2013 Medicare Part D Plan Formulary Information |
SCAN Healthy at Home (HMO SNP) (H9104-006-0)
Benefit Details
|
The SCAN Healthy at Home (HMO SNP) (H9104-006-0) Formulary Drugs Starting with the Letter T in Statewide County, CA: CMS MA Region 24 which includes: CA
|
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 |
$80.00 | $160.00 | P |
Tacrolimus 0.5mg/1 100 CAPSULE in 1 BOTTLE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | P |
Tacrolimus 1mg/1 100 CAPSULE in 1 BOTTLE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | P |
Tacrolimus 5mg/1 100 CAPSULE in 1 BOTTLE |
5 |
Specialty Tier |
33% | N/A | P |
Tamiflu 6mg/mL 1 BOTTLE, GLASS in 1 CARTON / 6 mL in 1 BOTTLE, GLASS |
3 |
Preferred Brand |
$39.00 | $78.00 | None |
TAMIFLU 75MG CAPSULE UD |
3 |
Preferred Brand |
$39.00 | $78.00 | None |
TAMOXIFEN CITRATE 20MG TABLET (30 CT) |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TAMOXIFEN CITRATE TABLETS 10MG 180 BOT |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TAMSULOSIN HCL 0.4 MG CAPSULE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TARCEVA 100MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TARCEVA 150MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
TARCEVA 25MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
TARGRETIN 1% GEL 60GM TUBE |
5 |
Specialty Tier |
33% | N/A | P |
TARGRETIN 75MG (100 CT) |
5 |
Specialty Tier |
33% | N/A | P |
Tasigna 150mg/1 4 BLISTER PACK in 1 CARTON / 28 CAPSULE in 1 BLISTER PACK |
5 |
Specialty Tier |
33% | N/A | P |
TASIGNA 200MG CAPSULE 28 BLPK |
5 |
Specialty Tier |
33% | N/A | P |
TAZORAC 0.05% CREAM |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | Q:60 /31Days |
TAZORAC 0.05% GEL |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | Q:100 /31Days |
TAZORAC 0.1% CREAM |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | Q:60 /31Days |
TAZORAC 0.1% GEL |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | Q:100 /31Days |
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | 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 |
$8.00 | $16.00 | None |
TAZTIA DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TAZTIA XT 240MG CAPSULE SA |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TAZTIA XT 360MG CAPSULE SA |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TECFIDERA DR 120 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P |
TECFIDERA DR 240 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P |
TECFIDERA STARTER PACK |
5 |
Specialty Tier |
33% | N/A | P |
TEGRETOL CHEWABLE TABLETS 100MG 100 BOT |
3 |
Preferred Brand |
$39.00 | $78.00 | None |
TEGRETOL SUSPENSION 100MG/5ML 450 ML BOT |
3 |
Preferred Brand |
$39.00 | $78.00 | None |
TEGRETOL TABLETS 200MG 100 BOT |
3 |
Preferred Brand |
$39.00 | $78.00 | None |
TEGRETOL XR TABLETS 100MG 100 BOT |
3 |
Preferred Brand |
$39.00 | $78.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TEGRETOL XR TABLETS 200MG 100 BOT |
3 |
Preferred Brand |
$39.00 | $78.00 | None |
TEGRETOL XR TABLETS 400MG 100 BOT |
3 |
Preferred Brand |
$39.00 | $78.00 | None |
TEKTURNA 150MG TABLET |
3 |
Preferred Brand |
$39.00 | $78.00 | S |
TEKTURNA 300MG TABLET |
3 |
Preferred Brand |
$39.00 | $78.00 | S |
TEKTURNA HCT 150-12.5MG TABLET |
3 |
Preferred Brand |
$39.00 | $78.00 | S |
TEKTURNA HCT 150MG-25MG TABLET |
3 |
Preferred Brand |
$39.00 | $78.00 | S |
TEKTURNA HCT 300-12.5MG TABLET |
3 |
Preferred Brand |
$39.00 | $78.00 | S |
TEKTURNA HCT 300MG-25MG TABLET |
3 |
Preferred Brand |
$39.00 | $78.00 | S |
Temazepam 15mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE in 1 BLISTER PACK |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Temazepam 22.5mg/1 30 CAPSULE in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TEMAZEPAM 30 MG CAPSULE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Temazepam 7.5mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Terazosin Hydrochloride 10mg/1 100 CAPSULE in 1 BOTTLE |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
Terazosin hydrochloride 1mg/1 500 CAPSULE in 1 BOTTLE |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
Terazosin Hydrochloride 2mg/1 100 CAPSULE in 1 BOTTLE |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
Terazosin Hydrochloride 5mg/1 100 CAPSULE in 1 BOTTLE |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
TERBINAFINE HCL 250MG TABLET |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TERBUTALINE SULF 1MG/ML VL |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TERBUTALINE SULF 2.5MG TABLET |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TERBUTALINE SULFATE 5MG TABLET |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TERCONAZOLE 0.4% CREAM WITH APPLICATOR |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TERCONAZOLE 0.8% CREAM |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TERCONAZOLE 80MG SUPPOSITORY VAGINAL |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TESTIM 1%(50MG) GEL |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
Testosterone Cypionate 200mg/mL 1 VIAL, MULTI-DOSE in 1 CARTON / 10 mL in 1 VIAL, MULTI-DOSE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TESTOSTERONE CYPIONATE INJECTION |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TESTOSTERONE ENANTHATE INJECTION |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Tetanus and Diphtheria Toxoids Adsorbed 2.0; 2.0[Lf]/0.5mL; [Lf]/0.5mL 10 VIAL, SINGLE-DOSE in 1 CA |
3 |
Preferred Brand |
$39.00 | $78.00 | None |
tetanus toxoid adsorbed vial |
3 |
Preferred Brand |
$39.00 | $78.00 | P |
Tetracycline Hydrochloride 250mg/1 1000 CAPSULE in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Tetracycline Hydrochloride 500mg/1 1000 CAPSULE in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
THALOMID 100MG CAPSULE 140 BOX |
5 |
Specialty Tier |
33% | N/A | P |
Thalomid 150mg/1 |
5 |
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 |
5 |
Specialty Tier |
33% | N/A | P |
THALOMID 50MG CAPSULE 280 BOX |
5 |
Specialty Tier |
33% | N/A | P |
Theophylline 100mg/1 500 CAPSULE in 1 BOTTLE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Theophylline 200mg/1 500 TABLET, EXTENDED RELEASE in 1 BOTTLE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
THEOPHYLLINE 400MG TABLET SA |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
THEOPHYLLINE 600MG TABLET SA |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
THEOPHYLLINE TABLET ER 300MG (100 CT) |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
THEOPHYLLINE TABLET ER 450MG (100 CT) |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Thermazene 10mg/g |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
THIORIDAZINE 100MG TABLET |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
THIORIDAZINE HCL 10MG TABLET (1000 CT) |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THIORIDAZINE HCL 25MG TABLET (1000 CT) |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Thioridazine Hydrochloride 50mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED in 1 |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
THIOTHIXENE 10MG CAPSULE |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
THIOTHIXENE 1MG CAPSULE (100 CT) |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
THIOTHIXENE 2MG CAPSULE |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
THIOTHIXENE 5MG CAPSULE |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
tiagabine hcl 2 mg tablet |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
tiagabine hcl 4 mg tablet |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TIKOSYN .125MG CAPSULE |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
TIKOSYN .250MG CAPSULE |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
TIKOSYN .5MG CAPSULE |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIMENTIN ADD-VANTAGE 1; 30mg/mL; mg/mL 10 VIAL in 1 TRAY / 50 mL in 1 VIAL |
3 |
Preferred Brand |
$39.00 | $78.00 | None |
TIMOLOL MAL SOL 0.25% OP 15ML BOT |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
TIMOLOL MAL SOL 0.5% OP 10ML BOT |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
TIMOLOL MALEATE 10MG TABLET |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
TIMOLOL MALEATE 20MG TABLET |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
Timolol Maleate 3.4mg/mL 1 BOTTLE, DISPENSING in 1 CARTON / 5 mL in 1 BOTTLE, DISPENSING |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TIMOLOL MALEATE 5MG TABLET |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
Timolol Maleate 6.8mg/mL 1 BOTTLE, DISPENSING in 1 CARTON / 5 mL in 1 BOTTLE, DISPENSING |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Tizanidine 4mg/1 1000 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TIZANIDINE HCL 2 MG CAPSULE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TIZANIDINE HCL 2 MG TABLET |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIZANIDINE HCL 4 MG CAPSULE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TIZANIDINE HCL 6 MG CAPSULE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TOBI 300mg/5mL 56 AMPULE in 1 CARTON / 5 mL in 1 AMPULE |
5 |
Specialty Tier |
33% | N/A | P |
TOBI PODHALER 28 MG INHALE CAP |
5 |
Specialty Tier |
33% | N/A | None |
TOBRADEX EYE OINTMENT |
3 |
Preferred Brand |
$39.00 | $78.00 | None |
TOBRAMYCIN 10MG/ML VIAL |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TOBRAMYCIN 40MG/ML VIAL |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TOBRAMYCIN 60MG/0.9% NACL |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TOBRAMYCIN 80MG/0.9% NACL |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TOBRAMYCIN OPHTHALMIC SOLUTION 0.3% 5ML BOT |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TOBRAMYCIN-DEXAMETH OPTH SUSP |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Topiramate 25mg/1 |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TOPIRAMATE SPRINKLE CAPSULES 15MG 60 BOT |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TOPIRAMATE TABLETS 100MG 1000 BOT |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TOPIRAMATE TABLETS 200MG 1000 BOT |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TOPIRAMATE TABLETS 25MG 1000 BOT |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TOPIRAMATE TABLETS 50MG 1000 BOT |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Torsemide 100mg/1 12 BOTTLE CASE / 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TORSEMIDE 20mg 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TORSEMIDE TABLETS |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TORSEMIDE TABLETS |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TOVIAZ TABLETS 4MG EXTENDED RELEASE |
3 |
Preferred Brand |
$39.00 | $78.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOVIAZ TABLETS 8MG EXTENDED RELEASE |
3 |
Preferred Brand |
$39.00 | $78.00 | None |
TPN ELECTROLYTES VIAL |
3 |
Preferred Brand |
$39.00 | $78.00 | None |
TRACLEER 125MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
TRACLEER 62.5MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
TRAMADOL ER 300 MG TABLET |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | Q:31 /31Days |
TRAMADOL HCL 50 MG TABLET |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TRAMADOL HCL-ACETAMINOPHEN 37.5-325MG TABLET (1000 CT) |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | Q:248 /31Days |
TRAMADOL HYDROCHLORIDE 100mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | Q:31 /31Days |
TRAMADOL HYDROCHLORIDE 200mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | Q:31 /31Days |
TRANDOLAPRIL 1MG TABLET |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TRANDOLAPRIL 2MG TABLET |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRANDOLAPRIL 4MG TABLET |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TRANEXAMIC ACID 1,000 MG/10 ML |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
tranexamic acid 650 mg tablet |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TRANSDERM-SCOP 1.5 MG/72HR |
3 |
Preferred Brand |
$39.00 | $78.00 | None |
TRANYLCYPROMINE SULFATE 10MG TABLET |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TRAVASOL 10% SOLUTION VIAFLEX |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
TRAZODONE 300MG TABLET |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
TRAZODONE HCL TABLET USP 100MG (500 CT) |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
TRAZODONE HCL TABLET USP 150MG (100 CT) |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
TRAZODONE HCL TABLET USP 50MG (500 CT) |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
TRECATOR 250MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRETINOIN 10MG CAPSULE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TRI-SPRINTEC 7DAYSX3 28 TABLET |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TRIAMCINOLONE 0.1% OINTMENT |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TRIAMCINOLONE ACETONIDE 0.025% CREAM 80GM TUBE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TRIAMCINOLONE ACETONIDE 0.025% LOTION 2 FL OZ BOT |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TRIAMCINOLONE ACETONIDE 0.025% OINTMENT 80GM TUBE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TRIAMCINOLONE ACETONIDE 0.1% CREAM 80GM TUBE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TRIAMCINOLONE ACETONIDE 0.1% LOTION 60ML BOTPL |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Triamcinolone Acetonide 1mg/g 1 TUBE in 1 CARTON / 5 g in 1 TUBE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Triamcinolone Acetonide 5mg/g 1 TUBE in 1 CARTON / 15 g in 1 TUBE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Triamterene and Hydrochlorothiazide 25; 37.5mg 100 CAPSULE BOTTLE |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
TRIAMTERENE/HCTZ 37.5/25 TABLET |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
TRIAMTERENE/HCTZ 75/50 TABLET |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
Triazolam 0.125mg/1 10 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Triazolam 0.25mg/1 10 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TRIDERM 0.1% CREAM |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TRIFLUOPERAZINE 1MG TABLET |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TRIFLUOPERAZINE HCL 2MG TABLET |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TRIFLUOPERAZINE HCL 5MG TABLET |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIHEXYPHENIDYL HYDROCHLORIDE 2mg/1 |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Trihexyphenidyl Hydrochloride 2mg/5mL 473 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Trihexyphenidyl Hydrochloride 5mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TRILEPTAL 150MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
TRILEPTAL 300MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
TRILEPTAL 300MG/5ML SUSP |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
TRILEPTAL 600MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
TRIMETHOPRIM TABLETS |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TRIMIPRAMINE MALEATE 100 MG CAP |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TRIMIPRAMINE MALEATE 25 MG CAP |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TRIMIPRAMINE MALEATE 50 MG CAP |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Trivora 6 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
TRIZIVIR 300; 150; 300mg/1; mg/1; mg/1 60 FILM COATED TABLETS in BOTTLE |
5 |
Specialty Tier |
33% | N/A | None |
TRUVADA TABLET |
5 |
Specialty Tier |
33% | N/A | None |
TUDORZA PRESSAIR 400 MCG INH |
3 |
Preferred Brand |
$39.00 | $78.00 | Q:1 /30Days |
TWINJECT AUTO INJECTOR INJECTION 1% AUTO INJECTOR TWO PACK SYR |
3 |
Preferred Brand |
$39.00 | $78.00 | None |
TWINJECT AUTO INJECTOR INJECTION 1% AUTO TWO PACK SYR |
3 |
Preferred Brand |
$39.00 | $78.00 | None |
TWINRIX TF PF VACCINE 720UNT/20ML 10 X 1ML VIALSD |
3 |
Preferred Brand |
$39.00 | $78.00 | None |
Tygacil 50mg/5mL 10 VIAL, SINGLE-USE in 1 CARTON / 50 mL in 1 VIAL, SINGLE-USE |
5 |
Specialty Tier |
33% | N/A | None |
TYKERB 250MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
TYPHIM VI 25MCG/0.5ML VIAL |
3 |
Preferred Brand |
$39.00 | $78.00 | None |
TYZEKA 600MG TABLET (30 CT) |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TYZINE 0.1% NOSE DROPS |
3 |
Preferred Brand |
$39.00 | $78.00 | None |