2014 Medicare Part D Plan Formulary Information |
Medicare y Mucho Mas - ELITE (HMO-POS) (H4003-001-0)
Benefit Details
|
The Medicare y Mucho Mas - ELITE (HMO-POS) (H4003-001-0) Formulary Drugs Starting with the Letter T in TRUJILLO ALTO County, PR: CMS MA Region 30 which includes: PR Plan Monthly Premium: $33.50 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 |
2 |
Preferred Brand |
$20.00 | $40.00 | None |
Tacrolimus 0.5mg/1 100 CAPSULE BOTTLE |
1 |
Preferred Generic |
$4.00 | $8.00 | P |
Tacrolimus 1mg/1 100 CAPSULE BOTTLE |
1 |
Preferred Generic |
$4.00 | $8.00 | P |
Tacrolimus 5mg/1 100 CAPSULE BOTTLE |
4 |
Specialty Tier |
25% | 25% | P |
TAFINLAR 50 MG CAPSULE |
4 |
Specialty Tier |
25% | 25% | P |
TAFINLAR 75 MG CAPSULE |
4 |
Specialty Tier |
25% | 25% | P |
Tamiflu 30mg/1 1 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK |
2 |
Preferred Brand |
$20.00 | $40.00 | Q:84 /180Days |
Tamiflu 45mg/1 1 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK |
2 |
Preferred Brand |
$20.00 | $40.00 | Q:42 /180Days |
TAMIFLU 6 MG/ML SUSPENSION |
2 |
Preferred Brand |
$20.00 | $40.00 | Q:600 /180Days |
TAMIFLU 75MG CAPSULE UD |
2 |
Preferred Brand |
$20.00 | $40.00 | Q:56 /365Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAMOXIFEN CITRATE 20MG TABLET (30 CT) |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TAMOXIFEN CITRATE TABLETS 10MG 180 BOT |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TAMSULOSIN HCL 0.4 MG CAPSULE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TARCEVA 100MG TABLET |
4 |
Specialty Tier |
25% | 25% | P |
TARCEVA 150MG TABLET |
4 |
Specialty Tier |
25% | 25% | P |
TARCEVA 25MG TABLET |
4 |
Specialty Tier |
25% | 25% | P |
TARGRETIN 1% GEL 60GM TUBE |
4 |
Specialty Tier |
25% | 25% | P |
TARGRETIN 75 MG CAPSULE |
4 |
Specialty Tier |
25% | 25% | P |
Tasigna 150mg/1 4 BLISTER PACK per CARTON / 28 CAPSULE per BLISTER PACK |
4 |
Specialty Tier |
25% | 25% | P |
TASIGNA 200MG CAPSULE 28 BLPK |
4 |
Specialty Tier |
25% | 25% | P |
TASMAR 100MG TABLET |
4 |
Specialty Tier |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAZORAC 0.05% GEL |
2 |
Preferred Brand |
$20.00 | $40.00 | P |
TAZORAC 0.1% GEL |
2 |
Preferred Brand |
$20.00 | $40.00 | P |
TAZTIA DILTIAZEM HYDROCHLORIDE 120MG EXTENDED RELEASE CAPSULES |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TAZTIA DILTIAZEM HYDROCHLORIDE 180MG EXTENDED RELEASE CAPSULES |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TAZTIA DILTIAZEM HYDROCHLORIDE 300MG EXTENDED RELEASE CAPSULES |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TAZTIA XT 240MG CAPSULE SA |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TAZTIA XT 360MG CAPSULE SA |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TEGRETOL SUSPENSION 100MG/5ML 450 ML BOT |
2 |
Preferred Brand |
$20.00 | $40.00 | None |
TEGRETOL TABLETS 200MG 100 BOT |
2 |
Preferred Brand |
$20.00 | $40.00 | None |
TEGRETOL XR TABLETS 100MG 100 BOT |
2 |
Preferred Brand |
$20.00 | $40.00 | None |
TEGRETOL XR TABLETS 200MG 100 BOT |
2 |
Preferred Brand |
$20.00 | $40.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TEGRETOL XR TABLETS 400MG 100 BOT |
2 |
Preferred Brand |
$20.00 | $40.00 | None |
Temazepam 15mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE per BLISTER PACK |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:30 /30Days |
Temazepam 22.5mg/1 30 CAPSULE BOTTLE, PLASTIC |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:30 /30Days |
TEMAZEPAM 30 MG CAPSULE |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:30 /30Days |
Temazepam 7.5mg/1 100 CAPSULE BOTTLE, PLASTIC |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:30 /30Days |
TERAZOSIN 1 MG CAPSULE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Terazosin Hydrochloride 10mg/1 100 CAPSULE BOTTLE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Terazosin Hydrochloride 2mg/1 100 CAPSULE BOTTLE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Terazosin Hydrochloride 5mg/1 100 CAPSULE BOTTLE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TERBINAFINE HCL 250 MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TERBUTALINE SULF 1MG/ML VL |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TERBUTALINE SULF 2.5MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TERBUTALINE SULFATE 5MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TERCONAZOLE 0.4% CREAM WITH APPLICATOR |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:45 /7Days |
TERCONAZOLE 0.8% CREAM |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:45 /7Days |
TERCONAZOLE 80MG SUPPOSITORY VAGINAL |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:3 /3Days |
TETANUS DIPHTHERIA TOXOIDS |
2 |
Preferred Brand |
$20.00 | $40.00 | None |
tetanus toxoid adsorbed vial |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TEVETEN HCT TABLETS 600;25MG;MG 100 BOT |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | S Q:30 /30Days |
TEVETEN TABLETS 400MG 100 BOT |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | S Q:30 /30Days |
TEVETEN TABLETS 600;12.5MG;MG 100 BOT |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | S Q:30 /30Days |
TEVETEN TABLETS 600MG 100 BOT |
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 |
THALOMID 100MG CAPSULE 140 BOX |
4 |
Specialty Tier |
25% | 25% | P |
Thalomid 150mg/1 |
4 |
Specialty Tier |
25% | 25% | P |
Thalomid 200mg/1 |
4 |
Specialty Tier |
25% | 25% | P |
THALOMID 50MG CAPSULE 280 BOX |
4 |
Specialty Tier |
25% | 25% | P |
Theophylline 100mg/1 500 CAPSULE BOTTLE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Theophylline 200mg/1 500 TABLET, EXTENDED RELEASE in 1 BOTTLE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
THEOPHYLLINE 400MG TABLET SA |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
THEOPHYLLINE 600MG TABLET SA |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
THEOPHYLLINE TABLET ER 300MG (100 CT) |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
THEOPHYLLINE TABLET ER 450MG (100 CT) |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Thermazene 10mg/g |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THIORIDAZINE 100MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | P |
THIORIDAZINE HCL 10MG TABLET (1000 CT) |
1 |
Preferred Generic |
$4.00 | $8.00 | P |
THIORIDAZINE HCL 25MG TABLET (1000 CT) |
1 |
Preferred Generic |
$4.00 | $8.00 | P |
Thioridazine Hydrochloride 50mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED in 1 |
1 |
Preferred Generic |
$4.00 | $8.00 | P |
THIOTHIXENE 10MG CAPSULE |
1 |
Preferred Generic |
$4.00 | $8.00 | P |
THIOTHIXENE 1MG CAPSULE (100 CT) |
1 |
Preferred Generic |
$4.00 | $8.00 | P |
THIOTHIXENE 2MG CAPSULE |
1 |
Preferred Generic |
$4.00 | $8.00 | P |
THIOTHIXENE 5MG CAPSULE |
1 |
Preferred Generic |
$4.00 | $8.00 | P |
tiagabine hcl 2 mg tablet [Gabitril] |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
tiagabine hcl 4 mg tablet [Gabitril] |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TIKOSYN .125MG CAPSULE |
2 |
Preferred Brand |
$20.00 | $40.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIKOSYN .250MG CAPSULE |
2 |
Preferred Brand |
$20.00 | $40.00 | None |
TIKOSYN .5MG CAPSULE |
2 |
Preferred Brand |
$20.00 | $40.00 | None |
TIMOLOL MAL SOL 0.25% OP 15ML BOT |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TIMOLOL MAL SOL 0.5% OP 10ML BOT |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TIMOLOL MALEATE 10MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TIMOLOL MALEATE 20MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TIMOLOL MALEATE 5MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TIVICAY 50 MG TABLET |
4 |
Specialty Tier |
25% | 25% | None |
Tizanidine 4mg/1 1000 TABLET BOTTLE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TIZANIDINE HCL 2 MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TOBRAMYCIN 10MG/ML VIAL |
1 |
Preferred Generic |
$4.00 | $8.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOBRAMYCIN 300 MG/5 ML AMPULE [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate] |
4 |
Specialty Tier |
25% | 25% | P Q:56 /28Days |
TOBRAMYCIN 40MG/ML VIAL |
1 |
Preferred Generic |
$4.00 | $8.00 | P |
TOBRAMYCIN OPHTHALMIC SOLUTION 0.3% 5ML BOT |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TOBRAMYCIN-DEXAMETH OPTH SUSP |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TOLAZAMIDE TABLETS 250MG 100 BOT |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:120 /30Days |
TOLAZAMIDE TABLETS 500MG 100 BOT |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:60 /30Days |
TOLBUTAMIDE 500MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:180 /30Days |
TOLMETIN SODIUM 200MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TOLMETIN SODIUM 400 MG CAP |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TOLMETIN SODIUM 600MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Topiramate 25mg/1 |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOPIRAMATE SPRINKLE CAPSULES 15MG 60 BOT |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TOPIRAMATE TABLETS 100MG 1000 BOT |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TOPIRAMATE TABLETS 200MG 1000 BOT |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TOPIRAMATE TABLETS 25MG 1000 BOT |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TOPIRAMATE TABLETS 50MG 1000 BOT |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Torsemide 100mg/1 12 BOTTLE CASE / 100 TABLET BOTTLE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TORSEMIDE 10MG TABLETS |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TORSEMIDE 20mg 100 TABLET BOTTLE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TORSEMIDE 5MG TABLETS |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TPN ELECTROLYTES16.5/25.4 VIAL |
2 |
Preferred Brand |
$20.00 | $40.00 | None |
TRACLEER 125MG TABLET |
4 |
Specialty Tier |
25% | 25% | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRACLEER 62.5MG TABLET |
4 |
Specialty Tier |
25% | 25% | P Q:60 /30Days |
TRADJENTA 5mg/1 90 FILM COATED TABLETS in BOTTLE |
2 |
Preferred Brand |
$20.00 | $40.00 | P Q:30 /30Days |
TRAMADOL HCL 50 MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:240 /30Days |
TRAMADOL HCL-ACETAMINOPHEN 37.5-325MG TABLET (1000 CT) |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:40 /5Days |
TRANDOLAPRIL 1MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TRANDOLAPRIL 2MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TRANDOLAPRIL 4MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TRANEXAMIC ACID 1,000 MG/10 ML |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TRANYLCYPROMINE SULFATE 10MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
travoprost 0.004% eye drop [Travatan] |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TRAZODONE 300MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRAZODONE HCL TABLET USP 100MG (500 CT) |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TRAZODONE HCL TABLET USP 150MG (100 CT) |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TRAZODONE HCL TABLET USP 50MG (500 CT) |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TRECATOR 250MG TABLET |
2 |
Preferred Brand |
$20.00 | $40.00 | None |
TRELSTAR DEPOT MIXJET FOR INJECTION 3.75 MG |
4 |
Specialty Tier |
25% | 25% | P |
TRELSTAR MIXJET FOR INJECTION 11.25 MG |
4 |
Specialty Tier |
25% | 25% | P |
Tretinoin 0.1mg/g 1 TUBE per CARTON / 45 g in 1 TUBE |
1 |
Preferred Generic |
$4.00 | $8.00 | P |
Tretinoin 0.25mg/g 1 TUBE per CARTON / 45 g in 1 TUBE |
1 |
Preferred Generic |
$4.00 | $8.00 | P |
Tretinoin 0.25mg/g 1 TUBE per CARTON / 45 g in 1 TUBE |
1 |
Preferred Generic |
$4.00 | $8.00 | P |
Tretinoin 0.5mg/g 1 TUBE per CARTON / 20 g in 1 TUBE |
1 |
Preferred Generic |
$4.00 | $8.00 | P |
TRETINOIN 10MG CAPSULE |
4 |
Specialty Tier |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Tretinoin 1mg/g 1 TUBE per CARTON / 45 g in 1 TUBE |
1 |
Preferred Generic |
$4.00 | $8.00 | P |
TRI PREVIFEM TABLETS |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TRI-LEGEST FE 5-7-9-7 TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TRI-SPRINTEC 7DAYSX3 28 TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TRIAMCINOLONE 0.1% OINTMENT |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TRIAMCINOLONE ACETONIDE 0.025% CREAM 80GM TUBE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TRIAMCINOLONE ACETONIDE 0.025% LOTION 2 FL OZ BOT |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TRIAMCINOLONE ACETONIDE 0.1% CREAM 80GM TUBE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TRIAMCINOLONE ACETONIDE 0.1% LOTION 60ML BOTPL |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
triamcinolone acetonide 0.25mg/g 80 g in 1 TUBE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Triamcinolone Acetonide 1mg/g 1 TUBE per CARTON / 5 g in 1 TUBE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Triamcinolone Acetonide 5mg/g 1 TUBE per CARTON / 15 g in 1 TUBE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Triamterene and Hydrochlorothiazide 25; 37.5mg 100 CAPSULE BOTTLE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TRIAMTERENE/HCTZ 37.5/25 TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TRIAMTERENE/HCTZ 50-25 MG CAP |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TRIAMTERENE/HCTZ 75/50 TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TRIDERM 0.1% CREAM |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TRIFLUOPERAZINE 1MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TRIFLUOPERAZINE HCL 2MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TRIFLUOPERAZINE HCL 5MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT) |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TRIHEXYPHENIDYL 5 MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TRIHEXYPHENIDYL HYDROCHLORIDE 2mg/1 |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Trihexyphenidyl Hydrochloride 2mg/5mL 473 mL in 1 BOTTLE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TRILEPTAL 300MG/5ML SUSP |
2 |
Preferred Brand |
$20.00 | $40.00 | None |
TRIMETHOPRIM 100MG TABLETS |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TRIMIPRAMINE MALEATE 100 MG CAP |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TRIMIPRAMINE MALEATE 25 MG CAP |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TRIMIPRAMINE MALEATE 50 MG CAP |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TRINESSA TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Trivora 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TROSPIUM CHLORIDE 20MG TABLETS |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TRUVADA 200/300MG TABLET |
4 |
Specialty Tier |
25% | 25% | None |
TWINRIX TF PF VACCINE 720UNT/20ML 10 X 1ML VIALSD |
2 |
Preferred Brand |
$20.00 | $40.00 | None |
Tygacil 50mg/5mL 10 VIAL, SINGLE-USE per CARTON / 50 mL in 1 VIAL, SINGLE-USE |
2 |
Preferred Brand |
$20.00 | $40.00 | P |
TYKERB 250MG TABLET |
4 |
Specialty Tier |
25% | 25% | P |
TYPHIM VI 25MCG/0.5ML VIAL |
2 |
Preferred Brand |
$20.00 | $40.00 | None |
TYSABRI 300 MG/15 ML VIAL |
4 |
Specialty Tier |
25% | 25% | P |
TYZEKA 600MG TABLET (30 CT) |
4 |
Specialty Tier |
25% | 25% | P |
TYZINE PEDIATRIC 0.05% DROP |
2 |
Preferred Brand |
$20.00 | $40.00 | None |