2016 Medicare Part D Plan Formulary Information |
Health Alliance Medicare HMO20 Rx (HMO) (H1463-003-0)
Benefit Details
|
The Health Alliance Medicare HMO20 Rx (HMO) (H1463-003-0) Formulary Drugs Starting with the Letter T in Kankakee County, IL: CMS MA Region 14 which includes: IL Plan Monthly Premium: $119.00 Deductible: $360 |
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 |
$100.00 | $300.00 | P |
Tacrolimus 0.03% ointment |
2 |
Generic |
$20.00 | $60.00 | None |
Tacrolimus 0.1% ointment |
2 |
Generic |
$20.00 | $60.00 | None |
Tacrolimus 0.5mg/1 100 CAPSULE BOTTLE |
2 |
Generic |
$20.00 | $60.00 | P |
Tacrolimus 1mg/1 100 CAPSULE BOTTLE |
2 |
Generic |
$20.00 | $60.00 | P |
Tacrolimus 5mg/1 100 CAPSULE BOTTLE |
2 |
Generic |
$20.00 | $60.00 | P |
TAFINLAR 50 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P |
TAFINLAR 75 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P |
TAGRISSO 40 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P |
TAGRISSO 80 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAMIFLU 30 MG 1 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
TAMIFLU 45 MG 1 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
TAMIFLU 6 MG/ML SUSPENSION |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
TAMIFLU 75 MG CAPSULE UD |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
TAMOXIFEN CITRATE 20MG TABLET (30 CT) |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TAMOXIFEN CITRATE TABLETS 10MG 180 BOT |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TAMSULOSIN HCL 0.4 MG CAPSULE |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TANZEUM 30 MG PEN INJECT |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | S |
TANZEUM 50 MG PEN INJECT |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | S |
TARCEVA 100MG TABLET |
5 |
Specialty Tier |
25% | 25% | P |
TARCEVA 150MG TABLET |
5 |
Specialty Tier |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TARCEVA 25MG TABLET |
5 |
Specialty Tier |
25% | 25% | P |
TARGRETIN 1% GEL |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
TARGRETIN 75 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P |
Tarina Fe 1-20 tablet |
2 |
Generic |
$20.00 | $60.00 | None |
Tasigna 150mg/1 4 BLISTER PACK per CARTON / 28 CAPSULE per BLISTER PACK |
5 |
Specialty Tier |
25% | 25% | P |
TASIGNA 200MG CAPSULE 28 BLPK |
5 |
Specialty Tier |
25% | 25% | P |
TAZICEF 1GM VIAL |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TAZICEF 2 GRAM VIAL |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TAZICEF 6 GRAM VIAL |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TAZORAC 0.05% CREAM |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | P |
TAZORAC 0.05% GEL |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAZORAC 0.1% CREAM |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | P |
TAZORAC 0.1% GEL |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | P |
TAZTIA DILTIAZEM HYDROCHLORIDE 120MG EXTENDED RELEASE CAPSULES |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TAZTIA DILTIAZEM HYDROCHLORIDE 180MG EXTENDED RELEASE CAPSULES |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TAZTIA DILTIAZEM HYDROCHLORIDE 300MG EXTENDED RELEASE CAPSULES |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TAZTIA XT 240MG CAPSULE SA |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TAZTIA XT 360MG CAPSULE SA |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TECENTRIQ 1,200 MG/20 ML VIAL |
5 |
Specialty Tier |
25% | 25% | P |
TECFIDERA DR 120 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | Q:60 /30Days |
TECFIDERA DR 240 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | None |
TECFIDERA STARTER PACK |
5 |
Specialty Tier |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Teflaro 400mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Teflaro 600mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Telmisartan 20 MG Tablet [Micardis] |
2 |
Generic |
$20.00 | $60.00 | None |
Telmisartan 40 MG Tablet [Micardis] |
2 |
Generic |
$20.00 | $60.00 | None |
Telmisartan 80 MG Tablet [Micardis] |
2 |
Generic |
$20.00 | $60.00 | None |
TELMISARTAN-HCTZ 40-12.5 MG TB [Micardis HCT] |
2 |
Generic |
$20.00 | $60.00 | None |
TELMISARTAN-HCTZ 80-12.5 MG TB [Micardis HCT] |
2 |
Generic |
$20.00 | $60.00 | None |
TELMISARTAN-HCTZ 80-25 MG TAB [Micardis HCT] |
2 |
Generic |
$20.00 | $60.00 | None |
Temazepam 15mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE per BLISTER PACK |
2 |
Generic |
$20.00 | $60.00 | Q:30 /30Days |
Temazepam 22.5mg/1 30 CAPSULE BOTTLE, PLASTIC |
2 |
Generic |
$20.00 | $60.00 | Q:30 /30Days |
TEMAZEPAM 30 MG CAPSULE |
2 |
Generic |
$20.00 | $60.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Temazepam 7.5mg/1 100 CAPSULE BOTTLE, PLASTIC |
2 |
Generic |
$20.00 | $60.00 | Q:30 /30Days |
TENIVAC SYRINGE |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
TERAZOSIN 1 MG CAPSULE |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
Terazosin Hydrochloride 10mg/1 100 CAPSULE BOTTLE |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
Terazosin Hydrochloride 2mg/1 100 CAPSULE BOTTLE |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
Terazosin Hydrochloride 5mg/1 100 CAPSULE BOTTLE |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
Terbinafine HCl 250 MG Tablet |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TERBUTALINE SULF 1MG/ML VL |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TERBUTALINE SULF 2.5MG TABLET |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TERBUTALINE SULFATE 5MG TABLET |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TERCONAZOLE 0.4% CREAM WITH APPLICATOR |
2 |
Generic |
$20.00 | $60.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TERCONAZOLE 0.8% CREAM |
2 |
Generic |
$20.00 | $60.00 | None |
TERCONAZOLE 80MG SUPPOSITORY VAGINAL |
2 |
Generic |
$20.00 | $60.00 | None |
TESTOSTERONE 10 MG GEL PUMP |
3 |
Preferred Brand |
$47.00 | $141.00 | P |
TESTOSTERONE 12.5 MG/1.25 GRAM |
3 |
Preferred Brand |
$47.00 | $141.00 | P |
TESTOSTERONE 25 MG/2.5 GM PKT |
3 |
Preferred Brand |
$47.00 | $141.00 | P |
TESTOSTERONE 50 MG/5 GRAM PKT |
3 |
Preferred Brand |
$47.00 | $141.00 | P |
Testosterone cyp 100 mg/ml |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
Testosterone cyp 200 mg/ml |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TESTOSTERONE ENANTHATE 200MG/ML INJECTION |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TETANUS DIPHTHERIA TOXOIDS |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
TETRABENAZINE 12.5 MG TABLET [XENAZINE] |
5 |
Specialty Tier |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TETRABENAZINE 25 MG TABLET [XENAZINE] |
5 |
Specialty Tier |
25% | 25% | P |
TETRACYCLINE 250 MG CAPSULE |
2 |
Generic |
$20.00 | $60.00 | None |
TETRACYCLINE 500 MG CAPSULE |
2 |
Generic |
$20.00 | $60.00 | None |
THALOMID 100MG CAPSULE 140 BOX |
5 |
Specialty Tier |
25% | 25% | P |
Thalomid 150mg/1 |
5 |
Specialty Tier |
25% | 25% | P |
Thalomid 200mg/1 |
5 |
Specialty Tier |
25% | 25% | P |
THALOMID 50MG CAPSULE 280 BOX |
5 |
Specialty Tier |
25% | 25% | P |
THEO-24 ER 100 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
THEO-24 ER 200 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
THEO-24 ER 300 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
THEO-24 ER 400 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Theophylline 100mg/1 500 CAPSULE BOTTLE |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
Theophylline 200mg/1 500 TABLET, EXTENDED RELEASE in 1 BOTTLE |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
THEOPHYLLINE 400MG TABLET SA |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
THEOPHYLLINE 600MG TABLET SA |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
Theophylline 80mg/15mL 473 mL in 1 BOTTLE, PLASTIC |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
THEOPHYLLINE TABLET ER 300MG (100 CT) |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
THEOPHYLLINE TABLET ER 450MG (100 CT) |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
THIOLA 100 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
THIORIDAZINE 100MG TABLET |
2 |
Generic |
$20.00 | $60.00 | None |
THIORIDAZINE HCL 10MG TABLET (1000 CT) |
2 |
Generic |
$20.00 | $60.00 | None |
THIORIDAZINE HCL 25MG TABLET (1000 CT) |
2 |
Generic |
$20.00 | $60.00 | 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 |
Generic |
$20.00 | $60.00 | None |
THIOTEPA 15 MG VIAL |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
THIOTHIXENE 10MG CAPSULE |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
THIOTHIXENE 1MG CAPSULE (100 CT) |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
THIOTHIXENE 2MG CAPSULE |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
THIOTHIXENE 5MG CAPSULE |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
THYMOGLOBULIN 25MG VIAL |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
THYROLAR-1 TABLETS |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
THYROLAR-1/2 TABLETS |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
THYROLAR-1/4 TABLETS |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
THYROLAR-2 TABLETS |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THYROLAR-3 TABLETS |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
tiagabine hcl 2 mg tablet [Gabitril] |
2 |
Generic |
$20.00 | $60.00 | None |
tiagabine hcl 4 mg tablet [Gabitril] |
2 |
Generic |
$20.00 | $60.00 | None |
TIKOSYN .125MG CAPSULE |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
TIKOSYN .250MG CAPSULE |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
TIKOSYN .5MG CAPSULE |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
TIMOLOL MAL SOL 0.25% OP 15ML BOT |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TIMOLOL MAL SOL 0.5% OP 10ML BOT |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TIMOLOL MALEATE 10MG TABLET |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TIMOLOL MALEATE 20MG TABLET |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
Timolol Maleate 3.4mg/mL 1 BOTTLE, DISPENSING per CARTON / 5 mL in 1 BOTTLE, DISPENSING |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIMOLOL MALEATE 5MG TABLET |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
Timolol Maleate 6.8mg/mL 1 BOTTLE, DISPENSING per CARTON / 5 mL in 1 BOTTLE, DISPENSING |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
tinidazole 250 mg tablet |
2 |
Generic |
$20.00 | $60.00 | None |
tinidazole 500 mg tablet |
2 |
Generic |
$20.00 | $60.00 | None |
Tirosint 100ug/1 4 BLISTER PACK per CARTON / 7 CAPSULE per BLISTER PACK |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Tirosint 112ug/1 4 BLISTER PACK per CARTON / 7 CAPSULE per BLISTER PACK |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Tirosint 125ug/1 4 BLISTER PACK per CARTON / 7 CAPSULE per BLISTER PACK |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Tirosint 137ug/1 4 BLISTER PACK per CARTON / 7 CAPSULE per BLISTER PACK |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Tirosint 13ug/1 4 BLISTER PACK per CARTON / 7 CAPSULE per BLISTER PACK |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Tirosint 150ug/1 4 BLISTER PACK per CARTON / 7 CAPSULE per BLISTER PACK |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Tirosint 25ug/1 4 BLISTER PACK per CARTON / 7 CAPSULE per BLISTER PACK |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Tirosint 50ug/1 4 BLISTER PACK per CARTON / 7 CAPSULE per BLISTER PACK |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Tirosint 75ug/1 4 BLISTER PACK per CARTON / 7 CAPSULE per BLISTER PACK |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Tirosint 88ug/1 4 BLISTER PACK per CARTON / 7 CAPSULE per BLISTER PACK |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
TIVICAY 10 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
TIVICAY 25 MG TABLET |
5 |
Specialty Tier |
25% | 25% | None |
TIVICAY 50 MG TABLET |
5 |
Specialty Tier |
25% | 25% | None |
Tizanidine 4mg/1 1000 TABLET BOTTLE |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TIZANIDINE HCL 2 MG CAPSULE |
2 |
Generic |
$20.00 | $60.00 | None |
TIZANIDINE HCL 2 MG TABLET |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TIZANIDINE HCL 4 MG CAPSULE |
2 |
Generic |
$20.00 | $60.00 | None |
TIZANIDINE HCL 6 MG CAPSULE |
2 |
Generic |
$20.00 | $60.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOBI PODHALER 28 MG INHALE CAP |
5 |
Specialty Tier |
25% | 25% | P |
TOBRAMYCIN 10MG/ML VIAL |
2 |
Generic |
$20.00 | $60.00 | None |
TOBRAMYCIN 300 MG/5 ML AMPULE [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate] |
5 |
Specialty Tier |
25% | 25% | P |
TOBRAMYCIN 40MG/ML VIAL |
2 |
Generic |
$20.00 | $60.00 | None |
TOBRAMYCIN OPHTHALMIC SOLUTION 0.3% 5ML BOT |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TOBRAMYCIN-DEXAMETH OPTH SUSP |
2 |
Generic |
$20.00 | $60.00 | None |
TOLAZAMIDE TABLETS 250MG 100 BOT |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TOLAZAMIDE TABLETS 500MG 100 BOT |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TOLBUTAMIDE 500MG TABLET |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
Tolcapone 100 MG TABLET [Tasmar] |
2 |
Generic |
$20.00 | $60.00 | None |
TOLMETIN SODIUM 400 MG CAP |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOLMETIN SODIUM 600MG TABLET |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
Tolterodine Tartrate 1 MG TABLET [Detrol LA] |
2 |
Generic |
$20.00 | $60.00 | None |
Tolterodine Tartrate 2 MG TABLET [Detrol LA] |
2 |
Generic |
$20.00 | $60.00 | None |
Tolterodine Tartrate ER 2 MG CAPSULE [Detrol LA] |
2 |
Generic |
$20.00 | $60.00 | None |
Tolterodine Tartrate ER 4 MG Capsule [Detrol LA] |
2 |
Generic |
$20.00 | $60.00 | None |
TOLVAPTAN 15 MG ORAL TABLET [SAMSCA] |
5 |
Specialty Tier |
25% | 25% | P |
TOLVAPTAN 30 MG ORAL TABLET [SAMSCA] |
5 |
Specialty Tier |
25% | 25% | P |
Topiramate 25mg/1 |
2 |
Generic |
$20.00 | $60.00 | None |
TOPIRAMATE ER 100 MG CAPSULE |
2 |
Generic |
$20.00 | $60.00 | None |
TOPIRAMATE ER 150 MG CAPSULE |
2 |
Generic |
$20.00 | $60.00 | None |
TOPIRAMATE ER 200 MG CAPSULE |
2 |
Generic |
$20.00 | $60.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOPIRAMATE ER 25 MG CAPSULE |
2 |
Generic |
$20.00 | $60.00 | None |
TOPIRAMATE ER 50 MG CAPSULE |
2 |
Generic |
$20.00 | $60.00 | None |
TOPIRAMATE SPRINKLE CAPSULES 15MG 60 BOT |
2 |
Generic |
$20.00 | $60.00 | None |
TOPIRAMATE TABLETS 100MG 1000 BOT |
2 |
Generic |
$20.00 | $60.00 | None |
TOPIRAMATE TABLETS 200MG 1000 BOT |
2 |
Generic |
$20.00 | $60.00 | None |
TOPIRAMATE TABLETS 25MG 1000 BOT |
2 |
Generic |
$20.00 | $60.00 | None |
TOPIRAMATE TABLETS 50MG 1000 BOT |
2 |
Generic |
$20.00 | $60.00 | None |
TOPOSAR INJECTION 20MG/ML 50ML VIAL MD CRTN |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
Torisel 1 KIT per CARTON |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
TORSEMIDE 10 MG TABLET |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
Torsemide 100mg/1 12 BOTTLE CASE / 100 TABLET BOTTLE |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TORSEMIDE 20mg 100 TABLET BOTTLE |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TORSEMIDE 5 MG TABLET |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TOUJEO SOLOSTAR 300 UNITS/ML |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:27 /30Days |
TOVIAZ TABLETS 4MG EXTENDED RELEASE |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
TOVIAZ TABLETS 8MG EXTENDED RELEASE |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
TPN ELECTROLYTES16.5/25.4 VIAL |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
TRACLEER 125MG TABLET |
5 |
Specialty Tier |
25% | 25% | P |
TRACLEER 62.5MG TABLET |
5 |
Specialty Tier |
25% | 25% | P |
TRADJENTA 5mg/1 90 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$47.00 | $141.00 | S Q:30 /30Days |
TRAMADOL ER 300 MG TABLET |
2 |
Generic |
$20.00 | $60.00 | S Q:30 /30Days |
TRAMADOL HCL 50 MG TABLET |
1* |
Preferred Generic |
$0.00 | $43.50 | Q:240 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRAMADOL HCL ER 100 MG CAPSULE |
2 |
Generic |
$20.00 | $60.00 | Q:60 /30Days |
TRAMADOL HCL ER 200 MG CAPSULE |
2 |
Generic |
$20.00 | $60.00 | Q:60 /30Days |
TRAMADOL HCL ER 300 MG CAPSULE |
2 |
Generic |
$20.00 | $60.00 | Q:60 /30Days |
TRAMADOL HCL-ACETAMINOPHEN 37.5-325MG TABLET (1000 CT) |
2 |
Generic |
$20.00 | $60.00 | S Q:240 /30Days |
TRAMADOL HYDROCHLORIDE 100mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Generic |
$20.00 | $60.00 | S Q:90 /30Days |
TRAMADOL HYDROCHLORIDE 200mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Generic |
$20.00 | $60.00 | S Q:30 /30Days |
TRANDOLAPRIL 1 MG TABLET |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TRANDOLAPRIL 2 MG TABLET |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TRANDOLAPRIL 4 MG TABLET |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TRANDOLAPRIL-VERAPAMIL ER 1-240 MG |
2 |
Generic |
$20.00 | $60.00 | None |
TRANDOLAPRIL-VERAPAMIL ER 2-180 MG |
2 |
Generic |
$20.00 | $60.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRANDOLAPRIL-VERAPAMIL ER 2-240 MG |
2 |
Generic |
$20.00 | $60.00 | None |
TRANDOLAPRIL-VERAPAMIL ER 4-240 MG |
2 |
Generic |
$20.00 | $60.00 | None |
TRANEXAMIC ACID 1,000 MG/10 ML |
2 |
Generic |
$20.00 | $60.00 | None |
tranexamic acid 650 mg tablet |
2 |
Generic |
$20.00 | $60.00 | None |
TRANSDERM-SCOP 1.5 MG/72HR |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
TRANYLCYPROMINE SULFATE 10MG TABLET |
2 |
Generic |
$20.00 | $60.00 | None |
TRAVASOL 10% SOLUTION VIAFLEX |
3 |
Preferred Brand |
$47.00 | $141.00 | P |
TRAVATAN Z 0.04MG DROPS 2.5ML BOT |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
travoprost 0.004% eye drop [Travatan] |
2 |
Generic |
$20.00 | $60.00 | None |
TRAZODONE 300MG TABLET |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TRAZODONE HCL TABLET USP 100MG (500 CT) |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRAZODONE HCL TABLET USP 150MG (100 CT) |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TRAZODONE HCL TABLET USP 50MG (500 CT) |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TREANDA FOR INJECTION 100MG/VIAL |
5 |
Specialty Tier |
25% | 25% | None |
TRECATOR 250MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Trelstar 22.5mg/2mL 2 mL in 1 VIAL, SINGLE-DOSE |
3 |
Preferred Brand |
$47.00 | $141.00 | P |
TRELSTAR DEPOT MIXJET FOR INJECTION 3.75 MG |
3 |
Preferred Brand |
$47.00 | $141.00 | P |
TRELSTAR MIXJET FOR INJECTION 11.25 MG |
3 |
Preferred Brand |
$47.00 | $141.00 | P |
TRESIBA FLEXTOUCH 100 UNITS/ML |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:54 /30Days |
TRESIBA FLEXTOUCH 200 UNITS/ML |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:54 /30Days |
TRETINOIN 0.01% GEL |
2 |
Generic |
$20.00 | $60.00 | P |
Tretinoin 0.05% gel |
1* |
Preferred Generic |
$0.00 | $43.50 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Tretinoin 0.25mg/g 1 TUBE per CARTON / 45 g in 1 TUBE |
1* |
Preferred Generic |
$0.00 | $43.50 | P |
Tretinoin 0.25mg/g 1 TUBE per CARTON / 45 g in 1 TUBE |
2 |
Generic |
$20.00 | $60.00 | P |
Tretinoin 0.5mg/g 1 TUBE per CARTON / 20 g in 1 TUBE |
2 |
Generic |
$20.00 | $60.00 | P |
TRETINOIN 10MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P |
Tretinoin 1mg/g 1 TUBE per CARTON / 45 g in 1 TUBE |
2 |
Generic |
$20.00 | $60.00 | P |
TRETINOIN GEL MICRO 0.04% PUMP |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | P |
TRETINOIN GEL MICRO 0.1% PUMP |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | P |
TRI PREVIFEM TABLETS |
2 |
Generic |
$20.00 | $60.00 | None |
TRI-LEGEST FE 5-7-9-7 TABLET |
2 |
Generic |
$20.00 | $60.00 | None |
TRI-SPRINTEC 7DAYSX3 28 TABLET |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TRIAMCINOLONE 0.1% OINTMENT |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIAMCINOLONE ACETONIDE 0.025% CREAM 80GM TUBE |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TRIAMCINOLONE ACETONIDE 0.025% LOTION 2 FL OZ BOT |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TRIAMCINOLONE ACETONIDE 0.1% CREAM 80GM TUBE |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TRIAMCINOLONE ACETONIDE 0.1% LOTION 60ML BOTPL |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
triamcinolone acetonide 0.25mg/g 80 g in 1 TUBE |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
Triamcinolone Acetonide 1mg/g 1 TUBE per CARTON / 5 g in 1 TUBE |
2 |
Generic |
$20.00 | $60.00 | None |
Triamcinolone Acetonide 5mg/g 1 TUBE per CARTON / 15 g in 1 TUBE |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
Triamterene and Hydrochlorothiazide 25; 37.5mg 100 CAPSULE BOTTLE |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TRIAMTERENE/HCTZ 37.5/25 TABLET |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TRIAMTERENE/HCTZ 50-25 MG CAP |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIAMTERENE/HCTZ 75/50 TABLET |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TRIAZOLAM 0.125 MG TABLET |
2 |
Generic |
$20.00 | $60.00 | Q:30 /30Days |
TRIAZOLAM 0.25 MG TABLET |
2 |
Generic |
$20.00 | $60.00 | Q:30 /30Days |
TRIDERM 0.1% CREAM |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TRIFLUOPERAZINE 1MG TABLET |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TRIFLUOPERAZINE HCL 2MG TABLET |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TRIFLUOPERAZINE HCL 5MG TABLET |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT) |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT |
2 |
Generic |
$20.00 | $60.00 | None |
TRILYTE WITH FLAVOR PACKETS |
2 |
Generic |
$20.00 | $60.00 | None |
TRIMETHOPRIM 100MG TABLETS |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIMIPRAMINE MALEATE 100 MG CP |
2 |
Generic |
$20.00 | $60.00 | None |
TRIMIPRAMINE MALEATE 25 MG CAP |
2 |
Generic |
$20.00 | $60.00 | None |
TRIMIPRAMINE MALEATE 50 MG CAP |
2 |
Generic |
$20.00 | $60.00 | None |
TRINESSA TABLET |
1* |
Preferred Generic |
$0.00 | $43.50 | None |
TRINTELLIX 10 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | S |
TRINTELLIX 20 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | S |
TRINTELLIX 5 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | S |
TRISENOX 10MG/10ML AMPULE |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
TRIUMEQ TABLET |
5 |
Specialty Tier |
25% | 25% | None |
Trivora 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
2 |
Generic |
$20.00 | $60.00 | None |
TROKENDI XR 100 MG CAPSULE |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TROKENDI XR 200 MG CAPSULE |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
TROKENDI XR 25 MG CAPSULE |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
TROKENDI XR 50 MG CAPSULE |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
TROPHAMINE INJECTION SOLUTION |
3 |
Preferred Brand |
$47.00 | $141.00 | P |
TROPHAMINE INJECTION SOLUTION 6% |
3 |
Preferred Brand |
$47.00 | $141.00 | P |
TROSPIUM CHLORIDE 20MG TABLETS |
2 |
Generic |
$20.00 | $60.00 | None |
TROSPIUM CHLORIDE ER 60 MG CAP |
2 |
Generic |
$20.00 | $60.00 | None |
TRUMENBA 120 MCG/0.5 ML VACCINE |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
TRUVADA 100 MG-150 MG TABLET |
5 |
Specialty Tier |
25% | 25% | None |
TRUVADA 133 MG-200 MG TABLET |
5 |
Specialty Tier |
25% | 25% | None |
TRUVADA 167 MG-250 MG TABLET |
5 |
Specialty Tier |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRUVADA 200/300MG TABLET |
5 |
Specialty Tier |
25% | 25% | None |
TUDORZA PRESSAIR 400 MCG INH |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
TUDORZA PRESSAIR 400 MCG INH |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
TWINRIX TF PF VACCINE 720UNT/20ML 10 X 1ML VIALSD |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
TYBOST 150 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
Tygacil 50mg/5mL 10 VIAL, SINGLE-USE per CARTON / 50 mL in 1 VIAL, SINGLE-USE |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
TYKERB 250MG TABLET |
5 |
Specialty Tier |
25% | 25% | P |
TYPHIM VI 25 MCG/0.5 ML SYRINGE |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
TYPHIM VI 25MCG/0.5ML VIAL |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
TYSABRI 300 MG/15 ML VIAL |
5 |
Specialty Tier |
25% | 25% | P |
Tyvaso 1.74mg/2.9mL |
5 |
Specialty Tier |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TYZEKA 600MG TABLET (30 CT) |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | P |
TYZINE PEDIATRIC 0.05% DROP |
3 |
Preferred Brand |
$47.00 | $141.00 | None |