2019 Medicare Part D Plan Formulary Information |
EON CHOICE (PPO) (H9589-003-0)
Benefit Details
|
The EON CHOICE (PPO) (H9589-003-0) Formulary Drugs Starting with the Letter T in Screven County, GA: CMS MA Region 8 which includes: GA Plan Monthly Premium: $25.00 Deductible: $150 |
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 Drug |
$95.00 | $190.00 | None |
TACLONEX SCALP SUSPENSION |
5 |
Specialty Tier |
28% | 28% | Q:400 /30Days |
Tacrolimus 0.03% ointment |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
Tacrolimus 0.1% ointment |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TACROLIMUS 0.5 MG CAPSULE |
2* |
Generic |
$10.00 | $20.00 | P |
TACROLIMUS 1 MG CAPSULE |
2* |
Generic |
$10.00 | $20.00 | P |
TACROLIMUS 5 MG CAPSULE |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P |
TADALAFIL 2.5 MG TABLET [Cialis] |
2* |
Generic |
$10.00 | $20.00 | P Q:30 /30Days |
TADALAFIL 20 MG TABLET [ALYQ] |
5 |
Specialty Tier |
28% | 28% | P Q:60 /30Days |
TADALAFIL 5 MG TABLET [Cialis] |
2* |
Generic |
$10.00 | $20.00 | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAFINLAR 50 MG CAPSULE |
5 |
Specialty Tier |
28% | 28% | P |
TAFINLAR 75 MG CAPSULE |
5 |
Specialty Tier |
28% | 28% | P |
TAGRISSO 40 MG TABLET |
5 |
Specialty Tier |
28% | 28% | P Q:30 /30Days |
TAGRISSO 80 MG TABLET |
5 |
Specialty Tier |
28% | 28% | P Q:30 /30Days |
TAKHZYRO 300 MG/2 ML VIAL |
5 |
Specialty Tier |
28% | 28% | P |
TALZENNA 0.25 MG CAPSULE |
5 |
Specialty Tier |
28% | 28% | P |
TALZENNA 1 MG CAPSULE |
5 |
Specialty Tier |
28% | 28% | P |
TAMOXIFEN 10 MG TABLET |
2* |
Generic |
$10.00 | $20.00 | None |
TAMOXIFEN CITRATE 20MG TABLET (30 CT) |
2* |
Generic |
$10.00 | $20.00 | None |
TAMSULOSIN HCL 0.4 MG CAPSULE |
2* |
Generic |
$10.00 | $20.00 | None |
TARCEVA 100MG TABLET |
5 |
Specialty Tier |
28% | 28% | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TARCEVA 150MG TABLET |
5 |
Specialty Tier |
28% | 28% | P Q:30 /30Days |
TARCEVA 25MG TABLET |
5 |
Specialty Tier |
28% | 28% | P Q:90 /30Days |
TARGRETIN 1% GEL |
5 |
Specialty Tier |
28% | 28% | P |
TARINA 24 FE 1 MG-20 MCG TABLET [Tarina Fe 1/20] |
2* |
Generic |
$10.00 | $20.00 | None |
Tarina Fe 1-20 tablet |
2* |
Generic |
$10.00 | $20.00 | None |
Tasigna 150mg/1 4 BLISTER PACK per CARTON / 28 CAPSULE per BLISTER PACK |
5 |
Specialty Tier |
28% | 28% | P |
TASIGNA 200 MG CAPSULE |
5 |
Specialty Tier |
28% | 28% | P |
TASIGNA 50 MG CAPSULE |
5 |
Specialty Tier |
28% | 28% | P |
TAVALISSE 100 MG TABLET |
5 |
Specialty Tier |
28% | 28% | P Q:60 /30Days |
TAVALISSE 150 MG TABLET |
5 |
Specialty Tier |
28% | 28% | P Q:60 /30Days |
TAZAROTENE 0.1% CREAM [Tazorac] |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAZICEF 1GM VIAL |
2* |
Generic |
$10.00 | $20.00 | None |
TAZICEF 2 GRAM VIAL |
2* |
Generic |
$10.00 | $20.00 | None |
TAZICEF 6 GRAM VIAL |
2* |
Generic |
$10.00 | $20.00 | None |
TAZORAC 0.05% CREAM |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TAZORAC 0.05% GEL |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TAZORAC 0.1% GEL |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TAZTIA DILTIAZEM HYDROCHLORIDE 120MG ER CAPSULES |
2* |
Generic |
$10.00 | $20.00 | None |
TAZTIA XT 180 MG CAPSULE |
2* |
Generic |
$10.00 | $20.00 | None |
TAZTIA XT 240MG CAPSULE SA |
2* |
Generic |
$10.00 | $20.00 | None |
TAZTIA XT 300 MG CAPSULE |
2* |
Generic |
$10.00 | $20.00 | None |
TAZTIA XT 360MG CAPSULE SA |
2* |
Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TECFIDERA DR 120 MG CAPSULE |
5 |
Specialty Tier |
28% | 28% | P Q:60 /30Days |
TECFIDERA DR 240 MG CAPSULE |
5 |
Specialty Tier |
28% | 28% | P Q:60 /30Days |
TECFIDERA STARTER PACK |
5 |
Specialty Tier |
28% | 28% | P Q:120 /365Days |
Teflaro 400mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE |
5 |
Specialty Tier |
28% | 28% | None |
Teflaro 600mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE |
5 |
Specialty Tier |
28% | 28% | None |
TEGRETOL SUSPENSION 100MG/5ML 450 ML BOT |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TEGRETOL TABLETS 200MG 100 BOT |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TEGRETOL XR TABLETS 100MG 100 BOT |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TEGRETOL XR TABLETS 200MG 100 BOT |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TEGRETOL XR TABLETS 400MG 100 BOT |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TEGSEDI 284 MG/1.5 ML SYRINGE |
5 |
Specialty Tier |
28% | 28% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TELMISARTAN 20 MG TABLET [Micardis] |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
TELMISARTAN 40 MG TABLET [Micardis] |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
TELMISARTAN 80 MG TABLET [Micardis] |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
Telmisartan-Amlodipine 40-10 MG [Micardis] |
2* |
Generic |
$10.00 | $20.00 | None |
Telmisartan-Amlodipine 40-5 MG [Micardis] |
2* |
Generic |
$10.00 | $20.00 | None |
Telmisartan-Amlodipine 80-10 MG [Micardis] |
2* |
Generic |
$10.00 | $20.00 | None |
Telmisartan-Amlodipine 80-5 MG [Micardis] |
2* |
Generic |
$10.00 | $20.00 | None |
TELMISARTAN-HCTZ 40-12.5 MG TB [Micardis] |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
TELMISARTAN-HCTZ 80-12.5 MG TAB [Micardis HCT] |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
TELMISARTAN-HCTZ 80-25 MG TAB [Micardis HCT] |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
TEMAZEPAM 15 MG CAPSULE |
2* |
Generic |
$10.00 | $20.00 | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TEMAZEPAM 22.5 MG CAPSULE |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P Q:30 /30Days |
TEMAZEPAM 30 MG CAPSULE |
2* |
Generic |
$10.00 | $20.00 | P Q:30 /30Days |
Temazepam 7.5mg/1 100 CAPSULE BOTTLE, PLASTIC |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P Q:30 /30Days |
Tencon 50-325 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P |
TENIVAC SYRINGE |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
TENOFOVIR DISOP FUM 300 MG TABLET [Viread] |
5 |
Specialty Tier |
28% | 28% | None |
TERAZOSIN 1 MG CAPSULE |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
TERAZOSIN 10 MG CAPSULE [Hytrin] |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
TERAZOSIN 2 MG CAPSULE |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
TERAZOSIN 5 MG CAPSULE [Hytrin] |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
TERBINAFINE HCL 250 MG TABLET |
1* |
Preferred Generic |
$2.00 | $4.00 | Q:84 /180Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TERBUTALINE SULFATE 2.5 MG TAB |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TERBUTALINE SULFATE 5MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TERCONAZOLE 0.4% CREAM WITH APPLICATOR |
2* |
Generic |
$10.00 | $20.00 | None |
TERCONAZOLE 0.8% CREAM |
2* |
Generic |
$10.00 | $20.00 | None |
TERCONAZOLE 80MG SUPPOSITORY VAGINAL |
2* |
Generic |
$10.00 | $20.00 | None |
TESTOSTERONE 1.62% (1.25 G) PKT GEL PACKET [AndroGel] |
3 |
Preferred Brand |
$45.00 | $90.00 | P |
TESTOSTERONE 1.62% (2.5 G) PKT GEL PACKET [AndroGel] |
3 |
Preferred Brand |
$45.00 | $90.00 | P |
TESTOSTERONE 1.62% GEL PUMP GEL MD PMP [AndroGel] |
3 |
Preferred Brand |
$45.00 | $90.00 | P |
TESTOSTERONE 12.5 MG/1.25 GRAM |
3 |
Preferred Brand |
$45.00 | $90.00 | P |
Testosterone 2500 MG 0.01 MG/MG Topical Gel |
3 |
Preferred Brand |
$45.00 | $90.00 | P |
TESTOSTERONE 30 MG/1.5 ML PUMP |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Testosterone 5000 MG 0.01 MG/MG Topical Gel |
3 |
Preferred Brand |
$45.00 | $90.00 | P |
Testosterone cyp 100 mg/ml |
2* |
Generic |
$10.00 | $20.00 | P |
TESTOSTERONE CYP 200 MG/ML |
2* |
Generic |
$10.00 | $20.00 | P |
TESTOSTERONE ENANTHATE 200MG/ML INJECTION |
2* |
Generic |
$10.00 | $20.00 | P |
TETRABENAZINE 12.5 MG TABLET [XENAZINE] |
5 |
Specialty Tier |
28% | 28% | P |
TETRABENAZINE 25 MG TABLET [XENAZINE] |
5 |
Specialty Tier |
28% | 28% | P |
TETRACYCLINE 250 MG CAPSULE |
2* |
Generic |
$10.00 | $20.00 | None |
TETRACYCLINE 500 MG CAPSULE |
2* |
Generic |
$10.00 | $20.00 | None |
THALOMID 100 MG CAPSULE |
5 |
Specialty Tier |
28% | 28% | P |
THALOMID 150 MG CAPSULE |
5 |
Specialty Tier |
28% | 28% | P |
THALOMID 200 MG CAPSULE |
5 |
Specialty Tier |
28% | 28% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THALOMID 50 MG CAPSULE |
5 |
Specialty Tier |
28% | 28% | P |
THEOPHYLLINE 80 MG/15 ML SOLN |
2* |
Generic |
$10.00 | $20.00 | None |
THEOPHYLLINE ER 100 MG TABLET |
2* |
Generic |
$10.00 | $20.00 | None |
THEOPHYLLINE ER 200 MG TABLET |
2* |
Generic |
$10.00 | $20.00 | None |
THEOPHYLLINE ER 300 MG TAB |
2* |
Generic |
$10.00 | $20.00 | None |
THEOPHYLLINE ER 400 MG TABLET |
2* |
Generic |
$10.00 | $20.00 | None |
THEOPHYLLINE ER 600 MG TABLET |
2* |
Generic |
$10.00 | $20.00 | None |
THIORIDAZINE 10 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P |
THIORIDAZINE 100MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P |
THIORIDAZINE 25 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P |
THIORIDAZINE 50 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THIOTHIXENE 1 MG CAPSULE |
2* |
Generic |
$10.00 | $20.00 | None |
THIOTHIXENE 10MG CAPSULE |
2* |
Generic |
$10.00 | $20.00 | None |
THIOTHIXENE 2MG CAPSULE |
2* |
Generic |
$10.00 | $20.00 | None |
THIOTHIXENE 5MG CAPSULE |
2* |
Generic |
$10.00 | $20.00 | None |
THYROLAR-1 TABLETS |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
THYROLAR-1/2 TABLETS |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
THYROLAR-1/4 TABLETS |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
THYROLAR-2 TABLETS |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
THYROLAR-3 TABLETS |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TIAGABINE HCL 12 MG TABLET [Gabitril] |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TIAGABINE HCL 16 MG TABLET [Gabitril] |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
tiagabine hcl 2 mg tablet [Gabitril] |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
tiagabine hcl 4 mg tablet [Gabitril] |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TIBSOVO 250 MG TABLET |
5 |
Specialty Tier |
28% | 28% | P Q:60 /30Days |
TIGECYCLINE 50 MG VIAL [Tygacil] |
5 |
Specialty Tier |
28% | 28% | None |
TIGLUTIK 50 MG/10 ML Oral Suspension |
5 |
Specialty Tier |
28% | 28% | P |
TIMOLOL 0.25% EYE DROPS |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
TIMOLOL 0.25% GFS GEL-SOLUTION |
2* |
Generic |
$10.00 | $20.00 | None |
TIMOLOL 0.5% EYE DROPS |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
TIMOLOL 0.5% EYE DROPS |
2* |
Generic |
$10.00 | $20.00 | None |
TIMOLOL 0.5% GFS GEL-SOLUTION |
2* |
Generic |
$10.00 | $20.00 | None |
TIMOLOL MALEATE 10MG TABLET |
2* |
Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIMOLOL MALEATE 20MG TABLET |
2* |
Generic |
$10.00 | $20.00 | None |
TIMOLOL MALEATE 5MG TABLET |
2* |
Generic |
$10.00 | $20.00 | None |
TINIDAZOLE 250 MG TABLET |
2* |
Generic |
$10.00 | $20.00 | None |
TINIDAZOLE 500 MG TABLET |
2* |
Generic |
$10.00 | $20.00 | None |
TIROSINT 100 MCG CAPSULE |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TIROSINT 112 MCG CAPSULE |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TIROSINT 125 MCG CAPSULE |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TIROSINT 13 MCG CAPSULE |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TIROSINT 137 MCG CAPSULE |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TIROSINT 150 MCG CAPSULE |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TIROSINT 175 MCG CAPSULE |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIROSINT 200 MCG CAPSULE |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TIROSINT 25 MCG CAPSULE |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TIROSINT 50 MCG CAPSULE |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TIROSINT 75 MCG CAPSULE |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TIROSINT 88 MCG CAPSULE |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TIVICAY 10 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TIVICAY 25 MG TABLET |
5 |
Specialty Tier |
28% | 28% | None |
TIVICAY 50 MG TABLET |
5 |
Specialty Tier |
28% | 28% | None |
TIZANIDINE HCL 2 MG CAPSULE |
2* |
Generic |
$10.00 | $20.00 | None |
TIZANIDINE HCL 2 MG TABLET |
2* |
Generic |
$10.00 | $20.00 | None |
TIZANIDINE HCL 4 MG CAPSULE |
2* |
Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIZANIDINE HCL 4 MG TABLET |
2* |
Generic |
$10.00 | $20.00 | None |
TIZANIDINE HCL 6 MG CAPSULE |
2* |
Generic |
$10.00 | $20.00 | None |
TOBI PODHALER 28 MG INHALE CAP |
5 |
Specialty Tier |
28% | 28% | Q:224 /56Days |
TOBRADEX EYE OINTMENT |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TOBRADEX ST 0.5; 3mg/mL; mg/mL 5 mL in 1 BOTTLE |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TOBRAMYCIN 0.3% EYE DROPS [Tobrex] |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
TOBRAMYCIN 10 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate] |
2* |
Generic |
$10.00 | $20.00 | None |
TOBRAMYCIN 300 MG/5 ML AMPULE [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate] |
5 |
Specialty Tier |
28% | 28% | P |
TOBRAMYCIN 40 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate] |
2* |
Generic |
$10.00 | $20.00 | None |
TOBRAMYCIN-DEXAMETH OPTH SUSP |
2* |
Generic |
$10.00 | $20.00 | None |
TOBREX 0.3% EYE OINTMENT |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | 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 |
$2.00 | $4.00 | None |
TOLAZAMIDE TABLETS 500MG 100 BOT |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
TOLBUTAMIDE 500 MG TABLET |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
Tolcapone 100 MG TABLET [Tasmar] |
5 |
Specialty Tier |
28% | 28% | None |
TOLMETIN SODIUM 400 MG CAP |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TOLMETIN SODIUM 600MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TOLSURA 65 MG CAPSULE SD DSP |
5 |
Specialty Tier |
28% | 28% | P |
TOLTERODINE TARTRATE 1 MG TAB [Detrol LA] |
2* |
Generic |
$10.00 | $20.00 | None |
TOLTERODINE TARTRATE 2 MG TABLET [Detrol] |
2* |
Generic |
$10.00 | $20.00 | None |
Tolterodine Tartrate 24 HR 4 MG Extended Release Oral Capsule [Detrol LA] |
2* |
Generic |
$10.00 | $20.00 | None |
Tolterodine Tartrate ER 2 MG CAPSULE [Detrol LA] |
2* |
Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOLVAPTAN 15 MG ORAL TABLET [SAMSCA] |
5 |
Specialty Tier |
28% | 28% | Q:30 /60Days |
TOLVAPTAN 30 MG ORAL TABLET [SAMSCA] |
5 |
Specialty Tier |
28% | 28% | Q:60 /30Days |
TOPIRAMATE 100 MG TABLET |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
TOPIRAMATE 15 MG SPRINKLE CAP |
2* |
Generic |
$10.00 | $20.00 | None |
TOPIRAMATE 200 MG TABLET |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
TOPIRAMATE 25 MG TABLET |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
Topiramate 25mg/1 |
2* |
Generic |
$10.00 | $20.00 | None |
TOPIRAMATE 50 MG TABLET |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
TOPIRAMATE ER 100 MG CAPSULE |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TOPIRAMATE ER 150 MG CAPSULE |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TOPIRAMATE ER 200 MG CAPSULE |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOPIRAMATE ER 25 MG CAPSULE |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TOPIRAMATE ER 50 MG CAPSULE |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TOREMIFENE CITRATE 60 MG TABLET [Fareston] |
5 |
Specialty Tier |
28% | 28% | None |
TORSEMIDE 10 MG TABLET |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
TORSEMIDE 100 MG TABLET |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
TORSEMIDE 20 MG TABLET |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
TORSEMIDE 5 MG TABLET |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
TOUJEO MAX SOLOSTAR 300UNIT/ML INSULN PEN |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
TOUJEO SOLOSTAR 300 UNITS/ML |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
TPN ELECTROLYTES16.5/25.4 VIAL |
2* |
Generic |
$10.00 | $20.00 | None |
TRADJENTA 5 MG TABLET |
3 |
Preferred Brand |
$45.00 | $90.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRAMADOL ER 100 MG TABLET |
2* |
Generic |
$10.00 | $20.00 | None |
TRAMADOL ER 200 MG TABLET |
2* |
Generic |
$10.00 | $20.00 | None |
TRAMADOL ER 300 MG TABLET |
2* |
Generic |
$10.00 | $20.00 | None |
TRAMADOL HCL 50 MG TABLET |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
TRAMADOL HCL ER 100 MG TABLET |
2* |
Generic |
$10.00 | $20.00 | None |
TRAMADOL HCL ER 200 MG TABLET |
2* |
Generic |
$10.00 | $20.00 | None |
TRAMADOL HCL ER 300 MG Tablet ER 24H [Ultram ER] |
2* |
Generic |
$10.00 | $20.00 | None |
TRAMADOL-ACETAMINOPHN 37.5-325 |
2* |
Generic |
$10.00 | $20.00 | None |
TRANDOLAPRIL 1 MG TABLET |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
TRANDOLAPRIL 2 MG TABLET |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
TRANDOLAPRIL 4 MG TABLET |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRANDOLAPRIL-VERAPAMIL ER 1-240 MG |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
TRANDOLAPRIL-VERAPAMIL ER 2-180 MG |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
TRANDOLAPRIL-VERAPAMIL ER 2-240 MG |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
TRANDOLAPRIL-VERAPAMIL ER 4-240 MG |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
tranexamic acid 650 mg tablet |
2* |
Generic |
$10.00 | $20.00 | None |
TRANSDERM-SCOP 1.5 MG/3 DAY |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TRANYLCYPROMINE SULF 10 MG TABLET [Parnate] |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TRAVASOL 10% SOLUTION VIAFLEX |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P |
TRAVATAN Z 0.04MG DROPS 2.5ML BOT |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:3 /25Days |
TRAZODONE 100 MG TABLET |
2* |
Generic |
$10.00 | $20.00 | None |
TRAZODONE 300 MG TABLET |
2* |
Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRAZODONE 50 MG TABLET |
2* |
Generic |
$10.00 | $20.00 | None |
TRAZODONE HCL TABLET USP 150MG (100 CT) |
2* |
Generic |
$10.00 | $20.00 | None |
TRECATOR 250MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TRELEGY ELLIPTA 100-62.5-25 |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:60 /30Days |
TRELSTAR 11.25 MG SYRINGE |
5 |
Specialty Tier |
28% | 28% | P Q:1 /84Days |
TRELSTAR 3.75 MG SYRINGE |
5 |
Specialty Tier |
28% | 28% | P Q:1 /28Days |
TREMFYA 100 MG/ML AUTOINJECTOR |
5 |
Specialty Tier |
28% | 28% | P |
TREMFYA 100 MG/ML SYRINGE |
5 |
Specialty Tier |
28% | 28% | P |
TRESIBA 100 UNIT/ML VIAL |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
TRESIBA FLEXTOUCH 100 UNITS/ML |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
TRESIBA FLEXTOUCH 200 UNITS/ML |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Tretinoin 0.0004 MG/MG Topical Gel |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P |
Tretinoin 0.001 MG/MG Topical Gel |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P |
TRETINOIN 0.01% GEL |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P |
TRETINOIN 0.025% CREAM |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P |
TRETINOIN 0.025% GEL |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P |
TRETINOIN 0.05% CREAM |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P |
TRETINOIN 0.05% GEL [Atralin] |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P |
TRETINOIN 0.1% CREAM |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P |
TRETINOIN 10MG CAPSULE |
5 |
Specialty Tier |
28% | 28% | None |
TREXALL 10MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TREXALL 15MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TREXALL 5MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TREXALL 7.5MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TRI-ESTARYLLA TABLET [Trinessa] |
2* |
Generic |
$10.00 | $20.00 | None |
TRI-LEGEST FE 5-7-9-7 TABLET |
2* |
Generic |
$10.00 | $20.00 | None |
TRI-LO-ESTARYLLA TABLET [Trinessa Lo] |
2* |
Generic |
$10.00 | $20.00 | None |
TRI-LO-SPRINTEC TABLET |
2* |
Generic |
$10.00 | $20.00 | None |
TRI-MILI 28 TABLET [Trinessa] |
2* |
Generic |
$10.00 | $20.00 | None |
TRI-PREVIFEM TABLET [Trinessa] |
2* |
Generic |
$10.00 | $20.00 | None |
TRI-SPRINTEC 7DAYSX3 28 TABLET |
2* |
Generic |
$10.00 | $20.00 | None |
TRI-VYLIBRA 28 TABLET [Trinessa] |
2* |
Generic |
$10.00 | $20.00 | None |
TRI-VYLIBRA LO TABLET [Trinessa Lo] |
2* |
Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIAMCINOLONE 0.025% CREAM |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
TRIAMCINOLONE 0.025% LOTION |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
TRIAMCINOLONE 0.025% OINT |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
TRIAMCINOLONE 0.1% CREAM |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
TRIAMCINOLONE 0.1% LOTION [Kenalog] |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
TRIAMCINOLONE 0.1% OINTMENT |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
TRIAMCINOLONE 0.1% PASTE |
2* |
Generic |
$10.00 | $20.00 | None |
Triamcinolone 0.147 MG/G Spray |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
Triamcinolone Acetonide 1 MG/ML Topical Cream [Triderm] |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
Triamcinolone Acetonide 5mg/g 1 TUBE per CARTON / 15 g in 1 TUBE |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIAMTERENE-HCTZ 37.5-25 MG CP |
2* |
Generic |
$10.00 | $20.00 | None |
TRIAMTERENE-HCTZ 37.5-25 MG TB |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
TRIAMTERENE-HCTZ 75-50 MG TAB |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
TRIENTINE HCL 250 MG CAPSULE [Syprine] |
5 |
Specialty Tier |
28% | 28% | None |
TRIFLUOPERAZINE 1 MG TABLET |
2* |
Generic |
$10.00 | $20.00 | None |
TRIFLUOPERAZINE HCL 2MG TABLET |
2* |
Generic |
$10.00 | $20.00 | None |
TRIFLUOPERAZINE HCL 5MG TABLET |
2* |
Generic |
$10.00 | $20.00 | None |
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT) |
2* |
Generic |
$10.00 | $20.00 | None |
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT |
2* |
Generic |
$10.00 | $20.00 | None |
TRIHEXYPHENIDYL 2 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TRIHEXYPHENIDYL 5 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Trihexyphenidyl Hydrochloride 2mg/5mL 473 mL in 1 BOTTLE |
2* |
Generic |
$10.00 | $20.00 | None |
TRILYTE WITH FLAVOR PACKETS |
2* |
Generic |
$10.00 | $20.00 | None |
TRIMETHOBENZAMIDE 300 MG CAP |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P |
TRIMETHOPRIM 100 MG TABLET |
1* |
Preferred Generic |
$2.00 | $4.00 | None |
TRIMIPRAMINE MALEATE 100 MG CP |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TRIMIPRAMINE MALEATE 25 MG CAP |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TRIMIPRAMINE MALEATE 50 MG CAP |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None |
TRINTELLIX 10 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | Q:30 /30Days |
TRINTELLIX 20 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | Q:30 /30Days |
TRINTELLIX 5 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | Q:30 /30Days |
Triptorelin 11.3 MG/ML Injectable Suspension [Trelstar] |
5 |
Specialty Tier |
28% | 28% | P Q:1 /168Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIUMEQ TABLET |
5 |
Specialty Tier |
28% | 28% | Q:30 /30Days |
TRIVORA-28 TABLET |
2* |
Generic |
$10.00 | $20.00 | None |
TROPHAMINE INJECTION SOLUTION |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P |
TROSPIUM CHLORIDE 20 MG TABLET |
2* |
Generic |
$10.00 | $20.00 | None |
TROSPIUM CHLORIDE ER 60 MG CAP |
2* |
Generic |
$10.00 | $20.00 | None |
TRULICITY 0.75 MG/0.5 ML PEN |
3 |
Preferred Brand |
$45.00 | $90.00 | S Q:2 /28Days |
TRULICITY 1.5 MG/0.5 ML PEN |
3 |
Preferred Brand |
$45.00 | $90.00 | S Q:2 /28Days |
TRUMENBA 120 MCG/0.5 ML VACCIN Syringe |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
TRUVADA 100 MG-150 MG TABLET |
5 |
Specialty Tier |
28% | 28% | Q:30 /30Days |
TRUVADA 133 MG-200 MG TABLET |
5 |
Specialty Tier |
28% | 28% | Q:30 /30Days |
TRUVADA 167 MG-250 MG TABLET |
5 |
Specialty Tier |
28% | 28% | 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 |
28% | 28% | Q:30 /30Days |
TUDORZA PRESSAIR 400 MCG INH |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | S Q:60 /30Days |
TUDORZA PRESSAIR 400 MCG INH |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | S Q:60 /30Days |
TWINRIX VACCINE SYRINGE |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
TYBOST 150 MG TABLET |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
TYDEMY TABLET |
2* |
Generic |
$10.00 | $20.00 | None |
TYKERB 250 MG TABLET |
5 |
Specialty Tier |
28% | 28% | P |
TYMLOS 80 MCG DOSE PEN INJECTR |
5 |
Specialty Tier |
28% | 28% | P |
TYPHIM VI 25 MCG/0.5 ML SYRINGE |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
TYPHIM VI 25MCG/0.5ML VIAL |
3 |
Preferred Brand |
$45.00 | $90.00 | None |