2009 Medicare Part D Plan Formulary Information |
SilverScript Complete (S5601-080-0)
Benefit Details
|
The SilverScript Complete (S5601-080-0) Formulary Drugs Starting with the Letter A in CMS PDP Region 9 which includes: SC
|
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 METHAPRED METHLYPREDNISOLONE SODIUM SUCCINATE FOR INJECTION 125 MG |
2 |
Generic |
$7.50 | $19.00 | None |
A-HYDROCORT 100MG VIAL |
2 |
Generic |
$7.50 | $19.00 | None |
A-METHAPRED 40MG UNIVIAL |
2 |
Generic |
$7.50 | $19.00 | None |
ABELCENT INJECTION SUSPENSION 5MG/ML |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ABILIFY 10MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ABILIFY 15MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ABILIFY 1MG/ML SOLUTION |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ABILIFY 20MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ABILIFY 2MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ABILIFY 30MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ABILIFY 5MG TABLET (OTSUKA) |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ABILIFY DISCMELT 10MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ABILIFY DISCMELT 15MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ABILIFY INJ 9.75MG |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ABRAXANE 100MG VIAL |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ACARBOSE 100MG TABLET S |
2 |
Generic |
$7.50 | $19.00 | None |
ACARBOSE 25MG TABLET S |
2 |
Generic |
$7.50 | $19.00 | None |
ACARBOSE 50MG TABLET S |
2 |
Generic |
$7.50 | $19.00 | None |
ACCOLATE 10MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ACCOLATE 20MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ACCUNEB 0.63MG/3ML INH TUBEX |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | P Q:300 /25Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACCUNEB 1.25MG/3ML INH TUBEX |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | P Q:300 /25Days |
ACCUPRIL 10MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ACCUPRIL 20MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ACCUPRIL 40MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ACCUPRIL 5MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ACCURETIC 10-12.5MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ACCURETIC 20-12.5MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ACCURETIC 20-25MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ACCUTANE 10MG CAPSULE |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ACCUTANE 20MG CAPSULE |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ACCUTANE 40MG CAPSULE |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACEBUTOLOL 200MG CAPSULE |
2 |
Generic |
$7.50 | $19.00 | None |
ACEBUTOLOL 400MG CAPSULE |
2 |
Generic |
$7.50 | $19.00 | None |
ACEON 2MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ACEON 4MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ACEON 8MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-15MG (1000 CT) |
2 |
Generic |
$7.50 | $19.00 | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT) |
2 |
Generic |
$7.50 | $19.00 | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT) |
2 |
Generic |
$7.50 | $19.00 | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT) |
2 |
Generic |
$7.50 | $19.00 | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT) |
2 |
Generic |
$7.50 | $19.00 | None |
ACETAMINOPHEN/COD SOLUTION |
2 |
Generic |
$7.50 | $19.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACETASOL HC SOLUTION 10ML 10 ML BOT |
2 |
Generic |
$7.50 | $19.00 | None |
ACETAZOLAMIDE 125MG TABLET |
2 |
Generic |
$7.50 | $19.00 | None |
ACETAZOLAMIDE 250MG TABLET (100 CT) |
2 |
Generic |
$7.50 | $19.00 | None |
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT |
2 |
Generic |
$7.50 | $19.00 | None |
ACETAZOLAMIDE SOD 500MG VL |
2 |
Generic |
$7.50 | $19.00 | None |
ACETIC ACID 2% SOLUTION NON-ORAL |
2 |
Generic |
$7.50 | $19.00 | None |
ACETIC ACID-HYDROCORTISONE 2%-1% DROPS |
2 |
Generic |
$7.50 | $19.00 | None |
ACETYLCYSTEINE 10% VIAL |
2 |
Generic |
$7.50 | $19.00 | P |
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN |
2 |
Generic |
$7.50 | $19.00 | P |
ACIPHEX 20MG TABLET EC |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | Q:90 /365Days |
ACLOVATE 0.05% CREAM |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACLOVATE ALCLOMETASONE DIPROPIONATE 0.05% OINTMENT(GM) TOPICAL |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ACTHIB VACCINE VIAL 10-24UNT/5ML |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ACTICIN 5% CREAM |
2 |
Generic |
$7.50 | $19.00 | None |
ACTIGALL 300MG CAPSULE |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ACTIMMUNE SOLUTION FOR INJECTION 100MCG |
5 |
Specialty |
33% | N/A | None |
ACTIQ 1200MCG LOZENGE |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | Q:120 /25Days |
ACTIQ 1600MCG LOZENGE |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | Q:120 /25Days |
ACTIQ 200MCG LOZENGE |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | Q:120 /25Days |
ACTIQ 400MCG LOZENGE |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | Q:120 /25Days |
ACTIQ 600MCG LOZENGE |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | Q:120 /25Days |
ACTIQ 800MCG LOZENGE |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | Q:120 /25Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACTIVELLA 0.5-0.1MG TABLET 28 DLPK |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ACTIVELLA 1-0.5MG TABLET 28 DLPK |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ACTONEL 150MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ACTONEL 30MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ACTONEL 35MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ACTONEL 5MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ACTONEL 75MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ACTONEL WITH CALCIUM TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ACTOPLUS MET 15MG/500MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ACTOPLUS MET 15MG/850MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ACTOS 15MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACTOS 30MG TABLET (500 CT) |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ACTOS 45MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ACULAR 0.5% EYE DROPS |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ACULAR LS 0.4% OPHTH SOL |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ACULAR PF 0.5% EYE DROPS |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ACYCLOVIR 200MG CAPSULE (1000 CT) |
2 |
Generic |
$7.50 | $19.00 | None |
ACYCLOVIR 200MG/5ML SUSP |
2 |
Generic |
$7.50 | $19.00 | None |
ACYCLOVIR 400MG TABLET (100 CT) |
2 |
Generic |
$7.50 | $19.00 | None |
ACYCLOVIR SOD 50MG/ML VIAL |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ACYCLOVIR SODIUM 1GM VIAL |
2 |
Generic |
$7.50 | $19.00 | None |
ACYCLOVIR SODIUM 500MG VIAL |
2 |
Generic |
$7.50 | $19.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACYCLOVIR TABLET USP 800MG (100 CT) |
2 |
Generic |
$7.50 | $19.00 | None |
ADACEL VIAL 2UNT/5UNT |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ADAGEN 250U/ML VIAL |
5 |
Specialty |
33% | N/A | None |
ADALAT CC 30MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ADALAT CC 60MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ADALAT CC 90MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ADDERALL 10MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | P |
ADDERALL 12.5MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | P |
ADDERALL 15MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | P |
ADDERALL 20MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | P |
ADDERALL 30MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADDERALL 5MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | P |
ADDERALL 7.5MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | P |
ADDERALL XR 10MG CAPSULE SA |
3 |
Preferred Brand |
$39.00 | $92.00 | P |
ADDERALL XR 15MG CAPSULE SA |
3 |
Preferred Brand |
$39.00 | $92.00 | P |
ADDERALL XR 20MG CAPSULE SA |
3 |
Preferred Brand |
$39.00 | $92.00 | P |
ADDERALL XR 25MG CAPSULE SA |
3 |
Preferred Brand |
$39.00 | $92.00 | P |
ADDERALL XR 30MG CAPSULE SA |
3 |
Preferred Brand |
$39.00 | $92.00 | P |
ADDERALL XR 5MG CAPSULE SA |
3 |
Preferred Brand |
$39.00 | $92.00 | P |
ADOXA 100MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ADOXA 50MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ADOXA 75MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADOXA PAK 100MG TABLET DSPK-31 |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ADOXA PAK 100MG TABLET DSPK-60 |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ADOXA PAK 150MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ADOXA PAK 75MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ADRIAMYCIN 10MG VIAL |
2 |
Generic |
$7.50 | $19.00 | None |
ADRIAMYCIN 20MG VIAL |
2 |
Generic |
$7.50 | $19.00 | None |
ADRIAMYCIN 50MG VIAL |
2 |
Generic |
$7.50 | $19.00 | None |
ADVAIR DISKU MIS 100/50 |
3 |
Preferred Brand |
$39.00 | $92.00 | Q:60 /25Days |
ADVAIR DISKU MIS 250/50 |
3 |
Preferred Brand |
$39.00 | $92.00 | Q:60 /25Days |
ADVAIR DISKU MIS 500/50 |
3 |
Preferred Brand |
$39.00 | $92.00 | Q:60 /25Days |
ADVAIR HFA 115/21MCG INHALER |
3 |
Preferred Brand |
$39.00 | $92.00 | Q:12 /25Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADVAIR HFA 230/21MCG INHALER |
3 |
Preferred Brand |
$39.00 | $92.00 | Q:12 /25Days |
ADVAIR HFA 45/21MCG INHALER |
3 |
Preferred Brand |
$39.00 | $92.00 | Q:12 /25Days |
ADVICOR 1000-20MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ADVICOR 1000MG/40MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ADVICOR 500-20MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ADVICOR ER 20-750MG TABLET (90 CT) |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
AEROBID AEROSOL W/ADAPTER |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | Q:21 /25Days |
AEROBID-M AEROSOL W/ADAPTER |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | Q:21 /25Days |
AFEDITAB CR 30MG TABLET SA |
2 |
Generic |
$7.50 | $19.00 | None |
AFEDITAB CR 60MG TABLET SA |
2 |
Generic |
$7.50 | $19.00 | None |
AGGRENOX 25-200MG CAPSULE |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AGRYLIN 0.5MG CAPSULE |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
AK-CON 0.1% EYE DROPS |
2 |
Generic |
$7.50 | $19.00 | None |
AK-POLY-BAC EYE OINTMENT 500UNT/1000UNT |
2 |
Generic |
$7.50 | $19.00 | None |
AK-SPORE EYE OINTMENT 3.5 MG |
1 |
Value Generic |
$2.50 | $6.00 | None |
AKNE-MYCIN 2% OINTMENT |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
AKTOB 0.3% EYE DROPS |
2 |
Generic |
$7.50 | $19.00 | None |
ALA-CORT 1% CREAM |
2 |
Generic |
$7.50 | $19.00 | None |
ALA-CORT 1% LOTION |
2 |
Generic |
$7.50 | $19.00 | None |
ALA-SCALP HP 2% LOTION |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ALAMAST 0.1% DROPS |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ALBALON LIQUIFILM 0.1% DROP |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALBENZA 200MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ALBUTEROL SULFATE 0.63MG/3ML VIAL NEBULIZER |
2 |
Generic |
$7.50 | $19.00 | P Q:300 /25Days |
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER |
2 |
Generic |
$7.50 | $19.00 | P Q:300 /25Days |
ALBUTEROL SULFATE 2.5MG/3ML VIAL NEBULIZER |
2 |
Generic |
$7.50 | $19.00 | P Q:300 /25Days |
ALBUTEROL SULFATE 4MG TABLET SR 12HR |
2 |
Generic |
$7.50 | $19.00 | None |
ALBUTEROL SULFATE 8MG TABLET SR 12HR |
2 |
Generic |
$7.50 | $19.00 | None |
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR |
2 |
Generic |
$7.50 | $19.00 | P Q:60 /25Days |
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT |
2 |
Generic |
$7.50 | $19.00 | None |
ALBUTEROL SULFATE TABLET 2MG (500 CT) |
2 |
Generic |
$7.50 | $19.00 | None |
ALBUTEROL TABLET 4MG (500 CT) |
2 |
Generic |
$7.50 | $19.00 | None |
ALCAINE 0.5% EYE DROPS |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALCLOMETASONE DIPROPIONATE 0.05% CREAM |
2 |
Generic |
$7.50 | $19.00 | None |
ALCLOMETASONE DIPROPIONATE 0.05% OINTMENT |
2 |
Generic |
$7.50 | $19.00 | None |
ALCOHOL 5%/DEXTROSE 5% |
2 |
Generic |
$7.50 | $19.00 | None |
ALCOHOL ANTISEPTIC PADS |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ALDACTAZIDE 25/25 TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ALDACTAZIDE 50/50 TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ALDACTONE 100MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ALDACTONE 25MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ALDACTONE 50MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ALDARA 5% CREAM |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ALDURAZYME 2.9MG/5ML VIAL |
5 |
Specialty |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALENDRONATE SODIUM 10MG TABLET |
2 |
Generic |
$7.50 | $19.00 | None |
ALENDRONATE SODIUM 40MG TABLET |
2 |
Generic |
$7.50 | $19.00 | None |
ALENDRONATE SODIUM 5MG TABLET |
2 |
Generic |
$7.50 | $19.00 | None |
ALENDRONATE SODIUM 70MG TABLET 4 BLPK |
2 |
Generic |
$7.50 | $19.00 | None |
ALENDRONATE SODIUM TABLET 35MG 20 CRTN |
2 |
Generic |
$7.50 | $19.00 | None |
ALFERON N INJ 5MU/ML |
5 |
Specialty |
33% | N/A | None |
ALIMTA 500MG VIAL |
5 |
Specialty |
33% | N/A | None |
ALIMTA INJECTION |
5 |
Specialty |
33% | N/A | None |
ALINIA 100MG/5ML SUSPENSION |
3 |
Preferred Brand |
$39.00 | $92.00 | Q:180 /25Days |
ALINIA 500MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | Q:6 /25Days |
ALKERAN 50MG VIAL |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALLEGRA 180MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ALLEGRA 30MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ALLEGRA 30MG/5ML SUSPENSION ORAL |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ALLEGRA 60MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ALLEGRA-D 12 HOUR TABLET 60-120MG (500 CT) |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ALLEGRA-D 24 HOUR TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ALLOPURINOL SODIUM 500MG VIAL |
2 |
Generic |
$7.50 | $19.00 | None |
ALLOPURINOL TABLET 300MG (1000 CT) |
1 |
Value Generic |
$2.50 | $6.00 | None |
ALLOPURINOL TABLET USP 100MG (1000 CT) |
1 |
Value Generic |
$2.50 | $6.00 | None |
ALOCRIL 2% EYE DROPS |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ALOMIDE 0.1% EYE DROPS |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALOPRIM 500MG VIAL |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ALORA 0.025MG PATCH |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ALORA 0.05MG PATCH |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ALORA 0.075MG PATCH |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ALORA 0.1MG PATCH |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ALOXI 0.25MG/5ML VIAL |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ALPHAGAN P 0.1% DROPS |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ALPHAGAN P 0.15% EYE DROPS |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ALREX 0.2% EYE DROPS |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ALTABAX 1% OINTMENT |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ALTACE 1.25MG CAPSULE |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALTACE 10MG CAPSULE (100 CT) |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ALTACE 2.5MG CAPSULE |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ALTACE 5MG CAPSULE |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ALTACE TABLETS 1.25MG 100 BOTPL |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ALTACE TABLETS 10MG 100 BOTPL |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ALTACE TABLETS 2.5MG 100 BOTPL |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ALTACE TABLETS 5MG 100 BOTPL |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ALTOPREV 20MG TABLET SR 24HR |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ALTOPREV 40MG TABLET SR 24HR |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ALTOPREV 60MG TABLET SR 24HR |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ALUPENT 650MCG INHALER COMP |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | Q:28 /25Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALVESCO 160MCG/ACT AERS |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | Q:13 /25Days |
ALVESCO 80MCG/ACT AERS |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | Q:13 /25Days |
AMANTADINE 100MG CAPSULE |
2 |
Generic |
$7.50 | $19.00 | None |
AMANTADINE 100MG TABLET |
2 |
Generic |
$7.50 | $19.00 | None |
AMARYL 1MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
AMARYL 2MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
AMARYL 4MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
AMBIEN 10MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | Q:30 /60Days |
AMBIEN 5MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | Q:30 /60Days |
AMBIEN CR 12.5MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | Q:30 /60Days |
AMBIEN CR 6.25MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | Q:30 /60Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMBISOME 50MG VIAL |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
AMCINONIDE 0.1% CREAM |
2 |
Generic |
$7.50 | $19.00 | None |
AMCINONIDE 0.1% LOTION |
2 |
Generic |
$7.50 | $19.00 | None |
AMCINONIDE 0.1% OINTMENT 60GM TUBE |
2 |
Generic |
$7.50 | $19.00 | None |
AMERGE 1MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | Q:9 /25Days |
AMERGE 2.5MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | Q:9 /25Days |
AMEVIVE ADMISTRATION PACK FOR INTRAMUSCULAR ADMINISTRATION KIT 15MG 1 X 4 PKGCOM |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
AMIFOSTINE FOR INJECTION 500MG/VIAL |
2 |
Generic |
$7.50 | $19.00 | None |
AMIKACIN 250MG/ML VIAL |
2 |
Generic |
$7.50 | $19.00 | None |
AMIKACIN 50MG/ML VIAL |
2 |
Generic |
$7.50 | $19.00 | None |
AMIKIN 250MG/ML VIAL |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMIKIN POWDER FOR INJECTION |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
AMILORIDE HCL 5MG TABLET |
2 |
Generic |
$7.50 | $19.00 | None |
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET |
2 |
Generic |
$7.50 | $19.00 | None |
AMINESS 5.2% IV SOLUTION |
3 |
Preferred Brand |
$39.00 | $92.00 | P |
AMINOPHYLLINE 100MG TABLET (100 CT) |
1 |
Value Generic |
$2.50 | $6.00 | None |
AMINOPHYLLINE 200MG TABLET (1000 CT) |
1 |
Value Generic |
$2.50 | $6.00 | None |
AMINOPHYLLINE INJECTION 250MG 10ML X 25 VIALSD |
2 |
Generic |
$7.50 | $19.00 | None |
AMINOSYN 10% IV SOLUTION |
3 |
Preferred Brand |
$39.00 | $92.00 | P |
AMINOSYN 3.5% IV SOLUTION |
3 |
Preferred Brand |
$39.00 | $92.00 | P |
AMINOSYN 5% IV SOLUTION |
3 |
Preferred Brand |
$39.00 | $92.00 | P |
AMINOSYN 7% IV SOLUTION |
3 |
Preferred Brand |
$39.00 | $92.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINOSYN 7%-ELECTROLYTE SOL |
3 |
Preferred Brand |
$39.00 | $92.00 | P |
AMINOSYN 8.5% IV SOLUTION |
3 |
Preferred Brand |
$39.00 | $92.00 | P |
AMINOSYN II 10% IV SOLUTION |
3 |
Preferred Brand |
$39.00 | $92.00 | P |
AMINOSYN II 15% IV SOLUTION |
3 |
Preferred Brand |
$39.00 | $92.00 | P |
AMINOSYN II 3.5% IN D25W IV |
3 |
Preferred Brand |
$39.00 | $92.00 | P |
AMINOSYN II 3.5% IN D5W IV |
3 |
Preferred Brand |
$39.00 | $92.00 | P |
AMINOSYN II 3.5% M/D5W IV |
3 |
Preferred Brand |
$39.00 | $92.00 | P |
AMINOSYN II 3.5% W/ELEC DEX |
3 |
Preferred Brand |
$39.00 | $92.00 | P |
AMINOSYN II 4.25% IN D10W |
3 |
Preferred Brand |
$39.00 | $92.00 | P |
AMINOSYN II 4.25% IN D20W |
3 |
Preferred Brand |
$39.00 | $92.00 | P |
AMINOSYN II 4.25% M/D10W IV |
3 |
Preferred Brand |
$39.00 | $92.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINOSYN II 4.25% W/ELEC DW |
3 |
Preferred Brand |
$39.00 | $92.00 | P |
AMINOSYN II 4.25%-D25W IV |
3 |
Preferred Brand |
$39.00 | $92.00 | P |
AMINOSYN II 5% IN D25W IV |
3 |
Preferred Brand |
$39.00 | $92.00 | P |
AMINOSYN II 7% IV SOLUTION |
3 |
Preferred Brand |
$39.00 | $92.00 | P |
AMINOSYN II 8.5% ELECTROLYT |
2 |
Generic |
$7.50 | $19.00 | P |
AMINOSYN II 8.5% IV SOLUTION |
3 |
Preferred Brand |
$39.00 | $92.00 | P |
AMINOSYN M 3.5% IV SOLUTION |
3 |
Preferred Brand |
$39.00 | $92.00 | P |
AMINOSYN PF INJECTION |
3 |
Preferred Brand |
$39.00 | $92.00 | P |
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5% |
2 |
Generic |
$7.50 | $19.00 | P |
AMINOSYN-HBC 7% IV SOLUTION |
3 |
Preferred Brand |
$39.00 | $92.00 | P |
AMINOSYN-HF 8% IV SOLUTION |
2 |
Generic |
$7.50 | $19.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINOSYN-PF 7% IV SOLUTION |
3 |
Preferred Brand |
$39.00 | $92.00 | P |
AMIODARONE HCL 200MG TABLET (60 CT) |
2 |
Generic |
$7.50 | $19.00 | None |
AMIODARONE HCL 400MG TABLET |
2 |
Generic |
$7.50 | $19.00 | None |
AMIODARONE HCL INJECTION |
2 |
Generic |
$7.50 | $19.00 | None |
AMITIZA 24 MCG CAPSULES |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
AMITIZA 8MCG CAPSULE |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
AMITRIP/CDP 25-10 TABLET |
2 |
Generic |
$7.50 | $19.00 | None |
AMITRIP/PERPHEN 10-2 TABLET |
2 |
Generic |
$7.50 | $19.00 | None |
AMITRIP/PERPHEN 10-4 TABLET |
2 |
Generic |
$7.50 | $19.00 | None |
AMITRIP/PERPHEN 25-2 TABLET |
2 |
Generic |
$7.50 | $19.00 | None |
AMITRIP/PERPHEN 25-4 TABLET |
2 |
Generic |
$7.50 | $19.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITRIP/PERPHEN 50-4 TABLET |
2 |
Generic |
$7.50 | $19.00 | None |
AMITRIPTYLINE HCL 100MG TABLET |
1 |
Value Generic |
$2.50 | $6.00 | None |
AMITRIPTYLINE HCL 10MG TABLET |
1 |
Value Generic |
$2.50 | $6.00 | None |
AMITRIPTYLINE HCL 150MG TABLET (100 CT) |
1 |
Value Generic |
$2.50 | $6.00 | None |
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT) |
1 |
Value Generic |
$2.50 | $6.00 | None |
AMITRIPTYLINE HCL 50MG TABLET |
1 |
Value Generic |
$2.50 | $6.00 | None |
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT) |
1 |
Value Generic |
$2.50 | $6.00 | None |
AMLODIPINE BESYLATE 10MG TABLET (90 CT) |
2 |
Generic |
$7.50 | $19.00 | None |
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT) |
2 |
Generic |
$7.50 | $19.00 | None |
AMLODIPINE BESYLATE 5MG TABLET (90 CT) |
2 |
Generic |
$7.50 | $19.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE |
2 |
Generic |
$7.50 | $19.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE |
2 |
Generic |
$7.50 | $19.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE |
2 |
Generic |
$7.50 | $19.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE |
2 |
Generic |
$7.50 | $19.00 | None |
AMMONIUM CHLORIDE 5 MEQ/ML |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
AMMONIUM LACTATE 12% CREAM |
2 |
Generic |
$7.50 | $19.00 | None |
AMMONIUM LACTATE 12% LOTION |
2 |
Generic |
$7.50 | $19.00 | None |
AMMONIUM LACTATE 12% LOTION |
2 |
Generic |
$7.50 | $19.00 | None |
AMNESTEEM 10MG CAPSULE |
2 |
Generic |
$7.50 | $19.00 | None |
AMNESTEEM 20MG CAPSULE |
2 |
Generic |
$7.50 | $19.00 | None |
AMNESTEEM 40MG CAPSULE |
2 |
Generic |
$7.50 | $19.00 | None |
AMOCLAN 200-28.5/5 SUSPENSION RECONSTITUTED ORAL |
2 |
Generic |
$7.50 | $19.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOCLAN 400-57MG/5 SUSPENSION RECONSTITUTED ORAL |
2 |
Generic |
$7.50 | $19.00 | None |
AMOX TR-K CLV 200-28.5 CHEW |
2 |
Generic |
$7.50 | $19.00 | None |
AMOX TR-K CLV 200-28.5/5 SU |
2 |
Generic |
$7.50 | $19.00 | None |
AMOX TR-K CLV 400-57 CHW TABLET |
2 |
Generic |
$7.50 | $19.00 | None |
AMOX TR-K CLV 400-57/5 SUSP |
2 |
Generic |
$7.50 | $19.00 | None |
AMOX TR-K CLV 500-125MG TABLET |
2 |
Generic |
$7.50 | $19.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL |
2 |
Generic |
$7.50 | $19.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE |
2 |
Generic |
$7.50 | $19.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET |
2 |
Generic |
$7.50 | $19.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE |
2 |
Generic |
$7.50 | $19.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL |
2 |
Generic |
$7.50 | $19.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOX TR-POTASSIUM CLAVULANATE 500-125MG TABLET |
2 |
Generic |
$7.50 | $19.00 | None |
AMOXAPINE 100MG TABLET |
2 |
Generic |
$7.50 | $19.00 | None |
AMOXAPINE 150MG TABLET |
2 |
Generic |
$7.50 | $19.00 | None |
AMOXAPINE 25MG TABLET |
2 |
Generic |
$7.50 | $19.00 | None |
AMOXAPINE 50MG TABLET |
2 |
Generic |
$7.50 | $19.00 | None |
AMOXICIILIN CLAVULNATE POTASSIUM FOR ORAL SUSPENSION |
2 |
Generic |
$7.50 | $19.00 | None |
AMOXICILLIN 125MG TABLET CHEW |
2 |
Generic |
$7.50 | $19.00 | None |
AMOXICILLIN 200MG TABLET CHEW |
2 |
Generic |
$7.50 | $19.00 | None |
AMOXICILLIN 250MG CAPSULE |
1 |
Value Generic |
$2.50 | $6.00 | None |
AMOXICILLIN 400MG TABLET CHEW |
1 |
Value Generic |
$2.50 | $6.00 | None |
AMOXICILLIN 500MG CAPSULE |
1 |
Value Generic |
$2.50 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXICILLIN 500MG TABLET (100 CT) |
1 |
Value Generic |
$2.50 | $6.00 | None |
AMOXICILLIN 875MG TABLET |
1 |
Value Generic |
$2.50 | $6.00 | None |
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT |
2 |
Generic |
$7.50 | $19.00 | None |
AMOXICILLIN CLAVULANATE POTASSIUM TABLET 875-125MG 1 BLPK |
2 |
Generic |
$7.50 | $19.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT |
1 |
Value Generic |
$2.50 | $6.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL |
1 |
Value Generic |
$2.50 | $6.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
1 |
Value Generic |
$2.50 | $6.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL |
1 |
Value Generic |
$2.50 | $6.00 | None |
AMOXICILLIN TABLET USP CHEWABLE 250MG (250 CT) |
1 |
Value Generic |
$2.50 | $6.00 | None |
AMOXIL 250MG/5ML SUSPENSION |
2 |
Generic |
$7.50 | $19.00 | None |
AMOXIL 400MG/5ML SUSPENSION |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXIL 500MG CAPSULE |
2 |
Generic |
$7.50 | $19.00 | None |
AMOXIL 50MG/ML PED DROPS |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
AMPHET ASP/ AMPHET/ D-AMPHET 10MG TABLET |
2 |
Generic |
$7.50 | $19.00 | P |
AMPHET ASP/ AMPHET/ D-AMPHET 5MG TABLET |
2 |
Generic |
$7.50 | $19.00 | P |
AMPHETAMINE SALT COMBO 12.5MG TABLET |
2 |
Generic |
$7.50 | $19.00 | P |
AMPHETAMINE SALT COMBO 15MG TABLET |
2 |
Generic |
$7.50 | $19.00 | P |
AMPHETAMINE SALT COMBO 30MG TABLET |
2 |
Generic |
$7.50 | $19.00 | P |
AMPHETAMINE SALT COMBO 7.5MG TABLET |
2 |
Generic |
$7.50 | $19.00 | P |
AMPHETAMINE SALTS 20MG TABLET |
2 |
Generic |
$7.50 | $19.00 | P |
AMPHETAMINE SALTS 30MG TABLET |
2 |
Generic |
$7.50 | $19.00 | P |
AMPHOTEC 100MG VIAL |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPHOTEC INJ 50MG |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
AMPHOTERICIN B FOR INJECTION 50 MG |
2 |
Generic |
$7.50 | $19.00 | None |
AMPICILLIN AND SULBACTAM FOR INJECTION 1-0.5 10 VIAL VIAL |
2 |
Generic |
$7.50 | $19.00 | None |
AMPICILLIN AND SULBACTAM FOR INJECTION 10-5 1 VIAL |
2 |
Generic |
$7.50 | $19.00 | None |
AMPICILLIN AND SULBACTAM FOR INJECTION 2-1 10 VIAL |
2 |
Generic |
$7.50 | $19.00 | None |
AMPICILLIN FOR INJECTION |
2 |
Generic |
$7.50 | $19.00 | None |
AMPICILLIN FOR INJECTION 1GM VIAL |
2 |
Generic |
$7.50 | $19.00 | None |
AMPICILLIN FOR INJECTION 2GM/ML 10 VIAL |
2 |
Generic |
$7.50 | $19.00 | None |
AMPICILLIN FOR INJECTION 500MG VIAL |
2 |
Generic |
$7.50 | $19.00 | None |
AMPICILLIN FOR INJECTION POWDER |
2 |
Generic |
$7.50 | $19.00 | None |
AMPICILLIN FOR INJECTION USP 125MG/ML 1 VIAL |
2 |
Generic |
$7.50 | $19.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT |
2 |
Generic |
$7.50 | $19.00 | None |
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT |
2 |
Generic |
$7.50 | $19.00 | None |
AMPICILLIN POWDER FOR INJECTION 1 GM/ML |
2 |
Generic |
$7.50 | $19.00 | None |
AMPICILLIN SODIUM STERILE 2 GM/VIAL |
2 |
Generic |
$7.50 | $19.00 | None |
AMPICILLIN TR 250MG CAPSULE |
2 |
Generic |
$7.50 | $19.00 | None |
AMPICILLIN TR 500MG CAPSULE |
2 |
Generic |
$7.50 | $19.00 | None |
AMRIX 15MG CAPSULE SR 24 HR |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
AMRIX 30MG CAPSULE SR 24 HR |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ANADROL-50 50MG TABLET (100 CT) |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ANAFRANIL 25MG CAPSULE |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ANAFRANIL 50MG CAPSULE |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ANAFRANIL 75MG CAPSULE |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ANAGRELIDE HCL 0.5MG CAPSULE |
2 |
Generic |
$7.50 | $19.00 | None |
ANAGRELIDE HCL 1MG CAPSULE |
2 |
Generic |
$7.50 | $19.00 | None |
ANAPROX 275MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ANAPROX DS 550MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ANCOBON 250MG CAPSULE |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ANCOBON 500MG CAPSULE |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ANDRODERM 2.5MG/24HR PATCH |
3 |
Preferred Brand |
$39.00 | $92.00 | P |
ANDRODERM 5MG/24HR PATCH |
3 |
Preferred Brand |
$39.00 | $92.00 | P |
ANDROGEL 1%(25MG) GEL PACKET |
3 |
Preferred Brand |
$39.00 | $92.00 | P |
ANDROGEL 1.25G (1%) GEL IN METERED-DOSE PUMP |
3 |
Preferred Brand |
$39.00 | $92.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ANDROGEL 1%(50MG) GEL PACKET |
3 |
Preferred Brand |
$39.00 | $92.00 | P |
ANDROID 10MG CAPSULE |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ANGELIQ 1-0.5MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ANTABUSE 250MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ANTABUSE 500MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ANTARA 130MG CAPSULE |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ANTARA 43MG CAPSULE |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ANTIVERT 12.5MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ANTIVERT 25MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ANTIVERT 50MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ANUSOL-HC 2.5% CREAM |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ANZEMET 100MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | P |
ANZEMET 20MG/ML VIAL |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ANZEMET 50MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | P |
APHTHASOL 5% PASTE |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
APIDRA 100UNITS/ML VIAL |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
APOKYN FOR INJECTION 30MG 5 CTG |
5 |
Specialty |
33% | N/A | None |
APRI 0.15-0.03 TABLET |
2 |
Generic |
$7.50 | $19.00 | None |
APTIVUS 250MG CAPSULE |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ARALAST 1000MG VIAL |
5 |
Specialty |
33% | N/A | None |
ARALAST 500MG VIAL |
5 |
Specialty |
33% | N/A | None |
ARALEN PHOSPHATE 500MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARANELLE 7-9-5 TABLET |
2 |
Generic |
$7.50 | $19.00 | None |
ARANESP 100MCG/ML VIAL |
5 |
Specialty |
33% | N/A | P |
ARANESP 200MCG/0.4ML SYRINGE |
5 |
Specialty |
33% | N/A | P |
ARANESP 200MCG/ML VIAL |
5 |
Specialty |
33% | N/A | P |
ARANESP 25MCG/ML VIAL |
3 |
Preferred Brand |
$39.00 | $92.00 | P |
ARANESP 300MCG/ML VIAL |
5 |
Specialty |
33% | N/A | P |
ARANESP 500MCG/1ML SYRINGE |
5 |
Specialty |
33% | N/A | P |
ARANESP 60MCG/ML VIAL |
5 |
Specialty |
33% | N/A | P |
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR |
5 |
Specialty |
33% | N/A | P |
ARANESP PREFILLED SYRINGE SINGLE USE 25MCG/0.42ML SYR |
3 |
Preferred Brand |
$39.00 | $92.00 | P |
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR |
5 |
Specialty |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARANESP SINGLE USE PREFILLED AUTOINJECTOR SOLUTION 100MCG/.5ML |
5 |
Specialty |
33% | N/A | P |
ARANESP SINGLE USE PREFILLED SURECLICK AUTOINJECTOR SOLUTION 500MCG/ML |
5 |
Specialty |
33% | N/A | P |
ARANESP SINGLE USE PREFILLED SURECLIK AUTOINJECTOR 60MCG/.3ML |
5 |
Specialty |
33% | N/A | P |
ARANESP SINGLE USE VIAL 150MCG 4 X 150MCG/ 0.75ML VIALSD |
5 |
Specialty |
33% | N/A | P |
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD |
5 |
Specialty |
33% | N/A | P |
ARAVA 10MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ARAVA 20MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
AREDIA 30MG VIAL |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
AREDIA 90MG VIAL |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ARICEPT 10MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ARICEPT 5MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARICEPT ODT 10MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ARICEPT ODT 5MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ARIMIDEX 1MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ARIXTRA 10MG SYRINGE |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ARIXTRA 2.5MG SYRINGE |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ARIXTRA 5MG SYRINGE |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ARIXTRA 7.5MG SYRINGE |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
AROMASIN 25MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ARRANON 250MG VIAL |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ARTHROTEC 50 50MG TABLET -200MCG (60 CT) |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ARTHROTEC 75 TABLET EC |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ASACOL 400MG TABLET EC |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
ASCOMP W/CODEINE 30-50-325 CAPSULE |
2 |
Generic |
$7.50 | $19.00 | None |
ASMANEX 220MCG(14) AEROSOL POWDER BREATH ACTIVATED |
3 |
Preferred Brand |
$39.00 | $92.00 | Q:7 /25Days |
ASMANEX TWISTHALER 220MCG #120 |
3 |
Preferred Brand |
$39.00 | $92.00 | Q:58 /25Days |
ASMANEX TWISTHALER 220MCG #30 |
3 |
Preferred Brand |
$39.00 | $92.00 | Q:15 /25Days |
ASMANEX TWISTHALER 220MCG #60 |
3 |
Preferred Brand |
$39.00 | $92.00 | Q:29 /25Days |
ASTELIN 137MCG AEROSOL SPRAY W/PUMP |
3 |
Preferred Brand |
$39.00 | $92.00 | Q:60 /25Days |
ASTEPRO NASAL SPRAY 137 MCG/SPRY |
3 |
Preferred Brand |
$39.00 | $92.00 | Q:60 /25Days |
ASTRAMORPH-PF 0.5MG/ML VIAL |
2 |
Generic |
$7.50 | $19.00 | None |
ASTRAMORPH-PF 1MG/ML VIAL |
2 |
Generic |
$7.50 | $19.00 | None |
ATACAND 16MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATACAND 32MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ATACAND 4MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ATACAND 8MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ATACAND HCT 16/12.5MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ATACAND HCT 32/12.5MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ATACAND HCT TABLETS 32;25MG;MG 90 TABLETS BOT |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ATAMET |
2 |
Generic |
$7.50 | $19.00 | None |
ATENOLOL 25MG TABLET (100 CT) |
1 |
Value Generic |
$2.50 | $6.00 | None |
ATENOLOL TABLET 100MG (100 CT) |
1 |
Value Generic |
$2.50 | $6.00 | None |
ATENOLOL TABLET USP 50MG (100 CT) |
1 |
Value Generic |
$2.50 | $6.00 | None |
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT) |
1 |
Value Generic |
$2.50 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT) |
1 |
Value Generic |
$2.50 | $6.00 | None |
ATGAM 50MG/ML AMPUL |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ATRALIN 0.05% GEL |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | P |
ATRIPLA TABLET 600MG/200MG |
5 |
Specialty |
33% | N/A | None |
ATROPINE 0.05MG/ML SYRINGE |
2 |
Generic |
$7.50 | $19.00 | None |
ATROPINE 0.1MG/ML SYRINGE |
2 |
Generic |
$7.50 | $19.00 | None |
ATROVENT HFA AER 17MCG |
3 |
Preferred Brand |
$39.00 | $92.00 | Q:26 /25Days |
ATROVENT NASAL SPRAY 0.03% |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ATROVENT NASAL SPRAY 0.06% |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
ATTENUVAX VACCINE W/DILUENT 1 DOSE/0.5ML |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
AUGMENTIN 125 SUSPENSION |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AUGMENTIN 200MG/5ML SUSP |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
AUGMENTIN 250 SUSPENSION |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
AUGMENTIN 250 TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
AUGMENTIN 250 TABLET CHEW |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
AUGMENTIN 400MG/5ML SUSP |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
AUGMENTIN 500MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
AUGMENTIN 875MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
AUGMENTIN ES-600 SUSPENSION |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
AUGMENTIN XR 1000-62.5 TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
AVALIDE 150-12.5MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
AVALIDE 300-12.5MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVALIDE 300-25MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
AVANDAMET 2MG/1000MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
AVANDAMET 2MG/500MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
AVANDAMET 4MG/500MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
AVANDAMET TABLET 4-1000MG |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
AVANDARYL 4MG/1MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
AVANDARYL 4MG/2MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
AVANDARYL 4MG/4MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
AVANDARYL 8MG-2MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
AVANDARYL 8MG-4MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
AVANDIA 2MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVANDIA 4MG TABLET (90 CT) |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
AVANDIA 8MG TABLET (90 CT) |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
AVAPRO 150MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
AVAPRO 300MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
AVAPRO 75MG TABLET (30 CT) |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
AVASTIN 100MG/4ML VIAL |
5 |
Specialty |
33% | N/A | None |
AVASTIN 400MG/16ML VIAL |
5 |
Specialty |
33% | N/A | None |
AVELOX 400MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
AVELOX ABC PACK 400MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
AVELOX IV 400MG/250ML |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
AVIANE 0.1-0.02 TABLET |
2 |
Generic |
$7.50 | $19.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVINZA 120MG CAPSULE MULTIPHASIC RELEASE 24 HR |
3 |
Preferred Brand |
$39.00 | $92.00 | Q:60 /25Days |
AVINZA 30MG CAPSULE MULTIPHASIC RELEASE 24 HR |
3 |
Preferred Brand |
$39.00 | $92.00 | Q:60 /25Days |
AVINZA 60MG CAPSULE MULTIPHASIC RELEASE 24 HR |
3 |
Preferred Brand |
$39.00 | $92.00 | Q:60 /25Days |
AVINZA 90MG CAPSULE MULTIPHASIC RELEASE 24 HR |
3 |
Preferred Brand |
$39.00 | $92.00 | Q:60 /25Days |
AVINZA CAPSULES EXTENDED RELEASE 45MG 100 BOTPL |
3 |
Preferred Brand |
$39.00 | $92.00 | Q:60 /25Days |
AVINZA CAPSULES EXTENDED RELEASE 75MG 100 BOTPL |
3 |
Preferred Brand |
$39.00 | $92.00 | Q:60 /25Days |
AVITA 0.025% CREAM |
2 |
Generic |
$7.50 | $19.00 | P |
AVODART 0.5MG SOFTGEL |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
AVONEX ADMIN PACK 30MCG SYR |
5 |
Specialty |
33% | N/A | None |
AVONEX ADMIN PACK 30MCG VL |
5 |
Specialty |
33% | N/A | None |
AXERT 12.5MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | Q:12 /25Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AXERT 6.25MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | Q:12 /25Days |
AXID 150MG PULVULE |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
AXID 15MG/ML ORAL SOLUTION |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
AXID NIZATIDINE CAPSULES 300MG (30 CT) |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
AYGESTIN 5MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
AZACTAM 1GM VIAL |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
AZACTAM 2GM VIAL |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
AZACTAM INJECTION 1GM 50ML BAG |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
AZACTAM/ISO-OSMOT 2GM/50ML |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
AZASAN 100MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | P |
AZASAN 75MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZASITE 1% DROPS |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
AZATHIOPRINE 50MG TABLET |
2 |
Generic |
$7.50 | $19.00 | P |
AZATHIOPRINE SOD 100MG VIAL |
2 |
Generic |
$7.50 | $19.00 | None |
AZELEX 20% CREAM 30GM TUBE |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
AZILECT 0.5MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
AZILECT 1MG TABLET |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL |
2 |
Generic |
$7.50 | $19.00 | None |
AZITHROMYCIN 1G PACKET |
2 |
Generic |
$7.50 | $19.00 | None |
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL |
2 |
Generic |
$7.50 | $19.00 | None |
AZITHROMYCIN 250MG TABLET (30 CT) |
2 |
Generic |
$7.50 | $19.00 | None |
AZITHROMYCIN 500MG TABLET (30 CT) |
2 |
Generic |
$7.50 | $19.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZITHROMYCIN FOR INJECTION 500MG 10 VIALSD |
2 |
Generic |
$7.50 | $19.00 | None |
AZITHROMYCIN TABLET 600MG (30 CT) |
2 |
Generic |
$7.50 | $19.00 | None |
AZMACORT AER 75MCG |
3 |
Preferred Brand |
$39.00 | $92.00 | Q:40 /25Days |
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT |
3 |
Preferred Brand |
$39.00 | $92.00 | None |
AZOR 10MG-20MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
AZOR 10MG-40MG TABLET (30 CT) |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
AZOR 5MG-20MG TABLET (30 CT) |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
AZOR 5MG-40MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
AZULFIDINE 500MG TABLET |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |
AZULFIDINE EN TABLET S 500MG TABLET 6 X (300 CT)PL |
4 |
Non-Preferred Brand |
$98.00 | $270.00 | None |