Drug List - T

T
Drug Name Tier Restrictions
TACLONEX OIN 2 Prior authorization, Quantity limit
TACROLIMUS OINT 1
TAFINLAR CAP 75MG 3 Prior authorization
TAGAMET NC
TAMIFLU 3 Prior authorization
TAMOXIFEN CITRATE 1
TAMSOLUSIN 1
TANZEUM 3 Step therapy
TARCEVA 3 Prior authorization
TASIGNA CAP 3 Prior authorization
TAZAROTENE 1 Prior authorization, Quantity limit
TAZORAC 3 Prior authorization, Quantity limit
TECFIDERA 2
TEGRETOL 3
TEGRETOL-XR 2
TEKTURNA 2
TEKTURNA HTC 2
TEKTURNA-XR 2
TELMISARTAN 1
TELMISARTAN/HCTZ 1
TEMAZEPAM 1
TEMODAR 3 Prior authorization
TEMOZOLOMIDE 1
TENORMIN 3 Prior authorization
TERAZOSIN HCL 1
TERBINAFINE HCL 1
TERBUTALINE SULFATE 1
TERCONAZOLE 1
TESFIDERA 3 Prior authorization
TESTERONE ENANTHATE INJ 1
TESTOSTERONE CYPIONATE INJ 1
TESTOSTERONE GEL 1
TETRACYCLINE CAP 1
TEV-TROPIN 3 Prior authorization, Step therapy
TEVETEN 3
THALOMID 2 Prior authorization, Quantity limit
THEOPHYLLINE ER 1
THERMAZENE 1 Quantity limit
THEROBEC TAB PLUS 1
THIOTHIXENE 1
THYROGEN INJ 2
THYROID 1
TIAGABINE HCL 1
TIAZAC 3 Prior authorization
TICLOPIDINE HCL 1
TICOSYN 3 Prior authorization
TIGAN 3 Prior authorization
TIKOSYN CAP 250MCG 3 Prior authorization
TILIA FE 1*
TIMOLOL MALEATE OP 1
TIMOLOL OP 1
TIMOPTIC 3 Prior authorization
TIMOPTIC-XE OP 2
TINDAMAX 2
TINIDAZOLE TAB 1
TIROSINT CAP 3 Prior authorization
TIVICAY TAB 50MG 3 Prior authorization
TIZANIDINE HCL 1
TOBI NEB 300/5ML 2
TOBRA/DEXAME SUS 0.3-0.1%
TOBRADEX 3 Prior authorization
TOBRAMYCIN SULFATE 1
TOBREX 3 Prior authorization
TOLAK 4% CREAM 2
TOLBUTAMIDE 1
TOLMETIN SODIUM 1
TOLTERODINE 1
TOPAMAX 3
TOPICORT 3 Prior authorization
TOPIRAMATE TAB 1
TOPROL XL 3 Prior authorization
TORSEMIDE 1
TOUJEO SOLO INJ 300IU/ML 3
TOVIAZ 3
TRADJENTA TAB 5MG 2 Step therapy
TRAMADOL HCL 1
TRAMADOL HYDROCHLORIDE/ACET 1
TRANDOLAPRIL TAB 2MG 1
TRANEXAMIC ACID 1
TRANSDERM-SCOP DIS 2 Travel
TRANYLCYPROMINE SULFATE 1
TRAVATAN Z 2
TRAZODONE HC 1
TRENTAL 3 Prior authorization
TRESIBA FLEX INJ 3 Prior authorization
TRETINOIN CRE 1 Quantity limit
TRETINOIN EMOLLIENT NC Quantity limit
TRETINOIN GEL & CREAM 1 Quantity limit
TREXIMET NC
TRI-LEGEST FE 1*
TRI-LO-SPRINTEC 1*
TRI-LUMA NC Quantity limit
TRI-PREVIFEM 1
TRI-SPRINTEC 1*
TRI-VITAMIN/FLUORIDE 1
TRIAMCINOLONE
TRIAMCINOLONE IN ORABASE 1 Quantity limit
TRIAMTERENE/HYDROCHLOROTHIA 1
TRIAZ 3 Quantity limit
TRIAZOLAM 1 Quantity limit
TRIBENZOR 3 Prior authorization
TRICON CAP 1
TRICOR 3 Step therapy
TRIFLUOPERAZINE 1
TRIFLURIDINE 1
TRIGLIDE 3
TRIHEXYPHENIDYL HCL 1
TRILEPTAL 3
TRILYTE 3 Prior authorization
TRIMETHOBENZAMIDE HCL 1
TRIMETHOPRIM 1
TRIMETHOPRIM SULFATE 1
TRINESSA 1*
TRINESSA LO 1*
TRINTELLIX TAB 3
TRIUMEQ TAB 3 Prior authorization
TRIVORA 1
TRIZIVIR 2
TROKENDI XR CAP 100MG 3 Prior authorization
TROPICAMIDE 1
TROSPIUM CHLORIDE ER 1
TRULICITY 2 Step therapy
TRUVADA 2
TUDORZA PRES AER 400/ACT 3
TYKOSIN 3 Prior authorization
TYLENOL/CODEINE #3 3 Prior authorization