2017 Medicare Part D Plan Formulary Information |
Educators Rx Advantage (PDP) (S5877-007-0)
Benefit Details
|
The Educators Rx Advantage (PDP) (S5877-007-0) Formulary Drugs Starting with the Letter T in CMS PDP Region 31 which includes: ID UT Plan Monthly Premium: $159.30 Deductible: $0 Qualifies for LIS: No |
Drugs Starting with Letter T
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
TABLOID 40 MG TABLET |
2 |
Preferred Brand |
20% | N/A | None |
TACLONEX OINTMENT |
3 |
Non-Preferred Drug |
40% | N/A | None |
TACLONEX SCALP SUSPENSION |
3 |
Non-Preferred Drug |
40% | N/A | None |
Tacrolimus 0.03% ointment |
1 |
Preferred Generic |
10% | N/A | P |
Tacrolimus 0.1% ointment |
1 |
Preferred Generic |
10% | N/A | P |
Tacrolimus 0.5mg/1 100 CAPSULE BOTTLE |
1 |
Preferred Generic |
10% | N/A | P |
Tacrolimus 1mg/1 100 CAPSULE BOTTLE |
1 |
Preferred Generic |
10% | N/A | P |
Tacrolimus 5mg/1 100 CAPSULE BOTTLE |
1 |
Preferred Generic |
10% | N/A | P |
TAFINLAR 50 MG CAPSULE |
4 |
Specialty Tier |
33% | N/A | P Q:180 /30Days |
TAFINLAR 75 MG CAPSULE |
4 |
Specialty Tier |
33% | N/A | P Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAGRISSO 40 MG TABLET |
4 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
TAGRISSO 80 MG TABLET |
4 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
TALTZ 80 MG/ML AUTOINJ (3-PK) |
4 |
Specialty Tier |
33% | N/A | P |
TALTZ 80 MG/ML SYRINGE |
4 |
Specialty Tier |
33% | N/A | P |
TAMIFLU 30 MG 1 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK |
2 |
Preferred Brand |
20% | N/A | None |
TAMIFLU 45 MG 1 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK |
2 |
Preferred Brand |
20% | N/A | None |
TAMIFLU 6 MG/ML SUSPENSION |
2 |
Preferred Brand |
20% | N/A | None |
TAMIFLU 75 MG CAPSULE UD |
2 |
Preferred Brand |
20% | N/A | None |
TAMOXIFEN 10 MG TABLET |
1 |
Preferred Generic |
10% | N/A | None |
TAMOXIFEN CITRATE 20MG TABLET (30 CT) |
1 |
Preferred Generic |
10% | N/A | None |
TAMSULOSIN HCL 0.4 MG CAPSULE |
1 |
Preferred Generic |
10% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TANZEUM 30 MG PEN INJECT |
3 |
Non-Preferred Drug |
40% | N/A | P Q:4 /28Days |
TANZEUM 50 MG PEN INJECT |
3 |
Non-Preferred Drug |
40% | N/A | P Q:4 /28Days |
TAPAZOLE 10MG TABLET |
3 |
Non-Preferred Drug |
40% | N/A | None |
TAPAZOLE 5MG TABLET |
3 |
Non-Preferred Drug |
40% | N/A | None |
TARCEVA 100MG TABLET |
4 |
Specialty Tier |
33% | N/A | P |
TARCEVA 150MG TABLET |
4 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
TARCEVA 25MG TABLET |
4 |
Specialty Tier |
33% | N/A | P |
TARGADOX 50 MG TABLET |
3 |
Non-Preferred Drug |
40% | N/A | S |
TARGRETIN 1% GEL |
4 |
Specialty Tier |
33% | N/A | None |
TARGRETIN 75 MG CAPSULE |
4 |
Specialty Tier |
33% | N/A | None |
Tarina Fe 1-20 tablet |
1 |
Preferred Generic |
10% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TARKA 1/240MG TABLET SA |
3 |
Non-Preferred Drug |
40% | N/A | None |
Tarka 2; 240mg/1; mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE |
3 |
Non-Preferred Drug |
40% | N/A | None |
TARKA 2/180MG TABLET SA |
3 |
Non-Preferred Drug |
40% | N/A | None |
Tarka 4; 240mg/1; mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE |
3 |
Non-Preferred Drug |
40% | N/A | None |
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 Q:112 /28Days |
TASMAR 100MG TABLET |
4 |
Specialty Tier |
33% | N/A | None |
TAXOTERE 80mg/4mL 1 VIAL, GLASS per CARTON / 4 mL in 1 VIAL, GLASS |
4 |
Specialty Tier |
33% | N/A | None |
Tazarotene 0.1% Cream [Tazorac] |
1 |
Preferred Generic |
10% | N/A | P |
TAZICEF 1GM VIAL |
3 |
Non-Preferred Drug |
40% | N/A | None |
TAZICEF 2 GRAM VIAL |
3 |
Non-Preferred Drug |
40% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAZICEF 6 GRAM VIAL |
3 |
Non-Preferred Drug |
40% | N/A | None |
TAZORAC 0.05% CREAM |
2 |
Preferred Brand |
20% | N/A | P |
TAZORAC 0.05% GEL |
2 |
Preferred Brand |
20% | N/A | P |
TAZORAC 0.1% CREAM |
2 |
Preferred Brand |
20% | N/A | P |
TAZORAC 0.1% GEL |
2 |
Preferred Brand |
20% | N/A | P |
TAZTIA DILTIAZEM HYDROCHLORIDE 120MG EXTENDED RELEASE CAPSULES |
1 |
Preferred Generic |
10% | N/A | None |
TAZTIA DILTIAZEM HYDROCHLORIDE 180MG EXTENDED RELEASE CAPSULES |
1 |
Preferred Generic |
10% | N/A | None |
TAZTIA DILTIAZEM HYDROCHLORIDE 300MG EXTENDED RELEASE CAPSULES |
1 |
Preferred Generic |
10% | N/A | None |
TAZTIA XT 240MG CAPSULE SA |
1 |
Preferred Generic |
10% | N/A | None |
TAZTIA XT 360MG CAPSULE SA |
1 |
Preferred Generic |
10% | N/A | None |
TECENTRIQ 1,200 MG/20 ML VIAL |
4 |
Specialty Tier |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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 |
TECHNIVIE DOSE PACK |
4 |
Specialty Tier |
33% | N/A | P Q:168 /84Days |
Teflaro 400mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE |
4 |
Specialty Tier |
33% | N/A | None |
Teflaro 600mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE |
4 |
Specialty Tier |
33% | N/A | None |
TEGRETOL SUSPENSION 100MG/5ML 450 ML BOT |
3 |
Non-Preferred Drug |
40% | N/A | None |
TEGRETOL TABLETS 200MG 100 BOT |
3 |
Non-Preferred Drug |
40% | N/A | None |
TEGRETOL XR TABLETS 100MG 100 BOT |
3 |
Non-Preferred Drug |
40% | N/A | None |
TEGRETOL XR TABLETS 200MG 100 BOT |
3 |
Non-Preferred Drug |
40% | N/A | None |
TEGRETOL XR TABLETS 400MG 100 BOT |
3 |
Non-Preferred Drug |
40% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TEKTURNA 150 MG TABLET |
2 |
Preferred Brand |
20% | N/A | None |
TEKTURNA 300 MG TABLET |
2 |
Preferred Brand |
20% | N/A | None |
TEKTURNA HCT 300-25 MG TABLET |
2 |
Preferred Brand |
20% | N/A | None |
Telmisartan 20 MG Tablet [Micardis] |
1 |
Preferred Generic |
10% | N/A | None |
Telmisartan 40 MG Tablet [Micardis] |
1 |
Preferred Generic |
10% | N/A | None |
Telmisartan 80 MG Tablet [Micardis] |
1 |
Preferred Generic |
10% | N/A | None |
Telmisartan-Amlodipine 40-10 MG [Micardis] |
1 |
Preferred Generic |
10% | N/A | None |
Telmisartan-Amlodipine 40-5 MG [Micardis] |
1 |
Preferred Generic |
10% | N/A | None |
Telmisartan-Amlodipine 80-10 MG [Micardis] |
1 |
Preferred Generic |
10% | N/A | None |
Telmisartan-Amlodipine 80-5 MG [Micardis] |
1 |
Preferred Generic |
10% | N/A | None |
TELMISARTAN-HCTZ 40-12.5 MG TB [Micardis] |
1 |
Preferred Generic |
10% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Telmisartan-hctz 80-12.5 mg tb [Micardis] |
1 |
Preferred Generic |
10% | N/A | None |
TELMISARTAN-HCTZ 80-25 MG TAB [Micardis] |
1 |
Preferred Generic |
10% | N/A | None |
Temazepam 15mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE per BLISTER PACK |
1 |
Preferred Generic |
10% | N/A | P |
Temazepam 22.5mg/1 30 CAPSULE BOTTLE, PLASTIC |
1 |
Preferred Generic |
10% | N/A | P |
TEMAZEPAM 30 MG CAPSULE |
1 |
Preferred Generic |
10% | N/A | P |
Temazepam 7.5mg/1 100 CAPSULE BOTTLE, PLASTIC |
1 |
Preferred Generic |
10% | N/A | P |
TEMOVATE 0.05% OINTMENT |
3 |
Non-Preferred Drug |
40% | N/A | S |
TENIVAC SYRINGE |
2 |
Preferred Brand |
20% | N/A | None |
TENORETIC 100 TABLET |
3 |
Non-Preferred Drug |
40% | N/A | None |
TENORETIC 50 TABLET |
3 |
Non-Preferred Drug |
40% | N/A | None |
TENORMIN 100 MG TABLET |
3 |
Non-Preferred Drug |
40% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TENORMIN 25 MG TABLET |
3 |
Non-Preferred Drug |
40% | N/A | None |
TENORMIN 50 MG TABLET |
3 |
Non-Preferred Drug |
40% | N/A | None |
TERAZOL 7 CREAM |
3 |
Non-Preferred Drug |
40% | N/A | None |
TERAZOSIN 1 MG CAPSULE |
1 |
Preferred Generic |
10% | N/A | Q:30 /30Days |
Terazosin Hydrochloride 10mg/1 100 CAPSULE BOTTLE |
1 |
Preferred Generic |
10% | N/A | Q:60 /30Days |
Terazosin Hydrochloride 2mg/1 100 CAPSULE BOTTLE |
1 |
Preferred Generic |
10% | N/A | Q:30 /30Days |
Terazosin Hydrochloride 5mg/1 100 CAPSULE BOTTLE |
1 |
Preferred Generic |
10% | N/A | Q:30 /30Days |
Terbinafine HCl 250 MG Tablet |
1 |
Preferred Generic |
10% | N/A | None |
TERBUTALINE SULF 1MG/ML VL |
1 |
Preferred Generic |
10% | N/A | None |
TERBUTALINE SULFATE 2.5 MG TAB |
1 |
Preferred Generic |
10% | N/A | None |
TERBUTALINE SULFATE 5MG TABLET |
1 |
Preferred Generic |
10% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TERCONAZOLE 0.4% CREAM WITH APPLICATOR |
1 |
Preferred Generic |
10% | N/A | None |
TERCONAZOLE 0.8% CREAM |
1 |
Preferred Generic |
10% | N/A | None |
TERCONAZOLE 80MG SUPPOSITORY VAGINAL |
1 |
Preferred Generic |
10% | N/A | None |
TESTIM 1%(50MG) GEL |
3 |
Non-Preferred Drug |
40% | N/A | P |
TESTOSTERONE 10 MG GEL PUMP |
3 |
Non-Preferred Drug |
40% | N/A | P |
TESTOSTERONE 12.5 MG/1.25 GRAM |
3 |
Non-Preferred Drug |
40% | N/A | P |
TESTOSTERONE 25 MG/2.5 GM PKT |
1 |
Preferred Generic |
10% | N/A | P |
TESTOSTERONE 50 MG/5 GRAM PKT |
3 |
Non-Preferred Drug |
40% | N/A | P |
Testosterone cyp 100 mg/ml |
1 |
Preferred Generic |
10% | N/A | None |
Testosterone cyp 200 mg/ml |
1 |
Preferred Generic |
10% | N/A | None |
TESTOSTERONE ENANTHATE 200MG/ML INJECTION |
1 |
Preferred Generic |
10% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TESTRED 10 MG CAPSULE |
4 |
Specialty Tier |
33% | N/A | None |
TETANUS DIPHTHERIA TOXOIDS |
2 |
Preferred Brand |
20% | N/A | None |
TETRABENAZINE 12.5 MG TABLET [XENAZINE] |
4 |
Specialty Tier |
33% | N/A | P |
TETRABENAZINE 25 MG TABLET [XENAZINE] |
4 |
Specialty Tier |
33% | N/A | P |
TETRACYCLINE 250 MG CAPSULE |
1 |
Preferred Generic |
10% | N/A | None |
TETRACYCLINE 500 MG CAPSULE |
3 |
Non-Preferred Drug |
40% | 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 |
THEO-24 ER 100 MG CAPSULE |
2 |
Preferred Brand |
20% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THEO-24 ER 200 MG CAPSULE |
2 |
Preferred Brand |
20% | N/A | None |
THEO-24 ER 300 MG CAPSULE |
2 |
Preferred Brand |
20% | N/A | None |
THEO-24 ER 400 MG CAPSULE |
2 |
Preferred Brand |
20% | N/A | None |
Theophylline 100mg/1 500 CAPSULE BOTTLE |
1 |
Preferred Generic |
10% | N/A | None |
Theophylline 200mg/1 500 TABLET, EXTENDED RELEASE in 1 BOTTLE |
1 |
Preferred Generic |
10% | N/A | None |
Theophylline 80mg/15mL 473 mL in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic |
10% | N/A | None |
Theophylline er 400 mg tablet |
1 |
Preferred Generic |
10% | N/A | None |
Theophylline er 600 mg tablet |
1 |
Preferred Generic |
10% | N/A | None |
THEOPHYLLINE TABLET ER 300MG (100 CT) |
1 |
Preferred Generic |
10% | N/A | None |
THEOPHYLLINE TABLET ER 450MG (100 CT) |
1 |
Preferred Generic |
10% | N/A | None |
THIOLA 100 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 |
THIORIDAZINE 100MG TABLET |
1 |
Preferred Generic |
10% | N/A | None |
THIORIDAZINE HCL 10MG TABLET (1000 CT) |
1 |
Preferred Generic |
10% | N/A | None |
THIORIDAZINE HCL 25MG TABLET (1000 CT) |
1 |
Preferred Generic |
10% | N/A | None |
Thioridazine Hydrochloride 50mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED in 1 |
1 |
Preferred Generic |
10% | N/A | None |
THIOTEPA 15 MG VIAL |
4 |
Specialty Tier |
33% | N/A | None |
THIOTHIXENE 10MG CAPSULE |
1 |
Preferred Generic |
10% | N/A | None |
THIOTHIXENE 1MG CAPSULE (100 CT) |
1 |
Preferred Generic |
10% | N/A | None |
THIOTHIXENE 2MG CAPSULE |
1 |
Preferred Generic |
10% | N/A | None |
THIOTHIXENE 5MG CAPSULE |
1 |
Preferred Generic |
10% | N/A | None |
THYMOGLOBULIN 25MG VIAL |
4 |
Specialty Tier |
33% | N/A | P |
THYROLAR-1 TABLETS |
3 |
Non-Preferred Drug |
40% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THYROLAR-1/2 TABLETS |
3 |
Non-Preferred Drug |
40% | N/A | None |
THYROLAR-1/4 TABLETS |
3 |
Non-Preferred Drug |
40% | N/A | None |
THYROLAR-2 TABLETS |
3 |
Non-Preferred Drug |
40% | N/A | None |
THYROLAR-3 TABLETS |
3 |
Non-Preferred Drug |
40% | N/A | None |
tiagabine hcl 2 mg tablet [Gabitril] |
3 |
Non-Preferred Drug |
40% | N/A | None |
tiagabine hcl 4 mg tablet [Gabitril] |
3 |
Non-Preferred Drug |
40% | N/A | None |
TIAZAC ER 120 MG CAPSULE |
3 |
Non-Preferred Drug |
40% | N/A | None |
TIAZAC ER 180 MG CAPSULE |
3 |
Non-Preferred Drug |
40% | N/A | None |
TIAZAC ER 240 MG CAPSULE |
3 |
Non-Preferred Drug |
40% | N/A | None |
TIAZAC ER 300 MG CAPSULE |
3 |
Non-Preferred Drug |
40% | N/A | None |
TIAZAC ER 360 MG CAPSULE |
3 |
Non-Preferred Drug |
40% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIAZAC ER 420 MG CAPSULE |
3 |
Non-Preferred Drug |
40% | N/A | None |
TIGECYCLINE 50 MG VIAL [Tygacil] |
4 |
Specialty Tier |
33% | N/A | None |
TIKOSYN .125MG CAPSULE |
3 |
Non-Preferred Drug |
40% | N/A | None |
TIKOSYN .250MG CAPSULE |
3 |
Non-Preferred Drug |
40% | N/A | None |
TIKOSYN .5MG CAPSULE |
3 |
Non-Preferred Drug |
40% | N/A | None |
TIMOLOL 0.25% GFS GEL-SOLUTION |
1 |
Preferred Generic |
10% | N/A | None |
TIMOLOL MAL SOL 0.25% OP 15ML BOT |
1 |
Preferred Generic |
10% | N/A | None |
TIMOLOL MAL SOL 0.5% OP 10ML BOT |
1 |
Preferred Generic |
10% | N/A | None |
TIMOLOL MALEATE 10MG TABLET |
1 |
Preferred Generic |
10% | N/A | None |
TIMOLOL MALEATE 20MG TABLET |
1 |
Preferred Generic |
10% | N/A | None |
TIMOLOL MALEATE 5MG TABLET |
1 |
Preferred Generic |
10% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Timolol Maleate 6.8mg/mL 1 BOTTLE, DISPENSING per CARTON / 5 mL in 1 BOTTLE, DISPENSING |
1 |
Preferred Generic |
10% | N/A | None |
TIMOPTIC 0.25% OCUDOSE DROP |
3 |
Non-Preferred Drug |
40% | N/A | None |
TIMOPTIC 0.5% OCUDOSE DROP |
3 |
Non-Preferred Drug |
40% | N/A | None |
Timoptic-XE 3.4mg/mL 1 BOTTLE, DISPENSING per CARTON / 5 mL in 1 BOTTLE, DISPENSING |
3 |
Non-Preferred Drug |
40% | N/A | None |
Timoptic-XE 6.8mg/mL 1 BOTTLE, DISPENSING per CARTON / 5 mL in 1 BOTTLE, DISPENSING |
3 |
Non-Preferred Drug |
40% | N/A | None |
TINDAMAX 500 MG TABLET |
3 |
Non-Preferred Drug |
40% | N/A | None |
tinidazole 250 mg tablet |
1 |
Preferred Generic |
10% | N/A | None |
tinidazole 500 mg tablet |
1 |
Preferred Generic |
10% | N/A | None |
Tirosint 100ug/1 4 BLISTER PACK per CARTON / 7 CAPSULE per BLISTER PACK |
3 |
Non-Preferred Drug |
40% | N/A | None |
Tirosint 112ug/1 4 BLISTER PACK per CARTON / 7 CAPSULE per BLISTER PACK |
3 |
Non-Preferred Drug |
40% | N/A | None |
Tirosint 125ug/1 4 BLISTER PACK per CARTON / 7 CAPSULE per BLISTER PACK |
3 |
Non-Preferred Drug |
40% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Tirosint 137ug/1 4 BLISTER PACK per CARTON / 7 CAPSULE per BLISTER PACK |
3 |
Non-Preferred Drug |
40% | N/A | None |
Tirosint 13ug/1 4 BLISTER PACK per CARTON / 7 CAPSULE per BLISTER PACK |
3 |
Non-Preferred Drug |
40% | N/A | None |
Tirosint 150ug/1 4 BLISTER PACK per CARTON / 7 CAPSULE per BLISTER PACK |
3 |
Non-Preferred Drug |
40% | N/A | None |
Tirosint 25ug/1 4 BLISTER PACK per CARTON / 7 CAPSULE per BLISTER PACK |
3 |
Non-Preferred Drug |
40% | N/A | None |
Tirosint 50ug/1 4 BLISTER PACK per CARTON / 7 CAPSULE per BLISTER PACK |
3 |
Non-Preferred Drug |
40% | N/A | None |
Tirosint 75ug/1 4 BLISTER PACK per CARTON / 7 CAPSULE per BLISTER PACK |
3 |
Non-Preferred Drug |
40% | N/A | None |
Tirosint 88ug/1 4 BLISTER PACK per CARTON / 7 CAPSULE per BLISTER PACK |
3 |
Non-Preferred Drug |
40% | N/A | None |
TIVICAY 10 MG TABLET |
2 |
Preferred Brand |
20% | 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 |
TIVORBEX 20 MG CAPSULE |
3 |
Non-Preferred Drug |
40% | N/A | S Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIVORBEX 40 MG CAPSULE |
3 |
Non-Preferred Drug |
40% | N/A | S Q:90 /30Days |
Tizanidine 4mg/1 1000 TABLET BOTTLE |
1 |
Preferred Generic |
10% | N/A | None |
TIZANIDINE HCL 2 MG CAPSULE |
1 |
Preferred Generic |
10% | N/A | None |
TIZANIDINE HCL 2 MG TABLET |
1 |
Preferred Generic |
10% | N/A | None |
TIZANIDINE HCL 4 MG CAPSULE |
1 |
Preferred Generic |
10% | N/A | None |
TIZANIDINE HCL 6 MG CAPSULE |
3 |
Non-Preferred Drug |
40% | N/A | None |
TOBI 300mg/5mL 56 AMPULE per CARTON / 5 mL in 1 AMPULE |
4 |
Specialty Tier |
33% | N/A | P Q:280 /28Days |
TOBI PODHALER 28 MG INHALE CAP |
4 |
Specialty Tier |
33% | N/A | Q:224 /28Days |
TOBRADEX EYE OINTMENT |
3 |
Non-Preferred Drug |
40% | N/A | None |
TOBRADEX ST 0.5; 3mg/mL; mg/mL 5 mL in 1 BOTTLE |
3 |
Non-Preferred Drug |
40% | N/A | None |
TOBRADEX SUSPENSION OPHTHALMIC 0.1%/0.3% 5ML BOT |
3 |
Non-Preferred Drug |
40% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOBRAMYCIN 10 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate] |
1 |
Preferred Generic |
10% | N/A | None |
TOBRAMYCIN 300 MG/5 ML AMPULE [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate] |
4 |
Specialty Tier |
33% | N/A | P Q:280 /28Days |
TOBRAMYCIN 40MG/ML VIAL |
1 |
Preferred Generic |
10% | N/A | None |
TOBRAMYCIN OPHTHALMIC SOLUTION 0.3% 5ML BOT |
1 |
Preferred Generic |
10% | N/A | None |
TOBRAMYCIN-DEXAMETH OPTH SUSP |
1 |
Preferred Generic |
10% | N/A | None |
TOBREX 0.3% EYE DROPS |
3 |
Non-Preferred Drug |
40% | N/A | None |
TOBREX 0.3% EYE OINTMENT |
2 |
Preferred Brand |
20% | N/A | None |
TOFRANIL 50MG TABLET (30 CT) |
3 |
Non-Preferred Drug |
40% | N/A | P |
TOFRANIL TABLETS 10MG 30 BOT |
3 |
Non-Preferred Drug |
40% | N/A | P |
TOFRANIL TABLETS 25MG 30 BOT |
3 |
Non-Preferred Drug |
40% | N/A | P |
TOLAK 4% CREAM |
3 |
Non-Preferred Drug |
40% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOLAZAMIDE TABLETS 250MG 100 BOT |
1 |
Preferred Generic |
10% | N/A | Q:120 /30Days |
TOLAZAMIDE TABLETS 500MG 100 BOT |
1 |
Preferred Generic |
10% | N/A | Q:60 /30Days |
TOLBUTAMIDE 500MG TABLET |
1 |
Preferred Generic |
10% | N/A | Q:180 /30Days |
Tolcapone 100 MG TABLET [Tasmar] |
4 |
Specialty Tier |
33% | N/A | None |
TOLMETIN SODIUM 400 MG CAP |
1 |
Preferred Generic |
10% | N/A | None |
TOLMETIN SODIUM 600MG TABLET |
1 |
Preferred Generic |
10% | N/A | None |
Tolterodine Tartrate 1 MG Oral Tablet [Detrol LA] |
1 |
Preferred Generic |
10% | N/A | None |
Tolterodine Tartrate 2 MG TABLET [Detrol LA] |
1 |
Preferred Generic |
10% | N/A | None |
Tolterodine Tartrate ER 2 MG CAPSULE [Detrol LA] |
1 |
Preferred Generic |
10% | N/A | None |
Tolterodine Tartrate ER 4 MG Capsule [Detrol LA] |
1 |
Preferred Generic |
10% | N/A | None |
TOLVAPTAN 15 MG ORAL TABLET [SAMSCA] |
4 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOLVAPTAN 30 MG ORAL TABLET [SAMSCA] |
4 |
Specialty Tier |
33% | N/A | P |
TOPAMAX 15 MG SPRINKLE CAP |
3 |
Non-Preferred Drug |
40% | N/A | P |
TOPAMAX 25 MG SPRINKLE CAP |
3 |
Non-Preferred Drug |
40% | N/A | P |
TOPAMAX TABLETS 100MG 60 BOT |
3 |
Non-Preferred Drug |
40% | N/A | P |
TOPAMAX TABLETS 200MG 60 BOT |
3 |
Non-Preferred Drug |
40% | N/A | P |
TOPAMAX TABLETS 25MG 60 BOT |
3 |
Non-Preferred Drug |
40% | N/A | P |
TOPAMAX TABLETS 50MG 60 BOT |
3 |
Non-Preferred Drug |
40% | N/A | P |
TOPICORT 0.25% SPRAY |
3 |
Non-Preferred Drug |
40% | N/A | S |
Topicort 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
3 |
Non-Preferred Drug |
40% | N/A | S |
Topicort 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
3 |
Non-Preferred Drug |
40% | N/A | S |
Topicort 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
3 |
Non-Preferred Drug |
40% | N/A | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Topicort 2.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
3 |
Non-Preferred Drug |
40% | N/A | S |
Topicort 2.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
3 |
Non-Preferred Drug |
40% | N/A | S |
Topiramate 25mg/1 |
1 |
Preferred Generic |
10% | N/A | P |
TOPIRAMATE ER 100 MG CAPSULE |
3 |
Non-Preferred Drug |
40% | N/A | P |
TOPIRAMATE ER 150 MG CAPSULE |
3 |
Non-Preferred Drug |
40% | N/A | P |
TOPIRAMATE ER 200 MG CAPSULE |
3 |
Non-Preferred Drug |
40% | N/A | P |
TOPIRAMATE ER 25 MG CAPSULE |
3 |
Non-Preferred Drug |
40% | N/A | P |
TOPIRAMATE ER 50 MG CAPSULE |
3 |
Non-Preferred Drug |
40% | N/A | P |
TOPIRAMATE SPRINKLE CAPSULES 15MG 60 BOT |
1 |
Preferred Generic |
10% | N/A | P |
TOPIRAMATE TABLETS 100MG 1000 BOT |
1 |
Preferred Generic |
10% | N/A | P |
TOPIRAMATE TABLETS 200MG 1000 BOT |
1 |
Preferred Generic |
10% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOPIRAMATE TABLETS 25MG 1000 BOT |
1 |
Preferred Generic |
10% | N/A | P |
TOPIRAMATE TABLETS 50MG 1000 BOT |
1 |
Preferred Generic |
10% | N/A | P |
TOPOSAR INJECTION 20MG/ML 50ML VIAL MD CRTN |
1 |
Preferred Generic |
10% | N/A | None |
TOPOTECAN HCL 4 MG VIAL |
4 |
Specialty Tier |
33% | N/A | None |
TOPROL XL 100MG TABLET SA |
3 |
Non-Preferred Drug |
40% | N/A | None |
TOPROL XL 200MG TABLET SA |
3 |
Non-Preferred Drug |
40% | N/A | None |
TOPROL XL 25MG TABLET SA |
3 |
Non-Preferred Drug |
40% | N/A | None |
TOPROL XL 50MG TABLET SA |
3 |
Non-Preferred Drug |
40% | N/A | None |
Torisel 1 KIT per CARTON |
4 |
Specialty Tier |
33% | N/A | None |
TORSEMIDE 10 MG TABLET |
1 |
Preferred Generic |
10% | N/A | None |
Torsemide 100mg/1 12 BOTTLE CASE / 100 TABLET BOTTLE |
1 |
Preferred Generic |
10% | N/A | 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 |
10% | N/A | None |
TORSEMIDE 5 MG TABLET |
1 |
Preferred Generic |
10% | N/A | None |
TOUJEO SOLOSTAR 300 UNITS/ML |
2 |
Preferred Brand |
20% | N/A | None |
TOVIAZ TABLETS 4MG EXTENDED RELEASE |
2 |
Preferred Brand |
20% | N/A | None |
TOVIAZ TABLETS 8MG EXTENDED RELEASE |
2 |
Preferred Brand |
20% | N/A | None |
TPN ELECTROLYTES16.5/25.4 VIAL |
3 |
Non-Preferred Drug |
40% | N/A | None |
TRACLEER 125MG TABLET |
4 |
Specialty Tier |
33% | N/A | P |
TRACLEER 62.5MG TABLET |
4 |
Specialty Tier |
33% | N/A | P |
TRADJENTA 5mg/1 90 FILM COATED TABLETS in BOTTLE |
3 |
Non-Preferred Drug |
40% | N/A | S Q:30 /30Days |
TRAMADOL ER 300 MG TABLET |
1 |
Preferred Generic |
10% | N/A | Q:30 /30Days |
TRAMADOL HCL 50 MG TABLET |
1 |
Preferred Generic |
10% | N/A | 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 |
3 |
Non-Preferred Drug |
40% | N/A | Q:30 /30Days |
TRAMADOL HCL ER 200 MG CAPSULE |
3 |
Non-Preferred Drug |
40% | N/A | Q:30 /30Days |
TRAMADOL HCL ER 300 MG CAPSULE |
3 |
Non-Preferred Drug |
40% | N/A | Q:30 /30Days |
TRAMADOL HCL-ACETAMINOPHEN 37.5-325MG TABLET (1000 CT) |
1 |
Preferred Generic |
10% | N/A | Q:240 /30Days |
TRAMADOL HYDROCHLORIDE 100mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic |
10% | N/A | Q:30 /30Days |
TRAMADOL HYDROCHLORIDE 200mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic |
10% | N/A | Q:30 /30Days |
TRANDOLAPRIL 1 MG TABLET |
1 |
Preferred Generic |
10% | N/A | None |
TRANDOLAPRIL 2 MG TABLET |
1 |
Preferred Generic |
10% | N/A | None |
TRANDOLAPRIL 4 MG TABLET |
1 |
Preferred Generic |
10% | N/A | None |
TRANDOLAPRIL-VERAPAMIL ER 1-240 MG |
1 |
Preferred Generic |
10% | N/A | None |
TRANDOLAPRIL-VERAPAMIL ER 2-180 MG |
1 |
Preferred Generic |
10% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRANDOLAPRIL-VERAPAMIL ER 2-240 MG |
1 |
Preferred Generic |
10% | N/A | None |
TRANDOLAPRIL-VERAPAMIL ER 4-240 MG |
1 |
Preferred Generic |
10% | N/A | None |
TRANEXAMIC ACID 1,000 MG/10 ML |
1 |
Preferred Generic |
10% | N/A | None |
tranexamic acid 650 mg tablet |
3 |
Non-Preferred Drug |
40% | N/A | None |
TRANSDERM-SCOP 1.5 MG/3 DAY |
3 |
Non-Preferred Drug |
40% | N/A | None |
TRANXENE T-TAB 7.5 MG |
3 |
Non-Preferred Drug |
40% | N/A | P |
TRANYLCYPROMINE SULFATE 10MG TABLET |
3 |
Non-Preferred Drug |
40% | N/A | None |
TRAVASOL 10% SOLUTION VIAFLEX |
3 |
Non-Preferred Drug |
40% | N/A | P |
TRAVATAN Z 0.04MG DROPS 2.5ML BOT |
2 |
Preferred Brand |
20% | N/A | None |
TRAZODONE 300MG TABLET |
1 |
Preferred Generic |
10% | N/A | None |
TRAZODONE HCL TABLET USP 100MG (500 CT) |
1 |
Preferred Generic |
10% | N/A | 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 |
10% | N/A | None |
TRAZODONE HCL TABLET USP 50MG (500 CT) |
1 |
Preferred Generic |
10% | N/A | None |
TREANDA FOR INJECTION 100MG/VIAL |
4 |
Specialty Tier |
33% | N/A | None |
TRECATOR 250MG TABLET |
2 |
Preferred Brand |
20% | N/A | None |
TRELSTAR 11.25 MG SYRINGE |
4 |
Specialty Tier |
33% | N/A | None |
TRELSTAR 3.75 MG SYRINGE |
4 |
Specialty Tier |
33% | N/A | None |
TRESIBA FLEXTOUCH 100 UNITS/ML |
2 |
Preferred Brand |
20% | N/A | None |
TRESIBA FLEXTOUCH 200 UNITS/ML |
2 |
Preferred Brand |
20% | N/A | None |
Tretinoin 0.0005 MG/MG Topical Gel |
1 |
Preferred Generic |
10% | N/A | P |
TRETINOIN 0.01% GEL |
1 |
Preferred Generic |
10% | N/A | P |
TRETINOIN 0.025% CREAM |
1 |
Preferred Generic |
10% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRETINOIN 0.05% CREAM |
1 |
Preferred Generic |
10% | N/A | P |
TRETINOIN 0.1% CREAM |
1 |
Preferred Generic |
10% | N/A | P |
Tretinoin 0.25mg/g 1 TUBE per CARTON / 45 g in 1 TUBE |
1 |
Preferred Generic |
10% | N/A | P |
TRETINOIN 10MG CAPSULE |
4 |
Specialty Tier |
33% | N/A | None |
TRETINOIN GEL MICRO 0.04% PUMP |
3 |
Non-Preferred Drug |
40% | N/A | P |
TRETINOIN GEL MICRO 0.1% PUMP |
3 |
Non-Preferred Drug |
40% | N/A | P |
TREXALL 10MG TABLET |
3 |
Non-Preferred Drug |
40% | N/A | P |
TREXALL 15MG TABLET |
3 |
Non-Preferred Drug |
40% | N/A | P |
TREXALL 5MG TABLET |
3 |
Non-Preferred Drug |
40% | N/A | P |
TREXALL 7.5MG TABLET |
3 |
Non-Preferred Drug |
40% | N/A | P |
TREXIMET 10-60 MG TABLET |
3 |
Non-Preferred Drug |
40% | N/A | Q:9 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TREXIMET 85-500 MG TABLET |
3 |
Non-Preferred Drug |
40% | N/A | Q:18 /28Days |
TREZIX 16-320.5-30 MG CAPSULE |
3 |
Non-Preferred Drug |
40% | N/A | Q:300 /30Days |
TRI PREVIFEM TABLETS |
1 |
Preferred Generic |
10% | N/A | None |
TRI-LEGEST FE 5-7-9-7 TABLET |
1 |
Preferred Generic |
10% | N/A | None |
TRI-LO-ESTARYLLA TABLET |
1 |
Preferred Generic |
10% | N/A | None |
TRI-LO-SPRINTEC TABLET |
1 |
Preferred Generic |
10% | N/A | None |
TRI-NORINYL 28 TABLET |
3 |
Non-Preferred Drug |
40% | N/A | None |
TRI-SPRINTEC 7DAYSX3 28 TABLET |
1 |
Preferred Generic |
10% | N/A | None |
TRIAMCINOLONE 0.1% OINTMENT |
1 |
Preferred Generic |
10% | N/A | None |
Triamcinolone 0.147 MG/G Spray |
1 |
Preferred Generic |
10% | N/A | None |
Triamcinolone 55 mcg nasal spr |
1 |
Preferred Generic |
10% | N/A | Q:17 /30Days |
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 |
10% | N/A | None |
TRIAMCINOLONE ACETONIDE 0.025% LOTION 2 FL OZ BOT |
1 |
Preferred Generic |
10% | N/A | None |
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE |
1 |
Preferred Generic |
10% | N/A | None |
TRIAMCINOLONE ACETONIDE 0.1% CREAM 80GM TUBE |
1 |
Preferred Generic |
10% | N/A | None |
TRIAMCINOLONE ACETONIDE 0.1% LOTION 60ML BOTPL |
1 |
Preferred Generic |
10% | N/A | None |
triamcinolone acetonide 0.25mg/g 80 g in 1 TUBE |
1 |
Preferred Generic |
10% | N/A | None |
Triamcinolone Acetonide 1mg/g 1 TUBE per CARTON / 5 g in 1 TUBE |
1 |
Preferred Generic |
10% | N/A | None |
Triamcinolone Acetonide 5mg/g 1 TUBE per CARTON / 15 g in 1 TUBE |
1 |
Preferred Generic |
10% | N/A | None |
Triamterene and Hydrochlorothiazide 25; 37.5mg 100 CAPSULE BOTTLE |
1 |
Preferred Generic |
10% | N/A | None |
TRIAMTERENE-HCTZ 37.5-25 MG TB |
1 |
Preferred Generic |
10% | N/A | None |
TRIAMTERENE/HCTZ 50-25 MG CAP |
1 |
Preferred Generic |
10% | N/A | 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 |
10% | N/A | None |
Trianex 0.05% Ointment |
1 |
Preferred Generic |
10% | N/A | None |
TRIBENZOR 20/5/12.5MG TABLETS |
3 |
Non-Preferred Drug |
40% | N/A | None |
TRIBENZOR 40/10/12.5MG TABLETS |
3 |
Non-Preferred Drug |
40% | N/A | None |
TRIBENZOR 40/10/25MG TABLETS |
3 |
Non-Preferred Drug |
40% | N/A | None |
Tribenzor 5; 12.5; 40mg/1; mg/1; mg/1 |
3 |
Non-Preferred Drug |
40% | N/A | None |
Tribenzor 5; 25; 40mg/1; mg/1; mg/1 |
3 |
Non-Preferred Drug |
40% | N/A | None |
TRICOR 145 MG TABLET |
3 |
Non-Preferred Drug |
40% | N/A | None |
TRICOR 48 MG TABLET |
3 |
Non-Preferred Drug |
40% | N/A | None |
TRIDERM 0.1% CREAM |
1 |
Preferred Generic |
10% | N/A | None |
TRIDESILON 0.05% CREAM |
3 |
Non-Preferred Drug |
40% | N/A | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIFLUOPERAZINE 1MG TABLET |
1 |
Preferred Generic |
10% | N/A | None |
TRIFLUOPERAZINE HCL 2MG TABLET |
1 |
Preferred Generic |
10% | N/A | None |
TRIFLUOPERAZINE HCL 5MG TABLET |
1 |
Preferred Generic |
10% | N/A | None |
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT) |
1 |
Preferred Generic |
10% | N/A | None |
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT |
1 |
Preferred Generic |
10% | N/A | None |
TRIGLIDE 160 MG TABLET |
3 |
Non-Preferred Drug |
40% | N/A | None |
TRILEPTAL 150MG TABLET |
3 |
Non-Preferred Drug |
40% | N/A | None |
TRILEPTAL 300MG TABLET |
3 |
Non-Preferred Drug |
40% | N/A | None |
TRILEPTAL 300MG/5ML SUSP |
3 |
Non-Preferred Drug |
40% | N/A | None |
TRILEPTAL 600MG TABLET |
3 |
Non-Preferred Drug |
40% | N/A | None |
TRILIPIX DR 135 MG CAPSULE |
3 |
Non-Preferred Drug |
40% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRILIPIX DR 45 MG CAPSULE |
3 |
Non-Preferred Drug |
40% | N/A | None |
TRILYTE WITH FLAVOR PACKETS |
1 |
Preferred Generic |
10% | N/A | None |
TRIMETHOPRIM 100MG TABLETS |
1 |
Preferred Generic |
10% | N/A | None |
TRIMIPRAMINE MALEATE 100 MG CP |
1 |
Preferred Generic |
10% | N/A | P |
TRIMIPRAMINE MALEATE 25 MG CAP |
1 |
Preferred Generic |
10% | N/A | P |
TRIMIPRAMINE MALEATE 50 MG CAP |
1 |
Preferred Generic |
10% | N/A | P |
TRINESSA TABLET |
1 |
Preferred Generic |
10% | N/A | None |
TRINTELLIX 10 MG TABLET |
2 |
Preferred Brand |
20% | N/A | Q:60 /30Days |
TRINTELLIX 20 MG TABLET |
2 |
Preferred Brand |
20% | N/A | Q:30 /30Days |
TRINTELLIX 5 MG TABLET |
2 |
Preferred Brand |
20% | N/A | Q:120 /30Days |
Triostat 10ug/mL 6 VIAL in 1 CARTON / 1 mL in 1 VIAL |
3 |
Non-Preferred Drug |
40% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Triptorelin 11.3 MG/ML Injectable Suspension [Trelstar] |
4 |
Specialty Tier |
33% | N/A | None |
TRISENOX 10MG/10ML AMPULE |
4 |
Specialty Tier |
33% | N/A | None |
TRIUMEQ TABLET |
4 |
Specialty Tier |
33% | N/A | None |
Trivora-28 tablet |
1 |
Preferred Generic |
10% | 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 Drug |
40% | N/A | P |
TROKENDI XR 200 MG CAPSULE |
4 |
Specialty Tier |
33% | N/A | P |
TROKENDI XR 25 MG CAPSULE |
3 |
Non-Preferred Drug |
40% | N/A | P |
TROKENDI XR 50 MG CAPSULE |
3 |
Non-Preferred Drug |
40% | N/A | P |
TROPHAMINE INJECTION SOLUTION |
2 |
Preferred Brand |
20% | N/A | P |
TROPHAMINE INJECTION SOLUTION 6% |
2 |
Preferred Brand |
20% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TROSPIUM CHLORIDE 20MG TABLETS |
1 |
Preferred Generic |
10% | N/A | None |
TROSPIUM CHLORIDE ER 60 MG CAP |
1 |
Preferred Generic |
10% | N/A | None |
TRULICITY 0.75 MG/0.5 ML PEN |
3 |
Non-Preferred Drug |
40% | N/A | P Q:2 /28Days |
TRULICITY 1.5 MG/0.5 ML PEN |
3 |
Non-Preferred Drug |
40% | N/A | P Q:2 /28Days |
TRUMENBA 120 MCG/0.5 ML VACCINE |
2 |
Preferred Brand |
20% | N/A | None |
TRUSOPT PLUS 2% EYE DROPS 10ML BOT |
3 |
Non-Preferred Drug |
40% | N/A | None |
TRUVADA 100 MG-150 MG TABLET |
4 |
Specialty Tier |
33% | N/A | None |
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 |
TUDORZA PRESSAIR 400 MCG INH |
2 |
Preferred Brand |
20% | N/A | Q:1 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TUDORZA PRESSAIR 400 MCG INH |
2 |
Preferred Brand |
20% | N/A | Q:1 /30Days |
TWINRIX TF PF VACCINE 720UNT/20ML 10 X 1ML VIALSD |
2 |
Preferred Brand |
20% | N/A | None |
Twynsta 10; 40mg/1; mg/1 3 BLISTER PACK per CARTON / 10 TABLET, MULTILAYER per BLISTER PACK |
3 |
Non-Preferred Drug |
40% | N/A | None |
Twynsta 10; 80mg/1; mg/1 3 BLISTER PACK per CARTON / 10 TABLET, MULTILAYER per BLISTER PACK |
3 |
Non-Preferred Drug |
40% | N/A | None |
Twynsta 5; 40mg/1; mg/1 3 BLISTER PACK per CARTON / 10 TABLET, MULTILAYER per BLISTER PACK |
3 |
Non-Preferred Drug |
40% | N/A | None |
Twynsta 5; 80mg/1; mg/1 3 BLISTER PACK per CARTON / 10 TABLET, MULTILAYER per BLISTER PACK |
3 |
Non-Preferred Drug |
40% | N/A | None |
TYBOST 150 MG TABLET |
3 |
Non-Preferred Drug |
40% | N/A | None |
Tygacil 50mg/5mL 10 VIAL, SINGLE-USE per CARTON / 50 mL in 1 VIAL, SINGLE-USE |
4 |
Specialty Tier |
33% | N/A | None |
TYKERB 250 MG TABLET |
4 |
Specialty Tier |
33% | N/A | P Q:180 /30Days |
TYLENOL with Codeine 300; 30mg/1; mg/1 1000 TABLET BOTTLE |
3 |
Non-Preferred Drug |
40% | N/A | Q:360 /30Days |
TYLENOL with Codeine 300; 60mg/1; mg/1 500 TABLET BOTTLE |
3 |
Non-Preferred Drug |
40% | N/A | Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TYMLOS 80 MCG DOSE PEN INJECTR |
4 |
Specialty Tier |
33% | N/A | P Q:2 /30Days |
TYPHIM VI 25 MCG/0.5 ML SYRINGE |
2 |
Preferred Brand |
20% | N/A | None |
TYPHIM VI 25MCG/0.5ML VIAL |
2 |
Preferred Brand |
20% | N/A | None |
TYSABRI 300 MG/15 ML VIAL |
4 |
Specialty Tier |
33% | N/A | P |