2018 Medicare Part D Plan Formulary Information |
Network PlatinumPremier Pharmacy (PPO) (H5215-005-0)
Benefit Details
|
The Network PlatinumPremier Pharmacy (PPO) (H5215-005-0) Formulary Drugs Starting with the Letter T in Brown County, WI: CMS MA Region 14 which includes: WI Plan Monthly Premium: $292.00 Deductible: $260 |
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 |
Preferred Brand |
$42.00 | N/A | None |
TACLONEX OINTMENT |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TACLONEX SCALP SUSPENSION |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Tacrolimus 0.03% ointment |
2* |
Generic |
$8.00 | N/A | None |
Tacrolimus 0.1% ointment |
2* |
Generic |
$8.00 | N/A | None |
TACROLIMUS 0.5 MG CAPSULE |
2* |
Generic |
$8.00 | N/A | P |
TACROLIMUS 1 MG CAPSULE |
2* |
Generic |
$8.00 | N/A | P |
TACROLIMUS 5 MG CAPSULE |
2* |
Generic |
$8.00 | N/A | P |
TAFINLAR 50 MG CAPSULE |
5 |
Specialty Tier |
27% | N/A | P |
TAFINLAR 75 MG CAPSULE |
5 |
Specialty Tier |
27% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAGRISSO 40 MG TABLET |
5 |
Specialty Tier |
27% | N/A | P |
TAGRISSO 80 MG TABLET |
5 |
Specialty Tier |
27% | N/A | P |
TAMIFLU 30 MG 1 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TAMIFLU 45 MG 1 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TAMIFLU 6 MG/ML SUSPENSION |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TAMIFLU 75 MG CAPSULE UD |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TAMOXIFEN 10 MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
TAMOXIFEN CITRATE 20MG TABLET (30 CT) |
2* |
Generic |
$8.00 | N/A | None |
TAMSULOSIN HCL 0.4 MG CAPSULE |
2* |
Generic |
$8.00 | N/A | None |
TANZEUM 30 MG PEN INJECT |
4 |
Non-Preferred Brand |
$84.00 | N/A | S Q:4 /28Days |
TANZEUM 50 MG PEN INJECT |
4 |
Non-Preferred Brand |
$84.00 | N/A | S Q:4 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAPAZOLE 10MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TAPAZOLE 5MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TAPERDEX 12 DAY 1.5 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TAPERDEX 6 DAY 1.5 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TARCEVA 100MG TABLET |
5 |
Specialty Tier |
27% | N/A | P |
TARCEVA 150MG TABLET |
5 |
Specialty Tier |
27% | N/A | P |
TARCEVA 25MG TABLET |
5 |
Specialty Tier |
27% | N/A | P |
TARGADOX 50 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TARGRETIN 1% GEL |
5 |
Specialty Tier |
27% | N/A | None |
TARGRETIN 75 MG CAPSULE |
5 |
Specialty Tier |
27% | N/A | None |
Tarina Fe 1-20 tablet |
2* |
Generic |
$8.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Tarka 2; 240mg/1; mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TARKA 2/180MG TABLET SA |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Tarka 4; 240mg/1; mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Tasigna 150mg/1 4 BLISTER PACK per CARTON / 28 CAPSULE per BLISTER PACK |
5 |
Specialty Tier |
27% | N/A | P |
TASIGNA 200 MG CAPSULE |
5 |
Specialty Tier |
27% | N/A | P |
TASIGNA 50 MG CAPSULE |
5 |
Specialty Tier |
27% | N/A | P |
TASMAR 100MG TABLET |
5 |
Specialty Tier |
27% | N/A | None |
TAVALISSE 100 MG TABLET |
5 |
Specialty Tier |
27% | N/A | P Q:60 /30Days |
TAVALISSE 150 MG TABLET |
5 |
Specialty Tier |
27% | N/A | P Q:60 /30Days |
TAXOTERE 80mg/4mL 1 VIAL, GLASS per CARTON / 4 mL in 1 VIAL, GLASS |
5 |
Specialty Tier |
27% | N/A | P |
TAZAROTENE 0.1% CREAM [Tazorac] |
2* |
Generic |
$8.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAZICEF 1GM VIAL |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TAZICEF 2 GRAM VIAL |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TAZICEF 6 GRAM VIAL |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TAZORAC 0.05% CREAM |
3 |
Preferred Brand |
$42.00 | N/A | P |
TAZORAC 0.05% GEL |
3 |
Preferred Brand |
$42.00 | N/A | P |
TAZORAC 0.1% CREAM |
3 |
Preferred Brand |
$42.00 | N/A | P |
TAZORAC 0.1% GEL |
3 |
Preferred Brand |
$42.00 | N/A | P |
TAZTIA DILTIAZEM HYDROCHLORIDE 120MG ER CAPSULES |
2* |
Generic |
$8.00 | N/A | None |
TAZTIA XT 180 MG CAPSULE |
2* |
Generic |
$8.00 | N/A | None |
TAZTIA XT 240MG CAPSULE SA |
2* |
Generic |
$8.00 | N/A | None |
TAZTIA XT 300 MG CAPSULE |
2* |
Generic |
$8.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAZTIA XT 360MG CAPSULE SA |
2* |
Generic |
$8.00 | N/A | None |
TECENTRIQ 1,200 MG/20 ML VIAL |
5 |
Specialty Tier |
27% | N/A | P |
TECFIDERA DR 120 MG CAPSULE |
5 |
Specialty Tier |
27% | N/A | None |
TECFIDERA DR 240 MG CAPSULE |
5 |
Specialty Tier |
27% | N/A | None |
TECFIDERA STARTER PACK |
5 |
Specialty Tier |
27% | N/A | None |
TECHNIVIE DOSE PACK |
5 |
Specialty Tier |
27% | N/A | P |
Teflaro 400mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE |
5 |
Specialty Tier |
27% | N/A | None |
Teflaro 600mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE |
5 |
Specialty Tier |
27% | N/A | None |
TEGRETOL SUSPENSION 100MG/5ML 450 ML BOT |
4 |
Non-Preferred Brand |
$84.00 | N/A | S |
TEGRETOL TABLETS 200MG 100 BOT |
4 |
Non-Preferred Brand |
$84.00 | N/A | S |
TEGRETOL XR TABLETS 100MG 100 BOT |
4 |
Non-Preferred Brand |
$84.00 | N/A | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TEGRETOL XR TABLETS 200MG 100 BOT |
4 |
Non-Preferred Brand |
$84.00 | N/A | S |
TEGRETOL XR TABLETS 400MG 100 BOT |
4 |
Non-Preferred Brand |
$84.00 | N/A | S |
TEKTURNA 150 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TEKTURNA 300 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TEKTURNA HCT 300-25 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Telmisartan 20 MG Tablet [Micardis] |
2* |
Generic |
$8.00 | N/A | None |
Telmisartan 40 MG Tablet [Micardis] |
2* |
Generic |
$8.00 | N/A | None |
Telmisartan 80 MG Tablet [Micardis] |
2* |
Generic |
$8.00 | N/A | None |
Telmisartan-Amlodipine 40-10 MG [Micardis] |
2* |
Generic |
$8.00 | N/A | None |
Telmisartan-Amlodipine 40-5 MG [Micardis] |
2* |
Generic |
$8.00 | N/A | None |
Telmisartan-Amlodipine 80-10 MG [Micardis] |
2* |
Generic |
$8.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Telmisartan-Amlodipine 80-5 MG [Micardis] |
2* |
Generic |
$8.00 | N/A | None |
TELMISARTAN-HCTZ 40-12.5 MG TB [Micardis] |
2* |
Generic |
$8.00 | N/A | None |
TELMISARTAN-HCTZ 80-12.5 MG TAB [Micardis HCT] |
2* |
Generic |
$8.00 | N/A | None |
TELMISARTAN-HCTZ 80-25 MG TAB [Micardis HCT] |
2* |
Generic |
$8.00 | N/A | None |
TEMAZEPAM 15 MG CAPSULE |
3 |
Preferred Brand |
$42.00 | N/A | P |
TEMAZEPAM 22.5 MG CAPSULE |
3 |
Preferred Brand |
$42.00 | N/A | P |
TEMAZEPAM 30 MG CAPSULE |
3 |
Preferred Brand |
$42.00 | N/A | P |
Temazepam 7.5mg/1 100 CAPSULE BOTTLE, PLASTIC |
3 |
Preferred Brand |
$42.00 | N/A | P |
Tencon 50-325 MG TABLET |
2* |
Generic |
$8.00 | N/A | Q:360 /30Days |
TENIVAC SYRINGE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TENOFOVIR DISOP FUM 300 MG TB [Viread] |
5 |
Specialty Tier |
27% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TENORETIC 100 TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TENORETIC 50 TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TENORMIN 100 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TENORMIN 25 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TENORMIN 50 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TERAZOSIN 1 MG CAPSULE |
2* |
Generic |
$8.00 | N/A | None |
TERAZOSIN 10 MG CAPSULE [Hytrin] |
2* |
Generic |
$8.00 | N/A | None |
TERAZOSIN 2 MG CAPSULE |
2* |
Generic |
$8.00 | N/A | None |
TERAZOSIN 5 MG CAPSULE [Hytrin] |
2* |
Generic |
$8.00 | N/A | None |
TERBINAFINE HCL 250 MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
TERBUTALINE SULF 1MG/ML VL |
2* |
Generic |
$8.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TERBUTALINE SULFATE 2.5 MG TAB |
2* |
Generic |
$8.00 | N/A | None |
TERBUTALINE SULFATE 5MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
TERCONAZOLE 0.4% CREAM WITH APPLICATOR |
2* |
Generic |
$8.00 | N/A | None |
TERCONAZOLE 0.8% CREAM |
2* |
Generic |
$8.00 | N/A | None |
TERCONAZOLE 80MG SUPPOSITORY VAGINAL |
2* |
Generic |
$8.00 | N/A | None |
TESTIM 1%(50MG) GEL |
4 |
Non-Preferred Brand |
$84.00 | N/A | P |
TESTOSTERONE 10 MG GEL PUMP |
4 |
Non-Preferred Brand |
$84.00 | N/A | P |
TESTOSTERONE 12.5 MG/1.25 GRAM |
4 |
Non-Preferred Brand |
$84.00 | N/A | P |
Testosterone 2500 MG 0.01 MG/MG Topical Gel |
2* |
Generic |
$8.00 | N/A | P |
TESTOSTERONE 30 MG/1.5 ML PUMP |
3 |
Preferred Brand |
$42.00 | N/A | P |
Testosterone 5000 MG 0.01 MG/MG Topical Gel |
4 |
Non-Preferred Brand |
$84.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Testosterone cyp 100 mg/ml |
2* |
Generic |
$8.00 | N/A | None |
TESTOSTERONE CYP 200 MG/ML |
2* |
Generic |
$8.00 | N/A | None |
Testosterone cypionate 200 MG/ML Injectable Solution [Depo-testosterone] |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TESTOSTERONE ENANTHATE 200MG/ML INJECTION |
2* |
Generic |
$8.00 | N/A | None |
TETRABENAZINE 12.5 MG TABLET [XENAZINE] |
5 |
Specialty Tier |
27% | N/A | P |
TETRABENAZINE 25 MG TABLET [XENAZINE] |
5 |
Specialty Tier |
27% | N/A | P |
TETRACYCLINE 250 MG CAPSULE |
2* |
Generic |
$8.00 | N/A | None |
TETRACYCLINE 500 MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TEXACORT 2.5% SOLUTION |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
THALOMID 100 MG CAPSULE |
5 |
Specialty Tier |
27% | N/A | None |
THALOMID 150 MG CAPSULE |
5 |
Specialty Tier |
27% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THALOMID 200 MG CAPSULE |
5 |
Specialty Tier |
27% | N/A | None |
THALOMID 50 MG CAPSULE |
5 |
Specialty Tier |
27% | N/A | None |
THEO-24 ER 100 MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
THEO-24 ER 200 MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
THEO-24 ER 300 MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
THEO-24 ER 400 MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
THEOPHYLLINE 80 MG/15 ML SOLN |
2* |
Generic |
$8.00 | N/A | None |
THEOPHYLLINE ER 100 MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
THEOPHYLLINE ER 200 MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
THEOPHYLLINE ER 300 MG TAB |
2* |
Generic |
$8.00 | N/A | None |
THEOPHYLLINE ER 400 MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THEOPHYLLINE ER 600 MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
THIOLA 100 MG TABLET |
5 |
Specialty Tier |
27% | N/A | None |
THIORIDAZINE 10 MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
THIORIDAZINE 100MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
THIORIDAZINE 25 MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
THIORIDAZINE 50 MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
THIOTEPA 15 MG VIAL |
5 |
Specialty Tier |
27% | N/A | P |
THIOTHIXENE 1 MG CAPSULE |
2* |
Generic |
$8.00 | N/A | None |
THIOTHIXENE 10MG CAPSULE |
2* |
Generic |
$8.00 | N/A | None |
THIOTHIXENE 2MG CAPSULE |
2* |
Generic |
$8.00 | N/A | None |
THIOTHIXENE 5MG CAPSULE |
2* |
Generic |
$8.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THYMOGLOBULIN 25MG VIAL |
5 |
Specialty Tier |
27% | N/A | P |
THYROLAR-1 TABLETS |
3 |
Preferred Brand |
$42.00 | N/A | None |
THYROLAR-1/2 TABLETS |
3 |
Preferred Brand |
$42.00 | N/A | None |
THYROLAR-1/4 TABLETS |
3 |
Preferred Brand |
$42.00 | N/A | None |
THYROLAR-2 TABLETS |
3 |
Preferred Brand |
$42.00 | N/A | None |
THYROLAR-3 TABLETS |
3 |
Preferred Brand |
$42.00 | N/A | None |
TIAGABINE HCL 12 MG TABLET [Gabitril] |
3 |
Preferred Brand |
$42.00 | N/A | None |
TIAGABINE HCL 16 MG TABLET [Gabitril] |
3 |
Preferred Brand |
$42.00 | N/A | None |
tiagabine hcl 2 mg tablet [Gabitril] |
3 |
Preferred Brand |
$42.00 | N/A | None |
tiagabine hcl 4 mg tablet [Gabitril] |
3 |
Preferred Brand |
$42.00 | N/A | None |
TIAZAC ER 120 MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIAZAC ER 180 MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TIAZAC ER 240 MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TIAZAC ER 300 MG CAPSULE CAP SA 24H |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TIAZAC ER 360 MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TIAZAC ER 420 MG CAPSULE CAP SA 24H |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TIGECYCLINE 50 MG VIAL [Tygacil] |
5 |
Specialty Tier |
27% | N/A | None |
TIKOSYN .125MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TIKOSYN .250MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TIKOSYN .5MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TIMOLOL 0.25% EYE DROPS |
2* |
Generic |
$8.00 | N/A | None |
TIMOLOL 0.25% GFS GEL-SOLUTION |
2* |
Generic |
$8.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIMOLOL 0.5% EYE DROPS |
2* |
Generic |
$8.00 | N/A | None |
TIMOLOL 0.5% EYE DROPS |
2* |
Generic |
$8.00 | N/A | None |
TIMOLOL 0.5% GFS GEL-SOLUTION |
2* |
Generic |
$8.00 | N/A | None |
TIMOLOL MALEATE 10MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
TIMOLOL MALEATE 20MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
TIMOLOL MALEATE 5MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
TIMOPTIC 0.25% OCUDOSE DROP |
4 |
Non-Preferred Brand |
$84.00 | N/A | S |
TIMOPTIC 0.5% OCUDOSE DROP |
4 |
Non-Preferred Brand |
$84.00 | N/A | S |
TIMOPTIC-XE 0.25% EYE GEL-SOLN SOL-GEL |
4 |
Non-Preferred Brand |
$84.00 | N/A | S |
TINDAMAX 500 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TINIDAZOLE 250 MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TINIDAZOLE 500 MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
Tirosint 100ug/1 4 BLISTER PACK per CARTON / 7 CAPSULE per BLISTER PACK |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Tirosint 112ug/1 4 BLISTER PACK per CARTON / 7 CAPSULE per BLISTER PACK |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Tirosint 125ug/1 4 BLISTER PACK per CARTON / 7 CAPSULE per BLISTER PACK |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Tirosint 137ug/1 4 BLISTER PACK per CARTON / 7 CAPSULE per BLISTER PACK |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Tirosint 13ug/1 4 BLISTER PACK per CARTON / 7 CAPSULE per BLISTER PACK |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Tirosint 150ug/1 4 BLISTER PACK per CARTON / 7 CAPSULE per BLISTER PACK |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Tirosint 25ug/1 4 BLISTER PACK per CARTON / 7 CAPSULE per BLISTER PACK |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Tirosint 50ug/1 4 BLISTER PACK per CARTON / 7 CAPSULE per BLISTER PACK |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Tirosint 75ug/1 4 BLISTER PACK per CARTON / 7 CAPSULE per BLISTER PACK |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Tirosint 88ug/1 4 BLISTER PACK per CARTON / 7 CAPSULE per BLISTER PACK |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIVICAY 10 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TIVICAY 25 MG TABLET |
5 |
Specialty Tier |
27% | N/A | None |
TIVICAY 50 MG TABLET |
5 |
Specialty Tier |
27% | N/A | None |
TIVORBEX 20 MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | P |
TIVORBEX 40 MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | P |
TIZANIDINE HCL 2 MG CAPSULE |
2* |
Generic |
$8.00 | N/A | None |
TIZANIDINE HCL 2 MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
TIZANIDINE HCL 4 MG CAPSULE |
2* |
Generic |
$8.00 | N/A | None |
TIZANIDINE HCL 4 MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
TIZANIDINE HCL 6 MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TOBI 300mg/5mL 56 AMPULE per CARTON / 5 mL in 1 AMPULE |
5 |
Specialty Tier |
27% | N/A | P Q:280 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOBI PODHALER 28 MG INHALE CAP |
5 |
Specialty Tier |
27% | N/A | Q:224 /28Days |
TOBRADEX EYE OINTMENT |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TOBRADEX ST 0.5; 3mg/mL; mg/mL 5 mL in 1 BOTTLE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TOBRADEX SUSPENSION OPHTHALMIC 0.1%/0.3% 5ML BOT |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TOBRAMYCIN 0.3% EYE DROPS [Tobrex] |
2* |
Generic |
$8.00 | N/A | None |
TOBRAMYCIN 10 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate] |
2* |
Generic |
$8.00 | N/A | None |
TOBRAMYCIN 300 MG/5 ML AMPULE [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate] |
5 |
Specialty Tier |
27% | N/A | P Q:280 /28Days |
TOBRAMYCIN 40 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate] |
2* |
Generic |
$8.00 | N/A | None |
TOBRAMYCIN-DEXAMETH OPTH SUSP |
2* |
Generic |
$8.00 | N/A | None |
TOBREX 0.3% EYE DROPS |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TOBREX 0.3% EYE OINTMENT |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOFRANIL 50MG TABLET (30 CT) |
4 |
Non-Preferred Brand |
$84.00 | N/A | P |
TOFRANIL TABLETS 10MG 30 BOT |
4 |
Non-Preferred Brand |
$84.00 | N/A | P |
TOFRANIL TABLETS 25MG 30 BOT |
4 |
Non-Preferred Brand |
$84.00 | N/A | P |
TOLAK 4% CREAM |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TOLAZAMIDE TABLETS 250MG 100 BOT |
2* |
Generic |
$8.00 | N/A | Q:120 /30Days |
TOLAZAMIDE TABLETS 500MG 100 BOT |
2* |
Generic |
$8.00 | N/A | Q:60 /30Days |
TOLBUTAMIDE 500 MG TABLET |
2* |
Generic |
$8.00 | N/A | Q:180 /30Days |
Tolcapone 100 MG TABLET [Tasmar] |
5 |
Specialty Tier |
27% | N/A | None |
TOLMETIN SODIUM 400 MG CAP |
2* |
Generic |
$8.00 | N/A | None |
TOLMETIN SODIUM 600MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
TOLTERODINE TARTRATE 1 MG TAB [Detrol LA] |
2* |
Generic |
$8.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOLTERODINE TARTRATE 2 MG TAB [Detrol LA] |
2* |
Generic |
$8.00 | N/A | None |
Tolterodine Tartrate ER 2 MG CAPSULE [Detrol LA] |
2* |
Generic |
$8.00 | N/A | None |
TOLVAPTAN 15 MG ORAL TABLET [SAMSCA] |
5 |
Specialty Tier |
27% | N/A | P |
TOLVAPTAN 30 MG ORAL TABLET [SAMSCA] |
5 |
Specialty Tier |
27% | N/A | P |
TOPAMAX 15 MG SPRINKLE CAP |
4 |
Non-Preferred Brand |
$84.00 | N/A | P |
TOPAMAX 25 MG SPRINKLE CAP |
4 |
Non-Preferred Brand |
$84.00 | N/A | P |
TOPAMAX TABLETS 100MG 60 BOT |
4 |
Non-Preferred Brand |
$84.00 | N/A | P |
TOPAMAX TABLETS 200MG 60 BOT |
4 |
Non-Preferred Brand |
$84.00 | N/A | P |
TOPAMAX TABLETS 25MG 60 BOT |
4 |
Non-Preferred Brand |
$84.00 | N/A | P |
TOPAMAX TABLETS 50MG 60 BOT |
4 |
Non-Preferred Brand |
$84.00 | N/A | P |
TOPICORT 0.25% SPRAY |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Topicort 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Topicort 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Topicort 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Topicort 2.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Topicort 2.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TOPIRAMATE 100 MG TABLET |
2* |
Generic |
$8.00 | N/A | P |
TOPIRAMATE 15 MG SPRINKLE CAP |
2* |
Generic |
$8.00 | N/A | P |
TOPIRAMATE 200 MG TABLET |
2* |
Generic |
$8.00 | N/A | P |
TOPIRAMATE 25 MG TABLET |
2* |
Generic |
$8.00 | N/A | P |
Topiramate 25mg/1 |
2* |
Generic |
$8.00 | N/A | P |
TOPIRAMATE 50 MG TABLET |
2* |
Generic |
$8.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOPIRAMATE ER 100 MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | P |
TOPIRAMATE ER 150 MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | P |
TOPIRAMATE ER 200 MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | P |
TOPIRAMATE ER 25 MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | P |
TOPIRAMATE ER 50 MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | P |
TOPOSAR INJECTION 20MG/ML 50ML VIAL MD CRTN |
2* |
Generic |
$8.00 | N/A | P |
Topotecan 4 MG Injection |
5 |
Specialty Tier |
27% | N/A | P |
TOPROL XL 100 MG TABLET ER 24H |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TOPROL XL 200 MG TABLET ER 24H |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TOPROL XL 25 MG TABLET ER 24H |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TOPROL XL 50 MG TABLET ER 24H |
4 |
Non-Preferred Brand |
$84.00 | 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 |
27% | N/A | P |
TORSEMIDE 10 MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
TORSEMIDE 100 MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
TORSEMIDE 20 MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
TORSEMIDE 5 MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
TOUJEO MAX SOLOSTAR 300UNIT/ML INSULN PEN |
3 |
Preferred Brand |
$42.00 | N/A | None |
TOUJEO SOLOSTAR 300 UNITS/ML |
3 |
Preferred Brand |
$42.00 | N/A | None |
TOVIAZ TABLETS 4MG EXTENDED RELEASE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TOVIAZ TABLETS 8MG EXTENDED RELEASE |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TPN ELECTROLYTES16.5/25.4 VIAL |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TRACLEER 125MG TABLET |
5 |
Specialty Tier |
27% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRACLEER 32 MG TABLET FOR SUSP |
5 |
Specialty Tier |
27% | N/A | None |
TRACLEER 62.5MG TABLET |
5 |
Specialty Tier |
27% | N/A | None |
TRADJENTA 5 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | S Q:30 /30Days |
TRAMADOL ER 100 MG TABLET |
2* |
Generic |
$8.00 | N/A | Q:30 /30Days |
TRAMADOL ER 200 MG TABLET |
2* |
Generic |
$8.00 | N/A | Q:30 /30Days |
TRAMADOL ER 300 MG TABLET |
2* |
Generic |
$8.00 | N/A | Q:30 /30Days |
TRAMADOL ER 300 MG TABLET |
2* |
Generic |
$8.00 | N/A | Q:30 /30Days |
TRAMADOL HCL 50 MG TABLET |
2* |
Generic |
$8.00 | N/A | Q:240 /30Days |
TRAMADOL HCL ER 100 MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | Q:30 /30Days |
TRAMADOL HCL ER 100 MG TABLET |
2* |
Generic |
$8.00 | N/A | Q:30 /30Days |
TRAMADOL HCL ER 200 MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRAMADOL HCL ER 200 MG TABLET |
2* |
Generic |
$8.00 | N/A | Q:30 /30Days |
TRAMADOL HCL ER 300 MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | Q:30 /30Days |
TRAMADOL-ACETAMINOPHN 37.5-325 |
2* |
Generic |
$8.00 | N/A | Q:240 /30Days |
TRANDOLAPRIL 1 MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
TRANDOLAPRIL 2 MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
TRANDOLAPRIL 4 MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
TRANDOLAPRIL-VERAPAMIL ER 1-240 MG |
2* |
Generic |
$8.00 | N/A | None |
TRANDOLAPRIL-VERAPAMIL ER 2-180 MG |
2* |
Generic |
$8.00 | N/A | None |
TRANDOLAPRIL-VERAPAMIL ER 2-240 MG |
2* |
Generic |
$8.00 | N/A | None |
TRANDOLAPRIL-VERAPAMIL ER 4-240 MG |
2* |
Generic |
$8.00 | N/A | None |
TRANEXAMIC ACID 1,000 MG/10 ML |
2* |
Generic |
$8.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
tranexamic acid 650 mg tablet |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TRANSDERM-SCOP 1.5 MG/3 DAY |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TRANXENE T-TAB 7.5 MG |
4 |
Non-Preferred Brand |
$84.00 | N/A | P |
TRANYLCYPROMINE SULFATE 10MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TRAVASOL 10% SOLUTION VIAFLEX |
4 |
Non-Preferred Brand |
$84.00 | N/A | P |
TRAVATAN Z 0.04MG DROPS 2.5ML BOT |
3 |
Preferred Brand |
$42.00 | N/A | S |
TRAZODONE 100 MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
TRAZODONE 300 MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
TRAZODONE 50 MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
TRAZODONE HCL TABLET USP 150MG (100 CT) |
2* |
Generic |
$8.00 | N/A | None |
TREANDA 25 MG VIAL |
5 |
Specialty Tier |
27% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TREANDA FOR INJECTION 100MG/VIAL |
5 |
Specialty Tier |
27% | N/A | P |
TRECATOR 250MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TRELEGY ELLIPTA 100-62.5-25 |
3 |
Preferred Brand |
$42.00 | N/A | Q:60 /30Days |
TRELSTAR 11.25 MG SYRINGE |
5 |
Specialty Tier |
27% | N/A | P |
TRELSTAR 3.75 MG SYRINGE |
5 |
Specialty Tier |
27% | N/A | P |
TREMFYA 100 MG/ML SYRINGE |
5 |
Specialty Tier |
27% | N/A | P |
TRESIBA FLEXTOUCH 100 UNITS/ML |
4 |
Non-Preferred Brand |
$84.00 | N/A | S |
TRESIBA FLEXTOUCH 200 UNITS/ML |
4 |
Non-Preferred Brand |
$84.00 | N/A | S |
Tretinoin 0.0004 MG/MG Topical Gel |
4 |
Non-Preferred Brand |
$84.00 | N/A | P |
Tretinoin 0.0005 MG/MG Topical Gel |
2* |
Generic |
$8.00 | N/A | P |
Tretinoin 0.001 MG/MG Topical Gel |
4 |
Non-Preferred Brand |
$84.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRETINOIN 0.01% GEL |
2* |
Generic |
$8.00 | N/A | P |
TRETINOIN 0.025% CREAM |
2* |
Generic |
$8.00 | N/A | P |
TRETINOIN 0.025% GEL |
2* |
Generic |
$8.00 | N/A | P |
TRETINOIN 0.05% CREAM |
2* |
Generic |
$8.00 | N/A | P |
TRETINOIN 0.1% CREAM |
2* |
Generic |
$8.00 | N/A | P |
Tretinoin 0.25 MG/ML Topical Cream [Retin-A] |
4 |
Non-Preferred Brand |
$84.00 | N/A | P |
Tretinoin 0.5 MG/ML Topical Cream [Retin-A] |
4 |
Non-Preferred Brand |
$84.00 | N/A | P |
Tretinoin 1 MG/ML Topical Cream [Retin-A] |
4 |
Non-Preferred Brand |
$84.00 | N/A | P |
TRETINOIN 10MG CAPSULE |
5 |
Specialty Tier |
27% | N/A | None |
TREXALL 10MG TABLET |
3 |
Preferred Brand |
$42.00 | N/A | P |
TREXALL 15MG TABLET |
3 |
Preferred Brand |
$42.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TREXALL 5MG TABLET |
3 |
Preferred Brand |
$42.00 | N/A | P |
TREXALL 7.5MG TABLET |
3 |
Preferred Brand |
$42.00 | N/A | P |
TREXIMET 10-60 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | S Q:18 /28Days |
TREXIMET 85-500 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | S Q:18 /28Days |
TREZIX 16-320.5-30 MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | Q:300 /30Days |
TRI PREVIFEM TABLETS |
2* |
Generic |
$8.00 | N/A | None |
TRI-LEGEST FE 5-7-9-7 TABLET |
2* |
Generic |
$8.00 | N/A | None |
TRI-LO-ESTARYLLA TABLET [Trinessa Lo] |
2* |
Generic |
$8.00 | N/A | None |
TRI-LO-SPRINTEC TABLET |
2* |
Generic |
$8.00 | N/A | None |
TRI-MILI 28 TABLET [Trinessa] |
2* |
Generic |
$8.00 | N/A | None |
TRI-NORINYL 28 TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRI-SPRINTEC 7DAYSX3 28 TABLET |
2* |
Generic |
$8.00 | N/A | None |
TRI-VYLIBRA 28 TABLET [Trinessa] |
2* |
Generic |
$8.00 | N/A | None |
TRIAMCINOLONE 0.025% CREAM |
2* |
Generic |
$8.00 | N/A | None |
TRIAMCINOLONE 0.025% LOTION |
2* |
Generic |
$8.00 | N/A | None |
TRIAMCINOLONE 0.025% OINT |
2* |
Generic |
$8.00 | N/A | None |
TRIAMCINOLONE 0.1% CREAM |
2* |
Generic |
$8.00 | N/A | None |
TRIAMCINOLONE 0.1% LOTION [Kenalog] |
2* |
Generic |
$8.00 | N/A | None |
TRIAMCINOLONE 0.1% OINTMENT |
2* |
Generic |
$8.00 | N/A | None |
TRIAMCINOLONE 0.1% PASTE |
2* |
Generic |
$8.00 | N/A | None |
Triamcinolone 0.147 MG/G Spray |
2* |
Generic |
$8.00 | N/A | None |
TRIAMCINOLONE 200 MG/5 ML VIAL [Triesence] |
2* |
Generic |
$8.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Triamcinolone 55 mcg nasal spr |
2* |
Generic |
$8.00 | N/A | S |
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE |
2* |
Generic |
$8.00 | N/A | None |
Triamcinolone Acetonide 1 MG/ML Topical Cream [Triderm] |
2* |
Generic |
$8.00 | N/A | None |
Triamcinolone Acetonide 5mg/g 1 TUBE per CARTON / 15 g in 1 TUBE |
2* |
Generic |
$8.00 | N/A | None |
TRIAMTERENE-HCTZ 37.5-25 MG CP |
2* |
Generic |
$8.00 | N/A | None |
TRIAMTERENE-HCTZ 37.5-25 MG TB |
2* |
Generic |
$8.00 | N/A | None |
TRIAMTERENE-HCTZ 75-50 MG TAB |
2* |
Generic |
$8.00 | N/A | None |
Trianex 0.05% Ointment |
2* |
Generic |
$8.00 | N/A | None |
TRIAZOLAM 0.125 MG TABLET |
3 |
Preferred Brand |
$42.00 | N/A | P |
TRIAZOLAM 0.25 MG TABLET |
3 |
Preferred Brand |
$42.00 | N/A | P |
TRIBENZOR 20/5/12.5MG TABLETS |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIBENZOR 40/10/12.5MG TABLETS |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TRIBENZOR 40/10/25MG TABLETS |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Tribenzor 5; 12.5; 40mg/1; mg/1; mg/1 |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Tribenzor 5; 25; 40mg/1; mg/1; mg/1 |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TRICOR 145 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TRICOR 48 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TRIDESILON 0.05% CREAM |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TRIENTINE HCL 250 MG CAPSULE [Syprine] |
5 |
Specialty Tier |
27% | N/A | None |
TRIFLUOPERAZINE 1MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
TRIFLUOPERAZINE HCL 2MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
TRIFLUOPERAZINE HCL 5MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT) |
2* |
Generic |
$8.00 | N/A | None |
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT |
2* |
Generic |
$8.00 | N/A | None |
TRIGLIDE 160 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TRIHEXYPHENIDYL 2 MG TABLET |
3 |
Preferred Brand |
$42.00 | N/A | None |
TRIHEXYPHENIDYL 5 MG TABLET |
3 |
Preferred Brand |
$42.00 | N/A | None |
Trihexyphenidyl Hydrochloride 2mg/5mL 473 mL in 1 BOTTLE |
3 |
Preferred Brand |
$42.00 | N/A | None |
TRILEPTAL 150MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | S |
TRILEPTAL 300MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | S |
TRILEPTAL 300MG/5ML SUSP |
4 |
Non-Preferred Brand |
$84.00 | N/A | S |
TRILEPTAL 600MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | S |
TRILIPIX DR 135 MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | 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 |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TRILYTE WITH FLAVOR PACKETS |
2* |
Generic |
$8.00 | N/A | None |
TRIMETHOPRIM 100 MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
TRIMIPRAMINE MALEATE 100 MG CP |
3 |
Preferred Brand |
$42.00 | N/A | P |
TRIMIPRAMINE MALEATE 25 MG CAP |
3 |
Preferred Brand |
$42.00 | N/A | P |
TRIMIPRAMINE MALEATE 50 MG CAP |
3 |
Preferred Brand |
$42.00 | N/A | P |
TRINESSA TABLET |
2* |
Generic |
$8.00 | N/A | None |
TRINTELLIX 10 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TRINTELLIX 20 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TRINTELLIX 5 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Triostat 10ug/mL 6 VIAL in 1 CARTON / 1 mL in 1 VIAL |
4 |
Non-Preferred Brand |
$84.00 | 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] |
5 |
Specialty Tier |
27% | N/A | P |
TRISENOX 12 MG/6 ML VIAL |
5 |
Specialty Tier |
27% | N/A | P |
TRIUMEQ TABLET |
5 |
Specialty Tier |
27% | N/A | None |
Trivora-28 tablet |
2* |
Generic |
$8.00 | N/A | None |
TRIZIVIR 300; 150; 300mg/1; mg/1; mg/1 60 FILM COATED TABLETS in BOTTLE |
5 |
Specialty Tier |
27% | N/A | None |
TROKENDI XR 100 MG CAPSULE ER 24H |
4 |
Non-Preferred Brand |
$84.00 | N/A | P |
TROKENDI XR 200 MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | P |
TROKENDI XR 25 MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | P |
TROKENDI XR 50 MG CAPSULE |
4 |
Non-Preferred Brand |
$84.00 | N/A | P |
TROPHAMINE INJECTION SOLUTION |
3 |
Preferred Brand |
$42.00 | N/A | P |
TROPHAMINE INJECTION SOLUTION 6% |
3 |
Preferred Brand |
$42.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TROSPIUM CHLORIDE 20 MG TABLET |
2* |
Generic |
$8.00 | N/A | None |
TROSPIUM CHLORIDE ER 60 MG CAP |
2* |
Generic |
$8.00 | N/A | None |
TRULANCE 3 MG TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TRULICITY 0.75 MG/0.5 ML PEN |
4 |
Non-Preferred Brand |
$84.00 | N/A | S Q:2 /28Days |
TRULICITY 1.5 MG/0.5 ML PEN |
4 |
Non-Preferred Brand |
$84.00 | N/A | S Q:2 /28Days |
TRUMENBA 120 MCG/0.5 ML VACCIN Syringe |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TRUSOPT PLUS 2% EYE DROPS 10ML BOT |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TRUVADA 100 MG-150 MG TABLET |
5 |
Specialty Tier |
27% | N/A | None |
TRUVADA 133 MG-200 MG TABLET |
5 |
Specialty Tier |
27% | N/A | None |
TRUVADA 167 MG-250 MG TABLET |
5 |
Specialty Tier |
27% | N/A | None |
TRUVADA 200/300MG TABLET |
5 |
Specialty Tier |
27% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TUDORZA PRESSAIR 400 MCG INH |
3 |
Preferred Brand |
$42.00 | N/A | Q:2 /30Days |
TUDORZA PRESSAIR 400 MCG INH |
3 |
Preferred Brand |
$42.00 | N/A | Q:2 /30Days |
TWINRIX VACCINE SYRINGE |
3 |
Preferred Brand |
$42.00 | N/A | None |
Twynsta 10; 40mg/1; mg/1 3 BLISTER PACK per CARTON / 10 TABLET, MULTILAYER per BLISTER PACK |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Twynsta 10; 80mg/1; mg/1 3 BLISTER PACK per CARTON / 10 TABLET, MULTILAYER per BLISTER PACK |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Twynsta 5; 40mg/1; mg/1 3 BLISTER PACK per CARTON / 10 TABLET, MULTILAYER per BLISTER PACK |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
Twynsta 5; 80mg/1; mg/1 3 BLISTER PACK per CARTON / 10 TABLET, MULTILAYER per BLISTER PACK |
4 |
Non-Preferred Brand |
$84.00 | N/A | None |
TYBOST 150 MG TABLET |
3 |
Preferred Brand |
$42.00 | N/A | None |
TYDEMY TABLET |
2* |
Generic |
$8.00 | N/A | None |
Tygacil 50mg/5mL 10 VIAL, SINGLE-USE per CARTON / 50 mL in 1 VIAL, SINGLE-USE |
5 |
Specialty Tier |
27% | N/A | None |
TYKERB 250 MG TABLET |
5 |
Specialty Tier |
27% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TYLENOL WITH CODEINE #3 TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | Q:360 /30Days |
TYLENOL WITH CODEINE #4 TABLET |
4 |
Non-Preferred Brand |
$84.00 | N/A | Q:180 /30Days |
TYMLOS 80 MCG DOSE PEN INJECTR |
5 |
Specialty Tier |
27% | N/A | S |
TYPHIM VI 25 MCG/0.5 ML SYRINGE |
3 |
Preferred Brand |
$42.00 | N/A | None |
TYPHIM VI 25MCG/0.5ML VIAL |
3 |
Preferred Brand |
$42.00 | N/A | None |
TYSABRI 300 MG/15 ML VIAL |
5 |
Specialty Tier |
27% | N/A | P |