2024 Medicare Part D Plan Formulary Information |
Kaiser Permanente Senior Advantage Choice DM (PPO) (H3138-001-0)
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 Kaiser Permanente Senior Advantage Choice DM (PPO) (H3138-001-0) Formulary Drugs Starting with the Letter T in Adams County, CO: CMS MA Region 20 which includes: CO
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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 |
5 |
Tier 5 |
33% | 33% | None |
TABRECTA 150 MG TABLET |
5 |
Tier 5 |
33% | 33% | None |
TABRECTA 200 MG TABLET |
5 |
Tier 5 |
33% | 33% | None |
TACROLIMUS 0.03% OINTMENT [Protopic] |
2 |
Generic |
$5.00 | $0.00 | None |
TACROLIMUS 0.1% OINTMENT [Protopic] |
2 |
Generic |
$5.00 | $0.00 | None |
TACROLIMUS 0.5 MG CAPSULE (IR) [Prograf] |
2 |
Generic |
$5.00 | $0.00 | P |
TACROLIMUS 1 MG CAPSULE (IR) [Prograf] |
2 |
Generic |
$5.00 | $0.00 | P |
TACROLIMUS 5 MG CAPSULE (IR) [Prograf] |
2 |
Generic |
$5.00 | $0.00 | P |
TADALAFIL 2.5 MG TABLET [Cialis] |
2 |
Generic |
$5.00 | $0.00 | P |
TADALAFIL 20 MG TABLET [Cialis] |
2 |
Generic |
$5.00 | $0.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TADALAFIL 5 MG TABLET [Cialis] |
2 |
Generic |
$5.00 | $0.00 | P |
TADLIQ 20 MG/5 ML ORAL SUSPENSION |
5 |
Tier 5 |
33% | 33% | P |
TAFINLAR 10 MG TABLET FOR SUSPENSION |
5 |
Tier 5 |
33% | 33% | None |
TAFINLAR 50 MG CAPSULE |
5 |
Tier 5 |
33% | 33% | None |
TAFINLAR 75 MG CAPSULE |
5 |
Tier 5 |
33% | 33% | None |
TAGRISSO 40 MG TABLET |
5 |
Tier 5 |
33% | 33% | None |
TAGRISSO 80 MG TABLET |
5 |
Tier 5 |
33% | 33% | None |
TAKHZYRO 150 MG/ML SYRINGE |
5 |
Tier 5 |
33% | 33% | None |
TAKHZYRO 300 MG/2 ML SYRINGE |
5 |
Tier 5 |
33% | 33% | None |
TAKHZYRO 300 MG/2 ML VIAL |
5 |
Tier 5 |
33% | 33% | None |
TALZENNA 0.1 MG CAPSULE |
5 |
Tier 5 |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TALZENNA 0.25 MG CAPSULE |
5 |
Tier 5 |
33% | 33% | None |
TALZENNA 0.35 MG CAPSULE |
5 |
Tier 5 |
33% | 33% | None |
TALZENNA 0.5 MG CAPSULE |
5 |
Tier 5 |
33% | 33% | None |
TALZENNA 0.75 MG CAPSULE |
5 |
Tier 5 |
33% | 33% | None |
TALZENNA 1 MG CAPSULE |
5 |
Tier 5 |
33% | 33% | None |
TAMOXIFEN 10 MG TABLET [Nolvadex] |
2 |
Generic |
$5.00 | $0.00 | None |
TAMOXIFEN 20 MG TABLET [Nolvadex] |
2 |
Generic |
$5.00 | $0.00 | None |
TAMSULOSIN HCL 0.4 MG CAPSULE [Flomax] |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
TARPEYO DR 4 MG CAPSULE DR |
5 |
Tier 5 |
33% | 33% | None |
TASCENSO ODT 0.25 MG TABLET RAPDIS |
5 |
Tier 5 |
33% | 33% | None |
TASCENSO ODT 0.5 MG TABLET RAPDIS |
5 |
Tier 5 |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Tasigna 150mg/1 4 BLISTER PACK per CARTON / 28 CAPSULE per BLISTER PACK |
5 |
Tier 5 |
33% | 33% | None |
TASIGNA 200 MG CAPSULE |
5 |
Tier 5 |
33% | 33% | None |
TASIGNA 50 MG CAPSULE |
5 |
Tier 5 |
33% | 33% | None |
TASIMELTEON 20 MG CAPSULE [HETLIOZ] |
5 |
Tier 5 |
33% | 33% | P |
TAVALISSE 100 MG TABLET |
5 |
Tier 5 |
33% | 33% | None |
TAVALISSE 150 MG TABLET |
5 |
Tier 5 |
33% | 33% | None |
TAVNEOS 10 MG CAPSULE |
5 |
Tier 5 |
33% | 33% | None |
TAYSOFY 1 MG-20 MCG CAPSULE [Taytulla] |
2 |
Generic |
$5.00 | $0.00 | None |
TAZAROTENE 0.05% GEL [TAZORAC] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
TAZAROTENE 0.1% CREAM [Tazorac] |
2 |
Generic |
$5.00 | $0.00 | P |
TAZAROTENE 0.1% GEL [TAZORAC] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TAZICEF 1GM VIAL |
2 |
Generic |
$5.00 | $0.00 | None |
TAZICEF 2 GRAM VIAL |
2 |
Generic |
$5.00 | $0.00 | None |
TAZICEF 6 GRAM VIAL |
2 |
Generic |
$5.00 | $0.00 | None |
TAZORAC 0.05% CREAM (G) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
TAZVERIK 200 MG TABLET |
5 |
Tier 5 |
33% | 33% | None |
TDVAX VIAL |
6 |
Tier 6 |
$0.00 | N/A | None |
Teflaro 600mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE |
5 |
Tier 5 |
33% | 33% | None |
TEGLUTIK 5 MG/ML ORAL SUSPENSION [TIGLUTIK] |
5 |
Tier 5 |
33% | 33% | None |
TEGSEDI 284 MG/1.5 ML SYRINGE |
5 |
Tier 5 |
33% | 33% | None |
TEMAZEPAM 15 MG CAPSULE [Restoril] |
2 |
Generic |
$5.00 | $0.00 | None |
TEMAZEPAM 30 MG CAPSULE [Restoril] |
2 |
Generic |
$5.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TEMAZEPAM 7.5 MG CAPSULE [Restoril] |
2 |
Generic |
$5.00 | $0.00 | None |
TENIVAC SYRINGE |
6 |
Tier 6 |
$0.00 | N/A | None |
TENIVAC VIAL |
6 |
Tier 6 |
$0.00 | N/A | None |
TENOFOVIR DISOP FUM 300 MG TABLET [Viread] |
2 |
Generic |
$5.00 | $0.00 | None |
TEPMETKO 225 MG TABLET |
5 |
Tier 5 |
33% | 33% | None |
TERAZOSIN 1 MG CAPSULE |
2 |
Generic |
$5.00 | $0.00 | None |
TERAZOSIN 10 MG CAPSULE [Hytrin] |
2 |
Generic |
$5.00 | $0.00 | None |
TERAZOSIN 2 MG CAPSULE |
2 |
Generic |
$5.00 | $0.00 | None |
TERAZOSIN 5 MG CAPSULE [Hytrin] |
2 |
Generic |
$5.00 | $0.00 | None |
TERBINAFINE HCL 250 MG TABLET [Terbinex] |
2 |
Generic |
$5.00 | $0.00 | None |
TERBUTALINE SULFATE 2.5 MG TABLET [Brethine] |
2 |
Generic |
$5.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TERBUTALINE SULFATE 5 MG TABLET [Brethine] |
2 |
Generic |
$5.00 | $0.00 | None |
TERCONAZOLE 0.4% CREAM WITH APPLICATOR |
2 |
Generic |
$5.00 | $0.00 | None |
TERCONAZOLE 80MG SUPPOSITORY VAGINAL |
2 |
Generic |
$5.00 | $0.00 | None |
TERIFLUNOMIDE 14 MG TABLET [AUBAGIO] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
TERIFLUNOMIDE 7 MG TABLET [AUBAGIO] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
TERIPARATIDE 620 MCG/2.48 ML PEN INJECTOR [Forteo] |
5 |
Tier 5 |
33% | 33% | None |
TESTOSTERON ENAN 1,000 MG/5 ML VIAL [Delatestryl] |
2 |
Generic |
$5.00 | $0.00 | None |
TESTOSTERONE 1.62% GEL MD PUMP [AndroGel] |
2 |
Generic |
$5.00 | $0.00 | None |
TESTOSTERONE 12.5 MG/1.25 GRAM GEL MD PMP [Vogelxo] |
2 |
Generic |
$5.00 | $0.00 | None |
TESTOSTERONE 25 MG/2.5 GM GEL PACKET [Vogelxo] |
2 |
Generic |
$5.00 | $0.00 | None |
TESTOSTERONE 50 MG/5 GRAM GEL PACKET [Vogelxo] |
2 |
Generic |
$5.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Testosterone cyp 100 mg/ml |
2 |
Generic |
$5.00 | $0.00 | None |
TESTOSTERONE CYP 2,000 MG/10ML VIAL [Virilon] |
2 |
Generic |
$5.00 | $0.00 | None |
TESTOSTERONE CYP 200 MG/ML VIAL [Virilon] |
2 |
Generic |
$5.00 | $0.00 | None |
TETRABENAZINE 12.5 MG TABLET [Xenazine] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
TETRABENAZINE 25 MG TABLET [Xenazine] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
TETRACYCLINE 250 MG CAPSULE [Panmycin] |
2 |
Generic |
$5.00 | $0.00 | None |
TETRACYCLINE 500 MG CAPSULE [Sumycin] |
2 |
Generic |
$5.00 | $0.00 | None |
THALOMID 100 MG CAPSULE |
5 |
Tier 5 |
33% | 33% | None |
THALOMID 150 MG CAPSULE |
5 |
Tier 5 |
33% | 33% | None |
THALOMID 200 MG CAPSULE |
5 |
Tier 5 |
33% | 33% | None |
THALOMID 50 MG CAPSULE |
5 |
Tier 5 |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THEO-24 ER 300 MG CAPSULE |
2 |
Generic |
$5.00 | $0.00 | None |
THEOPHYLLINE 80 MG/15 ML SOLUTION |
2 |
Generic |
$5.00 | $0.00 | None |
THEOPHYLLINE ER 100 MG TABLET 12H [Theochron] |
2 |
Generic |
$5.00 | $0.00 | None |
THEOPHYLLINE ER 200 MG TABLET 12H [Theochron] |
2 |
Generic |
$5.00 | $0.00 | None |
THEOPHYLLINE ER 300 MG TABLET |
2 |
Generic |
$5.00 | $0.00 | None |
THEOPHYLLINE ER 400 MG TABLET 24H [Uniphyl] |
2 |
Generic |
$5.00 | $0.00 | None |
THEOPHYLLINE ER 450 MG TABLET 12H |
2 |
Generic |
$5.00 | $0.00 | None |
THEOPHYLLINE ER 600 MG TABLET 24H [Uniphyl] |
2 |
Generic |
$5.00 | $0.00 | None |
THIOLA 100 MG TABLET |
5 |
Tier 5 |
33% | 33% | None |
THIOLA EC 100 MG TABLET DR |
5 |
Tier 5 |
33% | 33% | None |
THIOLA EC 300 MG TABLET DR |
5 |
Tier 5 |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
THIORIDAZINE 10 MG TABLET |
2 |
Generic |
$5.00 | $0.00 | None |
THIORIDAZINE 100MG TABLET |
2 |
Generic |
$5.00 | $0.00 | None |
THIORIDAZINE 25 MG TABLET |
2 |
Generic |
$5.00 | $0.00 | None |
THIORIDAZINE 50 MG TABLET |
2 |
Generic |
$5.00 | $0.00 | None |
THIOTHIXENE 1 MG CAPSULE [Navane] |
2 |
Generic |
$5.00 | $0.00 | None |
THIOTHIXENE 10 MG CAPSULE [Navane] |
2 |
Generic |
$5.00 | $0.00 | None |
THIOTHIXENE 2 MG CAPSULE [Navane] |
2 |
Generic |
$5.00 | $0.00 | None |
THIOTHIXENE 5 MG CAPSULE [Navane] |
2 |
Generic |
$5.00 | $0.00 | None |
TIAGABINE HCL 12 MG TABLET [Gabitril] |
2 |
Generic |
$5.00 | $0.00 | None |
TIAGABINE HCL 16 MG TABLET [Gabitril] |
2 |
Generic |
$5.00 | $0.00 | None |
TIAGABINE HCL 2 MG TABLET [Gabitril] |
2 |
Generic |
$5.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIAGABINE HCL 4 MG TABLET [Gabitril] |
2 |
Generic |
$5.00 | $0.00 | None |
TIBSOVO 250 MG TABLET |
5 |
Tier 5 |
33% | 33% | None |
TICOVAC 1.2 MCG/0.25 ML SYRINGE |
6 |
Tier 6 |
$0.00 | N/A | None |
TICOVAC 2.4 MCG/0.5 ML SYRINGE |
6 |
Tier 6 |
$0.00 | N/A | None |
TIGECYCLINE 50 MG VIAL [Tygacil] |
5 |
Tier 5 |
33% | 33% | 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 |
2 |
Generic |
$5.00 | $0.00 | None |
TINIDAZOLE 250 MG TABLET [Tindamax] |
2 |
Generic |
$5.00 | $0.00 | None |
TIOPRONIN 100 MG TABLET [Thiola] |
5 |
Tier 5 |
33% | 33% | None |
TIVICAY 10 MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TIVICAY 25 MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
TIVICAY 50 MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
TIVICAY PD 5 MG TABLET FOR SUSPENSION |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
TIZANIDINE HCL 2 MG TABLET |
2 |
Generic |
$5.00 | $0.00 | None |
TIZANIDINE HCL 4 MG TABLET |
2 |
Generic |
$5.00 | $0.00 | None |
TOBI PODHALER 28 MG INHALE CAPSULE W/DEV |
5 |
Tier 5 |
33% | 33% | None |
TOBRADEX EYE OINTMENT |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
TOBRAMYCIN 0.3% EYE DROPS [Tobrex] |
2 |
Generic |
$5.00 | $0.00 | None |
TOBRAMYCIN 10 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate] |
2 |
Generic |
$5.00 | $0.00 | None |
TOBRAMYCIN 300 MG/4 ML AMPULE-NEB [BETHKIS] |
5 |
Tier 5 |
33% | 33% | P |
TOBRAMYCIN 300 MG/5 ML AMPULE [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate] |
5 |
Tier 5 |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOBRAMYCIN 40 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate] |
2 |
Generic |
$5.00 | $0.00 | None |
TOBRAMYCIN-DEXAMETH OPTH SUSP |
2 |
Generic |
$5.00 | $0.00 | None |
TOBREX 0.3% EYE OINTMENT |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
TOLCAPONE 100 MG TABLET [Tasmar] |
5 |
Tier 5 |
33% | 33% | None |
TOLECTIN 600 MG TABLET |
5 |
Tier 5 |
33% | 33% | None |
TOLSURA 65 MG CAPSULE SD DSP |
5 |
Tier 5 |
33% | 33% | None |
TOLTERODINE TARTRATE 1 MG TABLET [Detrol] |
2 |
Generic |
$5.00 | $0.00 | None |
TOLTERODINE TARTRATE 2 MG TABLET [Detrol] |
2 |
Generic |
$5.00 | $0.00 | None |
TOLVAPTAN 15 MG TABLET [Samsca] |
5 |
Tier 5 |
33% | 33% | None |
TOLVAPTAN 30 MG TABLET [Samsca] |
5 |
Tier 5 |
33% | 33% | None |
TOPIRAMATE 100 MG TABLET [Topiragen] |
2 |
Generic |
$5.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TOPIRAMATE 15 MG SPRINKLE CAPSULE |
2 |
Generic |
$5.00 | $0.00 | None |
TOPIRAMATE 200 MG TABLET [Topiragen] |
2 |
Generic |
$5.00 | $0.00 | None |
TOPIRAMATE 25 MG TABLET [Topiragen] |
2 |
Generic |
$5.00 | $0.00 | None |
Topiramate 25mg/1 |
2 |
Generic |
$5.00 | $0.00 | None |
TOPIRAMATE 50 MG TABLET [Topiragen] |
2 |
Generic |
$5.00 | $0.00 | None |
TOPIRAMATE ER 100 MG CAPSULE SPR 24 [Qudexy XR] |
2 |
Generic |
$5.00 | $0.00 | None |
TOPIRAMATE ER 150 MG CAPSULE SPR 24 [Qudexy XR] |
2 |
Generic |
$5.00 | $0.00 | None |
TOPIRAMATE ER 200 MG CAPSULE SPR 24 [Qudexy XR] |
2 |
Generic |
$5.00 | $0.00 | None |
TOPIRAMATE ER 25 MG CAPSULE SPR 24 [Qudexy XR] |
2 |
Generic |
$5.00 | $0.00 | None |
TOPIRAMATE ER 50 MG CAPSULE SPR 24 [Qudexy XR] |
2 |
Generic |
$5.00 | $0.00 | None |
TOREMIFENE CITRATE 60 MG TABLET [Fareston] |
5 |
Tier 5 |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TORSEMIDE 10 MG TABLET |
2 |
Generic |
$5.00 | $0.00 | None |
TORSEMIDE 100 MG TABLET |
2 |
Generic |
$5.00 | $0.00 | None |
TORSEMIDE 20 MG TABLET [SOAANZ] |
2 |
Generic |
$5.00 | $0.00 | None |
TORSEMIDE 5 MG TABLET [Demadex] |
2 |
Generic |
$5.00 | $0.00 | None |
TRACLEER 32 MG TABLET FOR SUSPENSION TABLET SUSP |
5 |
Tier 5 |
33% | 33% | None |
TRADJENTA 5 MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
TRAMADOL HCL 5 MG/ML SOLUTION [QDOLO] |
5 |
Tier 5 |
33% | 33% | None |
TRAMADOL HCL 50 MG TABLET [Ultram] |
2 |
Generic |
$5.00 | $0.00 | None |
TRAMADOL-ACETAMINOPHN 37.5-325 TABLET [Ultracet] |
2 |
Generic |
$5.00 | $0.00 | None |
TRANEXAMIC ACID 650 MG TABLET [Lysteda] |
2 |
Generic |
$5.00 | $0.00 | None |
TRANYLCYPROMINE SULF 10 MG TABLET [Parnate] |
2 |
Generic |
$5.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRAVASOL 10% SOLUTION VIAFLEX |
2 |
Generic |
$5.00 | $0.00 | None |
TRAVOPROST 0.004% EYE DROPS [Travatan Z] |
2 |
Generic |
$5.00 | $0.00 | 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 |
TRAZODONE 300 MG TABLET [Desyrel] |
2 |
Generic |
$5.00 | $0.00 | None |
TRAZODONE 50 MG TABLET [Desyrel] |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
TRECATOR 250MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
TRELSTAR 11.25 MG VIAL |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
TRELSTAR 22.5 MG VIAL |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
TRELSTAR 3.75 MG VIAL |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
TREMFYA 100 MG/ML AUTOINJECTOR |
5 |
Tier 5 |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TREMFYA 100 MG/ML SYRINGE |
5 |
Tier 5 |
33% | 33% | None |
TRETINOIN 0.01% GEL [Tretin-X] |
2 |
Generic |
$5.00 | $0.00 | P |
TRETINOIN 0.025% CREAM (G) [Tretin-X] |
2 |
Generic |
$5.00 | $0.00 | P |
TRETINOIN 0.025% GEL [Tretin-X] |
2 |
Generic |
$5.00 | $0.00 | P |
TRETINOIN 0.05% CREAM |
2 |
Generic |
$5.00 | $0.00 | P |
TRETINOIN 0.1% CREAM |
2 |
Generic |
$5.00 | $0.00 | P |
Tretinoin 0.25 MG/ML Topical Cream [Retin-A] |
2 |
Generic |
$5.00 | $0.00 | P |
Tretinoin 0.5 MG/ML Topical Cream [Retin-A] |
2 |
Generic |
$5.00 | $0.00 | P |
TRETINOIN 10MG CAPSULE |
5 |
Tier 5 |
33% | 33% | None |
TREXALL 10MG TABLET |
2 |
Generic |
$5.00 | $0.00 | None |
TREXALL 15MG TABLET |
2 |
Generic |
$5.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TREXALL 5MG TABLET |
2 |
Generic |
$5.00 | $0.00 | None |
TREXALL 7.5MG TABLET |
2 |
Generic |
$5.00 | $0.00 | None |
TRI-LO-SPRINTEC TABLET |
2 |
Generic |
$5.00 | $0.00 | None |
TRI-SPRINTEC 7DAYSX3 28 TABLET |
2 |
Generic |
$5.00 | $0.00 | None |
TRIAMCINOLONE 0.025% CREAM |
2 |
Generic |
$5.00 | $0.00 | None |
TRIAMCINOLONE 0.025% LOTION [Kenalog] |
2 |
Generic |
$5.00 | $0.00 | None |
TRIAMCINOLONE 0.025% OINT |
2 |
Generic |
$5.00 | $0.00 | None |
TRIAMCINOLONE 0.1% CREAM (G) [Triderm] |
2 |
Generic |
$5.00 | $0.00 | None |
TRIAMCINOLONE 0.1% LOTION [Kenalog] |
2 |
Generic |
$5.00 | $0.00 | None |
TRIAMCINOLONE 0.1% OINTMENT [Triderm] |
2 |
Generic |
$5.00 | $0.00 | None |
TRIAMCINOLONE 0.1% PASTE (G) [Oralone] |
2 |
Generic |
$5.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE |
2 |
Generic |
$5.00 | $0.00 | None |
Triamcinolone Acetonide 5mg/g 1 TUBE per CARTON / 15 g in 1 TUBE |
2 |
Generic |
$5.00 | $0.00 | None |
TRIAMTERENE 100 MG CAPSULE [Dyrenium] |
2 |
Generic |
$5.00 | $0.00 | None |
TRIAMTERENE 50 MG CAPSULE [Dyrenium] |
2 |
Generic |
$5.00 | $0.00 | 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 |
TRIAZOLAM 0.125 MG TABLET [Halcion] |
2 |
Generic |
$5.00 | $0.00 | None |
TRIAZOLAM 0.25 MG TABLET [Halcion] |
2 |
Generic |
$5.00 | $0.00 | None |
TRIENTINE HCL 250 MG CAPSULE [Syprine] |
5 |
Tier 5 |
33% | 33% | None |
TRIENTINE HCL 500 MG CAPSULE |
5 |
Tier 5 |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIFLUOPERAZINE HCL 2MG TABLET |
2 |
Generic |
$5.00 | $0.00 | None |
TRIFLUOPERAZINE HCL 5MG TABLET |
2 |
Generic |
$5.00 | $0.00 | None |
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT) |
2 |
Generic |
$5.00 | $0.00 | None |
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOTTLE |
2 |
Generic |
$5.00 | $0.00 | None |
TRIHEXYPHENIDYL 2 MG TABLET [Artane] |
2 |
Generic |
$5.00 | $0.00 | None |
TRIHEXYPHENIDYL 5 MG TABLET [Artane] |
2 |
Generic |
$5.00 | $0.00 | None |
Trihexyphenidyl Hydrochloride 2mg/5mL 473 mL in 1 BOTTLE |
2 |
Generic |
$5.00 | $0.00 | None |
TRIKAFTA 100-50-75 MG/75MG GRANULES PACKET SQ |
5 |
Tier 5 |
33% | 33% | None |
TRIKAFTA 100/50/75 MG-150 MG TABLET SEQ |
5 |
Tier 5 |
33% | 33% | None |
TRIKAFTA 50-25-37.5 MG/75 MG TABLET SEQ |
5 |
Tier 5 |
33% | 33% | None |
TRIKAFTA 80-40-60MG/59.5MG GRANULES PACKET SQ |
5 |
Tier 5 |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TRIMETHOPRIM 100 MG TABLET [Proloprim] |
2 |
Generic |
$5.00 | $0.00 | None |
TRIMIPRAMINE MALEATE 100 MG CAPSULE |
2 |
Generic |
$5.00 | $0.00 | None |
TRIMIPRAMINE MALEATE 25 MG CAPSULE |
2 |
Generic |
$5.00 | $0.00 | None |
TRIMIPRAMINE MALEATE 50 MG CAPSULE |
2 |
Generic |
$5.00 | $0.00 | None |
TRINTELLIX 10 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
TRINTELLIX 20 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
TRINTELLIX 5 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
TRIUMEQ PD 60-5-30 MG TABLET SUSP |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
TRIUMEQ TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
TRIVORA-28 TABLET [Trivora] |
2 |
Generic |
$5.00 | $0.00 | None |
TRIZIVIR 300; 150; 300mg/1; mg/1; mg/1 60 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
TROPHAMINE 10% IV SOLUTION |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
TROSPIUM CHLORIDE 20 MG TABLET [Sanctura] |
2 |
Generic |
$5.00 | $0.00 | None |
TRULANCE 3 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
TRUMENBA 120 MCG/0.5 ML VACCIN Syringe |
6 |
Tier 6 |
$0.00 | N/A | None |
TRUQAP 160 MG TABLET |
5 |
Tier 5 |
33% | 33% | None |
TRUQAP 200 MG TABLET |
5 |
Tier 5 |
33% | 33% | None |
TUKYSA 150 MG TABLET |
5 |
Tier 5 |
33% | 33% | None |
TUKYSA 50 MG TABLET |
5 |
Tier 5 |
33% | 33% | None |
TURALIO 125 MG CAPSULE |
5 |
Tier 5 |
33% | 33% | None |
TWINRIX VACCINE SYRINGE |
6 |
Tier 6 |
$0.00 | N/A | None |
TYBOST 150 MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
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 |
6 |
Tier 6 |
$0.00 | N/A | None |
TYPHIM VI 25MCG/0.5ML VIAL |
6 |
Tier 6 |
$0.00 | N/A | None |
TYVASO DPI 16 MCG CARTRIDGE INHAL |
5 |
Tier 5 |
33% | 33% | None |
TYVASO DPI 16-32-48 MCG TITRAT CARTRIDGE INHAL |
5 |
Tier 5 |
33% | 33% | None |
TYVASO DPI 32 MCG CARTRIDGE INHAL |
5 |
Tier 5 |
33% | 33% | None |
TYVASO DPI 32-48 MCG MAINT KIT CARTRIDGE INHAL |
5 |
Tier 5 |
33% | 33% | None |
TYVASO DPI 48 MCG CARTRIDGE INHAL |
5 |
Tier 5 |
33% | 33% | None |
TYVASO DPI 64 MCG CARTRIDGE INHAL |
5 |
Tier 5 |
33% | 33% | None |