2021 Medicare Part D Plan Formulary Information |
Triple S Platino Blindao (HMO D-SNP) (H5774-028-0)
Benefit Details
|
The Triple S Platino Blindao (HMO D-SNP) (H5774-028-0) Formulary Drugs Starting with the Letter T in Juncos County, PR: CMS MA Region 30 which includes: PR Plan Monthly Premium: $0.00 Deductible: $445 |
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 Brand |
$95.00 | $190.00 | None |
TABRECTA 150 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P |
TABRECTA 200 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P |
TACROLIMUS 0.03% OINTMENT [Protopic] |
2 |
Generic |
$15.00 | $30.00 | S |
TACROLIMUS 0.1% OINTMENT [Protopic] |
2 |
Generic |
$15.00 | $30.00 | S |
TACROLIMUS 0.5 MG CAPSULE |
2 |
Generic |
$15.00 | $30.00 | P |
TACROLIMUS 1 MG CAPSULE |
2 |
Generic |
$15.00 | $30.00 | P |
TACROLIMUS 5 MG CAPSULE |
2 |
Generic |
$15.00 | $30.00 | P |
TADALAFIL 20 MG TABLET [ALYQ] |
5 |
Specialty Tier |
25% | 25% | P |
TAFINLAR 50 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAFINLAR 75 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P |
TAGRISSO 40 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P |
TAGRISSO 80 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P |
TALZENNA 0.25 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P |
TALZENNA 1 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P |
TAMOXIFEN 10 MG TABLET [Nolvadex] |
2 |
Generic |
$15.00 | $30.00 | None |
TAMOXIFEN 20 MG TABLET [Nolvadex] |
2 |
Generic |
$15.00 | $30.00 | None |
TAMSULOSIN HCL 0.4 MG CAPSULE [Flomax] |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
TARGRETIN 1% GEL |
5 |
Specialty Tier |
25% | 25% | P |
Tasigna 150mg/1 4 BLISTER PACK per CARTON / 28 CAPSULE per BLISTER PACK |
5 |
Specialty Tier |
25% | 25% | P |
TASIGNA 200 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TASIGNA 50 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P |
TAZAROTENE 0.1% CREAM [Tazorac] |
2 |
Generic |
$15.00 | $30.00 | P |
TAZORAC 0.05% GEL |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | P |
TAZORAC 0.1% GEL |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | P |
TAZVERIK 200 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P |
TDVAX VIAL |
3 |
Preferred Brand |
$42.00 | $84.00 | P |
TECFIDERA DR 120 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P |
TECFIDERA DR 240 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P |
TECFIDERA STARTER PACK |
5 |
Specialty Tier |
25% | 25% | P |
Teflaro 400mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE |
5 |
Specialty Tier |
25% | 25% | P |
Teflaro 600mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE |
5 |
Specialty Tier |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TEMAZEPAM 15 MG CAPSULE [Restoril] |
2 |
Generic |
$15.00 | $30.00 | None |
TEMAZEPAM 30 MG CAPSULE [Restoril] |
2 |
Generic |
$15.00 | $30.00 | None |
TENIVAC SYRINGE |
3 |
Preferred Brand |
$42.00 | $84.00 | None |
TENOFOVIR DISOP FUM 300 MG TABLET [Viread] |
2 |
Generic |
$15.00 | $30.00 | None |
TEPMETKO 225 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P |
TERAZOSIN 1 MG CAPSULE |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
TERAZOSIN 10 MG CAPSULE [Hytrin] |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
TERAZOSIN 2 MG CAPSULE |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
TERAZOSIN 5 MG CAPSULE [Hytrin] |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
TERBINAFINE HCL 250 MG TABLET [Terbinex] |
1 |
Preferred Generic |
$10.00 | $20.00 | Q:90 /180Days |
TERBUTALINE SULFATE 2.5 MG TAB |
2 |
Generic |
$15.00 | $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 |
Generic |
$15.00 | $30.00 | None |
TERCONAZOLE 0.4% CREAM WITH APPLICATOR |
2 |
Generic |
$15.00 | $30.00 | None |
TERCONAZOLE 0.8% CREAM |
2 |
Generic |
$15.00 | $30.00 | None |
TERCONAZOLE 80MG SUPPOSITORY VAGINAL |
2 |
Generic |
$15.00 | $30.00 | None |
TERIPARATIDE 620 MCG/2.48 ML PEN INJECTOR [Forteo] |
5 |
Specialty Tier |
25% | 25% | P |
TESTOSTERON ENAN 1,000 MG/5 ML VIAL [Delatestryl] |
2 |
Generic |
$15.00 | $30.00 | P |
TESTOSTERONE 25 MG/2.5 GM GEL PACKET [Vogelxo] |
2 |
Generic |
$15.00 | $30.00 | P Q:300 /30Days |
Testosterone cyp 100 mg/ml |
1 |
Preferred Generic |
$10.00 | $20.00 | P |
TESTOSTERONE CYP 200 MG/ML |
2 |
Generic |
$15.00 | $30.00 | P |
TETRABENAZINE 12.5 MG TABLET [XENAZINE] |
5 |
Specialty Tier |
25% | 25% | None |
TETRABENAZINE 25 MG TABLET [XENAZINE] |
5 |
Specialty Tier |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TETRACYCLINE 250 MG CAPSULE |
2 |
Generic |
$15.00 | $30.00 | None |
TETRACYCLINE 500 MG CAPSULE [Sumycin] |
2 |
Generic |
$15.00 | $30.00 | None |
THALOMID 100 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P |
THALOMID 150 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P |
THALOMID 200 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P |
THALOMID 50 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P |
THEOPHYLLINE ER 300 MG TAB |
2 |
Generic |
$15.00 | $30.00 | None |
THEOPHYLLINE ER 400 MG TABLET ER 24H [Uniphyl] |
2 |
Generic |
$15.00 | $30.00 | None |
THEOPHYLLINE ER 600 MG TABLET ER 24H [Uniphyl] |
2 |
Generic |
$15.00 | $30.00 | None |
THIORIDAZINE 10 MG TABLET |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
THIORIDAZINE 100MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THIORIDAZINE 25 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
THIORIDAZINE 50 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
THIOTHIXENE 1 MG CAPSULE [Navane] |
2 |
Generic |
$15.00 | $30.00 | None |
THIOTHIXENE 10 MG CAPSULE [Navane] |
2 |
Generic |
$15.00 | $30.00 | None |
THIOTHIXENE 2 MG CAPSULE [Navane] |
2 |
Generic |
$15.00 | $30.00 | None |
THIOTHIXENE 5MG CAPSULE |
2 |
Generic |
$15.00 | $30.00 | None |
TIAGABINE HCL 12 MG TABLET [Gabitril] |
2 |
Generic |
$15.00 | $30.00 | None |
TIAGABINE HCL 16 MG TABLET [Gabitril] |
2 |
Generic |
$15.00 | $30.00 | None |
TIAGABINE HCL 2 MG TABLET [Gabitril] |
2 |
Generic |
$15.00 | $30.00 | None |
TIAGABINE HCL 4 MG TABLET [Gabitril] |
2 |
Generic |
$15.00 | $30.00 | None |
TIBSOVO 250 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIGECYCLINE 50 MG VIAL [Tygacil] |
5 |
Specialty Tier |
25% | 25% | P |
TIMOLOL 0.25% EYE DROPS |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
TIMOLOL MALEATE 0.5% EYE DROPS [Timoptic Ocumeter] |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
TIMOLOL MALEATE 10MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
TIMOLOL MALEATE 20MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
TIMOLOL MALEATE 5MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
TIVICAY 10 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
TIVICAY 25 MG TABLET |
5 |
Specialty Tier |
25% | 25% | None |
TIVICAY 50 MG TABLET |
5 |
Specialty Tier |
25% | 25% | None |
TIVICAY PD 5 MG TABLET FOR SUSPENSION |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
TIZANIDINE HCL 2 MG TABLET |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIZANIDINE HCL 4 MG TABLET |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
TOBRAMYCIN 0.3% EYE DROPS [Tobrex] |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
TOBRAMYCIN 10 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate] |
2 |
Generic |
$15.00 | $30.00 | P |
TOBRAMYCIN 300 MG/5 ML AMPULE [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate] |
5 |
Specialty Tier |
25% | 25% | P |
TOBRAMYCIN 40 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate] |
1 |
Preferred Generic |
$10.00 | $20.00 | P |
TOBRAMYCIN-DEXAMETH OPTH SUSP |
2 |
Generic |
$15.00 | $30.00 | None |
TOLCAPONE 100 MG TABLET [Tasmar] |
5 |
Specialty Tier |
25% | 25% | None |
TOPIRAMATE 100 MG TABLET |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
TOPIRAMATE 15 MG SPRINKLE CAP |
2 |
Generic |
$15.00 | $30.00 | None |
TOPIRAMATE 200 MG TABLET [Topiragen] |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
TOPIRAMATE 25 MG TABLET |
1 |
Preferred Generic |
$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 |
Generic |
$15.00 | $30.00 | None |
TOPIRAMATE 50 MG TABLET [Topiragen] |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
TOPIRAMATE ER 100 MG CAPSULE |
2 |
Generic |
$15.00 | $30.00 | None |
TOPIRAMATE ER 150 MG CAPSULE |
2 |
Generic |
$15.00 | $30.00 | None |
TOPIRAMATE ER 200 MG CAPSULE |
2 |
Generic |
$15.00 | $30.00 | None |
TOPIRAMATE ER 25 MG CAPSULE |
2 |
Generic |
$15.00 | $30.00 | None |
TOPIRAMATE ER 50 MG CAPSULE |
2 |
Generic |
$15.00 | $30.00 | None |
TOREMIFENE CITRATE 60 MG TABLET [Fareston] |
5 |
Specialty Tier |
25% | 25% | None |
TORSEMIDE 10 MG TABLET |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
TORSEMIDE 100 MG TABLET |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
TORSEMIDE 20 MG TABLET |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TORSEMIDE 5 MG TABLET [Demadex] |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
TOUJEO MAX SOLOSTAR 300UNIT/ML INSULN PEN |
6 |
Select Care Drugs |
$2.00 | $4.00 | Q:10 /30Days |
TOUJEO SOLOSTAR 300 UNITS/ML |
6 |
Select Care Drugs |
$2.00 | $4.00 | Q:10 /30Days |
TPN ELECTROLYTES16.5/25.4 VIAL |
2 |
Generic |
$15.00 | $30.00 | P |
TRADJENTA 5 MG TABLET |
6 |
Select Care Drugs |
$2.00 | $4.00 | None |
TRAMADOL HCL 50 MG TABLET [Ultram] |
1 |
Preferred Generic |
$10.00 | $20.00 | Q:240 /30Days |
TRAMADOL-ACETAMINOPHN 37.5-325 |
1 |
Preferred Generic |
$10.00 | $20.00 | Q:240 /30Days |
TRANDOLAPRIL 1 MG TABLET |
6 |
Select Care Drugs |
$2.00 | $4.00 | None |
TRANDOLAPRIL 2 MG TABLET |
6 |
Select Care Drugs |
$2.00 | $4.00 | None |
TRANDOLAPRIL 4 MG TABLET |
6 |
Select Care Drugs |
$2.00 | $4.00 | None |
TRANEXAMIC ACID 650 MG TABLET [Lysteda] |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRANYLCYPROMINE SULF 10 MG TABLET [Parnate] |
2 |
Generic |
$15.00 | $30.00 | None |
TRAVASOL 10% SOLUTION VIAFLEX |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | P |
TRAZODONE 100 MG TABLET [Desyrel] |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
TRAZODONE 150 MG TABLET [Desyrel] |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
TRAZODONE 50 MG TABLET [Desyrel] |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
TRECATOR 250MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
TRELEGY ELLIPTA 100-62.5-25 |
3 |
Preferred Brand |
$42.00 | $84.00 | Q:60 /30Days |
TRELEGY ELLIPTA 200-62.5-25 BLST W/DEV |
3 |
Preferred Brand |
$42.00 | $84.00 | Q:60 /30Days |
TRETINOIN 0.025% CREAM (G) [Tretin-X] |
2 |
Generic |
$15.00 | $30.00 | P |
TRETINOIN 0.05% CREAM |
2 |
Generic |
$15.00 | $30.00 | P |
TRETINOIN 0.1% CREAM |
2 |
Generic |
$15.00 | $30.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRETINOIN 10MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | None |
TRIAMCINOLONE 0.025% CREAM |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
TRIAMCINOLONE 0.025% LOTION |
2 |
Generic |
$15.00 | $30.00 | None |
TRIAMCINOLONE 0.025% OINT |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
TRIAMCINOLONE 0.1% CREAM (g) [Triderm] |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
TRIAMCINOLONE 0.1% OINTMENT [Triderm] |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
TRIAMCINOLONE 0.1% PASTE PASTE (G) [Oralone] |
2 |
Generic |
$15.00 | $30.00 | None |
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
Triamcinolone Acetonide 5mg/g 1 TUBE per CARTON / 15 g in 1 TUBE |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
TRIAMTERENE-HCTZ 37.5-25 MG CAPSULE [Dyazide] |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
TRIAMTERENE-HCTZ 37.5-25 MG TABLET [Maxzide] |
1 |
Preferred 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 |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
TRIENTINE HCL 250 MG CAPSULE [Syprine] |
5 |
Specialty Tier |
25% | 25% | None |
TRIFLUOPERAZINE 1 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
TRIFLUOPERAZINE HCL 2MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
TRIFLUOPERAZINE HCL 5MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT) |
2 |
Generic |
$15.00 | $30.00 | None |
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT |
2 |
Generic |
$15.00 | $30.00 | None |
TRIHEXYPHENIDYL 2 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | P |
TRIHEXYPHENIDYL 5 MG TABLET [Artane] |
2 |
Generic |
$15.00 | $30.00 | P |
Trihexyphenidyl Hydrochloride 2mg/5mL 473 mL in 1 BOTTLE |
2 |
Generic |
$15.00 | $30.00 | P |
TRILYTE WITH FLAVOR PACKETS |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIMETHOPRIM 100 MG TABLET |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
TRIMIPRAMINE MALEATE 100 MG CP |
2 |
Generic |
$15.00 | $30.00 | None |
TRIMIPRAMINE MALEATE 25 MG CAP |
2 |
Generic |
$15.00 | $30.00 | None |
TRIMIPRAMINE MALEATE 50 MG CAP |
2 |
Generic |
$15.00 | $30.00 | None |
TRINTELLIX 10 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
TRINTELLIX 20 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
TRINTELLIX 5 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
TRIUMEQ TABLET |
5 |
Specialty Tier |
25% | 25% | None |
TROPHAMINE INJECTION SOLUTION |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | P |
TRULICITY 0.75 MG/0.5 ML PEN |
6 |
Select Care Drugs |
$2.00 | $4.00 | S |
TRULICITY 1.5 MG/0.5 ML PEN |
6 |
Select Care Drugs |
$2.00 | $4.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRULICITY 3 MG/0.5 ML PEN INJECTOR |
6 |
Select Care Drugs |
$2.00 | $4.00 | S |
TRULICITY 4.5 MG/0.5 ML PEN INJECTOR |
6 |
Select Care Drugs |
$2.00 | $4.00 | S |
TRUMENBA 120 MCG/0.5 ML VACCIN Syringe |
3 |
Preferred Brand |
$42.00 | $84.00 | None |
TUKYSA 150 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P |
TUKYSA 50 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P |
TURALIO 200 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P |
TWINRIX VACCINE SYRINGE |
3 |
Preferred Brand |
$42.00 | $84.00 | P |
TYBOST 150 MG TABLET |
3 |
Preferred Brand |
$42.00 | $84.00 | None |
TYMLOS 80 MCG DOSE PEN INJECTR |
5 |
Specialty Tier |
25% | 25% | P |
TYPHIM VI 25 MCG/0.5 ML SYRINGE |
3 |
Preferred Brand |
$42.00 | $84.00 | None |
TYPHIM VI 25MCG/0.5ML VIAL |
3 |
Preferred Brand |
$42.00 | $84.00 | None |