2024 Medicare Part D Plan Formulary Information |
Mutual of Omaha Rx Essential (PDP) (S7126-106-0)
Benefits & Contact Info
Insulin on a Medicare Part D plan's formulary will have a monthly copay of $35 or less. Call drug plan for more details. |
The Mutual of Omaha Rx Essential (PDP) (S7126-106-0) Formulary Drugs Starting with the Letter T in CMS PDP Region 4 which includes: NJ
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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 |
48% | N/A | None |
TABRECTA 150 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:112 /28Days |
TABRECTA 200 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:112 /28Days |
TACROLIMUS 0.03% OINTMENT [Protopic] |
4 |
Non-Preferred Drug |
48% | N/A | P Q:100 /30Days |
TACROLIMUS 0.1% OINTMENT [Protopic] |
4 |
Non-Preferred Drug |
48% | N/A | P Q:100 /30Days |
TACROLIMUS 0.5 MG CAPSULE (IR) [Prograf] |
4 |
Non-Preferred Drug |
48% | N/A | P |
TACROLIMUS 1 MG CAPSULE (IR) [Prograf] |
4 |
Non-Preferred Drug |
48% | N/A | P |
TACROLIMUS 5 MG CAPSULE (IR) [Prograf] |
4 |
Non-Preferred Drug |
48% | N/A | P |
TAFINLAR 10 MG TABLET FOR SUSPENSION |
5 |
Specialty Tier |
25% | N/A | P Q:840 /28Days |
TAFINLAR 50 MG CAPSULE |
5 |
Specialty Tier |
25% | 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 |
25% | N/A | P Q:120 /30Days |
TAFLUPROST 0.0015% EYE DROP DROPERETTE [ZIOPTAN] |
3 |
Preferred Brand |
20% | 20% | None |
TAGRISSO 40 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
TAGRISSO 80 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
TALZENNA 0.1 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
TALZENNA 0.25 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
TALZENNA 0.35 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
TALZENNA 0.5 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
TALZENNA 0.75 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
TALZENNA 1 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
TAMOXIFEN 10 MG TABLET [Nolvadex] |
2 |
Generic |
$15.00 | $37.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAMOXIFEN 20 MG TABLET [Nolvadex] |
2 |
Generic |
$15.00 | $37.50 | None |
TAMSULOSIN HCL 0.4 MG CAPSULE [Flomax] |
2 |
Generic |
$15.00 | $37.50 | None |
TARINA FE 1-20 EQ TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
Tasigna 150mg/1 4 BLISTER PACK per CARTON / 28 CAPSULE per BLISTER PACK |
5 |
Specialty Tier |
25% | N/A | P Q:112 /28Days |
TASIGNA 200 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:112 /28Days |
TASIGNA 50 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
TASIMELTEON 20 MG CAPSULE [HETLIOZ] |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
TAZAROTENE 0.05% GEL [TAZORAC] |
4 |
Non-Preferred Drug |
48% | N/A | P |
TAZAROTENE 0.1% CREAM [Tazorac] |
4 |
Non-Preferred Drug |
48% | N/A | P |
TAZAROTENE 0.1% GEL [TAZORAC] |
4 |
Non-Preferred Drug |
48% | N/A | P |
TAZICEF 1GM VIAL |
4 |
Non-Preferred Drug |
48% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAZICEF 2 GRAM VIAL |
4 |
Non-Preferred Drug |
48% | N/A | P |
TAZICEF 6 GRAM VIAL |
4 |
Non-Preferred Drug |
48% | N/A | P |
TAZVERIK 200 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
TDVAX VIAL |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
Teflaro 400mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE |
5 |
Specialty Tier |
25% | N/A | P |
Teflaro 600mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE |
5 |
Specialty Tier |
25% | N/A | P |
TEGLUTIK 5 MG/ML ORAL SUSPENSION [TIGLUTIK] |
4 |
Non-Preferred Drug |
48% | N/A | P |
TELMISARTAN 20 MG TABLET [Micardis] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
TELMISARTAN 40 MG TABLET [Micardis] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
TELMISARTAN 80 MG TABLET [Micardis] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
TELMISARTAN-AMLODIPINE 40-10 TABLET [Twynsta] |
2 |
Generic |
$15.00 | $37.50 | 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 TABLET [Twynsta] |
2 |
Generic |
$15.00 | $37.50 | Q:30 /30Days |
TELMISARTAN-AMLODIPINE 80-10 TABLET [Twynsta] |
2 |
Generic |
$15.00 | $37.50 | Q:30 /30Days |
TELMISARTAN-AMLODIPINE 80-5 MG TABLET [Twynsta] |
2 |
Generic |
$15.00 | $37.50 | Q:30 /30Days |
TELMISARTAN-HCTZ 40-12.5 MG TABLET [Micardis HCT] |
3 |
Preferred Brand |
20% | 20% | Q:30 /30Days |
TELMISARTAN-HCTZ 80-12.5 MG TABLET [Micardis HCT] |
3 |
Preferred Brand |
20% | 20% | Q:30 /30Days |
TELMISARTAN-HCTZ 80-25 MG TABLET [Micardis HCT] |
3 |
Preferred Brand |
20% | 20% | Q:30 /30Days |
TENIVAC SYRINGE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
TENIVAC VIAL |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
TENOFOVIR DISOP FUM 300 MG TABLET [Viread] |
4 |
Non-Preferred Drug |
48% | N/A | None |
TEPMETKO 225 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
TERAZOSIN 1 MG CAPSULE |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TERAZOSIN 10 MG CAPSULE [Hytrin] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days |
TERAZOSIN 2 MG CAPSULE |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
TERAZOSIN 5 MG CAPSULE [Hytrin] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
TERBINAFINE HCL 250 MG TABLET [Terbinex] |
2 |
Generic |
$15.00 | $37.50 | None |
TERBUTALINE SULFATE 2.5 MG TABLET [Brethine] |
4 |
Non-Preferred Drug |
48% | N/A | None |
TERBUTALINE SULFATE 5 MG TABLET [Brethine] |
4 |
Non-Preferred Drug |
48% | N/A | None |
TERCONAZOLE 0.4% CREAM WITH APPLICATOR |
3 |
Preferred Brand |
20% | 20% | None |
TERCONAZOLE 0.8% CREAM |
3 |
Preferred Brand |
20% | 20% | None |
TERCONAZOLE 80MG SUPPOSITORY VAGINAL |
3 |
Preferred Brand |
20% | 20% | None |
TERIPARATIDE 620 MCG/2.48 ML PEN INJECTOR [Forteo] |
5 |
Specialty Tier |
25% | N/A | P Q:2.48 /28Days |
TESTOSTERON ENAN 1,000 MG/5 ML VIAL [Delatestryl] |
3 |
Preferred Brand |
20% | 20% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TESTOSTERONE 1.62% (2.5 G) GEL PACKET [AndroGel] |
4 |
Non-Preferred Drug |
48% | N/A | P Q:150 /30Days |
TESTOSTERONE 1.62% GEL MD PUMP [AndroGel] |
4 |
Non-Preferred Drug |
48% | N/A | P Q:150 /30Days |
TESTOSTERONE 1.62%(1.25 G) GEL PACKET [AndroGel] |
4 |
Non-Preferred Drug |
48% | N/A | P Q:37.5 /30Days |
TESTOSTERONE 10 MG GEL MD PUMP [FORTESTA] |
4 |
Non-Preferred Drug |
48% | N/A | P Q:120 /30Days |
TESTOSTERONE 12.5 MG/1.25 GRAM GEL MD PMP [Vogelxo] |
4 |
Non-Preferred Drug |
48% | N/A | P Q:300 /30Days |
TESTOSTERONE 25 MG/2.5 GM GEL PACKET [Vogelxo] |
4 |
Non-Preferred Drug |
48% | N/A | P Q:300 /30Days |
TESTOSTERONE 30 MG/1.5 ML SOL MD PUMP [AXIRON] |
4 |
Non-Preferred Drug |
48% | N/A | P Q:180 /30Days |
TESTOSTERONE 50 MG/5 GRAM GEL PACKET [Vogelxo] |
4 |
Non-Preferred Drug |
48% | N/A | P Q:300 /30Days |
Testosterone cyp 100 mg/ml |
3 |
Preferred Brand |
20% | 20% | P |
TESTOSTERONE CYP 2,000 MG/10ML VIAL [Virilon] |
3 |
Preferred Brand |
20% | 20% | P |
TESTOSTERONE CYP 200 MG/ML VIAL [Virilon] |
3 |
Preferred Brand |
20% | 20% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TETRABENAZINE 12.5 MG TABLET [Xenazine] |
5 |
Specialty Tier |
25% | N/A | P Q:240 /30Days |
TETRABENAZINE 25 MG TABLET [Xenazine] |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
TETRACYCLINE 250 MG CAPSULE [Panmycin] |
4 |
Non-Preferred Drug |
48% | N/A | None |
TETRACYCLINE 500 MG CAPSULE [Sumycin] |
4 |
Non-Preferred Drug |
48% | N/A | None |
THALOMID 100 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:28 /28Days |
THALOMID 150 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:56 /28Days |
THALOMID 200 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:56 /28Days |
THALOMID 50 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:28 /28Days |
THEOPHYLLINE 80 MG/15 ML SOLUTION |
4 |
Non-Preferred Drug |
48% | N/A | None |
THEOPHYLLINE ER 100 MG TABLET 12H [Theochron] |
4 |
Non-Preferred Drug |
48% | N/A | None |
THEOPHYLLINE ER 200 MG TABLET 12H [Theochron] |
4 |
Non-Preferred Drug |
48% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THEOPHYLLINE ER 300 MG TABLET |
4 |
Non-Preferred Drug |
48% | N/A | None |
THEOPHYLLINE ER 400 MG TABLET 24H [Uniphyl] |
2 |
Generic |
$15.00 | $37.50 | None |
THEOPHYLLINE ER 450 MG TABLET 12H |
4 |
Non-Preferred Drug |
48% | N/A | None |
THEOPHYLLINE ER 600 MG TABLET 24H [Uniphyl] |
2 |
Generic |
$15.00 | $37.50 | None |
THIORIDAZINE 10 MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
THIORIDAZINE 100MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
THIORIDAZINE 25 MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
THIORIDAZINE 50 MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
THIOTHIXENE 1 MG CAPSULE [Navane] |
4 |
Non-Preferred Drug |
48% | N/A | None |
THIOTHIXENE 10 MG CAPSULE [Navane] |
4 |
Non-Preferred Drug |
48% | N/A | None |
THIOTHIXENE 2 MG CAPSULE [Navane] |
4 |
Non-Preferred Drug |
48% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THIOTHIXENE 5 MG CAPSULE [Navane] |
4 |
Non-Preferred Drug |
48% | N/A | None |
TIADYLT ER 120 MG CAPSULE SA 24H [Tiazac] |
2 |
Generic |
$15.00 | $37.50 | None |
TIADYLT ER 180 MG CAPSULE SA 24H [Tiazac] |
2 |
Generic |
$15.00 | $37.50 | None |
TIADYLT ER 240 MG CAPSULE SA 24H [Tiazac] |
2 |
Generic |
$15.00 | $37.50 | None |
TIADYLT ER 300 MG CAPSULE SA 24H [Tiazac] |
2 |
Generic |
$15.00 | $37.50 | None |
TIADYLT ER 360 MG CAPSULE SA 24H [Tiazac] |
2 |
Generic |
$15.00 | $37.50 | None |
TIADYLT ER 420 MG CAPSULE SA 24H [Tiazac] |
2 |
Generic |
$15.00 | $37.50 | None |
TIAGABINE HCL 12 MG TABLET [Gabitril] |
4 |
Non-Preferred Drug |
48% | N/A | None |
TIAGABINE HCL 16 MG TABLET [Gabitril] |
4 |
Non-Preferred Drug |
48% | N/A | None |
TIAGABINE HCL 2 MG TABLET [Gabitril] |
4 |
Non-Preferred Drug |
48% | N/A | None |
TIAGABINE HCL 4 MG TABLET [Gabitril] |
4 |
Non-Preferred Drug |
48% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIBSOVO 250 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
TICOVAC 1.2 MCG/0.25 ML SYRINGE |
3 |
Preferred Brand |
20% | 20% | None |
TICOVAC 2.4 MCG/0.5 ML SYRINGE |
3 |
Preferred Brand |
20% | 20% | None |
TIGECYCLINE 50 MG VIAL [Tygacil] |
5 |
Specialty Tier |
25% | N/A | P |
TILIA FE 28 TABLET [Tri-Legest Fe] |
4 |
Non-Preferred Drug |
48% | N/A | None |
TIMOLOL 0.25% GEL-SOLUTION [Timoptic-XE] |
4 |
Non-Preferred Drug |
48% | N/A | None |
TIMOLOL 0.5% GEL-SOLUTION [Timoptic-XE] |
4 |
Non-Preferred Drug |
48% | N/A | None |
TIMOLOL MALEATE 0.25% EYE DROPS [Timoptic Ocumeter] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
TIMOLOL MALEATE 0.5% EYE DROPS [Timoptic Ocumeter] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
TIMOLOL MALEATE 10MG TABLET |
4 |
Non-Preferred Drug |
48% | N/A | None |
TIMOLOL MALEATE 20MG TABLET |
4 |
Non-Preferred Drug |
48% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIMOLOL MALEATE 5MG TABLET |
4 |
Non-Preferred Drug |
48% | N/A | None |
TINIDAZOLE 250 MG TABLET [Tindamax] |
3 |
Preferred Brand |
20% | 20% | None |
TINIDAZOLE 500 MG TABLET [Tindamax] |
3 |
Preferred Brand |
20% | 20% | None |
TIOTROPIUM 18 MCG CAP-INHALER CAP W/DEV [Spiriva HandiHaler] |
3 |
Preferred Brand |
20% | 20% | Q:90 /90Days |
TIVICAY 10 MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
TIVICAY 25 MG TABLET |
5 |
Specialty Tier |
25% | N/A | None |
TIVICAY 50 MG TABLET |
5 |
Specialty Tier |
25% | N/A | None |
TIVICAY PD 5 MG TABLET FOR SUSPENSION |
5 |
Specialty Tier |
25% | N/A | None |
TIZANIDINE HCL 2 MG TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
TIZANIDINE HCL 4 MG TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
TOBRAMYCIN 0.3% EYE DROPS [Tobrex] |
2 |
Generic |
$15.00 | $37.50 | Q:10 /14Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOBRAMYCIN 10 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate] |
4 |
Non-Preferred Drug |
48% | N/A | P |
TOBRAMYCIN 300 MG/4 ML AMPULE-NEB [BETHKIS] |
5 |
Specialty Tier |
25% | N/A | P Q:224 /28Days |
TOBRAMYCIN 300 MG/5 ML AMPULE [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate] |
5 |
Specialty Tier |
25% | N/A | P Q:280 /28Days |
TOBRAMYCIN 40 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate] |
4 |
Non-Preferred Drug |
48% | N/A | P |
TOBRAMYCIN-DEXAMETH OPTH SUSP |
4 |
Non-Preferred Drug |
48% | N/A | Q:10 /14Days |
TOLTERODINE TART ER 2 MG CAPSULE 24H [Detrol LA] |
4 |
Non-Preferred Drug |
48% | N/A | None |
TOLTERODINE TART ER 4 MG CAPSULE 24H [Detrol LA] |
4 |
Non-Preferred Drug |
48% | N/A | None |
TOLTERODINE TARTRATE 1 MG TABLET [Detrol] |
4 |
Non-Preferred Drug |
48% | N/A | None |
TOLTERODINE TARTRATE 2 MG TABLET [Detrol] |
4 |
Non-Preferred Drug |
48% | N/A | None |
TOPIRAMATE 100 MG TABLET [Topiragen] |
2 |
Generic |
$15.00 | $37.50 | P |
TOPIRAMATE 15 MG SPRINKLE CAPSULE |
3 |
Preferred Brand |
20% | 20% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOPIRAMATE 200 MG TABLET [Topiragen] |
2 |
Generic |
$15.00 | $37.50 | P |
TOPIRAMATE 25 MG TABLET [Topiragen] |
2 |
Generic |
$15.00 | $37.50 | P |
Topiramate 25mg/1 |
3 |
Preferred Brand |
20% | 20% | P |
TOPIRAMATE 50 MG TABLET [Topiragen] |
2 |
Generic |
$15.00 | $37.50 | P |
TOREMIFENE CITRATE 60 MG TABLET [Fareston] |
5 |
Specialty Tier |
25% | N/A | None |
TORSEMIDE 10 MG TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
TORSEMIDE 100 MG TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
TORSEMIDE 20 MG TABLET [SOAANZ] |
2 |
Generic |
$15.00 | $37.50 | None |
TORSEMIDE 5 MG TABLET [Demadex] |
2 |
Generic |
$15.00 | $37.50 | None |
TOUJEO MAX SOLOSTAR 300UNIT/ML INSULN PEN |
3 |
Preferred Brand |
20% | 20% | None |
TOUJEO SOLOSTAR 300 UNITS/ML |
3 |
Preferred Brand |
20% | 20% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRAMADOL HCL 50 MG TABLET [Ultram] |
2 |
Generic |
$15.00 | $37.50 | Q:240 /30Days |
TRAMADOL-ACETAMINOPHN 37.5-325 TABLET [Ultracet] |
2 |
Generic |
$15.00 | $37.50 | Q:240 /30Days |
TRANDOLAPRIL 1 MG TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
TRANDOLAPRIL 2 MG TABLET [Mavik] |
2 |
Generic |
$15.00 | $37.50 | None |
TRANDOLAPRIL 4 MG TABLET [Mavik] |
2 |
Generic |
$15.00 | $37.50 | None |
TRANEXAMIC ACID 650 MG TABLET [Lysteda] |
3 |
Preferred Brand |
20% | 20% | None |
TRANYLCYPROMINE SULF 10 MG TABLET [Parnate] |
4 |
Non-Preferred Drug |
48% | N/A | None |
TRAVASOL 10% SOLUTION VIAFLEX |
4 |
Non-Preferred Drug |
48% | N/A | P |
TRAVOPROST 0.004% EYE DROPS [Travatan Z] |
3 |
Preferred Brand |
20% | 20% | None |
TRAZODONE 100 MG TABLET [Desyrel] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
TRAZODONE 150 MG TABLET [Desyrel] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRAZODONE 300 MG TABLET [Desyrel] |
2 |
Generic |
$15.00 | $37.50 | None |
TRAZODONE 50 MG TABLET [Desyrel] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
TRECATOR 250MG TABLET |
4 |
Non-Preferred Drug |
48% | N/A | None |
TRELSTAR 11.25 MG VIAL |
4 |
Non-Preferred Drug |
48% | N/A | P |
TRELSTAR 22.5 MG VIAL |
4 |
Non-Preferred Drug |
48% | N/A | P |
TRELSTAR 3.75 MG VIAL |
4 |
Non-Preferred Drug |
48% | N/A | P |
TRETINOIN 0.01% GEL [Tretin-X] |
3 |
Preferred Brand |
20% | 20% | P |
TRETINOIN 0.025% CREAM (G) [Tretin-X] |
4 |
Non-Preferred Drug |
48% | N/A | P |
TRETINOIN 0.025% GEL [Tretin-X] |
3 |
Preferred Brand |
20% | 20% | P |
TRETINOIN 0.05% CREAM |
4 |
Non-Preferred Drug |
48% | N/A | P |
TRETINOIN 0.05% GEL [Atralin] |
3 |
Preferred Brand |
20% | 20% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRETINOIN 0.1% CREAM |
4 |
Non-Preferred Drug |
48% | N/A | P |
TRETINOIN 10MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | None |
TRI-ESTARYLLA TABLET [Trinessa] |
2 |
Generic |
$15.00 | $37.50 | None |
TRI-LEGEST FE 5-7-9-7 TABLET |
4 |
Non-Preferred Drug |
48% | N/A | None |
TRI-LO-ESTARYLLA TABLET [Trinessa Lo] |
2 |
Generic |
$15.00 | $37.50 | None |
TRI-LO-SPRINTEC TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
TRI-SPRINTEC 7DAYSX3 28 TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
TRIAMCINOLONE 0.025% CREAM |
2 |
Generic |
$15.00 | $37.50 | None |
TRIAMCINOLONE 0.025% LOTION [Kenalog] |
2 |
Generic |
$15.00 | $37.50 | None |
TRIAMCINOLONE 0.025% OINT |
2 |
Generic |
$15.00 | $37.50 | None |
TRIAMCINOLONE 0.1% CREAM (G) [Triderm] |
2 |
Generic |
$15.00 | $37.50 | 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 |
$15.00 | $37.50 | None |
TRIAMCINOLONE 0.1% OINTMENT [Triderm] |
2 |
Generic |
$15.00 | $37.50 | None |
TRIAMCINOLONE 0.1% PASTE (G) [Oralone] |
2 |
Generic |
$15.00 | $37.50 | None |
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE |
2 |
Generic |
$15.00 | $37.50 | None |
Triamcinolone Acetonide 1 MG/ML Topical Cream [Triderm] |
2 |
Generic |
$15.00 | $37.50 | None |
Triamcinolone Acetonide 5mg/g 1 TUBE per CARTON / 15 g in 1 TUBE |
2 |
Generic |
$15.00 | $37.50 | None |
TRIAMTERENE-HCTZ 37.5-25 MG CAPSULE [Dyazide] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
TRIAMTERENE-HCTZ 37.5-25 MG TABLET [Maxzide-25] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
TRIAMTERENE-HCTZ 75-50 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
TRIDERM 0.5% CREAM (G) |
2 |
Generic |
$15.00 | $37.50 | None |
TRIENTINE HCL 250 MG CAPSULE [Syprine] |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIFLUOPERAZINE 1 MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
TRIFLUOPERAZINE HCL 2MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
TRIFLUOPERAZINE HCL 5MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT) |
3 |
Preferred Brand |
20% | 20% | None |
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOTTLE |
3 |
Preferred Brand |
20% | 20% | None |
TRIKAFTA 100/50/75 MG-150 MG TABLET SEQ |
5 |
Specialty Tier |
25% | N/A | P Q:84 /28Days |
TRIKAFTA 50-25-37.5 MG/75 MG TABLET SEQ |
5 |
Specialty Tier |
25% | N/A | P Q:84 /28Days |
TRIMETHOPRIM 100 MG TABLET [Proloprim] |
2 |
Generic |
$15.00 | $37.50 | None |
TRIMIPRAMINE MALEATE 100 MG CAPSULE |
4 |
Non-Preferred Drug |
48% | N/A | None |
TRIMIPRAMINE MALEATE 25 MG CAPSULE |
4 |
Non-Preferred Drug |
48% | N/A | None |
TRIMIPRAMINE MALEATE 50 MG CAPSULE |
4 |
Non-Preferred Drug |
48% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRINTELLIX 10 MG TABLET |
3 |
Preferred Brand |
20% | 20% | Q:30 /30Days |
TRINTELLIX 20 MG TABLET |
3 |
Preferred Brand |
20% | 20% | Q:30 /30Days |
TRINTELLIX 5 MG TABLET |
3 |
Preferred Brand |
20% | 20% | Q:30 /30Days |
TRIUMEQ PD 60-5-30 MG TABLET SUSP |
5 |
Specialty Tier |
25% | N/A | None |
TRIUMEQ TABLET |
5 |
Specialty Tier |
25% | N/A | None |
TRIVORA-28 TABLET [Trivora] |
2 |
Generic |
$15.00 | $37.50 | None |
TRIZIVIR 300; 150; 300mg/1; mg/1; mg/1 60 FILM COATED TABLETS in BOTTLE |
5 |
Specialty Tier |
25% | N/A | None |
TROPHAMINE 10% IV SOLUTION |
4 |
Non-Preferred Drug |
48% | N/A | P |
TROSPIUM CHLORIDE 20 MG TABLET [Sanctura] |
2 |
Generic |
$15.00 | $37.50 | None |
TRULICITY 0.75 MG/0.5 ML PEN |
3 |
Preferred Brand |
20% | 20% | P Q:2 /28Days |
TRULICITY 1.5 MG/0.5 ML PEN |
3 |
Preferred Brand |
20% | 20% | P Q:2 /28Days |
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 |
3 |
Preferred Brand |
20% | 20% | P Q:2 /28Days |
TRULICITY 4.5 MG/0.5 ML PEN INJECTOR |
3 |
Preferred Brand |
20% | 20% | P Q:2 /28Days |
TRUMENBA 120 MCG/0.5 ML VACCIN Syringe |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
TRUQAP 160 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:64 /28Days |
TRUQAP 200 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:64 /28Days |
TUKYSA 150 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
TUKYSA 50 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:300 /30Days |
TURALIO 125 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
TURQOZ-28 TABLET |
2 |
Generic |
$15.00 | $37.50 | None |
TWINRIX VACCINE SYRINGE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
TYMLOS 80 MCG DOSE PEN INJECTR |
5 |
Specialty Tier |
25% | N/A | P Q:1.56 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TYPHIM VI 25 MCG/0.5 ML SYRINGE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
TYPHIM VI 25MCG/0.5ML VIAL |
1* |
Preferred Generic |
$0.00 | $0.00 | None |