2018 Medicare Part D Plan Formulary Information |
Blue Medicare HMO Essential (HMO) (H3449-023-2)
Benefit Details
|
The Blue Medicare HMO Essential (HMO) (H3449-023-2) Formulary Drugs Starting with the Letter T in Gaston County, NC: CMS MA Region 7 which includes: NC Plan Monthly Premium: $76.00 Deductible: $355 |
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 |
45% | 45% | None |
TACROLIMUS 0.5 MG CAPSULE |
3 |
Preferred Brand |
$37.00 | $111.00 | P |
TACROLIMUS 1 MG CAPSULE |
3 |
Preferred Brand |
$37.00 | $111.00 | P |
TACROLIMUS 5 MG CAPSULE |
4 |
Non-Preferred Brand |
45% | 45% | P |
TAFINLAR 50 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
TAFINLAR 75 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
TAGRISSO 40 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
TAGRISSO 80 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
TAMIFLU 6 MG/ML SUSPENSION |
4 |
Non-Preferred Brand |
45% | 45% | None |
TAMOXIFEN 10 MG TABLET |
2* |
Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAMOXIFEN CITRATE 20MG TABLET (30 CT) |
2* |
Generic |
$10.00 | $30.00 | None |
TAMSULOSIN HCL 0.4 MG CAPSULE |
2* |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
TARCEVA 100MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
TARCEVA 150MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
TARCEVA 25MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
TARGRETIN 1% GEL |
5 |
Specialty Tier |
25% | N/A | None |
Tarina Fe 1-20 tablet |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
Tasigna 150mg/1 4 BLISTER PACK per CARTON / 28 CAPSULE per BLISTER PACK |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
TASIGNA 200 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
TASIGNA 50 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
TAZAROTENE 0.1% CREAM [Tazorac] |
4 |
Non-Preferred Brand |
45% | 45% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAZICEF 1GM VIAL |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
TAZICEF 2 GRAM VIAL |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
TAZICEF 6 GRAM VIAL |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
TAZORAC 0.05% CREAM |
4 |
Non-Preferred Brand |
45% | 45% | None |
TAZORAC 0.05% GEL |
4 |
Non-Preferred Brand |
45% | 45% | None |
TAZORAC 0.1% GEL |
4 |
Non-Preferred Brand |
45% | 45% | None |
TAZTIA DILTIAZEM HYDROCHLORIDE 120MG ER CAPSULES |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
TAZTIA XT 180 MG CAPSULE |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
TAZTIA XT 240MG CAPSULE SA |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
TAZTIA XT 300 MG CAPSULE |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
TAZTIA XT 360MG CAPSULE SA |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TECENTRIQ 1,200 MG/20 ML VIAL |
5 |
Specialty Tier |
25% | N/A | None |
TECFIDERA DR 120 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
TECFIDERA DR 240 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
TECFIDERA STARTER PACK |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
TECHNIVIE DOSE PACK |
5 |
Specialty Tier |
25% | N/A | P |
Teflaro 400mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE |
5 |
Specialty Tier |
25% | N/A | None |
Teflaro 600mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE |
5 |
Specialty Tier |
25% | N/A | None |
TEKTURNA 150 MG TABLET |
3 |
Preferred Brand |
$37.00 | $111.00 | Q:30 /30Days |
TEKTURNA 300 MG TABLET |
3 |
Preferred Brand |
$37.00 | $111.00 | Q:30 /30Days |
TEMAZEPAM 15 MG CAPSULE |
3 |
Preferred Brand |
$37.00 | $111.00 | Q:30 /30Days |
TEMAZEPAM 30 MG CAPSULE |
3 |
Preferred Brand |
$37.00 | $111.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TENIVAC SYRINGE |
4 |
Non-Preferred Brand |
45% | 45% | None |
TENOFOVIR DISOP FUM 300 MG TB [Viread] |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
TERAZOSIN 1 MG CAPSULE |
2* |
Generic |
$10.00 | $30.00 | Q:90 /30Days |
TERAZOSIN 10 MG CAPSULE [Hytrin] |
2* |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
TERAZOSIN 2 MG CAPSULE |
2* |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
TERAZOSIN 5 MG CAPSULE [Hytrin] |
2* |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
TERBINAFINE HCL 250 MG TABLET |
2* |
Generic |
$10.00 | $30.00 | None |
TERBUTALINE SULFATE 2.5 MG TAB |
2* |
Generic |
$10.00 | $30.00 | None |
TERBUTALINE SULFATE 5MG TABLET |
2* |
Generic |
$10.00 | $30.00 | None |
TERCONAZOLE 0.4% CREAM WITH APPLICATOR |
2* |
Generic |
$10.00 | $30.00 | None |
TERCONAZOLE 0.8% CREAM |
2* |
Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TESTOSTERONE 12.5 MG/1.25 GRAM |
2* |
Generic |
$10.00 | $30.00 | P Q:300 /30Days |
Testosterone 2500 MG 0.01 MG/MG Topical Gel |
2* |
Generic |
$10.00 | $30.00 | P Q:225 /30Days |
Testosterone 5000 MG 0.01 MG/MG Topical Gel |
2* |
Generic |
$10.00 | $30.00 | P Q:300 /30Days |
Testosterone cyp 100 mg/ml |
3 |
Preferred Brand |
$37.00 | $111.00 | P |
TESTOSTERONE CYP 200 MG/ML |
3 |
Preferred Brand |
$37.00 | $111.00 | P |
TETRABENAZINE 12.5 MG TABLET [XENAZINE] |
5 |
Specialty Tier |
25% | N/A | P Q:240 /30Days |
TETRABENAZINE 25 MG TABLET [XENAZINE] |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
TETRACYCLINE 250 MG CAPSULE |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
TETRACYCLINE 500 MG CAPSULE |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
THALOMID 100 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
THALOMID 150 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THALOMID 200 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
THALOMID 50 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
THEOPHYLLINE ER 100 MG TABLET |
2* |
Generic |
$10.00 | $30.00 | None |
THEOPHYLLINE ER 200 MG TABLET |
2* |
Generic |
$10.00 | $30.00 | None |
THEOPHYLLINE ER 300 MG TAB |
2* |
Generic |
$10.00 | $30.00 | None |
THEOPHYLLINE ER 400 MG TABLET |
2* |
Generic |
$10.00 | $30.00 | None |
THEOPHYLLINE ER 600 MG TABLET |
2* |
Generic |
$10.00 | $30.00 | None |
THIORIDAZINE 10 MG TABLET |
4 |
Non-Preferred Brand |
45% | 45% | P |
THIORIDAZINE 100MG TABLET |
4 |
Non-Preferred Brand |
45% | 45% | P |
THIORIDAZINE 25 MG TABLET |
4 |
Non-Preferred Brand |
45% | 45% | P |
THIORIDAZINE 50 MG TABLET |
4 |
Non-Preferred Brand |
45% | 45% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THIOTEPA 15 MG VIAL |
5 |
Specialty Tier |
25% | N/A | None |
THIOTHIXENE 1 MG CAPSULE |
3 |
Preferred Brand |
$37.00 | $111.00 | P |
THIOTHIXENE 10MG CAPSULE |
3 |
Preferred Brand |
$37.00 | $111.00 | P |
THIOTHIXENE 2MG CAPSULE |
3 |
Preferred Brand |
$37.00 | $111.00 | P |
THIOTHIXENE 5MG CAPSULE |
3 |
Preferred Brand |
$37.00 | $111.00 | P |
THYMOGLOBULIN 25MG VIAL |
5 |
Specialty Tier |
25% | N/A | P |
TIAGABINE HCL 12 MG TABLET [Gabitril] |
4 |
Non-Preferred Brand |
45% | 45% | None |
TIAGABINE HCL 16 MG TABLET [Gabitril] |
4 |
Non-Preferred Brand |
45% | 45% | None |
tiagabine hcl 2 mg tablet [Gabitril] |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
tiagabine hcl 4 mg tablet [Gabitril] |
4 |
Non-Preferred Brand |
45% | 45% | None |
TIGECYCLINE 50 MG VIAL [Tygacil] |
5 |
Specialty Tier |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIMOLOL 0.25% EYE DROPS |
1* |
Preferred Generic |
$3.00 | $9.00 | None |
TIMOLOL 0.25% GFS GEL-SOLUTION |
4 |
Non-Preferred Brand |
45% | 45% | None |
TIMOLOL 0.5% EYE DROPS |
2* |
Generic |
$10.00 | $30.00 | None |
TIMOLOL 0.5% GFS GEL-SOLUTION |
4 |
Non-Preferred Brand |
45% | 45% | None |
TIVICAY 10 MG TABLET |
4 |
Non-Preferred Brand |
45% | 45% | Q:60 /30Days |
TIVICAY 25 MG TABLET |
5 |
Specialty Tier |
25% | N/A | Q:60 /30Days |
TIVICAY 50 MG TABLET |
5 |
Specialty Tier |
25% | N/A | Q:60 /30Days |
TIZANIDINE HCL 2 MG TABLET |
2* |
Generic |
$10.00 | $30.00 | None |
TIZANIDINE HCL 4 MG TABLET |
2* |
Generic |
$10.00 | $30.00 | None |
TOBRAMYCIN 0.3% EYE DROPS [Tobrex] |
2* |
Generic |
$10.00 | $30.00 | None |
TOBRAMYCIN 10 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate] |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOBRAMYCIN 300 MG/5 ML AMPULE [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate] |
5 |
Specialty Tier |
25% | N/A | P |
TOBRAMYCIN 40 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate] |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
Tolterodine Tartrate ER 2 MG CAPSULE [Detrol LA] |
2* |
Generic |
$10.00 | $30.00 | Q:30 /30Days |
TOPIRAMATE 100 MG TABLET |
2* |
Generic |
$10.00 | $30.00 | None |
TOPIRAMATE 15 MG SPRINKLE CAP |
2* |
Generic |
$10.00 | $30.00 | None |
TOPIRAMATE 200 MG TABLET |
2* |
Generic |
$10.00 | $30.00 | None |
TOPIRAMATE 25 MG TABLET |
2* |
Generic |
$10.00 | $30.00 | None |
Topiramate 25mg/1 |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
TOPIRAMATE 50 MG TABLET |
2* |
Generic |
$10.00 | $30.00 | None |
TOPOSAR INJECTION 20MG/ML 50ML VIAL MD CRTN |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
Topotecan 4 MG Injection |
5 |
Specialty Tier |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Torisel 1 KIT per CARTON |
5 |
Specialty Tier |
25% | N/A | None |
TOUJEO MAX SOLOSTAR 300UNIT/ML INSULN PEN |
3 |
Preferred Brand |
$37.00 | $111.00 | Q:60 /30Days |
TOUJEO SOLOSTAR 300 UNITS/ML |
3 |
Preferred Brand |
$37.00 | $111.00 | Q:60 /30Days |
TOVIAZ TABLETS 4MG EXTENDED RELEASE |
3 |
Preferred Brand |
$37.00 | $111.00 | Q:30 /30Days |
TOVIAZ TABLETS 8MG EXTENDED RELEASE |
3 |
Preferred Brand |
$37.00 | $111.00 | Q:30 /30Days |
TRACLEER 125MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
TRACLEER 32 MG TABLET FOR SUSP |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
TRACLEER 62.5MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
TRADJENTA 5 MG TABLET |
4 |
Non-Preferred Brand |
45% | 45% | Q:30 /30Days |
TRAMADOL HCL 50 MG TABLET |
3 |
Preferred Brand |
$37.00 | $111.00 | Q:240 /30Days |
TRANEXAMIC ACID 1,000 MG/10 ML |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
tranexamic acid 650 mg tablet |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
TRANYLCYPROMINE SULFATE 10MG TABLET |
4 |
Non-Preferred Brand |
45% | 45% | None |
TRAVATAN Z 0.04MG DROPS 2.5ML BOT |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
TRAZODONE 100 MG TABLET |
2* |
Generic |
$10.00 | $30.00 | None |
TRAZODONE 300 MG TABLET |
2* |
Generic |
$10.00 | $30.00 | None |
TRAZODONE 50 MG TABLET |
2* |
Generic |
$10.00 | $30.00 | None |
TRAZODONE HCL TABLET USP 150MG (100 CT) |
2* |
Generic |
$10.00 | $30.00 | None |
TREANDA 25 MG VIAL |
5 |
Specialty Tier |
25% | N/A | None |
TREANDA FOR INJECTION 100MG/VIAL |
5 |
Specialty Tier |
25% | N/A | None |
TRECATOR 250MG TABLET |
4 |
Non-Preferred Brand |
45% | 45% | None |
TRELEGY ELLIPTA 100-62.5-25 |
3 |
Preferred Brand |
$37.00 | $111.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRELSTAR 11.25 MG SYRINGE |
5 |
Specialty Tier |
25% | N/A | None |
TRELSTAR 3.75 MG SYRINGE |
5 |
Specialty Tier |
25% | N/A | None |
TRETINOIN 0.025% GEL |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
TRETINOIN 10MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P |
TRI PREVIFEM TABLETS |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
TRI-LEGEST FE 5-7-9-7 TABLET |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
TRI-LO-ESTARYLLA TABLET [Trinessa Lo] |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
TRI-LO-SPRINTEC TABLET |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
TRI-MILI 28 TABLET [Trinessa] |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
TRI-SPRINTEC 7DAYSX3 28 TABLET |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
TRI-VYLIBRA 28 TABLET [Trinessa] |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIAMCINOLONE 0.025% CREAM |
2* |
Generic |
$10.00 | $30.00 | None |
TRIAMCINOLONE 0.025% OINT |
2* |
Generic |
$10.00 | $30.00 | None |
TRIAMCINOLONE 0.1% CREAM |
2* |
Generic |
$10.00 | $30.00 | None |
TRIAMCINOLONE 0.1% OINTMENT |
2* |
Generic |
$10.00 | $30.00 | None |
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE |
2* |
Generic |
$10.00 | $30.00 | None |
Triamcinolone Acetonide 1 MG/ML Topical Cream [Triderm] |
2* |
Generic |
$10.00 | $30.00 | None |
Triamcinolone Acetonide 5mg/g 1 TUBE per CARTON / 15 g in 1 TUBE |
2* |
Generic |
$10.00 | $30.00 | None |
TRIAMTERENE-HCTZ 37.5-25 MG CP |
2* |
Generic |
$10.00 | $30.00 | None |
TRIAMTERENE-HCTZ 37.5-25 MG TB |
2* |
Generic |
$10.00 | $30.00 | None |
TRIAMTERENE-HCTZ 75-50 MG TAB |
2* |
Generic |
$10.00 | $30.00 | None |
TRIENTINE HCL 250 MG CAPSULE [Syprine] |
5 |
Specialty Tier |
25% | N/A | P Q:240 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIFLUOPERAZINE 1MG TABLET |
3 |
Preferred Brand |
$37.00 | $111.00 | P |
TRIFLUOPERAZINE HCL 2MG TABLET |
3 |
Preferred Brand |
$37.00 | $111.00 | P |
TRIFLUOPERAZINE HCL 5MG TABLET |
3 |
Preferred Brand |
$37.00 | $111.00 | P |
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT) |
3 |
Preferred Brand |
$37.00 | $111.00 | P |
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
TRILYTE WITH FLAVOR PACKETS |
2* |
Generic |
$10.00 | $30.00 | None |
TRIMETHOPRIM 100 MG TABLET |
2* |
Generic |
$10.00 | $30.00 | None |
TRIMIPRAMINE MALEATE 100 MG CP |
4 |
Non-Preferred Brand |
45% | 45% | P |
TRIMIPRAMINE MALEATE 25 MG CAP |
4 |
Non-Preferred Brand |
45% | 45% | P |
TRIMIPRAMINE MALEATE 50 MG CAP |
4 |
Non-Preferred Brand |
45% | 45% | P |
TRINESSA TABLET |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRINTELLIX 10 MG TABLET |
4 |
Non-Preferred Brand |
45% | 45% | Q:30 /30Days |
TRINTELLIX 20 MG TABLET |
4 |
Non-Preferred Brand |
45% | 45% | Q:30 /30Days |
TRINTELLIX 5 MG TABLET |
4 |
Non-Preferred Brand |
45% | 45% | Q:30 /30Days |
Triptorelin 11.3 MG/ML Injectable Suspension [Trelstar] |
5 |
Specialty Tier |
25% | N/A | None |
TRISENOX 12 MG/6 ML VIAL |
5 |
Specialty Tier |
25% | N/A | None |
TRIUMEQ TABLET |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
Trivora-28 tablet |
3 |
Preferred Brand |
$37.00 | $111.00 | None |
TRUMENBA 120 MCG/0.5 ML VACCIN Syringe |
4 |
Non-Preferred Brand |
45% | 45% | None |
TRUVADA 100 MG-150 MG TABLET |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
TRUVADA 133 MG-200 MG TABLET |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
TRUVADA 167 MG-250 MG TABLET |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
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% | N/A | Q:30 /30Days |
TWINRIX VACCINE SYRINGE |
4 |
Non-Preferred Brand |
45% | 45% | None |
TYBOST 150 MG TABLET |
3 |
Preferred Brand |
$37.00 | $111.00 | Q:30 /30Days |
Tygacil 50mg/5mL 10 VIAL, SINGLE-USE per CARTON / 50 mL in 1 VIAL, SINGLE-USE |
5 |
Specialty Tier |
25% | N/A | None |
TYKERB 250 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:180 /30Days |
TYPHIM VI 25 MCG/0.5 ML SYRINGE |
4 |
Non-Preferred Brand |
45% | 45% | None |
TYPHIM VI 25MCG/0.5ML VIAL |
4 |
Non-Preferred Brand |
45% | 45% | None |
TYSABRI 300 MG/15 ML VIAL |
5 |
Specialty Tier |
25% | N/A | P |