1 CARTON / 5 mL in 1 AMPULE |
4 |
Specialty Tier |
33% | N/A | P |
TOBI PODHALER 28 MG INHALE CAP |
4 |
Specialty Tier |
33% | N/A | P Q:224 /56Days |
TOBRAMYCIN 10MG/ML VIAL |
1 |
Generic |
$5.00 | $10.00 | None |
TOBRAMYCIN 40MG/ML VIAL |
1 |
Generic |
$5.00 | $10.00 | None |
TOBRAMYCIN OPHTHALMIC SOLUTION 0.3% 5ML BOT |
1 |
Generic |
$5.00 | $10.00 | None |
TOBRAMYCIN-DEXAMETH OPTH SUSP |
1 |
Generic |
$5.00 | $10.00 | Q:20 /25Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOLAZAMIDE TABLETS 250MG 100 BOT |
1 |
Generic |
$5.00 | $10.00 | Q:360 /30Days |
TOLMETIN SODIUM 200MG TABLET |
1 |
Generic |
$5.00 | $10.00 | None |
TOLMETIN SODIUM 400 MG CAP |
1 |
Generic |
$5.00 | $10.00 | None |
TOLMETIN SODIUM 600MG TABLET |
1 |
Generic |
$5.00 | $10.00 | None |
tolterodine tartrate 1 mg tab |
1 |
Generic |
$5.00 | $10.00 | Q:60 /30Days |
tolterodine tartrate 2 mg tablet |
1 |
Generic |
$5.00 | $10.00 | Q:60 /30Days |
TOLVAPTAN 15 MG ORAL TABLET [SAMSCA] |
4 |
Specialty Tier |
33% | N/A | Q:30 /30Days |
TOLVAPTAN 30 MG ORAL TABLET [SAMSCA] |
4 |
Specialty Tier |
33% | N/A | Q:60 /30Days |
Topiramate 25mg/1 |
1 |
Generic |
$5.00 | $10.00 | None |
TOPIRAMATE SPRINKLE CAPSULES 15MG 60 BOT |
1 |
Generic |
$5.00 | $10.00 | None |
TOPIRAMATE TABLETS 100MG 1000 BOT |
1 |
Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOPIRAMATE TABLETS 200MG 1000 BOT |
1 |
Generic |
$5.00 | $10.00 | None |
TOPIRAMATE TABLETS 25MG 1000 BOT |
1 |
Generic |
$5.00 | $10.00 | None |
TOPIRAMATE TABLETS 50MG 1000 BOT |
1 |
Generic |
$5.00 | $10.00 | None |
TOPOSAR INJECTION 20MG/ML 50ML VIAL MD CRTN |
1 |
Generic |
$5.00 | $10.00 | None |
TOPOTECAN HYDROCHLORIDE FOR INJECTION |
1 |
Generic |
$5.00 | $10.00 | None |
Torisel 1 KIT in 1 CARTON |
4 |
Specialty Tier |
33% | N/A | P |
Torsemide 100mg/1 12 BOTTLE CASE / 100 TABLET BOTTLE |
1 |
Generic |
$5.00 | $10.00 | None |
TORSEMIDE 20mg 100 TABLET BOTTLE |
1 |
Generic |
$5.00 | $10.00 | None |
TORSEMIDE INJECTION 20MG/2ML |
1 |
Generic |
$5.00 | $10.00 | None |
TORSEMIDE TABLETS |
1 |
Generic |
$5.00 | $10.00 | None |
TORSEMIDE TABLETS |
1 |
Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TPN ELECTROLYTES VIAL |
1 |
Generic |
$5.00 | $10.00 | P |
TRACLEER 125MG TABLET |
4 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
TRACLEER 62.5MG TABLET |
4 |
Specialty Tier |
33% | N/A | P Q:120 /30Days |
TRAMADOL ER 300 MG TABLET |
1 |
Generic |
$5.00 | $10.00 | Q:30 /30Days |
TRAMADOL HCL 50 MG TABLET |
1 |
Generic |
$5.00 | $10.00 | Q:240 /30Days |
TRAMADOL HCL-ACETAMINOPHEN 37.5-325MG TABLET (1000 CT) |
1 |
Generic |
$5.00 | $10.00 | Q:240 /30Days |
TRAMADOL HYDROCHLORIDE 100mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Generic |
$5.00 | $10.00 | Q:60 /30Days |
TRAMADOL HYDROCHLORIDE 200mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Generic |
$5.00 | $10.00 | Q:30 /30Days |
TRANDOLAPRIL 1MG TABLET |
1 |
Generic |
$5.00 | $10.00 | Q:60 /30Days |
TRANDOLAPRIL 2MG TABLET |
1 |
Generic |
$5.00 | $10.00 | Q:60 /30Days |
TRANDOLAPRIL 4MG TABLET |
1 |
Generic |
$5.00 | $10.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRANEXAMIC ACID 1,000 MG/10 ML |
1 |
Generic |
$5.00 | $10.00 | None |
tranexamic acid 650 mg tablet |
1 |
Generic |
$5.00 | $10.00 | None |
TRANSDERM-SCOP 1.5 MG/72HR |
1 |
Generic |
$5.00 | $10.00 | None |
TRANYLCYPROMINE SULFATE 10MG TABLET |
1 |
Generic |
$5.00 | $10.00 | None |
travoprost 0.004% eye drop |
1 |
Generic |
$5.00 | $10.00 | Q:3 /25Days |
TRAZODONE 300MG TABLET |
1 |
Generic |
$5.00 | $10.00 | None |
TRAZODONE HCL TABLET USP 100MG (500 CT) |
1 |
Generic |
$5.00 | $10.00 | None |
TRAZODONE HCL TABLET USP 150MG (100 CT) |
1 |
Generic |
$5.00 | $10.00 | None |
TRAZODONE HCL TABLET USP 50MG (500 CT) |
1 |
Generic |
$5.00 | $10.00 | None |
TREANDA FOR INJECTION 100MG/VIAL |
4 |
Specialty Tier |
33% | N/A | None |
TRECATOR 250MG TABLET |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Trelstar 22.5mg/2mL 2 mL in 1 VIAL, SINGLE-DOSE |
4 |
Specialty Tier |
33% | N/A | P |
TRELSTAR DEPOT MIXJET FOR INJECTION 3.75 MG |
4 |
Specialty Tier |
33% | N/A | P |
TRELSTAR MIXJET FOR INJECTION 11.25 MG |
4 |
Specialty Tier |
33% | N/A | P |
Tretinoin 0.1mg/g 1 TUBE in 1 CARTON / 45 g in 1 TUBE |
1 |
Generic |
$5.00 | $10.00 | P |
Tretinoin 0.25mg/g 1 TUBE in 1 CARTON / 45 g in 1 TUBE |
1 |
Generic |
$5.00 | $10.00 | P |
Tretinoin 0.25mg/g 1 TUBE in 1 CARTON / 45 g in 1 TUBE |
1 |
Generic |
$5.00 | $10.00 | P |
Tretinoin 0.5mg/g 1 TUBE in 1 CARTON / 20 g in 1 TUBE |
1 |
Generic |
$5.00 | $10.00 | P |
TRETINOIN 10MG CAPSULE |
4 |
Specialty Tier |
33% | N/A | None |
Tretinoin 1mg/g 1 TUBE in 1 CARTON / 45 g in 1 TUBE |
1 |
Generic |
$5.00 | $10.00 | P |
TREXALL 10MG TABLET |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | P |
TREXALL 15MG TABLET |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TREXALL 5MG TABLET |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | P |
TREXALL 7.5MG TABLET |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | P |
TRI PREVIFEM TABLETS |
1 |
Generic |
$5.00 | $10.00 | Q:28 /28Days |
TRI-LEGEST FE 5-7-9-7 TABLET |
1 |
Generic |
$5.00 | $10.00 | None |
TRI-SPRINTEC 7DAYSX3 28 TABLET |
1 |
Generic |
$5.00 | $10.00 | Q:28 /28Days |
TRIAMCINOLONE 0.1% OINTMENT |
1 |
Generic |
$5.00 | $10.00 | None |
TRIAMCINOLONE ACETONIDE 0.025% CREAM 80GM TUBE |
1 |
Generic |
$5.00 | $10.00 | None |
TRIAMCINOLONE ACETONIDE 0.025% LOTION 2 FL OZ BOT |
1 |
Generic |
$5.00 | $10.00 | None |
TRIAMCINOLONE ACETONIDE 0.025% OINTMENT 80GM TUBE |
1 |
Generic |
$5.00 | $10.00 | None |
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE |
1 |
Generic |
$5.00 | $10.00 | None |
TRIAMCINOLONE ACETONIDE 0.1% CREAM 80GM TUBE |
1 |
Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIAMCINOLONE ACETONIDE 0.1% LOTION 60ML BOTPL |
1 |
Generic |
$5.00 | $10.00 | None |
Triamcinolone Acetonide 1mg/g 1 TUBE in 1 CARTON / 5 g in 1 TUBE |
1 |
Generic |
$5.00 | $10.00 | None |
Triamcinolone Acetonide 55ug/1 1 BOTTLE, SPRAY in 1 CARTON / 120 SPRAY, METERED in 1 BOTTLE, SPRAY |
1 |
Generic |
$5.00 | $10.00 | Q:17 /30Days |
Triamcinolone Acetonide 5mg/g 1 TUBE in 1 CARTON / 15 g in 1 TUBE |
1 |
Generic |
$5.00 | $10.00 | None |
Triamterene and Hydrochlorothiazide 25; 37.5mg 100 CAPSULE BOTTLE |
1 |
Generic |
$5.00 | $10.00 | None |
TRIAMTERENE/HCTZ 37.5/25 TABLET |
1 |
Generic |
$5.00 | $10.00 | None |
TRIAMTERENE/HCTZ 75/50 TABLET |
1 |
Generic |
$5.00 | $10.00 | None |
TRIDERM 0.1% CREAM |
1 |
Generic |
$5.00 | $10.00 | None |
TRIFLUOPERAZINE 1MG TABLET |
1 |
Generic |
$5.00 | $10.00 | None |
TRIFLUOPERAZINE HCL 2MG TABLET |
1 |
Generic |
$5.00 | $10.00 | None |
TRIFLUOPERAZINE HCL 5MG TABLET |
1 |
Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT) |
1 |
Generic |
$5.00 | $10.00 | None |
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT |
1 |
Generic |
$5.00 | $10.00 | None |
TRIHEXYPHENIDYL HYDROCHLORIDE 2mg/1 |
1 |
Generic |
$5.00 | $10.00 | P |
Trihexyphenidyl Hydrochloride 2mg/5mL 473 mL in 1 BOTTLE |
1 |
Generic |
$5.00 | $10.00 | P |
Trihexyphenidyl Hydrochloride 5mg/1 100 TABLET BOTTLE |
1 |
Generic |
$5.00 | $10.00 | P |
TRILEPTAL 300MG/5ML SUSP |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | None |
TRILIPIX CAPSULE DR 45MG |
2 |
Preferred Brand |
$25.00 | $50.00 | P Q:30 /30Days |
TRILIPIX DELAYED RELEASE CAPSULES 135MG |
2 |
Preferred Brand |
$25.00 | $50.00 | P Q:30 /30Days |
TRIMETHOBENZAMIDE HCL 300MG CAPSULE |
1 |
Generic |
$5.00 | $10.00 | P |
TRIMETHOPRIM TABLETS |
1 |
Generic |
$5.00 | $10.00 | None |
TRIMIPRAMINE MALEATE 100 MG CAP |
1 |
Generic |
$5.00 | $10.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIMIPRAMINE MALEATE 25 MG CAP |
1 |
Generic |
$5.00 | $10.00 | P |
TRIMIPRAMINE MALEATE 50 MG CAP |
1 |
Generic |
$5.00 | $10.00 | P |
TRINESSA TABLET |
1 |
Generic |
$5.00 | $10.00 | Q:28 /28Days |
TRISENOX 10MG/10ML AMPULE |
2 |
Preferred Brand |
$25.00 | $50.00 | None |
Trivora 6 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK |
1 |
Generic |
$5.00 | $10.00 | Q:28 /28Days |
TRIZIVIR 300; 150; 300mg/1; mg/1; mg/1 60 FILM COATED TABLETS in BOTTLE |
4 |
Specialty Tier |
33% | N/A | None |
TROSPIUM CHLORIDE ER 60 MG CAP |
1 |
Generic |
$5.00 | $10.00 | Q:30 /30Days |
TROSPIUM CHLORIDE TABLETS |
1 |
Generic |
$5.00 | $10.00 | None |
TRUVADA TABLET |
4 |
Specialty Tier |
33% | N/A | None |
TUDORZA PRESSAIR 400 MCG INH |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | Q:1 /30Days |
TWINJECT AUTO INJECTOR INJECTION 1% AUTO INJECTOR TWO PACK SYR |
2 |
Preferred Brand |
$25.00 | $50.00 | None |
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 |
$25.00 | $50.00 | None |
TWINRIX TF PF VACCINE 720UNT/20ML 10 X 1ML VIALSD |
2 |
Preferred Brand |
$25.00 | $50.00 | None |
Tygacil 50mg/5mL 10 VIAL, SINGLE-USE in 1 CARTON / 50 mL in 1 VIAL, SINGLE-USE |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | None |
TYKERB 250MG TABLET |
4 |
Specialty Tier |
33% | N/A | P |
TYPHIM VI 25MCG/0.5ML VIAL |
2 |
Preferred Brand |
$25.00 | $50.00 | None |
TYSABRI 300MG/15ML VIAL |
4 |
Specialty Tier |
33% | N/A | P |
Tyvaso 1.74mg/2.9mL |
4 |
Specialty Tier |
33% | N/A | P |
TYZEKA 600MG TABLET (30 CT) |
4 |
Specialty Tier |
33% | N/A | Q:30 /30Days |
TYZINE 0.1% NOSE DROPS |
2 |
Preferred Brand |
$25.00 | $50.00 | None |
TYZINE PEDIATRIC 0.05% DROP |
2 |
Preferred Brand |
$25.00 | $50.00 | None |