2019 Medicare Part D Plan Formulary Information |
Presbyterian MediCare PPO Plan 2 with Rx (PPO) (H3206-001-0)
Benefit Details
|
The Presbyterian MediCare PPO Plan 2 with Rx (PPO) (H3206-001-0) Formulary Drugs Starting with the Letter T in Colfax County, NM: CMS MA Region 20 which includes: NM Plan Monthly Premium: $175.00 Deductible: $325 |
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 | $285.00 | P |
Tacrolimus 0.03% ointment |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P Q:100 /60Days |
Tacrolimus 0.1% ointment |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P Q:120 /60Days |
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 |
2 |
Generic |
$10.00 | $20.00 | P |
TADALAFIL 20 MG TABLET [ALYQ] |
5 |
Specialty Tier |
25% | N/A | P Q:2 /1Days |
TAFINLAR 50 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:4 /1Days |
TAFINLAR 75 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:4 /1Days |
TAGRISSO 40 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:1 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAGRISSO 80 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:1 /1Days |
TALZENNA 0.25 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:3 /1Days |
TALZENNA 1 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:1 /1Days |
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 |
TARGRETIN 1% GEL |
5 |
Specialty Tier |
25% | N/A | P |
Tarina Fe 1-20 tablet |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
Tasigna 150mg/1 4 BLISTER PACK per CARTON / 28 CAPSULE per BLISTER PACK |
5 |
Specialty Tier |
25% | N/A | P Q:4 /1Days |
TASIGNA 200 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:4 /1Days |
TASIGNA 50 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:2 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAZAROTENE 0.1% CREAM [Tazorac] |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
TAZICEF 2 GRAM VIAL |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
TAZORAC 0.05% CREAM |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
TAZORAC 0.05% GEL |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
TAZORAC 0.1% GEL |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
TAZTIA DILTIAZEM HYDROCHLORIDE 120MG ER CAPSULES |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
TAZTIA XT 180 MG CAPSULE |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
TAZTIA XT 240MG CAPSULE SA |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
TAZTIA XT 300 MG CAPSULE |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
TAZTIA XT 360MG CAPSULE SA |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
Teflaro 400mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE |
5 |
Specialty Tier |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Teflaro 600mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE |
5 |
Specialty Tier |
25% | N/A | None |
TEMAZEPAM 15 MG CAPSULE |
2 |
Generic |
$10.00 | $20.00 | Q:2 /1Days |
TEMAZEPAM 30 MG CAPSULE |
2 |
Generic |
$10.00 | $20.00 | Q:1 /1Days |
TENIVAC SYRINGE |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
TENOFOVIR DISOP FUM 300 MG TABLET [Viread] |
5 |
Specialty Tier |
25% | N/A | None |
TERAZOSIN 1 MG CAPSULE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TERAZOSIN 10 MG CAPSULE [Hytrin] |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TERAZOSIN 2 MG CAPSULE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TERAZOSIN 5 MG CAPSULE [Hytrin] |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TERBINAFINE HCL 250 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | Q:90 /365Days |
TERBUTALINE SULFATE 2.5 MG TAB |
2 |
Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TERBUTALINE SULFATE 5MG TABLET |
2 |
Generic |
$10.00 | $20.00 | 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 | $112.50 | P Q:75 /30Days |
TESTOSTERONE 1.62% (2.5 G) PKT GEL PACKET [AndroGel] |
3 |
Preferred Brand |
$45.00 | $112.50 | P Q:150 /30Days |
TESTOSTERONE 1.62% GEL PUMP GEL MD PMP [AndroGel] |
3 |
Preferred Brand |
$45.00 | $112.50 | P Q:150 /30Days |
Testosterone 2500 MG 0.01 MG/MG Topical Gel |
3 |
Preferred Brand |
$45.00 | $112.50 | P Q:75 /30Days |
Testosterone 5000 MG 0.01 MG/MG Topical Gel |
3 |
Preferred Brand |
$45.00 | $112.50 | P Q:300 /30Days |
Testosterone cyp 100 mg/ml |
2 |
Generic |
$10.00 | $20.00 | P |
TESTOSTERONE CYP 200 MG/ML |
2 |
Generic |
$10.00 | $20.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TESTOSTERONE ENANTHATE 200MG/ML INJECTION |
2 |
Generic |
$10.00 | $20.00 | P |
TETRABENAZINE 12.5 MG TABLET [XENAZINE] |
5 |
Specialty Tier |
25% | N/A | P Q:3 /1Days |
TETRABENAZINE 25 MG TABLET [XENAZINE] |
5 |
Specialty Tier |
25% | N/A | P Q:4 /1Days |
TETRACYCLINE 500 MG CAPSULE |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
THALOMID 100 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P |
THALOMID 150 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P |
THALOMID 200 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P |
THALOMID 50 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P |
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 |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THIORIDAZINE 10 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
THIORIDAZINE 100MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
THIORIDAZINE 25 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
THIORIDAZINE 50 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
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 |
TIAGABINE HCL 12 MG TABLET [Gabitril] |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
TIAGABINE HCL 16 MG TABLET [Gabitril] |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
tiagabine hcl 2 mg tablet [Gabitril] |
2 |
Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
tiagabine hcl 4 mg tablet [Gabitril] |
2 |
Generic |
$10.00 | $20.00 | None |
TIBSOVO 250 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:2 /1Days |
TIGECYCLINE 50 MG VIAL [Tygacil] |
5 |
Specialty Tier |
25% | N/A | None |
TIGLUTIK 50 MG/10 ML Oral Suspension |
5 |
Specialty Tier |
25% | N/A | None |
TIMOLOL 0.25% EYE DROPS |
2 |
Generic |
$10.00 | $20.00 | None |
TIMOLOL 0.5% EYE DROPS |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
TIMOLOL 0.5% EYE DROPS |
2 |
Generic |
$10.00 | $20.00 | None |
TIMOLOL MALEATE 10MG TABLET |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
TIMOLOL MALEATE 20MG TABLET |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
TIMOLOL MALEATE 5MG TABLET |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
TIVICAY 10 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIVICAY 25 MG TABLET |
5 |
Specialty Tier |
25% | N/A | None |
TIVICAY 50 MG TABLET |
5 |
Specialty Tier |
25% | N/A | None |
TIZANIDINE HCL 2 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
TIZANIDINE HCL 4 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
TOBI PODHALER 28 MG INHALE CAP |
5 |
Specialty Tier |
25% | N/A | None |
TOBRADEX EYE OINTMENT |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
TOBRAMYCIN 0.3% EYE DROPS [Tobrex] |
2 |
Generic |
$10.00 | $20.00 | 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 |
25% | N/A | 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 |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOLBUTAMIDE 500 MG TABLET |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
Tolcapone 100 MG TABLET [Tasmar] |
5 |
Specialty Tier |
25% | N/A | None |
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] |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | S Q:1 /1Days |
Tolterodine Tartrate ER 2 MG CAPSULE [Detrol LA] |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | S Q:1 /1Days |
TOPIRAMATE 100 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
TOPIRAMATE 15 MG SPRINKLE CAP |
2 |
Generic |
$10.00 | $20.00 | None |
TOPIRAMATE 200 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
TOPIRAMATE 25 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
Topiramate 25mg/1 |
2 |
Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOPIRAMATE 50 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
TOREMIFENE CITRATE 60 MG TABLET [Fareston] |
5 |
Specialty Tier |
25% | N/A | Q:1 /1Days |
TORSEMIDE 10 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
TORSEMIDE 100 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
TORSEMIDE 20 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
TORSEMIDE 5 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
TPN ELECTROLYTES16.5/25.4 VIAL |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
TRADJENTA 5 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | S Q:1 /1Days |
TRAMADOL HCL 50 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | Q:8 /1Days |
TRAMADOL HCL ER 100 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | Q:3 /1Days |
TRAMADOL HCL ER 200 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | Q:1 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
tranexamic acid 650 mg tablet |
2 |
Generic |
$10.00 | $20.00 | None |
TRANYLCYPROMINE SULF 10 MG TABLET [Parnate] |
2 |
Generic |
$10.00 | $20.00 | None |
TRAVATAN Z 0.04MG DROPS 2.5ML BOT |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
TRAZODONE 100 MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TRAZODONE 300 MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TRAZODONE 50 MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TRAZODONE HCL TABLET USP 150MG (100 CT) |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
TRECATOR 250MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
TRESIBA 100 UNIT/ML VIAL |
3 |
Preferred Brand |
$45.00 | $112.50 | Q:50 /30Days |
TRESIBA FLEXTOUCH 100 UNITS/ML |
3 |
Preferred Brand |
$45.00 | $112.50 | Q:45 /30Days |
TRESIBA FLEXTOUCH 200 UNITS/ML |
3 |
Preferred Brand |
$45.00 | $112.50 | Q:45 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRETINOIN 0.025% CREAM |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
TRETINOIN 0.05% CREAM |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
TRETINOIN 0.1% CREAM |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
TRETINOIN 10MG CAPSULE |
2 |
Generic |
$10.00 | $20.00 | None |
TRI-ESTARYLLA TABLET [Trinessa] |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
TRI-LEGEST FE 5-7-9-7 TABLET |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
TRI-MILI 28 TABLET [Trinessa] |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
TRI-PREVIFEM TABLET [Trinessa] |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
TRI-SPRINTEC 7DAYSX3 28 TABLET |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
TRI-VYLIBRA 28 TABLET [Trinessa] |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
TRIAMCINOLONE 0.025% CREAM |
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% LOTION |
2 |
Generic |
$10.00 | $20.00 | None |
TRIAMCINOLONE 0.025% OINT |
2 |
Generic |
$10.00 | $20.00 | None |
TRIAMCINOLONE 0.1% CREAM |
2 |
Generic |
$10.00 | $20.00 | None |
TRIAMCINOLONE 0.1% LOTION [Kenalog] |
2 |
Generic |
$10.00 | $20.00 | None |
TRIAMCINOLONE 0.1% OINTMENT |
2 |
Generic |
$10.00 | $20.00 | None |
TRIAMCINOLONE 0.1% PASTE |
2 |
Generic |
$10.00 | $20.00 | None |
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
Triamcinolone Acetonide 1 MG/ML Topical Cream [Triderm] |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
Triamcinolone Acetonide 5mg/g 1 TUBE per CARTON / 15 g in 1 TUBE |
2 |
Generic |
$10.00 | $20.00 | None |
TRIAMTERENE-HCTZ 37.5-25 MG CP |
2 |
Generic |
$10.00 | $20.00 | None |
TRIAMTERENE-HCTZ 37.5-25 MG TB |
2 |
Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIAMTERENE-HCTZ 75-50 MG TAB |
2 |
Generic |
$10.00 | $20.00 | None |
TRIAZOLAM 0.125 MG TABLET [Halcion] |
2 |
Generic |
$10.00 | $20.00 | Q:2 /1Days |
TRIAZOLAM 0.25 MG TABLET [Halcion] |
2 |
Generic |
$10.00 | $20.00 | Q:2 /1Days |
TRIENTINE HCL 250 MG CAPSULE [Syprine] |
5 |
Specialty Tier |
25% | N/A | 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 |
2 |
Generic |
$10.00 | $20.00 | None |
TRIHEXYPHENIDYL 5 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 |
Trihexyphenidyl Hydrochloride 2mg/5mL 473 mL in 1 BOTTLE |
2 |
Generic |
$10.00 | $20.00 | None |
TRILYTE WITH FLAVOR PACKETS |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
TRIMETHOPRIM 100 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
TRIMIPRAMINE MALEATE 100 MG CP |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P |
TRIMIPRAMINE MALEATE 25 MG CAP |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P |
TRIMIPRAMINE MALEATE 50 MG CAP |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P |
TRINTELLIX 10 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | S Q:1 /1Days |
TRINTELLIX 20 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | S Q:1 /1Days |
TRINTELLIX 5 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | S Q:1 /1Days |
TRIUMEQ TABLET |
5 |
Specialty Tier |
25% | N/A | None |
TRIVORA-28 TABLET |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TROSPIUM CHLORIDE 20 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
TROSPIUM CHLORIDE ER 60 MG CAP |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | S Q:1 /1Days |
TRULICITY 0.75 MG/0.5 ML PEN |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | S Q:2 /28Days |
TRULICITY 1.5 MG/0.5 ML PEN |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | S Q:2 /28Days |
TRUMENBA 120 MCG/0.5 ML VACCIN Syringe |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
TRUVADA 100 MG-150 MG TABLET |
5 |
Specialty Tier |
25% | N/A | None |
TRUVADA 133 MG-200 MG TABLET |
5 |
Specialty Tier |
25% | N/A | None |
TRUVADA 167 MG-250 MG TABLET |
5 |
Specialty Tier |
25% | N/A | None |
TRUVADA 200/300MG TABLET |
5 |
Specialty Tier |
25% | N/A | None |
TUDORZA PRESSAIR 400 MCG INH |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
TWINRIX VACCINE SYRINGE |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TYBOST 150 MG TABLET |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
TYKERB 250 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:6 /1Days |
TYMLOS 80 MCG DOSE PEN INJECTR |
5 |
Specialty Tier |
25% | N/A | P Q:2 /30Days |
TYPHIM VI 25 MCG/0.5 ML SYRINGE |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
TYPHIM VI 25MCG/0.5ML VIAL |
3 |
Preferred Brand |
$45.00 | $112.50 | None |