2019 Medicare Part D Plan Formulary Information |
PriorityMedicare Value (HMO-POS) (H2320-011-0)
Benefit Details
|
The PriorityMedicare Value (HMO-POS) (H2320-011-0) Formulary Drugs Starting with the Letter T in Osceola County, MI: CMS MA Region 11 which includes: MI Plan Monthly Premium: $27.00 Deductible: $75 |
Drugs Starting with Letter T
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
TABLOID 40 MG TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
Tacrolimus 0.03% ointment |
4 |
Non-Preferred Drug |
45% | 45% | Q:100 /30Days |
Tacrolimus 0.1% ointment |
4 |
Non-Preferred Drug |
45% | 45% | Q:100 /30Days |
TACROLIMUS 0.5 MG CAPSULE |
2 |
Generic |
$10.00 | $0.00 | P |
TACROLIMUS 1 MG CAPSULE |
2 |
Generic |
$10.00 | $0.00 | P |
TACROLIMUS 5 MG CAPSULE |
2 |
Generic |
$10.00 | $0.00 | P |
TADALAFIL 2.5 MG TABLET [Cialis] |
4 |
Non-Preferred Drug |
45% | 45% | P Q:30 /30Days |
TADALAFIL 20 MG TABLET [ALYQ] |
5 |
Specialty Tier |
31% | N/A | P |
TADALAFIL 5 MG TABLET [Cialis] |
4 |
Non-Preferred Drug |
45% | 45% | P Q:30 /30Days |
TAFINLAR 50 MG CAPSULE |
5 |
Specialty Tier |
31% | N/A | P Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAFINLAR 75 MG CAPSULE |
5 |
Specialty Tier |
31% | N/A | P Q:120 /30Days |
TAGRISSO 40 MG TABLET |
5 |
Specialty Tier |
31% | N/A | P Q:30 /30Days |
TAGRISSO 80 MG TABLET |
5 |
Specialty Tier |
31% | N/A | P Q:30 /30Days |
TAKHZYRO 300 MG/2 ML VIAL |
5 |
Specialty Tier |
31% | N/A | P |
TALZENNA 0.25 MG CAPSULE |
5 |
Specialty Tier |
31% | N/A | P Q:30 /30Days |
TALZENNA 1 MG CAPSULE |
5 |
Specialty Tier |
31% | N/A | P Q:30 /30Days |
TAMOXIFEN 10 MG TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
TAMOXIFEN CITRATE 20MG TABLET (30 CT) |
2 |
Generic |
$10.00 | $0.00 | None |
TAMSULOSIN HCL 0.4 MG CAPSULE |
1 |
Preferred Generic |
$2.00 | $0.00 | None |
TARCEVA 100MG TABLET |
5 |
Specialty Tier |
31% | N/A | P |
TARCEVA 150MG TABLET |
5 |
Specialty Tier |
31% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TARCEVA 25MG TABLET |
5 |
Specialty Tier |
31% | N/A | P |
TARGRETIN 1% GEL |
5 |
Specialty Tier |
31% | N/A | P |
TARGRETIN 75 MG CAPSULE |
5 |
Specialty Tier |
31% | N/A | P |
Tasigna 150mg/1 4 BLISTER PACK per CARTON / 28 CAPSULE per BLISTER PACK |
5 |
Specialty Tier |
31% | N/A | P |
TASIGNA 200 MG CAPSULE |
5 |
Specialty Tier |
31% | N/A | P |
TASIGNA 50 MG CAPSULE |
5 |
Specialty Tier |
31% | N/A | P |
TAZAROTENE 0.1% CREAM [Tazorac] |
4 |
Non-Preferred Drug |
45% | 45% | None |
TAZICEF 1GM VIAL |
2 |
Generic |
$10.00 | $0.00 | None |
TAZICEF 2 GRAM VIAL |
2 |
Generic |
$10.00 | $0.00 | None |
TAZICEF 6 GRAM VIAL |
2 |
Generic |
$10.00 | $0.00 | None |
TAZTIA DILTIAZEM HYDROCHLORIDE 120MG ER CAPSULES |
2 |
Generic |
$10.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAZTIA XT 180 MG CAPSULE |
2 |
Generic |
$10.00 | $0.00 | None |
TAZTIA XT 240MG CAPSULE SA |
2 |
Generic |
$10.00 | $0.00 | None |
TAZTIA XT 300 MG CAPSULE |
2 |
Generic |
$10.00 | $0.00 | None |
TAZTIA XT 360MG CAPSULE SA |
2 |
Generic |
$10.00 | $0.00 | None |
TECFIDERA DR 120 MG CAPSULE |
5 |
Specialty Tier |
31% | N/A | None |
TECFIDERA DR 240 MG CAPSULE |
5 |
Specialty Tier |
31% | N/A | None |
TECFIDERA STARTER PACK |
5 |
Specialty Tier |
31% | N/A | None |
Teflaro 400mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE |
4 |
Non-Preferred Drug |
45% | 45% | None |
Teflaro 600mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE |
4 |
Non-Preferred Drug |
45% | 45% | None |
TEKTURNA 150 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
TEKTURNA 300 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TEKTURNA HCT 300-25 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
TELMISARTAN 20 MG TABLET [Micardis] |
2 |
Generic |
$10.00 | $0.00 | None |
TELMISARTAN 40 MG TABLET [Micardis] |
2 |
Generic |
$10.00 | $0.00 | None |
TELMISARTAN 80 MG TABLET [Micardis] |
2 |
Generic |
$10.00 | $0.00 | None |
Telmisartan-Amlodipine 40-10 MG [Micardis] |
2 |
Generic |
$10.00 | $0.00 | None |
Telmisartan-Amlodipine 40-5 MG [Micardis] |
2 |
Generic |
$10.00 | $0.00 | None |
Telmisartan-Amlodipine 80-10 MG [Micardis] |
2 |
Generic |
$10.00 | $0.00 | None |
Telmisartan-Amlodipine 80-5 MG [Micardis] |
2 |
Generic |
$10.00 | $0.00 | None |
TELMISARTAN-HCTZ 40-12.5 MG TB [Micardis] |
2 |
Generic |
$10.00 | $0.00 | None |
TELMISARTAN-HCTZ 80-12.5 MG TAB [Micardis HCT] |
2 |
Generic |
$10.00 | $0.00 | None |
TELMISARTAN-HCTZ 80-25 MG TAB [Micardis HCT] |
2 |
Generic |
$10.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TEMAZEPAM 15 MG CAPSULE |
1 |
Preferred Generic |
$2.00 | $0.00 | None |
TEMAZEPAM 22.5 MG CAPSULE |
2 |
Generic |
$10.00 | $0.00 | None |
TEMAZEPAM 30 MG CAPSULE |
1 |
Preferred Generic |
$2.00 | $0.00 | None |
Temazepam 7.5mg/1 100 CAPSULE BOTTLE, PLASTIC |
2 |
Generic |
$10.00 | $0.00 | None |
TENIVAC SYRINGE |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
TENOFOVIR DISOP FUM 300 MG TABLET [Viread] |
5 |
Specialty Tier |
31% | N/A | None |
TERAZOSIN 1 MG CAPSULE |
1 |
Preferred Generic |
$2.00 | $0.00 | None |
TERAZOSIN 10 MG CAPSULE [Hytrin] |
1 |
Preferred Generic |
$2.00 | $0.00 | None |
TERAZOSIN 2 MG CAPSULE |
1 |
Preferred Generic |
$2.00 | $0.00 | None |
TERAZOSIN 5 MG CAPSULE [Hytrin] |
1 |
Preferred Generic |
$2.00 | $0.00 | None |
TERBINAFINE HCL 250 MG TABLET |
2 |
Generic |
$10.00 | $0.00 | 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 |
$10.00 | $0.00 | None |
TERBUTALINE SULFATE 5MG TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
TERCONAZOLE 0.4% CREAM WITH APPLICATOR |
2 |
Generic |
$10.00 | $0.00 | None |
TERCONAZOLE 0.8% CREAM |
2 |
Generic |
$10.00 | $0.00 | None |
TERCONAZOLE 80MG SUPPOSITORY VAGINAL |
2 |
Generic |
$10.00 | $0.00 | None |
TESTOSTERONE 1.62% (1.25 G) PKT GEL PACKET [AndroGel] |
4 |
Non-Preferred Drug |
45% | 45% | P |
TESTOSTERONE 1.62% (2.5 G) PKT GEL PACKET [AndroGel] |
4 |
Non-Preferred Drug |
45% | 45% | P |
TESTOSTERONE 1.62% GEL PUMP GEL MD PMP [AndroGel] |
4 |
Non-Preferred Drug |
45% | 45% | P |
TESTOSTERONE 10 MG GEL PUMP |
4 |
Non-Preferred Drug |
45% | 45% | P |
TESTOSTERONE 12.5 MG/1.25 GRAM |
4 |
Non-Preferred Drug |
45% | 45% | P |
Testosterone 2500 MG 0.01 MG/MG Topical Gel |
4 |
Non-Preferred Drug |
45% | 45% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TESTOSTERONE 30 MG/1.5 ML PUMP |
4 |
Non-Preferred Drug |
45% | 45% | P |
Testosterone 5000 MG 0.01 MG/MG Topical Gel |
4 |
Non-Preferred Drug |
45% | 45% | P |
Testosterone cyp 100 mg/ml |
2 |
Generic |
$10.00 | $0.00 | None |
TESTOSTERONE CYP 200 MG/ML |
2 |
Generic |
$10.00 | $0.00 | None |
TESTOSTERONE ENANTHATE 200MG/ML INJECTION |
2 |
Generic |
$10.00 | $0.00 | None |
TETRABENAZINE 12.5 MG TABLET [XENAZINE] |
5 |
Specialty Tier |
31% | N/A | None |
TETRABENAZINE 25 MG TABLET [XENAZINE] |
5 |
Specialty Tier |
31% | N/A | None |
TETRACYCLINE 250 MG CAPSULE |
1 |
Preferred Generic |
$2.00 | $0.00 | None |
TETRACYCLINE 500 MG CAPSULE |
1 |
Preferred Generic |
$2.00 | $0.00 | None |
THALOMID 100 MG CAPSULE |
5 |
Specialty Tier |
31% | N/A | P |
THALOMID 150 MG CAPSULE |
5 |
Specialty Tier |
31% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THALOMID 200 MG CAPSULE |
5 |
Specialty Tier |
31% | N/A | P |
THALOMID 50 MG CAPSULE |
5 |
Specialty Tier |
31% | N/A | P |
THEOPHYLLINE ER 100 MG TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
THEOPHYLLINE ER 200 MG TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
THEOPHYLLINE ER 300 MG TAB |
2 |
Generic |
$10.00 | $0.00 | None |
THEOPHYLLINE ER 400 MG TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
THEOPHYLLINE ER 600 MG TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
THIORIDAZINE 10 MG TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
THIORIDAZINE 100MG TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
THIORIDAZINE 25 MG TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
THIORIDAZINE 50 MG TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
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 | $0.00 | None |
THIOTHIXENE 10MG CAPSULE |
2 |
Generic |
$10.00 | $0.00 | None |
THIOTHIXENE 2MG CAPSULE |
2 |
Generic |
$10.00 | $0.00 | None |
THIOTHIXENE 5MG CAPSULE |
2 |
Generic |
$10.00 | $0.00 | None |
THYROLAR-1 TABLETS |
4 |
Non-Preferred Drug |
45% | 45% | None |
THYROLAR-1/2 TABLETS |
4 |
Non-Preferred Drug |
45% | 45% | None |
THYROLAR-1/4 TABLETS |
4 |
Non-Preferred Drug |
45% | 45% | None |
THYROLAR-2 TABLETS |
4 |
Non-Preferred Drug |
45% | 45% | None |
THYROLAR-3 TABLETS |
4 |
Non-Preferred Drug |
45% | 45% | None |
TIAGABINE HCL 12 MG TABLET [Gabitril] |
4 |
Non-Preferred Drug |
45% | 45% | None |
TIAGABINE HCL 16 MG TABLET [Gabitril] |
4 |
Non-Preferred Drug |
45% | 45% | 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 |
45% | 45% | None |
tiagabine hcl 4 mg tablet [Gabitril] |
4 |
Non-Preferred Drug |
45% | 45% | None |
TIBSOVO 250 MG TABLET |
5 |
Specialty Tier |
31% | N/A | P |
TIGECYCLINE 50 MG VIAL [Tygacil] |
4 |
Non-Preferred Drug |
45% | 45% | None |
TIKOSYN .125MG CAPSULE |
4 |
Non-Preferred Drug |
45% | 45% | None |
TIKOSYN .250MG CAPSULE |
4 |
Non-Preferred Drug |
45% | 45% | None |
TIKOSYN .5MG CAPSULE |
4 |
Non-Preferred Drug |
45% | 45% | None |
TIMOLOL 0.25% EYE DROPS |
1 |
Preferred Generic |
$2.00 | $0.00 | None |
TIMOLOL 0.25% GFS GEL-SOLUTION |
4 |
Non-Preferred Drug |
45% | 45% | None |
TIMOLOL 0.5% EYE DROPS |
1 |
Preferred Generic |
$2.00 | $0.00 | None |
TIMOLOL 0.5% GFS GEL-SOLUTION |
4 |
Non-Preferred Drug |
45% | 45% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIMOLOL MALEATE 10MG TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
TIMOLOL MALEATE 20MG TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
TIMOLOL MALEATE 5MG TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
TIROSINT 100 MCG CAPSULE |
4 |
Non-Preferred Drug |
45% | 45% | None |
TIROSINT 112 MCG CAPSULE |
4 |
Non-Preferred Drug |
45% | 45% | None |
TIROSINT 125 MCG CAPSULE |
4 |
Non-Preferred Drug |
45% | 45% | None |
TIROSINT 13 MCG CAPSULE |
4 |
Non-Preferred Drug |
45% | 45% | None |
TIROSINT 137 MCG CAPSULE |
4 |
Non-Preferred Drug |
45% | 45% | None |
TIROSINT 150 MCG CAPSULE |
4 |
Non-Preferred Drug |
45% | 45% | None |
TIROSINT 175 MCG CAPSULE |
4 |
Non-Preferred Drug |
45% | 45% | None |
TIROSINT 200 MCG CAPSULE |
4 |
Non-Preferred Drug |
45% | 45% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIROSINT 25 MCG CAPSULE |
4 |
Non-Preferred Drug |
45% | 45% | None |
TIROSINT 50 MCG CAPSULE |
4 |
Non-Preferred Drug |
45% | 45% | None |
TIROSINT 75 MCG CAPSULE |
4 |
Non-Preferred Drug |
45% | 45% | None |
TIROSINT 88 MCG CAPSULE |
4 |
Non-Preferred Drug |
45% | 45% | None |
TIROSINT-SOL 100 MCG/ML SOLUTION |
4 |
Non-Preferred Drug |
45% | 45% | None |
TIROSINT-SOL 112 MCG/ML SOLUTION |
4 |
Non-Preferred Drug |
45% | 45% | None |
TIROSINT-SOL 125 MCG/ML SOLUTION |
4 |
Non-Preferred Drug |
45% | 45% | None |
TIROSINT-SOL 13 MCG/ML SOLUTION |
4 |
Non-Preferred Drug |
45% | 45% | None |
TIROSINT-SOL 137 MCG/ML SOLUTION |
4 |
Non-Preferred Drug |
45% | 45% | None |
TIROSINT-SOL 150 MCG/ML SOLUTION |
4 |
Non-Preferred Drug |
45% | 45% | None |
TIROSINT-SOL 175 MCG/ML SOLUTION |
4 |
Non-Preferred Drug |
45% | 45% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIROSINT-SOL 200 MCG/ML SOLUTION |
4 |
Non-Preferred Drug |
45% | 45% | None |
TIROSINT-SOL 25 MCG/ML SOLUTION |
4 |
Non-Preferred Drug |
45% | 45% | None |
TIROSINT-SOL 50 MCG/ML SOLUTION |
4 |
Non-Preferred Drug |
45% | 45% | None |
TIROSINT-SOL 75 MCG/ML SOLUTION |
4 |
Non-Preferred Drug |
45% | 45% | None |
TIROSINT-SOL 88 MCG/ML SOLUTION |
4 |
Non-Preferred Drug |
45% | 45% | None |
TIVICAY 10 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | Q:30 /30Days |
TIVICAY 25 MG TABLET |
5 |
Specialty Tier |
31% | N/A | Q:30 /30Days |
TIVICAY 50 MG TABLET |
5 |
Specialty Tier |
31% | N/A | Q:60 /30Days |
TIZANIDINE HCL 2 MG CAPSULE |
2 |
Generic |
$10.00 | $0.00 | None |
TIZANIDINE HCL 2 MG TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
TIZANIDINE HCL 4 MG CAPSULE |
2 |
Generic |
$10.00 | $0.00 | 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 | $0.00 | None |
TIZANIDINE HCL 6 MG CAPSULE |
2 |
Generic |
$10.00 | $0.00 | None |
TOBRADEX EYE OINTMENT |
4 |
Non-Preferred Drug |
45% | 45% | None |
TOBRAMYCIN 0.3% EYE DROPS [Tobrex] |
2 |
Generic |
$10.00 | $0.00 | None |
TOBRAMYCIN 10 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate] |
2 |
Generic |
$10.00 | $0.00 | None |
TOBRAMYCIN 300 MG/5 ML AMPULE [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate] |
5 |
Specialty Tier |
31% | N/A | P |
TOBRAMYCIN 40 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate] |
2 |
Generic |
$10.00 | $0.00 | None |
TOBRAMYCIN-DEXAMETH OPTH SUSP |
2 |
Generic |
$10.00 | $0.00 | None |
TOBREX 0.3% EYE OINTMENT |
4 |
Non-Preferred Drug |
45% | 45% | None |
TOLAK 4% CREAM |
4 |
Non-Preferred Drug |
45% | 45% | None |
TOLAZAMIDE TABLETS 250MG 100 BOT |
2 |
Generic |
$10.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOLAZAMIDE TABLETS 500MG 100 BOT |
2 |
Generic |
$10.00 | $0.00 | None |
TOLBUTAMIDE 500 MG TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
Tolcapone 100 MG TABLET [Tasmar] |
5 |
Specialty Tier |
31% | N/A | None |
TOLMETIN SODIUM 400 MG CAP |
2 |
Generic |
$10.00 | $0.00 | None |
TOLMETIN SODIUM 600MG TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
TOLTERODINE TARTRATE 1 MG TAB [Detrol LA] |
2 |
Generic |
$10.00 | $0.00 | None |
TOLTERODINE TARTRATE 2 MG TABLET [Detrol] |
2 |
Generic |
$10.00 | $0.00 | None |
Tolterodine Tartrate 24 HR 4 MG Extended Release Oral Capsule [Detrol LA] |
2 |
Generic |
$10.00 | $0.00 | None |
Tolterodine Tartrate ER 2 MG CAPSULE [Detrol LA] |
2 |
Generic |
$10.00 | $0.00 | None |
TOLVAPTAN 15 MG ORAL TABLET [SAMSCA] |
5 |
Specialty Tier |
31% | N/A | P |
TOLVAPTAN 30 MG ORAL TABLET [SAMSCA] |
5 |
Specialty Tier |
31% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOPIRAMATE 100 MG TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
TOPIRAMATE 15 MG SPRINKLE CAP |
2 |
Generic |
$10.00 | $0.00 | None |
TOPIRAMATE 200 MG TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
TOPIRAMATE 25 MG TABLET |
1 |
Preferred Generic |
$2.00 | $0.00 | None |
Topiramate 25mg/1 |
2 |
Generic |
$10.00 | $0.00 | None |
TOPIRAMATE 50 MG TABLET |
1 |
Preferred Generic |
$2.00 | $0.00 | None |
TOPIRAMATE ER 100 MG CAPSULE |
4 |
Non-Preferred Drug |
45% | 45% | S |
TOPIRAMATE ER 150 MG CAPSULE |
4 |
Non-Preferred Drug |
45% | 45% | S |
TOPIRAMATE ER 200 MG CAPSULE |
4 |
Non-Preferred Drug |
45% | 45% | S |
TOPIRAMATE ER 25 MG CAPSULE |
4 |
Non-Preferred Drug |
45% | 45% | S |
TOPIRAMATE ER 50 MG CAPSULE |
4 |
Non-Preferred Drug |
45% | 45% | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOREMIFENE CITRATE 60 MG TABLET [Fareston] |
5 |
Specialty Tier |
31% | N/A | None |
TORSEMIDE 10 MG TABLET |
1 |
Preferred Generic |
$2.00 | $0.00 | None |
TORSEMIDE 100 MG TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
TORSEMIDE 20 MG TABLET |
1 |
Preferred Generic |
$2.00 | $0.00 | None |
TORSEMIDE 5 MG TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
TOUJEO MAX SOLOSTAR 300UNIT/ML INSULN PEN |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
TOUJEO SOLOSTAR 300 UNITS/ML |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
TOVIAZ TABLETS 4MG EXTENDED RELEASE |
4 |
Non-Preferred Drug |
45% | 45% | None |
TOVIAZ TABLETS 8MG EXTENDED RELEASE |
4 |
Non-Preferred Drug |
45% | 45% | None |
TRACLEER 125MG TABLET |
5 |
Specialty Tier |
31% | N/A | None |
TRACLEER 32 MG TABLET FOR SUSP |
5 |
Specialty Tier |
31% | N/A | Q:112 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRACLEER 62.5MG TABLET |
5 |
Specialty Tier |
31% | N/A | None |
TRADJENTA 5 MG TABLET |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:30 /30Days |
TRAMADOL HCL 50 MG TABLET |
2 |
Generic |
$10.00 | $0.00 | Q:240 /30Days |
TRAMADOL HCL ER 100 MG TABLET |
2 |
Generic |
$10.00 | $0.00 | Q:30 /30Days |
TRAMADOL HCL ER 200 MG TABLET |
2 |
Generic |
$10.00 | $0.00 | Q:30 /30Days |
TRAMADOL HCL ER 300 MG Tablet ER 24H [Ultram ER] |
2 |
Generic |
$10.00 | $0.00 | Q:30 /30Days |
TRAMADOL-ACETAMINOPHN 37.5-325 |
2 |
Generic |
$10.00 | $0.00 | Q:240 /30Days |
TRANDOLAPRIL 1 MG TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
TRANDOLAPRIL 2 MG TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
TRANDOLAPRIL 4 MG TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
TRANDOLAPRIL-VERAPAMIL ER 1-240 MG |
2 |
Generic |
$10.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRANDOLAPRIL-VERAPAMIL ER 2-180 MG |
2 |
Generic |
$10.00 | $0.00 | None |
TRANDOLAPRIL-VERAPAMIL ER 2-240 MG |
2 |
Generic |
$10.00 | $0.00 | None |
TRANDOLAPRIL-VERAPAMIL ER 4-240 MG |
2 |
Generic |
$10.00 | $0.00 | None |
tranexamic acid 650 mg tablet |
2 |
Generic |
$10.00 | $0.00 | None |
TRANYLCYPROMINE SULF 10 MG TABLET [Parnate] |
2 |
Generic |
$10.00 | $0.00 | None |
TRAVATAN Z 0.04MG DROPS 2.5ML BOT |
4 |
Non-Preferred Drug |
45% | 45% | None |
TRAZODONE 100 MG TABLET |
1 |
Preferred Generic |
$2.00 | $0.00 | None |
TRAZODONE 300 MG TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
TRAZODONE 50 MG TABLET |
1 |
Preferred Generic |
$2.00 | $0.00 | None |
TRAZODONE HCL TABLET USP 150MG (100 CT) |
1 |
Preferred Generic |
$2.00 | $0.00 | None |
TRECATOR 250MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRELEGY ELLIPTA 100-62.5-25 |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
TRELSTAR 11.25 MG SYRINGE |
5 |
Specialty Tier |
31% | N/A | P |
TRELSTAR 3.75 MG SYRINGE |
5 |
Specialty Tier |
31% | N/A | P |
TREMFYA 100 MG/ML AUTOINJECTOR |
5 |
Specialty Tier |
31% | N/A | P |
TREMFYA 100 MG/ML SYRINGE |
5 |
Specialty Tier |
31% | N/A | P |
TRESIBA 100 UNIT/ML VIAL |
4 |
Non-Preferred Drug |
45% | 45% | None |
TRESIBA FLEXTOUCH 100 UNITS/ML |
4 |
Non-Preferred Drug |
45% | 45% | None |
TRESIBA FLEXTOUCH 200 UNITS/ML |
4 |
Non-Preferred Drug |
45% | 45% | None |
Tretinoin 0.0004 MG/MG Topical Gel |
4 |
Non-Preferred Drug |
45% | 45% | None |
Tretinoin 0.001 MG/MG Topical Gel |
4 |
Non-Preferred Drug |
45% | 45% | None |
TRETINOIN 0.01% GEL |
2 |
Generic |
$10.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRETINOIN 0.025% CREAM |
2 |
Generic |
$10.00 | $0.00 | None |
TRETINOIN 0.025% GEL |
2 |
Generic |
$10.00 | $0.00 | None |
TRETINOIN 0.05% CREAM |
2 |
Generic |
$10.00 | $0.00 | None |
TRETINOIN 0.05% GEL [Atralin] |
4 |
Non-Preferred Drug |
45% | 45% | None |
TRETINOIN 0.1% CREAM |
2 |
Generic |
$10.00 | $0.00 | None |
TRETINOIN 10MG CAPSULE |
5 |
Specialty Tier |
31% | N/A | P |
TREXALL 10MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | P |
TREXALL 15MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | P |
TREXALL 5MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | P |
TREXALL 7.5MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | P |
TREXIMET 10-60 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | S Q:18 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRI-ESTARYLLA TABLET [Trinessa] |
2 |
Generic |
$10.00 | $0.00 | None |
TRI-LEGEST FE 5-7-9-7 TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
TRI-LO-ESTARYLLA TABLET [Trinessa Lo] |
2 |
Generic |
$10.00 | $0.00 | None |
TRI-LO-SPRINTEC TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
TRI-PREVIFEM TABLET [Trinessa] |
2 |
Generic |
$10.00 | $0.00 | None |
TRI-SPRINTEC 7DAYSX3 28 TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
TRI-VYLIBRA 28 TABLET [Trinessa] |
2 |
Generic |
$10.00 | $0.00 | None |
TRIAMCINOLONE 0.025% CREAM |
2 |
Generic |
$10.00 | $0.00 | None |
TRIAMCINOLONE 0.025% LOTION |
2 |
Generic |
$10.00 | $0.00 | None |
TRIAMCINOLONE 0.025% OINT |
2 |
Generic |
$10.00 | $0.00 | None |
TRIAMCINOLONE 0.1% CREAM |
2 |
Generic |
$10.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIAMCINOLONE 0.1% LOTION [Kenalog] |
2 |
Generic |
$10.00 | $0.00 | None |
TRIAMCINOLONE 0.1% OINTMENT |
2 |
Generic |
$10.00 | $0.00 | None |
TRIAMCINOLONE 0.1% PASTE |
2 |
Generic |
$10.00 | $0.00 | None |
Triamcinolone 0.147 MG/G Spray |
2 |
Generic |
$10.00 | $0.00 | None |
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE |
2 |
Generic |
$10.00 | $0.00 | None |
Triamcinolone Acetonide 1 MG/ML Topical Cream [Triderm] |
2 |
Generic |
$10.00 | $0.00 | None |
Triamcinolone Acetonide 5mg/g 1 TUBE per CARTON / 15 g in 1 TUBE |
2 |
Generic |
$10.00 | $0.00 | None |
TRIAMTERENE-HCTZ 37.5-25 MG CP |
2 |
Generic |
$10.00 | $0.00 | None |
TRIAMTERENE-HCTZ 37.5-25 MG TB |
2 |
Generic |
$10.00 | $0.00 | None |
TRIAMTERENE-HCTZ 75-50 MG TAB |
2 |
Generic |
$10.00 | $0.00 | None |
TRIAZOLAM 0.125 MG TABLET [Halcion] |
4 |
Non-Preferred Drug |
45% | 45% | Q:10 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIAZOLAM 0.25 MG TABLET [Halcion] |
4 |
Non-Preferred Drug |
45% | 45% | Q:10 /30Days |
TRIENTINE HCL 250 MG CAPSULE [Syprine] |
2 |
Generic |
$10.00 | $0.00 | None |
TRIFLUOPERAZINE 1 MG TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
TRIFLUOPERAZINE HCL 2MG TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
TRIFLUOPERAZINE HCL 5MG TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT) |
2 |
Generic |
$10.00 | $0.00 | None |
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT |
2 |
Generic |
$10.00 | $0.00 | None |
TRIHEXYPHENIDYL 2 MG TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
TRIHEXYPHENIDYL 5 MG TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
Trihexyphenidyl Hydrochloride 2mg/5mL 473 mL in 1 BOTTLE |
2 |
Generic |
$10.00 | $0.00 | None |
TRILYTE WITH FLAVOR PACKETS |
2 |
Generic |
$10.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIMETHOPRIM 100 MG TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
TRIMIPRAMINE MALEATE 100 MG CP |
4 |
Non-Preferred Drug |
45% | 45% | P |
TRIMIPRAMINE MALEATE 25 MG CAP |
4 |
Non-Preferred Drug |
45% | 45% | P |
TRIMIPRAMINE MALEATE 50 MG CAP |
4 |
Non-Preferred Drug |
45% | 45% | P |
TRINTELLIX 10 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | S Q:30 /30Days |
TRINTELLIX 20 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | S Q:30 /30Days |
TRINTELLIX 5 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | S Q:30 /30Days |
Triptorelin 11.3 MG/ML Injectable Suspension [Trelstar] |
5 |
Specialty Tier |
31% | N/A | P |
TRIUMEQ TABLET |
5 |
Specialty Tier |
31% | N/A | Q:30 /30Days |
TRIVORA-28 TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
TRIZIVIR 300; 150; 300mg/1; mg/1; mg/1 60 FILM COATED TABLETS in BOTTLE |
5 |
Specialty Tier |
31% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TROPHAMINE INJECTION SOLUTION |
3 |
Preferred Brand |
$42.00 | $105.00 | P |
TROPHAMINE INJECTION SOLUTION 6% |
3 |
Preferred Brand |
$42.00 | $105.00 | P |
TROSPIUM CHLORIDE 20 MG TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
TROSPIUM CHLORIDE ER 60 MG CAP |
2 |
Generic |
$10.00 | $0.00 | None |
TRULICITY 0.75 MG/0.5 ML PEN |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
TRULICITY 1.5 MG/0.5 ML PEN |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
TRUMENBA 120 MCG/0.5 ML VACCIN Syringe |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
TRUVADA 100 MG-150 MG TABLET |
5 |
Specialty Tier |
31% | N/A | None |
TRUVADA 133 MG-200 MG TABLET |
5 |
Specialty Tier |
31% | N/A | None |
TRUVADA 167 MG-250 MG TABLET |
5 |
Specialty Tier |
31% | N/A | None |
TRUVADA 200/300MG TABLET |
5 |
Specialty Tier |
31% | 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 | $105.00 | Q:1 /30Days |
TUDORZA PRESSAIR 400 MCG INH |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:1 /30Days |
TWINRIX VACCINE SYRINGE |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
TYBOST 150 MG TABLET |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:30 /30Days |
TYDEMY TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
TYKERB 250 MG TABLET |
5 |
Specialty Tier |
31% | N/A | P |
TYMLOS 80 MCG DOSE PEN INJECTR |
5 |
Specialty Tier |
31% | N/A | P Q:2 /30Days |
TYPHIM VI 25 MCG/0.5 ML SYRINGE |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
TYPHIM VI 25MCG/0.5ML VIAL |
3 |
Preferred Brand |
$42.00 | $105.00 | None |