2020 Medicare Part D Plan Formulary Information |
MVP Preferred Gold with Part D (HMO-POS) (H3305-021-0)
Benefit Details
|
The MVP Preferred Gold with Part D (HMO-POS) (H3305-021-0) Formulary Drugs Starting with the Letter T in Madison County, NY: CMS MA Region 3 which includes: NY Plan Monthly Premium: $139.00 Deductible: $0 |
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 |
27% | 27% | None |
TABRECTA 150 MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
TABRECTA 200 MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
Tacrolimus 0.03% ointment |
3 |
Tier 3 |
$35.00 | $70.00 | None |
Tacrolimus 0.1% ointment |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TACROLIMUS 0.5 MG CAPSULE |
2 |
Tier 2 |
$10.00 | $20.00 | P |
TACROLIMUS 1 MG CAPSULE |
2 |
Tier 2 |
$10.00 | $20.00 | P |
TACROLIMUS 5 MG CAPSULE |
2 |
Tier 2 |
$10.00 | $20.00 | P |
TADALAFIL 2.5 MG TABLET [Cialis] |
4 |
Tier 4 |
27% | 27% | P Q:30 /30Days |
TADALAFIL 20 MG TABLET [ALYQ] |
5 |
Tier 5 |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TADALAFIL 5 MG TABLET [Cialis] |
4 |
Tier 4 |
27% | 27% | P Q:30 /30Days |
TAFINLAR 50 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | None |
TAFINLAR 75 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | None |
TAGRISSO 40 MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
TAGRISSO 80 MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
TAKHZYRO 300 MG/2 ML VIAL |
5 |
Tier 5 |
33% | N/A | P |
TALICIA DR 10-250-12.5 MG CAPSULE IR |
4 |
Tier 4 |
27% | 27% | None |
TALZENNA 0.25 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | P |
TALZENNA 1 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | P |
TAMOXIFEN 10 MG TABLET [Nolvadex] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TAMOXIFEN 20 MG TABLET [Nolvadex] |
2 |
Tier 2 |
$10.00 | $20.00 | 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 | $20.00 | None |
TARGRETIN 1% GEL |
5 |
Tier 5 |
33% | N/A | None |
TARINA 24 FE 1 MG-20 MCG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
Tarina Fe 1-20 tablet |
2 |
Tier 2 |
$10.00 | $20.00 | None |
Tasigna 150mg/1 4 BLISTER PACK per CARTON / 28 CAPSULE per BLISTER PACK |
5 |
Tier 5 |
33% | N/A | None |
TASIGNA 200 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | None |
TASIGNA 50 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | None |
TAZAROTENE 0.1% CREAM [Tazorac] |
4 |
Tier 4 |
27% | 27% | None |
TAZICEF 1GM VIAL |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TAZICEF 2 GRAM VIAL |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TAZICEF 6 GRAM VIAL |
2 |
Tier 2 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAZTIA XT 120 MG CAPSULE SA 24H [Tiazac] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TAZTIA XT 180 MG CAPSULE |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TAZTIA XT 240 MG CAPSULE SA 24H [Tiazac] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TAZTIA XT 300 MG CAPSULE |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TAZTIA XT 360 MG CAPSULE SA 24H [Tiazac] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TAZVERIK 200 MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
TDVAX VIAL |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TECFIDERA DR 120 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | Q:60 /30Days |
TECFIDERA DR 240 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | Q:60 /30Days |
TECFIDERA STARTER PACK |
5 |
Tier 5 |
33% | N/A | None |
Teflaro 400mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE |
4 |
Tier 4 |
27% | 27% | 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 |
4 |
Tier 4 |
27% | 27% | None |
TEGSEDI 284 MG/1.5 ML SYRINGE |
5 |
Tier 5 |
33% | N/A | P |
TEKTURNA HCT 300-25 MG TABLET |
4 |
Tier 4 |
27% | 27% | None |
TELMISARTAN 20 MG TABLET [Micardis] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TELMISARTAN 40 MG TABLET [Micardis] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TELMISARTAN 80 MG TABLET [Micardis] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Telmisartan-Amlodipine 40-10 MG [Micardis] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
Telmisartan-Amlodipine 40-5 MG [Micardis] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
Telmisartan-Amlodipine 80-10 MG [Micardis] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
Telmisartan-Amlodipine 80-5 MG [Micardis] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TELMISARTAN-HCTZ 40-12.5 MG TABLET [Micardis HCT] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TELMISARTAN-HCTZ 80-12.5 MG TABLET [Micardis HCT] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TELMISARTAN-HCTZ 80-25 MG TABLET [Micardis HCT] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TEMAZEPAM 15 MG CAPSULE [Restoril] |
2 |
Tier 2 |
$10.00 | $20.00 | Q:30 /30Days |
TEMAZEPAM 22.5 MG CAPSULE |
2 |
Tier 2 |
$10.00 | $20.00 | Q:30 /30Days |
TEMAZEPAM 30 MG CAPSULE |
2 |
Tier 2 |
$10.00 | $20.00 | Q:30 /30Days |
Temazepam 7.5mg/1 100 CAPSULE BOTTLE, PLASTIC |
2 |
Tier 2 |
$10.00 | $20.00 | Q:30 /30Days |
Tencon 50-325 MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | Q:60 /30Days |
TENIVAC SYRINGE |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TENOFOVIR DISOP FUM 300 MG TABLET [Viread] |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TERAZOSIN 1 MG CAPSULE |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TERAZOSIN 10 MG CAPSULE [Hytrin] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TERAZOSIN 2 MG CAPSULE |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TERAZOSIN 5 MG CAPSULE [Hytrin] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TERBINAFINE HCL 250 MG TABLET [Terbinex] |
2 |
Tier 2 |
$10.00 | $20.00 | Q:84 /365Days |
TERBUTALINE SULFATE 2.5 MG TAB |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TERBUTALINE SULFATE 5MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TERCONAZOLE 0.4% CREAM WITH APPLICATOR |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TERCONAZOLE 0.8% CREAM |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TERCONAZOLE 80MG SUPPOSITORY VAGINAL |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TERIPARATIDE 620 MCG/2.48 ML PEN INJECTOR [Forteo] |
5 |
Tier 5 |
33% | N/A | P Q:2 /28Days |
TESTOSTERON ENAN 1,000 MG/5 ML VIAL [Delatestryl] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TESTOSTERONE 1.62% (2.5 G) PKT GEL PACKET [AndroGel] |
3 |
Tier 3 |
$35.00 | $70.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TESTOSTERONE 1.62% GEL PUMP GEL MD PMP [AndroGel] |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TESTOSTERONE 1.62%(1.25 G) GEL PACKET [AndroGel] |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TESTOSTERONE 10 MG GEL PUMP |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TESTOSTERONE 12.5 MG/1.25 GRAM GEL MD PMP [Vogelxo] |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TESTOSTERONE 25 MG/2.5 GM GEL PACKET [Vogelxo] |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TESTOSTERONE 30 MG/1.5 ML PUMP |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TESTOSTERONE 50 MG/5 GRAM GEL PACKET [Vogelxo] |
3 |
Tier 3 |
$35.00 | $70.00 | None |
Testosterone cyp 100 mg/ml |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TESTOSTERONE CYP 200 MG/ML |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TETRABENAZINE 12.5 MG TABLET [XENAZINE] |
4 |
Tier 4 |
27% | 27% | P |
TETRABENAZINE 25 MG TABLET [XENAZINE] |
4 |
Tier 4 |
27% | 27% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TETRACYCLINE 250 MG CAPSULE |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TETRACYCLINE 500 MG CAPSULE |
3 |
Tier 3 |
$35.00 | $70.00 | None |
THALOMID 100 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | None |
THALOMID 150 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | None |
THALOMID 200 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | None |
THALOMID 50 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | None |
THEO-24 ER 100 MG CAPSULE |
4 |
Tier 4 |
27% | 27% | None |
THEO-24 ER 200 MG CAPSULE |
4 |
Tier 4 |
27% | 27% | None |
THEOPHYLLINE ER 300 MG TAB |
3 |
Tier 3 |
$35.00 | $70.00 | None |
THEOPHYLLINE ER 400 MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
THEOPHYLLINE ER 600 MG TABLET |
2 |
Tier 2 |
$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 |
3 |
Tier 3 |
$35.00 | $70.00 | None |
THIORIDAZINE 100MG TABLET |
3 |
Tier 3 |
$35.00 | $70.00 | None |
THIORIDAZINE 25 MG TABLET |
3 |
Tier 3 |
$35.00 | $70.00 | None |
THIORIDAZINE 50 MG TABLET |
3 |
Tier 3 |
$35.00 | $70.00 | None |
THIOTHIXENE 1 MG CAPSULE |
2 |
Tier 2 |
$10.00 | $20.00 | None |
THIOTHIXENE 10MG CAPSULE |
2 |
Tier 2 |
$10.00 | $20.00 | None |
THIOTHIXENE 2MG CAPSULE |
2 |
Tier 2 |
$10.00 | $20.00 | None |
THIOTHIXENE 5MG CAPSULE |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TIADYLT ER 120 MG CAPSULE SA 24H [Tiazac] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TIADYLT ER 180 MG CAPSULE SA 24H [Tiazac] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TIADYLT ER 240 MG CAPSULE SA 24H [Tiazac] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIADYLT ER 300 MG CAPSULE SA 24H [Tiazac] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TIADYLT ER 360 MG CAPSULE SA 24H [Tiazac] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TIADYLT ER 420 MG CAPSULE SA 24H [Tiazac] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TIAGABINE HCL 12 MG TABLET [Gabitril] |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TIAGABINE HCL 16 MG TABLET [Gabitril] |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TIAGABINE HCL 2 MG TABLET [Gabitril] |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TIAGABINE HCL 4 MG TABLET [Gabitril] |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TIBSOVO 250 MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
TIGECYCLINE 50 MG VIAL [Tygacil] |
4 |
Tier 4 |
27% | 27% | None |
TIMOLOL 0.25% EYE DROPS |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TIMOLOL 0.25% GFS GEL-SOLUTION |
2 |
Tier 2 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIMOLOL 0.5% EYE DROPS |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TIMOLOL 0.5% GFS GEL-SOLUTION |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TIMOLOL MALEATE 10MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TIMOLOL MALEATE 20MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TIMOLOL MALEATE 5MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TINIDAZOLE 250 MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TINIDAZOLE 500 MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TIROSINT 100 MCG CAPSULE |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TIROSINT 112 MCG CAPSULE |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TIROSINT 125 MCG CAPSULE |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TIROSINT 13 MCG CAPSULE |
3 |
Tier 3 |
$35.00 | $70.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIROSINT 137 MCG CAPSULE |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TIROSINT 150 MCG CAPSULE |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TIROSINT 175 MCG CAPSULE |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TIROSINT 200 MCG CAPSULE |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TIROSINT 25 MCG CAPSULE |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TIROSINT 50 MCG CAPSULE |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TIROSINT 75 MCG CAPSULE |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TIROSINT 88 MCG CAPSULE |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TIROSINT-SOL 100 MCG/ML SOLUTION |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TIROSINT-SOL 112 MCG/ML SOLUTION |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TIROSINT-SOL 125 MCG/ML SOLUTION |
3 |
Tier 3 |
$35.00 | $70.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIROSINT-SOL 13 MCG/ML SOLUTION |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TIROSINT-SOL 137 MCG/ML SOLUTION |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TIROSINT-SOL 150 MCG/ML SOLUTION |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TIROSINT-SOL 175 MCG/ML SOLUTION |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TIROSINT-SOL 200 MCG/ML SOLUTION |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TIROSINT-SOL 25 MCG/ML SOLUTION |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TIROSINT-SOL 50 MCG/ML SOLUTION |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TIROSINT-SOL 75 MCG/ML SOLUTION |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TIROSINT-SOL 88 MCG/ML SOLUTION |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TIVICAY 10 MG TABLET |
4 |
Tier 4 |
27% | 27% | Q:30 /30Days |
TIVICAY 25 MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIVICAY 50 MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
TIZANIDINE HCL 2 MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TIZANIDINE HCL 4 MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TOBI PODHALER 28 MG INHALE CAP |
3 |
Tier 3 |
$35.00 | $70.00 | P |
TOBRADEX EYE OINTMENT |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TOBRAMYCIN 0.3% EYE DROPS [Tobrex] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TOBRAMYCIN 10 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate] |
2 |
Tier 2 |
$10.00 | $20.00 | P |
TOBRAMYCIN 300 MG/5 ML AMPULE [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate] |
5 |
Tier 5 |
33% | N/A | P |
TOBRAMYCIN 40 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate] |
2 |
Tier 2 |
$10.00 | $20.00 | P |
TOBRAMYCIN-DEXAMETH OPTH SUSP |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TOBREX 0.3% EYE OINTMENT |
4 |
Tier 4 |
27% | 27% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOLCAPONE 100 MG TABLET [Tasmar] |
5 |
Tier 5 |
33% | N/A | None |
TOLTERODINE TART ER 2 MG CAPSULE ER 24H [Detrol LA] |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TOLTERODINE TART ER 4 MG CAPSULE ER 24H [Detrol LA] |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TOLTERODINE TARTRATE 1 MG TABLET [Detrol LA] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TOLTERODINE TARTRATE 2 MG TABLET [Detrol] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TOLVAPTAN 15 MG ORAL TABLET [SAMSCA] |
5 |
Tier 5 |
33% | N/A | P |
TOLVAPTAN 30 MG ORAL TABLET [SAMSCA] |
5 |
Tier 5 |
33% | N/A | P |
TOPIRAMATE 100 MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TOPIRAMATE 15 MG SPRINKLE CAP |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TOPIRAMATE 200 MG TABLET [Topiragen] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TOPIRAMATE 25 MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Topiramate 25mg/1 |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TOPIRAMATE 50 MG TABLET [Topiragen] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TOREMIFENE CITRATE 60 MG TABLET [Fareston] |
5 |
Tier 5 |
33% | N/A | None |
TORSEMIDE 10 MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TORSEMIDE 100 MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TORSEMIDE 20 MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TORSEMIDE 5 MG TABLET [Demadex] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TOUJEO MAX SOLOSTAR 300UNIT/ML INSULN PEN |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TOUJEO SOLOSTAR 300 UNITS/ML |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TOVET EMOLLIENT 0.05% FOAM [Olux-E] |
4 |
Tier 4 |
27% | 27% | Q:100 /30Days |
TOVIAZ TABLETS 4MG EXTENDED RELEASE |
4 |
Tier 4 |
27% | 27% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOVIAZ TABLETS 8MG EXTENDED RELEASE |
4 |
Tier 4 |
27% | 27% | None |
TRADJENTA 5 MG TABLET |
3 |
Tier 3 |
$35.00 | $70.00 | Q:30 /30Days |
TRAMADOL HCL 100 MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRAMADOL HCL 50 MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRAMADOL-ACETAMINOPHN 37.5-325 |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRANDOLAPRIL 1 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRANDOLAPRIL 2 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRANDOLAPRIL 4 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRANDOLAPRIL-VERAPAMIL ER 1-240 MG |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRANDOLAPRIL-VERAPAMIL ER 2-180 MG |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRANDOLAPRIL-VERAPAMIL ER 2-240 MG |
2 |
Tier 2 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRANDOLAPRIL-VERAPAMIL ER 4-240 MG |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRANEXAMIC ACID 650 MG TABLET [Lysteda] |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TRANSDERM-SCOP 1.5 MG/3 DAY |
3 |
Tier 3 |
$35.00 | $70.00 | Q:10 /30Days |
TRANYLCYPROMINE SULF 10 MG TABLET [Parnate] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRAVASOL 10% SOLUTION VIAFLEX |
3 |
Tier 3 |
$35.00 | $70.00 | P |
TRAVATAN Z 0.04MG DROPS 2.5ML BOT |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TRAVOPROST 0.004% EYE DROPS [Travatan] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRAZODONE 100 MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRAZODONE 150 MG TABLET [Desyrel] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRAZODONE 300 MG TABLET [Desyrel] |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TRAZODONE 50 MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRECATOR 250MG TABLET |
4 |
Tier 4 |
27% | 27% | None |
TRELEGY ELLIPTA 100-62.5-25 |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TRELSTAR 11.25 MG SYRINGE |
5 |
Tier 5 |
33% | N/A | None |
TRELSTAR 3.75 MG SYRINGE |
5 |
Tier 5 |
33% | N/A | None |
TRESIBA 100 UNIT/ML VIAL |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TRESIBA FLEXTOUCH 100 UNITS/ML |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TRESIBA FLEXTOUCH 200 UNITS/ML |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TRETINOIN 0.01% GEL [Tretin-X] |
3 |
Tier 3 |
$35.00 | $70.00 | P |
TRETINOIN 0.025% CREAM |
3 |
Tier 3 |
$35.00 | $70.00 | P |
TRETINOIN 0.025% GEL [Tretin-X] |
3 |
Tier 3 |
$35.00 | $70.00 | P |
TRETINOIN 0.05% CREAM |
3 |
Tier 3 |
$35.00 | $70.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRETINOIN 0.05% GEL [Atralin] |
3 |
Tier 3 |
$35.00 | $70.00 | P |
TRETINOIN 0.1% CREAM |
3 |
Tier 3 |
$35.00 | $70.00 | P |
TRETINOIN 10MG CAPSULE |
5 |
Tier 5 |
33% | N/A | None |
TRI-LEGEST FE 5-7-9-7 TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRI-PREVIFEM TABLET [Trinessa] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRI-SPRINTEC 7DAYSX3 28 TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRIAMCINOLONE 0.025% CREAM |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRIAMCINOLONE 0.025% LOTION |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRIAMCINOLONE 0.025% OINT |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRIAMCINOLONE 0.1% CREAM (g) [Triderm] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRIAMCINOLONE 0.1% LOTION [Kenalog] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIAMCINOLONE 0.1% OINTMENT [Triderm] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRIAMCINOLONE 0.1% PASTE (G) [Oralone] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE |
2 |
Tier 2 |
$10.00 | $20.00 | None |
Triamcinolone Acetonide 5mg/g 1 TUBE per CARTON / 15 g in 1 TUBE |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRIAMTERENE 100 MG CAPSULE [Dyrenium] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRIAMTERENE 50 MG CAPSULE [Dyrenium] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRIAMTERENE-HCTZ 37.5-25 MG CAPSULE [Dyazide] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRIAMTERENE-HCTZ 37.5-25 MG TB |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRIAMTERENE-HCTZ 75-50 MG TAB |
1 |
Tier 1 |
$0.00 | $0.00 | None |
TRIENTINE HCL 250 MG CAPSULE [Syprine] |
5 |
Tier 5 |
33% | N/A | P |
TRIFLUOPERAZINE 1 MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIFLUOPERAZINE HCL 2MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRIFLUOPERAZINE HCL 5MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT) |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRIHEXYPHENIDYL 2 MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRIHEXYPHENIDYL 5 MG TABLET [Artane] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
Trihexyphenidyl Hydrochloride 2mg/5mL 473 mL in 1 BOTTLE |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRIKAFTA 100/50/75 MG-150 MG TABLET SEQ |
5 |
Tier 5 |
33% | N/A | P Q:84 /28Days |
TRILYTE WITH FLAVOR PACKETS |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRIMETHOPRIM 100 MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TRIMIPRAMINE MALEATE 100 MG CP |
3 |
Tier 3 |
$35.00 | $70.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIMIPRAMINE MALEATE 25 MG CAP |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TRIMIPRAMINE MALEATE 50 MG CAP |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TRINTELLIX 10 MG TABLET |
4 |
Tier 4 |
27% | 27% | None |
TRINTELLIX 20 MG TABLET |
4 |
Tier 4 |
27% | 27% | None |
TRINTELLIX 5 MG TABLET |
4 |
Tier 4 |
27% | 27% | None |
Triptorelin 11.3 MG/ML Injectable Suspension [Trelstar] |
5 |
Tier 5 |
33% | N/A | None |
TRIUMEQ TABLET |
5 |
Tier 5 |
33% | N/A | None |
TRIVORA-28 TABLET [Trivora] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TROPHAMINE INJECTION SOLUTION |
4 |
Tier 4 |
27% | 27% | P |
TROSPIUM CHLORIDE 20 MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TROSPIUM CHLORIDE ER 60 MG CAP |
3 |
Tier 3 |
$35.00 | $70.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRULICITY 0.75 MG/0.5 ML PEN |
3 |
Tier 3 |
$35.00 | $70.00 | Q:2 /28Days |
TRULICITY 1.5 MG/0.5 ML PEN |
3 |
Tier 3 |
$35.00 | $70.00 | Q:2 /28Days |
TRUMENBA 120 MCG/0.5 ML VACCIN Syringe |
3 |
Tier 3 |
$35.00 | $70.00 | None |
TRUVADA 100 MG-150 MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
TRUVADA 133 MG-200 MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
TRUVADA 167 MG-250 MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
TRUVADA 200/300MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
TUKYSA 150 MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
TUKYSA 50 MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
TURALIO 200 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | P |
TWINRIX VACCINE SYRINGE |
3 |
Tier 3 |
$35.00 | $70.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TYBOST 150 MG TABLET |
4 |
Tier 4 |
27% | 27% | None |
TYDEMY TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
TYKERB 250 MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
TYPHIM VI 25 MCG/0.5 ML SYRINGE |
4 |
Tier 4 |
27% | 27% | None |
TYPHIM VI 25MCG/0.5ML VIAL |
4 |
Tier 4 |
27% | 27% | None |