2016 Medicare Part D Plan Formulary Information |
Freedom Medi-Medi Full (HMO SNP) (H5427-087-0)
Benefit Details
|
The Freedom Medi-Medi Full (HMO SNP) (H5427-087-0) Formulary Drugs Starting with the Letter T in Hernando County, FL: CMS MA Region 9 which includes: FL Plan Monthly Premium: $28.00 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 |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Tacrolimus 0.5mg/1 100 CAPSULE BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | P |
Tacrolimus 1mg/1 100 CAPSULE BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | P |
Tacrolimus 5mg/1 100 CAPSULE BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | P |
TAFINLAR 50 MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:150 /30Days |
TAFINLAR 75 MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:120 /30Days |
TAGRISSO 40 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
TAGRISSO 80 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
TAMIFLU 30 MG 1 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
TAMIFLU 45 MG 1 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK |
1 |
Tier 1 |
$0.00 | $0.00 | Q:28 /180Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAMIFLU 6 MG/ML SUSPENSION |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TAMIFLU 75 MG CAPSULE UD |
1 |
Tier 1 |
$0.00 | $0.00 | Q:28 /180Days |
TAMOXIFEN CITRATE 20MG TABLET (30 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TAMOXIFEN CITRATE TABLETS 10MG 180 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TAMSULOSIN HCL 0.4 MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
TANZEUM 30 MG PEN INJECT |
1 |
Tier 1 |
$0.00 | $0.00 | S Q:4 /30Days |
TANZEUM 50 MG PEN INJECT |
1 |
Tier 1 |
$0.00 | $0.00 | S Q:4 /30Days |
TARCEVA 100MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:30 /30Days |
TARCEVA 150MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:30 /30Days |
TARCEVA 25MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:30 /30Days |
TARGRETIN 1% GEL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TARGRETIN 75 MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Tasigna 150mg/1 4 BLISTER PACK per CARTON / 28 CAPSULE per BLISTER PACK |
1 |
Tier 1 |
$0.00 | $0.00 | P |
TASIGNA 200MG CAPSULE 28 BLPK |
1 |
Tier 1 |
$0.00 | $0.00 | P |
TASMAR 100MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TAXOTERE 80mg/4mL 1 VIAL, GLASS per CARTON / 4 mL in 1 VIAL, GLASS |
1 |
Tier 1 |
$0.00 | $0.00 | P |
TAZORAC 0.05% CREAM |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TAZORAC 0.05% GEL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TAZORAC 0.1% CREAM |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TAZORAC 0.1% GEL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TAZTIA DILTIAZEM HYDROCHLORIDE 120MG EXTENDED RELEASE CAPSULES |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
TAZTIA DILTIAZEM HYDROCHLORIDE 180MG EXTENDED RELEASE CAPSULES |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAZTIA DILTIAZEM HYDROCHLORIDE 300MG EXTENDED RELEASE CAPSULES |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
TAZTIA XT 240MG CAPSULE SA |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
TAZTIA XT 360MG CAPSULE SA |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
TECENTRIQ 1,200 MG/20 ML VIAL |
1 |
Tier 1 |
$0.00 | $0.00 | P |
TECFIDERA DR 120 MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | P |
TECFIDERA DR 240 MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | P |
TECFIDERA STARTER PACK |
1 |
Tier 1 |
$0.00 | $0.00 | P |
Teflaro 400mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE |
1 |
Tier 1 |
$0.00 | $0.00 | P |
Teflaro 600mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE |
1 |
Tier 1 |
$0.00 | $0.00 | P |
TEGRETOL XR TABLETS 100MG 100 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TEKTURNA 150MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TEKTURNA 300MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | S Q:30 /30Days |
TEKTURNA HCT 150-12.5MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | S Q:30 /30Days |
TEKTURNA HCT 150MG-25MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | S Q:30 /30Days |
TEKTURNA HCT 300-12.5MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | S Q:30 /30Days |
TEKTURNA HCT 300MG-25MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | S Q:30 /30Days |
Temazepam 15mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE per BLISTER PACK |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TEMAZEPAM 30 MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TENIVAC SYRINGE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TERAZOSIN 1 MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
Terazosin Hydrochloride 10mg/1 100 CAPSULE BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
Terazosin Hydrochloride 2mg/1 100 CAPSULE BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Terazosin Hydrochloride 5mg/1 100 CAPSULE BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
Terbinafine HCl 250 MG Tablet |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
TERBUTALINE SULF 2.5MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TERBUTALINE SULFATE 5MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TERCONAZOLE 0.8% CREAM |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TERCONAZOLE 80MG SUPPOSITORY VAGINAL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TESTOSTERONE 25 MG/2.5 GM PKT |
1 |
Tier 1 |
$0.00 | $0.00 | P |
TESTOSTERONE 50 MG/5 GRAM PKT |
1 |
Tier 1 |
$0.00 | $0.00 | P |
Testosterone cyp 100 mg/ml |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Testosterone cyp 200 mg/ml |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TESTOSTERONE ENANTHATE 200MG/ML INJECTION |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TETANUS DIPHTHERIA TOXOIDS |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TETRACYCLINE 250 MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TETRACYCLINE 500 MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
THALOMID 100MG CAPSULE 140 BOX |
1 |
Tier 1 |
$0.00 | $0.00 | P |
Thalomid 150mg/1 |
1 |
Tier 1 |
$0.00 | $0.00 | P |
Thalomid 200mg/1 |
1 |
Tier 1 |
$0.00 | $0.00 | P |
THALOMID 50MG CAPSULE 280 BOX |
1 |
Tier 1 |
$0.00 | $0.00 | P |
Theophylline 100mg/1 500 CAPSULE BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Theophylline 200mg/1 500 TABLET, EXTENDED RELEASE in 1 BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
THEOPHYLLINE 400MG TABLET SA |
1 |
Tier 1 |
$0.00 | $0.00 | None |
THEOPHYLLINE 600MG TABLET SA |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THEOPHYLLINE TABLET ER 300MG (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
THEOPHYLLINE TABLET ER 450MG (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
THIORIDAZINE 100MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
THIORIDAZINE HCL 10MG TABLET (1000 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
THIORIDAZINE HCL 25MG TABLET (1000 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Thioridazine Hydrochloride 50mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED in 1 |
1 |
Tier 1 |
$0.00 | $0.00 | None |
THIOTEPA 15 MG VIAL |
1 |
Tier 1 |
$0.00 | $0.00 | P |
THIOTHIXENE 10MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
THIOTHIXENE 1MG CAPSULE (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
THIOTHIXENE 2MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
THIOTHIXENE 5MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THYMOGLOBULIN 25MG VIAL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
THYROLAR-1 TABLETS |
1 |
Tier 1 |
$0.00 | $0.00 | None |
THYROLAR-1/2 TABLETS |
1 |
Tier 1 |
$0.00 | $0.00 | None |
THYROLAR-1/4 TABLETS |
1 |
Tier 1 |
$0.00 | $0.00 | None |
THYROLAR-2 TABLETS |
1 |
Tier 1 |
$0.00 | $0.00 | None |
THYROLAR-3 TABLETS |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TIAZAC ER 120 MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
TIAZAC ER 180 MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
TIAZAC ER 240 MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
TIAZAC ER 300 MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
TIAZAC ER 420 MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIKOSYN .125MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TIKOSYN .250MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TIKOSYN .5MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TIMOLOL MAL SOL 0.25% OP 15ML BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TIMOLOL MAL SOL 0.5% OP 10ML BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TIMOLOL MALEATE 10MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TIMOLOL MALEATE 20MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Timolol Maleate 3.4mg/mL 1 BOTTLE, DISPENSING per CARTON / 5 mL in 1 BOTTLE, DISPENSING |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TIMOLOL MALEATE 5MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Timolol Maleate 6.8mg/mL 1 BOTTLE, DISPENSING per CARTON / 5 mL in 1 BOTTLE, DISPENSING |
1 |
Tier 1 |
$0.00 | $0.00 | None |
tinidazole 250 mg tablet |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
tinidazole 500 mg tablet |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TIVICAY 10 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TIVICAY 25 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TIVICAY 50 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Tizanidine 4mg/1 1000 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TIZANIDINE HCL 2 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TOBI 300mg/5mL 56 AMPULE per CARTON / 5 mL in 1 AMPULE |
1 |
Tier 1 |
$0.00 | $0.00 | P |
TOBI PODHALER 28 MG INHALE CAP |
1 |
Tier 1 |
$0.00 | $0.00 | P |
TOBRADEX EYE OINTMENT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TOBRADEX SUSPENSION OPHTHALMIC 0.1%/0.3% 5ML BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TOBRAMYCIN 10MG/ML VIAL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOBRAMYCIN 40MG/ML VIAL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TOBRAMYCIN OPHTHALMIC SOLUTION 0.3% 5ML BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TOBREX 0.3% EYE OINTMENT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TOLAK 4% CREAM |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TOLAZAMIDE TABLETS 250MG 100 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TOLAZAMIDE TABLETS 500MG 100 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TOLBUTAMIDE 500MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TOLMETIN SODIUM 400 MG CAP |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TOLMETIN SODIUM 600MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Topiramate 25mg/1 |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TOPIRAMATE ER 100 MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOPIRAMATE ER 150 MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TOPIRAMATE ER 200 MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TOPIRAMATE ER 25 MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TOPIRAMATE ER 50 MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TOPIRAMATE SPRINKLE CAPSULES 15MG 60 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TOPIRAMATE TABLETS 100MG 1000 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TOPIRAMATE TABLETS 200MG 1000 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TOPIRAMATE TABLETS 25MG 1000 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TOPIRAMATE TABLETS 50MG 1000 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TOPOSAR INJECTION 20MG/ML 50ML VIAL MD CRTN |
1 |
Tier 1 |
$0.00 | $0.00 | P |
Torisel 1 KIT per CARTON |
1 |
Tier 1 |
$0.00 | $0.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TORSEMIDE 10 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Torsemide 100mg/1 12 BOTTLE CASE / 100 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TORSEMIDE 20mg 100 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TORSEMIDE 5 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TOUJEO SOLOSTAR 300 UNITS/ML |
1 |
Tier 1 |
$0.00 | $0.00 | Q:15 /30Days |
TOVIAZ TABLETS 4MG EXTENDED RELEASE |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
TOVIAZ TABLETS 8MG EXTENDED RELEASE |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
TPN ELECTROLYTES16.5/25.4 VIAL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRACLEER 125MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | P |
TRACLEER 62.5MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | P |
TRAMADOL HCL 50 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:240 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRANDOLAPRIL 1 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
TRANDOLAPRIL 2 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
TRANDOLAPRIL 4 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
TRANEXAMIC ACID 1,000 MG/10 ML |
1 |
Tier 1 |
$0.00 | $0.00 | None |
tranexamic acid 650 mg tablet |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRANSDERM-SCOP 1.5 MG/72HR |
1 |
Tier 1 |
$0.00 | $0.00 | Q:10 /30Days |
TRANYLCYPROMINE SULFATE 10MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRAVASOL 10% SOLUTION VIAFLEX |
1 |
Tier 1 |
$0.00 | $0.00 | P |
travoprost 0.004% eye drop [Travatan] |
1 |
Tier 1 |
$0.00 | $0.00 | Q:3 /25Days |
TRAZODONE 300MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRAZODONE HCL TABLET USP 100MG (500 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | 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 |
Tier 1 |
$0.00 | $0.00 | None |
TRAZODONE HCL TABLET USP 50MG (500 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TREANDA FOR INJECTION 100MG/VIAL |
1 |
Tier 1 |
$0.00 | $0.00 | P |
TRECATOR 250MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRELSTAR DEPOT MIXJET FOR INJECTION 3.75 MG |
1 |
Tier 1 |
$0.00 | $0.00 | P |
TRELSTAR MIXJET FOR INJECTION 11.25 MG |
1 |
Tier 1 |
$0.00 | $0.00 | P |
TRETINOIN 0.01% GEL |
1 |
Tier 1 |
$0.00 | $0.00 | P |
Tretinoin 0.25mg/g 1 TUBE per CARTON / 45 g in 1 TUBE |
1 |
Tier 1 |
$0.00 | $0.00 | P |
Tretinoin 0.25mg/g 1 TUBE per CARTON / 45 g in 1 TUBE |
1 |
Tier 1 |
$0.00 | $0.00 | P |
Tretinoin 0.5mg/g 1 TUBE per CARTON / 20 g in 1 TUBE |
1 |
Tier 1 |
$0.00 | $0.00 | P |
TRETINOIN 10MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | 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 |
Tier 1 |
$0.00 | $0.00 | P |
TRETINOIN GEL MICRO 0.04% PUMP |
1 |
Tier 1 |
$0.00 | $0.00 | P |
TRETINOIN GEL MICRO 0.1% PUMP |
1 |
Tier 1 |
$0.00 | $0.00 | P |
TREXALL 10MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | P |
TREXALL 15MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | P |
TREXALL 5MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | P |
TREXALL 7.5MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | P |
TREXIMET 85-500 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:9 /25Days |
TRI PREVIFEM TABLETS |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRIAMCINOLONE 0.1% OINTMENT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRIAMCINOLONE ACETONIDE 0.025% CREAM 80GM TUBE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIAMCINOLONE ACETONIDE 0.025% LOTION 2 FL OZ BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRIAMCINOLONE ACETONIDE 0.1% CREAM 80GM TUBE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRIAMCINOLONE ACETONIDE 0.1% LOTION 60ML BOTPL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
triamcinolone acetonide 0.25mg/g 80 g in 1 TUBE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Triamcinolone Acetonide 1mg/g 1 TUBE per CARTON / 5 g in 1 TUBE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Triamcinolone Acetonide 5mg/g 1 TUBE per CARTON / 15 g in 1 TUBE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Triamterene and Hydrochlorothiazide 25; 37.5mg 100 CAPSULE BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRIAMTERENE/HCTZ 37.5/25 TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRIAMTERENE/HCTZ 75/50 TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRIFLUOPERAZINE 1MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIFLUOPERAZINE HCL 2MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRIFLUOPERAZINE HCL 5MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRIHEXYPHENIDYL 5 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | P |
TRIHEXYPHENIDYL HYDROCHLORIDE 2mg/1 |
1 |
Tier 1 |
$0.00 | $0.00 | P |
Trihexyphenidyl Hydrochloride 2mg/5mL 473 mL in 1 BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | P |
TRILYTE WITH FLAVOR PACKETS |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRIMETHOBENZAMIDE HCL 300MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | S |
TRIMETHOPRIM 100MG TABLETS |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRINTELLIX 10 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRINTELLIX 20 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
TRINTELLIX 5 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:90 /30Days |
TRISENOX 10MG/10ML AMPULE |
1 |
Tier 1 |
$0.00 | $0.00 | P |
TRIUMEQ TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
TROPHAMINE INJECTION SOLUTION |
1 |
Tier 1 |
$0.00 | $0.00 | P |
TROPHAMINE INJECTION SOLUTION 6% |
1 |
Tier 1 |
$0.00 | $0.00 | P |
TRUMENBA 120 MCG/0.5 ML VACCINE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRUVADA 100 MG-150 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
TRUVADA 133 MG-200 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
TRUVADA 167 MG-250 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
TRUVADA 200/300MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TUDORZA PRESSAIR 400 MCG INH |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
TUDORZA PRESSAIR 400 MCG INH |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
TWINRIX TF PF VACCINE 720UNT/20ML 10 X 1ML VIALSD |
1 |
Tier 1 |
$0.00 | $0.00 | P |
TYBOST 150 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Tygacil 50mg/5mL 10 VIAL, SINGLE-USE per CARTON / 50 mL in 1 VIAL, SINGLE-USE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TYKERB 250MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:150 /30Days |
TYPHIM VI 25 MCG/0.5 ML SYRINGE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TYPHIM VI 25MCG/0.5ML VIAL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TYSABRI 300 MG/15 ML VIAL |
1 |
Tier 1 |
$0.00 | $0.00 | P |
TYZEKA 600MG TABLET (30 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | P |