2020 Medicare Part D Plan Formulary Information |
BlueMedicare Select (PPO) (H5434-002-0)
Benefit Details
|
The BlueMedicare Select (PPO) (H5434-002-0) Formulary Drugs Starting with the Letter T in Palm Beach County, FL: CMS MA Region 9 which includes: FL Plan Monthly Premium: $145.50 Deductible: $305 |
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 |
Tier 4 |
$93.00 | $279.00 | None |
TABRECTA 150 MG TABLET |
5 |
Tier 5 |
27% | N/A | P Q:120 /30Days |
TABRECTA 200 MG TABLET |
5 |
Tier 5 |
27% | N/A | P Q:120 /30Days |
Tacrolimus 0.03% ointment |
2 |
Tier 2 |
$10.00 | $30.00 | P |
Tacrolimus 0.1% ointment |
2 |
Tier 2 |
$10.00 | $30.00 | P |
TACROLIMUS 0.5 MG CAPSULE |
2 |
Tier 2 |
$10.00 | $30.00 | P |
TACROLIMUS 1 MG CAPSULE |
2 |
Tier 2 |
$10.00 | $30.00 | P |
TACROLIMUS 5 MG CAPSULE |
2 |
Tier 2 |
$10.00 | $30.00 | P |
TADALAFIL 20 MG TABLET [ALYQ] |
5 |
Tier 5 |
27% | N/A | P Q:60 /30Days |
TAFINLAR 50 MG CAPSULE |
5 |
Tier 5 |
27% | 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 |
Tier 5 |
27% | N/A | P Q:120 /30Days |
TAGRISSO 40 MG TABLET |
5 |
Tier 5 |
27% | N/A | P Q:30 /30Days |
TAGRISSO 80 MG TABLET |
5 |
Tier 5 |
27% | N/A | P Q:30 /30Days |
TALZENNA 0.25 MG CAPSULE |
5 |
Tier 5 |
27% | N/A | P Q:90 /30Days |
TALZENNA 1 MG CAPSULE |
5 |
Tier 5 |
27% | N/A | P Q:30 /30Days |
TAMIFLU 30 MG 1 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TAMIFLU 45 MG 1 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TAMIFLU 6 MG/ML SUSPENSION |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TAMIFLU 75 MG CAPSULE UD |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TAMOXIFEN 10 MG TABLET [Nolvadex] |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TAMOXIFEN 20 MG TABLET [Nolvadex] |
2 |
Tier 2 |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAMSULOSIN HCL 0.4 MG CAPSULE |
2 |
Tier 2 |
$10.00 | $30.00 | Q:60 /30Days |
TAPERDEX 6 DAY 1.5 MG TABLET |
1 |
Tier 1 |
$3.00 | $9.00 | None |
TARCEVA 100MG TABLET |
5 |
Tier 5 |
27% | N/A | P Q:30 /30Days |
TARCEVA 150MG TABLET |
5 |
Tier 5 |
27% | N/A | P Q:30 /30Days |
TARCEVA 25MG TABLET |
5 |
Tier 5 |
27% | N/A | P Q:60 /30Days |
TARGRETIN 1% GEL |
5 |
Tier 5 |
27% | N/A | None |
TARGRETIN 75 MG CAPSULE |
5 |
Tier 5 |
27% | N/A | P |
TARINA 24 FE 1 MG-20 MCG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
Tarina Fe 1-20 tablet |
2 |
Tier 2 |
$10.00 | $30.00 | None |
Tasigna 150mg/1 4 BLISTER PACK per CARTON / 28 CAPSULE per BLISTER PACK |
5 |
Tier 5 |
27% | N/A | P Q:120 /30Days |
TASIGNA 200 MG CAPSULE |
5 |
Tier 5 |
27% | N/A | P Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TASIGNA 50 MG CAPSULE |
5 |
Tier 5 |
27% | N/A | P Q:120 /30Days |
TASMAR 100MG TABLET |
5 |
Tier 5 |
27% | N/A | None |
TAZAROTENE 0.1% CREAM [Tazorac] |
2 |
Tier 2 |
$10.00 | $30.00 | P |
TAZICEF 1GM VIAL |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TAZICEF 2 GRAM VIAL |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TAZICEF 6 GRAM VIAL |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TAZORAC 0.05% CREAM (G) |
4 |
Tier 4 |
$93.00 | $279.00 | P |
TAZORAC 0.05% GEL |
4 |
Tier 4 |
$93.00 | $279.00 | P |
TAZORAC 0.1% GEL |
4 |
Tier 4 |
$93.00 | $279.00 | P |
TAZTIA XT 120 MG CAPSULE SA 24H [Tiazac] |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TAZTIA XT 180 MG CAPSULE |
2 |
Tier 2 |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAZTIA XT 240 MG CAPSULE SA 24H [Tiazac] |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TAZTIA XT 300 MG CAPSULE |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TAZTIA XT 360 MG CAPSULE SA 24H [Tiazac] |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TAZVERIK 200 MG TABLET |
5 |
Tier 5 |
27% | N/A | P Q:240 /30Days |
TDVAX VIAL |
3 |
Tier 3 |
$40.00 | $120.00 | P |
TECFIDERA DR 120 MG CAPSULE |
5 |
Tier 5 |
27% | N/A | P Q:60 /30Days |
TECFIDERA DR 240 MG CAPSULE |
5 |
Tier 5 |
27% | N/A | P Q:60 /30Days |
TECFIDERA STARTER PACK |
5 |
Tier 5 |
27% | N/A | P Q:60 /30Days |
Teflaro 400mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE |
5 |
Tier 5 |
27% | N/A | None |
Teflaro 600mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE |
5 |
Tier 5 |
27% | N/A | None |
TEGRETOL SUSPENSION 100MG/5ML 450 ML BOT |
4 |
Tier 4 |
$93.00 | $279.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TEGRETOL TABLETS 200MG 100 BOT |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TEGRETOL XR TABLETS 100MG 100 BOT |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TEGRETOL XR TABLETS 200MG 100 BOT |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TEGRETOL XR TABLETS 400MG 100 BOT |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TEKTURNA 150 MG TABLET |
4 |
Tier 4 |
$93.00 | $279.00 | Q:30 /30Days |
TEKTURNA 300 MG TABLET |
4 |
Tier 4 |
$93.00 | $279.00 | Q:30 /30Days |
TEKTURNA HCT 300-25 MG TABLET |
3 |
Tier 3 |
$40.00 | $120.00 | Q:30 /30Days |
TELMISARTAN 20 MG TABLET [Micardis] |
6* |
Tier 6 |
$0.00 | $0.00 | Q:30 /30Days |
TELMISARTAN 40 MG TABLET [Micardis] |
6* |
Tier 6 |
$0.00 | $0.00 | Q:30 /30Days |
TELMISARTAN 80 MG TABLET [Micardis] |
6* |
Tier 6 |
$0.00 | $0.00 | Q:30 /30Days |
Telmisartan-Amlodipine 40-10 MG [Micardis] |
6* |
Tier 6 |
$0.00 | $0.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Telmisartan-Amlodipine 40-5 MG [Micardis] |
6* |
Tier 6 |
$0.00 | $0.00 | Q:30 /30Days |
Telmisartan-Amlodipine 80-10 MG [Micardis] |
6* |
Tier 6 |
$0.00 | $0.00 | Q:30 /30Days |
Telmisartan-Amlodipine 80-5 MG [Micardis] |
6* |
Tier 6 |
$0.00 | $0.00 | Q:30 /30Days |
TELMISARTAN-HCTZ 40-12.5 MG TABLET [Micardis HCT] |
6* |
Tier 6 |
$0.00 | $0.00 | Q:30 /30Days |
TELMISARTAN-HCTZ 80-12.5 MG TABLET [Micardis HCT] |
6* |
Tier 6 |
$0.00 | $0.00 | Q:60 /30Days |
TELMISARTAN-HCTZ 80-25 MG TABLET [Micardis HCT] |
6* |
Tier 6 |
$0.00 | $0.00 | Q:30 /30Days |
TEMAZEPAM 15 MG CAPSULE [Restoril] |
1 |
Tier 1 |
$3.00 | $9.00 | Q:30 /30Days |
TEMAZEPAM 30 MG CAPSULE |
1 |
Tier 1 |
$3.00 | $9.00 | Q:30 /30Days |
Tencon 50-325 MG TABLET |
4 |
Tier 4 |
$93.00 | $279.00 | Q:180 /30Days |
TENIVAC SYRINGE |
3 |
Tier 3 |
$40.00 | $120.00 | P |
TENOFOVIR DISOP FUM 300 MG TABLET [Viread] |
2 |
Tier 2 |
$10.00 | $30.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TENORETIC 100 TABLET |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TENORETIC 50 TABLET |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TENORMIN 100 MG TABLET |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TENORMIN 25 MG TABLET |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TENORMIN 50 MG TABLET |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TERAZOSIN 1 MG CAPSULE |
1 |
Tier 1 |
$3.00 | $9.00 | Q:90 /30Days |
TERAZOSIN 10 MG CAPSULE [Hytrin] |
1 |
Tier 1 |
$3.00 | $9.00 | Q:60 /30Days |
TERAZOSIN 2 MG CAPSULE |
1 |
Tier 1 |
$3.00 | $9.00 | Q:60 /30Days |
TERAZOSIN 5 MG CAPSULE [Hytrin] |
1 |
Tier 1 |
$3.00 | $9.00 | Q:60 /30Days |
TERBINAFINE HCL 250 MG TABLET [Terbinex] |
1 |
Tier 1 |
$3.00 | $9.00 | None |
TERBUTALINE SULFATE 2.5 MG TAB |
2 |
Tier 2 |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TERBUTALINE SULFATE 5MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TERCONAZOLE 0.4% CREAM WITH APPLICATOR |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TERCONAZOLE 0.8% CREAM |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TERCONAZOLE 80MG SUPPOSITORY VAGINAL |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TESTOSTERON CYP 2,000 MG/10 ML VIAL [Virilon] |
2 |
Tier 2 |
$10.00 | $30.00 | P |
TESTOSTERON ENAN 1,000 MG/5 ML VIAL [Delatestryl] |
2 |
Tier 2 |
$10.00 | $30.00 | P |
TESTOSTERONE 1.62% (2.5 G) PKT GEL PACKET [AndroGel] |
2 |
Tier 2 |
$10.00 | $30.00 | P Q:150 /30Days |
TESTOSTERONE 1.62% GEL PUMP GEL MD PMP [AndroGel] |
2 |
Tier 2 |
$10.00 | $30.00 | P Q:150 /30Days |
TESTOSTERONE 1.62%(1.25 G) GEL PACKET [AndroGel] |
2 |
Tier 2 |
$10.00 | $30.00 | P Q:38 /30Days |
TESTOSTERONE 12.5 MG/1.25 GRAM GEL MD PMP [Vogelxo] |
2 |
Tier 2 |
$10.00 | $30.00 | P Q:300 /30Days |
TESTOSTERONE 25 MG/2.5 GM GEL PACKET [Vogelxo] |
2 |
Tier 2 |
$10.00 | $30.00 | P Q:225 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TESTOSTERONE 30 MG/1.5 ML PUMP |
2 |
Tier 2 |
$10.00 | $30.00 | P Q:180 /30Days |
TESTOSTERONE 50 MG/5 GRAM GEL PACKET [Vogelxo] |
2 |
Tier 2 |
$10.00 | $30.00 | P Q:300 /30Days |
Testosterone cyp 100 mg/ml |
2 |
Tier 2 |
$10.00 | $30.00 | P |
TESTOSTERONE CYP 200 MG/ML |
2 |
Tier 2 |
$10.00 | $30.00 | P |
TETRABENAZINE 12.5 MG TABLET [XENAZINE] |
5 |
Tier 5 |
27% | N/A | P Q:240 /30Days |
TETRABENAZINE 25 MG TABLET [XENAZINE] |
5 |
Tier 5 |
27% | N/A | P Q:120 /30Days |
TETRACYCLINE 250 MG CAPSULE |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TETRACYCLINE 500 MG CAPSULE |
2 |
Tier 2 |
$10.00 | $30.00 | None |
THALOMID 100 MG CAPSULE |
5 |
Tier 5 |
27% | N/A | P Q:30 /30Days |
THALOMID 150 MG CAPSULE |
5 |
Tier 5 |
27% | N/A | P Q:60 /30Days |
THALOMID 200 MG CAPSULE |
5 |
Tier 5 |
27% | N/A | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THALOMID 50 MG CAPSULE |
5 |
Tier 5 |
27% | N/A | P Q:30 /30Days |
THEO-24 ER 100 MG CAPSULE |
4 |
Tier 4 |
$93.00 | $279.00 | None |
THEO-24 ER 200 MG CAPSULE |
4 |
Tier 4 |
$93.00 | $279.00 | None |
THEO-24 ER 300 MG CAPSULE |
4 |
Tier 4 |
$93.00 | $279.00 | None |
THEO-24 ER 400 MG CAPSULE |
4 |
Tier 4 |
$93.00 | $279.00 | None |
THEOPHYLLINE ER 300 MG TAB |
2 |
Tier 2 |
$10.00 | $30.00 | None |
THEOPHYLLINE ER 400 MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
THEOPHYLLINE ER 600 MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
THIORIDAZINE 10 MG TABLET |
3 |
Tier 3 |
$40.00 | $120.00 | P |
THIORIDAZINE 100MG TABLET |
3 |
Tier 3 |
$40.00 | $120.00 | P |
THIORIDAZINE 25 MG TABLET |
3 |
Tier 3 |
$40.00 | $120.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THIORIDAZINE 50 MG TABLET |
3 |
Tier 3 |
$40.00 | $120.00 | P |
THIOTHIXENE 1 MG CAPSULE |
2 |
Tier 2 |
$10.00 | $30.00 | P |
THIOTHIXENE 10MG CAPSULE |
2 |
Tier 2 |
$10.00 | $30.00 | P |
THIOTHIXENE 2MG CAPSULE |
2 |
Tier 2 |
$10.00 | $30.00 | P |
THIOTHIXENE 5MG CAPSULE |
2 |
Tier 2 |
$10.00 | $30.00 | P |
TIADYLT ER 120 MG CAPSULE SA 24H [Tiazac] |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TIADYLT ER 180 MG CAPSULE SA 24H [Tiazac] |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TIADYLT ER 240 MG CAPSULE SA 24H [Tiazac] |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TIADYLT ER 300 MG CAPSULE SA 24H [Tiazac] |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TIADYLT ER 360 MG CAPSULE SA 24H [Tiazac] |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TIADYLT ER 420 MG CAPSULE SA 24H [Tiazac] |
2 |
Tier 2 |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIAGABINE HCL 12 MG TABLET [Gabitril] |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TIAGABINE HCL 16 MG TABLET [Gabitril] |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TIAGABINE HCL 2 MG TABLET [Gabitril] |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TIAGABINE HCL 4 MG TABLET [Gabitril] |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TIAZAC ER 120 MG CAPSULE |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TIAZAC ER 180 MG CAPSULE |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TIAZAC ER 240 MG CAPSULE |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TIAZAC ER 300 MG CAPSULE SA 24H |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TIAZAC ER 360 MG CAPSULE SA 24H |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TIAZAC ER 420 MG CAPSULE SA 24H |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TIBSOVO 250 MG TABLET |
5 |
Tier 5 |
27% | N/A | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIGECYCLINE 50 MG VIAL [Tygacil] |
5 |
Tier 5 |
27% | N/A | None |
TIKOSYN .125MG CAPSULE |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TIKOSYN .250MG CAPSULE |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TIKOSYN .5MG CAPSULE |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TIMOLOL 0.25% EYE DROPS |
1 |
Tier 1 |
$3.00 | $9.00 | None |
TIMOLOL 0.25% GFS GEL-SOLUTION |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TIMOLOL 0.5% EYE DROPS |
1 |
Tier 1 |
$3.00 | $9.00 | None |
TIMOLOL 0.5% EYE DROPS |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TIMOLOL 0.5% GFS GEL-SOLUTION |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TIMOLOL MALEATE 10MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TIMOLOL MALEATE 20MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIMOLOL MALEATE 5MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TIMOPTIC 0.25% OCUDOSE DROP |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TIMOPTIC 0.5% OCUDOSE DROP |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TIROSINT 100 MCG CAPSULE |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TIROSINT 112 MCG CAPSULE |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TIROSINT 125 MCG CAPSULE |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TIROSINT 13 MCG CAPSULE |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TIROSINT 137 MCG CAPSULE |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TIROSINT 150 MCG CAPSULE |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TIROSINT 175 MCG CAPSULE |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TIROSINT 200 MCG CAPSULE |
4 |
Tier 4 |
$93.00 | $279.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIROSINT 25 MCG CAPSULE |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TIROSINT 50 MCG CAPSULE |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TIROSINT 75 MCG CAPSULE |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TIROSINT 88 MCG CAPSULE |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TIROSINT-SOL 100 MCG/ML SOLUTION |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TIROSINT-SOL 112 MCG/ML SOLUTION |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TIROSINT-SOL 125 MCG/ML SOLUTION |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TIROSINT-SOL 13 MCG/ML SOLUTION |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TIROSINT-SOL 137 MCG/ML SOLUTION |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TIROSINT-SOL 150 MCG/ML SOLUTION |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TIROSINT-SOL 175 MCG/ML SOLUTION |
4 |
Tier 4 |
$93.00 | $279.00 | 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 |
Tier 4 |
$93.00 | $279.00 | None |
TIROSINT-SOL 25 MCG/ML SOLUTION |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TIROSINT-SOL 50 MCG/ML SOLUTION |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TIROSINT-SOL 75 MCG/ML SOLUTION |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TIROSINT-SOL 88 MCG/ML SOLUTION |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TIVICAY 10 MG TABLET |
4 |
Tier 4 |
$93.00 | $279.00 | Q:60 /30Days |
TIVICAY 25 MG TABLET |
5 |
Tier 5 |
27% | N/A | Q:60 /30Days |
TIVICAY 50 MG TABLET |
5 |
Tier 5 |
27% | N/A | Q:60 /30Days |
TIZANIDINE HCL 2 MG CAPSULE |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TIZANIDINE HCL 2 MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TIZANIDINE HCL 4 MG CAPSULE |
2 |
Tier 2 |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIZANIDINE HCL 4 MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TIZANIDINE HCL 6 MG CAPSULE |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TOBRADEX EYE OINTMENT |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TOBRADEX SUSPENSION OPHTHALMIC 0.1%/0.3% 5ML BOT |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TOBRAMYCIN 0.3% EYE DROPS [Tobrex] |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TOBRAMYCIN 10 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate] |
3 |
Tier 3 |
$40.00 | $120.00 | None |
TOBRAMYCIN 300 MG/5 ML AMPULE [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate] |
5 |
Tier 5 |
27% | N/A | P |
TOBRAMYCIN 40 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate] |
3 |
Tier 3 |
$40.00 | $120.00 | None |
TOBRAMYCIN-DEXAMETH OPTH SUSP |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TOLCAPONE 100 MG TABLET [Tasmar] |
5 |
Tier 5 |
27% | N/A | None |
TOLMETIN SODIUM 400 MG CAP |
3 |
Tier 3 |
$40.00 | $120.00 | Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOLTERODINE TART ER 2 MG CAPSULE ER 24H [Detrol LA] |
2 |
Tier 2 |
$10.00 | $30.00 | Q:30 /30Days |
TOLTERODINE TART ER 4 MG CAPSULE ER 24H [Detrol LA] |
2 |
Tier 2 |
$10.00 | $30.00 | Q:30 /30Days |
TOLTERODINE TARTRATE 1 MG TABLET [Detrol LA] |
2 |
Tier 2 |
$10.00 | $30.00 | Q:60 /30Days |
TOLTERODINE TARTRATE 2 MG TABLET [Detrol] |
2 |
Tier 2 |
$10.00 | $30.00 | Q:60 /30Days |
TOLVAPTAN 15 MG ORAL TABLET [SAMSCA] |
5 |
Tier 5 |
27% | N/A | P |
TOLVAPTAN 30 MG ORAL TABLET [SAMSCA] |
5 |
Tier 5 |
27% | N/A | P |
TOPIRAMATE 100 MG TABLET |
1 |
Tier 1 |
$3.00 | $9.00 | None |
TOPIRAMATE 15 MG SPRINKLE CAP |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TOPIRAMATE 200 MG TABLET [Topiragen] |
1 |
Tier 1 |
$3.00 | $9.00 | None |
TOPIRAMATE 25 MG TABLET |
1 |
Tier 1 |
$3.00 | $9.00 | None |
Topiramate 25mg/1 |
2 |
Tier 2 |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOPIRAMATE 50 MG TABLET [Topiragen] |
1 |
Tier 1 |
$3.00 | $9.00 | None |
TOPROL XL 100 MG TABLET ER 24H |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TOPROL XL 200 MG TABLET ER 24H |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TOPROL XL 25 MG TABLET ER 24H |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TOPROL XL 50 MG TABLET ER 24H |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TOREMIFENE CITRATE 60 MG TABLET [Fareston] |
5 |
Tier 5 |
27% | N/A | None |
TORSEMIDE 10 MG TABLET |
1 |
Tier 1 |
$3.00 | $9.00 | None |
TORSEMIDE 100 MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TORSEMIDE 20 MG TABLET |
1 |
Tier 1 |
$3.00 | $9.00 | None |
TORSEMIDE 5 MG TABLET [Demadex] |
1 |
Tier 1 |
$3.00 | $9.00 | None |
TOUJEO MAX SOLOSTAR 300UNIT/ML INSULN PEN |
3 |
Tier 3 |
$40.00 | $120.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOUJEO SOLOSTAR 300 UNITS/ML |
3 |
Tier 3 |
$40.00 | $120.00 | Q:60 /30Days |
TOVIAZ TABLETS 4MG EXTENDED RELEASE |
3 |
Tier 3 |
$40.00 | $120.00 | Q:30 /30Days |
TOVIAZ TABLETS 8MG EXTENDED RELEASE |
3 |
Tier 3 |
$40.00 | $120.00 | Q:30 /30Days |
TRACLEER 125MG TABLET |
5 |
Tier 5 |
27% | N/A | P Q:60 /30Days |
TRACLEER 32 MG TABLET FOR SUSP |
5 |
Tier 5 |
27% | N/A | P Q:120 /30Days |
TRACLEER 62.5MG TABLET |
5 |
Tier 5 |
27% | N/A | P Q:60 /30Days |
TRADJENTA 5 MG TABLET |
4 |
Tier 4 |
$93.00 | $279.00 | Q:30 /30Days |
TRAMADOL HCL 50 MG TABLET |
1 |
Tier 1 |
$3.00 | $9.00 | Q:240 /30Days |
TRAMADOL HCL ER 100 MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | P Q:30 /30Days |
TRAMADOL HCL ER 200 MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | P Q:30 /30Days |
TRAMADOL HCL ER 300 MG Tablet ER 24H [Ultram ER] |
2 |
Tier 2 |
$10.00 | $30.00 | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRAMADOL-ACETAMINOPHN 37.5-325 |
2 |
Tier 2 |
$10.00 | $30.00 | Q:240 /30Days |
TRANDOLAPRIL 1 MG TABLET |
6* |
Tier 6 |
$0.00 | $0.00 | None |
TRANDOLAPRIL 2 MG TABLET |
6* |
Tier 6 |
$0.00 | $0.00 | None |
TRANDOLAPRIL 4 MG TABLET |
6* |
Tier 6 |
$0.00 | $0.00 | None |
TRANEXAMIC ACID 650 MG TABLET [Lysteda] |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TRANYLCYPROMINE SULF 10 MG TABLET [Parnate] |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TRAVATAN Z 0.04MG DROPS 2.5ML BOT |
3 |
Tier 3 |
$40.00 | $120.00 | None |
TRAVOPROST 0.004% EYE DROPS [Travatan] |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TRAZODONE 100 MG TABLET |
1 |
Tier 1 |
$3.00 | $9.00 | None |
TRAZODONE 150 MG TABLET [Desyrel] |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TRAZODONE 300 MG TABLET [Desyrel] |
2 |
Tier 2 |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRAZODONE 50 MG TABLET |
1 |
Tier 1 |
$3.00 | $9.00 | None |
TRECATOR 250MG TABLET |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TRELEGY ELLIPTA 100-62.5-25 |
3 |
Tier 3 |
$40.00 | $120.00 | Q:60 /30Days |
TRELSTAR 11.25 MG SYRINGE |
5 |
Tier 5 |
27% | N/A | P |
TRELSTAR 3.75 MG SYRINGE |
5 |
Tier 5 |
27% | N/A | P |
TREMFYA 100 MG/ML AUTOINJECTOR |
5 |
Tier 5 |
27% | N/A | P |
TREMFYA 100 MG/ML SYRINGE |
5 |
Tier 5 |
27% | N/A | P |
TRESIBA 100 UNIT/ML VIAL |
3 |
Tier 3 |
$40.00 | $120.00 | Q:60 /30Days |
TRESIBA FLEXTOUCH 100 UNITS/ML |
3 |
Tier 3 |
$40.00 | $120.00 | Q:60 /30Days |
TRESIBA FLEXTOUCH 200 UNITS/ML |
3 |
Tier 3 |
$40.00 | $120.00 | Q:60 /30Days |
TRETINOIN 0.01% GEL [Tretin-X] |
2 |
Tier 2 |
$10.00 | $30.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRETINOIN 0.025% CREAM |
2 |
Tier 2 |
$10.00 | $30.00 | P |
TRETINOIN 0.025% GEL [Tretin-X] |
2 |
Tier 2 |
$10.00 | $30.00 | P |
TRETINOIN 0.05% CREAM |
2 |
Tier 2 |
$10.00 | $30.00 | P |
TRETINOIN 0.1% CREAM |
2 |
Tier 2 |
$10.00 | $30.00 | P |
Tretinoin 0.25 MG/ML Topical Cream [Retin-A] |
4 |
Tier 4 |
$93.00 | $279.00 | P |
Tretinoin 0.5 MG/ML Topical Cream [Retin-A] |
4 |
Tier 4 |
$93.00 | $279.00 | P |
TRETINOIN 10MG CAPSULE |
5 |
Tier 5 |
27% | N/A | P |
TRI-ESTARYLLA TABLET [Trinessa] |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TRI-LEGEST FE 5-7-9-7 TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TRI-LO-ESTARYLLA TABLET [Trinessa Lo] |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TRI-LO-SPRINTEC TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRI-MILI 28 TABLET [Trinessa] |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TRI-PREVIFEM TABLET [Trinessa] |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TRI-SPRINTEC 7DAYSX3 28 TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TRI-VYLIBRA 28 TABLET [Trinessa] |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TRI-VYLIBRA LO TABLET [Trinessa Lo] |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TRIAMCINOLONE 0.025% CREAM |
1 |
Tier 1 |
$3.00 | $9.00 | Q:454 /30Days |
TRIAMCINOLONE 0.025% LOTION |
2 |
Tier 2 |
$10.00 | $30.00 | Q:120 /30Days |
TRIAMCINOLONE 0.025% OINT |
2 |
Tier 2 |
$10.00 | $30.00 | Q:454 /30Days |
TRIAMCINOLONE 0.1% CREAM (g) [Triderm] |
1 |
Tier 1 |
$3.00 | $9.00 | Q:454 /30Days |
TRIAMCINOLONE 0.1% LOTION [Kenalog] |
2 |
Tier 2 |
$10.00 | $30.00 | Q:120 /30Days |
TRIAMCINOLONE 0.1% OINTMENT [Triderm] |
2 |
Tier 2 |
$10.00 | $30.00 | Q:454 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIAMCINOLONE 0.1% PASTE (G) [Oralone] |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE |
2 |
Tier 2 |
$10.00 | $30.00 | Q:120 /30Days |
Triamcinolone Acetonide 1 MG/ML Topical Cream [Triderm] |
1 |
Tier 1 |
$3.00 | $9.00 | Q:454 /30Days |
Triamcinolone Acetonide 5mg/g 1 TUBE per CARTON / 15 g in 1 TUBE |
2 |
Tier 2 |
$10.00 | $30.00 | Q:454 /30Days |
TRIAMTERENE-HCTZ 37.5-25 MG CAPSULE [Dyazide] |
1 |
Tier 1 |
$3.00 | $9.00 | None |
TRIAMTERENE-HCTZ 37.5-25 MG TB |
1 |
Tier 1 |
$3.00 | $9.00 | None |
TRIAMTERENE-HCTZ 75-50 MG TAB |
1 |
Tier 1 |
$3.00 | $9.00 | None |
TRIBENZOR 20/5/12.5MG TABLETS |
4 |
Tier 4 |
$93.00 | $279.00 | Q:30 /30Days |
TRIBENZOR 40/10/12.5MG TABLETS |
4 |
Tier 4 |
$93.00 | $279.00 | Q:30 /30Days |
TRIBENZOR 40/10/25MG TABLETS |
4 |
Tier 4 |
$93.00 | $279.00 | Q:30 /30Days |
Tribenzor 5; 12.5; 40mg/1; mg/1; mg/1 |
4 |
Tier 4 |
$93.00 | $279.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Tribenzor 5; 25; 40mg/1; mg/1; mg/1 |
4 |
Tier 4 |
$93.00 | $279.00 | Q:30 /30Days |
TRIENTINE HCL 250 MG CAPSULE [Syprine] |
5 |
Tier 5 |
27% | N/A | P Q:240 /30Days |
TRIFLUOPERAZINE 1 MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | P |
TRIFLUOPERAZINE HCL 2MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | P |
TRIFLUOPERAZINE HCL 5MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | P |
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT) |
2 |
Tier 2 |
$10.00 | $30.00 | P |
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT |
3 |
Tier 3 |
$40.00 | $120.00 | None |
TRIKAFTA 100/50/75 MG-150 MG TABLET SEQ |
5 |
Tier 5 |
27% | N/A | P Q:90 /30Days |
TRILEPTAL 150MG TABLET |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TRILEPTAL 300MG TABLET |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TRILEPTAL 300MG/5ML SUSP |
5 |
Tier 5 |
27% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRILEPTAL 600MG TABLET |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TRILYTE WITH FLAVOR PACKETS |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TRIMETHOPRIM 100 MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TRIMIPRAMINE MALEATE 100 MG CP |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TRIMIPRAMINE MALEATE 25 MG CAP |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TRIMIPRAMINE MALEATE 50 MG CAP |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TRINTELLIX 10 MG TABLET |
4 |
Tier 4 |
$93.00 | $279.00 | Q:30 /30Days |
TRINTELLIX 20 MG TABLET |
4 |
Tier 4 |
$93.00 | $279.00 | Q:30 /30Days |
TRINTELLIX 5 MG TABLET |
4 |
Tier 4 |
$93.00 | $279.00 | Q:30 /30Days |
Triptorelin 11.3 MG/ML Injectable Suspension [Trelstar] |
5 |
Tier 5 |
27% | N/A | P |
TRIUMEQ TABLET |
5 |
Tier 5 |
27% | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIVORA-28 TABLET [Trivora] |
2 |
Tier 2 |
$10.00 | $30.00 | None |
TROSPIUM CHLORIDE 20 MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | Q:60 /30Days |
TROSPIUM CHLORIDE ER 60 MG CAP |
2 |
Tier 2 |
$10.00 | $30.00 | Q:30 /30Days |
TRULICITY 0.75 MG/0.5 ML PEN |
3 |
Tier 3 |
$40.00 | $120.00 | Q:2 /28Days |
TRULICITY 1.5 MG/0.5 ML PEN |
3 |
Tier 3 |
$40.00 | $120.00 | Q:2 /28Days |
TRUMENBA 120 MCG/0.5 ML VACCIN Syringe |
3 |
Tier 3 |
$40.00 | $120.00 | None |
TRUSOPT PLUS 2% EYE DROPS 10ML BOT |
4 |
Tier 4 |
$93.00 | $279.00 | None |
TRUVADA 100 MG-150 MG TABLET |
5 |
Tier 5 |
27% | N/A | Q:30 /30Days |
TRUVADA 133 MG-200 MG TABLET |
5 |
Tier 5 |
27% | N/A | Q:30 /30Days |
TRUVADA 167 MG-250 MG TABLET |
5 |
Tier 5 |
27% | N/A | Q:30 /30Days |
TRUVADA 200/300MG TABLET |
5 |
Tier 5 |
27% | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TUKYSA 150 MG TABLET |
5 |
Tier 5 |
27% | N/A | P Q:120 /30Days |
TUKYSA 50 MG TABLET |
5 |
Tier 5 |
27% | N/A | P Q:300 /30Days |
TURALIO 200 MG CAPSULE |
5 |
Tier 5 |
27% | N/A | P Q:120 /30Days |
TWINRIX VACCINE SYRINGE |
3 |
Tier 3 |
$40.00 | $120.00 | None |
TYBOST 150 MG TABLET |
3 |
Tier 3 |
$40.00 | $120.00 | Q:30 /30Days |
TYDEMY TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
Tygacil 50mg/5mL 10 VIAL, SINGLE-USE per CARTON / 50 mL in 1 VIAL, SINGLE-USE |
5 |
Tier 5 |
27% | N/A | None |
TYKERB 250 MG TABLET |
5 |
Tier 5 |
27% | N/A | P Q:180 /30Days |
TYMLOS 80 MCG DOSE PEN INJECTR |
5 |
Tier 5 |
27% | N/A | P |
TYPHIM VI 25 MCG/0.5 ML SYRINGE |
3 |
Tier 3 |
$40.00 | $120.00 | None |
TYPHIM VI 25MCG/0.5ML VIAL |
3 |
Tier 3 |
$40.00 | $120.00 | None |