2017 Medicare Part D Plan Formulary Information |
Apollo - Constellation Health (HMO) (H8266-001-0)
Benefit Details
|
The Apollo - Constellation Health (HMO) (H8266-001-0) Formulary Drugs Starting with the Letter T in TOA ALTA County, PR: CMS MA Region 30 which includes: PR Plan Monthly Premium: $0.00 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 |
Non-Preferred Brand |
$75.00 | N/A | None |
Tacrolimus 0.03% ointment |
1 |
Generic |
$5.00 | N/A | None |
Tacrolimus 0.1% ointment |
1 |
Generic |
$5.00 | N/A | None |
Tacrolimus 0.5mg/1 100 CAPSULE BOTTLE |
1 |
Generic |
$5.00 | N/A | P |
Tacrolimus 1mg/1 100 CAPSULE BOTTLE |
1 |
Generic |
$5.00 | N/A | P |
Tacrolimus 5mg/1 100 CAPSULE BOTTLE |
1 |
Generic |
$5.00 | N/A | P |
TAFINLAR 50 MG CAPSULE |
4 |
Specialty Tier |
33% | N/A | P |
TAFINLAR 75 MG CAPSULE |
4 |
Specialty Tier |
33% | N/A | P |
TAGRISSO 40 MG TABLET |
4 |
Specialty Tier |
33% | N/A | P |
TAGRISSO 80 MG TABLET |
4 |
Specialty Tier |
33% | N/A | 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 |
Non-Preferred Brand |
$75.00 | N/A | None |
TAMIFLU 45 MG 1 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TAMIFLU 6 MG/ML SUSPENSION |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TAMIFLU 75 MG CAPSULE UD |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TAMOXIFEN 10 MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
TAMOXIFEN CITRATE 20MG TABLET (30 CT) |
1 |
Generic |
$5.00 | N/A | None |
TAMSULOSIN HCL 0.4 MG CAPSULE |
1 |
Generic |
$5.00 | N/A | None |
TAPAZOLE 10MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TAPAZOLE 5MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TARCEVA 100MG TABLET |
4 |
Specialty Tier |
33% | N/A | P |
TARCEVA 150MG TABLET |
4 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TARCEVA 25MG TABLET |
4 |
Specialty Tier |
33% | N/A | P |
TARGRETIN 1% GEL |
4 |
Specialty Tier |
33% | N/A | None |
TARGRETIN 75 MG CAPSULE |
4 |
Specialty Tier |
33% | N/A | None |
TARKA 1/240MG TABLET SA |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:60 /30Days |
Tarka 2; 240mg/1; mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:60 /30Days |
TARKA 2/180MG TABLET SA |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:60 /30Days |
Tarka 4; 240mg/1; mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:30 /30Days |
Tasigna 150mg/1 4 BLISTER PACK per CARTON / 28 CAPSULE per BLISTER PACK |
4 |
Specialty Tier |
33% | N/A | P |
TASIGNA 200MG CAPSULE 28 BLPK |
4 |
Specialty Tier |
33% | N/A | P |
TASMAR 100MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Tazarotene 0.1% Cream [Tazorac] |
1 |
Generic |
$5.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAZORAC 0.05% CREAM |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
TAZORAC 0.05% GEL |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
TAZORAC 0.1% CREAM |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
TAZORAC 0.1% GEL |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
TAZTIA DILTIAZEM HYDROCHLORIDE 120MG EXTENDED RELEASE CAPSULES |
1 |
Generic |
$5.00 | N/A | None |
TAZTIA DILTIAZEM HYDROCHLORIDE 300MG EXTENDED RELEASE CAPSULES |
1 |
Generic |
$5.00 | N/A | None |
TAZTIA XT 240MG CAPSULE SA |
1 |
Generic |
$5.00 | N/A | None |
TECENTRIQ 1,200 MG/20 ML VIAL |
4 |
Specialty Tier |
33% | N/A | P |
TECFIDERA DR 120 MG CAPSULE |
4 |
Specialty Tier |
33% | N/A | P |
TECFIDERA DR 240 MG CAPSULE |
4 |
Specialty Tier |
33% | N/A | P |
TECFIDERA STARTER PACK |
4 |
Specialty Tier |
33% | N/A | P |
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 |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
Teflaro 600mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
TEGRETOL SUSPENSION 100MG/5ML 450 ML BOT |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TEGRETOL TABLETS 200MG 100 BOT |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TEGRETOL XR TABLETS 100MG 100 BOT |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TEGRETOL XR TABLETS 200MG 100 BOT |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TEGRETOL XR TABLETS 400MG 100 BOT |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TEKTURNA 150 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:30 /30Days |
TEKTURNA 300 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:30 /30Days |
TEKTURNA HCT 300-25 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:30 /30Days |
Temazepam 15mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE per BLISTER PACK |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Temazepam 22.5mg/1 30 CAPSULE BOTTLE, PLASTIC |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
TEMAZEPAM 30 MG CAPSULE |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
Temazepam 7.5mg/1 100 CAPSULE BOTTLE, PLASTIC |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
TEMOVATE 0.05% OINTMENT |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TENIVAC SYRINGE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TENORETIC 100 TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TENORETIC 50 TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TENORMIN 100 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TENORMIN 25 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TENORMIN 50 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TERAZOL 7 CREAM |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TERAZOSIN 1 MG CAPSULE |
1 |
Generic |
$5.00 | N/A | None |
Terazosin Hydrochloride 10mg/1 100 CAPSULE BOTTLE |
1 |
Generic |
$5.00 | N/A | None |
Terazosin Hydrochloride 2mg/1 100 CAPSULE BOTTLE |
1 |
Generic |
$5.00 | N/A | None |
Terazosin Hydrochloride 5mg/1 100 CAPSULE BOTTLE |
1 |
Generic |
$5.00 | N/A | None |
Terbinafine HCl 250 MG Tablet |
1 |
Generic |
$5.00 | N/A | None |
TERBUTALINE SULFATE 2.5 MG TAB |
1 |
Generic |
$5.00 | N/A | None |
TERBUTALINE SULFATE 5MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
TERCONAZOLE 0.4% CREAM WITH APPLICATOR |
1 |
Generic |
$5.00 | N/A | None |
TERCONAZOLE 0.8% CREAM |
1 |
Generic |
$5.00 | N/A | None |
TERCONAZOLE 80MG SUPPOSITORY VAGINAL |
1 |
Generic |
$5.00 | N/A | None |
Testosterone cyp 100 mg/ml |
1 |
Generic |
$5.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Testosterone cyp 200 mg/ml |
1 |
Generic |
$5.00 | N/A | None |
TESTOSTERONE ENANTHATE 200MG/ML INJECTION |
1 |
Generic |
$5.00 | N/A | None |
TETANUS DIPHTHERIA TOXOIDS |
2 |
Preferred Brand |
$40.00 | N/A | None |
TETRABENAZINE 12.5 MG TABLET [XENAZINE] |
4 |
Specialty Tier |
33% | N/A | None |
TETRABENAZINE 25 MG TABLET [XENAZINE] |
4 |
Specialty Tier |
33% | N/A | None |
TETRACYCLINE 250 MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TETRACYCLINE 500 MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
THALOMID 100MG CAPSULE 140 BOX |
4 |
Specialty Tier |
33% | N/A | P |
Thalomid 150mg/1 |
4 |
Specialty Tier |
33% | N/A | P |
Thalomid 200mg/1 |
4 |
Specialty Tier |
33% | N/A | P |
THALOMID 50MG CAPSULE 280 BOX |
4 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Theophylline 100mg/1 500 CAPSULE BOTTLE |
1 |
Generic |
$5.00 | N/A | None |
Theophylline 200mg/1 500 TABLET, EXTENDED RELEASE in 1 BOTTLE |
1 |
Generic |
$5.00 | N/A | None |
Theophylline er 400 mg tablet |
1 |
Generic |
$5.00 | N/A | None |
Theophylline er 600 mg tablet |
1 |
Generic |
$5.00 | N/A | None |
THEOPHYLLINE TABLET ER 300MG (100 CT) |
1 |
Generic |
$5.00 | N/A | None |
THEOPHYLLINE TABLET ER 450MG (100 CT) |
1 |
Generic |
$5.00 | N/A | None |
THIORIDAZINE 100MG TABLET |
1 |
Generic |
$5.00 | N/A | P |
THIORIDAZINE HCL 10MG TABLET (1000 CT) |
1 |
Generic |
$5.00 | N/A | P |
THIORIDAZINE HCL 25MG TABLET (1000 CT) |
1 |
Generic |
$5.00 | N/A | P |
Thioridazine Hydrochloride 50mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED in 1 |
1 |
Generic |
$5.00 | N/A | P |
THIOTHIXENE 10MG CAPSULE |
1 |
Generic |
$5.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THIOTHIXENE 1MG CAPSULE (100 CT) |
1 |
Generic |
$5.00 | N/A | None |
THIOTHIXENE 2MG CAPSULE |
1 |
Generic |
$5.00 | N/A | None |
THIOTHIXENE 5MG CAPSULE |
1 |
Generic |
$5.00 | N/A | None |
tiagabine hcl 2 mg tablet [Gabitril] |
1 |
Generic |
$5.00 | N/A | None |
tiagabine hcl 4 mg tablet [Gabitril] |
1 |
Generic |
$5.00 | N/A | None |
TIAZAC ER 120 MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TIAZAC ER 180 MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TIAZAC ER 240 MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TIAZAC ER 300 MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TIAZAC ER 360 MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TIAZAC ER 420 MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIKOSYN .125MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TIKOSYN .250MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TIKOSYN .5MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TIMOLOL 0.25% GFS GEL-SOLUTION |
1 |
Generic |
$5.00 | N/A | None |
TIMOLOL MAL SOL 0.25% OP 15ML BOT |
1 |
Generic |
$5.00 | N/A | None |
TIMOLOL MAL SOL 0.5% OP 10ML BOT |
1 |
Generic |
$5.00 | N/A | None |
TIMOLOL MALEATE 10MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
TIMOLOL MALEATE 20MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
TIMOLOL MALEATE 5MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
Timolol Maleate 6.8mg/mL 1 BOTTLE, DISPENSING per CARTON / 5 mL in 1 BOTTLE, DISPENSING |
1 |
Generic |
$5.00 | N/A | None |
TIMOPTIC 0.25% OCUDOSE DROP |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIMOPTIC 0.5% OCUDOSE DROP |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Timoptic-XE 3.4mg/mL 1 BOTTLE, DISPENSING per CARTON / 5 mL in 1 BOTTLE, DISPENSING |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Timoptic-XE 6.8mg/mL 1 BOTTLE, DISPENSING per CARTON / 5 mL in 1 BOTTLE, DISPENSING |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TIVICAY 10 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TIVICAY 25 MG TABLET |
4 |
Specialty Tier |
33% | N/A | None |
TIVICAY 50 MG TABLET |
4 |
Specialty Tier |
33% | N/A | None |
Tizanidine 4mg/1 1000 TABLET BOTTLE |
1 |
Generic |
$5.00 | N/A | None |
TIZANIDINE HCL 2 MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
TOBI 300mg/5mL 56 AMPULE per CARTON / 5 mL in 1 AMPULE |
4 |
Specialty Tier |
33% | N/A | P |
TOBI PODHALER 28 MG INHALE CAP |
4 |
Specialty Tier |
33% | N/A | P |
TOBRADEX EYE OINTMENT |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOBRADEX SUSPENSION OPHTHALMIC 0.1%/0.3% 5ML BOT |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TOBRAMYCIN 10 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate] |
1 |
Generic |
$5.00 | N/A | P |
TOBRAMYCIN 300 MG/5 ML AMPULE [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate] |
4 |
Specialty Tier |
33% | N/A | P |
TOBRAMYCIN 40MG/ML VIAL |
1 |
Generic |
$5.00 | N/A | P |
TOBRAMYCIN OPHTHALMIC SOLUTION 0.3% 5ML BOT |
1 |
Generic |
$5.00 | N/A | None |
TOBRAMYCIN-DEXAMETH OPTH SUSP |
1 |
Generic |
$5.00 | N/A | None |
TOBREX 0.3% EYE DROPS |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TOBREX 0.3% EYE OINTMENT |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TOFRANIL 50MG TABLET (30 CT) |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TOFRANIL TABLETS 10MG 30 BOT |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TOFRANIL TABLETS 25MG 30 BOT |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOLAK 4% CREAM |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Tolcapone 100 MG TABLET [Tasmar] |
1 |
Generic |
$5.00 | N/A | None |
Tolterodine Tartrate 1 MG Oral Tablet [Detrol LA] |
1 |
Generic |
$5.00 | N/A | Q:60 /30Days |
Tolterodine Tartrate 2 MG TABLET [Detrol LA] |
1 |
Generic |
$5.00 | N/A | Q:60 /30Days |
Tolterodine Tartrate ER 2 MG CAPSULE [Detrol LA] |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
Tolterodine Tartrate ER 4 MG Capsule [Detrol LA] |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
TOPAMAX 15 MG SPRINKLE CAP |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TOPAMAX 25 MG SPRINKLE CAP |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TOPAMAX TABLETS 100MG 60 BOT |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TOPAMAX TABLETS 200MG 60 BOT |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TOPAMAX TABLETS 25MG 60 BOT |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOPAMAX TABLETS 50MG 60 BOT |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Topicort 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Topicort 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Topicort 2.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Topicort 2.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Topiramate 25mg/1 |
1 |
Generic |
$5.00 | N/A | None |
TOPIRAMATE SPRINKLE CAPSULES 15MG 60 BOT |
1 |
Generic |
$5.00 | N/A | None |
TOPIRAMATE TABLETS 100MG 1000 BOT |
1 |
Generic |
$5.00 | N/A | None |
TOPIRAMATE TABLETS 200MG 1000 BOT |
1 |
Generic |
$5.00 | N/A | None |
TOPIRAMATE TABLETS 25MG 1000 BOT |
1 |
Generic |
$5.00 | N/A | None |
TOPIRAMATE TABLETS 50MG 1000 BOT |
1 |
Generic |
$5.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOPOSAR INJECTION 20MG/ML 50ML VIAL MD CRTN |
1 |
Generic |
$5.00 | N/A | P |
TOPOTECAN HCL 4 MG VIAL |
1 |
Generic |
$5.00 | N/A | P |
TOPROL XL 100MG TABLET SA |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:60 /30Days |
TOPROL XL 200MG TABLET SA |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TOPROL XL 25MG TABLET SA |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:60 /30Days |
TOPROL XL 50MG TABLET SA |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:60 /30Days |
TORSEMIDE 10 MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
Torsemide 100mg/1 12 BOTTLE CASE / 100 TABLET BOTTLE |
1 |
Generic |
$5.00 | N/A | None |
TORSEMIDE 20mg 100 TABLET BOTTLE |
1 |
Generic |
$5.00 | N/A | None |
TORSEMIDE 5 MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
TOUJEO SOLOSTAR 300 UNITS/ML |
2 |
Preferred Brand |
$40.00 | N/A | Q:9 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOVIAZ TABLETS 4MG EXTENDED RELEASE |
2 |
Preferred Brand |
$40.00 | N/A | Q:30 /30Days |
TOVIAZ TABLETS 8MG EXTENDED RELEASE |
2 |
Preferred Brand |
$40.00 | N/A | Q:30 /30Days |
TRADJENTA 5mg/1 90 FILM COATED TABLETS in BOTTLE |
2 |
Preferred Brand |
$40.00 | N/A | Q:30 /30Days |
TRAMADOL HCL 50 MG TABLET |
1 |
Generic |
$5.00 | N/A | Q:240 /30Days |
TRAMADOL HCL-ACETAMINOPHEN 37.5-325MG TABLET (1000 CT) |
1 |
Generic |
$5.00 | N/A | Q:240 /30Days |
TRANDOLAPRIL 1 MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
TRANDOLAPRIL 2 MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
TRANDOLAPRIL 4 MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
TRANDOLAPRIL-VERAPAMIL ER 1-240 MG |
1 |
Generic |
$5.00 | N/A | Q:60 /30Days |
TRANDOLAPRIL-VERAPAMIL ER 2-180 MG |
1 |
Generic |
$5.00 | N/A | Q:60 /30Days |
TRANDOLAPRIL-VERAPAMIL ER 2-240 MG |
1 |
Generic |
$5.00 | N/A | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRANDOLAPRIL-VERAPAMIL ER 4-240 MG |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
TRANEXAMIC ACID 1,000 MG/10 ML |
1 |
Generic |
$5.00 | N/A | P |
tranexamic acid 650 mg tablet |
1 |
Generic |
$5.00 | N/A | None |
TRANSDERM-SCOP 1.5 MG/3 DAY |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TRANXENE T-TAB 7.5 MG |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TRANYLCYPROMINE SULFATE 10MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
TRAVASOL 10% SOLUTION VIAFLEX |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
TRAVATAN Z 0.04MG DROPS 2.5ML BOT |
2 |
Preferred Brand |
$40.00 | N/A | None |
TRAZODONE 300MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
TRAZODONE HCL TABLET USP 100MG (500 CT) |
1 |
Generic |
$5.00 | N/A | None |
TRAZODONE HCL TABLET USP 150MG (100 CT) |
1 |
Generic |
$5.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRAZODONE HCL TABLET USP 50MG (500 CT) |
1 |
Generic |
$5.00 | N/A | None |
TREANDA FOR INJECTION 100MG/VIAL |
4 |
Specialty Tier |
33% | N/A | P |
TRECATOR 250MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TRETINOIN 0.01% GEL |
1 |
Generic |
$5.00 | N/A | P |
TRETINOIN 0.025% CREAM |
1 |
Generic |
$5.00 | N/A | P |
TRETINOIN 0.05% CREAM |
1 |
Generic |
$5.00 | N/A | P |
TRETINOIN 0.1% CREAM |
1 |
Generic |
$5.00 | N/A | P |
Tretinoin 0.25mg/g 1 TUBE per CARTON / 45 g in 1 TUBE |
1 |
Generic |
$5.00 | N/A | P |
TRETINOIN 10MG CAPSULE |
4 |
Specialty Tier |
33% | N/A | None |
TRI PREVIFEM TABLETS |
1 |
Generic |
$5.00 | N/A | None |
TRI-LEGEST FE 5-7-9-7 TABLET |
1 |
Generic |
$5.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRI-NORINYL 28 TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TRI-SPRINTEC 7DAYSX3 28 TABLET |
1 |
Generic |
$5.00 | N/A | None |
TRIAMCINOLONE 0.1% OINTMENT |
1 |
Generic |
$5.00 | N/A | None |
TRIAMCINOLONE ACETONIDE 0.025% CREAM 80GM TUBE |
1 |
Generic |
$5.00 | N/A | None |
TRIAMCINOLONE ACETONIDE 0.025% LOTION 2 FL OZ BOT |
1 |
Generic |
$5.00 | N/A | None |
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE |
1 |
Generic |
$5.00 | N/A | None |
TRIAMCINOLONE ACETONIDE 0.1% CREAM 80GM TUBE |
1 |
Generic |
$5.00 | N/A | None |
TRIAMCINOLONE ACETONIDE 0.1% LOTION 60ML BOTPL |
1 |
Generic |
$5.00 | N/A | None |
triamcinolone acetonide 0.25mg/g 80 g in 1 TUBE |
1 |
Generic |
$5.00 | N/A | None |
Triamcinolone Acetonide 1mg/g 1 TUBE per CARTON / 5 g in 1 TUBE |
1 |
Generic |
$5.00 | N/A | None |
Triamcinolone Acetonide 5mg/g 1 TUBE per CARTON / 15 g in 1 TUBE |
1 |
Generic |
$5.00 | N/A | 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 |
Generic |
$5.00 | N/A | None |
TRIAMTERENE-HCTZ 37.5-25 MG TB |
1 |
Generic |
$5.00 | N/A | None |
TRIAMTERENE/HCTZ 75/50 TABLET |
1 |
Generic |
$5.00 | N/A | None |
TRICOR 145 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TRICOR 48 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:30 /30Days |
TRIFLUOPERAZINE 1MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
TRIFLUOPERAZINE HCL 2MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
TRIFLUOPERAZINE HCL 5MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT) |
1 |
Generic |
$5.00 | N/A | None |
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT |
1 |
Generic |
$5.00 | N/A | None |
TRIGLIDE 160 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Trihexyphenidyl 2 mg tablet |
1 |
Generic |
$5.00 | N/A | None |
Trihexyphenidyl 5 mg tablet |
1 |
Generic |
$5.00 | N/A | None |
Trihexyphenidyl Hydrochloride 2mg/5mL 473 mL in 1 BOTTLE |
1 |
Generic |
$5.00 | N/A | None |
TRILEPTAL 150MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TRILEPTAL 300MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TRILEPTAL 300MG/5ML SUSP |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TRILEPTAL 600MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TRILIPIX DR 135 MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TRILIPIX DR 45 MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TRIMETHOPRIM 100MG TABLETS |
1 |
Generic |
$5.00 | N/A | None |
TRIMIPRAMINE MALEATE 100 MG CP |
1 |
Generic |
$5.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIMIPRAMINE MALEATE 25 MG CAP |
1 |
Generic |
$5.00 | N/A | None |
TRIMIPRAMINE MALEATE 50 MG CAP |
1 |
Generic |
$5.00 | N/A | None |
TRINESSA TABLET |
1 |
Generic |
$5.00 | N/A | None |
TRINTELLIX 10 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:30 /30Days |
TRINTELLIX 20 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:30 /30Days |
TRINTELLIX 5 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:30 /30Days |
TRISENOX 10MG/10ML AMPULE |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
TRIUMEQ TABLET |
4 |
Specialty Tier |
33% | N/A | None |
Trivora-28 tablet |
1 |
Generic |
$5.00 | N/A | None |
TRIZIVIR 300; 150; 300mg/1; mg/1; mg/1 60 FILM COATED TABLETS in BOTTLE |
4 |
Specialty Tier |
33% | N/A | None |
TROKENDI XR 100 MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TROKENDI XR 200 MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TROKENDI XR 25 MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TROKENDI XR 50 MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TROPHAMINE INJECTION SOLUTION |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
TROPHAMINE INJECTION SOLUTION 6% |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
TROSPIUM CHLORIDE 20MG TABLETS |
1 |
Generic |
$5.00 | N/A | Q:60 /30Days |
TRULICITY 0.75 MG/0.5 ML PEN |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:2 /28Days |
TRULICITY 1.5 MG/0.5 ML PEN |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:2 /28Days |
TRUMENBA 120 MCG/0.5 ML VACCINE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TRUSOPT PLUS 2% EYE DROPS 10ML BOT |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TRUVADA 100 MG-150 MG TABLET |
4 |
Specialty Tier |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRUVADA 133 MG-200 MG TABLET |
4 |
Specialty Tier |
33% | N/A | None |
TRUVADA 167 MG-250 MG TABLET |
4 |
Specialty Tier |
33% | N/A | None |
TRUVADA 200/300MG TABLET |
4 |
Specialty Tier |
33% | N/A | None |
TWINRIX TF PF VACCINE 720UNT/20ML 10 X 1ML VIALSD |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TYBOST 150 MG TABLET |
2 |
Preferred Brand |
$40.00 | N/A | None |
Tygacil 50mg/5mL 10 VIAL, SINGLE-USE per CARTON / 50 mL in 1 VIAL, SINGLE-USE |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
TYKERB 250 MG TABLET |
4 |
Specialty Tier |
33% | N/A | P |
TYLENOL with Codeine 300; 30mg/1; mg/1 1000 TABLET BOTTLE |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:360 /30Days |
TYLENOL with Codeine 300; 60mg/1; mg/1 500 TABLET BOTTLE |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:180 /30Days |
TYPHIM VI 25 MCG/0.5 ML SYRINGE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
TYPHIM VI 25MCG/0.5ML VIAL |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TYSABRI 300 MG/15 ML VIAL |
4 |
Specialty Tier |
33% | N/A | P |