2014 Medicare Part D Plan Formulary Information |
Medicare Plus Blue PPO Assure (PPO) (H9572-003-6)
Benefit Details
|
The Medicare Plus Blue PPO Assure (PPO) (H9572-003-6) Formulary Drugs Starting with the Letter T in MACOMB County, MI: CMS MA Region 11 which includes: MI Plan Monthly Premium: $272.00 Deductible: $0 |
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 |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
TACLONEX OINTMENT |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
TACLONEX SCALP SUSPENSION |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
Tacrolimus 0.5mg/1 100 CAPSULE BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | P |
Tacrolimus 1mg/1 100 CAPSULE BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | P |
Tacrolimus 5mg/1 100 CAPSULE BOTTLE |
5 |
Specialty Tier |
33% | N/A | P |
TAFINLAR 50 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P |
TAFINLAR 75 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P |
Tamiflu 30mg/1 1 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:90 /180Days |
Tamiflu 45mg/1 1 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:50 /180Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAMIFLU 6 MG/ML SUSPENSION |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:540 /180Days |
TAMIFLU 75MG CAPSULE UD |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:50 /180Days |
TAMOXIFEN CITRATE 20MG TABLET (30 CT) |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TAMOXIFEN CITRATE TABLETS 10MG 180 BOT |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TAMSULOSIN HCL 0.4 MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:180 /90Days |
TARCEVA 100MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
TARCEVA 150MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
TARCEVA 25MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
TARGRETIN 1% GEL 60GM TUBE |
5 |
Specialty Tier |
33% | N/A | P |
TARGRETIN 75 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P |
TARKA 1/240MG TABLET SA |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:90 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Tarka 2; 240mg/1; mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:90 /90Days |
TARKA 2/180MG TABLET SA |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:90 /90Days |
Tarka 4; 240mg/1; mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:90 /90Days |
Tasigna 150mg/1 4 BLISTER PACK per CARTON / 28 CAPSULE per BLISTER PACK |
5 |
Specialty Tier |
33% | N/A | None |
TASIGNA 200MG CAPSULE 28 BLPK |
5 |
Specialty Tier |
33% | N/A | None |
TASMAR 100MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
TAZORAC 0.05% CREAM |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
TAZORAC 0.05% GEL |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
TAZORAC 0.1% CREAM |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
TAZORAC 0.1% GEL |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
TAZTIA DILTIAZEM HYDROCHLORIDE 120MG EXTENDED RELEASE CAPSULES |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAZTIA DILTIAZEM HYDROCHLORIDE 180MG EXTENDED RELEASE CAPSULES |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
TAZTIA DILTIAZEM HYDROCHLORIDE 300MG EXTENDED RELEASE CAPSULES |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
TAZTIA XT 240MG CAPSULE SA |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
TAZTIA XT 360MG CAPSULE SA |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
TECFIDERA DR 120 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:62 /31Days |
TECFIDERA DR 240 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:62 /31Days |
TECFIDERA STARTER PACK |
5 |
Specialty Tier |
33% | N/A | P |
Teflaro 400mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
Teflaro 600mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
TEGRETOL XR TABLETS 100MG 100 BOT |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
TEKTURNA 150MG TABLET |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:90 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TEKTURNA 300MG TABLET |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:90 /90Days |
TEKTURNA HCT 150-12.5MG TABLET |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:90 /90Days |
TEKTURNA HCT 150MG-25MG TABLET |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:90 /90Days |
TEKTURNA HCT 300-12.5MG TABLET |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:90 /90Days |
TEKTURNA HCT 300MG-25MG TABLET |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:90 /90Days |
Telmisartan 20 MG Tablet [Micardis] |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
Telmisartan 40 MG Tablet [Micardis] |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
Telmisartan 80 MG Tablet [Micardis] |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
Telmisartan-Amlodipine 40-10 MG [Micardis] |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
Telmisartan-Amlodipine 40-5 MG [Micardis] |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
Telmisartan-Amlodipine 80-10 MG [Micardis] |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Telmisartan-Amlodipine 80-5 MG [Micardis] |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
Telmisartan-HCTZ 40-12.5 mg tablet [Micardis HCT] |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
Telmisartan-HCTZ 80-12.5 mg tablet [Micardis HCT] |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
Telmisartan-HCTZ 80-25 mg tablet [Micardis HCT] |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
Temazepam 15mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE per BLISTER PACK |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Temazepam 22.5mg/1 30 CAPSULE BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TEMAZEPAM 30 MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Temazepam 7.5mg/1 100 CAPSULE BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TERAZOSIN 1 MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Terazosin Hydrochloride 10mg/1 100 CAPSULE BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Terazosin Hydrochloride 2mg/1 100 CAPSULE BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Terazosin Hydrochloride 5mg/1 100 CAPSULE BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TERBINAFINE HCL 250 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TERBUTALINE SULF 1MG/ML VL |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TERBUTALINE SULF 2.5MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TERBUTALINE SULFATE 5MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TERCONAZOLE 0.4% CREAM WITH APPLICATOR |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TERCONAZOLE 0.8% CREAM |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TERCONAZOLE 80MG SUPPOSITORY VAGINAL |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TESTIM 1%(50MG) GEL |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
TESTOSTERONE CYPIONATE 100MG/ML INJECTION |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Testosterone Cypionate 200mg/mL 1 VIAL, MULTI-DOSE per CARTON / 10 mL in 1 VIAL, MULTI-DOSE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TESTOSTERONE ENANTHATE 200MG/ML INJECTION |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TESTRED 10MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
TETANUS DIPHTHERIA TOXOIDS |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
tetanus toxoid adsorbed vial |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TEV-TROPIN 2 CARTON in 1 BOX / 1 POWDER, FOR SOLUTION per CARTON |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P |
TEVETEN HCT TABLETS 600;25MG;MG 100 BOT |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
TEVETEN TABLETS 400MG 100 BOT |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
TEVETEN TABLETS 600;12.5MG;MG 100 BOT |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
THALOMID 100MG CAPSULE 140 BOX |
5 |
Specialty Tier |
33% | N/A | P |
Thalomid 150mg/1 |
5 |
Specialty Tier |
33% | N/A | P |
Thalomid 200mg/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 50MG CAPSULE 280 BOX |
5 |
Specialty Tier |
33% | N/A | P |
Theophylline 100mg/1 500 CAPSULE BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Theophylline 200mg/1 500 TABLET, EXTENDED RELEASE in 1 BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
THEOPHYLLINE 400MG TABLET SA |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
THEOPHYLLINE 600MG TABLET SA |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
THEOPHYLLINE TABLET ER 300MG (100 CT) |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
THEOPHYLLINE TABLET ER 450MG (100 CT) |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Thermazene 10mg/g |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
THIORIDAZINE 100MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
THIORIDAZINE HCL 10MG TABLET (1000 CT) |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
THIORIDAZINE HCL 25MG TABLET (1000 CT) |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Thioridazine Hydrochloride 50mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED in 1 |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
THIOTHIXENE 10MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
THIOTHIXENE 1MG CAPSULE (100 CT) |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
THIOTHIXENE 2MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
THIOTHIXENE 5MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
THYMOGLOBULIN 25MG VIAL |
5 |
Specialty Tier |
33% | N/A | None |
THYROLAR-1 TABLETS |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
THYROLAR-1/2 TABLETS |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
THYROLAR-1/4 TABLETS |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
THYROLAR-2 TABLETS |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
THYROLAR-3 TABLETS |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
tiagabine hcl 2 mg tablet [Gabitril] |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
tiagabine hcl 4 mg tablet [Gabitril] |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TIKOSYN .125MG CAPSULE |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
TIKOSYN .250MG CAPSULE |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
TIKOSYN .5MG CAPSULE |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
TIMOLOL MAL SOL 0.25% OP 15ML BOT |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
TIMOLOL MAL SOL 0.5% OP 10ML BOT |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
TIMOLOL MALEATE 10MG TABLET |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
TIMOLOL MALEATE 20MG TABLET |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
Timolol Maleate 3.4mg/mL 1 BOTTLE, DISPENSING per CARTON / 5 mL in 1 BOTTLE, DISPENSING |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
TIMOLOL MALEATE 5MG TABLET |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Timolol Maleate 6.8mg/mL 1 BOTTLE, DISPENSING per CARTON / 5 mL in 1 BOTTLE, DISPENSING |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
Timoptic 3.4mg/mL 4 POUCH per CARTON / 15 CONTAINER in 1 POUCH / 0.2 mL in 1 CONTAINER [TIMOPTIC] |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
Timoptic 6.8mg/mL 4 POUCH per CARTON / 15 CONTAINER in 1 POUCH / 0.2 mL in 1 CONTAINER [TIMOPTIC] |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
tinidazole 250 mg tablet |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
tinidazole 500 mg tablet |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TIVICAY 50 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
Tizanidine 4mg/1 1000 TABLET BOTTLE |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
TIZANIDINE HCL 2 MG CAPSULE |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
TIZANIDINE HCL 2 MG TABLET |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
TIZANIDINE HCL 4 MG CAPSULE |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
TIZANIDINE HCL 6 MG CAPSULE |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOBI 300mg/5mL 56 AMPULE per 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 | P |
TOBRADEX EYE OINTMENT |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
TOBRADEX ST 0.5; 3mg/mL; mg/mL 5 mL in 1 BOTTLE |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
TOBRAMYCIN 10MG/ML VIAL |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TOBRAMYCIN 300 MG/5 ML AMPULE [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate] |
5 |
Specialty Tier |
33% | N/A | P |
TOBRAMYCIN 40MG/ML VIAL |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TOBRAMYCIN 80MG/0.9% NACL |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TOBRAMYCIN OPHTHALMIC SOLUTION 0.3% 5ML BOT |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
TOBRAMYCIN-DEXAMETH OPTH SUSP |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TOBREX 0.3% EYE OINTMENT |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | 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 |
$3.00 | $7.50 | None |
TOLAZAMIDE TABLETS 500MG 100 BOT |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
TOLBUTAMIDE 500MG TABLET |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
TOLMETIN SODIUM 200MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TOLMETIN SODIUM 400 MG CAP |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TOLMETIN SODIUM 600MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Tolterodine Tartrate 1 MG TABLET [Detrol LA] |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Tolterodine Tartrate 2 MG TABLET [Detrol LA] |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Tolterodine Tartrate ER 2 MG CAPSULE [Detrol LA] |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Tolterodine Tartrate ER 4 MG CAPSULE [Detrol LA] |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TOLVAPTAN 15 MG ORAL TABLET [SAMSCA] |
5 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOLVAPTAN 30 MG ORAL TABLET [SAMSCA] |
5 |
Specialty Tier |
33% | N/A | P |
TOPICORT 0.25% SPRAY |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
Topiramate 25mg/1 |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TOPIRAMATE SPRINKLE CAPSULES 15MG 60 BOT |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TOPIRAMATE TABLETS 100MG 1000 BOT |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TOPIRAMATE TABLETS 200MG 1000 BOT |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TOPIRAMATE TABLETS 25MG 1000 BOT |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TOPIRAMATE TABLETS 50MG 1000 BOT |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TOPOSAR INJECTION 20MG/ML 50ML VIAL MD CRTN |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Topotecan hcl 4 mg vial |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Torisel 1 KIT per CARTON |
5 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Torsemide 100mg/1 12 BOTTLE CASE / 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TORSEMIDE 10MG TABLETS |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TORSEMIDE 20mg 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TORSEMIDE 5MG TABLETS |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TORSEMIDE INJECTION 20MG/2ML |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TOVIAZ TABLETS 4MG EXTENDED RELEASE |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:180 /90Days |
TOVIAZ TABLETS 8MG EXTENDED RELEASE |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:90 /90Days |
TRACLEER 125MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
TRACLEER 62.5MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
TRADJENTA 5mg/1 90 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
TRAMADOL ER 300 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:90 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRAMADOL HCL 50 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:720 /90Days |
TRAMADOL HCL-ACETAMINOPHEN 37.5-325MG TABLET (1000 CT) |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:1080 /90Days |
TRAMADOL HYDROCHLORIDE 100mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:90 /90Days |
TRAMADOL HYDROCHLORIDE 200mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:90 /90Days |
TRANDOLAPRIL 1MG TABLET |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
TRANDOLAPRIL 2MG TABLET |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
TRANDOLAPRIL 4MG TABLET |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
TRANEXAMIC ACID 1,000 MG/10 ML |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TRANSDERM-SCOP 1.5 MG/72HR |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
TRANYLCYPROMINE SULFATE 10MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TRAVASOL 10% SOLUTION VIAFLEX |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRAVATAN Z 0.04MG DROPS 2.5ML BOT |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
travoprost 0.004% eye drop [Travatan] |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TRAZODONE 300MG TABLET |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
TRAZODONE HCL TABLET USP 100MG (500 CT) |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
TRAZODONE HCL TABLET USP 150MG (100 CT) |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
TRAZODONE HCL TABLET USP 50MG (500 CT) |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
TREANDA FOR INJECTION 100MG/VIAL |
5 |
Specialty Tier |
33% | N/A | P |
TRECATOR 250MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
Trelstar 22.5mg/2mL 2 mL in 1 VIAL, SINGLE-DOSE |
5 |
Specialty Tier |
33% | N/A | None |
TRELSTAR DEPOT MIXJET FOR INJECTION 3.75 MG |
5 |
Specialty Tier |
33% | N/A | None |
TRELSTAR MIXJET FOR INJECTION 11.25 MG |
5 |
Specialty Tier |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Tretinoin 0.1mg/g 1 TUBE per CARTON / 45 g in 1 TUBE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Tretinoin 0.25mg/g 1 TUBE per CARTON / 45 g in 1 TUBE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Tretinoin 0.25mg/g 1 TUBE per CARTON / 45 g in 1 TUBE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Tretinoin 0.5mg/g 1 TUBE per CARTON / 20 g in 1 TUBE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TRETINOIN 10MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | None |
Tretinoin 1mg/g 1 TUBE per CARTON / 45 g in 1 TUBE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TREXIMET 500; 85mg/1; mg/1 |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:9 /1Days |
TRI PREVIFEM TABLETS |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TRI-LEGEST FE 5-7-9-7 TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TRI-SPRINTEC 7DAYSX3 28 TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TRIAMCINOLONE 0.1% OINTMENT |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Triamcinolone acet 40mg/ml vl |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Triamcinolone acet 50mg/5ml vl |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TRIAMCINOLONE ACETONIDE 0.025% CREAM 80GM TUBE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TRIAMCINOLONE ACETONIDE 0.025% LOTION 2 FL OZ BOT |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TRIAMCINOLONE ACETONIDE 0.1% CREAM 80GM TUBE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TRIAMCINOLONE ACETONIDE 0.1% LOTION 60ML BOTPL |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
triamcinolone acetonide 0.25mg/g 80 g in 1 TUBE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Triamcinolone Acetonide 1mg/g 1 TUBE per CARTON / 5 g in 1 TUBE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Triamcinolone Acetonide 55ug/1 1 BOTTLE, SPRAY per CARTON / 120 SPRAY, METERED in 1 BOTTLE, SPRAY |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Triamcinolone Acetonide 5mg/g 1 TUBE per CARTON / 15 g in 1 TUBE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | 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 | $7.50 | None |
TRIAMTERENE/HCTZ 37.5/25 TABLET |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
TRIAMTERENE/HCTZ 50-25 MG CAP |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
TRIAMTERENE/HCTZ 75/50 TABLET |
1 |
Preferred Generic |
$3.00 | $7.50 | None |
TRIDERM 0.1% CREAM |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TRIFLUOPERAZINE 1MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TRIFLUOPERAZINE HCL 2MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TRIFLUOPERAZINE HCL 5MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TRIGLIDE 160 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:90 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIHEXYPHENIDYL 5 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TRIHEXYPHENIDYL HYDROCHLORIDE 2mg/1 |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Trihexyphenidyl Hydrochloride 2mg/5mL 473 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TRILIPIX CAPSULE DR 45MG |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:270 /90Days |
TRILIPIX DELAYED RELEASE CAPSULES 135MG |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:90 /90Days |
TRILYTE WITH FLAVOR PACKETS |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TRIMETHOPRIM 100MG TABLETS |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TRIMIPRAMINE MALEATE 100 MG CAP |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TRIMIPRAMINE MALEATE 25 MG CAP |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TRIMIPRAMINE MALEATE 50 MG CAP |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TRINESSA TABLET |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRISENOX 10MG/10ML AMPULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
Trivora 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TRIZIVIR 300; 150; 300mg/1; mg/1; mg/1 60 FILM COATED TABLETS in BOTTLE |
5 |
Specialty Tier |
33% | N/A | None |
TROPHAMINE INJECTION SOLUTION |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P |
TROPHAMINE INJECTION SOLUTION 6% |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P |
TROSPIUM CHLORIDE 20MG TABLETS |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None |
TROSPIUM CHLORIDE ER 60 MG CAP |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:90 /90Days |
TRUVADA 200/300MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
TUDORZA PRESSAIR 400 MCG INH |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:3 /90Days |
TWINRIX TF PF VACCINE 720UNT/20ML 10 X 1ML VIALSD |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
Tygacil 50mg/5mL 10 VIAL, SINGLE-USE per CARTON / 50 mL in 1 VIAL, SINGLE-USE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | 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% | N/A | None |
TYPHIM VI 25MCG/0.5ML VIAL |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
TYSABRI 300 MG/15 ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
Tyvaso 1.74mg/2.9mL |
5 |
Specialty Tier |
33% | N/A | None |
TYZEKA 600MG TABLET (30 CT) |
5 |
Specialty Tier |
33% | N/A | None |
TYZINE PEDIATRIC 0.05% DROP |
3 |
Preferred Brand |
$40.00 | $100.00 | None |