2009 Medicare Part D Plan Formulary Information |
First Health Part D-Secure (S5768-112-0)
Benefit Details
|
The First Health Part D-Secure (S5768-112-0) Formulary Drugs Starting with the Letter A in CMS PDP Region 30 which includes: OR WA
|
Drugs Starting with Letter A
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
A-HYDROCORT 100MG VIAL |
1 |
Preferred Generic |
$4.00 | N/A | None |
ABILIFY 10MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | P Q:30 /30Days |
ABILIFY 15MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | P Q:30 /30Days |
ABILIFY 1MG/ML SOLUTION |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | P Q:900 /30Days |
ABILIFY 20MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | P Q:30 /30Days |
ABILIFY 2MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | P Q:30 /30Days |
ABILIFY 30MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | P Q:30 /30Days |
ABILIFY 5MG TABLET (OTSUKA) |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | P Q:30 /30Days |
ABILIFY DISCMELT 10MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | P Q:60 /30Days |
ABILIFY DISCMELT 15MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ABILIFY INJ 9.75MG |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | P |
ACARBOSE 100MG TABLET S |
1 |
Preferred Generic |
$4.00 | N/A | None |
ACARBOSE 25MG TABLET S |
1 |
Preferred Generic |
$4.00 | N/A | None |
ACARBOSE 50MG TABLET S |
1 |
Preferred Generic |
$4.00 | N/A | None |
ACCOLATE 10MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:60 /30Days |
ACCOLATE 20MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:60 /30Days |
ACEBUTOLOL 200MG CAPSULE |
1 |
Preferred Generic |
$4.00 | N/A | None |
ACEBUTOLOL 400MG CAPSULE |
1 |
Preferred Generic |
$4.00 | N/A | None |
ACEON 2MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:30 /30Days |
ACEON 4MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:30 /30Days |
ACEON 8MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-15MG (1000 CT) |
1 |
Preferred Generic |
$4.00 | N/A | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT) |
1 |
Preferred Generic |
$4.00 | N/A | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT) |
1 |
Preferred Generic |
$4.00 | N/A | None |
ACETAMINOPHEN/COD SOLUTION |
1 |
Preferred Generic |
$4.00 | N/A | None |
ACETAZOLAMIDE 125MG TABLET |
1 |
Preferred Generic |
$4.00 | N/A | None |
ACETAZOLAMIDE 250MG TABLET (100 CT) |
1 |
Preferred Generic |
$4.00 | N/A | None |
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT |
1 |
Preferred Generic |
$4.00 | N/A | None |
ACETIC ACID 2% SOLUTION NON-ORAL |
1 |
Preferred Generic |
$4.00 | N/A | None |
ACETIC ACID-HYDROCORTISONE 2%-1% DROPS |
1 |
Preferred Generic |
$4.00 | N/A | None |
ACETYLCYSTEINE 10% VIAL |
1 |
Preferred Generic |
$4.00 | N/A | None |
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN |
1 |
Preferred Generic |
$4.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACTHIB VACCINE VIAL 10-24UNT/5ML |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | None |
ACTICIN 5% CREAM |
1 |
Preferred Generic |
$4.00 | N/A | None |
ACTIMMUNE SOLUTION FOR INJECTION 100MCG |
4 |
Specialty-Generic and Brand |
28% | N/A | None |
ACTIVELLA 0.5-0.1MG TABLET 28 DLPK |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:28 /28Days |
ACTONEL 150MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:1 /30Days |
ACTONEL 30MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:30 /30Days |
ACTONEL 35MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:5 /30Days |
ACTONEL 5MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:30 /30Days |
ACTONEL 75MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:2 /30Days |
ACTONEL WITH CALCIUM TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:28 /28Days |
ACTOS 15MG TABLET |
2 |
Preferred Brand |
$20.00 | N/A | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACTOS 30MG TABLET (500 CT) |
2 |
Preferred Brand |
$20.00 | N/A | S Q:30 /30Days |
ACTOS 45MG TABLET |
2 |
Preferred Brand |
$20.00 | N/A | S Q:30 /30Days |
ACULAR 0.5% EYE DROPS |
2 |
Preferred Brand |
$20.00 | N/A | Q:10 /30Days |
ACULAR LS 0.4% OPHTH SOL |
2 |
Preferred Brand |
$20.00 | N/A | Q:10 /30Days |
ACULAR PF 0.5% EYE DROPS |
2 |
Preferred Brand |
$20.00 | N/A | Q:24 /30Days |
ACYCLOVIR 200MG CAPSULE (1000 CT) |
1 |
Preferred Generic |
$4.00 | N/A | None |
ACYCLOVIR 200MG/5ML SUSP |
1 |
Preferred Generic |
$4.00 | N/A | None |
ACYCLOVIR 400MG TABLET (100 CT) |
1 |
Preferred Generic |
$4.00 | N/A | None |
ACYCLOVIR TABLET USP 800MG (100 CT) |
1 |
Preferred Generic |
$4.00 | N/A | None |
ADACEL VIAL 2UNT/5UNT |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | None |
ADAGEN 250U/ML VIAL |
4 |
Specialty-Generic and Brand |
28% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADDERALL XR 10MG CAPSULE SA |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:30 /30Days |
ADDERALL XR 15MG CAPSULE SA |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:30 /30Days |
ADDERALL XR 20MG CAPSULE SA |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:30 /30Days |
ADDERALL XR 25MG CAPSULE SA |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:30 /30Days |
ADDERALL XR 30MG CAPSULE SA |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:60 /30Days |
ADDERALL XR 5MG CAPSULE SA |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:30 /30Days |
ADVICOR 1000-20MG TABLET |
2 |
Preferred Brand |
$20.00 | N/A | Q:60 /30Days |
ADVICOR 1000MG/40MG TABLET |
2 |
Preferred Brand |
$20.00 | N/A | Q:30 /30Days |
ADVICOR 500-20MG TABLET |
2 |
Preferred Brand |
$20.00 | N/A | Q:30 /30Days |
ADVICOR ER 20-750MG TABLET (90 CT) |
2 |
Preferred Brand |
$20.00 | N/A | Q:60 /30Days |
AFINITOR TABLETS |
4 |
Specialty-Generic and Brand |
28% | N/A | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AFINITOR TABLETS 5 MG |
4 |
Specialty-Generic and Brand |
28% | N/A | P Q:30 /30Days |
AGGRENOX 25-200MG CAPSULE |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:60 /30Days |
AK-CON 0.1% EYE DROPS |
1 |
Preferred Generic |
$4.00 | N/A | None |
AK-POLY-BAC EYE OINTMENT 500UNT/1000UNT |
1 |
Preferred Generic |
$4.00 | N/A | None |
ALBENZA 200MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | None |
ALBUTEROL SULFATE 0.63MG/3ML VIAL NEBULIZER |
1 |
Preferred Generic |
$4.00 | N/A | P |
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER |
1 |
Preferred Generic |
$4.00 | N/A | P |
ALBUTEROL SULFATE 2.5MG/3ML VIAL NEBULIZER |
1 |
Preferred Generic |
$4.00 | N/A | P |
ALBUTEROL SULFATE 4MG TABLET SR 12HR |
1 |
Preferred Generic |
$4.00 | N/A | None |
ALBUTEROL SULFATE 8MG TABLET SR 12HR |
1 |
Preferred Generic |
$4.00 | N/A | None |
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR |
1 |
Preferred Generic |
$4.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT |
1 |
Preferred Generic |
$4.00 | N/A | None |
ALBUTEROL SULFATE TABLET 2MG (500 CT) |
1 |
Preferred Generic |
$4.00 | N/A | None |
ALBUTEROL TABLET 4MG (500 CT) |
1 |
Preferred Generic |
$4.00 | N/A | None |
ALCLOMETASONE DIPROPIONATE 0.05% CREAM |
1 |
Preferred Generic |
$4.00 | N/A | None |
ALCLOMETASONE DIPROPIONATE 0.05% OINTMENT |
1 |
Preferred Generic |
$4.00 | N/A | None |
ALCOHOL ANTISEPTIC PADS |
1 |
Preferred Generic |
$4.00 | N/A | None |
ALDARA 5% CREAM |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:12 /30Days |
ALDURAZYME 2.9MG/5ML VIAL |
4 |
Specialty-Generic and Brand |
28% | N/A | P |
ALENDRONATE SODIUM 10MG TABLET |
1 |
Preferred Generic |
$4.00 | N/A | None |
ALENDRONATE SODIUM 40MG TABLET |
1 |
Preferred Generic |
$4.00 | N/A | None |
ALENDRONATE SODIUM 5MG TABLET |
1 |
Preferred Generic |
$4.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALENDRONATE SODIUM 70MG TABLET 4 BLPK |
1 |
Preferred Generic |
$4.00 | N/A | None |
ALENDRONATE SODIUM TABLET 35MG 20 CRTN |
1 |
Preferred Generic |
$4.00 | N/A | None |
ALIMTA 500MG VIAL |
4 |
Specialty-Generic and Brand |
28% | N/A | P |
ALIMTA INJECTION |
4 |
Specialty-Generic and Brand |
28% | N/A | P |
ALINIA 100MG/5ML SUSPENSION |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | None |
ALINIA 500MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | None |
ALKERAN 50MG VIAL |
2 |
Preferred Brand |
$20.00 | N/A | P |
ALLEGRA-D 12 HOUR TABLET 60-120MG (500 CT) |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:60 /30Days |
ALLOPURINOL TABLET 300MG (1000 CT) |
1 |
Preferred Generic |
$4.00 | N/A | None |
ALLOPURINOL TABLET USP 100MG (1000 CT) |
1 |
Preferred Generic |
$4.00 | N/A | None |
ALPHAGAN P 0.1% DROPS |
2 |
Preferred Brand |
$20.00 | N/A | Q:10 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALPHAGAN P 0.15% EYE DROPS |
2 |
Preferred Brand |
$20.00 | N/A | Q:10 /30Days |
ALREX 0.2% EYE DROPS |
2 |
Preferred Brand |
$20.00 | N/A | Q:15 /30Days |
ALTABAX 1% OINTMENT |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:15 /30Days |
ALTOPREV 20MG TABLET SR 24HR |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:30 /30Days |
ALTOPREV 40MG TABLET SR 24HR |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:30 /30Days |
ALTOPREV 60MG TABLET SR 24HR |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:30 /30Days |
ALVESCO 160MCG/ACT AERS |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:6 /30Days |
ALVESCO 80MCG/ACT AERS |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:6 /30Days |
AMANTADINE 100MG CAPSULE |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMANTADINE 100MG TABLET |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMCINONIDE 0.1% CREAM |
1 |
Preferred Generic |
$4.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMCINONIDE 0.1% LOTION |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMCINONIDE 0.1% OINTMENT 60GM TUBE |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMEVIVE ADMISTRATION PACK FOR INTRAMUSCULAR ADMINISTRATION KIT 15MG 1 X 4 PKGCOM |
4 |
Specialty-Generic and Brand |
28% | N/A | P |
AMIKACIN 250MG/ML VIAL |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMIKACIN 50MG/ML VIAL |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMILORIDE HCL 5MG TABLET |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMINOPHYLLINE 100MG TABLET (100 CT) |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMINOPHYLLINE 200MG TABLET (1000 CT) |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMINOPHYLLINE INJECTION 250MG 10ML X 25 VIALSD |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMINOSYN 10% IV SOLUTION |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINOSYN 3.5% IV SOLUTION |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | P |
AMINOSYN 5% IV SOLUTION |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | P |
AMINOSYN 7% IV SOLUTION |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | P |
AMINOSYN 7%-ELECTROLYTE SOL |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | P |
AMINOSYN 8.5% IV SOLUTION |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | P |
AMINOSYN II 10% IV SOLUTION |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | P |
AMINOSYN II 15% IV SOLUTION |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | P |
AMINOSYN II 3.5% IN D25W IV |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | P |
AMINOSYN II 3.5% IN D5W IV |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | P |
AMINOSYN II 3.5% M/D5W IV |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | P |
AMINOSYN II 3.5% W/ELEC DEX |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINOSYN II 4.25% IN D10W |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | P |
AMINOSYN II 4.25% IN D20W |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | P |
AMINOSYN II 4.25% M/D10W IV |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | P |
AMINOSYN II 4.25% W/ELEC DW |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | P |
AMINOSYN II 4.25%-D25W IV |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | P |
AMINOSYN II 5% IN D25W IV |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | P |
AMINOSYN II 7% IV SOLUTION |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | P |
AMINOSYN II 8.5% ELECTROLYT |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | P |
AMINOSYN II 8.5% IV SOLUTION |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | P |
AMINOSYN M 3.5% IV SOLUTION |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | P |
AMINOSYN PF INJECTION |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINOSYN-HBC 7% IV SOLUTION |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | P |
AMINOSYN-HF 8% IV SOLUTION |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | P |
AMINOSYN-PF 7% IV SOLUTION |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | P |
AMIODARONE HCL 200MG TABLET (60 CT) |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMIODARONE HCL 400MG TABLET |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMITIZA 24 MCG CAPSULES |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | S Q:60 /30Days |
AMITIZA 8MCG CAPSULE |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | S Q:60 /30Days |
AMITRIP/CDP 25-10 TABLET |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMITRIP/PERPHEN 10-2 TABLET |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMITRIP/PERPHEN 10-4 TABLET |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMITRIP/PERPHEN 25-2 TABLET |
1 |
Preferred Generic |
$4.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITRIP/PERPHEN 25-4 TABLET |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMITRIP/PERPHEN 50-4 TABLET |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMITRIPTYLINE HCL 100MG TABLET |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMITRIPTYLINE HCL 10MG TABLET |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMITRIPTYLINE HCL 150MG TABLET (100 CT) |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT) |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMITRIPTYLINE HCL 50MG TABLET |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT) |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMLODIPINE BESYLATE 10MG TABLET (90 CT) |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT) |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMLODIPINE BESYLATE 5MG TABLET (90 CT) |
1 |
Preferred Generic |
$4.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE |
1 |
Preferred Generic |
$4.00 | N/A | Q:30 /30Days |
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE |
1 |
Preferred Generic |
$4.00 | N/A | Q:30 /30Days |
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE |
1 |
Preferred Generic |
$4.00 | N/A | Q:30 /30Days |
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE |
1 |
Preferred Generic |
$4.00 | N/A | Q:60 /30Days |
AMMONIUM LACTATE 12% CREAM |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMMONIUM LACTATE 12% LOTION |
1 |
Preferred Generic |
$4.00 | N/A | Q:400 /30Days |
AMOX TR-K CLV 500-125MG TABLET |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE |
1 |
Preferred Generic |
$4.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMOXAPINE 100MG TABLET |
2 |
Preferred Brand |
$20.00 | N/A | None |
AMOXAPINE 150MG TABLET |
2 |
Preferred Brand |
$20.00 | N/A | None |
AMOXAPINE 25MG TABLET |
2 |
Preferred Brand |
$20.00 | N/A | None |
AMOXAPINE 50MG TABLET |
2 |
Preferred Brand |
$20.00 | N/A | None |
AMOXICILLIN 125MG TABLET CHEW |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMOXICILLIN 200MG TABLET CHEW |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMOXICILLIN 250MG CAPSULE |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMOXICILLIN 400MG TABLET CHEW |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMOXICILLIN 500MG CAPSULE |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMOXICILLIN 500MG TABLET (100 CT) |
1 |
Preferred Generic |
$4.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXICILLIN 875MG TABLET |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMOXICILLIN CLAVULANATE POTASSIUM TABLET 875-125MG 1 BLPK |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMOXICILLIN TABLET USP CHEWABLE 250MG (250 CT) |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMOXIL 500MG CAPSULE |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMPHET ASP/ AMPHET/ D-AMPHET 5MG TABLET |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMPHETAMINE SALT COMBO 12.5MG TABLET |
1 |
Preferred Generic |
$4.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPHETAMINE SALT COMBO 15MG TABLET |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMPHETAMINE SALT COMBO 7.5MG TABLET |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMPHETAMINE SALTS 30MG TABLET |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMPICILLIN AND SULBACTAM FOR INJECTION 1-0.5 10 VIAL VIAL |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMPICILLIN AND SULBACTAM FOR INJECTION 10-5 1 VIAL |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMPICILLIN AND SULBACTAM FOR INJECTION 2-1 10 VIAL |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMPICILLIN FOR INJECTION |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMPICILLIN FOR INJECTION 1GM VIAL |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMPICILLIN FOR INJECTION 2GM/ML 10 VIAL |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMPICILLIN FOR INJECTION 500MG VIAL |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMPICILLIN FOR INJECTION POWDER |
1 |
Preferred Generic |
$4.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPICILLIN FOR INJECTION USP 125MG/ML 1 VIAL |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMPICILLIN POWDER FOR INJECTION 1 GM/ML |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMPICILLIN SODIUM STERILE 2 GM/VIAL |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMPICILLIN TR 250MG CAPSULE |
1 |
Preferred Generic |
$4.00 | N/A | None |
AMPICILLIN TR 500MG CAPSULE |
1 |
Preferred Generic |
$4.00 | N/A | None |
ANADROL-50 50MG TABLET (100 CT) |
2 |
Preferred Brand |
$20.00 | N/A | P |
ANAGRELIDE HCL 0.5MG CAPSULE |
1 |
Preferred Generic |
$4.00 | N/A | None |
ANAGRELIDE HCL 1MG CAPSULE |
1 |
Preferred Generic |
$4.00 | N/A | None |
ANCOBON 250MG CAPSULE |
4 |
Specialty-Generic and Brand |
28% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ANCOBON 500MG CAPSULE |
4 |
Specialty-Generic and Brand |
28% | N/A | P |
ANDROGEL 1%(25MG) GEL PACKET |
2 |
Preferred Brand |
$20.00 | N/A | P |
ANDROGEL 1.25G (1%) GEL IN METERED-DOSE PUMP |
2 |
Preferred Brand |
$20.00 | N/A | P |
ANDROGEL 1%(50MG) GEL PACKET |
2 |
Preferred Brand |
$20.00 | N/A | P |
ANGELIQ 1-0.5MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:30 /30Days |
ANTABUSE 250MG TABLET |
2 |
Preferred Brand |
$20.00 | N/A | None |
ANTABUSE 500MG TABLET |
2 |
Preferred Brand |
$20.00 | N/A | None |
ANTARA 130MG CAPSULE |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:30 /30Days |
ANTARA 43MG CAPSULE |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:30 /30Days |
APHTHASOL 5% PASTE |
2 |
Preferred Brand |
$20.00 | N/A | None |
APOKYN FOR INJECTION 30MG 5 CTG |
4 |
Specialty-Generic and Brand |
28% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
APRI 0.15-0.03 TABLET |
1 |
Preferred Generic |
$4.00 | N/A | None |
APTIVUS 250MG CAPSULE |
4 |
Specialty-Generic and Brand |
28% | N/A | Q:120 /30Days |
ARALAST 1000MG VIAL |
2 |
Preferred Brand |
$20.00 | N/A | P |
ARALAST 500MG VIAL |
2 |
Preferred Brand |
$20.00 | N/A | P |
ARANELLE 7-9-5 TABLET |
1 |
Preferred Generic |
$4.00 | N/A | None |
ARANESP 100MCG/ML VIAL |
4 |
Specialty-Generic and Brand |
28% | N/A | P S Q:4 /28Days |
ARANESP 200MCG/0.4ML SYRINGE |
4 |
Specialty-Generic and Brand |
28% | N/A | P S Q:4 /28Days |
ARANESP 200MCG/ML VIAL |
4 |
Specialty-Generic and Brand |
28% | N/A | P S Q:4 /28Days |
ARANESP 25MCG/ML VIAL |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | P S Q:4 /28Days |
ARANESP 300MCG/ML VIAL |
4 |
Specialty-Generic and Brand |
28% | N/A | P S Q:4 /28Days |
ARANESP 500MCG/1ML SYRINGE |
4 |
Specialty-Generic and Brand |
28% | N/A | P S Q:1 /21Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARANESP 60MCG/ML VIAL |
4 |
Specialty-Generic and Brand |
28% | N/A | P S Q:4 /28Days |
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR |
4 |
Specialty-Generic and Brand |
28% | N/A | P S Q:4 /28Days |
ARANESP PREFILLED SYRINGE SINGLE USE 25MCG/0.42ML SYR |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | P S Q:4 /28Days |
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR |
4 |
Specialty-Generic and Brand |
28% | N/A | P S Q:4 /28Days |
ARANESP SINGLE USE PREFILLED AUTOINJECTOR SOLUTION 100MCG/.5ML |
4 |
Specialty-Generic and Brand |
28% | N/A | P S Q:4 /28Days |
ARANESP SINGLE USE PREFILLED SURECLICK AUTOINJECTOR SOLUTION 500MCG/ML |
4 |
Specialty-Generic and Brand |
28% | N/A | P S Q:4 /28Days |
ARANESP SINGLE USE PREFILLED SURECLIK AUTOINJECTOR 60MCG/.3ML |
4 |
Specialty-Generic and Brand |
28% | N/A | P S Q:4 /28Days |
ARANESP SINGLE USE VIAL 150MCG 4 X 150MCG/ 0.75ML VIALSD |
4 |
Specialty-Generic and Brand |
28% | N/A | P S Q:4 /28Days |
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD |
4 |
Specialty-Generic and Brand |
28% | N/A | P S Q:4 /28Days |
ARCALYST INJECTION 220MG/VIAL |
4 |
Specialty-Generic and Brand |
28% | N/A | P Q:4 /30Days |
ARICEPT 10MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARICEPT 5MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:30 /30Days |
ARICEPT ODT 10MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:30 /30Days |
ARICEPT ODT 5MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:30 /30Days |
ARIMIDEX 1MG TABLET |
2 |
Preferred Brand |
$20.00 | N/A | Q:30 /30Days |
ARIXTRA 10MG SYRINGE |
4 |
Specialty-Generic and Brand |
28% | N/A | P |
ARIXTRA 2.5MG SYRINGE |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | P |
ARIXTRA 5MG SYRINGE |
4 |
Specialty-Generic and Brand |
28% | N/A | P |
ARIXTRA 7.5MG SYRINGE |
4 |
Specialty-Generic and Brand |
28% | N/A | P |
AROMASIN 25MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:60 /30Days |
ASACOL 400MG TABLET EC |
2 |
Preferred Brand |
$20.00 | N/A | None |
ASMANEX TWISTHALER 220MCG #120 |
2 |
Preferred Brand |
$20.00 | N/A | Q:1 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ASMANEX TWISTHALER 220MCG #30 |
2 |
Preferred Brand |
$20.00 | N/A | Q:1 /30Days |
ASMANEX TWISTHALER 220MCG #60 |
2 |
Preferred Brand |
$20.00 | N/A | Q:1 /30Days |
ASTELIN 137MCG AEROSOL SPRAY W/PUMP |
2 |
Preferred Brand |
$20.00 | N/A | None |
ATACAND 16MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:30 /30Days |
ATACAND 32MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:30 /30Days |
ATACAND 4MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:30 /30Days |
ATACAND 8MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:30 /30Days |
ATACAND HCT 16/12.5MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:30 /30Days |
ATACAND HCT 32/12.5MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:30 /30Days |
ATACAND HCT TABLETS 32;25MG;MG 90 TABLETS BOT |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:30 /30Days |
ATENOLOL 25MG TABLET (100 CT) |
1 |
Preferred Generic |
$4.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATENOLOL TABLET 100MG (100 CT) |
1 |
Preferred Generic |
$4.00 | N/A | None |
ATENOLOL TABLET USP 50MG (100 CT) |
1 |
Preferred Generic |
$4.00 | N/A | None |
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT) |
1 |
Preferred Generic |
$4.00 | N/A | None |
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT) |
1 |
Preferred Generic |
$4.00 | N/A | None |
ATRIPLA TABLET 600MG/200MG |
4 |
Specialty-Generic and Brand |
28% | N/A | Q:30 /30Days |
ATROVENT HFA AER 17MCG |
2 |
Preferred Brand |
$20.00 | N/A | Q:25 /30Days |
ATTENUVAX VACCINE W/DILUENT 1 DOSE/0.5ML |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | None |
AUGMENTIN XR 1000-62.5 TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | None |
AVALIDE 150-12.5MG TABLET |
2 |
Preferred Brand |
$20.00 | N/A | Q:30 /30Days |
AVALIDE 300-12.5MG TABLET |
2 |
Preferred Brand |
$20.00 | N/A | Q:30 /30Days |
AVALIDE 300-25MG TABLET |
2 |
Preferred Brand |
$20.00 | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVANDAMET 2MG/1000MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | S Q:60 /30Days |
AVANDAMET 2MG/500MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | S Q:60 /30Days |
AVANDAMET 4MG/500MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | S Q:60 /30Days |
AVANDAMET TABLET 4-1000MG |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | S Q:60 /30Days |
AVANDARYL 4MG/1MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | S Q:60 /30Days |
AVANDARYL 4MG/2MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | S Q:60 /30Days |
AVANDARYL 4MG/4MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | S Q:60 /30Days |
AVANDARYL 8MG-2MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | S Q:30 /30Days |
AVANDARYL 8MG-4MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | S Q:30 /30Days |
AVANDIA 2MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | S Q:60 /30Days |
AVANDIA 4MG TABLET (90 CT) |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | S Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVANDIA 8MG TABLET (90 CT) |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | S Q:30 /30Days |
AVAPRO 150MG TABLET |
2 |
Preferred Brand |
$20.00 | N/A | Q:30 /30Days |
AVAPRO 300MG TABLET |
2 |
Preferred Brand |
$20.00 | N/A | Q:30 /30Days |
AVAPRO 75MG TABLET (30 CT) |
2 |
Preferred Brand |
$20.00 | N/A | Q:30 /30Days |
AVASTIN 100MG/4ML VIAL |
4 |
Specialty-Generic and Brand |
28% | N/A | P |
AVASTIN 400MG/16ML VIAL |
4 |
Specialty-Generic and Brand |
28% | N/A | P |
AVELOX 400MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:30 /30Days |
AVELOX IV 400MG/250ML |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | None |
AVIANE 0.1-0.02 TABLET |
1 |
Preferred Generic |
$4.00 | N/A | None |
AVODART 0.5MG SOFTGEL |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | Q:30 /30Days |
AVONEX ADMIN PACK 30MCG SYR |
4 |
Specialty-Generic and Brand |
28% | N/A | P Q:4 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVONEX ADMIN PACK 30MCG VL |
4 |
Specialty-Generic and Brand |
28% | N/A | P Q:4 /30Days |
AZACTAM 1GM VIAL |
2 |
Preferred Brand |
$20.00 | N/A | P |
AZACTAM 2GM VIAL |
2 |
Preferred Brand |
$20.00 | N/A | P |
AZACTAM INJECTION 1GM 50ML BAG |
2 |
Preferred Brand |
$20.00 | N/A | P |
AZACTAM/ISO-OSMOT 2GM/50ML |
2 |
Preferred Brand |
$20.00 | N/A | P |
AZASITE 1% DROPS |
2 |
Preferred Brand |
$20.00 | N/A | Q:2 /30Days |
AZATHIOPRINE 50MG TABLET |
1 |
Preferred Generic |
$4.00 | N/A | None |
AZILECT 0.5MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | S Q:30 /30Days |
AZILECT 1MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$48.00 | N/A | S Q:30 /30Days |
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Preferred Generic |
$4.00 | N/A | None |
AZITHROMYCIN 1G PACKET |
1 |
Preferred Generic |
$4.00 | N/A | Q:2 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Preferred Generic |
$4.00 | N/A | None |
AZITHROMYCIN 250MG TABLET (30 CT) |
1 |
Preferred Generic |
$4.00 | N/A | None |
AZITHROMYCIN 500MG TABLET (30 CT) |
1 |
Preferred Generic |
$4.00 | N/A | None |
AZITHROMYCIN FOR INJECTION 500MG 10 VIALSD |
1 |
Preferred Generic |
$4.00 | N/A | None |
AZITHROMYCIN TABLET 600MG (30 CT) |
1 |
Preferred Generic |
$4.00 | N/A | None |
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT |
2 |
Preferred Brand |
$20.00 | N/A | None |