2013 Medicare Part D Plan Formulary Information |
Windsor Medicare Extra Gold Plan (HMO) (H5698-028-0)
Benefit Details
|
The Windsor Medicare Extra Gold Plan (HMO) (H5698-028-0) Formulary Drugs Starting with the Letter T in COPIAH County, MS: CMS MA Region 16 which includes: MS
|
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 |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | None |
Tacrolimus 0.5mg/1 100 CAPSULE in 1 BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
Tacrolimus 1mg/1 100 CAPSULE in 1 BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
Tacrolimus 5mg/1 100 CAPSULE in 1 BOTTLE |
5 |
Specialty Tier |
33% | 33% | P |
TAMIFLU 75MG CAPSULE UD |
3 |
Preferred Brand |
$43.00 | $129.00 | Q:50 /180Days |
TAMOXIFEN CITRATE 20MG TABLET (30 CT) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TAMOXIFEN CITRATE TABLETS 10MG 180 BOT |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TAMSULOSIN HCL 0.4 MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TARCEVA 100MG TABLET |
5 |
Specialty Tier |
33% | 33% | Q:30 /30Days |
TARCEVA 150MG TABLET |
5 |
Specialty Tier |
33% | 33% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TARCEVA 25MG TABLET |
5 |
Specialty Tier |
33% | 33% | Q:180 /30Days |
TARGRETIN 1% GEL 60GM TUBE |
5 |
Specialty Tier |
33% | 33% | None |
TARGRETIN 75MG (100 CT) |
5 |
Specialty Tier |
33% | 33% | None |
Tasigna 150mg/1 4 BLISTER PACK in 1 CARTON / 28 CAPSULE in 1 BLISTER PACK |
5 |
Specialty Tier |
33% | 33% | None |
TASIGNA 200MG CAPSULE 28 BLPK |
5 |
Specialty Tier |
33% | 33% | None |
TASMAR 100MG TABLET |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | None |
TAXOTERE 80mg/4mL 1 VIAL, GLASS in 1 CARTON / 4 mL in 1 VIAL, GLASS |
5 |
Specialty Tier |
33% | 33% | None |
TAZORAC 0.05% CREAM |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
TAZORAC 0.05% GEL |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
TAZORAC 0.1% CREAM |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
TAZORAC 0.1% GEL |
3 |
Preferred Brand |
$43.00 | $129.00 | 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 |
$10.00 | $30.00 | None |
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TAZTIA XT 240MG CAPSULE SA |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TAZTIA XT 360MG CAPSULE SA |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Tekamlo 150; 10mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
Tekamlo 150; 5mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
Tekamlo 300; 10mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
Tekamlo 300; 5mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
TEKTURNA 150MG TABLET |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
TEKTURNA 300MG TABLET |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TEKTURNA HCT 150-12.5MG TABLET |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
TEKTURNA HCT 150MG-25MG TABLET |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
TEKTURNA HCT 300-12.5MG TABLET |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
TEKTURNA HCT 300MG-25MG TABLET |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
Temazepam 15mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE in 1 BLISTER PACK |
1 |
Preferred Generic |
$3.00 | $9.00 | Q:30 /30Days |
Temazepam 22.5mg/1 30 CAPSULE in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic |
$3.00 | $9.00 | Q:30 /30Days |
TEMAZEPAM 30 MG CAPSULE |
1 |
Preferred Generic |
$3.00 | $9.00 | Q:30 /30Days |
Temazepam 7.5mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic |
$3.00 | $9.00 | Q:30 /30Days |
Terazosin Hydrochloride 10mg/1 100 CAPSULE in 1 BOTTLE |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
Terazosin hydrochloride 1mg/1 500 CAPSULE in 1 BOTTLE |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
Terazosin Hydrochloride 2mg/1 100 CAPSULE in 1 BOTTLE |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Terazosin Hydrochloride 5mg/1 100 CAPSULE in 1 BOTTLE |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
TERBINAFINE HCL 250MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | Q:90 /365Days |
TERBUTALINE SULF 2.5MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TERBUTALINE SULFATE 5MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TERCONAZOLE 0.4% CREAM WITH APPLICATOR |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TERCONAZOLE 0.8% CREAM |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | None |
TERCONAZOLE 80MG SUPPOSITORY VAGINAL |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Testosterone Cypionate 200mg/mL 1 VIAL, MULTI-DOSE in 1 CARTON / 10 mL in 1 VIAL, MULTI-DOSE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
TESTOSTERONE CYPIONATE INJECTION |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
TESTOSTERONE ENANTHATE INJECTION |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | P |
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 |
$67.00 | $201.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
tetanus toxoid adsorbed vial |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | None |
Tetracycline Hydrochloride 250mg/1 1000 CAPSULE in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
Tetracycline Hydrochloride 500mg/1 1000 CAPSULE in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
TEV-TROPIN 2 CARTON in 1 BOX / 1 POWDER, FOR SOLUTION in 1 CARTON |
5 |
Specialty Tier |
33% | 33% | P |
THALOMID 100MG CAPSULE 140 BOX |
5 |
Specialty Tier |
33% | 33% | Q:28 /28Days |
Thalomid 150mg/1 |
5 |
Specialty Tier |
33% | 33% | Q:60 /30Days |
Thalomid 200mg/1 |
5 |
Specialty Tier |
33% | 33% | Q:60 /30Days |
THALOMID 50MG CAPSULE 280 BOX |
5 |
Specialty Tier |
33% | 33% | Q:28 /28Days |
Theophylline 100mg/1 500 CAPSULE in 1 BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Theophylline 200mg/1 500 TABLET, EXTENDED RELEASE in 1 BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
THEOPHYLLINE 400MG TABLET SA |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THEOPHYLLINE 600MG TABLET SA |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
THEOPHYLLINE TABLET ER 300MG (100 CT) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
THEOPHYLLINE TABLET ER 450MG (100 CT) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
THIORIDAZINE 100MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
THIORIDAZINE HCL 10MG TABLET (1000 CT) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
THIORIDAZINE HCL 25MG TABLET (1000 CT) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
Thioridazine Hydrochloride 50mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED in 1 |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
THIOTHIXENE 10MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
THIOTHIXENE 1MG CAPSULE (100 CT) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
THIOTHIXENE 2MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
THIOTHIXENE 5MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
tiagabine hcl 2 mg tablet |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | None |
tiagabine hcl 4 mg tablet |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | None |
TICLOPIDINE 250 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TIKOSYN .125MG CAPSULE |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
TIKOSYN .250MG CAPSULE |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
TIKOSYN .5MG CAPSULE |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
TIMENTIN ADD-VANTAGE 1; 30mg/mL; mg/mL 10 VIAL in 1 TRAY / 50 mL in 1 VIAL |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | None |
TIMOLOL MAL SOL 0.25% OP 15ML BOT |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
TIMOLOL MAL SOL 0.5% OP 10ML BOT |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
TIMOLOL MALEATE 10MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TIMOLOL MALEATE 20MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | 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 |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | None |
TIMOLOL MALEATE 5MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Timolol Maleate 6.8mg/mL 1 BOTTLE, DISPENSING in 1 CARTON / 5 mL in 1 BOTTLE, DISPENSING |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | None |
Tizanidine 4mg/1 1000 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TIZANIDINE HCL 2 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TOBI 300mg/5mL 56 AMPULE in 1 CARTON / 5 mL in 1 AMPULE |
5 |
Specialty Tier |
33% | 33% | P |
TOBRADEX EYE OINTMENT |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
TOBRAMYCIN OPHTHALMIC SOLUTION 0.3% 5ML BOT |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
TOBRAMYCIN-DEXAMETH OPTH SUSP |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | None |
TOBREX 0.3% EYE OINTMENT |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
TOLAZAMIDE TABLETS 250MG 100 BOT |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOLAZAMIDE TABLETS 500MG 100 BOT |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TOLBUTAMIDE 500MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TOLMETIN SODIUM 200MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TOLMETIN SODIUM 400 MG CAP |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TOLMETIN SODIUM 600MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
tolterodine tartrate 1 mg tab |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | Q:60 /30Days |
tolterodine tartrate 2 mg tablet |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | Q:60 /30Days |
TOLVAPTAN 15 MG ORAL TABLET [SAMSCA] |
5 |
Specialty Tier |
33% | 33% | P |
TOLVAPTAN 30 MG ORAL TABLET [SAMSCA] |
5 |
Specialty Tier |
33% | 33% | P |
Topiramate 25mg/1 |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TOPIRAMATE SPRINKLE CAPSULES 15MG 60 BOT |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOPIRAMATE TABLETS 100MG 1000 BOT |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TOPIRAMATE TABLETS 200MG 1000 BOT |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TOPIRAMATE TABLETS 25MG 1000 BOT |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TOPIRAMATE TABLETS 50MG 1000 BOT |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TOPOTECAN HYDROCHLORIDE FOR INJECTION |
5 |
Specialty Tier |
33% | 33% | P |
Torisel 1 KIT in 1 CARTON |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
Torsemide 100mg/1 12 BOTTLE CASE / 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TORSEMIDE 20mg 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TORSEMIDE INJECTION 20MG/2ML |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TORSEMIDE TABLETS |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TORSEMIDE TABLETS |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOVIAZ TABLETS 4MG EXTENDED RELEASE |
3 |
Preferred Brand |
$43.00 | $129.00 | Q:30 /30Days |
TOVIAZ TABLETS 8MG EXTENDED RELEASE |
3 |
Preferred Brand |
$43.00 | $129.00 | Q:30 /30Days |
TPN ELECTROLYTES VIAL |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
TRACLEER 125MG TABLET |
5 |
Specialty Tier |
33% | 33% | P Q:60 /30Days |
TRACLEER 62.5MG TABLET |
5 |
Specialty Tier |
33% | 33% | P Q:120 /30Days |
TRADJENTA 5mg/1 90 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
TRAMADOL HCL 50 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | Q:240 /30Days |
TRAMADOL HCL-ACETAMINOPHEN 37.5-325MG TABLET (1000 CT) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | Q:300 /30Days |
TRANDOLAPRIL 1MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TRANDOLAPRIL 2MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TRANDOLAPRIL 4MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRANEXAMIC ACID 1,000 MG/10 ML |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
TRANYLCYPROMINE SULFATE 10MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TRAVASOL 10% SOLUTION VIAFLEX |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | P |
TRAVATAN Z 0.04MG DROPS 2.5ML BOT |
3 |
Preferred Brand |
$43.00 | $129.00 | Q:3 /30Days |
travoprost 0.004% eye drop |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | Q:3 /30Days |
TRAZODONE HCL TABLET USP 100MG (500 CT) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TRAZODONE HCL TABLET USP 150MG (100 CT) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TRAZODONE HCL TABLET USP 50MG (500 CT) |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
TREANDA FOR INJECTION 100MG/VIAL |
5 |
Specialty Tier |
33% | 33% | None |
TRECATOR 250MG TABLET |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | None |
Tretinoin 0.1mg/g 1 TUBE in 1 CARTON / 45 g in 1 TUBE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P Q:45 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Tretinoin 0.25mg/g 1 TUBE in 1 CARTON / 45 g in 1 TUBE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P Q:45 /30Days |
Tretinoin 0.25mg/g 1 TUBE in 1 CARTON / 45 g in 1 TUBE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P Q:45 /30Days |
Tretinoin 0.5mg/g 1 TUBE in 1 CARTON / 20 g in 1 TUBE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P Q:45 /30Days |
TRETINOIN 10MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | None |
Tretinoin 1mg/g 1 TUBE in 1 CARTON / 45 g in 1 TUBE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P Q:45 /30Days |
TRI-LEGEST FE 5-7-9-7 TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TRI-SPRINTEC 7DAYSX3 28 TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TRIAMCINOLONE 0.1% OINTMENT |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TRIAMCINOLONE ACETONIDE 0.025% CREAM 80GM TUBE |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
TRIAMCINOLONE ACETONIDE 0.025% LOTION 2 FL OZ BOT |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TRIAMCINOLONE ACETONIDE 0.025% OINTMENT 80GM TUBE |
1 |
Preferred Generic |
$3.00 | $9.00 | 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 |
$10.00 | $30.00 | None |
TRIAMCINOLONE ACETONIDE 0.1% CREAM 80GM TUBE |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
TRIAMCINOLONE ACETONIDE 0.1% LOTION 60ML BOTPL |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Triamcinolone Acetonide 1mg/g 1 TUBE in 1 CARTON / 5 g in 1 TUBE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Triamcinolone Acetonide 55ug/1 1 BOTTLE, SPRAY in 1 CARTON / 120 SPRAY, METERED in 1 BOTTLE, SPRAY |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | Q:17 /30Days |
Triamcinolone Acetonide 5mg/g 1 TUBE in 1 CARTON / 15 g in 1 TUBE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Triamterene and Hydrochlorothiazide 25; 37.5mg 100 CAPSULE BOTTLE |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
TRIAMTERENE/HCTZ 37.5/25 TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
TRIAMTERENE/HCTZ 75/50 TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
Tribenzor 5; 12.5; 40mg/1; mg/1; mg/1 |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
Tribenzor 5; 25; 40mg/1; mg/1; mg/1 |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIBENZOR TABLETS |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
TRIBENZOR TABLETS |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
TRIBENZOR TABLETS |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
TRIFLUOPERAZINE 1MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TRIFLUOPERAZINE HCL 2MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TRIFLUOPERAZINE HCL 5MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | None |
TRIHEXYPHENIDYL HYDROCHLORIDE 2mg/1 |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Trihexyphenidyl Hydrochloride 2mg/5mL 473 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Trihexyphenidyl Hydrochloride 5mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIMETHOBENZAMIDE HCL 300MG CAPSULE |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | None |
TRIMETHOPRIM TABLETS |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TRIMIPRAMINE MALEATE 100 MG CAP |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TRIMIPRAMINE MALEATE 25 MG CAP |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TRIMIPRAMINE MALEATE 50 MG CAP |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TRISENOX 10MG/10ML AMPULE |
5 |
Specialty Tier |
33% | 33% | None |
Trivora 6 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
TRIZIVIR 300; 150; 300mg/1; mg/1; mg/1 60 FILM COATED TABLETS in BOTTLE |
5 |
Specialty Tier |
33% | 33% | None |
TRUVADA TABLET |
5 |
Specialty Tier |
33% | 33% | None |
TWINRIX TF PF VACCINE 720UNT/20ML 10 X 1ML VIALSD |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
Tygacil 50mg/5mL 10 VIAL, SINGLE-USE in 1 CARTON / 50 mL in 1 VIAL, SINGLE-USE |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TYKERB 250MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
TYPHIM VI 25MCG/0.5ML VIAL |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
TYZEKA 600MG TABLET (30 CT) |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | P |
TYZINE 0.1% NOSE DROPS |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
TYZINE PEDIATRIC 0.05% DROP |
3 |
Preferred Brand |
$43.00 | $129.00 | None |