2015 Medicare Part D Plan Formulary Information |
Peoples Health Secure Choice #011 (HMO SNP) (H1961-011-0)
Benefit Details
|
The Peoples Health Secure Choice #011 (HMO SNP) (H1961-011-0) Formulary Drugs Starting with the Letter T in WINN Parish, LA: CMS MA Region 16 which includes: LA Plan Monthly Premium: $31.30 Deductible: $320 |
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 |
Tier 4 |
15% | 15% | None |
TACLONEX OINTMENT |
4 |
Tier 4 |
15% | 15% | None |
Tacrolimus 0.03% ointment |
2 |
Tier 2 |
15% | 15% | None |
Tacrolimus 0.1% ointment |
2 |
Tier 2 |
15% | 15% | None |
Tacrolimus 0.5mg/1 100 CAPSULE BOTTLE |
2 |
Tier 2 |
15% | 15% | P |
Tacrolimus 1mg/1 100 CAPSULE BOTTLE |
2 |
Tier 2 |
15% | 15% | P |
Tacrolimus 5mg/1 100 CAPSULE BOTTLE |
5 |
Tier 5 |
15% | 15% | P |
TAFINLAR 50 MG CAPSULE |
5 |
Tier 5 |
15% | 15% | P |
TAFINLAR 75 MG CAPSULE |
5 |
Tier 5 |
15% | 15% | P |
TAMIFLU 30mg/1 1 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK |
4 |
Tier 4 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAMIFLU 45mg/1 1 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK |
4 |
Tier 4 |
15% | 15% | None |
TAMIFLU 6 MG/ML SUSPENSION |
4 |
Tier 4 |
15% | 15% | None |
TAMIFLU 75MG CAPSULE UD |
4 |
Tier 4 |
15% | 15% | None |
TAMOXIFEN CITRATE 20MG TABLET (30 CT) |
1 |
Tier 1 |
15% | 15% | None |
TAMOXIFEN CITRATE TABLETS 10MG 180 BOT |
1 |
Tier 1 |
15% | 15% | None |
TAMSULOSIN HCL 0.4 MG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
TANZEUM 30 MG PEN INJECT |
3 |
Tier 3 |
15% | 15% | None |
TANZEUM 50 MG PEN INJECT |
3 |
Tier 3 |
15% | 15% | None |
TAPAZOLE 10MG TABLET |
4 |
Tier 4 |
15% | 15% | None |
TAPAZOLE 5MG TABLET |
4 |
Tier 4 |
15% | 15% | None |
TARCEVA 100MG TABLET |
5 |
Tier 5 |
15% | 15% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TARCEVA 150MG TABLET |
5 |
Tier 5 |
15% | 15% | P |
TARCEVA 25MG TABLET |
5 |
Tier 5 |
15% | 15% | P |
TARGRETIN 75 MG CAPSULE |
5 |
Tier 5 |
15% | 15% | P |
Tarina Fe 1-20 tablet |
2 |
Tier 2 |
15% | 15% | None |
TARKA 1/240MG TABLET SA |
4 |
Tier 4 |
15% | 15% | None |
Tarka 2; 240mg/1; mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE |
4 |
Tier 4 |
15% | 15% | None |
TARKA 2/180MG TABLET SA |
4 |
Tier 4 |
15% | 15% | None |
Tarka 4; 240mg/1; mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE |
4 |
Tier 4 |
15% | 15% | None |
Tasigna 150mg/1 4 BLISTER PACK per CARTON / 28 CAPSULE per BLISTER PACK |
5 |
Tier 5 |
15% | 15% | P |
TASIGNA 200MG CAPSULE 28 BLPK |
5 |
Tier 5 |
15% | 15% | P |
TAZICEF 1GM VIAL |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAZICEF 2 GM/VIAL INJECTION |
2 |
Tier 2 |
15% | 15% | None |
TAZICEF 6 GM/VIAL INJECTION |
2 |
Tier 2 |
15% | 15% | None |
TAZORAC 0.05% CREAM |
3 |
Tier 3 |
15% | 15% | None |
TAZORAC 0.05% GEL |
3 |
Tier 3 |
15% | 15% | None |
TAZORAC 0.1% CREAM |
3 |
Tier 3 |
15% | 15% | None |
TAZORAC 0.1% GEL |
3 |
Tier 3 |
15% | 15% | None |
TAZTIA DILTIAZEM HYDROCHLORIDE 120MG EXTENDED RELEASE CAPSULES |
2 |
Tier 2 |
15% | 15% | None |
TAZTIA DILTIAZEM HYDROCHLORIDE 180MG EXTENDED RELEASE CAPSULES |
2 |
Tier 2 |
15% | 15% | None |
TAZTIA DILTIAZEM HYDROCHLORIDE 300MG EXTENDED RELEASE CAPSULES |
2 |
Tier 2 |
15% | 15% | None |
TAZTIA XT 240MG CAPSULE SA |
2 |
Tier 2 |
15% | 15% | None |
TAZTIA XT 360MG CAPSULE SA |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TECFIDERA DR 120 MG CAPSULE |
5 |
Tier 5 |
15% | 15% | P |
TECFIDERA DR 240 MG CAPSULE |
5 |
Tier 5 |
15% | 15% | P |
TECFIDERA STARTER PACK |
5 |
Tier 5 |
15% | 15% | P |
Teflaro 400mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE |
4 |
Tier 4 |
15% | 15% | P |
Teflaro 600mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE |
4 |
Tier 4 |
15% | 15% | P |
TEGRETOL SUSPENSION 100MG/5ML 450 ML BOT |
4 |
Tier 4 |
15% | 15% | None |
TEGRETOL TABLETS 200MG 100 BOT |
4 |
Tier 4 |
15% | 15% | None |
TEGRETOL XR TABLETS 100MG 100 BOT |
3 |
Tier 3 |
15% | 15% | None |
TEGRETOL XR TABLETS 200MG 100 BOT |
4 |
Tier 4 |
15% | 15% | None |
TEGRETOL XR TABLETS 400MG 100 BOT |
4 |
Tier 4 |
15% | 15% | None |
Tekamlo 150; 10mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE |
3 |
Tier 3 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Tekamlo 150; 5mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE |
3 |
Tier 3 |
15% | 15% | None |
Tekamlo 300; 10mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE |
3 |
Tier 3 |
15% | 15% | None |
Tekamlo 300; 5mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE |
3 |
Tier 3 |
15% | 15% | None |
TEKTURNA 150MG TABLET |
3 |
Tier 3 |
15% | 15% | None |
TEKTURNA 300MG TABLET |
3 |
Tier 3 |
15% | 15% | None |
TEKTURNA HCT 150-12.5MG TABLET |
3 |
Tier 3 |
15% | 15% | None |
TEKTURNA HCT 150MG-25MG TABLET |
3 |
Tier 3 |
15% | 15% | None |
TEKTURNA HCT 300-12.5MG TABLET |
3 |
Tier 3 |
15% | 15% | None |
TEKTURNA HCT 300MG-25MG TABLET |
3 |
Tier 3 |
15% | 15% | None |
Temazepam 15mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE per BLISTER PACK |
4 |
Tier 4 |
15% | 15% | P |
Temazepam 22.5mg/1 30 CAPSULE BOTTLE, PLASTIC |
4 |
Tier 4 |
15% | 15% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TEMAZEPAM 30 MG CAPSULE |
4 |
Tier 4 |
15% | 15% | P |
Temazepam 7.5mg/1 100 CAPSULE BOTTLE, PLASTIC |
4 |
Tier 4 |
15% | 15% | P |
TEMOVATE 0.05% CREAM |
4 |
Tier 4 |
15% | 15% | None |
TEMOVATE 0.05% GEL 60GM BOX |
4 |
Tier 4 |
15% | 15% | None |
TEMOVATE 0.05% OINTMENT |
4 |
Tier 4 |
15% | 15% | None |
TENIVAC SYRINGE |
3 |
Tier 3 |
15% | 15% | None |
TENORETIC 100 TABLET |
4 |
Tier 4 |
15% | 15% | None |
TENORETIC 50 TABLET |
4 |
Tier 4 |
15% | 15% | None |
TENORMIN 100 MG TABLET |
4 |
Tier 4 |
15% | 15% | None |
TENORMIN 25 MG TABLET |
4 |
Tier 4 |
15% | 15% | None |
TENORMIN 50 MG TABLET |
4 |
Tier 4 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TERAZOL 3 CREAM |
4 |
Tier 4 |
15% | 15% | None |
TERAZOL 7 CREAM |
4 |
Tier 4 |
15% | 15% | None |
TERAZOSIN 1 MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
Terazosin Hydrochloride 10mg/1 100 CAPSULE BOTTLE |
1 |
Tier 1 |
15% | 15% | None |
Terazosin Hydrochloride 2mg/1 100 CAPSULE BOTTLE |
1 |
Tier 1 |
15% | 15% | None |
Terazosin Hydrochloride 5mg/1 100 CAPSULE BOTTLE |
1 |
Tier 1 |
15% | 15% | None |
Terbinafine HCl 250 MG Tablet |
2 |
Tier 2 |
15% | 15% | None |
TERBUTALINE SULF 1MG/ML VL |
2 |
Tier 2 |
15% | 15% | None |
TERBUTALINE SULF 2.5MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
TERBUTALINE SULFATE 5MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
TERCONAZOLE 0.4% CREAM WITH APPLICATOR |
3 |
Tier 3 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TERCONAZOLE 0.8% CREAM |
3 |
Tier 3 |
15% | 15% | None |
TERCONAZOLE 80MG SUPPOSITORY VAGINAL |
3 |
Tier 3 |
15% | 15% | None |
TESTIM 1%(50MG) GEL |
3 |
Tier 3 |
15% | 15% | P |
TESTOSTERONE CYPIONATE 2,000 MG/10 ML |
3 |
Tier 3 |
15% | 15% | P |
TESTOSTERONE ENANTHATE 200MG/ML INJECTION |
3 |
Tier 3 |
15% | 15% | P |
TETANUS DIPHTHERIA TOXOIDS |
3 |
Tier 3 |
15% | 15% | None |
tetanus toxoid adsorbed vial |
3 |
Tier 3 |
15% | 15% | None |
TETRACYCLINE 250 MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
TETRACYCLINE 500 MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
THALOMID 100MG CAPSULE 140 BOX |
5 |
Tier 5 |
15% | 15% | P |
Thalomid 150mg/1 |
5 |
Tier 5 |
15% | 15% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Thalomid 200mg/1 |
5 |
Tier 5 |
15% | 15% | P |
THALOMID 50MG CAPSULE 280 BOX |
5 |
Tier 5 |
15% | 15% | P |
THEO-24 ER 100 MG CAPSULE |
3 |
Tier 3 |
15% | 15% | None |
THEO-24 ER 200 MG CAPSULE |
3 |
Tier 3 |
15% | 15% | None |
THEO-24 ER 300 MG CAPSULE |
3 |
Tier 3 |
15% | 15% | None |
THEO-24 ER 400 MG CAPSULE |
3 |
Tier 3 |
15% | 15% | None |
Theophylline 100mg/1 500 CAPSULE BOTTLE |
2 |
Tier 2 |
15% | 15% | None |
Theophylline 200mg/1 500 TABLET, EXTENDED RELEASE in 1 BOTTLE |
2 |
Tier 2 |
15% | 15% | None |
THEOPHYLLINE 400MG TABLET SA |
2 |
Tier 2 |
15% | 15% | None |
Theophylline 80mg/15mL 473 mL in 1 BOTTLE, PLASTIC |
2 |
Tier 2 |
15% | 15% | None |
THEOPHYLLINE TABLET ER 300MG (100 CT) |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THEOPHYLLINE TABLET ER 450MG (100 CT) |
2 |
Tier 2 |
15% | 15% | None |
THIORIDAZINE 100MG TABLET |
4 |
Tier 4 |
15% | 15% | P |
THIORIDAZINE HCL 10MG TABLET (1000 CT) |
4 |
Tier 4 |
15% | 15% | P |
THIORIDAZINE HCL 25MG TABLET (1000 CT) |
4 |
Tier 4 |
15% | 15% | P |
Thioridazine Hydrochloride 50mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED in 1 |
4 |
Tier 4 |
15% | 15% | P |
THIOTHIXENE 10MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
THIOTHIXENE 1MG CAPSULE (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
THIOTHIXENE 2MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
THIOTHIXENE 5MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
THYMOGLOBULIN 25MG VIAL |
4 |
Tier 4 |
15% | 15% | P |
THYROLAR-1 TABLETS |
3 |
Tier 3 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THYROLAR-1/2 TABLETS |
3 |
Tier 3 |
15% | 15% | None |
THYROLAR-1/4 TABLETS |
3 |
Tier 3 |
15% | 15% | None |
THYROLAR-2 TABLETS |
3 |
Tier 3 |
15% | 15% | None |
THYROLAR-3 TABLETS |
3 |
Tier 3 |
15% | 15% | None |
tiagabine hcl 2 mg tablet [Gabitril] |
2 |
Tier 2 |
15% | 15% | None |
tiagabine hcl 4 mg tablet [Gabitril] |
2 |
Tier 2 |
15% | 15% | None |
TIAZAC ER 120 MG CAPSULE |
4 |
Tier 4 |
15% | 15% | None |
TIAZAC ER 180 MG CAPSULE |
4 |
Tier 4 |
15% | 15% | None |
TIAZAC ER 240 MG CAPSULE |
4 |
Tier 4 |
15% | 15% | None |
TIAZAC ER 300 MG CAPSULE |
4 |
Tier 4 |
15% | 15% | None |
TIAZAC ER 360 MG CAPSULE |
4 |
Tier 4 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIAZAC ER 420 MG CAPSULE |
4 |
Tier 4 |
15% | 15% | None |
TIKOSYN .125MG CAPSULE |
4 |
Tier 4 |
15% | 15% | None |
TIKOSYN .250MG CAPSULE |
4 |
Tier 4 |
15% | 15% | None |
TIKOSYN .5MG CAPSULE |
4 |
Tier 4 |
15% | 15% | None |
TIMOLOL MAL SOL 0.25% OP 15ML BOT |
1 |
Tier 1 |
15% | 15% | None |
TIMOLOL MAL SOL 0.5% OP 10ML BOT |
1 |
Tier 1 |
15% | 15% | None |
TIMOLOL MALEATE 10MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
TIMOLOL MALEATE 20MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
Timolol Maleate 3.4mg/mL 1 BOTTLE, DISPENSING per CARTON / 5 mL in 1 BOTTLE, DISPENSING |
2 |
Tier 2 |
15% | 15% | None |
TIMOLOL MALEATE 5MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
Timolol Maleate 6.8mg/mL 1 BOTTLE, DISPENSING per CARTON / 5 mL in 1 BOTTLE, DISPENSING |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Timoptic 3.4mg/mL 4 POUCH per CARTON / 15 CONTAINER in 1 POUCH / 0.2 mL in 1 CONTAINER [TIMOPTIC] |
4 |
Tier 4 |
15% | 15% | None |
Timoptic 6.8mg/mL 4 POUCH per CARTON / 15 CONTAINER in 1 POUCH / 0.2 mL in 1 CONTAINER [TIMOPTIC] |
4 |
Tier 4 |
15% | 15% | None |
Timoptic-XE 3.4mg/mL 1 BOTTLE, DISPENSING per CARTON / 5 mL in 1 BOTTLE, DISPENSING |
4 |
Tier 4 |
15% | 15% | None |
Timoptic-XE 6.8mg/mL 1 BOTTLE, DISPENSING per CARTON / 5 mL in 1 BOTTLE, DISPENSING |
4 |
Tier 4 |
15% | 15% | None |
TINDAMAX 500 MG TABLET |
4 |
Tier 4 |
15% | 15% | None |
tinidazole 250 mg tablet |
2 |
Tier 2 |
15% | 15% | None |
tinidazole 500 mg tablet |
2 |
Tier 2 |
15% | 15% | None |
TIVICAY 50 MG TABLET |
5 |
Tier 5 |
15% | 15% | None |
Tizanidine 4mg/1 1000 TABLET BOTTLE |
1 |
Tier 1 |
15% | 15% | None |
TIZANIDINE HCL 2 MG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
TIZANIDINE HCL 2 MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIZANIDINE HCL 4 MG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
TIZANIDINE HCL 6 MG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
TOBI PODHALER 28 MG INHALE CAP |
5 |
Tier 5 |
15% | 15% | P |
TOBRADEX EYE OINTMENT |
4 |
Tier 4 |
15% | 15% | None |
TOBRADEX ST 0.5; 3mg/mL; mg/mL 5 mL in 1 BOTTLE |
4 |
Tier 4 |
15% | 15% | None |
TOBRADEX SUSPENSION OPHTHALMIC 0.1%/0.3% 5ML BOT |
4 |
Tier 4 |
15% | 15% | None |
TOBRAMYCIN 10MG/ML VIAL |
3 |
Tier 3 |
15% | 15% | None |
TOBRAMYCIN 300 MG/5 ML AMPULE [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate] |
5 |
Tier 5 |
15% | 15% | P |
TOBRAMYCIN 40MG/ML VIAL |
3 |
Tier 3 |
15% | 15% | None |
TOBRAMYCIN 80MG/0.9% NACL |
2 |
Tier 2 |
15% | 15% | None |
TOBRAMYCIN OPHTHALMIC SOLUTION 0.3% 5ML BOT |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOBRAMYCIN-DEXAMETH OPTH SUSP |
2 |
Tier 2 |
15% | 15% | None |
TOBREX 0.3% EYE DROPS |
4 |
Tier 4 |
15% | 15% | None |
TOBREX 0.3% EYE OINTMENT |
4 |
Tier 4 |
15% | 15% | None |
TOLAZAMIDE TABLETS 250MG 100 BOT |
2 |
Tier 2 |
15% | 15% | Q:120 /30Days |
TOLAZAMIDE TABLETS 500MG 100 BOT |
2 |
Tier 2 |
15% | 15% | Q:60 /30Days |
TOLBUTAMIDE 500MG TABLET |
2 |
Tier 2 |
15% | 15% | Q:180 /30Days |
TOLMETIN SODIUM 200MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
TOLMETIN SODIUM 400 MG CAP |
2 |
Tier 2 |
15% | 15% | None |
TOLMETIN SODIUM 600MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
TOPAMAX 15 MG SPRINKLE CAP |
4 |
Tier 4 |
15% | 15% | None |
TOPAMAX 25 MG SPRINKLE CAP |
4 |
Tier 4 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOPAMAX TABLETS 100MG 60 BOT |
4 |
Tier 4 |
15% | 15% | None |
TOPAMAX TABLETS 200MG 60 BOT |
4 |
Tier 4 |
15% | 15% | None |
TOPAMAX TABLETS 25MG 60 BOT |
4 |
Tier 4 |
15% | 15% | None |
TOPAMAX TABLETS 50MG 60 BOT |
4 |
Tier 4 |
15% | 15% | None |
Topicort 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
4 |
Tier 4 |
15% | 15% | None |
Topicort 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
4 |
Tier 4 |
15% | 15% | None |
Topicort 2.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
4 |
Tier 4 |
15% | 15% | None |
Topicort 2.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
4 |
Tier 4 |
15% | 15% | None |
Topiramate 25mg/1 |
2 |
Tier 2 |
15% | 15% | None |
TOPIRAMATE ER 100 MG CAPSULE |
4 |
Tier 4 |
15% | 15% | None |
TOPIRAMATE ER 150 MG CAPSULE |
4 |
Tier 4 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOPIRAMATE ER 200 MG CAPSULE |
4 |
Tier 4 |
15% | 15% | None |
TOPIRAMATE ER 25 MG CAPSULE |
4 |
Tier 4 |
15% | 15% | None |
TOPIRAMATE ER 50 MG CAPSULE |
4 |
Tier 4 |
15% | 15% | None |
TOPIRAMATE SPRINKLE CAPSULES 15MG 60 BOT |
2 |
Tier 2 |
15% | 15% | None |
TOPIRAMATE TABLETS 100MG 1000 BOT |
2 |
Tier 2 |
15% | 15% | None |
TOPIRAMATE TABLETS 200MG 1000 BOT |
2 |
Tier 2 |
15% | 15% | None |
TOPIRAMATE TABLETS 25MG 1000 BOT |
2 |
Tier 2 |
15% | 15% | None |
TOPIRAMATE TABLETS 50MG 1000 BOT |
2 |
Tier 2 |
15% | 15% | None |
TOPOSAR INJECTION 20MG/ML 50ML VIAL MD CRTN |
2 |
Tier 2 |
15% | 15% | P |
Topotecan Hydrochloride 4mg/4mL 1 VIAL in 1 CARTON / 4 mL in 1 VIAL |
5 |
Tier 5 |
15% | 15% | P |
TOPROL XL 100MG TABLET SA |
4 |
Tier 4 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOPROL XL 200MG TABLET SA |
4 |
Tier 4 |
15% | 15% | None |
TOPROL XL 25MG TABLET SA |
4 |
Tier 4 |
15% | 15% | None |
TOPROL XL 50MG TABLET SA |
4 |
Tier 4 |
15% | 15% | None |
Torisel 1 KIT per CARTON |
5 |
Tier 5 |
15% | 15% | P |
Torsemide 100mg/1 12 BOTTLE CASE / 100 TABLET BOTTLE |
2 |
Tier 2 |
15% | 15% | None |
Torsemide 10mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Tier 1 |
15% | 15% | None |
TORSEMIDE 20mg 100 TABLET BOTTLE |
1 |
Tier 1 |
15% | 15% | None |
Torsemide 5mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Tier 1 |
15% | 15% | None |
TPN ELECTROLYTES16.5/25.4 VIAL |
2 |
Tier 2 |
15% | 15% | None |
TRACLEER 125MG TABLET |
5 |
Tier 5 |
15% | 15% | P |
TRACLEER 62.5MG TABLET |
5 |
Tier 5 |
15% | 15% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRADJENTA 5mg/1 90 FILM COATED TABLETS in BOTTLE |
3 |
Tier 3 |
15% | 15% | Q:30 /30Days |
TRAMADOL HCL 50 MG TABLET |
2 |
Tier 2 |
15% | 15% | Q:240 /30Days |
TRAMADOL HCL-ACETAMINOPHEN 37.5-325MG TABLET (1000 CT) |
3 |
Tier 3 |
15% | 15% | Q:240 /30Days |
TRANDOLAPRIL 1MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
TRANDOLAPRIL 2MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
TRANDOLAPRIL 4MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
TRANDOLAPRIL-VERAPAMIL ER 1-240 MG |
2 |
Tier 2 |
15% | 15% | None |
TRANDOLAPRIL-VERAPAMIL ER 2-180 MG |
2 |
Tier 2 |
15% | 15% | None |
TRANDOLAPRIL-VERAPAMIL ER 2-240 MG |
2 |
Tier 2 |
15% | 15% | None |
TRANDOLAPRIL-VERAPAMIL ER 4-240 MG |
2 |
Tier 2 |
15% | 15% | None |
TRANEXAMIC ACID 1,000 MG/10 ML |
3 |
Tier 3 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
tranexamic acid 650 mg tablet |
2 |
Tier 2 |
15% | 15% | None |
TRANSDERM-SCOP 1.5 MG/72HR |
4 |
Tier 4 |
15% | 15% | None |
TRANYLCYPROMINE SULFATE 10MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
TRAVATAN Z 0.04MG DROPS 2.5ML BOT |
4 |
Tier 4 |
15% | 15% | None |
travoprost 0.004% eye drop [Travatan] |
2 |
Tier 2 |
15% | 15% | None |
TRAZODONE 300MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
TRAZODONE HCL TABLET USP 100MG (500 CT) |
2 |
Tier 2 |
15% | 15% | None |
TRAZODONE HCL TABLET USP 150MG (100 CT) |
2 |
Tier 2 |
15% | 15% | None |
TRAZODONE HCL TABLET USP 50MG (500 CT) |
2 |
Tier 2 |
15% | 15% | None |
TREANDA 45 MG/0.5 ML VIAL |
4 |
Tier 4 |
15% | 15% | P |
TREANDA FOR INJECTION 100MG/VIAL |
5 |
Tier 5 |
15% | 15% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRECATOR 250MG TABLET |
4 |
Tier 4 |
15% | 15% | None |
Trelstar 22.5mg/2mL 2 mL in 1 VIAL, SINGLE-DOSE |
4 |
Tier 4 |
15% | 15% | P |
TRELSTAR DEPOT MIXJET FOR INJECTION 3.75 MG |
4 |
Tier 4 |
15% | 15% | P |
TRELSTAR MIXJET FOR INJECTION 11.25 MG |
4 |
Tier 4 |
15% | 15% | P |
Tretinoin 0.1mg/g 1 TUBE per CARTON / 45 g in 1 TUBE |
3 |
Tier 3 |
15% | 15% | None |
Tretinoin 0.25mg/g 1 TUBE per CARTON / 45 g in 1 TUBE |
3 |
Tier 3 |
15% | 15% | None |
Tretinoin 0.25mg/g 1 TUBE per CARTON / 45 g in 1 TUBE |
3 |
Tier 3 |
15% | 15% | None |
Tretinoin 0.5mg/g 1 TUBE per CARTON / 20 g in 1 TUBE |
3 |
Tier 3 |
15% | 15% | None |
TRETINOIN 10MG CAPSULE |
5 |
Tier 5 |
15% | 15% | None |
Tretinoin 1mg/g 1 TUBE per CARTON / 45 g in 1 TUBE |
3 |
Tier 3 |
15% | 15% | None |
TREXALL 10MG TABLET |
3 |
Tier 3 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TREXALL 15MG TABLET |
3 |
Tier 3 |
15% | 15% | None |
TREXALL 5MG TABLET |
3 |
Tier 3 |
15% | 15% | None |
TREXALL 7.5MG TABLET |
3 |
Tier 3 |
15% | 15% | None |
TRI PREVIFEM TABLETS |
2 |
Tier 2 |
15% | 15% | None |
TRI-SPRINTEC 7DAYSX3 28 TABLET |
2 |
Tier 2 |
15% | 15% | None |
TRIAMCINOLONE 0.1% OINTMENT |
1 |
Tier 1 |
15% | 15% | None |
Triamcinolone 0.147 MG/G Spray |
2 |
Tier 2 |
15% | 15% | None |
TRIAMCINOLONE ACETONIDE 0.025% CREAM 80GM TUBE |
1 |
Tier 1 |
15% | 15% | None |
TRIAMCINOLONE ACETONIDE 0.025% LOTION 2 FL OZ BOT |
3 |
Tier 3 |
15% | 15% | None |
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE |
1 |
Tier 1 |
15% | 15% | None |
TRIAMCINOLONE ACETONIDE 0.1% CREAM 80GM TUBE |
1 |
Tier 1 |
15% | 15% | 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 |
3 |
Tier 3 |
15% | 15% | None |
triamcinolone acetonide 0.25mg/g 80 g in 1 TUBE |
1 |
Tier 1 |
15% | 15% | None |
Triamcinolone Acetonide 1mg/g 1 TUBE per CARTON / 5 g in 1 TUBE |
3 |
Tier 3 |
15% | 15% | None |
Triamcinolone Acetonide 5mg/g 1 TUBE per CARTON / 15 g in 1 TUBE |
1 |
Tier 1 |
15% | 15% | None |
Triamterene and Hydrochlorothiazide 25; 37.5mg 100 CAPSULE BOTTLE |
2 |
Tier 2 |
15% | 15% | None |
TRIAMTERENE/HCTZ 37.5/25 TABLET |
2 |
Tier 2 |
15% | 15% | None |
TRIAMTERENE/HCTZ 50-25 MG CAP |
2 |
Tier 2 |
15% | 15% | None |
TRIAMTERENE/HCTZ 75/50 TABLET |
2 |
Tier 2 |
15% | 15% | None |
TRIAZOLAM 0.125 MG TABLET |
4 |
Tier 4 |
15% | 15% | P |
TRIAZOLAM 0.25 MG TABLET |
4 |
Tier 4 |
15% | 15% | P |
TRIBENZOR 20/5/12.5MG TABLETS |
3 |
Tier 3 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIBENZOR 40/10/12.5MG TABLETS |
3 |
Tier 3 |
15% | 15% | None |
TRIBENZOR 40/10/25MG TABLETS |
3 |
Tier 3 |
15% | 15% | None |
Tribenzor 5; 12.5; 40mg/1; mg/1; mg/1 |
3 |
Tier 3 |
15% | 15% | None |
Tribenzor 5; 25; 40mg/1; mg/1; mg/1 |
3 |
Tier 3 |
15% | 15% | None |
TRICOR 145MG TABLET |
4 |
Tier 4 |
15% | 15% | None |
TRICOR 48mg/1 90 TABLET BOTTLE |
4 |
Tier 4 |
15% | 15% | None |
TRIDERM 0.1% CREAM |
1 |
Tier 1 |
15% | 15% | None |
TRIFLUOPERAZINE 1MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
TRIFLUOPERAZINE HCL 2MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
TRIFLUOPERAZINE HCL 5MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT) |
2 |
Tier 2 |
15% | 15% | 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 |
2 |
Tier 2 |
15% | 15% | None |
TRIGLIDE 160 MG TABLET |
4 |
Tier 4 |
15% | 15% | None |
TRILEPTAL 150MG TABLET |
4 |
Tier 4 |
15% | 15% | None |
TRILEPTAL 300MG TABLET |
4 |
Tier 4 |
15% | 15% | None |
TRILEPTAL 300MG/5ML SUSP |
4 |
Tier 4 |
15% | 15% | None |
TRILEPTAL 600MG TABLET |
4 |
Tier 4 |
15% | 15% | None |
TRILYTE WITH FLAVOR PACKETS |
2 |
Tier 2 |
15% | 15% | None |
TRIMETHOBENZAMIDE HCL 300MG CAPSULE |
4 |
Tier 4 |
15% | 15% | P |
TRIMETHOPRIM 100MG TABLETS |
1 |
Tier 1 |
15% | 15% | None |
TRINESSA TABLET |
2 |
Tier 2 |
15% | 15% | None |
Triostat 10ug/mL 6 VIAL in 1 CARTON / 1 mL in 1 VIAL |
4 |
Tier 4 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRISENOX 10MG/10ML AMPULE |
5 |
Tier 5 |
15% | 15% | P |
TRIUMEQ TABLET |
5 |
Tier 5 |
15% | 15% | None |
TROKENDI XR 100 MG CAPSULE |
4 |
Tier 4 |
15% | 15% | None |
TROKENDI XR 200 MG CAPSULE |
4 |
Tier 4 |
15% | 15% | None |
TROKENDI XR 25 MG CAPSULE |
4 |
Tier 4 |
15% | 15% | None |
TROKENDI XR 50 MG CAPSULE |
4 |
Tier 4 |
15% | 15% | None |
TROSPIUM CHLORIDE 20MG TABLETS |
2 |
Tier 2 |
15% | 15% | None |
TROSPIUM CHLORIDE ER 60 MG CAP |
2 |
Tier 2 |
15% | 15% | None |
TRUMENBA 120 MCG/0.5 ML VACCINE |
4 |
Tier 4 |
15% | 15% | None |
TRUSOPT PLUS 2% EYE DROPS 10ML BOT |
4 |
Tier 4 |
15% | 15% | None |
TRUVADA 200/300MG TABLET |
3 |
Tier 3 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TUDORZA PRESSAIR 400 MCG INH |
3 |
Tier 3 |
15% | 15% | None |
TUDORZA PRESSAIR 400 MCG INH |
3 |
Tier 3 |
15% | 15% | None |
TWINRIX TF PF VACCINE 720UNT/20ML 10 X 1ML VIALSD |
4 |
Tier 4 |
15% | 15% | P |
TYBOST 150 MG TABLET |
4 |
Tier 4 |
15% | 15% | None |
Tygacil 50mg/5mL 10 VIAL, SINGLE-USE per CARTON / 50 mL in 1 VIAL, SINGLE-USE |
5 |
Tier 5 |
15% | 15% | None |
TYKERB 250MG TABLET |
5 |
Tier 5 |
15% | 15% | P |
TYPHIM VI 25 MCG/0.5 ML SYRINGE |
4 |
Tier 4 |
15% | 15% | None |
TYPHIM VI 25MCG/0.5ML VIAL |
4 |
Tier 4 |
15% | 15% | None |
TYSABRI 300 MG/15 ML VIAL |
5 |
Tier 5 |
15% | 15% | P |
Tyvaso 1.74mg/2.9mL |
3 |
Tier 3 |
15% | 15% | P |
TYZEKA 600MG TABLET (30 CT) |
3 |
Tier 3 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TYZINE PEDIATRIC 0.05% DROP |
4 |
Tier 4 |
15% | 15% | None |